Out-patient treatment

Out-patient treatment is substantially cheaper than in-patient management and is generally as effective (Lowman, 1991). A French study on patients with generalized anxiety disorder estimated costs per patient over 3 months to he US 423 for hospitalization, 335 for out-patient services and 43 for medications (Souetre et al, 1994). Comorbid conditions (mostly alcoholism and depression) doubled these direct health-care costs. Over three-quarters of all patients were taking anxiolytic medication. 

Most clinical trials, including the ones my colleagues and I analysed, are conducted on volunteers, many of whom are recruited for the trial by advertisements. Perhaps these depressed people are not as responsive to antidepressants as the patients seen in clinical practice. The STAR D trial that I described earlier was designed specifically to evaluate the effect of antidepressants on the kinds of patients who are typically seen in clinical practice. None of the patients in this trial were recruited by advertising. Instead, they were all patients who sought treatment for depression in family practice or psychiatric out-patient treatment facilities. Also, the usual exclusion criteria were relaxed, so that a broader range of patients was evaluated. The trial did exclude patients who had already tried antidepressants but had not responded to them, although this exclusion should result in better response rates, not worse ones. 

Vorma H, Naukkarinen H, Sarna S, et al Treatment of out-patients with complicated benzodiazepine dependence comparison of two approaches. Addiction 97 851-859, 2002... 

Differences exist in primary care between the patterns of prescribing fluoxetine, paroxetine or sertraline, which may influence cost outcomes. Sertraline-treated patients are more likely to have their dose increased (Sclar et al, 1995 Donoghue, 1998), and to drop out of treatment prematurely (Donoghue, 1998). The apparent need to titrate doses upwards with sertraline may require more involvement by the clinician and may delay response to treatment, with resultant increases in direct health costs (Sclar et al, 1995). However, these economic findings are retrospective, may suffer from selection bias, and being derived from HMO patients may not be generalizable to other populations confirmation in further studies is required. 

Wagner etal. (1998) investigated the ethnic differences in antidepressant response to fluoxetine or placebo in 118 depressed, predominantly male, HIVpositive patients (White n = 79, Hispanic n = 17, African American n = 22). Nine Hispanic subjects (53%) dropped out of treatment making the results difficult to interpret. Among completers in the placebo arm, 80% (four out of five) of Hispanic subjects were responders as compared to 36% of African American subjects and 43% of White subjects. 

When we began using reserpine at the Maudsley Hospital less than two years ago there were very few reliable accounts of its use in the treatment of neuropsychiatric conditions and almost no controlled clinical studies. Dr D. L. Davies and I therefore conducted a clinical trial on a mixed group of out-patients, the majority of whom were suffering from anxiety and depressive reactions. The patients were given either reserpine, prescribed as Serpasil in a dose of 0.5 mg. by mouth twice daily, or a seemingly identical placebo, for a period of six weeks. The two substances... 

From the perspective of clinical trial methodology, concurrent medications can create a dilemma for the investigator by complicating the interpretation of results. Intermediate rescue medications are often required, however, because mood stabilizers are relatively slow in their onset of action. Further, if rescue medications are avoided, this usually introduces the confound of dropouts before the experimental drug can be fully effective. When feasible, a reasonable compromise is the use of modest amounts of a benzodiazepine (BZD), such as lorazepam, only when necessary for a limited time (e.g., 7 to 10 days) into the active phase of treatment. This can reduce the number of nonresponding, highly agitated patients who may otherwise drop out of treatment and in a trial of several weeks, the initial lorazepam effect should have dissipated by the final assessments. 

With the use of major tranquillisers, for example, thioridazine, chlorpromazine, or perphenazine, it is possible to withdraw opiate dependents who are highly motivated. The dosages can be titrated to the degree of clinical symptoms and this can be monitored with key carers through an out-patient clinic. The use of hypnotics should be restricted to short-term use due to their own dependency problems, but they can be a useful addition, particularly in the early phases of the treatment programme. 

Most of the clinical work is done with individuals, although there are groups for opiate users on out-patient detoxification and benzodiazepine withdrawal groups. Before the CDT was set up it had been assumed that its main task would be to provide a treatment and rehabilitation service to drug users who had been detoxified by the prescribing clinic. It became clear that this was unrealistic because so few patients of that clinic completed straightforward detoxification. During the first year of operation clinic patients could freely choose whether or not to use the services of the CDT, and... 

FYRof Macedonia ARQ 2005 98.7% - - - 1.3% - - 902 Psychiatric Hospital "Skopje", in-patient and out-patient facilities, 5 new Services for prevention and treatment of drug use and neuro-psychiatrics departments in aeneral hosDitals... 

Glossop M, Johns A, Green L. Opiate withdrawal inpatient vs out-patient programmes and preferred vs random assignment to treatment. BMJ (Clin Res Ed) 1986 293 103. 

A. Individual psychoanalytic therapy including out-patient or residential psycholytic treatment and follow-up visits in psychoanalytic one-on-one sessions. 

Adefovir is an adenine analogue reverse transcriptase inhibitor. While it has activity against both HIV and hepatitis B, its use in HIV infection is limited by nephrotoxicity due to the high doses needed (1). The dose used for treatment of hepatitis B is about one-tenth that needed to treat HIV infection, so patients with hepatitis B must have co-infection with HIV ruled out before treatment is started. 

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