Abstract
Response to ‘Outcome measurement, outcome management and monitoring’
We reply to the concern expressed by [Andrews] and Page in their review paper ‘Outcome measurement, outcome management and monitoring’, that they could ‘find no published report of health services providing data for clinical management or for outcome measurement’ and in particular use of the Health of the Nation Outcome Scales (HoNOS) [1]. We wish to advise that the Aged Care Psychiatry Service at Braeside Hospital has been utilizing HONOS 65+ and Kessler-10 scores to change clinical practice and service management. Unfortunately competing demands have frustrated our intention to publish this work to date, and believe this is the case for others developing innovative practice incorporating outcome measures.
The Braeside Service conducted a wide-ranging review of its systems and practices in the context of wishing to improve the breadth of evidence-based care and being unwilling to increase data collections without making practical use of such data. HoNOS 65+ data were seen as a vital part of our evidence base portfolio. However, there is fragility in developing such projects within small services, such as being sensitive to key changes in personnel, and limited infrastructure support. Nevertheless, the data are being used to guide clinical care, and has provided previously unavailable information to guide service development.
Key features of the revised system include team reviews for all patients (both inpatient and community), with access to standardized patient information, including selected outcome measurement scores. Patients have a HoNOS65+ key item score identified that best describes the team's clinical focus for change during the episode of care, which is discussed at case reviews. For inpatients, a discussion between the registrar and ward nurses regarding the nurses rating of that item over the time period since last review occurs the day prior to case conference. For community patients the case manager provides this rating. If this process reveals differences of opinion, reasons for this difference are discussed. This allows a more standardized measure of progress, facilitates communication between team members, and encourages clear identification of care planning goals.
On a service level, information from this process, and other service data, is collated and analysed to improve understanding of the range of clinical and social problems patients have, and how changes in these affect service delivery. A similar approach is also being conducted in inter-service benchmarking.
So while sharing the concerns of Andrews and Page [1] regarding under-utilization of the HoNOS clinically, we believe that there are services using it as they had hoped. We strongly encourage all clinicians to re-examine the utility of HoNOS scores. The HoNOS family of scales are tools that clinicians were unfamiliar with; but are widely collected, and in which staff have been trained. With innovative application routine outcome data can show positive outcomes in communication, clinical care and service management.
XXYY syndrome with schizophrenia: implications for genetic research in psychotic spectrum disorders
The role of the X-chromosome abnormalities in schizophrenia has been proposed by Lishman [1]. We wish to highlight the possible role of the X chromosome in the aetiology of psychosis through the following case.
A 26-year-old man with a documented XXYY genotype was admitted to hospital with paranoid delusions, extracampine auditory hallucinations, deterioration in personality and an increase in aggressive behaviour towards his mother. He appeared to have borderline intelligence, and was currently employed as a milkman.
His father's brother was diagnosed with schizophrenia. He was commenced on olanzapine 5 mg nocte, which was changed to risperidone 2 mg OD (once a day) due to sedation. He seemed to be unusually sensitive to small doses of antipsychotics. He reported a decrease in his auditory hallucinations and was discharged after 2 weeks on the ward.
The 48, XXYY syndrome is considered a variant of Klinefelter's syndrome (47, XXY). We found one previous case report of schizophrenia in a man with XXYY syndrome [2]. We found no other reports of psychosis in XXYY syndrome. Most cases come to attention due to behavioural disturbances [3].
The phenotype described is of tall stature, gynaecomastia, truncal obesity, skin ulcers and craniofacial dysmorphism described as pugilistic facial appearance. In Klinefelter's syndrome, however, van Rijn et al. found high levels of schizophrenia spectrum pathology. They concluded that there was a link between X-chromosomal abnormality and liability to schizophrenia [4]. They also proposed that the X-chromosome abnormality is related to amygdala deficits, which are an endophenotype in schizophrenia leading to subtle emotion processing deficits [5].
It may be, however, important to consider the role of both the X and Y chromosomes. Using meta-analyses Sommer et al. concluded that there was strong evidence for decreased cerebral lateralization in schizophrenia. They pointed out that unravelling the locus of the gene for cerebral lateralization could unravel the genetic predisposition in schizophrenia [6]. The XY region of homology has been postulated as one such candidate.
Protocadherin XY in the Xq 21.3/Yp region of homology determines cerebral lateralization, and Crow argues that it is this, rather than unidentified environmental factors, that accounts for the variability of transmission of psychosis [7].
Recent genetic studies have shown considerable advances in identifying susceptibility genes (D-amino acid oxidase activator G72/G30 locus on 13q, DISC1 on chromosome 1, Neureglin etc.) [8, 9, 10], which, in conjunction with the environment, influence the expression of psychosis across the kraeplinian divide (bipolar affective psychosis and schizophrenia). Linking biological processes to clinical phenotypes will create a better understanding of psychotic disorders and increase their validity. In order to achieve this we need to use large samples and also to adopt broader inclusion criteria for psychosis than the traditional descriptive narrow categories that we use at present. Operational diagnostic criteria serve us well in clinical practice and bring reproducibility to research but we need to concentrate on phenomenology and the underlying biological mechanisms to elucidate the fundamental aetiology of psychosis.