Atypical psychosis (first onset) - neuro-imaging: Appraisal consultation document

Appraisal consultation document


Key dates
Appraisal Committee's preliminary recommendations
Clinical need and practice
The technologies
Evidence and interpretation
Proposed recommendations for further research
Related guidance
Proposed date for review of guidance
Appendix A: Appraisal Committee members and NICE project team
Appendix B: Sources of evidence considered by the Committee


The Department of Health has asked the National Institute for Health and Clinical Excellence (NICE or the Institute) to conduct a multiple technology appraisal of structural neuroimaging and provide guidance on its use to the NHS in England and Wales. The Appraisal Committee has had its first meeting to consider both the evidence submitted and the views put forward by non-manufacturer consultees and commentators, and by the clinical specialist and patient expert representatives nominated for this appraisal by non-manufacturer consultees and commentators. The Committee has developed preliminary recommendations on the use of structural neuroimaging.

This document has been prepared for consultation with the formal consultees. It summarises the evidence and views that have been considered and sets out the preliminary recommendations developed by the Committee. The Institute is now inviting comments from the formal consultees in the appraisal process (the consultees for this appraisal are listed on the NICE website ). This document should be read in conjunction with the evidence base for this appraisal (the evaluation report) which is also available from the NICE website.

Note that this document does not constitute the Institute's formal guidance on structural neuroimaging. The recommendations made in section 1 are preliminary and may change after consultation.

The process the Institute will follow after the consultation period is summarised below. For further details, see the 'Guide to the technology appraisal process' (this document is available on the NICE website ).

  • The Appraisal Committee will meet again to consider the original evidence and this appraisal consultation document in the light of the views of the formal consultees.
  • At that meeting, the Committee will also consider comments made on the document by people who are not formal consultees in the appraisal process.
  • After considering feedback from the consultation process, the Committee will prepare the final appraisal determination (FAD) and submit it to the Institute.
  • Subject to any appeal by consultees, the FAD may be used as the basis for the Institute's guidance on the use of the appraised technology in the NHS in England and Wales.




The key dates for this appraisal are:

Closing date for comments: 18 October 2007
Second Appraisal Committee meeting: 6 November 2007

Details of membership of the Appraisal Committee are given in appendix A, and a list of the sources of evidence used in the preparation of this document is given in appendix B.

Note that this document does not constitute the Institute's formal guidance on structural neuroimaging. The recommendations made in section 1 are preliminary and may change after consultation.




1 Appraisal Committee's preliminary recommendations
1.1 Routine structural neuroimaging techniques (either magnetic resonance imaging [MRI] or computed axial tomography [CT]) are not recommended as part of the initial investigations for the management of people with first-episode psychosis.




2 Clinical need and practice
2.1 Psychosis is not a diagnosis in itself but a term used to describe a group of conditions in which severe symptoms of mental illness such as delusions and hallucinations occur, accompanied by the inability to distinguish between subjective experiences and reality. Usually people with psychotic symptoms lack insight into their condition. Psychosis can develop at any age from childhood to late old age. First-episode psychosis refers to the first time that a person presents with psychotic symptoms.
2.2 Psychoses sometimes occur in association with the use of psychoactive drugs or with specific physical illnesses, such as space-occupying lesions in the brain (benign or malignant tumour, a cyst or an abscess), strokes, Alzheimer's disease, head injury or encephalitis. Psychoses that occur as a result of physical illness and associated with structural changes to the brain are sometimes referred to as 'organic psychoses'. All other psychoses, including those where the diagnosis is schizophrenia or bipolar disorder, are referred to as 'functional psychoses'. The causes of psychosis vary with age and sex, and young adults who develop psychotic symptoms are most often diagnosed as having functional psychosis, while organic psychoses are more common in older people. It is thought that psychosis is associated with an organic cause in 5-10% of people who present with symptoms.
2.3 The prevalence of psychosis varies with age, gender and ethnic group. Prevalence is greatest in the age range 35-64 years. Hospital Episode Statistics from the UK show that 0.2% of episodes of psychosis occur in people in the age range 0-14 years, 83.3% in the age range 15-59 years, and 16.5% in people aged 60 years and above. Of finished episodes of psychosis, 59% occur in men and 41% in women. Information on the incidence of psychosis in the UK is mostly related to schizophrenia or functional psychoses rather than all psychoses. A study in Nottingham, UK on the incidence of first-episode psychotic disorders in two cohorts (1978-1980 and 1992-1994) found that the age-standardised incidence rate for schizophrenia and related disorders was 0.14 per 1000 per year.
2.4 Mortality figures for all psychosis are not available; however, the mortality rates with schizophrenia as an underlying cause in the UK (1996-2004) were estimated at 0.7 per million for men and 0.8 per million for women. It is also estimated that the suicide rate for psychosis is around 7.52 per 1000 patient years (based on a small sample study). It is estimated that the lifetime suicide rate for people with psychosis is 4% and the lifetime suicide attempt rate is 22%.
2.5 People with psychosis tend to have a poor quality of life as a result of severe problems with social functioning and meeting the demands of daily life. If psychosis is not well controlled it may lead to self-harm or, rarely, harm to others. People with psychosis may be reluctant to disclose or accept their condition because of the stigma attached to mental illness. The problems associated with psychosis can also place a significant burden on the person's family and carers.
2.6 Current management for psychosis aims to reduce relapse rates and promote functional recovery; it includes standard physical, mental state, neurological and laboratory examinations. Acute onset and delirium can be an indication of an organic cause of psychosis. Where an organic cause is suspected, standard practice of care involves appropriate confirmatory tests. This may include use of structural neuroimaging techniques but these are not routinely used in the UK. Where no organic cause for psychosis is found, it is assumed that a person has functional psychosis. Treatment of psychosis usually involves psychological and pharmacological approaches.




3 The technologies
3.1 Structural neuroimaging involves non-invasive visualisation of the anatomical structure of the brain; in contrast to functional neuroimaging, which involves visualisation of neurophysiological function of the brain. Two structural neuroimaging techniques that are currently used within the NHS are standard magnetic resonance imaging (MRI) and computed axial tomography (CT) scanning. MRI exploits the nuclear magnetic resonance phenomenon while CT scanning is based on a series of X-rays.
3.2 MRI is considered to be the preferred option for neuroimaging as it provides higher image resolutions than CT scans. MRI scanning is better able to picture the soft tissues of the brain whereas CT scanning is more effective for picturing bone and hard tissues. It is generally a safe diagnostic technique and few safety concerns are reported in practice. Common safety concerns usually relate to interactions of MRI scanners with magnetic objects (for instance, pacemakers), noise, hyperthermia and peripheral nerve stimulation. There is a refusal rate in the general public of about 5-10% because of anxiety and claustrophobia (this rate may be much higher for people with psychosis). MRI scanning results in a number of false positive tests. In a retrospective study of 1000 healthy volunteers, 82% of MRI results were completely normal, 1.1% required urgent referral. The remaining 16.9% may have been worried by a positive MRI result of no medical consequence.
3.3 CT scanning is thought to have lower sensitivity than MRI in the diagnosis of brain lesions because of various artefacts that affect the quality of scans. It is estimated that 40% of all radiation exposure in people from diagnostic imaging comes from CT scanning. CT scanning can only detect differences in tissue density; lesions that have the same density as adjoining tissues will not be detected. However, in this case, an iodine-based contrast dye may be used for better visualisation. Contrast dyes may cause allergic reactions in some people.
3.4 The acquisition cost of an MRI scanner is £1-2 million and that for a CT machine is approximately £500,000. Other costs associated with an MRI scanner include the space that the scanner and other computerised equipment occupy, regular maintenance, additional clinical support, and staff and training to use the scanner. The costs of individual MRI and CT scans are estimated at £244 and £78 respectively (2005-2006 NHS Reference costs, code RBF1 and RBC5 respectively).




4 Evidence and interpretation
  The Appraisal Committee (appendix A) considered evidence from a number of sources (appendix B). No submissions were received from the manufacturers of the technologies considered. The evidence base comprised the evidence presented by the Assessment Group and the personal perspectives of the nominated experts. The Assessment Group's objective was to determine whether it is clinically and cost effective to scan routinely all those with first-episode psychosis by either structural MRI or CT techniques compared with the standard practice of carrying out selective radiological examinations contingent on clinical findings suggestive of an underlying structural cause.
4.1 Clinical effectiveness
4.1.1 The Assessment Group identified 25 studies with a wide range of study populations that had been conducted for different purposes. Among the relevant studies identified, no studies were found in which people with psychosis had specifically experienced deterioration in psychotic symptoms and only two of the studies were conducted in the UK. Nine studies were considered to relate to first-episode psychosis. Two of the studies in first-episode psychosis involved MRI scanning, six involved CT scanning and one study involved both techniques. All of the studies included for the clinical effectiveness review most resembled before-and-after studies.
4.1.2 The Assessment Group judged the methodological quality and internal validity of the studies identified to be questionable. The studies identified had varying patient populations, and a high level methodological heterogeneity. There was incomplete reporting of results and sampling bias was thought likely to be a factor affecting the results. Consequently, a quantitative meta-analysis of the study results was not possible.
4.1.3 Studies that included people with first-episode psychosis did not generally explain how this was defined. Furthermore, the current definition of first-episode psychosis (that is, the first time a person presents with symptoms of psychotic episodes) is not clear as it could include people who have been treated for many years without remission. In addition, the date of presentation with a first episode of psychosis may not coincide with the onset of the condition given that the first point of contact may not necessarily be healthcare services; it could be religious workers or officials in the criminal justice system, for example. Based on a review of the 25 studies identified, the Assessment Group estimated that MRI scanning resulted in findings that would influence clinical management in approximately 5% of people with psychosis (range of 0-10%). The corresponding figure for CT scanning was approximately 0.5% (range of 0-5%). These estimates, however, are subject to considerable uncertainty, given the questionable quality of studies and also the possibility of publication bias where studies that do not demonstrate the usefulness of the technology are less likely to be published.
4.1.4 Overall, the Assessment Group concluded that there was a paucity of good quality evidence on which to base an assessment of clinical effectiveness of routine MRI or CT scanning in people with first-episode psychosis where there were no signs or symptoms of additional pathology.
4.2 Cost effectiveness
4.2.1 A systematic review of studies on the cost effectiveness of structural neuroimaging in first-episode psychosis found no relevant economic evaluations. In addition, no evidence was found on differential treatment responses to antipsychotic drugs in organic and functional psychoses or on quality-of-life benefits following early diagnosis (from routine screening). Because of the lack of data to populate a comprehensive decision analytical model, the Assessment Group used a threshold analysis to estimate the cost effectiveness of routine scanning as compared with the standard diagnostic strategy of selective scanning. A threshold analysis predicts the quality-adjusted life year (QALY) gain required for a technology to be regarded as cost effective. By combining the incremental cost of routine scanning with cost effectiveness thresholds of £20,000 and £30,000 per QALY, the QALY gains needed to make routine scanning cost effective (or the QALY losses that could be tolerated if the strategy is cost saving) are estimated. A 12-month time horizon was assumed in the Assessment Group?s threshold analysis. It was assumed that people considered to have functional psychoses will receive a predefined sequence of atypical antipsychotic medications.
4.2.2 The Assessment Group noted that some organic causes of psychosis cannot be diagnosed using MRI or CT scans. The Assessment Group's threshold analysis therefore considers the case of an organic psychosis due to brain tumours or cysts diagnosed following routine or selective scanning. The threshold analysis assumed that treatment of a brain tumour was not altered as a result of earlier detection with an MRI or CT scan. The analysis also assumed no deterioration in disease states when detected at a later stage with selective scanning compared with early-stage detection with routine scanning.
4.2.3 The cost of treatment for a brain tumour or cyst is common to both the routine and selective scanning strategies (using MRI or CT), as it was assumed that, even with selective scanning, diagnosis (and subsequent treatment) of a brain tumour or cyst would be achieved within the 12-month time horizon of the threshold analysis. It was assumed that patients' response to antipsychotic medications is monitored over an 8-week period. The costs associated with this monitoring phase were determined by a proportional split of patients receiving either hospital care or home care. The Assessment Group estimated test accuracy rates for detecting brain tumours or cysts to be 100% for MRI and above 90% for CT scans. It was assumed that the prevalence of brain tumours or cysts among a population with psychosis was 5%. This was based on MRI scanning having a sensitivity rate at or close to 100%. Also, the probability of detecting a brain tumour or cyst after an MRI scan was estimated to be 5% based on the Assessment Group's review of the evidence from studies that reported scans affecting clinical management.
4.2.4 The base-case threshold analysis incorporating the above assumptions found that the strategy of routine scanning with MRI was cost saving. These cost savings were influenced by the following parameters: the time period during which a brain tumour or cyst is undetected and antipsychotic medications are provided under selective scanning; the dosage and costs of antipsychotic medications; and the proportional split of people receiving hospital and home care within a monitoring phase. The greatest cost saving was apparent when the largest proportion of people were hospitalised during the monitoring phase. A 50/50 split between hospital and home care had the largest impact on incremental costs. Under a conservative assumption that no people were hospitalised (0/100 split), routine structural neuroimaging was still cost saving.
4.2.5 At a threshold value for willingness to pay for an additional QALY of £20,000, and under the conservative scenario of a 0/100 split in hospital/home care, a QALY loss of 0.011 for the full cohort and 0.228 for people with brain tumours or cysts only are needed to offset cost savings. The Assessment Group stated that, under their base-case assumptions, QALY losses needed to render routine MRI scanning not cost effective seemed implausibly large.
4.2.6 The base-case threshold analysis for CT scanning also showed that the scenario that achieved the greatest cost saving was that with the highest proportion of people receiving hospitalised care. However, even when this proportion was assumed to be zero, the antipsychotic drug dosage was assumed to be low and the duration of antipsychotic treatment was assumed to be only 6 months, a routine scanning strategy remained cost saving. Threshold analysis suggests that QALY loss (needed to render routine CT scanning not cost effective) is greatest in the scenario where the proportion of hospitalised care is highest (50%), the dose of antipsychotics is highest, and the duration of treatment under selective scanning is 12 months and that for people with false negative CT scans is also 12 months. Under a conservative assumption of no hospitalised care, the QALY loss needed to render routine CT scanning not cost effective appears implausibly high, if the base-case assumptions regarding the probability of detecting a brain tumour or cyst after a scan are correct.
4.2.7 The Assessment Group conducted a number of sensitivity analyses, one of which varied the prevalence rate of brain tumours or cysts to 0.5% and 1%. The results of this sensitivity analysis showed for MRI that routine scanning was no longer cost saving at these prevalence rates. Therefore, for MRI to be cost effective, a QALY gain would be needed. Under all scenarios (duration of untreated psychosis, hospital and home care split, dose of antipsychotic treatments), the maximum QALY gain needed to make MRI cost effective at an incremental cost-effectiveness threshold of £30,000 per QALY was small: 0.007 and 0.005 for the full cohort at 0.5% and 1% prevalences of brain tumours or cysts, respectively. At an incremental cost-effectiveness threshold of £20,000 per QALY, the corresponding maximum QALY gains were 0.010 and 0.007 for the full cohort at 0.5% and 1% prevalences of brain tumours or cysts, respectively.
4.2.8 When the prevalence rate of brain tumours or cysts was set at 0.5% and hospital care was given in 20% of cases or less, routine scanning was no longer cost saving and a QALY gain was needed to make CT cost effective at conventional thresholds. For all scenarios with a 50/50 split of hospital/home care, routine CT scanning was cost saving. When prevalence was set to 1%, routine CT scanning was cost saving under all scenarios.
4.2.9 The analyses carried out by the Assessment Group suggest that routine structural neuroimaging would be cost saving if the base-case assumptions regarding the probability of detecting a brain tumour or cyst after a scan are correct. The maximum acceptable QALY loss for MRI to be cost effective ranged from 0.011 to 0.039, and for CT the maximum acceptable QALY loss ranged from 0.017 to 0.043. These results appear robust to variations in the various parameters investigated except for variations in the prevalence rates of brain tumours or cysts in people with psychosis.
4.2.10 In conclusion, the threshold analysis showed that if the prevalence of organic psychosis due to a brain tumour or cyst lies in the region of 5%, then under the Assessment Group's assumptions, routine structural neuroimaging is cost saving. If the prevalence of organic psychoses is close to 0.5%, then under the Assessment Group's assumptions, MRI is no longer cost saving, and CT is only cost saving if 50% of people receive hospital care. However, evidence for determining the true prevalence of treatable lesions in the population under test is extremely limited.
4.3 Consideration of the evidence
4.3.1 The Appraisal Committee reviewed the data available on the clinical and cost effectiveness of structural neuroimaging (using MRI or CT scanning), having considered evidence on the nature of the condition and the value placed on the benefits of structural neuroimaging by clinical specialists. It was also mindful of the need to take account of the effective use of NHS resources.
4.3.2 The Committee discussed whether it would be feasible to scan people who were particularly disturbed when they presented with acute psychosis. The clinical expert stated that some people may be more willing to undergo a neuroimaging scan than to have thorough clinical examinations, viewing it as less intrusive. The Committee understood that structural abnormalities in the brain may be present for several years before clinical presentation of first-episode psychosis. The Committee agreed that because structural abnormalities in the brain progress over time, for people with a first episode of psychosis without signs or symptoms of additional pathology, the early positive detection and management of structural lesions after routine scanning could have health benefits.
4.3.3 The Committee noted the paucity of good quality evidence presented and agreed that there was substantial uncertainty about the true prevalence of structural lesions in the population under test. The Committee heard from the clinical expert that the assumption of a 5% prevalence of organic psychosis may be an underestimate and that the figure could be as high as 10% because the studies reported had excluded people with any clinical sign of neurological abnormalities, which would reduce the likelihood of including people with psychosis of an organic cause in the study population. However, the clinical expert considered that the figures for organic psychosis due specifically to a brain tumour or cyst may be less than 5%.
4.3.4 The Committee discussed whether the prevalence estimate of 5% for organic psychosis due to a brain tumour or cyst was reasonable. It agreed, given the lack of good quality evidence, that it could not accept this estimate as the number of potential true positives that would alter clinical management of first-episode psychosis and lead to better outcomes. The Committee noted that this estimate was based on the results from before-and-after studies of questionable methodological quality and internal validity and agreed that this estimate could not be relied on. The Committee further considered that incidental findings and false positives associated with neuroimaging may increase anxiety levels of people with psychosis, leading to additional investigations and treatments, with questionable returns in terms of improved health outcomes from clinical care.
4.3.5 On balance, the Committee agreed that although routine scanning could have potential benefits in the management of first-episode psychosis, the current evidence base, particularly in relation to the prevalence of treatable lesions in the population under examination, was too weak to support a decision to implement routine use of MRI or CT scanning in all those with first-episode psychosis. The Committee agreed that this decision should not affect the current practice of using structural neuroimaging techniques selectively to exclude organic causes of psychosis where patients' symptoms, or other aspects of their presentation, suggest a higher likelihood of an underlying organic cause.
4.3.6 The Committee considered the evidence presented on the cost effectiveness of routine structural neuroimaging in first-episode psychosis. It discussed the tentative results of the Assessment Group's threshold analysis, which suggested that neuroimaging may be cost saving in a number of scenarios. The Committee noted that one limitation of the Assessment Group's threshold analysis is the uncertainty surrounding estimates of the prevalence of brain tumours or cysts in people with first-episode psychosis. It also noted other limitations relating to the 12-month time horizon of the model and its failure to capture potential costs associated with false positives, the need for repeat investigations and subsequent treatments, and potential health benefits and losses. The Committee considered that, although the Assessment Group's approach was appropriate given the lack of good quality data, substantial uncertainties existed about key parameters in the threshold analysis, in particular the estimates of the prevalence rates of brain tumours or cysts in the population of people with first-episode psychosis.
4.3.7 The Committee further discussed the assumption in the Assessment Group's approach that people in whom structural lesions were identified by neuroimaging could discontinue antipsychotic medication and thus eliminate subsequent costs for these drugs. However, the Committee heard from the clinical expert that this may not routinely be the case if the lesion is not treatable and the psychotic symptoms persist. The Committee was aware that effects on mortality had not been considered in the threshold analysis and that the analysis did not consider possible deterioration in the underlying organic conditions as a result of late detection and diagnosis under selective scanning. The Committee agreed that these limitations of the threshold analysis undermine applicability of the economic results to the NHS context.
4.3.8 The Committee considered that the limited evidence base to support routine scanning using structural neuroimaging techniques made it difficult to ascertain whether routine structural neuroimaging was clinically effective. The Committee further considered that the evidence base in support of routine structural neuroimaging techniques as a cost effective use of NHS resources was inconclusive and was subject to a number of uncertainties. The Committee, therefore, concluded that the routine use of structural neuroimaging techniques (either MRI or CT) should not be recommended as part of the initial investigations for the management of people with first-episode psychosis.




5 Implementation
5.1 The Healthcare Commission assesses the performance of NHS organisations in meeting core and developmental standards set by the Department of Health in 'Standards for better health' issued in July 2004. The Secretary of State has directed that the NHS provides funding and resources for medicines and treatments that have been recommended by NICE technology appraisals normally within 3 months from the date that NICE publishes the guidance. Core standard C5 states that healthcare organisations should ensure they conform to NICE technology appraisals.
5.2 'Healthcare Standards for Wales' was issued by the Welsh Assembly Government in May 2005 and provides a framework both for self-assessment by healthcare organisations and for external review and investigation by Healthcare Inspectorate Wales. Standard 12a requires healthcare organisations to ensure that patients and service users are provided with effective treatment and care that conforms to NICE technology appraisal guidance. The Assembly Minister for Health and Social Services issued a Direction in October 2003 which requires Local Health Boards and NHS Trusts to make funding available to enable the implementation of NICE technology appraisal guidance, normally within 3 months.
5.3 NICE has developed tools to help organisations implement this guidance (listed below). These are available on our website (
  • Slides highlighting key messages for local discussion.
  • Costing report and costing template to estimate the savings and costs associated with implementation.
  • Implementation advice on how to put the guidance into practice and national initiatives which support this locally.
  • Audit criteria to monitor local practice.




6 Proposed recommendations for further research
6.1 The Committee recommends that further evidence should be collected and systematic studies on the clinical benefits of routine scanning with structural neuroimaging in first-episode psychosis should be carried out.
6.2 Research studies should evaluate whether routine scanning is associated with early detection and treatment of organic causes of psychosis and improved health outcomes including effects on health-related quality of life.




7 Related NICE guidance
  NICE is developing the following guidance (details available from ).
  • Guidance for primary care and for residential care institutions on the promotion of good mental health in older people. NICE public health intervention (publication expected April, 2008).
  • Schizophrenia (update). NICE clinical guideline (publication expected January, 2009).




8 Proposed date for review of guidance
8.1 The review date for a technology appraisal refers to the month and year in which the Guidance Executive will consider whether the technology should be reviewed. This decision will be taken in the light of information gathered by the Institute, and in consultation with consultees and commentators.
8.2 It is proposed that the guidance on this technology is considered for review in January 2011. The Institute would particularly welcome comment on this proposed date.


David Barnett Chair, Appraisal Committee September 2007




Appendix A: Appraisal Committee members and NICE project team

A Appraisal Committee members
  The Appraisal Committee is a standing advisory committee of the Institute. Its members are appointed for a 3-year term. A list of the Committee members who took part in the discussions for this appraisal appears below. The Appraisal Committee meets twice a month except in December, when there are no meetings. The Committee membership is split into three branches, each with a chair and vice-chair. Each branch considers its own list of technologies and ongoing topics are not moved between the branches.
  Committee members are asked to declare any interests in the technology to be appraised. If it is considered there is a conflict of interest, the member is excluded from participating further in that appraisal.
  The minutes of each Appraisal Committee meeting, which include the names of the members who attended and their declarations of interests, are posted on the NICE website.
  Professor Keith Abrams
Professor of Medical Statistics, University of Leicester
  Dr Jeff Aronson
Reader in Clinical Pharmacology, Radcliffe Infirmary
  Professor David Barnett (Chair)
Professor of Clinical Pharmacology, University of Leicester
  Professor Stirling Bryan
Director of the Health Economics Facility, University of Birmingham
  Professor John Cairns
Public Health and Policy,London School of Hygiene and Tropical Medicine
  Dr Mark Charkravarty
Head of Government Affairs and NHS Policy, Procter and Gamble Pharmaceuticals (UK) Ltd
  Ms Lynn Field
Nurse Director, Pan Birmingham Cancer Network
  Professor Christopher Fowler
Professor of Surgical Education, University of London
  Dr Fergus Gleeson
Consultant Radiologist, Churchill Hospital
  Ms Sally Gooch
Former Director of Nursing & Workforce Development, Mid Essex Hospitals Services NHS Trust
  Mrs Barbara Greggains
Lay Member
  Mr Sanjay Gupta
Former Service Manager in Stroke, Gastroenterology, Diabetes and Endocrinology, Basildon and Thurrock University Hospitals Foundation NHS Trust
  Mr Terence Lewis
Mental Health Consultant, National Institute for Mental Health in England
  Professor Gary McVeigh
Professor of Cardiovascular Medicine, Queens University, Belfast
  Dr Ruairidh Milne
Senior Lecturer in Health Technology Assessment, National Coordinating Centre for Health Technology
  Dr Neil Milner
General Medical Practitioner, Tramways Medical Centre, Sheffield
  Dr Rubin Minhas
General Practitioner, CHD Clinical Lead, Medway PCT
  Dr Stephen Saltissi
Consultant Cardiologist, Royal Liverpool University Hospital
  Dr Lindsay Smith
General Practitioner, East Somerset Research Consortium
  Mr Cliff Snelling
Lay Member
  Dr Ken Stein
Senior Lecturer, Peninsula Technology Assessment Group (PenTAG), University of Exeter
  Dr Rod Taylor
Associate Professor in Health Services Research, Peninsula Medical School, Universities of Exeter and Plymouth.


 B NICE project team
  Each technology appraisal is assigned to a team consisting of one or more health technology analysts (who act as technical leads for the appraisal), a technical advisor and a project manager.
  Ebenezer Tetteh
Technical Lead
  Janet Robertson
Technical Adviser
  Natalie Bemrose
Project Manager




Appendix B: Sources of evidence considered by the Committee

A The assessment report for this appraisal was prepared by the West Midlands Health Technology Assessment Group, University of Birmingham.

  • Albon, E., Tsourapas, A., Frew, E. et al., Structural neuroimaging in psychosis. Systematic review and economic evaluation, June 2007

B The following organisations accepted the invitation to participate in this appraisal. They were invited to comment on the draft scope,assessment report and the appraisal consultation document (ACD). Organisations listed in I and II were also invited to make written submissions and have the opportunity to appeal against the final appraisal determination.

I Manufacturers/sponsors:

GE Medical Systems

Phillips Medical Systems

II Professional/specialist and patient/carer groups:

Counsel and Care


British Association for Psychopharmacology

British Neuropsychiatry Association

British Psychological Society

Royal College of General Practitioners

Royal College of Nursing

Royal College of Radiologists

III Commentator organisations (without the right of appeal):

Department of Health, Social Services and Public Safety for Northern Ireland


NHS Quality Improvement Scotland

Institute of Psychiatry

National Coordinating Centre for Health Technology Assessment

West Midlands HTA Collaboration

C The following individuals were selected from clinical specialist and patient advocate nominations from the non-manufacturer/sponsor consultees and commentators. They participated in the Appraisal Committee discussions and provided evidence to inform the Appraisal Committee?s deliberations. They gave their expert personal view on structural neuroimaging by attending the initial Committee discussion and/or providing written evidence to the Committee. They are invited to comment on the ACD.

  • Professor Philip McGuire, Professor of Psychiatry & Cognitive Neuroscience, Institute of Psychiatry - clinical specialist
  • Dr Sophia Frangou, Reader, Institute of Psychiatry - clinical specialist


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