text:
I have so many thoughts in my head and the only way I can deal with them is by writing.
Most times I can't even talk about these thoughts to 'people' because honestly, I feel like I am dealing with them by myself.
Lately, I have been so insecure in my body. Nothing seems to look right or even feel right and on the rare occasions I do feel good, I only have to take a picture and see what I really look like and then it's back to reality.
It's funny because when I am writing this I know that I am still not over these feelings but it feels kind of good to know that I am documenting this to read sometime in the future.
As women, it's inevitable that our bodies will change, but when it does change I don't think we're quite ready for it. I know I wasn't.
I was about 20 years old when I started to notice these changes. My lifestyle hadn't changed, my eating habits were exactly the same but for some weird reason, it started to take a toll on my size 6/8 frame. I became bigger, I inherited thighs,a butt, my face is a bit rounder than preferred, my breasts were fuller and my toned stomach was near enough non-existent. Being two years from 30, my metabolism has definitely slowed down.
I wasn't used to carrying the extra weight but I forced myself to get over it because I had no other choice, plus Suli thought the weight looked good on me. Even though deep down though it pissed me off that I weighed more than I wanted to weigh.
But even then, at that point of not being happy with my weight, I still genuinely believed I was beautiful.
Because beauty for me is, frankly everything. And it has no particular form, it has no particular shape. Simply because I have always grown up with the belief that God doesn't make ugly people so that has sort stuck with me my whole life.
I know for some, this sometimes it's a hard phenomenon to accept and at times even I have trouble believing this, especially now more than ever, hence these thoughts. But it's true. It has to be true.
Like no matter what decade it is, every body type has its own beauty, and we can't sit around waiting for our bodies to be validated by a trend… It's up to us to find assurance within ourselves and it's up to us to define our own ideals and make them a reality. It's up to us to stop all the self-criticism and judgement. It's up to us to find our own beauty and ignore the rest.
And in case you think this post was written for just you, it wasn't. It was written for me. While I do work out I am not in the shape that I want to be. I am 75kgs. So this post is for the days when I am feeling heavier than normal, or the days when I look like the fat friend in the picture or even for the good days too. Beauty is more than appearance. And I know this isn't the usual time I post, mainly because I have found it hard to write this but because I don't want many people to read it either 🙂
Hope you guys had a good day, though.
Don't forget to subscribe to Asklychee via email above.
Love Lychee
I wondered why a post popped up today! I thought I was getting my days wrong.
I absolutely loved reading it. Thank you for sharing so honestly (as always). I'm experiencing the same feelings and have been for some time. I don't want to have to replace my wardrobe because a lot of my clothes are getting too tight but I may just have to.
I love your thoughts on beauty too and it being anything. I believe beauty can be found in everything. It's a case of perception because as you said, I don't think God created ugliness in people.
hahaha! Thank you 🙂 Yeah replacing wardrobe is not an option for me and shouldn't be for you too! We can do it 🙂 Yep beauty is definitely a case of perception! Thanks for reading. x
Thanks for the encouragement. I agree…we can do it!
You can be my accountability partner lol


text:
How Houston Cooks: Up All Night at Kraftsmen Bakery
The lights are always on at Kraftsmen Bakery, where workers are busy around the clock making bread, packing it up and getting it shipped out across the area. We spent a day and night with the folks there to see what their operation is like. You can find out more in our blog, "Kraftsmen Baking Keeps H-Town Fed Day and Night."

subset: commoncrawl


text:
6-29-2013: Fixed a bug relating to Pre-retirement contributions reported by user "arebelspy".
6-29-2013: Added "Portfolio Median" to output page. Colorized the Average, Median, Low, and High portfolios for visibility.
7-1-2013: Fixed issues with Investigate Portfolio and Investigate Spending Level. cFIREsim now used the binary search algorithm to find the min/max values of these investigations within $1.
7-1-2013: Changed the output of the Investigation's to hide the graph/results and only show the results of the Investigation itself, to avoid confusion.
7-1-2013: Updated the graphing library to jqplot, which supports Axis labels. Added axis labels to all graphs.
7-2-2013: Updated Investigate Allocation to provide a graph instead of a table.
7-2-2013: Updated Output page to show all inputs (except individual/recurring portfolio adjustments, which might take up too much space)
7-2-2013: Added specific area for Social Security inputs (they act just like any other recurring inflation adjusted adjustment)
7-2-2013: Added the option to make One-time adjustments either Inflation Adjusted or not. Also, changed the wording in that section from "Lump Sum" to "One-time"
7-2-2013: Fixed bug that displayed incorrect "Starting Portfolio" in debug mode, even though it was simulating with the correct values.
7-2-2013: Added preliminary "Advanced Input" - Need to work on explanation, or a new interface.
7-3-2013: Fixed bug with "Advanced Input" where Adblocker was preventing it from opening.
7-3-2013: Changed usage notation in "Advanced Input" to be a little more intuitive (I think).
7-3-2013: Added same CSS styling to Output as was already present in the Input form.
7-3-2013: Fixed bug with "Advanced Input" that was zero'ing out the Spending every 10 years.
7-3-2013: Added Gold/Cash/Bonds asset allocation using historical data. Though, the output needs to be styled correctly for the debug table.
7-8-2013: Fixed a bug with "Constant Annual Market Growth" and the calculation for inflation that didn't mathematically make sense. Test Case: 0 spending, $1M portfolio, 0 fees, 3% inflation, 3% Constant Annual Market Growth. Should yield a consistent $1M inflation adjusted portfolio.
7-8-2013: Updated output page to include a "Test String", which is a string containing all of the variables used for a particular simulation. This long string can be used on the input to replay a simulation. This is a temporary solution for testing purposes, and will eventually be replaced by the ability to login and save a simulation.
7-12-2013: Added input validation to check for numeric values only.
7-12-2013: Changed output graph to show all years from 1871-2013, rather than jamming every point onto a 30yr graph. This shows how your simulation did through specific time periods.
7-12-2013: Released the link to a couple public forums. Oh god.
7-14-2013: Fixed issue with Retirement year. Inputs set for the future were not ignoring spending inputs like they should.
7-14-2013: Fixed issue with Advanced Spending Input not functioning.
7-15-2013: Added "Single Cycle Year" to the Investigation menu. This option runs a single simulation cycle from a user-inputted Start Year.
7-15-2013: Fixed issue with "Investigate Portfolio" which was affecting calculations for 100% success rate simulations.
7-15-2013: Changed the behavior of the add-on fields resulting from choices in the "Investigate" menu. Now, "Percent Success Threshold" and "Start Year" will only pop up if the appropriate investigation was selected.
7-26-2013: Major Revamp of UI - Changed a lot of menus and options so that the user could not choose redundant options. Made it easier (I hope) to enter multiple portfolio adjustments. Got rid of the "Advanced Inputs" in favor of the current streamlined menus.
7-26-2013: Added ability to do Monte Carlo simulation under Investigate section.
7-26-2013: Added the ability to do constant % increases to any portfolio adjustment (pensions, spending, etc)
7-26-2013: Added the ability to run a simulation starting from a specific year in history (Single Cycle - Investigate)
7-26-2013: Revamped the test string so that all portfolio adjustments are included.
7-26-2013: Added the ability to put independent Upper and Lower Limits when choosing a Spending of "Percent of Portfolio".
7-26-2013: Updated "Instructions" for each section, though I plan on adding examples with pictures.
7-26-2013: Updated main tutorial page to include pictures and a hypothetical example.
7-27-2013: Fixed a bug with "Investigate Allocation" where it wasn't properly updating the bond %.
7-29-2013: Added ability to change Asset Allocation gradually over an inputted time period (commonly known as "glide path")
7-29-2013: Fixed a bug involving "Investigate Spending" with a small portfolio and added savings inputs. It was incorrectly determining the maximum spending level because the algorithm was using the Portfolio amount as a starting point.
8-4-2013: Added ability to use historical data from specific time range.
8-4-2013: Deleted "beta" and "alpha" pages in favor of a "main" page and a "development" page.
8-8-2013: Added "Guyton-Klinger" method of Spending Adjustment
8-8-2013: Added "Variable Spending" method of Spending Adjustment - created by ERD50
8-8-2013: Added "Hebelers' Autopilot" method of Spending Adjustment
8-8-2013: Added a Spending graph on the output of applicable simulations
8-8-2013: Added a "Average Nominal Total Withdrawals" to the output page for comparison of simulations
8-8-2013: Fixed a bug giving errors for long simulation periods
8-20-2013: Added '"Retire Again & Again" withdrawal method
8-20-2013: Added ability to download simulation data to CSV file (under Debug section)
8-20-2013: Added "End Year" to Social Security inputs.
8-20-2013: Added "Cycle Start Year" to the information on the graph when you hover over a data series.
8-20-2013: Added ability to weight the 2 different types of strategies used in Hebeler's Autpilot Method.
8-20-2013: Expanded the information in the "Inputs" section at the top of the Output page. Allows for showing more of the different variables used in the current simulation.
Version 1.11 - 9/24/2013
- Fixed bug with "Investigate Allocation" that resulted in timeout. Changed granularity of that investigation to 5% increments to make it faster.
- Disabled "Investigate Spending" for when "Variable Spending Method" is chosen. There is a long-term bug that needs to be worked out for this.
- Fixed bug that was preventing the "Change Allocation Gradually" menu from opening.
- Fixed various logic errors in "Guyton-Klinger" and "Retire Again & Again" method of spending.
Version 1.12 - 9/26/2013
- Fixed bug causing the overall simulation inflation method to be erroneously changed when changing a Pension's inflation method. This was causing division by 0 errors.
Version 1.2 - 10/23/2013
- Added "Login" feature. This allows registered users of the cFIREsim forums to do the following:
* Save a set of inputs for a simulation, with a name
* Load a Saved Simulation by name
* Delete Saved Simulations
* Edit the name of Saved Simulations
- Added a feature for registered or non-registered users to load a Saved Simulation by a unique ID number.
- Changed VPW method of spending to "Custom VPW" and revamped it using updated work from the bogleheads forums.
- Removed old "Test String" functionality in lieu of new Save Simulation functionality.
- Changed wording of "Debug" section to reflect it's only current use: "CSV Output".
Version 1.21 - 10/24/2013
- Fixed an issue with the <form> tag for "Load Saved Simulation by ID" that caused certain portfolio adjustments to not load/save correctly
- Temporarily moved location of "Load Saved Simulation by ID"
Version 1.22 - 10/30/2013
- Fixed a bug that if you saved a sim with a Savings/Income that is "Not Inflation Adjusted", it is spitting out a database error. This caused that particular sim to not load correctly.
Version 1.23 - 12/02/2013
- Added a privacy statement to show that there is no intent to share/sell user data captured from the "Save Simulation" capability.
- Added output metrics to the Monte Carlo simulation option, to be in line with the other simulation outputs.
- Added spending graph to Monte Carlo simulation option.
Version 1.24 - 12/13/2013
- Added ability to add "labels" to each Savings/Income or Spending input (such as "401k savings", "IRA Savings", "College Tuition Costs", etc)
- Added ability to load those labels from a saved simulation
Version 1.25 - 1/14/2014
- Changed how bond returns were calculated, due to discussions in this thread: viewtopic.php?f=2&t=119
Version 1.3 - 5/19/2014
Code: Select all
- Updated Output Statistics Table
- added Median/St.Dev./Highest/Lowest for "Yearly Withdrawals"
- added Median/St.Dev./Highest/Lowest for "Total Withdrawals"
- added "Withdrawal Analysis"
- Shows Avg/Median/St.Dev./Highest/Lowest/Failures for 4 different subsets of your retirement period
- First 5 years
- Beginning Third
- Middle Third
- Final Third
- added "Dip Analysis"
- Shows how many simulation cycles that your Portfolio/Withdrawals dipped >10%, >20%, >40%, or >60% below the initial value at retirement.
- If a simulation cycle did show a dip for one of those categories, it shows the max total # of years it dipped during that specific simulation cycle.
- added Lowest 5 Withdrawal Dips
- Shows dip amount
- Shows Cycle Start / Dip Year
- Updated "Help" section for Output Table with better explanations of the fields
- Added 2 new fields to "Investigate" Section
- Added "Withdrawal Failure Value"
- This defines what a "failure" is to cFIREsim, in regards to Withdrawals (spending). If spending gets below this value, it will be considered a failure.
- Added "Portfolio Failure Value"
- This defines what a "failure" is to cFIREsim, in regards to your portfolio value. By default, this value was always $0. If your portfolio ever got to $0, it was considered a failure. Now, this field is customizable.
- Changed "Investigate Fees" to "Investigate Drag (Fees/Market Underperformance/Inflation)" to represent alternative ways to use this feature
- Increased the range of investigation from 0-3% to 0-10%
- Added the ability to Save/Load "Investigate" options
- Fixed bug in Original VPW withdrawal method, where inflation was not factoring into results
- Changed spending cap in "Investigate Spending Level for ______ % success" to $1,000,000.
- Added a small checkbox next to "Save Simulation as:" field
- If you save a simulation, you can now check this box to disable the "Save Simulation as:" text field so you can re-run the same simulation without error.
- Updated "Instructions" pages for all sections


text:
There are lots of messenger application are available on you smart phone and one of the most famous is the whatsapp , it is recently bought by the facebook and so we are all hoping some big changes that are going to come on whatsapp and now that big change that whatsapp bring on the whatsapp is that now you can officially use whatsapp on your personal computer(PC) , laptop and desktop and now might be you are thinking that to use whatsapp on PC you are required to install a separate a software on your PC but here comes a surprise that you don't need to install any separate software on your PC , so you might be thinking how then it actually going to work , so lets see a complete guide on how to use whatsapp on PC using officially whatsapp solution .
Using Whatsapp on PC
To use whatsapp on PC we required Internet connectivity and browser on our personal computer and the most important things latest whatsapp on our mobile .
Make sure you have the latest WhatsApp installed on your phone , at least required version of whatsapp is 'version 2.11.498' to use whatsapp on PC
1.) As i earlier told you that we don't required any separate software to installed on our PC , so we synchronize our WhatsApp via Web Application , so go to below web page.
Open the website using only Google chrome/Opera because as of now Google chrome and Opera these are the only two browser on which its working
After opening up web page you find a QR code there so we need to scan that QR code and we need to scan that code through our whatsapp and to scan QR code is only available on the latest whatsapp.
2.) if you have latest version of whatsapp installed on your phone then open up your whatsapp and click on the setting and then click on the 'WhatsApp Web' , see below image for more details .
3.)Now after clicking 'WhatsApp Web' scan QR code which is visible on you PC ,desktop (See below image for more details)
That's it now your whatsapp is finally synchronized with your personal computer or desktop and now you can able to send any message to your contacts and you can also enable push notification for the desktop so when ever a new message come you will get notification , if you no more want to use whatsapp for PC then you need to log out from the setting in the whatsapp over the web page.That's it for today post if you like this post please share this post with other and don't forget to subscribe to my blog and if you have any query and problem then please do comment in below comment section .


text:
Amazon Kindle Touch: First Impressions [PICS]
Kindle, Kindle Touch & Kindle Touch 3G
The Kindle Fire wasn't the only new ereader Amazon showed off Wednesday. The company also announced a revamped lineup of e-ink Kindle devices, including the brand new Kindle Touch.
With the Kindle Touch, Amazon is addressing one of the most common complaints about the original Kindle — its navigation system. Touchscreen ereaders are already available from manufacturers like Sony, but Amazon's approach is unique in its own right.
On stage, Amazon CEO Jeff Bezos discussed the way that customers tend to use the Kindle today. After finding that users frequently use a Kindle by holding it in one hand, Amazon wanted to make sure that the Kindle Touch would be easy to use without requiring the user to use another hand to turn the digital page. As a result, the Kindle Touch has a new feature called EasyReach — narrow tapzones, about the width of a thumb, that allow the user to quickly flip forward or backward through a book with one hand.
Kindle Touch has other new features too, including something called X-Ray. X-Ray lets users dive into the meta-data of a book to quickly get access to information about the locations, characters and situations in a book.
The screen on the Kindle Touch is crisp and clear, thanks to eink. It's also a lot faster than previous Kindles. Watching the demonstrations, we were struck by the quick response time and fast page loading speed of the new device.
Still, the most notable new thing about the Kindle Touch might just be its price. Starting at $99 for the Wi-Fi only Special Offers version (a Kindle Touch 3G will be available for $149 with Special Offers), the Kindle Touch finally pushes the device under that magic $100 price point. Amazon is actually also selling a $79 non-touchscreen Kindle as well, but we think most users are going to wind up going for the Kindle Touch or Kindle Touch 3G.
Personally, I don't have an actual need for a Kindle — I have an iPad 2 and an iPhone 4. At $99, however, I can see myself picking one up for subway and beach reading. I love EasyReach. I think it perfectly captures how consumers use an ereader.
The Kindle Fire might be getting all of the buzz today, but the Kindle Touch is still worth keeping an eye on. The $99 price point truly does make the Kindle affordable to almost everyone. For users who already have an iPad or just want a high quality, inexpensive ereader, the Kindle Touch delivers.


text:
Dutch festival Best Kept Secret has just announced the first wave of acts to head-up 2015's festivities in the small southern town of Hilvarenbeek, with The Libertines, Noel Gallagher's High Flying Birds and alt-J to fill the headline slots over the course of the weekend.
Perhaps not the best of headliners – I speak based on an incredibly disappointing set by alt-J at 2012's Green Man festival – this promising and relatively unknown festival (hence the appropriate name) has bags of great bands in the wings, including the likes of The Tallest Man On Earth, Chet Faker, Death Cab For Cutie, Little May, First Aid Kit, Alvvays, Bass Drum of Death, Wolf Alice… You get the idea.
With still over 30 bands to be announced, this is already shaping up to be one of the more promising line-ups of the summer. Tickets will go on general sale this Saturday, the 7th of February and for a weekend ticket with own-tent camping it'll cost £111.10 – admittedly this and the cost of travelling to Holland may put people off, but I'm willing to bet that those who do will enjoy a uniquely memorable weekend in the Dutch woods.


text:
FISE calls for entries for taking part in the VARP
FISE as a host organization calls for entries for craft/design professionals from the Czech Republic, Slovakia and Poland, for taking part in the three-month long Visegrad Artist Residency Program for a scholarship grant of 750 euro/month
Deadline of online application at FISE: 1th of September, 2018.
Not to forget, that you have to prepare the description of your Residency Project (advantageous with Hungarian partners) and you have to enclose the original letter of acceptance from us (not via e-mail).
Deadline of application at VARP: 10th of September, 2018.
For more information on FISE please visit website: www.fise.hu
For more information on VARP (rules, application info) :
Participating in the program, FISE offers opportunity of
- living in the association's apartment during the scholarship holder's research or studio work
(http://www.fise.hu/www/guestroom?language=en )
- cooperating FISE members in common projects or workshop / studio visiting possibilities in different fields of craft, photo, design, etc.
- cooperating studios in Budapest
- exhibiting in FISE Gallery as a closing event of the scholarship
- gathering impressions in Budapest, thanks to the fact, that the apartment, workshop and gallery are situated downtown of the city
The Studio of Young Designers Association (FISE/SYDA) is an NGO and working as a professional organization since 1982. Its main task is to support young professionals in starting their careers in different fields of design, including interior design, industrial design, applied graphics, textile, silicate and applied metal design. It provides the members publicity and space for exhibitions all year long in its Gallery, as well as the possibility to work in four studios. It also wishes to promote international mobility, encouraging cooperation and building networks between young designers, also from V4 countries.
Taking part in the program, please contact FISE at email@example.com email address.
Application is already open.
Robert Mascher DLA, designer
president of FISE


text:
During these uncertain times, how can we help?
See below to participate in our Impact Sector survey, access our COVID-19 Resource Hub, and explore our growing directory of COVID-19-specific and virtual volunteering opportunities.
We are a new hub for the Lower East Side, a cultural and community center that is committed to bringing together our vibrant and diverse neighborhood. Our newly-renovated space offers award-winning programs, critical services and exciting events for toddlers, teens, young adults, and older adults of all backgrounds.
Our commitment to the diversity of the Lower East Side is reflected in our programming: Head Start classrooms sit alongside our private preschool; the Weinberg Center for Balanced Living creates community for older adults of all backgrounds and abilities; our fitness center is utilized by neighborhood residents of all ethnicities, income levels, and ages through an innovative tiered membership model. The Educational Alliance Art School uses the study and mastery of fine arts to forge connections between students and master teachers. Afterschool programs serve community needs for recreation, fitness, education, and college preparation. Community and cultural programming invites deep conversation and calls to action.
The Manny Cantor Center is the flagship building of Educational Alliance, a community-based organization offering a wide range of programs that integrate education, social services, arts and recreation throughout the Lower East Side and East Village. Created to assist Eastern European Jews immigrating to NYC, it has been serving the area since 1889. Educational Alliance has grown and changed as the Lower East Side has; now serving the diverse population that currently resides here.


text:
Kanwer Singh, professionally known as Humble The Poet, is a Sikh Canadian author, rapper, and artist.
Here are some of his quotes that will help you live a better life:
Q1. "We gain more from letting go, there's nothing mystical and secretive about this idea."
Q2. "We hide the darkness with our smiles, feel lonely in crowded rooms, and become so accustomed to these feelings that we begin to believe they're a part of who we are."
Q3. "Expectations are a bigger enemy to our happiness than our circumstances."
Q4. "The bravest people I know are the most in tune with their fears and phobias, and have decided not to let those get in the way of their happiness."
Q5. "The most important relationships you have is with yourself, simple."
Q6. "Regret is a burden we all hold, for whatever reason, and holding does nothing but weigh us down."
Q7. "Love is something you share because you have it, not something you give desperately because you need it."
"The most important relationships you have is with yourself, simple."-
Humble The Poet
Q8. "Life is too short to be in any situation you don't want to be in, or to be with or around people you don't want to be around."
Q9. "Instead of trying to find that right person for you, focus on becoming that right person yourself."
Q10. "The strongest don't survive, the most adaptable do."
Q11. "Let's enjoy what we have, while we have it, and not spend it worrying about a future we may never see or an ending we can't afford."
Q12. "If people don't like you for who you are, change the people, not yourself."
Q13. "Life doesn't start after the obstacles; life is the obstacles."
Q14. "Don't try to numb the pain that may just delay the healing."
Q15. "Love when you're ready, not when you are lonely."
Q16. "We don't always have the power to change our circumstances, but we can change how we feel about them."
Q17. "Once you start moving, all those limitations and ideas of impossible fade. It's not going to be easy, but nothing worth accomplishing ever is."
Q18. "Before you can concern yourself with how you want it to be, you have to understand how it is."
Q19. "Get out there. Be comfortable. Make mistakes. Get embarrassed. We'll all be dead soon, it's not a big deal."
Q20. "You don't need to trust a world you can't control, just trust yourself to do your best to get through it."
Q21. "We tend to sabotage our happiness by ignoring the wonderful things in our life."
Q22. "Comforting lies are those fluffy pillows, while harsh realities are those cold showers."
Q23. "We can't control the ignorance or apathy of others, but we can recognize it in ourselves; let's start there."
Q24. "Instead of comparing yourself with others, try connecting yourself with others."
Q25. "Things take time, and if you don't have the patience to let things slow cook and form then expect a life continually unfulfilled."
Q26. "You are not your beliefs."
Q27. "Worry does not empty tomorrow of its sorrow, it empties today of its strength."
Q28. "Your time is limited, so please be picky about the people you spend it with…"
Q29. "Suffering is a key reason we evolve and improve our situation."
Q30. "The fear of uncomfortable ideas, and uncomfortable situations, and uncomfortable places robs us of the amazing potential we all have."
Q31. "I CAN'T learn about myself by focusing on HOW others see me, but I can learn by focusing on WHY I care."
Q32. "Confidence isn't a light switch; it's a foundation you build."
Q33. "Being open to trying new things, though sometimes daunting, is the best way to broaden the world around you."
Q34. "Every moment is a moment to try to make the life we want and change the things we dislike."
Q35. "Within all of us there are things worth celebrating, and things that we're not the most proud of, the choice is what we decide to focus on."
Q36. "Don't be afraid to get hurt, it's part of life; it's only unnecessary if there's nothing to learn from it."
Q37. "All the things you're looking to receive from someone else you can give to yourself, especially love."
Q38. "You're going to realize very quickly the biggest battles you fight are with yourself."
Q39. "Paint your picture the way you want it painted, it's your canvas, don't let anyone else hold the brush."
Q40. "You'll never be able to make everyone happy, trying to do so is a key ingredient to failure."
Q41. "Settling is death, please don't settle."
Q42. "If you want the power to make yourself happy, you have to assume the responsibility for your happiness."


text:
- Research
- Open Access
- Published:
Preventing panic disorder: cost-effectiveness analysis alongside a pragmatic randomised trial
Cost Effectiveness and Resource Allocation volume 7, Article number: 8 (2009)
18k Accesses
19 Citations
0 Altmetric
Panic disorder affects many people, is associated with a formidable disease burden, and imposes costs on society. The annual influx of new cases of panic disorder is substantial. From the public health perspective it may therefore be a sound policy to reduce the influx of new cases, to maintain the quality of life in many people, and to avoid the economic costs associated with the full-blown disorder. For this purpose, prevention is needed. Here we present the first economic evaluation of such an intervention.
Randomised trial of 117 people with panic disorder symptoms not meeting the diagnostic criteria of DSM-IV panic disorder. The interventions were time-limited cognitive-behavioural therapy v care-as-usual. The central clinical endpoint was DSM-IV panic disorder-free survival over 3 months. Costs were calculated from the societal perspective. Using the bootstrap method, incremental cost-effectiveness ratios were obtained, placed in 95% confidence intervals, projected on the cost-effectiveness plane, and presented as acceptability curves.
The median incremental cost-effectiveness ratio is €6,198 (95% CI 2,435 – 60,731) per PD-free survival gained, which has a likelihood of 75.2% of being more acceptable from a cost-effectiveness point of view than care-as-usual when a willingness-to-pay ceiling is assumed of €10,000 per PD-free survival. The most significant cost driver was therapists' time. A sensitivity analysis indicated that cost-effectiveness improves when the number of therapist hours is reduced.
This is the first economic evaluation alongside a prevention trial in panic disorder. The small sample (n = 117) and the short time horizon of 3 months preclude firm conclusions, but our findings suggest that the intervention may be acceptable from a cost-effectiveness point of view, especially when therapist involvement can be kept minimal. Nevertheless, our results must await replication in a larger trial with longer follow-up times before we can confidently recommend implementation of the intervention on a broad scale. In the light of our findings and given the burden of panic disorder, such a new trial is well worth the effort.
Trial registration
Current Controlled Trials ISRCTN33407455.
Panic disorder (PD) is characterised by a substantial influx of new cases. This influx occurs at a rate of 780 new (ie, first-ever) cases per 100,000 person-years in the adult population of 18 – 65 years in the Netherlands [1]. Their numbers should be compared with the annual number of 2,200 prevalent cases of PD in the same source population [2]. Looking at these figures one cannot escape the conclusion that 780/2,200 = 35.5% of the prevalent cases are, in fact, new cases. This casts doubts on the wisdom of relying solely on curative treatments directed at full-blown PD cases, and underscores the importance of prevention directed at sub-clinical cases, i.e. people with some PD symptoms who do not meet the diagnostic criteria for the disorder, and are thus 'at risk' of becoming cases [3]. In this context, it is worth noting that primary prevention of mental disorders appears to be a viable option [4].
Both sub-clinical and full-blown forms of panic disorder are associated with substantial costs due to excessive health care uptake, patients' out-of-pocket costs and production losses. By a conservative estimate, a full-blown PD case generates costs of about € 10,000 per patient per year, and a sub-clinical case generates € 6,000, even surpassing the costs of, for example, depressive disorder [5–8]. This suggests that offering preventive interventions for PD are likely to be cost-effective [9, 10].
Against this background it was decided to develop and evaluate a brief preventive intervention based on cognitive-behavioural therapy (CBT) for panic disorder. Here, we report on the incremental cost-effectiveness ratio expressed as costs per PD-free survival time. Therapists' involvement is a significant cost driver, but can be brought under some control, for example by reducing the number of hours they invest in the intervention and by relying more on self-help on the part of the participants [11]. The latter can be done with the aid of computers [12, 13]. Therefore, we conducted a sensitivity analysis for different hypothetical levels of therapist involvement: two therapists all sessions (high), one therapist all sessions (medium), one therapist only the first part of each session (low). To our knowledge this is the first economic evaluation of a preventive intervention in sub-clinical manifestations of panic disorder.
This study was part of a larger multi-site trial. The larger trial was described in detail by Meulenbeek and colleagues [14]. In the larger trial two groups were recruited: people with relatively mild manifestations of MINI-DSM-IV panic disorder (N = 100) and people with sub-clinical manifestations not meeting the diagnostic criteria (N = 117). Here we limit attention to the latter group: people at risk of becoming cases of panic disorder. It is worth noting that the large trial was conducted with randomisation stratified for both groups. Therefore, one can consider the subset of people with sub-clinical panic disorder as constituting a trial within a trial. The study was designed as a pragmatic trial, mimicking the Dutch health care system as closely as possible in terms of patient recruitment and the methods used for intake, offering the intervention, and monitoring outcomes. Measurements were carried out at baseline (t0) and after three months (t1). In the treatment arm an extended follow-up was conducted after 6 months (t2) to monitor effect maintenance over time. The design was approved by an independent medical ethics committee (METIGG), and the trial was registered at ISRCTN under number 33407455 before commencement.
Participants were recruited through media announcements and via the internet. People who expressed interest underwent intake at any of the 17 participating regional mental health services. Participants had to meet the following criteria for inclusion: age over 18 years, presenting with symptoms of PD falling below the cut-off of 13 on the Panic Disorder Severity Scale (PDSS) [15], no current treatment for PD related complaints, no illness requiring immediate medical attention, and able to function independently as well as in a group. In addition, each of the candidates received a diagnostic interview with the Mini International Neuropsychiatric Interview, MINI [16]. This was done to ascertain the DSM-IV PD status [17], assess the presence of co-morbid agoraphobia, and to exclude the presence of major depressive disorder. The participants had to give written informed consent before entering the trial. See Figure 1 for the flow of participants through the trial.
With n = 139 per condition, the original trial was powered to detect a clinically relevant difference between the conditions corresponding to a mean standardised difference score (Cohen's d) of at least 0.35 in a 2-sided test at α = 0.05 and a power of (1-β) = 0.80. However, the present study is based on only a subset of the data, and is underpowered. Therefore, we refrain from hypothesis testing. Instead we present outcomes in probabilistic terms, e.g. the likelihood (in %) that the intervention is superior to care-as-usual in terms of avoiding new onsets of panic disorder in a cost-effective way.
Concealed randomisation was conducted centrally by an independent third party who was 'blind' with respect to the participants. Participants were randomised in blocks of 2 with equal probability to either care-as-usual (N = 108, of these N = 58 with sub-clinical PD), or to the intervention (N = 109, of these N = 59 with sub-clinical PD). As said, randomisation was stratified for sub-clinical v clinical case levels of PD, and also with regard to presence v absence of co-occurring agoraphobia. The latter was done because it was assumed that agoraphobia is a prognostically relevant factor for outcome.
The experimental condition was a time-limited cognitive-behavioural preventive intervention for panic disorder: the Don't Panic course [18]. The choice for cognitive-behavioural therapy (CBT) was based on the understanding that CBT is the most cost-effective intervention for PD in the curative setting [19, 20]. The intervention consisted of 8 sessions of 2 hours each, followed by one booster session, again of 2 hours. The booster session was offered three months after completion of the course. The course was offered by a prevention worker and a clinician to groups of 10 (9 to 12) adults. The prevention workers and clinicians were all experienced in giving CBT-based interventions. In addition, they received training in offering the Don't Panic course, and they were to adhere to the treatment protocol [18]. Participants received an accompanying course book [21]. The intervention was well structured and consisted of psycho-education about anxiety and panic attacks, changing life-style, managing stress, relaxation training, cognitive restructuring, interoceptive exposure and in vivo exposure. Each session consisted of a review of homework assignments, followed by feedback, rehearsals, information about the upcoming topic and practical skill-training. The intervention was extensively pilot tested before entering the clinical trial stage [22].
The control condition consisted of people randomised to a waiting list. They entered the waiting list on the understanding that they would receive the Don't Panic intervention after 3 (max. 6) months. Waitlisted participants were free to make use of health services and take medication if so required. The control condition could therefore be described as care-as-usual (CAU), but it is CAU with one exception: people were expecting to receive help for their PD symptoms in the near future.
The central clinical endpoint was DSM-IV panic disorder status (APA, 1994) at follow-up as measured with the Mini International Neuropsychiatric Interview, MINI [16]. In order to monitor effect maintenance over time the self-report version of Panic Disorder Severity Scale, PDSS-SR [15] was used to measure severity of panic and agoraphobic symptoms, which was done at t0, t1 and t2.
Data on costs were collected with the Trimbos Institute and institute of Medical Technology Assessment Cost questionnaire for Psychiatry, TIC-P [23]. The TIC-P was the most frequently used heath service receipt questionnaire in the Netherlands. It used a self-report format about resource use in the last four weeks. It also contained a section on productivity losses due to absenteeism and working less efficient while at work but not feeling well. All costs that were relevant from the societal perspective were included. These costs can be grouped as follows:
Costs of health service uptake in primary care and outpatient mental health services, including transport by ambulance, visits to emergency departments and use of ECG when tachycardia or myocardial infarction was suspected (see Table 1 for details).
Costs of medication, specifically benzodiazepines, tranquilisers and sleep medication (calculated as cost price per standard daily dose as obtained from the Pharmaceutical Compass at http://www.fk.cvz.nl, plus 6% value added tax, multiplied by the number of prescription days, plus the pharmacist's dispensing costs of €6.45 per prescription).
Patients' out-of-pocket costs for making visits to health services, i.e. costs of travel, parking and time costs (see Table 1 for details).
Costs related to production losses due to absenteeism [24, 25] and lesser efficiency while at work but not feeling well [26] were valued at €33.90 per lost hour in paid work [27] and in the domestic sphere at €8.30 per lost hour, equivalent to the cost of one hour domestic help [27].
Intervention costs were calculated as the costs of therapists' time (€124 per hour) devoted to the intake (1 hour), 8 sessions plus one booster session (2 hours each), administration and preparation (1 hour per session), the intervention protocol (€45 per therapist), and the course book (€25 per participant). A naturalistic study showed that the number of participants in the Don't Panic courses was on average ten participants [22]. Accordingly, the per-participant costs of the intervention were calculated to be €750.
Because the number of hours invested by therapists in the intervention was the single largest cost-driver, the per-patient costs for the hypothetical scenarios when therapists' involvement is reduced to 50% and 25% were calculated at €375 and €190 for both lower intensity levels, and these figures were used in the sensitivity analysis.
The costs were calculated in accordance with the pertinent Dutch guideline [27] and they reflect the full economic costs of the services. The sum of all costs is called 'total costs', and is expressed as monthly per capita costs in Euro (€). The reference year is 2003. For that year, the Organisation for Economic Co-operation and Development (OECD) equates US$1 with €0.932, taking into account both the currency exchange rate and the purchasing power in the US and in the Netherlands (see: http://www.oecd.org and look for purchasing power parities, PPPs).
All analyses were conducted in agreement with the intention-to-treat principle [28]. Therefore, all participants were analysed in the condition to which they were randomised, and missing endpoints at follow-up were imputed using a regression model with the best available predictors of outcome and the best predictors for dropout. The first set of predictors was required to get the most precise estimates for the missing values, the latter to correct for bias that may stem from differential loss-to-follow-up associated with t0 variables [29]. These variables were identified using logistic regression analyses with MINI PD status and dropout as the dependent variables, and age, gender, partner status, employment status were measured at baseline. With help of these variables missing endpoint were predicted and the predicted values were used to replace missing endpoints. The remainder of the analyses was conducted on the imputed data, in four steps.
First, it was ascertained how many people became a case of MINI DSM-IV PD in each of the conditions at follow-up. This was done to assess the risk of becoming a case conditional on receiving or not receiving the intervention. The probability of not becoming a PD case is equal to 1-risk, and this was interpreted as the likelihood of having a panic disorder-free survival over three months. The incremental effectiveness was computed as the difference between the probabilities of PD-free survival.
Second, the mean total costs for each of the conditions were calculated, both at baseline and follow-up. The pre-post difference in costs were computed to obtain the increase (or decrease) of costs over time within each of the conditions. The incremental cost-effectiveness ratio (ICER) was subsequently calculated as the incremental costs for a health gain of a PD-free survival over three months [30–32].
Third, a scatter plot of 2,500 bootstrapped ICERs on the cost-effectiveness plane was produced, by repeatedly drawing a random sample with replacement of size n from the original trial data (also of size n), computing the ICER and plotting that ICER on the cost-effectiveness plane [33]. This helped to produce estimates of the probability that (i) better health was generated for additional costs, (ii) that the intervention was inferior relative to the control condition because less health was produced for additional costs, (iii) that less health was generated for less costs, and (iv) that the intervention dominates because better outcomes were obtained for less costs. The bootstrap analysis also helped to obtain the median ICER and its 95% confidence interval. The latter was based on the 2.5th and 97.5th percentile of the distribution of the 2,500 bootstrapped ICERs.
Finally, we wanted to answer the question whether the incremental costs were balanced by the heath gains to such an extent that one would be willing to pay for the additional costs to receive the additional health gain. Making such a judgement was complicated by the fact that the exact willingness to pay (WTP) ceiling for a unit health gain is an unknown quantity. Instead of relying on a single WTP ceiling, a series of ceilings was used to calculate the probability that the intervention was more acceptable than care-as-usual from a cost-effectiveness point of view for each of the WTP ceilings. This was presented as an ICER acceptability curve [33, 34], where increasing WTP ceilings were placed on the horizontal axis, while the probability of finding the intervention acceptable from a cost-effectiveness point of view was placed on the vertical axis.
All analyses were conducted in Stata [35] and Excel Professional 2003. Three analysts independently performed the analyses to cross-check results (see Authors' Contributions).
Sensitivity analysis
The single most important cost-driver was therapists' time. It was also a cost-driver that can be brought under some amount of control, for example by relying more on (computer-aided) self-help, reducing the number of sessions, or increasing the number of participants. By way of sensitivity analyses all previous analyses were repeated under different time-investment scenarios. In the actual situation 2 therapists participated in all sessions during the full two-hour session. This is an intensive form of therapist guidance and we refer to the costs in this situation as 'high'. In an alternative hypothetical scenario a single therapist conducts the sessions, thus avoiding the costs of the co-therapist. We refer to this scenario as 'medium'. Finally, one therapist could spend one hour with the group of participants (not the full two-hours per session), which would further cut down therapist time. This scenario we call 'low'. The analyses were repeated for the three scenarios under the assumption that the effectiveness of the intervention would be reduced when therapist time was reduced. We will return to this issue later.
Characteristics of the sample
At baseline, no differences were found between the treatment (n = 58) and care-as-usual (n = 59) conditions with regard to gender (71% female), age (mean 43.16 years, s.d. = 13.05), years of education (mean 13.72, s.d. = 3.09), partner status (75% living with a partner) and employment status (66% had a job). The mean PDSS-SR panic and agoraphobic symptom severity level in the experimental group was 6.26 (s.d. = 4.00); in the control group this was 6.01 (s.d. = 3.76), which was not statistically different (mean difference = 0.25, s.e = 0.72, t = 0.34, P = 0.732). It was also checked whether randomisation had resulted in a balanced distribution of co-morbid depression, agoraphobia and social phobia across the treatment conditions, and that this was indeed the case (χ2 (1) = 0.000, P = 1.00; χ2 (1) = 0.031, P = 0.86; χ2 (1) = 0.006, P = 0.94, respectively). Finally, age of onset of panic disorder symptoms was also evenly distributed across the conditions (mean age of 30.6 and 31.3 years in the control and treatment conditions respectively; t = 0.34; P = 0.738).
Adherence to the intervention
After each session the therapists registered the attendance of the participants and ascertained whether they had done their homework. On the basis of this information, 2 (3%) of the 59 subjects randomized to the experimental group did not start the course. Reasons for not starting the course were either starting another course or lack of time because of work. Forty-six (78%) subjects of the experimental group completed the course (completing the course is defined as attending at least 6 sessions). The main reasons for not completing the course were of a practical nature (e.g., work, illness). The mean number of attended sessions was 6.4 sessions. Of the attending participants, 77% had completed their homework for each session, 21% did not complete their homework for 1 session, and 2% for 4 sessions.
Concurrent medication use
There was no significant difference in the use of medication between the groups at baseline. In the experimental group 16 (27%) participants used medication at baseline, 1 (2%) started medication during the course and 3 (5%) stopped using medication. In the control group 28 (48%) participants used medication at baseline, 2 (3%) started and 2 (3%) stopped medication in the period between baseline and T1. Therefore, it is unlikely that the present findings can be explained by changes in medication use.
Incremental effectiveness
After the intervention, at t1, the intervention group had 51 people not meeting the DSM-IV/MINI criteria for PD. The probability of PD-free survival over three months was therefore 51/59 = 0.86. In the care-as-usual group the probability of PD-free survival was 0.74 (43/58). The incremental effectiveness was calculated as the difference between the probabilities of a beneficial outcome in each of the conditions, i.e. 0.86-0.74 = 0.12. The incremental effectiveness has been defined as the clinical parameter of interest in the remainder of this study. Its inverse equalled the number needed to be treated, NNT, as 1/0.12 = 8.3, indicating that somewhat more than 8 people with sub-clinical symptom levels have to become recipients of the intervention (rather then care-as-usual) to generate a health gain of one additional PD-free survival over three months in one of them.
Incremental costs
Table 2 gives an overview of the monthly per capita costs (means, s.d.) in each of the conditions at t0 and t1. The base-line costs are presented in the column labelled t0. As can be seen, the total costs in the care-as-usual group (mean €346) are higher than in the treatment group (mean €222). This indicates that randomisation failed to produce evenly distributed costs across the conditions at t0. Closer inspection reveals that this difference is caused by the higher costs associated with production losses in the care-as-usual group. In the light of the difference between the conditions at baseline, we decided to calculate the pre-post differences in the costs in each of the conditions, because it would be wrong to solely focus on the costs at t1 and to ignore the 'false start' at t0. The pre-post difference of the total costs in the treatment group is €222 – €255 = -€33. Likewise the pre-post difference in the care-as-usual group is €346 – €426 = -€80. Finally, the incremental costs are calculated as the difference between the conditions, hence €80 – €33 = €47, indicating that the intervention is associated with somewhat higher monthly per capita costs than care-as-usual, but this difference is hardly appreciable from an economic point of view.
It is worth noting that the costs in the treatment condition were further reduced at the extended six month follow-up (t2). These costs were €222 at t0, became €255 at t1, and then became €197 (s.d. = 351) at t2.
So far we have ignored the intervention costs. These are €750 per recipient. These costs dominate the incremental costs of €47 at t1. Therefore, the intervention costs must be seen as the single most important cost driver. When the intervention costs are included in the above calculations then the incremental costs at t1 are €797, €422 and €237 for each of the (hypothetical) intensity levels.
Incremental cost-effectiveness
Substitution of the incremental costs (€797) and the incremental effects (0.12) in the formula for the incremental costs effectiveness ratio,
indicates that the corresponding mean ICER is €6,642 per three months PD-free survival time for the factual condition. The arrhythmic mean may not provide the best estimate for the ICER. Therefore we also present the median ICER, which is based on the bootstrap distribution of 2,500 simulated ICERs. The median ICER is €6,198, which has a 95% confidence interval of 2,435 – 60,731, indicating a large amount of stochastic uncertainty.
Sensitivity analysis
The above analyses were repeated for the hypothetical scenarios where therapist time is reduced. Reducing therapist time is associated with lower incremental costs of €797, €422 and €237, respectively for the high, medium and low intensity levels. The literature shows that reducing therapist time in delivering cognitive-behavioural therapy (CBT) for panic disorder has only a limited impact on effectiveness. To illustrate, Kenardy and colleagues [12] found that 12 sessions of CBT were only somewhat more effective than 6 sessions. Moreover, they found that 6 sessions of CBT augmented with computer-aided CBT was almost as good as 12 CBT sessions under the guidance of a therapist. This appears an interesting option for reducing therapist's time, while not sacrificing too much by way of the intervention's efficacy. Nevertheless, we prefer to make conservative assumptions and assume that the observed incremental effect of 0.12 will be reduced to 0.09 and 0.06 when therapist involvement is reduced. This results in mean ICERs of €6,642, €4,689 and €3,950 per three months PD-free survival time for the factual condition and the two hypothetical scenarios. Table 3 presents the median ICERs and their confidence intervals. The upper limit of the scenario where a single therapist is only involved in one hour per session could not be calculated, and was replaced by an infinity sign.
Uncertainty and acceptability
A way to obtain an understanding of the uncertainty is given in Figure 2. This figure presents a scatter of 2,500 simulated bootstrap ICERs on the cost-effectiveness plane for each of the intensity levels (left-hand panel). The axes divide the cost-effectiveness plane into four quadrants. The vast majority (>87%) of the simulated ICERs fall into the north-east quadrant for each of the three intensity levels, indicating that better health is produced at additional costs by the intervention relative to the comparator condition. This is true for all three scenarios. It is also shown that the scatter shifts to the south when we move from the high to the low intensity level of therapist involvement. This indicates that the intervention gets progressively less costly in producing health gains when therapists' time is reduced. At the same time it is shown that the scatters move slightly to the west, indicating that effectiveness also diminishes when intensity levels are reduced.
The degree of uncertainty precludes statistically significant findings, but one way to tackle this problem is to adopt a probabilistic approach. That is, to present an ICER acceptability curve, which gives the probability (in %) that the treatment is more acceptable from a cost-effectiveness point of view than its alternative, given various ceilings for the willingness to pay (WTP) for a PD-free survival of three months. To illustrate, when the WTP ceiling for a PD-free period is €10,000, then the intervention has a probability of 75.2% of being more acceptable than care-as-usual under factual conditions characterised by high levels of therapist involvement. For the hypothetical medium and low levels of therapist involvement, this probability changes to 82.4% and 75.4%, respectively.
As can be seen, under the WTP ceiling of €10,000 the acceptability depends greatly on the willingness to pay: the curve is steep at the lower end of WTP ceilings, but beyond € 10,000 it becomes flat and is then fairly insensitive to WTP levels. This indicates that a decision-maker's choice at WTP € 10,000 and over is not surrounded by much uncertainty, even when the ICERs have broad confidence intervals. Below the €10,000 threshold the conclusion about the relative cost-effectiveness of the intervention depends on the precise WTP ceiling. It also depends on the intensity level of therapist involvement.
This study was conducted to assess the potential of a time-limited cognitive behavioural intervention for preventing onsets in panic disorder in a cost-effective way. From a larger trial the group at risk of becoming PD cases (n = 117) was selected. Of these 59 participated in the Don't Panic course, while 58 participants were randomised to a waiting list with unrestricted access to care-as-usual. The cost-effectiveness analysis was conducted from the societal perspective, thus including the direct medical, direct non-medical and indirect costs. The central clinical outcome was MINI/DSM-IV panic disorder (PD) free survival time over three months. Therapists' involvement was the single most important cost driver, and three intensity levels (high, medium and low) were evaluated, with the high level corresponding to the factual situation, and the medium and low levels being presented as hypothetical scenarios.
Main findings
The data suggest that the Don't Panic course is more successful in preventing new onsets of DSM-IV panic disorder in people with sub-clinical symptoms than a waitlist control condition with unrestricted access to care-as-usual. The success rates are 86% in the treatment condition versus 74% in the care-as-usual condition, yielding a difference of 12% in favour of the intervention.
Not only is the incidence of a disabling disorder reduced, but this is achieved on average for €6,642 (median €6,198) per PD-free survival over three months. It can be concluded that there is a probability larger than 75% that the intervention is more acceptable from a cost-effectiveness point of view than care-as-usual when the willingness to pay (WTP) for a PD-free survival time of three months has a ceiling of €10,000. Beyond that ceiling, the likelihood that the intervention must be regarded as acceptable from the health economic point of view remains high and is not surrounded by doubt. However, below the WTP ceiling of €10,000 the acceptability of the intervention depends crucially on the WTP and is also sensitive to the level of therapist involvement. In fact, sensitivity analyses showed that the amount of therapist involvement in the intervention is an important cost driver. It is also a parameter that is under (partial) control of the management of mental health service offering the intervention. The cost-effectiveness of the intervention is much improved when therapist involvement is reduced by a factor 2 and 4. The median ICERs then become €3,792 and €2,511, even when taking into account that reduced therapist involvement may be associated with lesser efficacy of the intervention.
The findings of this study have to be placed in the context of its limitations.
First, the study was part of a larger trial and was not powered to detect statistically significant differences in outcomes and costs. Therefore we refrained from hypothesis testing. Instead, we took a probabilistic appraoch indicating the likelihood (in %) that the intervention is superior to care-as-usual from a health economic point of view.
Second, the time horizon of the trial was limited to only three months. This period is too short to draw convincing conclusions about preventing a disorder with an often chronic and recurrent course. Moreover, the MINI/DSM-IV PD status at t1 refers to the last month, but we interpreted it as an indicator of PD-free survival over the last three months. Hence, we may have missed an episode of PD between t0 and t1. However, it is worth mentioning that the extended follow-up in the treatment arm of the trial showed that effects are maintained for at least six months over a range of clinical outcomes (data not shown). This strengthens the impression that effects induced by the intervention persist over time, making it less likely that some people who were PD free at t1 had experienced PD between t0 and t1.
Third, the baseline costs were somewhat higher in the control group as compared with the intervention group. This difference of €124 was not significant (s.e. = 77.87; t = -1.59; P = 0.131). Nevertheless, we took care of this baseline difference in our analysis by subtracting the baseline difference from the costs at follow-up.
Fourth, in a sensitivity analysis the actual situation was compared with two hypothetical scenarios. This indicated how reducing therapist involvement would help to lower the costs of the intervention and thus improve its cost-effectiveness. Reducing therapist time could be achieved, for example, by delegating certain tasks from the therapist to a computer and offerering adjunctive computer-aided CBT for panic disorder [12, 13]. However, in these scenarios we had to make assumptions of how less therapist involvement would impact on efficacy. To this end we reduced the incremental effectiveness from the observed 0.12 to hypothetical values 0.09 and 0.06, but these values are somewhat arbitrary, and the trade-offs between costs and effects may have been different from what was modelled. It is worth mentioning, however, that we made a conscious decision to make conservative assumptions about the effect of lesser therapist time on the treatment response – such that the null-hypothesis of no effect was strengthened.
In light of these limitations our findings should be interpreted with some caution.
This is the first economic evaluation of a preventive intervention in panic disorder. The outcomes are encouraging, but are based on a small trial with a short follow-up. Therefore, our principal conclusion is that our findings must await replication in a larger trial with a longer follow-up before confident recommendations can be made with regard to the broader implementation of the intervention. It is our recommendation that such a trial should be conducted in the near future. After all, panic disorder is a crippling condition associated with reduced quality of life and has formidable economic ramifications for patients, the health care system, and society as a whole. To curb the massive annual influx of new cases of panic disorder, to maintain the quality of life in many, and perhaps to avoid some of the costs associated with the full-blown disorder we need a cost-effective preventive intervention for panic disorder. Our data suggest that the Don't Panic course is likely to be one such candidate, especially when the intervention is offered by one qualified therapist. Still, a larger replication study is needed to further test this proposition. Under the current conditions, the Don't Panic course is perhaps best offered as an economically affordable first step in a stepped-care approach for PD, thus allowing people to step up to more intensive forms of treatment, should that be required.
Cognitive-behavioural therapy
Diagnostic and Statistical Manual, Fourth edition
Incremental cost-effectiveness ratio
Mini International Neuropsychiatric Interview
Organisation for Economic Co-operation and Development
Panic Disorder Severity Scale (self-report)
Purchasing power parities
Willingness to pay.
- 1.
Bijl RV, De Graaf R, Ravelli A, Smit F, Vollebergh WAM: Gender and age-specific first incidence of DSM-III-R psychiatric disorders in the general population: results from the Netherlands Mental Health Survey and Incidence Study (Nemesis). Soc Psychiatry Psychiatr Epidemiol 2002, 37: 372–379. 10.1007/s00127-002-0566-3
- 2.
Bijl RV, Ravelli A, Van Zessen G: Prevalence of psychiatric disorder in the general population: results of the Netherlands Mental Health Survey and Incidence Study (Nemesis). Soc Psychiatry Psychiatr Epidemiol 1998, 33: 587–595. 10.1007/s001270050098
- 3.
Smit F, Comijs HC, Schoevers R, Cuijpers P, Deeg D, Beekman A: Target groups for the prevention of late-life anxiety. Brit J Psychiat 2007, 190: 428–434. 10.1192/bjp.bp.106.023127
- 4.
Cuijpers P, Van Straten A, Smit F: Preventing the incidence of new cases of mental disorders: a meta-analytic review. J Nerv Ment Dis 2005, 193: 119–125. 10.1097/01.nmd.0000152810.76190.a6
- 5.
Smit F, Cuijpers P, Oostenbrink J, Batelaan N, De Graaf R, Beekman A: Costs of common mental disorders: implications for curative and preventive psychiatry. J Ment Health Policy and Economics 2006, 9: 193–200.
- 6.
Batelaan N, Smit F, Van Balkom T, De Graaf R, Vollebergh W, Beekman A: Societal costs of panic disorder and subthreshold panic disorder. J Affect Disorders 2007, 104: 127–136. 10.1016/j.jad.2007.03.013
- 7.
Greenberg PE, Sisitsky T, Kessler RC, Finkelstein SN, Berndt ER, Davidson JRT, Ballenger JC, Fyer AJ: The economic burden of anxiety disorders in the 1990s. J Clin Psychiatry 1999, 60: 427–435.
- 8.
Marciniak M, Lage MJ, Landbloom RP, Dunayevich E, Bowman L: Medical and productivity costs of anxiety disorders: case control study. Depress Anxiety 2004, 19: 112–120. 10.1002/da.10131
- 9.
Andrews G, Issakidis C, Sanderson K, Corry J, Lapsley H: Utilising survey data to inform public policy: comparison of the cost-effectiveness of treatment of ten mental disorders. Brit J Psychiat 2004, 184: 526–533. 10.1192/bjp.184.6.526
- 10.
Salvador-Carulla L, Seguí J, Fernández-Cano P, Canet J: Costs and offset effect in panic disorders. Br J Psychiatry Suppl 1995, (27):23–28.
- 11.
Bower P, Richards D, Lovell K: The clinical and cost-effectiveness of self-help treatments for anxiety and depressive disorders in primary care: a systematic review. Br J Gen Pract 2001,51(471):838–845.
- 12.
Kenardy JA, Dow MGT, Johnston DW, Newman MG, Thomson A, Taylor CB: A comparison of delivery methods of cognitive-behavioural therapy for panic disorder: an international multicentre trial. J Consult Clin Psychol 2003, 71: 1068–1075. 10.1037/0022-006X.71.6.1068
- 13.
Carlbring P, Bohman S, Brunt S, Buhrman M, Westling BE, Ekselius L, Andersson G: Remote treatment of panic disorder: a randomised trial of internet-based cognitive behaviour therapy supplemented with telephone calls. Am J Psychiatry 2006, 163: 2119–2125. 10.1176/appi.ajp.163.12.2119
- 14.
Meulenbeek P, Willemse G, Smit F, Van Balkom A, Spinhoven P, Cuijpers P: Early intervention in panic: randomized controlled trial and cost-effectiveness analysis. Trials 2008, 9: 67. 10.1186/1745-6215-9-67
- 15.
Houck PR, Spiegel DA, Shear MK, Rucci P: Reliability of the self-report version of the PDSS-SR. Depression and Anxiety 2002, 15: 183–185. 10.1002/da.10049
- 16.
Sheehan DV, Lecrubier Y, Sheehan KH, Amorim P, Janavs J, Weiler E, Hergueta T, Baker R, Dunbar GC: The Mini-International Neuropsychiatric Interview (M.I.N.I.): the development and validation of a structured diagnostic psychiatric interview for DSM-IV and ICD-10. Journal of Clinical Psychiatry 1998, 59: 22–33.
- 17.
American Psychiatric Association: Diagnostic and Statistical Manual of Mental Disorders. 4th edition. Washington, DC, APA; 1994.
- 18.
Meulenbeek P, Herzmanatus J, Smit F, Willemse G, Zanden R: Draaiboek Geen Paniek, leren omgaan met paniekklachten [Don't Panic: intervention protocol]. Utrecht: Trimbos-instituut/GGNet; 2005.
- 19.
Heuzenroeder L, Donnelly M, Haby MM, Mihalopoulos C, Rossell R, Carter R, Andrews G, Vos T: Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder. Australian and New Zealand Journal of Psychiatry 2004, 38: 602–612. 10.1111/j.1440-1614.2004.01423.x
- 20.
Myhr G, Payne K: Cost-effectiveness of cognitive-behavioural therapy for mental disorders: implications for public health care funding policy in Canada. Can J Psychiatry 2006, 51: 662–670.
- 21.
Meulenbeek P, Herzmanatus J, Smit F, Willemse G, Zanden R: Cursusmap Geen Paniek, leren omgaan met paniekklachten [Don't Panic: course book]. Utrecht: Trimbos-instituut/GGNet; 2005.
- 22.
Meulenbeek P, Willemse G, Smit F, Smits N, Van Balkom A, Spinhoven P, Cuijpers P: Effects and feasibility of a preventive intervention in sub-threshold and mild panic disorder: results of a pilot study. BMC Research Notes 2009, 2: 4. 10.1186/1756-0500-2-4
- 23.
Hakkaart – Van Roijen L, Van Straten A, Donker M, Tiemens B: Manual Trimbos/iMTA questionnaire for costs associated with psychiatric illness (TIC-P, in Dutch). Rotterdam: Erasmus University; 2002.
- 24.
Kessler RC, Frank R: The impact of psychiatric disorders on work loss days. Psychol Med 1997, 17: 861–873. 10.1017/S0033291797004807
- 25.
Lim D, Sanderson K, Andrews G: Lost productivity among full-time workers with mental disorders. J Ment Health Policy Economics 2000, 3: 139–146. 10.1002/mhp.93
- 26.
Brower WB, Koopmanschap MA, Rutten FF: Productivity losses without absence: measurement validation and empirical evidence. Health Policy 1999, 48: 13–27. 10.1016/S0168-8510(99)00028-7
- 27.
Oostenbrink JB, Bouwmans CA, Koopmanschap MA, Rutten FF: Manual for Costing: Methods and standard costs for economic evaluations in health care (in Dutch). Diemen: Health Insurance Board; 2004.
- 28.
Everitt BS: Modern medical statistics: a practical guide. New York: Oxford University Press; 2003.
- 29.
Demirtas H: Simulation driven inferences for multiply imputed longitudinal datasets. Statistica Neerlandica 2004, 58: 466–482. 10.1111/j.1467-9574.2004.00271.x
- 30.
Langley PC: The November 1995 revised Australian Guidelines for the economic evaluation of pharmaceuticals. Pharmacoeconomics 1996, 9: 341–352. 10.2165/00019053-199609040-00007
- 31.
Siegel JE, Torrance GW, Russel LB, Luce BR, Weinstein MC, Gold MR: Guidelines for pharmacoeconomic studies: recommendations from the panel on cost effectiveness in health and medicine. Pharmacoeconomics 1997, 11: 159–168. 10.2165/00019053-199711020-00005
- 32.
Torrance GW, Blaker D, Destky A, Kennedy W, Schubert F, Menon D, Tugwell P, Konchak R, Hubbard E, Firestone T: Canadian guidelines for economic evaluation of pharmaceuticals. Pharmaeconomics 1996, 9: 535–559. 10.2165/00019053-199609060-00008
- 33.
Van Hout BA, Al M, Gordon GS, Rutten FF: Costs, effects and C/E-ratios alongside a clinical trial. Health Economics 1994, 3: 309–319. 10.1002/hec.4730030505
- 34.
Barrett B, Byford S: Acceptable mental health care? A new decision-making tool for cost-effectiveness analysis. Mental Health Research Review 2003, 9: 39–41.
- 35.
StataCorp: Stata Statistical Software, release 8.2. College Station, Texas: StataPress; 2004.
We acknowledge, with many thanks, the participants in the trial, both trainers and trainees for making this study possible. Special thanks are due to Jessica Herzmanatus (GGNet) and Rianne van der Zande (Trimbos Institute) for their help with the development of the Don't Panic intervention. The Don't Panic intervention was developed with the financial support of a foundation of health insurance companies (Nuts-OHRA, Amsterdam; grant # SNO-T-04-30) awarded to the first author. The study was made possible by a research grant from the Netherlands Health Research Council (ZonMw, The Hague; grant # 50-50110-98-035) awarded to the first author.
Additional information
Competing interests
The authors declare that they have no competing interests.
Authors' contributions
FS designed the study, conducted the analysis and wrote the manuscript. GW was principal investigator, was involved in pre-testing the intervention, was responsible for running the trial, and cross-checked the analysis of the clinical outcomes. PM designed the intervention, was involved in pre-testing it, assisted in collecting the data, and cross-checked the analysis of the economic data. MK acted as HTA advisor. PS, AvB and PC acted as a Quality Assurance Committee for this trial. All were involved in the interpretation of the data and agree with the contents of the manuscript.
Filip Smit, Godelief Willemse, Peter Meulenbeek contributed equally to this work.
Authors' original submitted files for images
Below are the links to the authors' original submitted files for images.
Rights and permissions
This article is published under license to BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.
About this article
Cite this article
Smit, F., Willemse, G., Meulenbeek, P. et al. Preventing panic disorder: cost-effectiveness analysis alongside a pragmatic randomised trial. Cost Eff Resour Alloc 7, 8 (2009). https://doi.org/10.1186/1478-7547-7-8
- Panic Disorder
- Panic Disorder
- Incremental Effectiveness
- Therapist Involvement
- Panic Disorder Severity Scale


text:
- Credits
- Hair: Éric Maurice
Makeup: Laurie Hadji
Photo: Pascal Latil
- Products: Wella Professionals
top news
Enjoy Life by Eric MauriceTuesday, 10 January 2017 10:59
Come, delight in and appreciate the universe of Eric Maurice: modern, sensual, soft... yet strong and original. There's many styles to illustrate the new season's look: pure and graphic lines, structured haircuts, glamorous styles… Blond or brunette, never mind, the important thing is to enjoy!
Published in Collections


text:
Obviously, I don't need to brag about the importance of Dhabas (Roadside Eating Joints) stationed on almost all highways in India. Whether it is about feeding our gurgling stomachs or reflecting the authentic taste of any region or the hospitality with which the food is served, these roadside eateries certainly know the way to win one's heart. It is amazing to see how some of these Dhabas, which were once merely stopovers for travellers, have become destinations unto themselves. It can be safely said that Dhabas are serious business. Ok, enough of talking! Let me also get back to my business and present to you a list of Dhabas that you must stop by if you are travelling on Indian highways:
Stop by this lone Dhaba situated 50kms from Leh on the Srinagar-Leh Highway. With nothing more than a roughly maintained concrete shack, this place is still a paradise for travellers. You will see many foreign travellers basking and having black tea here. However, as an Indian you will love to savour the freshly prepared aaloo parantha and gobhi ki sabzi along with a refreshing cup of tea.
More of a restaurant and less of a Dhaba… call it by any name; Giani is certainly a great food haunt in Dharampur, situated on Shimla-Kalka Road NH 22. A well maintain eatery with nice ambiance and great food, Giani is nothing short of treat on the way to awe-inspiring Shimla!
You just cannot ignore this classy place situated on GT Road, Murthal NH 1. Once a small shack catering to the appetite of truck drivers who ply on these roads, Sukhdev Dhaba or the Amrik Sukhdev Dhaba is now a serious affair. A tall, well-maintained AC building is what stands instead of the thatched-hay shack, serving sumptuous Indian as well as Chinese cuisine to the starving travellers who make sure to stop nowhere else but here. Amritsari Kulcha and aloo paratha with tongue slurping white butter is the delight of Sukhdev… The taste and the feel are just unforgettable!
No, I am not disoriented on my topic of this blog but when it comes to highway and food, you ought to include Karnal Haveli in the list. I would call it a 'Dhaba Redefined', Karnal Haveli has every reason to make it to the list of popular highway Dhabas that you must stop by. Situated on the GT Road, Karnal NH 1, this place serves authentic Punjabi cuisine. The rustic influence on the exterior and interior décor of the restaurant adds to the fame of the place and an amusement park for kids is yet another asset here.
You are going to love this place! Situated on the Zirakpur–Patiala Road, NH 21, Grand Lassi Shop offers some lipsmacking Lassi and heavenly Aaloo Parantha topped with semi-melting butter, chana (Chick peas) and homemade yogurt. This place is 25kms away from Chandigarh and is quiet easy to find!
Get ready for some Punjabi Treat at Puran Singh Da Dhaba. Located on NH 1, somewhere near Ambala City, this place is an absolute delight. Don't think about the ambiance once you are here or else you will miss out on a great place to eat in Punjab! Try Keema Kaleji, Kabab, Chicken Curry and Mutton curry with 'Kadak' Tandoori Roti or you can even try the sumptuous Kadhi Chawal that attracts many vegetarians here.
It may be a restaurant, but Cheetal Grand on the Delhi-Dehradun Highway is one place that you must visit if you are on the highway. From the traditional dal, sabzi, roti, chawal to grilled sandwiches and cold coffee with ice cream, you name it and you get it! A neat restaurant with nice ambiance and surroundings, Cheetal, situated at as short distance from Khatauli, Muzzafarnagar can be a great food haunt. Try the tubular omellette and also the paneer pakodas here.
This is one of the most picturesque Dhaba that I have seen. Neat and clean area with a thatched-hay shacks and delectable food, if you are by any chance travelling on NH 24 and you are anywhere near Gajraula, then you have to visit this place. This highway Dhaba offers great food at reasonable prices; try paneer butter masala, kadhi pakora along with garlic lachchha here and believe me you shall never forget the taste!
Sharma Dhaba brings you Rajasthan on a platter! Situated on Jaipur-Sikar Road, Sharma Dhaba is one of its kinds. They serve authentic veg Rajasthani delicacy and their Mawa Naan is to die for! There are two dining areas that you can choose from, one is just off the road and other is in the backside and is known as Sharma Garden. Try Paneer Butter Masala, Malai Matar, Missi Roti and Dal Tadka here.
You are about to get fed with some of the best Dhaba food ever! At Rao's Dhaba, you are likely to lick your fingers after finishing your delectable meal. Situated on National Highway 8 on Delhi-Jaipur Road, this Dhaba is known for its yummilicious veg Indian cuisine; one thing you must try here is paneer butter masala with tandoori naan.
This eatery is near the bypass that connects the new expressway in Gujarat; well technically it is still on NH 8 in Anand district. However, you don't need a reason to visit this incredible place! Serving you the right taste of Kathiyawad (precisely beckons SPICE AND CHILLI, unlike Gujarati cuisine). The food here is prepared over wood fire, thus expect rustic flavour in everything that you eat. You must try lassan aaloo, besan gatta and sev tamatar with rotla (local bread) here.
Go vegan at Ramdev Dhaba and enjoy some of the most delectable Rajasthani food. Situated on the Mumbai-Pune Highway at Nigdi, this place is great to fill your stomach right! Must-try items here are Dal Baati and Rabdi.
If you are travelling from Pune to Lonavala through Old Mumbai-Pune Highway, then you ought to pay Sunny Da Dhaba a visit. The tin-shed Dhaba with long decorated tables and some out of the box food will leave you awestruck. You are going to love Rajoli Kabab, Tandoori Pomfret, Dal Bati and Jalebi here.
With a patriotic banner, Jai Hind Deluxe Dhaba is your savior if you are on National Highway 4, somewhere around Kaneriwadi. The Dhaba has good seating arrangements and it offers authentic taste of local food. You can halt here and relax while munching on some tasty food.
The rainbow DO inside the Dhaba is fantastic and the food is just the kind you need on a highway. Shree Sai Ashirwad Dhaba is situated on National Highway 7 near Muskura, Madhya Pradesh. The Dhaba offers delicious local food and a must try here would be Dal Bafla.
Sher-e-Punjab is situated on the National Highway between Kolkata and Digha and is known for hoisting the Punjabi flag high in West Bengal. It is one of those well-maintained highway restaurants-cum-Dhabas that serve some really lip smacking food. You would like to try the mixed platter and chicken tikka masala here.
24hrs food service in Kolkata and yummilicious food is what keeps Azad Hind Dhaba a personal favourite of travellers. The Dhaba is situated on National Highway 1, Kolkata and offers authentic Punjabi cuisine. There are two sections, one AC and the other Non AC, so you can decide where you want to sit, although the service in both the sections is outstanding. Order Chicken Tikka Masala and Dal Makhani here.
You will certainly fall for this place – its extensive menu, location and design. Situated on the road to Tezpur (37A highway connector) between Bhomoraguri and Sonitpur, it is a great place to relish the taste of authentic Assamese cuisine. The Pigeon curry is the highlight of the place, although you can try Aaloo pitika in case you are a vegetarian.
You have every reason to like this place, delicious seafood, neat and clean ambiance and great surroundings. Bask on the manji and savour the taste of Odisha; you may not want to miss out on Chilli Prawns and Giant Crabs here. Also, the Dhaba serves some great vegetarian items that you may like to munch upon. Situated on NH 5 in Barkul, this Dhaba is at a short distance from the famous Chilika Lake, so after filling your stomach you can head to capture the beauty of the same.
A one of its kind highway Dhaba that you would come across on National Highway 4, Satara Dhaba is probably the only Dhaba in India that is run by transgenders AND there is no way that you can miss out on visiting this place! Unmatched hospitality, Kadak Chai and Capsicum Masala are the highlight of this amazing highway eatery. Well, here you go! You actually got Highway on Your Platter! Next time when you are whizzing you wheels through the meandering highways, do not forget to grab a quick meal at one of these roadside galleys. Happy Journey!!


text:
The narwhal looks like something out of mythology. Males have a long, spiral tusk that's earned them the nickname "the unicorn of the sea." The narwhal sounds a bit fictional, too -- a bit like a droid from Star Wars.
Researchers recorded the sounds of the East Greenland narwhal. It's found in a fjord on the central eastern coast of Greenland.
The project was designed to reveal details about the lives of these elusive creatures. In addition, more ice-free conditions in the years ahead are expected to bring more boat traffic and oil exploration. That'll increase the underwater noise, perhaps altering the narwhal's behavior. The study will help biologists assess those changes.
From 2013 to 2016, researchers attached tracking devices equipped with recorders to one male and five females. The trackers stayed in place for a few days, then floated to the surface. The scientists recovered the devices and analyzed the recordings, which were the longest ever made of narwhals.
The whales use echolocation to find and track prey. They emit a series of clicks to find the prey, then a "buzz" when they close in for the kill. The animals in the study typically hunted at depths of about 1,000 to 2,000 feet, although they sometimes went up to a mile deep.
Near the surface, where they spent more than half their time, they "called" other narwhals -- staying in touch with other unicorns of the sea.


text:
The Sentinel Slash Movies Project
This is a site
generously hosted by a FREE web provider.
Hotlinking (direct linking) means abuse of the bandwidth that we are offered.
Please help us keep the website online & problem free.
Graphics Lite Site
Awards &
Title Graphic by Helyn Highwater © 2005
Photo Manips & Background Graphic by Peter © 2005
Intro Movie by Max D. © 2005
Sign my Guestbook View my Guestbook
Problems with the site? Please click the button below to notify the WEBMASTER.
This is an independent fan site, in no way affiliated with or
endorsed by the
legal owners and/or copyright holders of featured fictional universes & characters.
No infringement whatsoever is intended. All website contents are intellectual
property of their respectively credited authors.


text:
Sinking Millennium Tower can survive big earthquake, report finds
The dramatic sinking of San Francisco's Millennium Tower has not compromised the building's ability to withstand a strong earthquake, according to a report released Tuesday by an engineer for the high-rise's developer.
The report, which analyzes settlement data through June, says the foundation mat of the 58-story condominium tower at 301 Mission St. has experienced "minor yielding in a few locations, but not to an extent that compromises its ability to safely support the building."
"We determined that the effect of settlement on the building elements is negligible," said the report, which was prepared by structural engineer Ron Hamburger of the firm Simpson Gumpertz and Heger.
The developer, Millennium Partners, has blamed the sinking on construction at the neighboring Transbay Transit Center, where hundreds of millions of gallons of water have been pumped out of the ground. Millennium Partners says the "dewatering" has compressed and weakened the soil under the building, prompting it to sink deeper into the bay mud.
The Transbay Joint Powers Authority, which is building the transit center, says the Millennium Tower is settling more than expected because it was built atop piles that were driven 60 to 90 feet into bay clay, rather than the 220 feet that would have been necessary to reach bedrock.
Hamburger's investigation used sophisticated computer modeling to determine whether the skyscraper is likely to suffer heavy damage during a quake. It concluded that "most" of the building's elements, despite the lopsided settlement, would meet the standards of similar high-rises popping up around the city.
Hamburger said the building's "structural elements do not experience appreciable stress as a result of these settlements. This includes bearing walls around the building core, which provide most of the building's resistance to earthquake loads, as well as the floor slabs, most columns and beams."
The report did highlight cracking in several parts of the building, including a basement shear wall in the north stairwell, the northwest corner of the basement, and the northwest corner of the elevator pit. It said the tower's pile cap — a 10-foot-thick slab of concrete that sits above the tower's 900 piles — is "highly stressed in several areas."
"None of the settlement-related demands on these elements are at levels that indicate impending failure," the report said.
The report's release comes as Millennium Tower Homeowners Association enters week two of its own investigation into the luxury tower, which has settled 16 inches since 2007 and is leaning 2 inches to the northwest. The homeowners association's geotechnical engineers are digging three holes down to bedrock and will investigate groundwater levels, soil conditions and settlement rates.
In a statement, the homeowners association said Hamburger's report "clearly states that the building is safe for occupancy, and that settlement conditions have not compromised the building's ability to withstand a major earthquake."
But not all Millennium condo dwellers were comforted by the report. One, Jerry Dodson, said the report raised as many questions as it answered.
"It's a report that in a way is welcome because it has a level of rigor that no other report has had to date," he said. "But it really does require a lot of peer review to test these assumptions."
Dodson, an attorney and engineer, has sued Millennium Partners, claiming the developer engaged in fraud by not disclosing the building's sinking when he bought his 42nd-floor unit in 2012. More than a dozen other Millennium condo owners have joined the lawsuit.
Parts of the new report are at odds with a draft version that Hamburger wrote in 2014, which found that "some limited elements" of the tower were under "significant stresses" as a result of the settlement and were "more susceptible to damage from an earthquake."
The new report included a supplemental analysis to determine the effect of additional settlement as well as a "nonlinear analysis" of the building's ductility, or the "ability of a structure to withstand excessive loading without failure."
"We are not trying to spin the report one way or another," said Millennium Partners spokesman P.J. Johnston. "The investigation led to the conclusions that are encapsulated in the report."
The Millennium Partners spokesman did use the release of the report — along with another report on the effect of the Transbay Transit Center dewatering program on the tower — as a chance to take a shot at the Transbay Joint Powers Authority, which has said it would continue to dewater into 2017.
The agency's "years of dewatering, which it continues to this day, have drastically dropped the water table beneath 301 Mission St. and has caused excessive settlement," Johnston said.
The Transbay Joint Powers Authority called the charges "a distraction from the exclusive cause of the tilt to the west/northwest and the excessive vertical settlement of the tower: the tower's inadequate foundation."
The agency said that the fact that the tower sank 8.3 inches before construction began on the transit center proves that the problem is the foundation, not the water pumping.
Also on Tuesday, a Department of Building Inspection advisory panel discussed beefing up the level of geotechnical review that high-rise developments will face. The agency has been criticized for not looking more closely at the Millennium's foundation plans when the project was being reviewed more than a decade ago.
"Right now no building in San Francisco undergoes a focused geotechnical review," said Stephen Harris, a structural engineer and chairman of the advisory panel.
J.K. Dineen is a San Francisco Chronicle staff writer. Email: firstname.lastname@example.com
Twitter: @sfjkdineen