Survey of roles of community psychiatric nurses and occupational therapists

The roles of community mental health professionals may overlap and need clarifying. A survey is described of 95 occupational therapists (OT) and 200 community psychiatric nurses (CPN), of their views on their respective roles, and information on current practices. Administering medication and crisis intervention were regarded as specifically CPN roles, yet 26% of CPNs did not regularly administer medication. Half of the CPNs' clients were not chronically mentally ill, and over two-thirds of the nurses regularly carried out counselling and anxiety management. Assessing activities of daily living and work skills were seen specifically as OT tasks, yet 60% of the OTs did not usually assess work skills in practice. Roles overlapped considerably, suggesting that a more efficient approach might be to develop a generic core training for community mental health workers.

Fund-holding and commissioning general practitioners

General practice fund-holders purchase secondary care for their patients directly, encouraging competition between providers. The scheme now includes almost all community mental health services. Practice counsellors may now be funded from secondary care budgets. Fund-holders may use their purchasing power to influence out-patient policies, have consultant sessions in their surgeries, gain direct referral to community psychiatric nurses, resist sectorisation, or change to a different provider altogether. The implications for mental health teams and their patients are discussed. Mental health workers must define their roles very dearly, and get involved in negotiating contracts now, to influence future service provision.

A systematic review to assess the 'treat-and-extend' dosing regimen for neovascular age-related macular degeneration using ranibizumab

Age-related macular degeneration (AMD) is the leading cause of irreversible blindness in the developed world. Monthly or as-needed (PRN) dosing strategies of intravitreal ranibizumab have been established as efficacious treatment options for neovascular AMD. More recently, the 'treat-and-extend' dosing regimen (TREX) is being adopted in clinical practice as it represents a patient-centric and economical option, reducing treatment burden by extending injection intervals when possible. However, the efficacy of TREX using ranibizumab monotherapy remains to be defined. Therefore, we performed a systematic review to assess the current evidence for TREX using ranibizumab by searching MEDLINE, Embase and PubMed. Of the 1733 articles identified, nine TREX studies were included in our analysis (n=748 eyes). Average patient age was 79.25 (range: 77.34-82.00; SD: 7.27). Baseline BCVA ranged from 48.5-68.9 ETDRS letters. BCVA improvement was 8.92 letters at 1 year (range: 6.5-11.5; SD: 7.54), as a weighted mean accounting for numbers of study eyes. The weighted mean number of injections at one year was 8.60 (range: 7.3-12.0; SD: 1.73). Previously, the landmark ANCHOR and MARINA trials reported gains of 11.3 and 7.2 letters, respectively, using monthly ranibizumab. Chin-Yee et al reported a gain of 3.5 ETDRS letters with 5.3 (S.D. 0.66) PRN ranibizumab injections as weighted means at 1 year in their recent systematic review. Our analysis suggests that TREX delivers visual outcomes superior to PRN and approaches similar efficacy to monthly injections. Further RCTs are needed to fully evaluate the efficacy and economy of TREX in the long-term.

'You feel like your whole world is caving in': A qualitative study of primary care patients' conceptualisations of emotional distress

General practitioners are tasked with determining the nature of patients' emotional distress and providing appropriate care. For patients whose symptoms appear to fall near the 'boundaries' of psychiatric disorder, this can be difficult with important implications for treatment. There is a lack of qualitative research among patients with symptoms severe enough to warrant consultation, but where general practitioners have refrained from diagnosis. We aimed to explore how patients in this potentially large group conceptualise their symptoms and consequently investigate lay understandings of complex distinctions between emotional distress and psychiatric disorder. Interviews were conducted with 20 primary care patients whom general practitioners had identified as experiencing emotional distress, but had not diagnosed with major depressive disorder. Participants described severe emotional experiences with substantial impact on their lives. The term 'depression' was used in many different ways; however, despite severity, they often considered their emotional experience to be different to their perceived notions of 'actual' depression or mental illness. Where anxiety was mentioned, use appeared to refer to an underlying generalised state. Participants drew on complex, sometimes fluid and often theoretically coherent conceptualisations of their emotional distress, as related to, but distinct from, mental disorder. These conceptualisations differ from those frequently drawn on in research and treatment guidelines, compounding the difficulty for general practitioners. Developing models of psychological symptoms that draw on patient experience and integrate psychological/psychiatric theory may help patients understand the nature of their experience and, critically, provide the basis for a broader range of primary care interventions.

Patient-reported outcome measures for monitoring primary care patients with depression: PROMDEP feasibility randomised trial

OBJECTIVES

To determine the feasibility of a trial of patient-reported outcome measures (PROMs) for monitoring primary care patients with depression.

DESIGN

Partly individually randomised, partly cluster-randomised controlled trial.

SETTING

Nine general practices in Southern England.

PARTICIPANTS

47 adults with new episodes of depression: 22 intervention, 25 control.

RANDOMISATION

Remote computerised sequence generation and allocation.

INTERVENTIONS

Patient Health Questionnaire, Distress Thermometer Analogue Scale and PSYCHLOPS problem profile for monitoring depression, following diagnosis and at 10-35 days later. Feedback of scores to patients was determined by practitioners.

BLINDING

Non-blinded, using self-completed measures.

PRIMARY OUTCOME

Beck Depression Inventory (BDI-II).

SECONDARY OUTCOME MEASURES

Work and Social Adjustment Scale (WSAS), EuroQol Five-item, Five-level (EQ-5D-5L) Scale for quality of life, modified Client Service Receipt Inventory for costs, Medical Informant Satisfaction Scale (MISS), qualitative interviews with 14 patients and 13 practice staff about feasibility and acceptability of trial design.

RESULTS

Three practices failed to recruit the target of six patients in 12 months. Follow-up rates were intervention patients: 18 (82%) at 12 weeks and 15 (68%) at 26 weeks; controls: 18 (72%) and 15 (60%), respectively. At 12 weeks, mean BDI-II score was lower among intervention group patients than controls by 5.8 points (95% CI -11.1 to -0.5), adjusted for baseline differences and clustering. WSAS scores were not significantly different. At 26 weeks, there were no significant differences in symptoms, social functioning, quality of life or costs, but mean satisfaction score was higher among controls by 22.0 points (95% CI -40.7 to -3.29). Intervention patients liked completing PROMs, but were disappointed when practitioners did not use the results to inform management.

CONCLUSIONS

PROMs may improve depression outcome in the short term, even if PROM scores do not inform practitioners' management. Challenges in recruiting and following up patients need addressing for a definitive trial of relatively brief measures which can potentially inform management. https://www.isrctn.com/search?q=97492541 TRIAL REGISTRATION NUMBER: ISRCTN 97492541; Pre-results.

Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults

BACKGROUND

Routine outcome monitoring of common mental health disorders (CMHDs), using patient reported outcome measures (PROMs), has been promoted across primary care, psychological therapy and multidisciplinary mental health care settings, but is likely to be costly, given the high prevalence of CMHDs. There has been no systematic review of the use of PROMs in routine outcome monitoring of CMHDs across these three settings.

OBJECTIVES

To assess the effects of routine measurement and feedback of the results of PROMs during the management of CMHDs in 1) improving the outcome of CMHDs; and 2) in changing the management of CMHDs.

SEARCH METHODS

We searched the Cochrane Depression Anxiety and Neurosis group specialised controlled trials register (CCDANCTR-Studies and CCDANCTR-References), the Oxford University PROMS Bibliography (2002-5), Ovid PsycINFO, Web of Science, The Cochrane Library, and International trial registries, initially to 30 May 2014, and updated to 18 May 2015.

SELECTION CRITERIA

We selected cluster and individually randomised controlled trials (RCTs) including participants with CMHDs aged 18 years and over, in which the results of PROMs were fed back to treating clinicians, or both clinicians and patients. We excluded RCTs in child and adolescent treatment settings, and those in which more than 10% of participants had diagnoses of eating disorders, psychoses, substance use disorders, learning disorders or dementia.

DATA COLLECTION AND ANALYSIS

At least two authors independently identified eligible trials, assessed trial quality, and extracted data. We conducted meta-analysis across studies, pooling outcome measures which were sufficiently similar to each other to justify pooling.

MAIN RESULTS

We included 17 studies involving 8787 participants: nine in multidisciplinary mental health care, six in psychological therapy settings, and two in primary care. Pooling of outcome data to provide a summary estimate of effect across studies was possible only for those studies using the compound Outcome Questionnaire (OQ-45) or Outcome Rating System (ORS) PROMs, which were all conducted in multidisciplinary mental health care or psychological therapy settings, because both primary care studies identified used single symptom outcome measures, which were not directly comparable to the OQ-45 or ORS.Meta-analysis of 12 studies including 3696 participants using these PROMs found no evidence of a difference in outcome in terms of symptoms, between feedback and no-feedback groups (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.16 to 0.01; P value = 0.10). The evidence for this comparison was graded as low quality however, as all included studies were considered at high risk of bias, in most cases due to inadequate blinding of assessors and significant attrition at follow-up.Quality of life was reported in only two studies, social functioning in one, and costs in none. Information on adverse events (thoughts of self-harm or suicide) was collected in one study, but differences between arms were not reported.It was not possible to pool data on changes in drug treatment or referrals as only two studies reported these. Meta-analysis of seven studies including 2608 participants found no evidence of a difference in management of CMHDs between feedback and no-feedback groups, in terms of the number of treatment sessions received (mean difference (MD) -0.02 sessions, 95% CI -0.42 to 0.39; P value = 0.93). However, the evidence for this comparison was also graded as low quality.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies, and should follow them up for longer than six months.

Low birth weight and features of neuroticism and mood disorder in 83 545 participants of the UK Biobank cohort

BACKGROUND

Low birth weight has been inconsistently associated with risk of developing affective disorders, including major depressive disorder (MDD). To date, studies investigating possible associations between birth weight and bipolar disorder (BD), or personality traits known to predispose to affective disorders such as neuroticism, have not been conducted in large cohorts.

AIMS

To assess whether very low birth weight (<1500 g) and low birth weight (1500-2490 g) were associated with higher neuroticism scores assessed in middle age, and lifetime history of either MDD or BD. We controlled for possible confounding factors.

METHOD

Retrospective cohort study using baseline data on the 83 545 UK Biobank participants with detailed mental health and birth weight data. Main outcomes were prevalent MDD and BD, and neuroticism assessed using the Eysenck Personality Inventory Neuroticism scale - Revised (EPIN-R).

RESULTS

Referent to normal birth weight, very low/low birth weight were associated with higher neuroticism scores, increased MDD and BD. The associations between birth weight category and MDD were partially mediated by higher neuroticism.

CONCLUSIONS

These findings suggest that intrauterine programming may play a role in lifetime vulnerability to affective disorders.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Did NICE guidelines and the Quality Outcomes Framework change GP antidepressant prescribing in England? Observational study with time trend analyses 2003-2013

BACKGROUND

Both the 2004 NICE depression guidelines and 2006 general practice Quality Outcomes Framework (QOF) encouraged improved targeting of antidepressant treatment for depression.

METHODS

Possible effects of the NICE guideline from January 2005, and QOF from April 2006, on rates of GP antidepressant prescribing were examined using time trend analyses of anonymised data from 142 English practices contributing to the Clinical Practice Research Datalink (CPRD), 2003-2013.

RESULTS

Sustained reductions were found in the proportion of first-ever depression episodes treated within 12 months, of 4.2% (95% C.I. 1.0-7.3%) following introduction of the NICE guideline, and 4.4% (2.3-6.5%) following introduction of the QOF. Treatment rates for first-ever episodes fell from 72.5% (70.8-74.1%) in Quarter 2 (Q2) 2003 to 61.0% (59.3-62.7%) in Q1 2012, but treatment rates for recurrent episodes increased from 74.3% (72.8-75.8%) to 77.8% (76.5-79.1%), so overall rates remained around 70%. Mean prescriptions per patient per year doubled from 2.06 (2.05-2.07) to 3.98 (3.97-3.99).

LIMITATIONS

Participating practices were larger than average and not representative across regions. Inferences of cause and effect from time trend analyses are subject to the possibility of unidentified confounders. No data were available on depression severity or appropriateness of prescribing.

CONCLUSIONS

Rates of GP antidepressant treatment for patients with incident depression fell following introduction of NICE depression guidelines and the QOF, but treatment rates for recurrent depression increased. Prescription numbers increased due to longer treatment courses. To impact on antidepressant prescribing rates, guidelines and performance indicators must address recurrent and long-term prescribing, rather than initial treatment decisions.

Determinants of hospital length of stay for people with serious mental illness in England and implications for payment systems: a regression analysis

BACKGROUND

Serious mental illness (SMI), which encompasses a set of chronic conditions such as schizophrenia, bipolar disorder and other psychoses, accounts for 3.4 m (7 %) total bed days in the English NHS. The introduction of prospective payment to reimburse hospitals makes an understanding of the key drivers of length of stay (LOS) imperative. Existing evidence, based on mainly small scale and cross-sectional studies, is mixed. Our study is the first to use large-scale national routine data to track English hospitals' LOS for patients with a main diagnosis of SMI over time to examine the patient and local area factors influencing LOS and quantify the provider level effects to draw out the implications for payment systems.

METHODS

We analysed variation in LOS for all SMI admissions to English hospitals from 2006 to 2010 using Hospital Episodes Statistics (HES). We considered patients with a LOS of up to 180 days and estimated Poisson regression models with hospital fixed effects, separately for admissions with one of three main diagnoses: schizophrenia; psychotic and schizoaffective disorder; and bipolar affective disorder. We analysed the independent contribution of potential determinants of LOS including clinical and socioeconomic characteristics of the patient, access to and quality of primary care, and local area characteristics. We examined the degree of unexplained variation in provider LOS.

RESULTS

Most risk factors did not have a differential effect on LOS for different diagnostic sub-groups, however we did find some heterogeneity in the effects. Shorter LOS in the pooled model was associated with co-morbid substance or alcohol misuse (4 days), and personality disorder (8 days). Longer LOS was associated with older age (up to 19 days), black ethnicity (4 days), and formal detention (16 days). Gender was not a significant predictor. Patients who self-discharged had shorter LOS (20 days). No association was found between higher primary care quality and LOS. We found large differences between providers in unexplained variation in LOS.

CONCLUSIONS

By identifying key determinants of LOS our results contribute to a better understanding of the implications of case-mix to ensure prospective payment systems reflect accurately the resource use within sub-groups of patients with SMI.

Distinguishing between emotional distress and psychiatric disorder in primary care attenders: A cross sectional study of the four-dimensional symptom questionnaire (4DSQ)

BACKGROUND

Detection of psychiatric disorder in primary care is a complex issue. Distinctions between 'normal' emotional distress and psychiatric disorder depend on how disorder is conceptualized. Our aim was to explore two different conceptualizations by examining patients' scores on one-dimensional depression measures and scores on the Four Dimensional Symptom Questionnaire (4DSQ), a measure that uniquely has separate dimensions for general distress and depressive disorder.

METHODS

This was a cross sectional study of 487 primary care patients attending general clinics in Hampshire, UK. Patients completed the 4DSQ, Patient Health Questionnaire-9 (PHQ-9), General Health Questionnaire-12 (GHQ-12) and the Hospital Anxiety and Depression Scale (HADS) whilst in the waiting room.

RESULTS

The 4DSQ classified 26% (126/485) of patients as having heightened distress levels and 8% (38/468) as possible cases of depressive disorder. Casesness was consistently higher across the one-dimensional measures (PHQ-9: 16%, GHQ-12: 28%, HADS-D: 13%). Of those patients deemed possible cases by the PHQ-9 (≥ 10), the 4DSQ classified 91% (71/78) as having heightened distress and 44% (32/72) as possible cases of depressive disorder.

LIMITATIONS

The sample was predominately older and white, which may limit generalizability of the findings to more diverse patient groups. There are limits to self-report measures in the assessment of complex diagnostic issues.

CONCLUSIONS

Inclusion of a distinct general distress dimension alongside a dimension focusing on specific depression symptomatology lowered the number of primary care patients classified as possible cases of disorder. This view of symptoms may have implications for the targeting of existing treatments, and may be useful in guiding the development of novel self-management interventions.

Changes in rates of recorded depression in English primary care 2003-2013: Time trend analyses of effects of the economic recession, and the GP contract quality outcomes framework (QOF)

BACKGROUND

Depression may be increasing, particularly since the economic recession. Introduction of quality outcomes framework (QOF) performance indicators may have altered GP recording of depression.

METHODS

Time trend analyses of GP recording of depression before and after the recession (from April 2008), and the QOF (from April 2006) were conducted on anonymised consultation data from 142 English practices contributing to the Clinical Practice Research Datalink, April 2003-March 2013.

RESULTS

293,596 patients had computer codes for depressive diagnoses or symptoms in the 10 years. Prevalence of depression codes fell from 44.6 (95% CI 44.2, 45.0) per 1000 person years at risk (PYAR) in 2003/2004 to 38.0 (37.7, 38.3) in 2008/2009, rising to 39.5 (39.2, 39.9) in 2012/2013. Incidence of first-ever depression codes fell from 11.9 (95% CI 11.7, 12.1) per 1000 PYAR in 2003/2004 to 9.5 (9.3, 9.7) in 2008/2009, rising to 10.0 (9.8, 10.2) in 2012/1203. Prevalence increased in men but not women following the recession, associated with increased unemployment. Following introduction of the QOF, GPs used more non-QOF-qualifying symptom or other codes than QOF-qualifying diagnostic codes for new episodes.

LIMITATIONS

Clinical data recording is probably incomplete. Participating practices were relatively large and not representative across English regions.

CONCLUSIONS

Rates of recorded depression in English general practices were falling prior to the economic recession but increased again subsequently, among men, associated with increased unemployment. GPs responded to the QOF by switching from diagnostic to symptom codes, removing most depressed patients from the denominator for measuring GP performance in assessing depression.

Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis

BACKGROUND

The Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better proactive primary care may reduce the risk of psychiatric admissions to hospital, but this has never been tested empirically.

METHODS

The QOF data set included 8234 general practices in England from 2006/2007 to 2010/2011. Rates of hospital admissions with primary diagnoses of SMI or bipolar disorder were estimated from national routine hospital data and aggregated to practice level. Poisson regression was used to analyse associations.

RESULTS

Practices with higher achievement on the annual review for SMI patients (MH9), or that performed better on either of the two lithium indicators for bipolar patients (MH4 or MH5), had more psychiatric admissions. An additional 1% in achievement rates for MH9 was associated with an average increase in the annual practice admission rate of 0.19% (95% CI 0.10% to 0.28%) or 0.007 patients (95% CI 0.003 to 0.01).

CONCLUSIONS

The positive association was contrary to expectation, but there are several possible explanations: better quality primary care may identify unmet need for secondary care; higher QOF achievement may not prevent the need for secondary care; individuals may receive their QOF checks postdischarge rather than prior to admission; individuals with more severe SMI may be more likely to be registered with practices with better QOF performance; and QOF may be a poor measure of the quality of care for people with SMI.

Do higher primary care practice performance scores predict lower rates of emergency admissions for persons with serious mental illness? An analysis of secondary panel data

Background

Serious mental illness (SMI) is a set of chronic enduring conditions including schizophrenia and bipolar disorder. SMIs are associated with poor outcomes, high costs and high levels of disease burden. Primary care plays a central role in the care of people with a SMI in the English NHS. Good-quality primary care has the potential to reduce emergency hospital admissions, but also to increase elective admissions if physical health problems are identified by regular health screening of people with SMIs. Better-quality primary care may reduce length of stay (LOS) by enabling quicker discharge, and it may also reduce NHS expenditure.

Objectives

We tested whether or not better-quality primary care, as assessed by the SMI quality indicators measured routinely in the Quality and Outcomes Framework (QOF) in English general practice, is associated with lower rates of emergency hospital admissions for people with SMIs, for both mental and physical conditions and with higher rates of elective admissions for physical conditions in people with a SMI. We also tested the impact of SMI QOF indicators on LOS and costs.

Data

We linked administrative data from around 8500 general practitioner (GP) practices and from Hospital Episode Statistics for the study period 2006/7 to 2010/11. We identified SMI admissions by a mainInternational Classification of Diseases, 10th revision (ICD-10) diagnosis of F20–F31. We included information on GP practice and patient population characteristics, area deprivation and other potential confounders such as access to care. Analyses were carried out at a GP practice level for admissions, but at a patient level for LOS and cost analyses.

Methods

We ran mixed-effects count data and linear models taking account of the nested structure of the data. All models included year indicators for temporal trends.

Results

Contrary to expectation, we found a positive association between QOF achievement and admissions, for emergency admissions for both mental and physical health. An additional 10% in QOF achievement was associated with an increase in the practice emergency SMI admission rate of approximately 1.9%. There was no significant association of QOF achievement with either LOS or cost. All results were robust to sensitivity analyses.

Conclusions

Possible explanations for our findings are (1) higher quality of primary care, as measured by QOF may not effectively prevent the need for secondary care; (2) patients may receive their QOF checks post discharge, rather than prior to admission; (3) people with more severe SMIs, at a greater risk of admission, may select into practices that are better organised to provide their care and which have better QOF performance; (4) better-quality primary care may be picking up unmet need for secondary care; and (5) QOF measures may not accurately reflect quality of primary care. Patient-level data on quality of care in general practice is required to determine the reasons for the positive association of QOF quality and admissions. Future research should also aim to identify the non-QOF measures of primary care quality that may reduce unplanned admissions more effectively and could potentially be incentivised.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

A new measure of multimorbid illness and treatment representations: the example of diabetes and depression

BACKGROUND

Depression is two to three times more common in people with diabetes than in the general population. Although multimorbid diabetes and depression is associated with poor health outcome, existing research has focused on patients׳ understanding and management of each condition in isolation. This study describes the development and validation of the Diabetes and Depression Representation and Management Questionnaire (DDRMQ), a measure of understanding, management and medication beliefs in people with diabetes and depression.

METHODS

In Study 1, DDRMQ items were developed through further analysis of an earlier qualitative study and refined through 18 cognitive interviews. In Study 2, 334 adults with diabetes and depression from general practices, diabetes clinics and support groups completed the DDRMQ, demographic questions and validating measures.

RESULTS

Factor analysis of the DDRMQ using principal axis factoring resulted in a 35 item scale organised into ten subscales. The modified measure had adequate internal and test-retest reliability. Initial evidence of construct validity was also demonstrated.

LIMITATIONS

Low participant response rates and the high percentage of well-educated white participants limit the generalisability of results. As Study 2 was cross-sectional, future research is needed to establish if different ways of thinking about and managing diabetes and depression can predict patient outcome.

CONCLUSIONS

The DDRMQ is the first measure of patient understanding, management and medication beliefs in people with established diagnoses of both diabetes and depression. The DDRMQ will facilitate an increased awareness of the patient experience of diabetes and depression and help inform patient centred care and intervention development for people with multiple conditions.

Do patients׳ illness beliefs predict depression measures at six months in primary care; a longitudinal study

BACKGROUND

Depressive disorders are prevalent and costly but there is a lack of evidence on how best to select treatments for mild to moderate depression in primary care. Illness beliefs have been shown to affect the outcome from physical illness, but there is limited information on the beliefs of patients who are depressed.

AIMS

To measure patients׳ beliefs about depression at baseline and determine whether these relate to depression severity at six months.

METHODS

Primary care patients with a recently diagnosed episode of depression completed the Beliefs about Depression Questionnaire and depression severity scores at baseline. The primary outcome was the change in depression severity score on the Hospital Anxiety and Depression Scale after six months.

RESULTS

227/292 (78%) participants completed follow-up questionnaires. Initial severity of depression at baseline, and particular beliefs about the causes, consequences and timeline of depression predicted poorer outcomes, whereas a belief in using exercise or keeping busy to treat depression predicted improved outcomes. Prescription of antidepressants did not appear to mediate these relationships.

LIMITATIONS

This was an initial study using a new validated questionnaire and it cannot be predicted whether these results are representative or would be reproduced in other populations. Although participants were primary care patients whose GP (General Practitioner) had coded as having a new incident episode of depression in the preceding six months, 43% of participants stated they had been depressed for more than a year. Sufficient participants were recruited to ensure the study was adequately powered but participation rate was 30%, raising the possibility of response bias.

CONCLUSIONS AND CLINICAL RELEVANCE

Illness beliefs may help to predict outcomes in depression and therefore assessing and addressing patients׳ beliefs about their depression may enhance treatment.

Referral for psychological therapy of people with long term conditions improves adherence to antidepressants and reduces emergency department attendance: controlled before and after study

BACKGROUND

Referral to psychological therapies is recommended for people with common mental health problems (CMHP) however its impact on healthcare utilisation in people with long term conditions (LTCs) is not known.

METHOD

Routinely collected primary care, psychological therapy clinic and hospital data were extracted for the registered population of 20 practices (N = 121,199). These data were linked using the SAPREL (Secure and Private Record Linkage) method. We linked the 1118 people referred to psychological therapies with 6711 controls, matched for age, gender and practice. We compared utilisation of healthcare resources by people with LTCs, 6 months before and after referral, and conducted a controlled before and after study to compare health utilisation with controls. We made the assumption that collection of a greater number of repeat prescriptions for antidepressants was associated with greater adherence.

RESULTS

Overall 21.8% of people with an LTC had CMHP vs. 18.8% without (p < 0.001). People with LTCs before referral were more likely to use health care resources (2-tailed t-test p < 0.001). Cases with LTCs showed referral to the psychological therapies clinic was associated with increased antidepressant medication prescribing (mean differences 0.62, p < 0.001) and less use of emergency department than controls (mean difference -0.21, p = 0.003).

CONCLUSIONS

Referral to improved access to psychological therapies (IAPT) services appears of value to people with LTC. It is associated with the issue of a greater number of prescriptions for anti-depressant medicines and less use of emergency services. Further studies are needed to explore bed occupancy and outpatient attendance.

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data

OBJECTIVE

To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression.

DESIGN

Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care.

SETTING

Primary care and community settings.

PARTICIPANTS

2470 patients with depression.

INTERVENTIONS

Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions).

MAIN OUTCOME MEASURES

Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions.

RESULTS

Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient -0.1 (95% CI -0.19 to -0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant.

CONCLUSIONS

The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

'Watchful waiting' or 'active monitoring' in depression management in primary care: exploring the recalled content of general practitioner consultations

BACKGROUND

Current NICE depression guidelines recommend a period of 'active monitoring' prior to commencing treatment with antidepressants. The content of consultations during active monitoring or supportive care has not been previously prescribed.

METHODS

As part of a randomised trial of supportive care versus supportive care plus SSRI consultation content was measured through patient recall for the purpose of testing equity in content between trial arms. An exploratory analysis of the consultation content measure is presented together with a measure of consultation satisfaction (MISS) and depression severity (HMRD). A score for 'psychoactive consultation content' (PSAC) was generated to enable comparison between groups.

RESULTS

220 patients were randomised in the study. The majority of participants recalled a discussion of practical problems they faced and many reported some element of problem solving; a significant minority reported discussions about changing the way they thought, addressing relationships or talking to trusted friends or family. Consultation content was unrelated to depression outcome although in multivariate analysis it was strongly related to consultation satisfaction.

LIMITATIONS

This is a secondary analysis based on patient recall of consultation content.

CONCLUSIONS

Supportive care is not a passive process as patients report several potentially therapeutic discussions within the consultation and these occur regardless of whether antidepressants are prescribed. It is not known whether these discussions do have any therapeutic value in this context. Consultation content was unrelated to outcome in this study but did predict satisfaction with the consultation. Further work is required to validate the patient report of consultation content and to identify what if any consultation strategies have therapeutic effect.

Illness perceptions and glycaemic control in diabetes: a systematic review with meta-analysis

AIMS

The Illness Perception Questionnaire, the Revised Illness Perception Questionnaire and the Brief Illness Perception Questionnaire have been widely used to measure people's beliefs about diabetes. This review aimed to synthesize evidence on the relationship between the dimensions of the Illness Perception Questionnaire, the Revised Illness Perception Questionnaire and the Brief Illness Perception Questionnaire and HbA(1c) level in adults with diabetes.

METHODS

A systematic literature search was carried out in January 2010 to identify relevant studies. Random-effects model meta-analyses were conducted with cross-sectional data to quantify the relationship between Illness Perception Questionnaire dimensions and HbA(1c) across studies. Randomized controlled trials that targeted Illness Perception Questionnaire perceptions and included HbA(1c) as an outcome measure were discussed in a narrative review.

RESULTS

Nine cross-sectional studies and four randomized controlled trials were included. Stronger Identity (r+=0.14), Consequences (r+=0.14), Timeline Cyclical (r+ = 0.26) Concern (r+= 0.21), and Emotional Representations (r+=0.18) perceptions had significant positive associations with HbA(1c.) Greater Personal Control (r+=- 0.12) was negatively associated with HbA(1c) . For all relationships, heterogeneity tests were non-significant, suggesting little variability in effect size estimates. Two of the four randomized controlled trials successfully changed illness perceptions, with one also reporting an intervention group reduction in HbA(1c).

CONCLUSIONS

Some Illness Perception Questionnaire dimensions had small significant associations with HbA(1c) , although the direction of these associations remains unclear. There was also tentative evidence that illness perceptions can be positively changed through targeted intervention and that these changes may also impact on glycaemic control. Future research could benefit from tailoring intervention content to perceptions that are most highly associated with HbA(1c).

Detecting referral and selection bias by the anonymous linkage of practice, hospital and clinic data using Secure and Private Record Linkage (SAPREL): case study from the evaluation of the Improved Access to Psychological Therapy (IAPT) service

Background

The evaluation of demonstration sites set up to provide improved access to psychological therapies (IAPT) comprised the study of all people identified as having common mental health problems (CMHP), those referred to the IAPT service, and a sample of attenders studied in-depth. Information technology makes it feasible to link practice, hospital and IAPT clinic data to evaluate the representativeness of these samples. However, researchers do not have permission to browse and link these data without the patients' consent.

Objective

To demonstrate the use of a mixed deterministic-probabilistic method of secure and private record linkage (SAPREL) - to describe selection bias in subjects chosen for in-depth evaluation.

Method

We extracted, pseudonymised and used fuzzy logic to link multiple health records without the researcher knowing the patient's identity. The method can be characterised as a three party protocol mainly using deterministic algorithms with dynamic linking strategies; though incorporating some elements of probabilistic linkage. Within the data providers' safe haven we extracted: Demographic data, hospital utilisation and IAPT clinic data; converted post code to index of multiple deprivation (IMD); and identified people with CMHP. We contrasted the age, gender, ethnicity and IMD for the in-depth evaluation sample with people referred to IAPT, use hospital services, and the population as a whole.

Results

The in IAPT-in-depth group had a mean age of 43.1 years; CI: 41.0 - 45.2 (n = 166); the IAPT-referred 40.2 years; CI: 39.4 - 40.9 (n = 1118); and those with CMHP 43.6 years SEM 0.15. (n = 12210). Whilst around 67% of those with a CMHP were women, compared to 70% of those referred to IAPT, and 75% of those subject to in-depth evaluation (Chi square p < 0.001). The mean IMD score for the in-depth evaluation group was 36.6; CI: 34.2 - 38.9; (n = 166); of those referred to IAPT 38.7; CI: 37.9 - 39.6; (n = 1117); and of people with CMHP 37.6; CI 37.3-37.9; (n = 12143).

Conclusions

The sample studied in-depth were older, more likely female, and less deprived than people with CMHP, and fewer had recorded ethnic minority status. Anonymous linkage using SAPREL provides insight into the representativeness of a study population and possible adjustment for selection bias.