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Teoh KRH, Dunning A, Taylor AK, Gopfert A, Chew-Graham CA, Spiers J, Appleby L, Van Hove M, Buszewicz M, Riley R. Working conditions, psychological distress and suicidal ideation: cross-sectional survey study of UK junior doctors. BJPsych Open 2023; 10:e14. [PMID: 38099399 PMCID: PMC10755551 DOI: 10.1192/bjo.2023.619] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/01/2023] [Accepted: 11/01/2023] [Indexed: 12/31/2023] Open
Abstract
BACKGROUND Evidence attests a link between junior doctors' working conditions and psychological distress. Despite increasing concerns around suicidality among junior doctors, little is known about its relationship to their working conditions. AIMS To (a) establish the prevalence of suicidal ideation among junior doctors in the National Health Service; (b) examine the relationships between perceived working conditions and suicidal ideation; and (c) explore whether psychological distress (e.g. symptoms of depression and anxiety) mediates these relationships. METHOD Junior doctors were recruited between March 2020 and January 2021, for a cross-sectional online survey. We used the Health and Safety Executive's Management Standards Tool; Depression, Anxiety and Stress Scale 21; and Paykel Suicidality Scale to assess working conditions, psychological distress and suicidality, respectively. RESULTS Of the 424 participants, 50.2% reported suicidal ideation, including 6.1% who had made an attempt on their own life. Participants who identified as LGBTQ+ (odds ratio 2.18, 95% CI 1.15-4.12) or reported depression symptoms (odds ratio 1.10, 95% CI 1.07-1.14) were more likely to report suicidal ideation. No direct relationships were reported between working conditions (i.e. control, support, role clarity, strained relationships, demand and change) and suicidal ideation. However, depression symptoms mediated all six relationships. CONCLUSIONS This sample of junior doctors reported alarming levels of suicidal ideation. There may be an indirect relationship between working conditions and suicidal ideation via depressive symptoms. Clearer research exploring the experience of suicidality in junior doctors is needed, including those who identify as LGBTQ+. Systematic interventions addressing working environment are needed to support junior doctors' mental health.
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Affiliation(s)
- Kevin Rui-Han Teoh
- Department of Organizational Psychology, Birkbeck, University of London, UK
| | - Alice Dunning
- School of Health and Related Research, University of Sheffield, UK
| | - Anna Kathryn Taylor
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, UK
| | - Anya Gopfert
- Department of Sports Sciences and Public Health, University of Exeter, UK
| | | | | | - Louis Appleby
- Division of Psychology and Mental Health, School of Medicine, University of Manchester, UK
| | - Maria Van Hove
- Department of Health and Community Sciences, University of Exeter, UK
| | - Marta Buszewicz
- UCL Great Ormand Street Institute of Child Health, University College London, UK
| | - Ruth Riley
- School of Health Sciences, University of Surrey, UK
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2
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McOwat K, Pinto Pereira SM, Nugawela MD, Ladhani SN, Newlands F, Stephenson T, Simmons R, Semple MG, Segal T, Buszewicz M, Heyman I, Chalder T, Ford T, Dalrymple E, Shafran R. The CLoCk study: A retrospective exploration of loneliness in children and young people during the COVID-19 pandemic, in England. PLoS One 2023; 18:e0294165. [PMID: 37988366 PMCID: PMC10662715 DOI: 10.1371/journal.pone.0294165] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Accepted: 10/26/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND During the COVID-19 pandemic children and young people (CYP) were socially restricted during a stage of life crucial to development, potentially putting an already vulnerable population at higher risk of loneliness, social isolation, and poorer wellbeing. The objectives of this study are to conduct an exploratory analysis into loneliness before and during the pandemic, and determine which self-reported factors are associated with loneliness. METHODS AND FINDINGS Participants from The Children with Long COVID (CLoCk) national study were invited to take part via an online survey, with a total of 31,017 participants taking part, 31,016 of which reported on their experience of loneliness. Participants retrospectively answered questions on demographics, lifestyle, physical health and mental health and loneliness before the pandemic and at the time of answering the survey. Before the pandemic 6.5% (2,006/31,016) of participants reported experiencing loneliness "Often/Always" and at the time of survey completion 17.4% (5,395/31,016) reported feeling lonelier. There was an association between meeting the research definition of long COVID and loneliness [3.49 OR, 95%CI 3.28-3.72]. CYP who reported feeling lonelier at the time of the survey than before the pandemic were assigned female at birth, older CYP, those from Black/African/Caribbean/Black British or other ethnicity groups, those that had 3-4 siblings and lived in more deprived areas. CONCLUSIONS We demonstrate associations between multiple factors and experiences of loneliness during the pandemic. There is a need for a multi-faceted integrated approach when developing interventions targeted at loneliness. It is important to follow up the CYP involved at regular intervals to investigate the progression of their experience of loneliness over time.
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Affiliation(s)
- Kelsey McOwat
- Immunisations and Vaccine Preventable Diseases Department, UK Health Security Agency, London, United Kingdom
| | - Snehal M. Pinto Pereira
- Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, London, United Kingdom
| | - Manjula D. Nugawela
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Shamez N. Ladhani
- Immunisations and Vaccine Preventable Diseases Department, UK Health Security Agency, London, United Kingdom
| | - Fiona Newlands
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Terence Stephenson
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Ruth Simmons
- Immunisations and Vaccine Preventable Diseases Department, UK Health Security Agency, London, United Kingdom
| | - Malcolm G. Semple
- NIHR Health Protection Research Unit for Emerging and Zoonotic Infections, Institute of Infection, Veterinary and Ecological Sciences University of Liverpool, Liverpool, United Kingdom
- Respiratory Medicine, Alder Hey Children’s Hospital, Institute in The Park, University of Liverpool, Liverpool, United Kingdom
| | - Terry Segal
- Department of Paediatrics and Adolescence, University College London Hospital, London, United Kingdom
| | - Marta Buszewicz
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Isobel Heyman
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Hershel Smith Building Cambridge Biomedical Campus, Cambridge, United Kingdom
| | - Emma Dalrymple
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
| | | | - Roz Shafran
- University College London—Great Ormond Street Institute of Child Health, London, United Kingdom
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3
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Newlands F, Rojas NK, Nugawela M, Pinto Pereira SM, Buszewicz M, Chalder T, Cheung EY, Dalrymple E, Ford T, Heyman I, Ladhani SN, McOwat K, Simmons R, Stephenson T, Shafran R. A Cross-Sectional Study of the Health of Emerging Young Adults in England Following a COVID-19 Infection. J Adolesc Health 2023; 73:20-28. [PMID: 37024311 PMCID: PMC9910021 DOI: 10.1016/j.jadohealth.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Revised: 12/15/2022] [Accepted: 01/25/2023] [Indexed: 02/11/2023]
Abstract
PURPOSE This study describes long COVID symptomatology in a national sample of 18- to 20-year-olds with Polymerase Chain Reaction (PCR)-confirmed Severe acute respiratory syndrome coronavirus 2 (SARS‑CoV‑2) and matched test-negative controls in England. Symptoms in 18- to 20-year-olds were compared to symptoms in younger adolescents (aged 11-17 years) and all adults (18+). METHODS A national database was used to identify SARS-CoV-2 PCR-positive 18- to 20-year-olds and test-negative controls matched by time of test, age, gender, and geographical region. Participants were invited to complete a questionnaire about their health retrospectively at time of test and also when completing the questionnaire. Comparison cohorts included children and young people with long COVID and REal-time Assessment of Community Transmission studies. RESULTS Of 14,986 people invited, 1,001 were included in the analysis (562 test-positive; 440 test-negative). At testing, 46.5% of test-positives and 16.4% of test-negatives reported at least one symptom. At the time of questionnaire completion (median 7 months post-testing), 61.5% of test-positives and 47.5% of test-negatives reported one or more symptoms. The most common symptoms were similar amongst test-positives and test-negatives and included tiredness (44.0%; 35.7%), shortness of breath (28.8%; 16.3%), and headaches (13.7%; 12.0%). Prevalence rates were similar to those reported by 11-17-year-olds (66.5%) and higher than those reported in all adults (37.7%). For 18- to 20-year-olds, there was no significant difference in health-related quality of life and well-being (p > .05). However, test-positives reported being significantly more tired than test-negatives (p = .04). DISCUSSION Seven months after PCR test, a high proportion of test-positive and test-negative 18- to 20-year-olds reported similar symptoms to each other and to those experienced by younger and older counterparts.
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Affiliation(s)
- Fiona Newlands
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom.
| | - Natalia K Rojas
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Manjula Nugawela
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Snehal M Pinto Pereira
- Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, United Kingdom
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, Faculty of Population and Health Sciences, University College London, Royal Free Campus, London, United Kingdom
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, United Kingdom
| | - Emily Y Cheung
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Emma Dalrymple
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Hershel Smith Building Cambridge Biomedical Campus, United Kingdom
| | - Isobel Heyman
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Shamez N Ladhani
- Paediatric Infectious Diseases Research Group, St. George's University of London, Cranmer Terrace, London, United Kingdom
| | - Kelsey McOwat
- Immunisation Department, Public Health England, London, United Kingdom
| | - Ruth Simmons
- Immunisation Department, Public Health England, London, United Kingdom
| | - Terence Stephenson
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health, London, United Kingdom
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Bertran M, Pinto Pereira SM, Nugawela MD, Stephenson T, Shafran R, Ford T, Buszewicz M, Whittaker E, Heyman I, Segal TY, Dalrymple E, Ladhani SN. The relationship between Post COVID symptoms in young people and their parents. J Infect 2022; 85:702-769. [PMID: 36216186 DOI: 10.1016/j.jinf.2022.10.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 10/02/2022] [Indexed: 11/06/2022]
Affiliation(s)
- Marta Bertran
- Immunisations and Vaccine Preventable Diseases Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, United Kingdom
| | - Snehal M Pinto Pereira
- Division of Surgery & Interventional Science, Faculty of Medical Sciences, University College London, WC1E 6BT, United Kingdom
| | - Manjula D Nugawela
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom
| | - Terence Stephenson
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom
| | - Tamsin Ford
- Department of Psychiatry, University of Cambridge, Hershel Smith Building Cambridge Biomedical Campus, CB2 0SZ, United Kingdom
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, University College London Medical School London United Kingdom
| | - Elizabeth Whittaker
- Department of Paediatric Infectious Diseases, Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Isobel Heyman
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom
| | - Terry Y Segal
- Paediatric and Adolescent Division, University College London Hospitals NHS Foundation Trust, London, United Kingdom
| | - Emma Dalrymple
- UCL Great Ormond Street Institute of Child Health, 30 Guilford Street, London, WC1N 1EH, United Kingdom
| | - Shamez N Ladhani
- Immunisations and Vaccine Preventable Diseases Division, UK Health Security Agency, 61 Colindale Avenue, London NW9 5EQ, United Kingdom; Paediatric Infectious Diseases Research Group, St. George's University of London, Cranmer Terrace, London, SW17 0RE, United Kingdom.
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5
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Spiers J, Kokab F, Buszewicz M, Chew-Graham CA, Dunning A, Taylor AK, Gopfert A, van Hove M, Teoh KRH, Appleby L, Martin J, Riley R. Recommendations for improving the working conditions and cultures of distressed junior doctors, based on a qualitative study and stakeholder perspectives. BMC Health Serv Res 2022; 22:1333. [PMCID: PMC9647238 DOI: 10.1186/s12913-022-08728-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 10/07/2022] [Indexed: 11/11/2022] Open
Abstract
Abstract
Background
Doctors, including junior doctors, are vulnerable to greater levels of distress and mental health difficulties than the public. This is exacerbated by their working conditions and cultures. While this vulnerability has been known for many years, little action has been taken to protect and support junior doctors working in the NHS. As such, we present a series of recommendations from the perspective of junior doctors and other relevant stakeholders, designed to improve junior doctors’ working conditions and, thus, their mental health.
Methods
We interviewed 36 junior doctors, asking them for recommendations for improving their working conditions and culture. Additionally, we held an online stakeholder meeting with a variety of healthcare professionals (including junior doctors), undergraduate medical school leads, postgraduate speciality school leads and NHS policymakers where we asked what could be done to improve junior doctors’ working conditions. We combined interview data with notes from the stakeholder discussions to produce this set of recommendations.
Results
Junior doctor participants and stakeholders made organisational and interpersonal recommendations. Organisational recommendations include the need for more environmental, staff and educational resources as well as changes to rotas. Interpersonal recommendations include changes to communication and recommendations for better support and teamwork.
Conclusion
We suggest that NHS policymakers, employers and managers consider and hopefully implement the recommendations set out by the study participants and stakeholders as reported in this paper and that the gold standards of practice which are reported here (such as examples of positive learning environments and supportive supervision) are showcased so that others can learn from them.
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6
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Dunning A, Teoh K, Martin J, Spiers J, Buszewicz M, Chew-Graham C, Taylor AK, Gopfert A, Van Hove M, Appleby L, Riley R. Relationship between working conditions and psychological distress experienced by junior doctors in the UK during the COVID-19 pandemic: a cross-sectional survey study. BMJ Open 2022; 12:e061331. [PMID: 35998957 PMCID: PMC9402444 DOI: 10.1136/bmjopen-2022-061331] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES This paper explored the self-reported prevalence of depression, anxiety and stress among junior doctors during the COVID-19 pandemic. It also reports the association between working conditions and psychological distress experienced by junior doctors. DESIGN A cross-sectional online survey study was conducted, using the 21-item Depression, Anxiety and Stress Scale and Health and Safety Executive scale to measure psychological well-being and working cultures of junior doctors. SETTING The National Health Service in the UK. PARTICIPANTS A sample of 456 UK junior doctors was recruited online during the COVID-19 pandemic from March 2020 to January 2021. RESULTS Junior doctors reported poor mental health, with over 40% scoring extremely severely depressed (45.2%), anxious (63.2%) and stressed (40.2%). Both gender and ethnicity were found to have a significant influence on levels of anxiety. Hierarchical multiple linear regression analysis outlined the specific working conditions which significantly predicted depression (increased demands (β=0.101), relationships (β=0.27), unsupportive manager (β=-0.111)), anxiety (relationships (β=0.31), change (β=0.18), demands (β=0.179)) and stress (relationships (β=0.18), demands (β=0.28), role (β=0.11)). CONCLUSIONS The findings illustrate the importance of working conditions for junior doctors' mental health, as they were significant predictors for depression, anxiety and stress. Therefore, if the mental health of junior doctors is to be improved, it is important that changes or interventions specifically target the working environment rather than factors within the individual clinician.
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Affiliation(s)
- Alice Dunning
- Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Kevin Teoh
- Department of Organizational Psychology, Birkbeck University of London, London, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Johanna Spiers
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | | | - Anya Gopfert
- School of Medicine, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maria Van Hove
- London School of Hygiene & Tropical Medicine, London, UK
| | - Louis Appleby
- Department of Psychiatry & Behavioral Sciences, The University of Manchester Faculty of Medical and Human Sciences, Manchester, UK
| | - Ruth Riley
- School of Health Sciences, University of Surrey, Guildford, UK
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7
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Spiers J, Buszewicz M, Chew-Graham C, Dunning A, Taylor AK, Gopfert A, Van Hove M, Teoh KRH, Appleby L, Martin J, Riley R. What challenges did junior doctors face while working during the COVID-19 pandemic? A qualitative study. BMJ Open 2021; 11:e056122. [PMID: 34903552 PMCID: PMC8671849 DOI: 10.1136/bmjopen-2021-056122] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES This paper reports findings exploring junior doctors' experiences of working during the COVID-19 pandemic in the UK. DESIGN Qualitative study using in-depth interviews with 15 junior doctors. Interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.12 to facilitate data management. Data were analysed using reflexive thematic analysis. SETTING National Health Service (NHS) England. PARTICIPANTS A purposive sample of 12 female and 3 male junior doctors who indicated severe depression and/or anxiety on the DASS-21 questionnaire or high suicidality on Paykel's measure were recruited. These doctors self-identified as having lived experience of distress due to their working conditions. RESULTS We report three major themes. First, the challenges of working during the COVID-19 pandemic, which were both personal and organisational. Personal challenges were characterised by helplessness and included the trauma of seeing many patients dying, fears about safety and being powerless to switch off. Work-related challenges revolved around change and uncertainty and included increasing workloads, decreasing staff numbers and negative impacts on relationships with colleagues and patients. The second theme was strategies for coping with the impact of COVID-19 on work, which were also both personal and organisational. Personal coping strategies, which appeared limited in their usefulness, were problem and emotion focused. Several participants appeared to have moved from coping towards learnt helplessness. Some organisations reacted to COVID-19 collaboratively and flexibly. Third, participants reported a positive impact of the COVID-19 pandemic on working practices, which included simplified new ways of working-such as consistent teams and longer rotations-as well as increased camaraderie and support. CONCLUSIONS The trauma that junior doctors experienced while working during COVID-19 led to powerlessness and a reduction in the benefit of individual coping strategies. This may have resulted in feelings of resignation. We recommend that, postpandemic, junior doctors are assigned to consistent teams and offered ongoing support.
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Affiliation(s)
- Johanna Spiers
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | - Alice Dunning
- Yorkshire Quality and Safety Research Group, Bradford Institute for Health Research, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Anna Kathryn Taylor
- Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | | | | | - Kevin Rui-Han Teoh
- Department of Organizational Psychology, Birkbeck, University of London, London, Greater London, UK
| | - Louis Appleby
- Department of Psychology and Mental Health, School of Medicine, University of Manchester, Manchester, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
| | - Ruth Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, West Midlands, UK
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8
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Grigoroglou C, van der Feltz-Cornelis C, Hodkinson A, Coventry PA, Zghebi SS, Kontopantelis E, Bower P, Lovell K, Gilbody S, Waheed W, Dickens C, Archer J, Blakemore A, Adler DA, Aragones E, Björkelund C, Bruce ML, Buszewicz M, Carney RM, Cole MG, Davidson KW, Gensichen J, Grote NK, Russo J, Huijbregts K, Huffman JC, Menchetti M, Patel V, Richards DA, Rollman B, Smit A, Zijlstra-Vlasveld MC, Wells KB, Zimmermann T, Unutzer J, Panagioti M. Effectiveness of collaborative care in reducing suicidal ideation: An individual participant data meta-analysis. Gen Hosp Psychiatry 2021; 71:27-35. [PMID: 33915444 DOI: 10.1016/j.genhosppsych.2021.04.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 04/15/2021] [Accepted: 04/18/2021] [Indexed: 10/21/2022]
Abstract
UNLABELLED To assess whether CC is more effective at reducing suicidal ideation in people with depression compared with usual care, and whether study and patient factors moderate treatment effects. METHOD We searched Medline, Embase, PubMed, PsycINFO, CINAHL, CENTRAL from inception to March 2020 for Randomised Controlled Trials (RCTs) that compared the effectiveness of CC with usual care in depressed adults, and reported changes in suicidal ideation at 4 to 6 months post-randomisation. Mixed-effects models accounted for clustering of participants within trials and heterogeneity across trials. This study is registered with PROSPERO, CRD42020201747. RESULTS We extracted data from 28 RCTs (11,165 patients) of 83 eligible studies. We observed a small significant clinical improvement of CC on suicidal ideation, compared with usual care (SMD, -0.11 [95%CI, -0.15 to -0.08]; I2, 0·47% [95%CI 0.04% to 4.90%]). CC interventions with a recognised psychological treatment were associated with small reductions in suicidal ideation (SMD, -0.15 [95%CI -0.19 to -0.11]). CC was more effective for reducing suicidal ideation among patients aged over 65 years (SMD, - 0.18 [95%CI -0.25 to -0.11]). CONCLUSION Primary care based CC with an embedded psychological intervention is the most effective CC framework for reducing suicidal ideation and older patients may benefit the most.
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Affiliation(s)
- Christos Grigoroglou
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England.
| | | | - Alexander Hodkinson
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Peter A Coventry
- Department of Health Sciences, University of York, York, England
| | - Salwa S Zghebi
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Evangelos Kontopantelis
- Faculty of Biology, Medicine and Health, Division of Informatics, Imaging and Data Sciences, University of Manchester, Manchester, England
| | - Peter Bower
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, England; Greater Manchester Mental Health NHS Foundation Trust, Manchester, England
| | - Simon Gilbody
- Department of Health Sciences, Hull York Medical School, HYMS, University of York, York, England
| | - Waquas Waheed
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
| | | | - Janine Archer
- School of Health and Society, School of Health and Society, University of Salford, England
| | - Amy Blakemore
- Division of Nursing, Midwifery and Social Work, School of Health Sciences, University of Manchester, Manchester, England
| | - David A Adler
- Departments of Psychiatry and Medicine, Tufts Medical Center and Tufts University School of Medicine, England
| | - Enric Aragones
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAPJGol), Barcelona, Spain
| | - Cecilia Björkelund
- Primary Health Care School of Public Health and Community Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Martha L Bruce
- Department of Psychiatry, Geisel School of Medicine at Dartmouth, Hanover, New Hampshire, USA
| | - Marta Buszewicz
- Institute of Epidemiology and Health, Faculty of Population and Health Sciences, University College London, London, England
| | - Robert M Carney
- Department of Psychiatry, Washington University in St. Louis (WUSTL), St. Louis, Missouri, USA
| | - Martin G Cole
- Department of Psychiatry, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
| | - Karina W Davidson
- Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, New York, USA
| | - Jochen Gensichen
- Institute of General Practice and Family Medicine, LMU Klinikum, Ludwig-Maximilians, University Munich Pettenkoferstr. 10, 80336 Munich, Germany
| | - Nancy K Grote
- School of Social Work, University of Washington, Seattle, USA
| | - Joan Russo
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Klaas Huijbregts
- Department of Psychiatry and Amsterdam Public Health Research Institute, Amsterdam, Netherlands
| | - Jeff C Huffman
- Harvard Medical School, Department of Psychiatry, Massachusetts General Hospital, Boston, Massachusetts
| | - Marco Menchetti
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Vikram Patel
- The Pershing Square Professor of Global Health, Harvard Medical School, Boston, MA, USA
| | - David A Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, Exeter, England; Western University of Norway, Bergen, Norway
| | - Bruce Rollman
- Center for Behavioral Health, Media and Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Annet Smit
- HAN University of Applied Sciences, Nijmegen, Netherlands
| | | | - Kenneth B Wells
- Department of Psychiatry and Biobehavioral Sciences, University of California, Los Angeles, USA; Jane and Terry Semel Institute for Neuroscience and Human Behavior, University of California, Los Angeles, USA
| | - Thomas Zimmermann
- Department of General Practice / Primary Care, Centre for Psychosocial Medicine, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jurgen Unutzer
- Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, USA
| | - Maria Panagioti
- National Institute of Health Research School for Primary Care Research, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, England
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Riley R, Buszewicz M, Kokab F, Teoh K, Gopfert A, Taylor AK, Van Hove M, Martin J, Appleby L, Chew-Graham C. Sources of work-related psychological distress experienced by UK-wide foundation and junior doctors: a qualitative study. BMJ Open 2021; 11:e043521. [PMID: 34162634 PMCID: PMC8231022 DOI: 10.1136/bmjopen-2020-043521] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES This paper reports findings exploring work cultures, contexts and conditions associated with psychological distress in foundation and junior doctors. DESIGN Qualitative study using in-depth interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING NHS in England. PARTICIPANTS A purposive sample of 16 female and five male junior doctor junior doctor participants who self-identified as having stress, distress, anxiety, depression and suicidal thoughts, or having attempted to kill themselves. RESULTS Analysis reported four key themes: (1) workload and working conditions; (2) toxic work cultures-including abuse and bullying, sexism and racism, culture of blaming and shaming; (3) lack of support; (4) stigma and a perceived need to appear invulnerable. CONCLUSION This study highlights the need for future solutions and interventions targeted at improving work cultures and conditions. There needs to be greater recognition of the components and cumulative effects of potentially toxic workplaces and stressors intrinsic to the work of junior doctors, such as the stress of managing high workloads and lack of access to clinical and emotional support. A cultural shift is needed within medicine to more supportive and compassionate leadership and work environments, and a zero-tolerance approach to bullying, harassment and discrimination.
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Affiliation(s)
- Ruth Riley
- Institute of Applied Health Research, University of Birmingham College of Medical and Dental Sciences, Birmingham, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Farina Kokab
- School of Social Policy, University of Birmingham, Birmingham, UK
| | - Kevin Teoh
- Department of Organizational Psychology, Birkbeck University of London, London, UK
| | - Anya Gopfert
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Anna K Taylor
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Maria Van Hove
- London School of Hygiene & Tropical Medicine, London, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Louis Appleby
- Psychiatry and Behavioral Sciences, University of Manchester, Manchester, UK
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Riley R, Kokab F, Buszewicz M, Gopfert A, Van Hove M, Taylor AK, Teoh K, Martin J, Appleby L, Chew-Graham C. Protective factors and sources of support in the workplace as experienced by UK foundation and junior doctors: a qualitative study. BMJ Open 2021; 11:e045588. [PMID: 34162643 PMCID: PMC8231035 DOI: 10.1136/bmjopen-2020-045588] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
OBJECTIVES This paper reports findings identifying foundation and junior doctors' experiences of occupational and psychological protective factors in the workplace and sources of effective support. DESIGN Interpretative, inductive, qualitative study involving in-depth interviews with 21 junior doctor participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING National Health Service in the UK. PARTICIPANTS Participants were recruited from junior doctors through social media (eg, the British Medical Association (BMA) junior doctors' Facebook group, Twitter and the mental health research charity websites). A purposive sample of 16 females and 5 males, ethnically diverse, from a range of specialities, across the UK. Junior doctor participants self-identified as having stress, distress, anxiety, depression and suicidal thoughts or having attempted to kill themselves. RESULTS Analysis identified three main themes, with corresponding subthemes relating to protective work factors and facilitators of support: (1) support from work colleagues - help with managing workloads and emotional support; (2) supportive leadership strategies, including feeling valued and accepted, trust and communication, supportive learning environments, challenging stigma and normalising vulnerability; and (3) access to professional support - counselling, cognitive-behavioural therapy and medication through general practitioners, specialist support services for doctors and private therapy. CONCLUSIONS Findings show that supportive leadership, effective management practices, peer support and access to appropriate professional support can help mitigate the negative impact of working conditions and cultures experienced by junior doctors. Feeling connected, supported and valued by colleagues and consultants acts as an important buffer against emotional distress despite working under challenging working conditions.
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Affiliation(s)
- Ruth Riley
- College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Farina Kokab
- School of Social Policy, University of Birmingham, Birmingham, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Anya Gopfert
- Oxford University Hospitals NHS Trust, Oxford, UK
| | - Maria Van Hove
- London School of Hygiene & Tropical Medicine, London, UK
| | - Anna K Taylor
- Faculty of Medicine and Health, Leeds Institute of Health Sciences, Leeds, UK
| | - Kevin Teoh
- Department of Organizational Psychology, Birkbeck University of London, London, UK
| | - James Martin
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Louis Appleby
- Department of Psychiatry & Behavioral Sciences, University of Manchester, Manchester, UK
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Scope A, Leaviss J, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R. The acceptability of primary care or community-based behavioural interventions for persistent physical symptoms: Qualitative systematic review. Br J Health Psychol 2021; 26:1069-1094. [PMID: 33797174 DOI: 10.1111/bjhp.12521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 03/09/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE Persistent physical symptoms (PPS) are often associated with profound physical disability and psychological distress. Interventions for PPS that promote behavioural change aim to reduce levels of symptoms and improve overall functioning in patients. The evidence for these interventions is mixed, with effective relationships between patients and health practitioners (HPs) reported as the key to the success of primary care interventions. The objectives of this systematic review were to synthesize the qualitative evidence and to evaluate the acceptability of behavioural interventions for PPS in primary care, from the perspective of both patients and HPs. METHODS A comprehensive literature search was conducted in seven major electronic bibliographic databases, to February 2019. The aim was to identify a broad range of literature including, qualitative research, mixed methods research, and qualitative data embedded in trial reports or process evaluations. Fifty-eight full papers were screened against the inclusion criteria. Nine studies were included and quality-assessed. A qualitative evidence synthesis was conducted using thematic synthesis. RESULTS Some patients and HPs reported positive gains from taking part in or delivering interventions, with appropriate support and explanation of their symptoms important for patients. Barriers appeared to be underpinned by the relationship between the patients and HPs, and by beliefs and attitudes held by both parties. CONCLUSIONS Patients should be provided with adequate information to make an informed decision about whether an intervention is appropriate for them, and interventions should not end suddenly or without adequate follow-up. HPs should receive training and supervision to address their lack of confidence, and improve their knowledge of PPS.
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Affiliation(s)
- Alison Scope
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Joanna Leaviss
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), The University of Sheffield, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, UK
| | - Rona Moss-Morris
- Psychological Medicine and Integrated Care Clinical Academic Group, Department of Psychology, Kings College London, UK
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Abstract
OBJECTIVES Depression and anxiety are common in later life, particularly when people are frail. This leads to reduced quality of life, faster decline in physical health and increased health/social care use. Available treatments are commonly not tailored to people with frailty. We explored frail older peoples' experiences of depression and/or anxiety and how services could be adapted to their needs. METHODS Semi-structured interviews with 28 older people in the UK purposively sampled for practice location and severity of frailty and anxiety/depression. We asked about symptoms, interactions with physical health, help-seeking, treatments and what might help in future. We audio-recorded and transcribed interviews, using thematic analysis to inductively derive themes. RESULTS Frail older people had low expectations of their wellbeing at this point in life due to multiple physical health issues and so anxiety and mild depressive symptoms were normalised. There was a particular reluctance and uncertainty regarding help-seeking for anxiety. Treatments were considered appropriate where they aligned with coping skills developed over their lifetime, and facilitated independence and problem-solving skills. Most older people felt their knowledge of mental health was limited and relied upon information about and endorsement of therapies from an expert. This was usually their GP, but access was often problematic. Online methods of accessing information and therapies were not popular. CONCLUSION Mental health support for frail older people needs to address late-life anxieties as well as depression, account for physical health issues, align with older people's need for independence and facilitate coping skills.
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Affiliation(s)
- Rachael Frost
- Department of Primary Care and Population Health, University College London, London, UK,CONTACT Rachael Frost
| | - Pushpa Nair
- Department of Primary Care and Population Health, University College London, London, UK
| | - Su Aw
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | - Kalpa Kharicha
- Department of Primary Care and Population Health, University College London, London, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London, London, UK
| | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
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Nair P, Bhanu C, Frost R, Buszewicz M, Walters KR. A Systematic Review of Older Adults' Attitudes Towards Depression and Its Treatment. Gerontologist 2020; 60:e93-e104. [PMID: 31115449 DOI: 10.1093/geront/gnz048] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Late-life depression is a major societal concern, but older adults' attitudes toward its treatment remain complex. We aimed to explore older adults' views regarding depression and its treatment. RESEARCH DESIGN AND METHODS We undertook a systematic review and thematic synthesis of qualitative studies that explored the views of older community-dwelling adults with depression (not actively engaged in treatment), about depression and its treatment. We searched 7 databases (inception-November 2018) and 2 reviewers independently quality-appraised studies using the CASP checklist. RESULTS Out of 8,351 records, we included 11 studies for thematic synthesis. Depression was viewed as a normal reaction to life stressors and ageing. Consequently, older adults preferred self-management strategies (e.g., socializing, prayer) that aligned with their lived experiences and self-image. Professional interventions (e.g., antidepressants, psychological therapies) were sometimes considered necessary for more severe depression, but participants had mixed views. Willingness to try treatments was based on a balance of different judgments, including perceptions about potential harm and attitudes based on trust, familiarity, and past experiences. Societal and structural factors, including stigma, ethnicity, and ageism, also influenced treatment attitudes. DISCUSSION AND IMPLICATIONS Supporting older adults to self-manage milder depressive symptoms may be more acceptable than professional interventions. Assisting older adults with accessing professional help for more severe symptoms might be better achieved by integrating access to help within familiar, convenient locations to reduce stigma and increase accessibility. Discussing treatment choices using narratives that engage with older adults' lived experiences of depression may lead to greater acceptability and engagement.
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Affiliation(s)
- Pushpa Nair
- Department of Primary Care and Population Health, University College London, UK
| | - Cini Bhanu
- Department of Primary Care and Population Health, University College London, UK
| | - Rachael Frost
- Department of Primary Care and Population Health, University College London, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London, UK
| | - Kate R Walters
- Department of Primary Care and Population Health, University College London, UK
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Wright DM, Konstantakopoulou E, Montesano G, Nathwani N, Garg A, Garway-Heath D, Crabb DP, Gazzard G, Adeleke M, Ambler G, Barton K, Bourne R, Broadway D, Bunce C, Buszewicz M, Crabb D, Davis A, Garg A, Garway-Heath D, Gazzard G, Hornan D, Hunter R, Jayaram H, Jiang Y, Konstantakopoulou E, Lim S, Liput J, Manners T, Montesano G, Morris S, Nathwani N, Ometto G, Rubin G, Strouthidis N, Vickerstaff V, Wilson S, Wormald R, Wright D, Zhu H. Visual Field Outcomes from the Multicenter, Randomized Controlled Laser in Glaucoma and Ocular Hypertension Trial (LiGHT). Ophthalmology 2020; 127:1313-1321. [PMID: 32402553 DOI: 10.1016/j.ophtha.2020.03.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 03/20/2020] [Accepted: 03/23/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To compare visual field outcomes of ocular hypertensive and glaucoma patients treated first with medical therapy with those treated first with selective laser trabeculoplasty (SLT). DESIGN Secondary analysis of patients from the Laser in Glaucoma and Ocular Hypertension study, a multicenter randomized controlled trial. PARTICIPANTS Three hundred forty-four patients (588 eyes) treated first with medical therapy and 344 patients (590 eyes) treated first with SLT. METHODS Visual fields (VFs) were measured using standard automated perimetry and arranged in series (median length and duration, 9 VFs over 48 months). Hierarchical linear models were used to estimate pointwise VF progression rates, which were then averaged to produce a global progression estimate for each eye. Proportions of points and patients in each treatment group with fast (<-1 dB/year) or moderate (<-0.5 dB/year) progression were compared using log-binomial regression. MAIN OUTCOME MEASURES Pointwise and global progression rates of total deviation (TD) and pattern deviation (PD). RESULTS A greater proportion of eyes underwent moderate or fast TD progression in the medical therapy group compared with the SLT group (26.2% vs. 16.9%; risk ratio [RR], 1.55; 95% confidence interval [CI], 1.23-1.93; P < 0.001). A similar pattern was observed for pointwise rates (medical therapy, 26.1% vs. SLT, 19.0%; RR, 1.37; 95% CI, 1.33-1.42; P < 0.001). A greater proportion of pointwise PD rates were categorized as moderate or fast in the medical therapy group (medical therapy, 11.5% vs. SLT, 8.3%; RR, 1.39; 95% CI, 1.32-1.46; P < 0.001). No statistical difference was found in the proportion of eyes that underwent moderate or fast PD progression (medical therapy, 9.9% vs. SLT, 7.1%; RR, 1.39; 95% CI, 0.95, 2.03; P = 0.0928). CONCLUSIONS A slightly larger proportion of ocular hypertensive and glaucoma patients treated first with medical therapy underwent rapid VF progression compared with those treated first with SLT.
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Affiliation(s)
- David M Wright
- Centre for Public Health, Queen's University Belfast, Belfast, United Kingdom; Health Data Research UK, London, United Kingdom
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom; Division of Optics and Optometry, University of West Attica, Athens, Greece
| | - Giovanni Montesano
- Optometry and Visual Science, School of Health Science, City, University of London, London, United Kingdom
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom
| | - David P Crabb
- Optometry and Visual Science, School of Health Science, City, University of London, London, United Kingdom.
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, United Kingdom; Institute of Ophthalmology, University College London, United Kingdom
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15
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Morris S, Buszewicz M. Selective laser trabeculoplasty versus drops for newly diagnosed ocular hypertension and glaucoma: the LiGHT RCT. Health Technol Assess 2020; 23:1-102. [PMID: 31264958 DOI: 10.3310/hta23310] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND Newly diagnosed open-angle glaucoma (OAG) and ocular hypertension (OHT) are habitually treated with intraocular pressure (IOP)-lowering eyedrops. Selective laser trabeculoplasty (SLT) is a safe alternative to drops and is rarely used as first-line treatment. OBJECTIVES To compare health-related quality of life (HRQoL) in newly diagnosed, treatment-naive patients with OAG or OHT, treated with two treatment pathways: topical IOP-lowering medication from the outset (Medicine-1st) or primary SLT followed by topical medications as required (Laser-1st). We also compared the clinical effectiveness and cost-effectiveness of the two pathways. DESIGN A 36-month pragmatic, unmasked, multicentre randomised controlled trial. SETTINGS Six collaborating specialist glaucoma clinics across the UK. PARTICIPANTS Newly diagnosed patients with OAG or OHT in one or both eyes who were aged ≥ 18 years and able to provide informed consent and read and understand English. Patients needed to qualify for treatment, be able to perform a reliable visual field (VF) test and have visual acuity of at least 6 out of 36 in the study eye. Patients with VF loss mean deviation worse than -12 dB in the better eye or -15 dB in the worse eye were excluded. Patients were also excluded if they had congenital, early childhood or secondary glaucoma or ocular comorbidities; if they had any previous ocular surgery except phacoemulsification, at least 1 year prior to recruitment or any active treatment for ophthalmic conditions; if they were pregnant; or if they were unable to use topical medical therapy or had contraindications to SLT. INTERVENTIONS SLT according to a predefined protocol compared with IOP-lowering eyedrops, as per national guidelines. MAIN OUTCOME MEASURES The primary outcome was HRQoL at 3 years [as measured using the EuroQol-5 Dimensions, five-level version (EQ-5D-5L) questionnaire]. Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness and safety. RESULTS Of the 718 patients enrolled, 356 were randomised to Laser-1st (initial SLT followed by routine medical treatment) and 362 to Medicine-1st (routine medical treatment only). A total of 652 (91%) patients returned the primary outcome questionnaire at 36 months. The EQ-5D-5L score was not significantly different between the two arms [adjusted mean difference (Laser-1st - Medicine-1st) 0.01, 95% confidence interval (CI) -0.01 to 0.03; p = 0.23] at 36 months. Over 36 months, the proportion of visits at which IOP was within the target range was higher in the Laser-1st arm (93.0%, 95% CI 91.9% to 94.0%) than in the Medicine-1st arm (91.3%, 95% CI 89.9% to 92.5%), with IOP-lowering glaucoma surgery required in 0 and 11 patients, respectively. There was a 97% probability of Laser-1st being more cost-effective than Medicine-1st for the NHS, at a willingness to pay for a quality-adjusted life-year of £20,000, with a reduction in ophthalmology costs of £458 per patient (95% of bootstrap iterations between -£585 and -£345). LIMITATION An unmasked design, although a limitation, was essential to capture any treatment effects on patients' perception. The EQ-5D-5L questionnaire is a generic tool used in multiple settings and may not have been the most sensitive tool to investigate HRQoL. CONCLUSIONS Compared with medication, SLT provided a stable, drop-free IOP control to 74.2% of patients for at least 3 years, with a reduced need for surgery, lower cost and comparable HRQoL. Based on the evidence, SLT seems to be the most cost-effective first-line treatment option for OAG and OHT, also providing better clinical outcomes. FUTURE WORK Longitudinal research into the clinical efficacy of SLT as a first-line treatment will specify the long-term differences of disease progression, treatment intensity and ocular surgery rates between the two pathways. TRIAL REGISTRATION Current Controlled Trials ISRCTN32038223. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 31. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Gus Gazzard
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Evgenia Konstantakopoulou
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - David Garway-Heath
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Anurag Garg
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Catey Bunce
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard Wormald
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK.,London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Nathwani
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- National Institute for Health Research Biomedical Research Centre, Moorfields Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
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Spiers J, Buszewicz M, Chew-Graham CA, Riley R. The experiences of general practitioner partners living with distress: An interpretative phenomenological analysis. J Health Psychol 2020; 25:1439-1449. [PMID: 29468904 PMCID: PMC7479991 DOI: 10.1177/1359105318758860] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
Doctors, including general practitioners, experience higher levels of mental illness than the general population. General practitioners who are partners in their practices may face heightened stress. In total, 10 general practitioner partners living with work-related distress were interviewed, and transcripts were analysed using interpretative phenomenological analysis. Three major themes arose: (1) extreme distress, (2) conflicted doctor identity and (3) toxic versus supportive workplace relationships. Participants detailed symptoms of depression, anxiety and burnout; reported conflicted identities; and discussed the impact of bullying partnerships. We recommend that organisational interventions tackling issues such as bullying be implemented and opportunities to debrief be offered as protected time activities to general practitioner partners.
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Affiliation(s)
- Johanna Spiers
- University of Bristol, UK,Johanna Spiers, 2 The Old Byre, East Dundry
Lane, East Dundry, Bristol BS41 8NH, UK.
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Leaviss J, Davis S, Ren S, Hamilton J, Scope A, Booth A, Sutton A, Parry G, Buszewicz M, Moss-Morris R, White P. Behavioural modification interventions for medically unexplained symptoms in primary care: systematic reviews and economic evaluation. Health Technol Assess 2020; 24:1-490. [PMID: 32975190 PMCID: PMC7548871 DOI: 10.3310/hta24460] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND The term 'medically unexplained symptoms' is used to cover a wide range of persistent bodily complaints for which adequate examination and appropriate investigations do not reveal sufficiently explanatory structural or other specified pathologies. A wide range of interventions may be delivered to patients presenting with medically unexplained symptoms in primary care. Many of these therapies aim to change the behaviours of the individual who may have worsening symptoms. OBJECTIVES An evidence synthesis to determine the clinical effectiveness and cost-effectiveness of behavioural modification interventions for medically unexplained symptoms delivered in primary care settings was undertaken. Barriers to and facilitators of the effectiveness and acceptability of these interventions from the perspective of patients and service providers were evaluated through qualitative review and realist synthesis. DATA SOURCES Full search strategies were developed to identify relevant literature. Eleven electronic sources were searched. Eligibility criteria - for the review of clinical effectiveness, randomised controlled trials were sought. For the qualitative review, UK studies of any design were included. For the cost-effectiveness review, papers were restricted to UK studies reporting outcomes as quality-adjusted life-year gains. Clinical searches were conducted in November 2015 and December 2015, qualitative searches were conducted in July 2016 and economic searches were conducted in August 2016. The databases searched included MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO and EMBASE. Updated searches were conducted in February 2019 and March 2019. PARTICIPANTS Adult participants meeting the criteria for medically unexplained symptoms, including somatoform disorders, chronic unexplained pain and functional somatic syndromes. INTERVENTIONS Behavioural interventions were categorised into types. These included psychotherapies, exercise-based interventions, multimodal therapies (consisting of more than one intervention type), relaxation/stretching/social support/emotional support, guided self-help and general practitioner interventions, such as reattribution. Evidence synthesis: a network meta-analysis was conducted to allow a simultaneous comparison of all evaluated interventions in a single coherent analysis. Separate network meta-analyses were performed at three time points: end of treatment, short-term follow-up (< 6 months since the end of treatment) and long-term follow-up (≥ 6 months after the end of treatment). Outcomes included physical and psychological symptoms, physical functioning and impact of the illness on daily activities. Economic evaluation: within-trial estimates of cost-effectiveness were generated for the subset of studies where utility values (or quality-adjusted life-years) were reported or where these could be estimated by mapping from Short Form questionnaire-36 items or Short Form questionnaire-12 items outcomes. RESULTS Fifty-nine studies involving 9077 patients were included in the clinical effectiveness review. There was a large degree of heterogeneity both between and within intervention types, and the networks were sparse across all outcomes. At the end of treatment, behavioural interventions showed some beneficial effects when compared with usual care, in particular for improvement of specific physical symptoms [(1) pain: high-intensity cognitive-behavioural therapy (CBTHI) standardised mean difference (SMD) 0.54 [95% credible interval (CrI) 0.28 to 0.84], multimodal SMD 0.52 (95% CrI 0.19 to 0.89); and (2) fatigue: low-intensity cognitive-behavioural therapy (CBTLI) SMD 0.72 (95% CrI 0.27 to 1.21), relaxation/stretching/social support/emotional support SMD 0.87 (95% CrI 0.20 to 1.55), graded activity SMD 0.51 (95% CrI 0.14 to 0.93), multimodal SMD 0.52 (95% CrI 0.14 to 0.92)] and psychological outcomes [(1) anxiety CBTHI SMD 0.52 (95% CrI 0.06 to 0.96); (2) depression CBTHI SMD 0.80 (95% CrI 0.26 to 1.38); and (3) emotional distress other psychotherapy SMD 0.58 (95% CrI 0.05 to 1.13), relaxation/stretching/social support/emotional support SMD 0.66 (95% CrI 0.18 to 1.28) and sport/exercise SMD 0.49 (95% CrI 0.03 to 1.01)]. At short-term follow-up, behavioural interventions showed some beneficial effects for specific physical symptoms [(1) pain: CBTHI SMD 0.73 (95% CrI 0.10 to 1.39); (2) fatigue: CBTLI SMD 0.62 (95% CrI 0.11 to 1.14), relaxation/stretching/social support/emotional support SMD 0.51 (95% CrI 0.06 to 1.00)] and psychological outcomes [(1) anxiety: CBTHI SMD 0.74 (95% CrI 0.14 to 1.34); (2) depression: CBTHI SMD 0.93 (95% CrI 0.37 to 1.52); and (3) emotional distress: relaxation/stretching/social support/emotional support SMD 0.82 (95% CrI 0.02 to 1.65), multimodal SMD 0.43 (95% CrI 0.04 to 0.91)]. For physical functioning, only multimodal therapy showed beneficial effects: end-of-treatment SMD 0.33 (95% CrI 0.09 to 0.59); and short-term follow-up SMD 0.78 (95% CrI 0.23 to 1.40). For impact on daily activities, CBTHI was the only behavioural intervention to show beneficial effects [end-of-treatment SMD 1.30 (95% CrI 0.59 to 2.00); and short-term follow-up SMD 2.25 (95% CrI 1.34 to 3.16)]. Few effects remained at long-term follow-up. General practitioner interventions showed no significant beneficial effects for any outcome. No intervention group showed conclusive beneficial effects for measures of symptom load (somatisation). A large degree of heterogeneity was found across individual studies in the assessment of cost-effectiveness. Several studies suggested that the interventions produce fewer quality-adjusted life-years than usual care. For those interventions that generated quality-adjusted life-year gains, the mid-point incremental cost-effectiveness ratios (ICERs) ranged from £1397 to £129,267, but, where the mid-point ICER fell below £30,000, the exploratory assessment of uncertainty suggested that it may be above £30,000. LIMITATIONS Sparse networks meant that it was not possible to conduct a metaregression to explain between-study differences in effects. Results were not consistent within intervention type, and there were considerable differences in characteristics between studies of the same type. There were moderate to high levels of statistical heterogeneity. Separate analyses were conducted for three time points and, therefore, analyses are not repeated-measures analyses and do not account for correlations between time points. CONCLUSIONS Behavioural interventions showed some beneficial effects for specific medically unexplained symptoms, but no one behavioural intervention was effective across all medically unexplained symptoms. There was little evidence that these interventions are effective for measures of symptom load (somatisation). General practitioner-led interventions were not shown to be effective. Considerable heterogeneity in interventions, populations and sparse networks mean that results should be interpreted with caution. The relationship between patient and service provider is perceived to play a key role in facilitating a successful intervention. Future research should focus on testing the therapeutic effects of the general practitioner-patient relationship within trials of behavioural interventions, and explaining the observed between-study differences in effects within the same intervention type (e.g. with more detailed reporting of defined mechanisms of the interventions under study). STUDY REGISTRATION This study is registered as PROSPERO CRD42015025520. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 24, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joanna Leaviss
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Shijie Ren
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Jean Hamilton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Alison Scope
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Andrew Booth
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Anthea Sutton
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Glenys Parry
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Marta Buszewicz
- Department of Primary Care and Population Health, University College London Medical School, London, UK
| | | | - Peter White
- Barts and The London School of Medicine and Dentistry, London, UK
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Serfaty M, Deborah H, Buszewicz M, Blanchard M, Murad S, King M. FC16-04 - The clinical effectiveness of individual cognitive behaviour therapy for depressed older people in primary care and the use of a talking control (TC). Eur Psychiatry 2020. [DOI: 10.1016/s0924-9338(11)73611-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
ObjectiveTo determine the clinical effectiveness of Cognitive Behaviour Therapy (CBT) delivered in primary care for older people with depression and evaluation of a talking control (TC).MethodsA single-blind, randomized, controlled trial with 4- and 10-month follow-up. 204 people, aged 65 years or more, with a Geriatric Mental State diagnosis of depression were recruited from primary care. The interventions were: treatment as usual (TAU), TAU plus TC, or TAU plus CBT. The TC and CBT were offered over 4 months. The TC was to control for common effects in therapy. The Beck Depression Inventory-II (BDI-II) was the main outcome. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intention to treat analysis (ITT) and Compliance Average Causal Effect (CACE) analyses was employed. The Cognitive therapy scale (CTS) evaluated common and specific factors in therapy.ResultsA mean of 7 sessions of TC or CBT were delivered. ITT analysis found improvements of −3.07 (95% confidence interval [CI], −5.73 to −0.42) and −3.65 (95% CI, −6.18 to −1.12) in BDI-II scores in favour of CBT vs TAU and TC respectively. CACE analysis found a benefit of 0.4 points (95% CI, 0.01 to 0.72) per therapy session of CBT over TC. Ratings for CBT on the CTS were high (mean [SD], 54.2 [4.1]) and showed no difference for nonspecific, but significant differences for specific factors in therapy.ConclusionCBT is an effective treatment for depressed older people. Improvement appears to be associated with specific factors in CBT.
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19
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Serfaty M, Aspden T, Satchell J, Kessel A, Laycock G, Brewin CR, Buszewicz M, O'Keeffe A, Hunter R, Leavey G, Cuming-Higgs J, Drennan V, Riveros M, Andrew D, Blanchard M. The clinical and cost-effectiveness of a Victim Improvement Package (VIP) for the reduction of chronic symptoms of depression or anxiety in older victims of common crime (the VIP trial): study protocol for a randomised controlled trial. Trials 2020; 21:333. [PMID: 32299478 PMCID: PMC7161204 DOI: 10.1186/s13063-020-4211-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Accepted: 02/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Older people are vulnerable to sustained high levels of psychosocial distress following a crime. A cognitive behavioural therapy (CBT)-informed psychological therapy, the Victim Improvement Package (VIP) may aid recovery. The VIP trial aims to test the clinical and cost-effectiveness of the VIP for alleviating depressive and anxiety symptoms in older victims of crime. METHODS/DESIGN People aged 65 years or more who report being a victim of crime will be screened by Metropolitan Police Service Safer Neighbourhood Teams within a month of the crime for distress using the Patient Health Questionnaire-2 and the Generalised Anxiety Disorder-2. Those who screen positive will be signposted to their GP for assistance, and re-screened at 3 months. Participants who screen positive for depression and/or anxiety at re-screening are randomised to a CBT informed VIP added to treatment as usual (TAU) compared to TAU alone. The intervention consists of 10 individual 1-h sessions, delivered weekly by therapists from the mental health charity Mind. The primary outcome measure is the Beck Depression Inventory-II (BDI-II) and the Beck Anxiety Inventory (BAI), used as a composite measure, assessed at 6 months after the crime (post therapy) with a 9-month post-crime follow-up. Secondary outcome measures include the EQ-5D, and a modified Client Service Receipt Inventory. A total of 226 participants will be randomised VIP:TAU with a ratio 1:1, in order to detect a standardised difference of at least 0.5 between groups, using a mixed-effects linear-regression model with 90% power and a 5% significance level (adjusting for therapist clustering and potential drop-out). A cost-effectiveness analysis will incorporate intervention costs to compare overall health care costs and quality of life years between treatment arms. An embedded study will examine the impact of past trauma and engagement in safety behaviours and distress on the main outcomes. DISCUSSION This trial should provide data on the clinical and cost-effectiveness of a CBT-informed psychological therapy for older victims of crime with anxiety and/or depressive symptoms and should demonstrate a model of integrated cross-agency working. Our findings should provide evidence for policy-makers, commissioners and clinicians responding to the needs of older victims of crime. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number, ID: ISRCTN16929670. Registered on 3 August 2016.
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Affiliation(s)
- Marc Serfaty
- Division of Psychiatry, UCL, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK. .,Priory Hospital North London, London, N14 6RA, UK.
| | - Trefor Aspden
- Division of Psychiatry, UCL, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Jessica Satchell
- Division of Psychiatry, UCL, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Anthony Kessel
- Public Health England, 133-155 Waterloo Road, London, SE1 8UG, UK
| | - Gloria Laycock
- Jill Dando Institute of Security and Crime Science, UCL, 35 Tavistock Square, London, WC1H 9EZ, UK
| | - Chris R Brewin
- Clinical Psychology, UCL, Gower Street, London, WC1E 6BT, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, Gower Street, London, WC1E 6BT, UK
| | - Aidan O'Keeffe
- Department of Statistical Science, UCL, Gower St., London, WC1E 6BT, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, UCL, Royal Free Medical School, London, NW3 2PF, UK
| | - Gerard Leavey
- Bamford Centre for Mental Health Wellbeing, Ulster University, Cromore Road, Coleraine, Northern Ireland
| | | | - Vari Drennan
- Joint Faculty of Health, Social Care and Education, Kingston University and St. George's University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Monica Riveros
- Age UK Camden, Tavis House, 1-6 Tavistock Square, London, WC1H 9NA, UK
| | - David Andrew
- Lived experience researcher/user representative Middlesex, London, UK
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20
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Garg A, Vickerstaff V, Nathwani N, Garway-Heath D, Konstantakopoulou E, Ambler G, Bunce C, Wormald R, Barton K, Gazzard G, Adeleke M, Ambler G, Barton K, Bourne R, Broadway D, Bunce C, Buszewicz M, Crabb D, Davis A, Garg A, Garway-Heath D, Gazzard G, Hornan D, Hunter R, Jayaram H, Jiang Y, Konstantakopoulou E, Lim S, Liput J, Manners T, Montesano G, Morris S, Nathwani N, Ometto G, Rubin G, Strouthidis N, Vickerstaff V, Wilson S, Wormald R, Wright D, Zhu H. Efficacy of Repeat Selective Laser Trabeculoplasty in Medication-Naive Open-Angle Glaucoma and Ocular Hypertension during the LiGHT Trial. Ophthalmology 2020; 127:467-476. [PMID: 32005561 DOI: 10.1016/j.ophtha.2019.10.023] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Revised: 09/28/2019] [Accepted: 10/22/2019] [Indexed: 11/28/2022] Open
Abstract
PURPOSE To determine the efficacy of repeat selective laser trabeculoplasty (SLT) in medication-naive open-angle glaucoma (OAG) and ocular hypertensive (OHT) patients requiring repeat treatment for early to medium-term failure during the Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. DESIGN Post hoc analysis of SLT treatment arm of a multicenter prospective randomized controlled trial. PARTICIPANTS Treatment-naive OAG or OHT requiring repeat 360-degree SLT within 18 months. Retreatment was triggered by predefined IOP and disease-progression criteria (using objective individualized target IOPs). METHODS After SLT at baseline, patients were followed for a minimum of 18 months after second (repeat) SLT. A mixed-model analysis was performed with the eye as the unit of analysis, with crossed random effects to adjust for correlation between fellow eyes and repeated measures within eyes. Kaplan-Meier curves plot the duration of effect. MAIN OUTCOME MEASURES Initial (early) IOP lowering at 2 months and duration of effect after initial and repeat SLT. RESULTS A total of 115 eyes of 90 patients received repeat SLT during the first 18 months of the trial. Pretreatment IOP before initial SLT was significantly higher than before retreatment IOP of repeat SLT (mean difference, 3.4 mmHg; 95% confidence interval [CI], 2.6-4.3 mmHg; P < 0.001). Absolute IOP reduction at 2 months was greater after initial SLT compared with repeat SLT (mean difference, 1.0 mmHg; 95% CI, 0.2-1.8 mmHg; P = 0.02). Adjusted absolute IOP reduction at 2 months (adjusting for IOP before initial or repeat laser) was greater after repeat SLT (adjusted mean difference, -1.1 mmHg, 95% CI, -1.7 to -0.5 mmHg; P = 0.001). A total of 34 eyes were early failures (retreatment 2 months after initial SLT) versus 81 later failures (retreatment >2 months after initial SLT). No significant difference in early absolute IOP reduction at 2 months after repeat SLT was noted between early and later failures (mean difference, 0.3 mmHg; 95% CI, -1.1 to 1.8 mmHg; P = 0.655). Repeat SLT maintained drop-free IOP control in 67% of 115 eyes at 18 months, with no clinically relevant adverse events. CONCLUSIONS These exploratory analyses demonstrate that repeat SLT can maintain IOP at or below target IOP in medication-naive OAG and OHT eyes requiring retreatment with at least an equivalent duration of effect to initial laser.
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Affiliation(s)
- Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, United Kingdom; The Research Department of Primary Care and Population Health, University College London, London, United Kingdom
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, United Kingdom
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom; School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom; London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom
| | - Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust and UCL Institute of Ophthalmology, London, United Kingdom.
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21
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Bennett SD, Heyman I, Coughtrey AE, Buszewicz M, Byford S, Dore CJ, Fonagy P, Ford T, Moss-Morris R, Stephenson T, Varadkar S, Walker E, Shafran R. Assessing feasibility of routine identification tools for mental health disorder in neurology clinics. Arch Dis Child 2019; 104:1161-1166. [PMID: 31079075 DOI: 10.1136/archdischild-2018-316595] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 02/14/2019] [Accepted: 03/07/2019] [Indexed: 11/04/2022]
Abstract
OBJECTIVE We aimed to test the feasibility of using an online parent-completed diagnostic assessment for detecting common mental health disorders in children attending neurology clinics. The assessment does not require intervention by a mental health professional or additional time in the clinic appointment. SETTING Two parallel and related screening studies were undertaken: Study 1: Tertiary paediatric neurology clinics. Study 2: Secondary and tertiary paediatric neurology clinics. PATIENTS Study 1: 406 Young people aged 7-18 attending paediatric neurology clinics. Study 2: 225 Young people aged 3-18 attending paediatric epilepsy clinics. INTERVENTIONS Parents completed online versions of the Strengths and Difficulties Questionnaire (SDQ) and Development and Well-being Assessment (DAWBA). MAIN OUTCOME MEASURES We investigated: the willingness of families to complete the measures, proportion identified as having mental health disorders, time taken to complete the measures and acceptability to families and clinicians. RESULTS The mean total difficulties score of those that had completed the SDQ fell in the 'high' and 'very high' ranges. 60% and 70% of the DAWBAS completed met criteria for at least one DSM-IV disorder in study 1 and 2 respectively. 98% of the parents reported that the screening methods used were acceptable.
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Affiliation(s)
| | - Isobel Heyman
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Anna E Coughtrey
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Sarah Byford
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Caroline J Dore
- Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Peter Fonagy
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Tamsin Ford
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Rona Moss-Morris
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | | | - Sophia Varadkar
- UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Erin Walker
- Patient Insight and Involvement, UCLPartners, London, UK
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health, London, UK
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22
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Nielsen G, Stone J, Buszewicz M, Carson A, Goldstein LH, Holt K, Hunter R, Marsden J, Marston L, Noble H, Reuber M, Edwards MJ. Physio4FMD: protocol for a multicentre randomised controlled trial of specialist physiotherapy for functional motor disorder. BMC Neurol 2019; 19:242. [PMID: 31638942 PMCID: PMC6802344 DOI: 10.1186/s12883-019-1461-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/10/2019] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND Patients with functional motor disorder (FMD) experience persistent and disabling neurological symptoms such as weakness, tremor, dystonia and disordered gait. Physiotherapy is usually considered an important part of treatment; however, sufficiently-powered controlled studies are lacking. Here we present the protocol of a randomised controlled trial (RCT) that aims to evaluate the clinical and cost effectiveness of a specialist physiotherapy programme for FMD. METHODS/DESIGN The trial is a pragmatic, multicentre, single blind parallel arm randomised controlled trial (RCT). 264 Adults with a clinically definite diagnosis of FMD will be recruited from neurology clinics and randomised to receive either the trial intervention (a specialist physiotherapy protocol) or treatment as usual control (referral to a community physiotherapy service suitable for people with neurological symptoms). Participants will be followed up at 6 and 12 months. The primary outcome is the Physical Function domain of the Short Form 36 questionnaire at 12 months. Secondary domains of measurement will include participant perception of change, mobility, health-related quality of life, health service utilisation, anxiety and depression. Health economic analysis will evaluate the cost impact of trial and control interventions from a health and social care perspective as well as societal perspective. DISCUSSION This trial will be the first adequately-powered RCT of physical-based rehabilitation for FMD. TRIAL REGISTRATION International Standard Randomised Controlled Trials Number ISRCTN56136713 . Registered 27 March 2018.
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Affiliation(s)
- Glenn Nielsen
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
- Priment Clinical Trials Unit, UCL, London, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Laura H. Goldstein
- King’s College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, UK
| | - Kate Holt
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, UCL, London, UK
- Priment Clinical Trials Unit, UCL, London, UK
| | - Jonathan Marsden
- School of Health Professions, University of Plymouth, Plymouth, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, UCL, London, UK
- Priment Clinical Trials Unit, UCL, London, UK
| | - Hayley Noble
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Sheffield, UK
| | - Mark J. Edwards
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Garg A, Vickerstaff V, Hunter R, Ambler G, Bunce C, Wormald R, Nathwani N, Barton K, Rubin G, Buszewicz M. Selective laser trabeculoplasty versus eye drops for first-line treatment of ocular hypertension and glaucoma (LiGHT): a multicentre randomised controlled trial. Lancet 2019; 393:1505-1516. [PMID: 30862377 PMCID: PMC6495367 DOI: 10.1016/s0140-6736(18)32213-x] [Citation(s) in RCA: 286] [Impact Index Per Article: 57.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2018] [Revised: 08/28/2018] [Accepted: 09/04/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Primary open angle glaucoma and ocular hypertension are habitually treated with eye drops that lower intraocular pressure. Selective laser trabeculoplasty is a safe alternative but is rarely used as first-line treatment. We compared the two. METHODS In this observer-masked, randomised controlled trial treatment-naive patients with open angle glaucoma or ocular hypertension and no ocular comorbidities were recruited between 2012 and 2014 at six UK hospitals. They were randomly allocated (web-based randomisation) to initial selective laser trabeculoplasty or to eye drops. An objective target intraocular pressure was set according to glaucoma severity. The primary outcome was health-related quality of life (HRQoL) at 3 years (assessed by EQ-5D). Secondary outcomes were cost and cost-effectiveness, disease-specific HRQoL, clinical effectiveness, and safety. Analysis was by intention to treat. This study is registered at controlled-trials.com (ISRCTN32038223). FINDINGS Of 718 patients enrolled, 356 were randomised to the selective laser trabeculoplasty and 362 to the eye drops group. 652 (91%) returned the primary outcome questionnaire at 36 months. Average EQ-5D score was 0·89 (SD 0·18) in the selective laser trabeculoplasty group versus 0·90 (SD 0·16) in the eye drops group, with no significant difference (difference 0·01, 95% CI -0·01 to 0·03; p=0·23). At 36 months, 74·2% (95% CI 69·3-78·6) of patients in the selective laser trabeculoplasty group required no drops to maintain intraocular pressure at target. Eyes of patients in the selective laser trabeculoplasty group were within target intracoluar pressure at more visits (93·0%) than in the eye drops group (91·3%), with glaucoma surgery to lower intraocular pressure required in none versus 11 patients. Over 36 months, from an ophthalmology cost perspective, there was a 97% probability of selective laser trabeculoplasty as first treatment being more cost-effective than eye drops first at a willingness to pay of £20 000 per quality-adjusted life-year gained. INTERPRETATION Selective laser trabeculoplasty should be offered as a first-line treatment for open angle glaucoma and ocular hypertension, supporting a change in clinical practice. FUNDING National Institute for Health Research, Health and Technology Assessment Programme.
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Affiliation(s)
- Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK.
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Anurag Garg
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, UCL Division of Psychiatry, University College London, London, UK; The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Hunter
- The Research Department of Primary Care and Population Health, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK; London School of Hygiene & Tropical Medicine, London, UK
| | - Neil Nathwani
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields Eye Hospital NHS Foundation Trust, London, UK; Institute of Ophthalmology, University College London, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College London, London, UK
| | - Marta Buszewicz
- The Research Department of Primary Care and Population Health, University College London, London, UK
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Panca M, Buszewicz M, Strydom A, Hassiotis A, Welch CA, Hunter RM. Resource use and cost of annual health checks in primary care for people with intellectual disabilities. J Intellect Disabil Res 2019; 63:233-243. [PMID: 30461105 PMCID: PMC6451619 DOI: 10.1111/jir.12569] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Revised: 10/10/2018] [Accepted: 10/14/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND The annual health check (AHC) programme, as part of a Directed Enhanced Service, offers an incentive to general practitioners in England to conduct health checks for people with intellectual disabilities (IDs). The aim of this analysis was to estimate the impact on health care costs of AHCs in primary care to the National Health Service in England by comparing adults with ID who did or did not have AHCs using data obtained from The Health Improvement Network. METHODS Two hundred eight records of people with ID from The Health Improvement Network database were analysed. Baseline health care resource use was captured at the time the first AHC was recorded (i.e. index date), or the earliest date after 1 April 2008 for those without an AHC. We examined the volume of resource use and associated costs that occurred at the time AHCs were performed, as well as before and after the index date. We then estimated the impact of AHCs on health care costs. RESULTS The average cost of AHC was estimated at £142.57 (95%CI £135.41 to £149.74). Primary, community and secondary health care costs increased significantly after the index date in the no AHC group owing to higher increase in resource utilisation. Regression analysis showed that the expected health care cost for those who have an AHC is 56% higher than for those who did not have an AHC. Age and gender were also associated with increase in expected health care cost. CONCLUSION The level of resource utilisation increased in both (AHC and no AHC) groups after the index date. Although the level of resource use before index date was lower in the no AHC group, it increased after the index date up to almost reaching the level of resource utilisation in the AHC group. Further research is needed to explore if the AHCs are effective in reducing health inequalities.
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Affiliation(s)
- Monica Panca
- UCL Institute of Epidemiology & Health Care, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF
| | - Marta Buszewicz
- UCL Institute of Epidemiology & Health Care, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF
| | - André Strydom
- Institute of Psychiatry Psychology and Neuroscience, King's College London, 16 De Crespigny Park, London SE5 8AF
| | - Angela Hassiotis
- UCL Division of Psychiatry, 149 Tottenham Court Road, London W1T 7NF
| | - Catherine A Welch
- Department of Cardiovascular Sciences, University of Leicester, Leicester, LE3 9QP
| | - Rachael M Hunter
- UCL Institute of Epidemiology & Health Care, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London NW3 2PF
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Nielsen G, Buszewicz M, Edwards MJ, Stevenson F. A qualitative study of the experiences and perceptions of patients with functional motor disorder. Disabil Rehabil 2019; 42:2043-2048. [DOI: 10.1080/09638288.2018.1550685] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Glenn Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Mark J. Edwards
- Motor Control and Movement Disorders Group, Institute of Molecular and Clinical Sciences, St Georges University of London, London, UK
| | - Fiona Stevenson
- Research Department of Primary Care and Population Health, UCL, London, UK
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Riley R, Spiers J, Chew-Graham CA, Taylor AK, Thornton GA, Buszewicz M. 'Treading water but drowning slowly': what are GPs' experiences of living and working with mental illness and distress in England? A qualitative study. BMJ Open 2018; 8:e018620. [PMID: 29724736 PMCID: PMC5942433 DOI: 10.1136/bmjopen-2017-018620] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES This paper provides an in-depth account of general practitioners' (GPs) experiences of living and working with mental illness and distress, as part of a wider study reporting the barriers and facilitators to help-seeking for mental illness and burn-out, and sources of stress/distress for GP participants. DESIGN Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING England. PARTICIPANTS A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face to face or over the telephone. RESULTS The findings report GP participants' in-depth experiences of distress and mental illness with many recollecting their distressing experiences and significant psychological and physical symptoms relating to chronic stress, anxiety, depression and/or burn-out, and a quarter articulating thoughts of suicide. Many talked about their shame, humiliation and embarrassment at their perceived inability to cope with the stresses of their job and/or their symptoms of mental illness. CONCLUSIONS These findings paint a concerning picture of the situation affecting primary care doctors, with participants' accounts suggesting there is a considerable degree of mental ill health and reduced well-being among GPs. The solutions are complex and lie in prevention and provision. There needs to be greater recognition of the components and cumulative effect of occupational stressors for doctors, such as the increasing workload and the clinical and emotional demands of the job, as well as the need for a culture shift within medicine to more supportive and compassionate work environments.
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Affiliation(s)
- Ruth Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Johanna Spiers
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | | | - Anna K Taylor
- Faculty of Health Sciences, University of Bristol, Bristol, UK
| | - Gail A Thornton
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
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Riley R, Spiers J, Buszewicz M, Taylor AK, Thornton G, Chew-Graham CA. What are the sources of stress and distress for general practitioners working in England? A qualitative study. BMJ Open 2018; 8:e017361. [PMID: 29326181 PMCID: PMC5780684 DOI: 10.1136/bmjopen-2017-017361] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 06/29/2017] [Accepted: 07/13/2017] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES This paper reports the sources of stress and distress experienced by general practitioners (GP) as part of a wider study exploring the barriers and facilitators to help-seeking for mental illness and burnout among this medical population. DESIGN Qualitative study using in-depth interviews with 47 GP participants. The interviews were audio-recorded, transcribed, anonymised and imported into NVivo V.11 to facilitate data management. Data were analysed using a thematic analysis employing the constant comparative method. SETTING England. PARTICIPANTS A purposive sample of GP participants who self-identified as: (1) currently living with mental distress, (2) returning to work following treatment, (3) off sick or retired early as a result of mental distress or (4) without experience of mental distress. Interviews were conducted face-to-face or over the telephone. RESULTS The key sources of stress/distress related to: (1) emotion work-the work invested and required in managing and responding to the psychosocial component of GPs' work, and dealing with abusive or confrontational patients; (2) practice culture-practice dynamics and collegial conflict, bullying, isolation and lack of support; (3) work role and demands-fear of making mistakes, complaints and inquests, revalidation, appraisal, inspections and financial worries. CONCLUSION In addition to addressing escalating workloads through the provision of increased resources, addressing unhealthy practice cultures is paramount. Collegial support, a willingness to talk about vulnerability and illness, and having open channels of communication enable GPs to feel less isolated and better able to cope with the emotional and clinical demands of their work. Doctors, including GPs, are not invulnerable to the clinical and emotional demands of their work nor the effects of divisive work cultures-culture change and access to informal and formal support is therefore crucial in enabling GPs to do their job effectively and to stay well.
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Affiliation(s)
- Ruth Riley
- Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Johanna Spiers
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | | | - Gail Thornton
- Bristol Medical School, University of Bristol, Bristol, UK
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Warner A, Walters K, Lamahewa K, Buszewicz M. How do hospital doctors manage patients with medically unexplained symptoms: a qualitative study of physicians. J R Soc Med 2017; 110:65-72. [PMID: 28169588 DOI: 10.1177/0141076816686348] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Objective Medically unexplained symptoms are a common presentation in medical practice and are associated with significant morbidity and high levels of service use. Most research exploring the attitudes and training of doctors in treating patients with unexplained symptoms has been conducted in primary care. This study aims to explore the ways in which doctors working in secondary care approach and manage patients with medically unexplained symptoms. Design A qualitative study using in-depth interviews and thematic analysis. Setting Three hospitals in the North Thames area. Participants Twenty consultant and training-grade physicians working in cardiology, gastroenterology, rheumatology and neurology. Main outcome measure Physicians' approach to patients with medically unexplained symptoms and their views on managing these patients. Results There was considerable variation in how the physicians approached patients who presented with medically unexplained symptoms. Investigations were often ordered without a clear rationale and the explanations given to patients when results of investigations were normal were highly variable, both within and across specialties. The doctor's level of experience appeared to be a more important factor in their investigation and management strategies than their medical specialty. Physicians reported little or no formal training in how to manage such presentations, with no apparent consistency in how they had developed their approach. Doctors described learning from their own experience and from senior role models. Organisational barriers were identified to the effective management of these patients, particularly in terms of continuity of care. Conclusions Given the importance of this topic, there is a need for serious consideration as to how the management of patients with medically unexplained symptoms is included in medical training and in the planning and delivery of services.
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Affiliation(s)
- Alex Warner
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, NW3 2PF, UK
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Gazzard G, Konstantakopoulou E, Garway-Heath D, Barton K, Wormald R, Morris S, Hunter R, Rubin G, Buszewicz M, Ambler G, Bunce C. Laser in Glaucoma and Ocular Hypertension (LiGHT) trial. A multicentre, randomised controlled trial: design and methodology. Br J Ophthalmol 2017; 102:593-598. [PMID: 28903966 DOI: 10.1136/bjophthalmol-2017-310877] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 07/30/2017] [Accepted: 08/05/2017] [Indexed: 11/03/2022]
Abstract
PURPOSE The Laser in Glaucoma and Ocular Hypertension (LiGHT) Trial aims to establish whether initial treatment with selective laser trabeculoplasty (SLT) is superior to initial treatment with topical medication for primary open-angle glaucoma (POAG) or ocular hypertension (OHT). DESIGN The LiGHT Trial is a prospective, unmasked, multicentre, pragmatic, randomised controlled trial. 718 previously untreated patients with POAG or OHT were recruited at six collaborating centres in the UK between 2012 and 2014. The trial comprises two treatment arms: initial SLT followed by conventional medical therapy as required, and medical therapy without laser therapy. Randomisation was provided online by a web-based randomisation service. Participants will be monitored for 3 years, according to routine clinical practice. The target intraocular pressure (IOP) was set at baseline according to an algorithm, based on disease severity and lifetime risk of loss of vision at recruitment, and subsequently adjusted on the basis of IOP control, optic disc and visual field. The primary outcome measure is health-related quality of life (HRQL) (EQ-5D five-level). Secondary outcomes are treatment pathway cost and cost-effectiveness, Glaucoma Utility Index, Glaucoma Symptom Scale, Glaucoma Quality of Life, objective measures of pathway effectiveness, visual function and safety profiles and concordance. A single main analysis will be performed at the end of the trial on an intention-to-treat basis. CONCLUSIONS The LiGHT Trial is a multicentre, pragmatic, randomised clinical trial that will provide valuable data on the relative HRQL, clinical effectiveness and cost-effectiveness of SLT and topical IOP-lowering medication. TRIAL REGISTRATION NUMBER ISRCTN32038223, Pre-results.
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Affiliation(s)
- Gus Gazzard
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Evgenia Konstantakopoulou
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK.,Centre for Public Health Research, School of Health Sciences, City University, London, UK
| | - David Garway-Heath
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Keith Barton
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK
| | - Richard Wormald
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,Institute of Ophthalmology, University College, London, UK
| | - Stephen Morris
- Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, London, UK
| | - Rachael Hunter
- Priment Clinical Trials Unit, University College London, Royal Free Medical School, London, UK
| | - Gary Rubin
- Institute of Ophthalmology, University College, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College Medical School, London, UK
| | - Gareth Ambler
- Department of Statistical Science, Faculty of Mathematics and Physical Sciences, University College London, London, UK
| | - Catey Bunce
- NIHR Biomedical Research Centre at Moorfields, Eye Hospital NHS Foundation Trust, London, UK.,International Centre for Eye Health (ICEH), Clinical Research Department, London School of Hygiene & Tropical Medicine, London, UK.,Department of Primary Care and Public Health, King's College London, London, UK
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Buszewicz M, Cape J, Serfaty M, Shafran R, Kabir T, Tyrer P, Clarke CS, Nazareth I. Pilot of a randomised controlled trial of the selective serotonin reuptake inhibitor sertraline versus cognitive behavioural therapy for anxiety symptoms in people with generalised anxiety disorder who have failed to respond to low-intensity psychological treatments as defined by the National Institute for Health and Care Excellence guidelines. Health Technol Assess 2017; 21:1-138. [PMID: 28853392 DOI: 10.3310/hta21450] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Generalised anxiety disorder (GAD) is common, causing unpleasant symptoms and impaired functioning. The National Institute for Health and Care Excellence (NICE) guidelines have established good evidence for low-intensity psychological interventions, but a significant number of patients will not respond and require more intensive step 3 interventions, recommended as either high-intensity cognitive behavioural therapy (CBT) or a pharmacological treatment such as sertraline. However, there are no head-to-head comparisons evaluating which is more clinically effective and cost-effective, and current guidelines suggest that treatment choice at step 3 is based mainly on patient preference. OBJECTIVES To assess clinical effectiveness and cost-effectiveness at 12 months of treatment with the selective serotonin reuptake inhibitor (SSRI) sertraline compared with CBT for patients with persistent GAD not improved with NICE-defined low-intensity psychological interventions. DESIGN Participant randomised trial comparing treatment with sertraline with high-intensity CBT for patients with GAD who had not responded to low-intensity psychological interventions. SETTING Community-based recruitment from local Improving Access to Psychological Therapies (IAPT) services. Four pilot services located in urban, suburban and semirural settings. PARTICIPANTS People considered likely to have GAD and not responding to low-intensity psychological interventions identified at review by IAPT psychological well-being practitioners (PWPs). Those scoring ≥ 10 on the Generalised Anxiety Disorder-7 (GAD-7) anxiety measure were asked to consider involvement in the trial. INCLUSION CRITERIA Aged ≥ 18 years, a score of ≥ 10 on the GAD-7, a primary diagnosis of GAD diagnosed on the Mini International Neuropsychiatric Interview questionnaire and failure to respond to NICE-defined low-intensity interventions. EXCLUSION CRITERIA Inability to participate because of insufficient English or cognitive impairment, current major depression, comorbid anxiety disorder(s) causing greater distress than GAD, significant dependence on alcohol or illicit drugs, comorbid psychotic disorder, received antidepressants in past 8 weeks or high-intensity psychological therapy in previous 6 months and any contraindications to treatment with sertraline. RANDOMISATION Consenting eligible participants randomised via an independent, web-based, computerised system. INTERVENTIONS (1) The SSRI sertraline prescribed in therapeutic doses by the patient's general practitioner for 12 months and (2) 14 (± 2) CBT sessions delivered by high-intensity IAPT psychological therapists in accordance with a standardised manual designed for GAD. MAIN OUTCOME MEASURES The primary outcome was the Hospital Anxiety and Depression Scale - Anxiety component at 12 months. Secondary outcomes included measures of depression, social functioning, comorbid anxiety disorders, patient satisfaction and economic evaluation, collected by postal self-completion questionnaires. RESULTS Only seven internal pilot participants were recruited against a target of 40 participants at 7 months. Far fewer potential participants were identified than anticipated from IAPT services, probably because PWPs rarely considered GAD the main treatment priority. Of those identified, three-quarters declined participation; the majority (30/45) were reluctant to consider the possibility of randomisation to medication. LIMITATIONS Poor recruitment was the main limiting factor, and the trial closed prematurely. CONCLUSIONS It is unclear how much of the recruitment difficulty was a result of conducting the trial within a psychological therapy service and how much was possibly a result of difficulty identifying participants with primary GAD. FUTURE WORK It may be easier to answer this important question by recruiting people from primary care rather than from those already engaged in a psychological treatment service. TRIAL REGISTRATION Current Controlled Trials ISCRTN14845583. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 45. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - John Cape
- Department of Clinical Health Psychology, University College London, London, UK
| | - Marc Serfaty
- Division of Psychiatry, University College London, London, UK.,The Priory Hospital North London, The Bourne, London, UK
| | - Roz Shafran
- UCL Great Ormond Street Institute of Child Health, University College London, London, UK
| | | | - Peter Tyrer
- Centre for Mental Health, Imperial College London, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK
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Appleton A, Singh S, Eady N, Buszewicz M. Why did you choose psychiatry? a qualitative study of psychiatry trainees investigating the impact of psychiatry teaching at medical school on career choice. BMC Psychiatry 2017; 17:276. [PMID: 28754157 PMCID: PMC5534074 DOI: 10.1186/s12888-017-1445-5] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 07/25/2017] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND There is no consensus regarding the optimal content of the undergraduate psychiatry curriculum as well as factors contributing to young doctors choosing a career in psychiatry. Our aim was to explore factors which had influenced psychiatry trainees' attitudes towards mental health and career choice. METHOD Qualitative in-depth interviews with 21 purposively sampled London psychiatry trainees analysed using the Framework method. RESULTS Early exposure and sufficient time in undergraduate psychiatry placements were important in influencing psychiatry as a career choice and positive role models were often very influential. Integration of psychiatry with teaching about physical health was viewed positively, although concerns were raised about the potential dilution of psychiatry teaching. Foundation posts in psychiatry were very valuable in positively impacting career choice. Other suggestions included raising awareness at secondary school level, challenging negative attitudes amongst all medical educators, and promoting integration within medical specialties. CONCLUSIONS Improvements in teaching psychiatry could improve medical attitudes and promote recruitment into psychiatry.
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Affiliation(s)
- A. Appleton
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
| | - S. Singh
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
| | - N. Eady
- 0000 0004 0426 7183grid.450709.fEast London NHS Foundation Trust, 9 Alie Street, London, E1 8DE UK
| | - M. Buszewicz
- 0000000121901201grid.83440.3bResearch Department of Primary Care and Population Health, University College London, London, NW3 2PF UK
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Nielsen G, Buszewicz M, Stevenson F, Hunter R, Holt K, Dudziec M, Ricciardi L, Marsden J, Joyce E, Edwards MJ. Randomised feasibility study of physiotherapy for patients with functional motor symptoms. J Neurol Neurosurg Psychiatry 2017; 88:484-490. [PMID: 27694498 DOI: 10.1136/jnnp-2016-314408] [Citation(s) in RCA: 138] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 08/30/2016] [Accepted: 09/06/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To determine the feasibility of conducting a randomised controlled trial of a specialist physiotherapy intervention for functional motor symptoms (FMS). METHODS A randomised feasibility study was conducted recruiting patients with a clinically established diagnosis of FMS from a tertiary neurology clinic in London, UK. Participants were randomised to the intervention or a treatment as usual control. Measures of feasibility and clinical outcome were collected and assessed at 6 months. RESULTS 60 individuals were recruited over a 9-month period. Three withdrew, leaving 29 intervention and 28 controls participants in the final analysis. 32% of patients with FMS met the inclusion criteria, of which 90% enrolled. Acceptability of the intervention was high and there were no adverse events. At 6 months, 72% of the intervention group rated their symptoms as improved, compared to 18% in the control group. There was a moderate to large treatment effect across a range of outcomes, including three of eight Short Form 36 (SF36) domains (d=0.46-0.79). The SF36 Physical function was found to be a suitable primary outcome measure for a future trial; adjusted mean difference 19.8 (95% CI 10.2 to 29.5). The additional quality adjusted life years (QALY) with intervention was 0.08 (95% CI 0.03 to 0.13), the mean incremental cost per QALY gained was £12 087. CONCLUSIONS This feasibility study demonstrated high rates of recruitment, retention and acceptability. Clinical effect size was moderate to large with high probability of being cost-effective. A randomised controlled trial is needed. TRIAL REGISTRATION NUMBER NCT02275000; Results.
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Affiliation(s)
- G Nielsen
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.,Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - M Buszewicz
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - F Stevenson
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - R Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - K Holt
- Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK.,Institute of Cardiovascular and Cell Sciences, St Georges University of London, London, UK
| | - M Dudziec
- Therapy Services Department, National Hospital for Neurology and Neurosurgery, London, UK
| | - L Ricciardi
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - J Marsden
- School of Health Professions, Peninsula Allied Health Centre, University of Plymouth, Plymouth, UK
| | - E Joyce
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK
| | - M J Edwards
- Sobell Department of Motor Neuroscience and Movement Disorders, UCL Institute of Neurology, London, UK.,Institute of Cardiovascular and Cell Sciences, St Georges University of London, London, UK
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Yon K, Habermann S, Rosenthal J, Walters KR, Nettleton S, Warner A, Lamahewa K, Buszewicz M. Improving teaching about medically unexplained symptoms for newly qualified doctors in the UK: findings from a questionnaire survey and expert workshop. BMJ Open 2017; 7:e014720. [PMID: 28450466 PMCID: PMC5719648 DOI: 10.1136/bmjopen-2016-014720] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVES Medically unexplained symptoms (MUS) present frequently in healthcare, can be complex and frustrating for clinicians and patients and are often associated with overinvestigation and significant costs. Doctors need to be aware of appropriate management strategies for such patients early in their training. A previous qualitative study with foundation year doctors (junior doctors in their first 2 years postqualification) indicated significant lack of knowledge about this topic and appropriate management strategies. This study reviewed whether, and in what format, UK foundation training programmes for newly qualified doctors include any teaching about MUS and sought recommendations for further development of such training. DESIGN Mixed-methods design comprising a web-based questionnaire survey and an expert consultation workshop. SETTING Nineteen foundation schools in England, Wales and Northern Ireland PARTICIPANTS: Questionnaire administered via email to 155 foundation training programme directors (FTPDs) attached to the 19 foundation schools, followed by an expert consultation workshop attended by 13 medical educationalists, FTPDs and junior doctors. RESULTS The 53/155 (34.2%) FTPDs responding to the questionnaire represented 15 of the 19 foundation schools, but only 6/53 (11%) reported any current formal teaching about MUS within their programmes. However, most recognised the importance of providing such teaching, suggesting 2-3 hours per year. All those attending the expert consultation workshop recommended case-based discussions, role-play and the use of videos to illustrate positive and negative examples of doctor-patient interactions as educational methods of choice. Educational sessions should cover the skills needed to provide appropriate explanations for patients' symptoms as well as avoid unnecessary investigations, and providing information about suitable treatment options. CONCLUSIONS There is an urgent need to improve foundation level training about MUS, as current provision is very limited. An interactive approach covering a range of topics is recommended, but must be delivered within a realistic time frame for the curriculum.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kate R Walters
- Research Department of Primary Care and Population Health, UCL, London, UK
| | | | - Alex Warner
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care and Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL, London, UK
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Panagioti M, Bower P, Kontopantelis E, Lovell K, Gilbody S, Waheed W, Dickens C, Archer J, Simon G, Ell K, Huffman JC, Richards DA, van der Feltz-Cornelis C, Adler DA, Bruce M, Buszewicz M, Cole MG, Davidson KW, de Jonge P, Gensichen J, Huijbregts K, Menchetti M, Patel V, Rollman B, Shaffer J, Zijlstra-Vlasveld MC, Coventry PA. Association Between Chronic Physical Conditions and the Effectiveness of Collaborative Care for Depression: An Individual Participant Data Meta-analysis. JAMA Psychiatry 2016; 73:978-89. [PMID: 27602561 DOI: 10.1001/jamapsychiatry.2016.1794] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Collaborative care is an intensive care model involving several health care professionals working together, typically a physician, a case manager, and a mental health professional. Meta-analyses of aggregate data have shown that collaborative care is particularly effective in people with depression and comorbid chronic physical conditions. However, only participant-level analyses can rigorously test whether the treatment effect is influenced by participant characteristics, such as chronic physical conditions. OBJECTIVE To assess whether the effectiveness of collaborative care for depression is moderated by the presence, type, and number of chronic physical conditions. DATA SOURCES Data were obtained from MEDLINE, EMBASE, PubMed, PsycINFO, CINAHL Complete, and Cochrane Central Register of Controlled Trials, and references from relevant systematic reviews. The search and collection of eligible studies was ongoing until May 22, 2015. STUDY SELECTION This was an update to a previous meta-analysis. Two independent reviewers were involved in the study selection process. Randomized clinical trials that compared the effectiveness of collaborative care with usual care in adults with depression and reported measured changes in depression severity symptoms at 4 to 6 months after randomization were included in the analysis. Key search terms included depression, dysthymia, anxiety, panic, phobia, obsession, compulsion, posttraumatic, care management, case management, collaborative care, enhanced care, and managed care. DATA EXTRACTION AND SYNTHESIS Individual participant data on baseline demographics and chronic physical conditions as well as baseline and follow-up depression severity symptoms were requested from authors of the eligible studies. One-step meta-analysis of individual participant data using appropriate mixed-effects models was performed. MAIN OUTCOMES AND MEASURES Continuous outcomes of depression severity symptoms measured using self-reported or observer-rated measures. RESULTS Data sets from 31 randomized clinical trials including 36 independent comparisons (N = 10 962 participants) were analyzed. Individual participant data analyses found no significant interaction effects, indicating that the presence (interaction coefficient, 0.02 [95% CI, -0.10 to 0.13]), numbers (interaction coefficient, 0.01 [95% CI, -0.01 to 0.02]), and types of chronic physical conditions do not influence the treatment effect. CONCLUSIONS AND RELEVANCE There is evidence that collaborative care is effective for people with depression alone and also for people with depression and chronic physical conditions. Existing guidance that recommends limiting collaborative care to people with depression and physical comorbidities is not supported by this individual participant data meta-analysis.
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Affiliation(s)
- Maria Panagioti
- National Institute of Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England
| | - Peter Bower
- National Institute of Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England
| | - Evangelos Kontopantelis
- National Institute of Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, England
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences, Hull York Medical School, University of York, York, England
| | - Waquas Waheed
- National Institute of Health Research School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, England
| | - Chris Dickens
- Institute of Health Research, University of Exeter Medical School, Exeter, England 5National Institute of Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula, University of Exeter, Exeter, England
| | - Janine Archer
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, England
| | - Gregory Simon
- Group Health Research Institute, Seattle, Washington
| | - Kathleen Ell
- Ethnicity and Poverty, School of Social Work, University of Southern California, Los Angeles
| | - Jeff C Huffman
- Harvard Medical School, General Hospital/Blake 11, Boston, Massachusetts
| | - David A Richards
- Institute of Health Research, University of Exeter Medical School, Exeter, England
| | - Christina van der Feltz-Cornelis
- Department of Psychiatry and Behavioral Sciences, Faculty of Social and Behavioral Sciences, Tilburg University, the Netherlands
| | - David A Adler
- Department of Psychiatry, Tufts Medical Center, Boston, Massachusetts
| | - Martha Bruce
- Department of Psychiatry, Weill Cornell Medical College, White Plains, New York
| | - Marta Buszewicz
- Institute of Epidemiology and Health, Faculty of Population and Health Sciences, University College London, London, England
| | - Martin G Cole
- Department of Psychiatry, St. Mary's Hospital Center, McGill University, Montreal, Quebec, Canada
| | - Karina W Davidson
- Center for Behavioral Cardiovascular Health, Department of Medicine, Columbia University, New York, New York
| | - Peter de Jonge
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen, Groningen, the Netherlands
| | - Jochen Gensichen
- Institute of General Practice, Friedrich-Schiller-University, School of Medicine, University Hospital, Jena, Germany
| | - Klaas Huijbregts
- Netherlands Institute of Mental Health and Addiction, Trimbos Institute, Utrecht, the Netherlands
| | - Marco Menchetti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vikram Patel
- Public Health Foundation of India, Gurgaon, India
| | - Bruce Rollman
- Psychiatry, Biomedical Informatics, and Clinical and Translational Science, Department of Biomedical Informatics, University of Pittsburgh, Pittsburgh, Pennsylvania
| | | | | | - Peter A Coventry
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, England23Centre for Reviews and Dissemination, University of York, York, England
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Buszewicz M, Griffin M, McMahon EM, Walters K, King M. Practice nurse-led proactive care for chronic depression in primary care: a randomised controlled trial. Br J Psychiatry 2016; 208:374-80. [PMID: 26795423 DOI: 10.1192/bjp.bp.114.153312] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 04/15/2015] [Indexed: 11/23/2022]
Abstract
BACKGROUND Management of long-term depression is a significant problem in primary care populations with considerable on-going morbidity, but few studies have focused on this group. AIMS To evaluate whether structured, nurse-led proactive care of patients with chronic depression in primary care improves outcomes. METHOD Participants with chronic/recurrent major depression or dysthymia were recruited from 42 UK general practices and randomised to general practitioner (GP) treatment as usual or nurse intervention over 2 years (the ProCEED trial, trial registration:ISRCTN36610074). RESULTS In total 282 people received the intervention and there were 276 controls. At 24 months there was no significant improvement in Beck Depression Inventory (BDI-II) score or quality of life (Euroquol-EQ-VAS), but a significant improvement in functional impairment (Work and Social Activity Schedule, WSAS) of 2.5 (95% CI 0.6-4.3,P= 0.010) in the intervention group. The impact per practice-nurse intervention session was -0.37 (95% CI -0.68 to -0.07,P= 0.017) on the BDI-II score and 70.33 (95% CI 70.55 to -0.10,P= 0.004) on the WSAS score, indicating that attending all 10 intervention sessions could lead to a BDI-II score reduction of 3.7 points compared with controls. CONCLUSIONS The intervention improved functioning in these patients, the majority of whom had complex long-term difficulties, but only had a significant impact on depressive symptoms in those engaging with the full intervention.
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Affiliation(s)
- Marta Buszewicz
- Marta Buszewicz, MBBS, MRCGP, MRCPsych, Mark Griffin, MSc, Elaine M. McMahon, BA, MPhil, Kate Walters, MBBS, MSc, PhD, Research Department of Primary Care & Population Health, University College London (Royal Free Campus), London; Michael King, MBBS, PhD, FRCPsych, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Mark Griffin
- Marta Buszewicz, MBBS, MRCGP, MRCPsych, Mark Griffin, MSc, Elaine M. McMahon, BA, MPhil, Kate Walters, MBBS, MSc, PhD, Research Department of Primary Care & Population Health, University College London (Royal Free Campus), London; Michael King, MBBS, PhD, FRCPsych, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Elaine M McMahon
- Marta Buszewicz, MBBS, MRCGP, MRCPsych, Mark Griffin, MSc, Elaine M. McMahon, BA, MPhil, Kate Walters, MBBS, MSc, PhD, Research Department of Primary Care & Population Health, University College London (Royal Free Campus), London; Michael King, MBBS, PhD, FRCPsych, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kate Walters
- Marta Buszewicz, MBBS, MRCGP, MRCPsych, Mark Griffin, MSc, Elaine M. McMahon, BA, MPhil, Kate Walters, MBBS, MSc, PhD, Research Department of Primary Care & Population Health, University College London (Royal Free Campus), London; Michael King, MBBS, PhD, FRCPsych, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Michael King
- Marta Buszewicz, MBBS, MRCGP, MRCPsych, Mark Griffin, MSc, Elaine M. McMahon, BA, MPhil, Kate Walters, MBBS, MSc, PhD, Research Department of Primary Care & Population Health, University College London (Royal Free Campus), London; Michael King, MBBS, PhD, FRCPsych, Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
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Howman M, Walters K, Rosenthal J, Ajjawi R, Buszewicz M. "You kind of want to fix it don't you?" Exploring general practice trainees' experiences of managing patients with medically unexplained symptoms. BMC Med Educ 2016; 16:27. [PMID: 26810389 PMCID: PMC4727318 DOI: 10.1186/s12909-015-0523-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 12/22/2015] [Indexed: 06/05/2023]
Abstract
BACKGROUND Much of a General Practitioner's (GP) workload consists of managing patients with medically unexplained symptoms (MUS). GP trainees are often taking responsibility for looking after people with MUS for the first time and so are well placed to reflect on this and the preparation they have had for it; their views have not been documented in detail in the literature. This study aimed to explore GP trainees' clinical and educational experiences of managing people presenting with MUS. METHOD A mixed methods approach was adopted. All trainees from four London GP vocational training schemes were invited to take part in a questionnaire and in-depth semi-structured interviews. The questionnaire explored educational and clinical experiences and attitudes towards MUS using Likert scales and free text responses. The interviews explored the origins of these views and experiences in more detail and documented ideas about optimising training about MUS. Interviews were analysed using the framework analysis approach. RESULTS Eighty questionnaires out of 120 (67%) were returned and a purposive sample of 15 trainees interviewed. Results suggested most trainees struggled to manage the uncertainty inherent in MUS consultations, feeling they often over-investigated or referred for their own reassurance. They described difficulty in broaching possible psychological aspects and/or providing appropriate explanations to patients for their symptoms. They thought that more preparation was needed throughout their training. Some had more positive experiences and found such consultations rewarding, usually after several consultations and developing a relationship with the patient. CONCLUSION Managing MUS is a common problem for GP trainees and results in a disproportionate amount of anxiety, frustration and uncertainty. Their training needs to better reflect their clinical experience to prepare them for managing such scenarios, which should also improve patient care.
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Affiliation(s)
- Mary Howman
- Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Kate Walters
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Joe Rosenthal
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
| | - Rola Ajjawi
- Centre for Medical Education, Dundee Medical School, The Mackenzie Building, Kirsty Semple Way, Dundee, DD2 4BF, UK.
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, UCL (Royal Free Campus), Upper Third Floor, Rowland Hill Street, London, NW32PF, UK.
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Abstract
OBJECTIVES To explore junior doctors' knowledge about and experiences of managing patients with medically unexplained symptoms (MUS) and to seek their recommendations for improved future training on this important topic about which they currently receive little education. DESIGN Qualitative study using in-depth interviews analysed using the framework method. SETTING Participants were recruited from three North Thames London hospitals within the UK. PARTICIPANTS Twenty-two junior doctors undertaking the UK foundation two-year training programme (FY1/FY2). RESULTS The junior doctors interviewed identified a significant gap in their training on the topic of MUS, particularly in relation to their awareness of the topic, the appropriate level of investigations, possible psychological comorbidities, the formulation of suitable explanations for patients' symptoms and longer term management strategies. Many junior doctors expressed feelings of anxiety, frustration and a self-perceived lack of competency in this area, and spoke of over-investigating patients or avoiding patient contact altogether due to the challenging nature of MUS and a difficulty in managing the accompanying uncertainty. They also identified the negative attitudes of some senior clinicians and potential role models towards patients with MUS as a factor contributing to their own attitudes and management choices. Most reported a need for more training during the foundation years, and recommended interactive case-based group discussions with a focus on providing meaningful explanations to patients for their symptoms. CONCLUSIONS There is an urgent need to improve postgraduate training about the topics of MUS and avoiding over-investigation, as current training does not equip junior doctors with the necessary knowledge and skills to effectively and confidently manage patients in these areas. Training needs to focus on practical skill development to increase clinical knowledge in areas such as delivering suitable explanations, and to incorporate individual management strategies to help junior doctors tolerate the uncertainty associated with MUS.
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Affiliation(s)
- Katherine Yon
- Research Department of Primary Care & Population Health, UCL, London, UK
| | | | - Kate Walters
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Kethakie Lamahewa
- Research Department of Primary Care & Population Health, UCL, London, UK
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, UCL, London, UK
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Buszewicz M, Welch C, Horsfall L, Nazareth I, Osborn D, Hassiotis A, Glover G, Chauhan U, Hoghton M, Cooper SA, Moulster G, Hithersay R, Hunter R, Heslop P, Courtenay K, Strydom A. Assessment of an incentivised scheme to provide annual health checks in primary care for adults with intellectual disability: a longitudinal cohort study. Lancet Psychiatry 2014; 1:522-30. [PMID: 26361311 DOI: 10.1016/s2215-0366(14)00079-0] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 08/27/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND People with intellectual disabilities (ID) have many comorbidities but experience inequities in access to health care. National Health Service England uses an opt-in incentive scheme to encourage annual health checks of patients with ID in primary care. We investigated whether the first 3 years of the programme had improved health care of people with ID. METHODS We did a longitudinal cohort study that used data from The Health Improvement Network primary care database. We did multivariate logistic regression to assess associations between various characteristics and whether or not practices had opted in to the incentivised scheme. FINDINGS We assessed data for 8692 patients from 222 incentivised practices and those for 918 patients in 48 non-incentivised practices. More blood tests (eg, total cholesterol, odds ratio [OR] 1·88, 95% CI 1·47-2·41, p<0·0001) general health measurements (eg, smoking status, 6·0, 4·10-8·79, p<0·0001), specific health assessments (eg, hearing, 24·0, 11·5-49·9, p<0·0001), and medication reviews (2·23, 1·68-2·97, p<0·0001) were done in incentivised than in non-incentivised practices, and more health action plans (6·15, 1·41-26·9, p=0·0156) and secondary care referrals (1·47, 1·05-2·05, p=0·0256) were made. Identification rates were higher in incentivised practices for thyroid disorder (OR 2·72, 95% CI 1·09-6·81, p=0·0323), gastrointestinal disorders (1·94, 1·03-3·65, p=0·0390), and obesity (2·49, 1·76-3·53, p<0·0001). INTERPRETATION Targeted annual health checks for people with ID in primary care could reduce health inequities. FUNDING National Institute for Health Research.
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Affiliation(s)
- Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, London, UK.
| | - Catherine Welch
- Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, London, UK
| | - Laura Horsfall
- Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, London, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, London, UK
| | - David Osborn
- Division of Psychiatry, University College London, London, UK
| | | | - Gyles Glover
- Learning Disabilities team, Public Health England, IPH, University Forvie Site, Cambridge, UK
| | - Umesh Chauhan
- NHS East Lancashire Clinical Commissioning Group, Nelson, UK
| | | | - Sally-Ann Cooper
- Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Gwen Moulster
- South Staffordshire and Shropshire NHS Foundation Trust, St Georges Hospital, Stafford, UK
| | | | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London Medical School, Royal Free Campus, London, UK
| | - Pauline Heslop
- Norah Fry Research Centre, University of Bristol, Bristol, UK
| | - Ken Courtenay
- Barnet, Enfield and Haringey Mental Health Trust, Haringey Learning Disabilities Partnership, London, UK
| | - André Strydom
- Division of Psychiatry, University College London, London, UK
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Hithersay R, Strydom A, Moulster G, Buszewicz M. Carer-led health interventions to monitor, promote and improve the health of adults with intellectual disabilities in the community: a systematic review. Res Dev Disabil 2014; 35:887-907. [PMID: 24495402 DOI: 10.1016/j.ridd.2014.01.010] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2013] [Revised: 01/06/2014] [Accepted: 01/06/2014] [Indexed: 06/03/2023]
Abstract
Using carers to help assess, monitor, or promote health in people with intellectual disabilities (ID) may be one way of improving health outcomes in a population that experiences significant health inequalities. This paper provides a review of carer-led health interventions in various populations and healthcare settings, in order to investigate potential roles for carers in ID health care. We used rapid review methodology, using the Scopus database, citation tracking and input from ID healthcare professionals to identify relevant research. 24 studies were included in the final review. For people with ID, the only existing interventions found were carer-completed health diaries which, while being well received, failed to improve health outcomes. Studies in non-ID populations show that carers can successfully deliver screening procedures, health promotion interventions and interventions to improve coping skills, pain management and cognitive functioning. While such examples provide a useful starting point for the development of future carer-led health interventions for people with ID, the paucity of research in this area means that the most appropriate means of engaging carers in a way that will reliably impact on health outcomes in this population remains, as yet, unknown.
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Affiliation(s)
- Rosalyn Hithersay
- Research Department of Mental Health Sciences, Charles Bell House, 2nd Floor, 67-73 Riding House Street, London W1W 7EJ, United Kingdom.
| | - André Strydom
- Research Department of Mental Health Sciences, Charles Bell House, 2nd Floor, 67-73 Riding House Street, London W1W 7EJ, United Kingdom
| | - Gwen Moulster
- Haringey Learning Disabilities Partnership, Cumberland House, Cumberland Road, Wood Green N22 7SJ, United Kingdom
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, Upper Third Floor, UCL Medical School (Royal Free Campus), Rowland Hill Street, London NW3 2PF, United Kingdom
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Bennett M, Walters K, Drennan V, Buszewicz M. Structured pro-active care for chronic depression by practice nurses in primary care: a qualitative evaluation. PLoS One 2013; 8:e75810. [PMID: 24069451 PMCID: PMC3772088 DOI: 10.1371/journal.pone.0075810] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Accepted: 08/22/2013] [Indexed: 12/21/2022] Open
Abstract
PURPOSE This qualitative study explored the impact and appropriateness of structured pro-active care reviews by practice nurses for patients with chronic or recurrent depression and dysthymia within the ProCEED trial. ProCEED (Pro-active Care and its Evaluation for Enduring Depression) was a United Kingdom wide randomised controlled trial, comparing usual general practitioner care with structured 'pro-active care' which involved 3 monthly review appointments with practice nurses over 2 years for patients with chronic or recurrent depression. METHOD In-depth interviews were completed with 41 participants: 26 patients receiving pro-active care and 15 practice nurses providing this care. Interview transcripts were analysed thematically using a 'framework' approach. RESULTS Patients perceived the practice nurses to be appropriate professionals to engage with regarding their depression and most nurses felt confident in a case management role. The development of a therapeutic alliance between the patient and nurse was central to this model and, where it appeared lacking, dissatisfaction was felt by both patients and nurses with a likely negative impact on outcomes. Patient and nurse factors impacting on the therapeutic alliance were identified and nurse typologies explored. DISCUSSION Pro-active care reviews utilising practice nurses as case managers were found acceptable by the majority of patients and practice nurses and may be a suitable way to provide care for patients with long-term depression in primary care. Motivated and interested practice nurses could be an appropriate and valuable resource for this patient group. This has implications for resource decisions by clinicians and commissioners within primary care.
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Affiliation(s)
- Madeleine Bennett
- Research Department of Primary Care & Population Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Kate Walters
- Research Department of Primary Care & Population Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Vari Drennan
- Faculty of Health & Social Care Sciences, St. George’s University of London & Kingston University, London, United Kingdom
| | - Marta Buszewicz
- Research Department of Primary Care & Population Health, University College London, Royal Free Hospital, London, United Kingdom
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Walters K, Rait G, Griffin M, Buszewicz M, Nazareth I. Recent trends in the incidence of anxiety diagnoses and symptoms in primary care. PLoS One 2012; 7:e41670. [PMID: 22870242 PMCID: PMC3411689 DOI: 10.1371/journal.pone.0041670] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 06/25/2012] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Anxiety is common, with significant morbidity, but little is known about presentations and recording of anxiety diagnoses and symptoms in primary care. This study aimed to determine trends in incidence and socio-demographic variation in General Practitioner (GP) recorded diagnoses of anxiety, mixed anxiety/depression, panic and anxiety symptoms. METHODOLOGY/PRINCIPAL FINDINGS Annual incidence rates of anxiety diagnoses and symptoms were calculated from 361 UK general practices contributing to The Health Improvement Network (THIN) database between 1998 and 2008, adjusted for year of diagnosis, gender, age, and deprivation. Incidence of GP recorded anxiety diagnosis fell from 7.9 to 4.9/1000PYAR from 1998 to 2008, while incidence of anxiety symptoms rose from 3.9 to 5.8/1000PYAR. Incidence of mixed anxiety/depression fell from 4.0 to 2.2/1000PYAR, and incidence of panic disorder fell from 0.9/1000PYAR in 1998 to 0.5/1000PYAR in 2008. All these entries were approximately twice as common in women and more common in deprived areas. GP-recorded anxiety diagnoses, symptoms and mixed anxiety/depression were commonest aged 45-64 years, whilst panic disorder/attacks were more common in those 16-44 years. GPs predominately use broad non-specific codes to record anxiety problems in the UK. CONCLUSIONS/SIGNIFICANCE GP recording of anxiety diagnoses has fallen whilst recording of anxiety symptoms has increased over time. The incidence of GP recorded diagnoses of anxiety diagnoses was lower than in screened populations in primary care. The reasons for this apparent under-recording and whether it represents under-detection in those being seen, a reluctance to report anxiety to their GP, or a reluctance amongst GPs to label people with anxiety requires investigation.
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Affiliation(s)
- Kate Walters
- Department of Primary Care and Population Health, University College London (UCL), London, United Kingdom.
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McMahon EM, Buszewicz M, Griffin M, Beecham J, Bonin EM, Rost F, Walters K, King M. Chronic and recurrent depression in primary care: socio-demographic features, morbidity, and costs. Int J Family Med 2012; 2012:316409. [PMID: 22720155 PMCID: PMC3375145 DOI: 10.1155/2012/316409] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Revised: 03/28/2012] [Accepted: 04/01/2012] [Indexed: 06/01/2023]
Abstract
Background. Major depression is often chronic or recurrent and is usually treated within primary care. Little is known about the associated morbidity and costs. Objectives. To determine socio-demographic characteristics of people with chronic or recurrent depression in primary care and associated morbidity, service use, and costs. Method. 558 participants were recruited from 42 GP practices in the UK. All participants had a history of chronic major depression, recurrent major depression, or dysthymia. Participants completed questionnaires including the BDI-II, Work and Social Adjustment Scale, Euroquol, and Client Service Receipt Inventory documenting use of primary care, mental health, and other services. Results. The sample was characterised by high levels of depression, functional impairment, and high service use and costs. The majority (74%) had been treated with an anti-depressant, while few had seen a counsellor (15%) or a psychologist (3%) in the preceding three months. The group with chronic major depression was most depressed and impaired with highest service use, whilst those with dysthymia were least depressed, impaired, and costly to support but still had high morbidity and associated costs. Conclusion. This is a patient group with very significant morbidity and high costs. Effective interventions to reduce both are required.
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Affiliation(s)
- Elaine M. McMahon
- Research Department of Primary Care and Population Health, University College London, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Mark Griffin
- Research Department of Primary Care and Population Health, University College London, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Jennifer Beecham
- Personal Social Services Research Unit, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
- Personal Social Services Research Unit, University of Kent, Cornwallis Building, Canterbury, Kent CT2 7NF, UK
| | - Eva-Maria Bonin
- Personal Social Services Research Unit, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK
| | - Felicitas Rost
- Research Department of Primary Care and Population Health, University College London, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, Upper Third Floor, Royal Free Hospital, Rowland Hill Street, London NW3 2PF, UK
| | - Michael King
- Research Department of Mental Health Sciences, University College London, Royal Free Campus, Rowland Hill Street, London NW3 2PF, UK
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Howman M, Walters K, Rosenthal J, Good M, Buszewicz M. Teaching about medically unexplained symptoms at medical schools in the United Kingdom. Med Teach 2012; 34:327-329. [PMID: 22455702 DOI: 10.3109/0142159x.2012.660219] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND Medically unexplained symptoms (MUS) are very common in primary and secondary care. They are often inappropriately managed, resulting in potential harm to patients as well as wasted resources. To bring about change, it is important that newly qualified doctors are equipped with the skills to manage MUS effectively. We do not know if and how this topic is currently taught at U.K. medical schools. AIM To document whether, how and when this topic is currently taught in U.K. medical schools. To assess potential barriers to this teaching and consider how it can be improved. METHODS A questionnaire survey emailed to GP and psychiatry teaching leads at all 31 U.K. medical schools. RESULTS Responses received from 24/31 schools showed that MUS teaching across U.K. medical schools is very variable in terms of amount, method, assessment and integration of the teaching within the curriculum. Most respondents identified a need for a greater quantity of cross-discipline teaching and for greater value to be attributed to the topic. CONCLUSION Inconsistent and disparate teaching across medical schools may lead to very variable practice amongst qualified clinicians. In order to overcome this, consensus is needed as to how and where in the undergraduate curriculum there should be teaching about MUS.
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Affiliation(s)
- Mary Howman
- Department of Primary Care and Population Health, UCL Medical School, London, UK.
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De Lepeleire J, Oud M, Buszewicz M. Mental health problems in family medicine/general practice. Int J Family Med 2012; 2012:794845. [PMID: 23476768 PMCID: PMC3582092 DOI: 10.1155/2012/794845] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/26/2012] [Accepted: 08/26/2012] [Indexed: 05/12/2023]
Affiliation(s)
- Jan De Lepeleire
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 33, Blok J, 3000 Leuven, Belgium
- *Jan De Lepeleire:
| | - Marian Oud
- Universitair Medisch Centrum Groningen, Groningen, The Netherlands
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London, London NW3 2PF, UK
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Abstract
BACKGROUND Mixed anxiety and depressive disorder (MADD) is common yet ill-defined, with little known about outcomes. AIMS To determine MADD outcomes over 1 year. METHOD We recruited 250 adults attending seven London general practices with mild-moderate distress. Three groups were defined using a diagnostic interview: MADD, other ICD-10 psychiatric diagnosis, no psychiatric diagnosis. We assessed symptoms of distress (General Health Questionnaire-28), quality of life (12-item Short Form Health Survey), general practitioner (GP) diagnosis and consultation rate at baseline, 3 months and 1 year. RESULTS Two-thirds of participants with MADD had no significant psychological distress at 3 months (61%) or 1 year (69%). However, compared with those with no diagnosis, individuals had twice the risk of significant distress (incidence rate ratio 2.39, 95% CI 1.29-4.42) at 3 months but not 1 year, and persistently lower quality of life (mental health functioning). There was no significant difference in GP consultation rate/diagnosis. CONCLUSIONS The majority with MADD improved, but individuals had an increased risk of significant distress at 3 months and a lower quality of life. As we cannot currently predict those with a poorer prognosis these patients should be actively monitored in primary care.
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Affiliation(s)
- Kate Walters
- Research Department of Primary Care & Population Health, Hampstead Campus, University College London, London, UK.
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Abstract
BACKGROUND High levels of depression in junior doctors prompted this research into the prevalence of depression in medical students, compared with other non-medical university students. We also explored potential vulnerability factors that may be associated with student depression. METHODS A comparative cross-sectional internet-based questionnaire design was used. This self-administered questionnaire, consisting of demographic details and questions about potential vulnerability factors, was disseminated to both medical and non-medical life-sciences students via their university e-mail accounts. The Patient Health Questionnaire 9 (PHQ-9), a self-completed depression-specific questionnaire, was included. RESULTS Non-medical students showed a higher prevalence of moderate and severe depressive symptoms than their medical student peers, although medical students reported more symptoms of mild depression. Multivariable logistic regression analysis indicated that belonging to an ethnic minority (p = 0.021), and having a personal (p < 0.001) or family history of depression (p < 0.001) were associated with a higher risk of depression. Having studied for a previous degree appeared to be protective against depression (p = 0.029). Around half (50% of medical and 54% of non-medical) students indicated that they would not feel able to consult their university tutors if depressed. DISCUSSION Significant levels of depression were reported by both medical and non-medical students. Potential vulnerability factors included: a personal or family history of depression, point of degree entry and belonging to an ethnic minority. The reluctance of students to consult their tutors about such problems highlights the potentially stigmatising nature of depression, and reinforces the need for higher education institutions to address these issues.
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Affiliation(s)
- Katie Honney
- Research Department of Primary Care and Population Health, Division of Population Health, University College London, UK.
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Cape J, Geyer C, Barker C, Pistrang N, Buszewicz M, Dowrick C, Salmon P. Facilitating understanding of mental health problems in GP consultations: a qualitative study using taped-assisted recall. Br J Gen Pract 2010; 60:837-45. [PMID: 20939945 PMCID: PMC2965968 DOI: 10.3399/bjgp10x532567] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2009] [Revised: 02/09/2010] [Accepted: 03/11/2010] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Mental health problems are common in primary care and most are managed solely by the GP. Patients strive to understand their mental health problems, and facilitating patients' understanding may be important in their care, yet little is known about this process in GP consultations. AIM To explore how patients' understanding of common mental health problems is developed in GP consultations. DESIGN OF STUDY Qualitative study. SETTING Ten general practices in North Central London. METHOD Fourteen patients and their GPs were interviewed using the taped-assisted recall (TAR) method, and asked how understanding of the patients' mental health problems had been discussed in a recent consultation. The resulting 42 transcripts of the GP-patient consultations and separate GP and patient TAR interviews were analysed using qualitative thematic and process analytic methods. RESULTS Patients considered understanding their mental health problems to be important, and half reported their GP consultations as helpful in this respect. The process of coming to an understanding was predominantly patient-led. Patients suggested their own explanations, and these were facilitated and focused by the doctors' questioning, listening, validating, and elaborating aspects they considered important. Both doctors and patients experienced constraints on the extent to which developing understanding of problems was possible in GP consultations. CONCLUSION GPs can help patients understand their mental health problems by recognising patients' own attempts at explanation and helping to shape and develop these.
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Affiliation(s)
- John Cape
- Camden and Islington NHS Foundation Trust, London.
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Buszewicz M, Griffin M, McMahon EM, Beecham J, King M. Evaluation of a system of structured, pro-active care for chronic depression in primary care: a randomised controlled trial. BMC Psychiatry 2010; 10:61. [PMID: 20684786 PMCID: PMC2923105 DOI: 10.1186/1471-244x-10-61] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2010] [Accepted: 08/04/2010] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND People with chronic depression are frequently lost from effective care, with resulting psychological, physical and social morbidity and considerable social and financial societal costs. This randomised controlled trial will evaluate whether regular structured practice nurse reviews lead to better mental health and social outcomes for these patients and will assess the cost-effectiveness of the structured reviews compared to usual care.The hypothesis is that structured, pro-active care of patients with chronic depression in primary care will lead to a cost-effective improvement in medical and social outcomes when compared with usual general practitioner (GP) care. METHODS/DESIGN Participants were recruited from 42 general practices throughout the United Kingdom. Eligible participants had to have a history of chronic major depression, recurrent major depression or chronic dsythymia confirmed using the Composite International Diagnostic Interview (CIDI). They also needed to score 14 or above on the Beck Depression Inventory (BDI-II) at recruitment.Once consented, participants were randomised to treatment as usual from their general practice (controls) or the practice nurse led intervention. The intervention includes a specially prepared education booklet and a comprehensive baseline assessment of participants' mood and any associated physical and psycho-social factors, followed by regular 3 monthly reviews by the nurse over the 2 year study period. At these appointments intervention participants' mood will be reviewed, together with their current pharmacological and psychological treatments and any relevant social factors, with the nurse suggesting possible amendments according to evidence based guidelines. This is a chronic disease management model, similar to that used for other long-term conditions in primary care.The primary outcome is the BDI-II, measured at baseline and 6 monthly by self-complete postal questionnaire. Secondary outcomes collected by self-complete questionnaire at baseline and 2 years include social functioning, quality of life and data for the economic analyses. Health service data will be collected from GP notes for the 24 months before recruitment and the 24 months of the study. DISCUSSION 558 participants were recruited, 282 to the intervention and 276 to the control arm. The majority were recruited via practice database searches using relevant READ codes. TRIAL REGISTRATION ISRCTN36610074.
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Affiliation(s)
- Marta Buszewicz
- Research Department of Primary Care & Population Health, University College London (Archway Campus), Highgate Hill, London N19 5LW, UK
| | - Mark Griffin
- Research Department of Primary Care & Population Health, University College London (Archway Campus), Highgate Hill, London N19 5LW, UK
| | - Elaine M McMahon
- Research Department of Primary Care & Population Health, University College London (Archway Campus), Highgate Hill, London N19 5LW, UK
| | - Jennifer Beecham
- Personal Social Services Research Unit, London School of Economics and Political Science, Houghton Street, London WC2A 2AE, UK & University of Kent, Cornwallis Building, Canterbury, Kent CT2 7NF, UK
| | - Michael King
- Academic Department of Psychiatry, University College London (Royal Free Campus), Rowland Hill Street, London NW3 2PF, UK
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Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression. BMC Med 2010; 8:38. [PMID: 20579335 PMCID: PMC2908553 DOI: 10.1186/1741-7015-8-38] [Citation(s) in RCA: 160] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Accepted: 06/25/2010] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Psychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders. METHODS Meta-analysis and meta-regression of randomized controlled trials of brief psychological therapies of adult patients with anxiety, depression or mixed common mental health problems treated in primary care compared to primary care treatment as usual. RESULTS Thirty-four studies, involving 3962 patients, were included. Most were of brief cognitive behaviour therapy (CBT; n = 13), counselling (n = 8) or problem solving therapy (PST; n = 12). There was differential effectiveness between studies of CBT, with studies of CBT for anxiety disorders having a pooled effect size [d -1.06, 95% confidence interval (CI) -1.31 to -0.80] greater than that of studies of CBT for depression (d -0.33, 95% CI -0.60 to -0.06) or studies of CBT for mixed anxiety and depression (d -0.26, 95% CI -0.44 to -0.08). Counselling for depression and mixed anxiety and depression (d -0.32, 95% CI -0.52 to -0.11) and problem solving therapy (PST) for depression and mixed anxiety and depression (d -0.21, 95% CI -0.37 to -0.05) were also effective. Controlling for diagnosis, meta-regression found no difference between CBT, counselling and PST. CONCLUSIONS Brief CBT, counselling and PST are all effective treatments in primary care, but effect sizes are low compared to longer length treatments. The exception is brief CBT for anxiety, which has comparable effect sizes.
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Affiliation(s)
- John Cape
- Camden and Islington NHS Foundation Trust, St Pancras Hospital, 4 St Pancras Way, London NW1 0PE, UK
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK
| | - Craig Whittington
- Research Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London WC1E 6BT, UK
| | - Marta Buszewicz
- Research Department of Primary Care and Population Health, University College London Medical School, 2nd floor, Holborn Union Building, Archway Campus, Highgate Hill, London, N19 5LW, UK
| | - Paul Wallace
- Research Department of Primary Care and Population Health, University College London Medical School, 2nd floor, Holborn Union Building, Archway Campus, Highgate Hill, London, N19 5LW, UK
| | - Lisa Underwood
- Health Service and Population Research Department, Institute of Psychiatry, Kings College London, De Crespigny Park, London SE5 8AF, UK
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Serfaty MA, Haworth D, Blanchard M, Buszewicz M, Murad S, King M. Clinical effectiveness of individual cognitive behavioral therapy for depressed older people in primary care: a randomized controlled trial. ACTA ACUST UNITED AC 2009; 66:1332-40. [PMID: 19996038 DOI: 10.1001/archgenpsychiatry.2009.165] [Citation(s) in RCA: 139] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
CONTEXT In older people, depressive symptoms are common, psychological adjustment to aging is complex, and associated chronic physical illness limits the use of antidepressants. Despite this, older people are rarely offered psychological interventions, and only 3 randomized controlled trials of individual cognitive behavioral therapy (CBT) in a primary care setting have been published. OBJECTIVE To determine the clinical effectiveness of CBT delivered in primary care for older people with depression. DESIGN A single-blind, randomized, controlled trial with 4- and 10-month follow-up visits. PATIENTS A total of 204 people aged 65 years or older (mean [SD] age, 74.1 [7.0] years; 79.4% female; 20.6% male) with a Geriatric Mental State diagnosis of depression were recruited from primary care. INTERVENTIONS Treatment as usual (TAU), TAU plus a talking control (TC), or TAU plus CBT. The TC and CBT were offered over 4 months. OUTCOME MEASURES Beck Depression Inventory-II (BDI-II) scores collected at baseline, end of therapy (4 months), and 10 months after the baseline visit. Subsidiary measures were the Beck Anxiety Inventory, Social Functioning Questionnaire, and Euroqol. Intent to treat using Generalized Estimating Equation and Compliance Average Causal Effect analyses were used. RESULTS Eighty percent of participants were followed up. The mean number of sessions of TC or CBT was just greater than 7. Intent-to-treat analysis found improvements of -3.07 (95% confidence interval [CI], -5.73 to -0.42) and -3.65 (95% CI, -6.18 to -1.12) in BDI-II scores in favor of CBT vs TAU and TC, respectively. Compliance Average Causal Effect analysis compared CBT with TC. A significant benefit of CBT of 0.4 points (95% CI, 0.01 to 0.72) on the BDI-II per therapy session was observed. The cognitive therapy scale showed no difference for nonspecific, but significant differences for specific factors in therapy. Ratings for CBT were high (mean [SD], 54.2 [4.1]). CONCLUSION Cognitive behavioral therapy is an effective treatment for older people with depressive disorder and appears to be associated with its specific effects. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN18271323.
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Affiliation(s)
- Marc Antony Serfaty
- Department of Mental Health Sciences, University College Medical School, Rowland Hill St, London NW3 2PF, England.
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