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Holt RIG, Abdelrahman T, Hirsch M, Dhesi Z, George T, Blincoe T, Peveler RC. The prevalence of undiagnosed metabolic abnormalities in people with serious mental illness. J Psychopharmacol 2010; 24:867-73. [PMID: 19304868 DOI: 10.1177/0269881109102788] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [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: 11/17/2022]
Abstract
The prevalence of metabolic syndrome is increased 2-3-fold in people with serious mental illness (SMI). Monitoring of physical health in these individuals is poor, despite clear guidance from the National Institute of Health and Clinical Excellence. The aim of this study was to assess the proportion of people with SMI who had been screened for metabolic abnormalities within the previous year and in a further study to assess the prevalence of undiagnosed metabolic abnormalities in people who had not been screened. The notes and computer records of 100 patients with SMI from community and in-patient settings were evaluated. In a subsequent study, the prevalence of metabolic syndrome was assessed in 71 previously unscreened patients. The study was carried out at the psychiatric in-patient and out-patient units in Southampton and Winchester. The frequency of screening and prevalence of the metabolic syndrome as defined by the International Diabetes Federation (IDF) were assessed. There was documented evidence that the following cardiovascular risk factors had been measured in the previous year: blood pressure (32%), glucose (16%), lipids (9%) and weight (2%). In the metabolic abnormalities study, 41 of 71 (58%) patients were found to fulfil the IDF criteria for the metabolic syndrome. Two had previously undiagnosed diabetes. Twelve percent of patients had a greater than 20% risk of a cardiovascular event within the next 10 years. Despite clear guidance and a high prevalence of undiagnosed metabolic syndrome, screening rates for metabolic abnormalities in people with SMI remain low. Improved screening of metabolic complications should lead to better identification and treatment of this clinical problem.
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Affiliation(s)
- R I G Holt
- Endocrinology & Metabolism Sub-division, Developmental Origins of Adult Disease Division, University of Southampton, Southampton, UK.
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Holt RIG, Peveler RC. Diabetes and cardiovascular risk in severe mental illness: a missed opportunity and challenge for the future. ACTA ACUST UNITED AC 2010. [DOI: 10.1002/pdi.1451] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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Abstract
AIMS To assess the relationship between depression scores and diabetes, glucose and insulin in a cross-sectional population-based study. METHODS One thousand, five hundred and seventy-nine men and 1418 women from the Hertfordshire Cohort Study were assessed for diabetes. Plasma glucose and insulin concentrations were measured at 0, 30 and 120 min during a standard 75-g oral glucose tolerance test. Depressive and anxiety symptoms were measured using the Hospital Anxiety and Depression Scale (HADS). RESULTS Overall, 431 (14.6%) were diagnosed with diabetes [232 men (14.9%) and 199 women (14.3%)]. One hundred and eight (47%) men and 74 (37%) women had known diabetes. The remainder were previously undiagnosed. Fifty-nine (3.7%) men and 65 (4.6%) women had possible depression (HAD-D scores 8-10) and 17 (1.1%) men and 20 (1.4%) women had probable depression (HAD-D scores > or = 11). Probable depression was associated with an adjusted odds ratio for diabetes of 3.89 [95% confidence interval (CI) 1.28-11.88] in men and 1.51 (95% CI 0.47-4.84) in women. In men without previously diagnosed diabetes, fasting insulin (P = 0.035), 2-h glucose concentrations (P = 0.028) and insulin resistance (P = 0.032) were significantly associated with HAD-D scores. With the exception of 2-h glucose concentrations (P = 0.034), the associations were not significant in women. CONCLUSIONS These data support the hypothesis that depression may increase the risk for diabetes. The relationship between depression score and metabolic variables extends across the whole population and is not confined to those with either diagnosed depression or diabetes. This relationship should lead clinicians to consider screening for diabetes in those with depression and vice versa.
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Affiliation(s)
- R I G Holt
- The Institute of Developmental Sciences (IDS Building), MP887, Developmental Origins of Health and Disease Division, School of Medicine, University of Southampton, Tremona Road, Southampton SO16 6YD, UK.
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Anderson IM, Ferrier IN, Baldwin RC, Cowen PJ, Howard L, Lewis G, Matthews K, McAllister-Williams RH, Peveler RC, Scott J, Tylee A. Evidence-based guidelines for treating depressive disorders with antidepressants: a revision of the 2000 British Association for Psychopharmacology guidelines. J Psychopharmacol 2008; 22:343-96. [PMID: 18413657 DOI: 10.1177/0269881107088441] [Citation(s) in RCA: 335] [Impact Index Per Article: 20.9] [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] [Indexed: 12/28/2022]
Abstract
A revision of the 2000 British Association for Psychopharmacology evidence-based guidelines for treating depressive disorders with antidepressants was undertaken to incorporate new evidence and to update the recommendations where appropriate. A consensus meeting involving experts in depressive disorders and their management was held in May 2006. Key areas in treating depression were reviewed, and the strength of evidence and clinical implications were considered. The guidelines were drawn up after extensive feedback from participants and interested parties. A literature review is provided, which identifies the quality of evidence to inform the recommendations, the strength of which are based on the level of evidence. These guidelines cover the nature and detection of depressive disorders, acute treatment with antidepressant drugs, choice of drug versus alternative treatment, practical issues in prescribing and management, next-step treatment, relapse prevention, treatment of relapse, and stopping treatment.
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Affiliation(s)
- I M Anderson
- Senior Lecturer and Honorary Consultant Psychiatrist, Neuroscience and Psychiatry Unit, University of Manchester, UK.
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Smith M, Hopkins D, Peveler RC, Holt RIG, Woodward M, Ismail K. First- v. second-generation antipsychotics and risk for diabetes in schizophrenia: systematic review and meta-analysis. Br J Psychiatry 2008; 192:406-11. [PMID: 18515889 DOI: 10.1192/bjp.bp.107.037184] [Citation(s) in RCA: 174] [Impact Index Per Article: 10.9] [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] [Indexed: 01/20/2023]
Abstract
BACKGROUND The increased prevalence of diabetes in schizophrenia is partly attributed to antipsychotic treatment, in particular second-generation antipsychotics, but the evidence has not been systematically reviewed. AIMS Systematic review and meta-analysis comparing diabetes risk for different antipsychotics in people with schizophrenia. METHOD We searched MEDLINE, PsycINFO, EMBASE, International Pharmaceutical Abstracts, CINAHL and Web of Knowledge until September 2006. Studies were eligible for inclusion if the design was cross-sectional, case-control, cohort or a controlled trial in individuals with schizophrenia or related psychotic disorders, where second-generation antipsychotics (defined as clozapine, olanzapine, risperidone and quetiapine) were compared with first-generation antipsychotics and diabetes was an outcome. Data were pooled using random effects inverse variance weighted meta-analysis. RESULTS Of the studies that met the inclusion criteria (n=14), 11 had sufficient data to include in the meta-analysis. Four of these were retrospective cohort studies. The relative risk of diabetes in patients with schizophrenia prescribed one of the second-generation v. first-generation antipsychotics was 1.32 (95% CI 1.15-1.51). There were insufficient data to include aripiprazole, ziprasidone and amisulpride in this analysis. CONCLUSIONS There is tentative evidence that the second-generation antipsychotics included in this study are associated with a small increased risk for diabetes compared with first-generation antipsychotics in people with schizophrenia. Methodological limitations were found in most studies, leading to heterogeneity and difficulty interpreting data. Regardless of type of antipsychotic, screening for diabetes in all people with schizophrenia should be routine.
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Affiliation(s)
- M Smith
- Department of Psychological Medicine, Institute of Psychiatry, King's College London, London SE5 9RJ, UK.
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Jones RM, Butler JA, Thomas VA, Peveler RC, Prevett M. Adherence to treatment in patients with epilepsy: Associations with seizure control and illness beliefs. Seizure 2006; 15:504-8. [PMID: 16861012 DOI: 10.1016/j.seizure.2006.06.003] [Citation(s) in RCA: 153] [Impact Index Per Article: 8.5] [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: 04/27/2005] [Revised: 05/23/2006] [Accepted: 06/13/2006] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE This study investigated non-adherence to antiepileptic drug treatment amongst patients with epilepsy in secondary care. The associations between adherence and seizure control, perceptions of illness and medication, anxiety and depression were also examined. METHODS A cross-sectional study of fifty-four patients with epilepsy were recruited from a hospital epilepsy clinic. RESULTS Fifty-nine percent were estimated to be non-adherent to medication. There was a negative correlation between adherence and frequency of seizures. Patients with poorly controlled epilepsy were more anxious, and expected a longer duration of their epilepsy. CONCLUSION Assessment of adherence should be a routine part of management of epilepsy. Further recognition and support should be given to patients who have poor seizure control since they are more likely to be more anxious and have unhelpful illness and treatment beliefs.
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Affiliation(s)
- R M Jones
- Mental Health Group, Community Clinical Sciences Division, University of Southampton, Royal South Hants Hospital, Brintons Terrace, Southampton SO14 OYG, United Kingdom.
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Abstract
There is concern that antipsychotic drugs cause diabetes. Although there has been an explosion in the quantity of literature about this subject, it remains confusing and inconsistent. To assess whether the association between antipsychotic drugs and diabetes is causative, we applied the Austin Bradford Hill criteria to the available evidence. In support of a causative relationship, there is temporality for some cases of diabetes, and there is a biologically plausible explanation. The causative link between antipsychotic drugs and diabetes is coherent with our understanding of diabetes and there are other analogies. However the strength of association is weak, there is lack of consistency or specificity, and there is little evidence to support a biological gradient. We should therefore conclude that the evidence surrounding a causative link between antipsychotic drugs and diabetes is inconclusive. Moreover, the risk is probably low and the attributable risk of developing diabetes is greater for traditional risk factors such as family history, ethnicity, obesity and ageing than it is for receiving an antipsychotic drug. Consequently, the majority of patients receiving second-generation antipsychotics will not develop diabetes as a result of their medication.
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Affiliation(s)
- R I G Holt
- Endocrinology & Metabolism Subdivision, Developmental Origins of Health and Disease Division, School of Medicine, University of Southampton, Southampton, UK.
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Abstract
The prevalence of diabetes is increased in patients with schizophrenia. Although many reasons, including hereditary and lifestyle factors, contribute to this association, recently there has been heightened interest in the subject because of the link between the use of the newer atypical anti-psychotic drugs and the development of diabetes. These drugs cause significant weight gain and this may be one of the mechanisms by which they increase incident diabetes. The increased prevalence of diabetes among people with schizophrenia has implications for the delivery of care by psychiatrists, diabetologists and primary care.
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Affiliation(s)
- R I G Holt
- Endocrinology & Metabolism Sub-division, Fetal Origins of Adult Disease Division, School of Medicine, University of Southampton, Southampton, UK.
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Thompson C, Ostler K, Peveler RC, Baker N, Kinmonth AL. Dimensional perspective on the recognition of depressive symptoms in primary care: The Hampshire Depression Project 3. Br J Psychiatry 2001; 179:317-23. [PMID: 11581111 DOI: 10.1192/bjp.179.4.317] [Citation(s) in RCA: 84] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Most studies of the recognition of depression in primary care have used a categorical definition of depression. This may overstate the extent of the problem. AIMS Our objective was to investigate the relationship between severity and recognition of depression, and its modification by patient and practitioner characteristics. METHOD An association study in multiple consecutive adult cohorts of 18 414 primary care consultations drawn from a representative sample of 156 general practitioners in Hampshire, UK. RESULTS There was a curvilinear relationship between the severity of depression and practitioners' ratings of depression. One case of probable depression was missed in every 28.6 consultations. Anxiety and unemployment altered the chances of recognition, but age, gender and deprivation scores did not. CONCLUSIONS A dimensional approach to severity of depression shows that general practitioners may be better able to recognise depression than previous categorical studies have suggested. Efforts to improve the care of depression should therefore focus on doctors who have been shown to have difficulty making the diagnosis and on improving the treatment of identified patients.
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Affiliation(s)
- C Thompson
- Community Clinical Sciences Research Division, Faculty of Medicine Health and Biological Sciences, University of Southampton, Southhampton, UK
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Bryden KS, Peveler RC, Stein A, Neil A, Mayou RA, Dunger DB. Clinical and psychological course of diabetes from adolescence to young adulthood: a longitudinal cohort study. Diabetes Care 2001; 24:1536-40. [PMID: 11522695 DOI: 10.2337/diacare.24.9.1536] [Citation(s) in RCA: 275] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine the clinical and psychological course of diabetes through adolescence and the relationship with glycemic control in young adulthood. RESEARCH DESIGN AND METHODS A longitudinal cohort study of adolescents recruited from the register of the outpatient pediatric diabetes clinic. A total of 76 individuals (43 male patients, 33 female patients) aged 11-18 years completed baseline assessments, and 65 individuals (86%) were reinterviewed as young adults (20-28 years of age). Longitudinal assessments were made of glycemic control (HbA(1c)), weight gain (BMI), and development of complications. Adolescents completed self-report questionnaires to assess emotional and behavioral problems as well as self-esteem. As young adults, psychological state was assessed by the Revised Clinical Interview Schedule and the self-report Brief Symptom Inventory. RESULTS Mean HbA(1c) levels peaked in late adolescence and were worse in female participants (average 11.1% at 18-19 years of age). The proportion of individuals who were overweight (BMI >25.0 kg/m(2)) increased during the 8-year period from 21 to 54% in female patients and from 2 to 28% in male patients. Serious diabetes-related events included death in one patient and cognitive impairment in two patients. Individuals in whom diabetic complications developed (25% of male patients and 38% of female patients) had significantly higher mean HbA(1c) levels than those without complications (difference 1.9%, 95% CI 1.1-2.7, P < 0.0001). Behavioral problems at baseline were related to higher mean HbA(1c) during the subsequent 8 years (beta = 0.15, SEM (beta) 0.04, P < 0.001, 95% CI 0.07-0.24). CONCLUSIONS The outcome for this cohort was generally poor. Behavioral problems in adolescence seem to be important in influencing later glycemic control.
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Affiliation(s)
- K S Bryden
- University Department of Paediatrics, John Radcliffe Hospital, Oxford, U.K
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Ostler K, Thompson C, Kinmonth AL, Peveler RC, Stevens L, Stevens A. Influence of socio-economic deprivation on the prevalence and outcome of depression in primary care: the Hampshire Depression Project. Br J Psychiatry 2001; 178:12-7. [PMID: 11136204 DOI: 10.1192/bjp.178.1.12] [Citation(s) in RCA: 112] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Health inequalities exist for many disorders, but the contribution of deprivation to the prevalence and outcome of depressive symptoms in primary care populations has been infrequently studied. AIMS To examine the influence of Jarman under-privileged area (UPA) scores on the prevalence and outcome of depressive symptoms in general practice patients. METHOD 18 414 patients attending 55 representative practices completed the Hospital Anxiety and Depression Scale and a questionnaire for employment status. Outcome of those screening positive was assessed at 6 weeks and 6 months. RESULTS The UPA score accounted for 48.3% of the variance between practices in prevalence of depressive symptoms. Attending a high UPA score practice predicted persistence of depressive symptoms to 6 months. CONCLUSIONS The socio-economic deprivation of a practice locality is a powerful predictor of the prevalence and persistence of depressive symptoms.
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Affiliation(s)
- K Ostler
- Community Based Clinical Sciences Research Division, Faculty of Medicine, Health and Biological Sciences, University of Southampton
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Abstract
AIMS To assess the advantages and disadvantages of four methods for studying compliance with antidepressants: self-report scores, tablet counts, a microprocessor (MEMS) container system and the assay of nordothiepin and dothiepin concentrations in plasma. METHODS The techniques were used in 88 patients commencing tricyclic antidepressants in the setting of UK general practice. RESULTS The MEMS system proved to be the most informative technique allowing identification of the precise time of container opening, the demonstration of 'drug holidays' and early cessation of therapy. Self-report scores (Morisky) proved a useful screening technique with a sensitivity of 72.2% and specificity of 74.1% for > or = 80% compliance. Although tablet counts were possible in 84 patients (95. 5%) they were unreliable in 19 (21.6%). Blood concentration assays proved the least acceptable method to patients and were possible in only 53 (60.2%). A ratio of nordothiepin:dothiepin > or = 1.1 claimed, by others, to identify noncompliance was only reliable when concentrations were low. CONCLUSIONS Both the MEMS system and self-report scores proved useful methods for identifying noncompliant patients in the setting of UK general practice. Although compliance was higher than reported in previous studies with 70 patients (79.5%) completing 6 weeks treatment, general practitioners tended to prescribe subtherapeutic doses.
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Affiliation(s)
- C F George
- Clinical Pharmacology Group, School of Medicine, University of Southampton, Southampton
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Thompson C, Peveler RC, Stephenson D, McKendrick J. Compliance with antidepressant medication in the treatment of major depressive disorder in primary care: a randomized comparison of fluoxetine and a tricyclic antidepressant. Am J Psychiatry 2000; 157:338-43. [PMID: 10698807 DOI: 10.1176/appi.ajp.157.3.338] [Citation(s) in RCA: 77] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Many claims have been made for superior compliance with selective serotonin reuptake inhibitors (SSRIs) compared with tricyclic antidepressants, but to date meta-analyses have not confirmed reduced dropouts in randomized controlled trials. The authors used a randomized study design to evaluate differential compliance with antidepressant medications in a primary care setting. METHOD A total of 152 patients treated in 10 primary care practices in the United Kingdom were included in a randomized, open-label, parallel-group study of fluoxetine and dothiepin at therapeutic doses for 12 weeks. Compliance was assessed by using pill count, patient questionnaires, and the Medication Event Monitoring System. RESULTS The level of compliance with fluoxetine was numerically higher than the level of compliance with dothiepin on all three primary outcome measures, although the differences were not significant. In a secondary analysis using data from the Medication Event Monitoring System, both a survival analysis for length of time without a gap in medicine taking and a derived compliance index showed a significant advantage to fluoxetine. Patients in the fluoxetine group reported superior response on the health transition scale of the 36-item Short-Form Health Survey Questionnaire and numerically greater improvement on the Hamilton Depression Rating Scale. In both treatment arms patients with a superior compliance index were more likely to have improved in Hamilton depression scale scores by the last study visit. CONCLUSIONS This study supports recent meta-analyses of SSRIs versus tricyclic antidepressants in finding no significant differences in crude indices of compliance between fluoxetine and dothiepin, despite marked differences in side effect profile and dose regimen. However, both a survival analysis and a new measure that takes account of prolonged periods of noncompliance distinguished between the treatments and was associated with improvement in both groups.
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Affiliation(s)
- C Thompson
- Department of Mental Health, University of Southampton, England.
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Thompson C, Kinmonth AL, Stevens L, Peveler RC, Stevens A, Ostler KJ, Pickering RM, Baker NG, Henson A, Preece J, Cooper D, Campbell MJ. Effects of a clinical-practice guideline and practice-based education on detection and outcome of depression in primary care: Hampshire Depression Project randomised controlled trial. Lancet 2000; 355:185-91. [PMID: 10675118 DOI: 10.1016/s0140-6736(99)03171-2] [Citation(s) in RCA: 276] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Depression is a major individual and public-health burden throughout the world and is managed mainly in primary care. The most effective strategy to reduce this burden has been believed to be education of primary-care practitioners. We tested this assumption by assessing the effectiveness of an educational programme based on a clinical-practice guideline in improving the recognition and outcome of primary-care depression. METHODS We carried out a randomised controlled trial in a representative sample of 60 primary-care practices (26% of the total) in an English health district. Education was delivered to practice teams and quality tested by feedback from participants and expert raters. The primary endpoints were recognition of depression, defined by the hospital anxiety and depression (HAD) scale, and clinical improvement. Analysis was by intention to treat. FINDINGS The education was well received by participants, 80% of whom thought it would change their management of patients with depression. 21409 patients were screened, of whom 4192 were classified as depressed by the HAD scale. The sensitivity of physicians to depressive symptoms was 39% in the intervention group and 36% in the control group after education (odds ratio 1.2 [95% CI 0.88-1.61]). The outcome of depressed patients as a whole at 6 weeks or 6 months after the assessment did not significantly improve. INTERPRETATION Although well received, this in-practice programme, which was designed to convey the current consensus on best practice for the care of depression, did not deliver improvements in recognition of or recovery from depression.
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Affiliation(s)
- C Thompson
- Department of Mental Health, University of Southampton, Royal South Hants Hospital, Brinton's Terrace, UK
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Bryden KS, Neil A, Mayou RA, Peveler RC, Fairburn CG, Dunger DB. Eating habits, body weight, and insulin misuse. A longitudinal study of teenagers and young adults with type 1 diabetes. Diabetes Care 1999; 22:1956-60. [PMID: 10587825 DOI: 10.2337/diacare.22.12.1956] [Citation(s) in RCA: 236] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To examine disordered eating, insulin misuse, weight change, and their relationships with glycemic control and diabetic complications in adolescents with type 1 diabetes followed up over eight years. RESEARCH DESIGN AND METHODS Of 76 adolescents (43 male, 33 female) with type 1 diabetes aged 11-18 years at the first assessment, 65 were interviewed as young adults (aged 20-28 years). Eating habits were assessed using a standardized Eating Disorder Examination. Height and weight were determined and BMI calculated. Three consecutive urine specimens were collected for measurement of albumin/creatinine ratio and other significant diabetic complications were recorded. Glycemic control was assessed by glycated hemoglobin. RESULTS Weight and BMI increased from adolescence to young adulthood. Females were overweight as adolescents and both sexes were overweight as young adults. Concern over weight and shape increased significantly for both sexes from adolescence to young adulthood. This increase in concern was reflected in increased levels of dietary restraint. Features of disordered eating were apparent in females at both assessments, but no patients met the criteria for anorexia nervosa or bulimia nervosa at either assessment. A total of 10 (30%) females, but none of the males admitted underusing insulin to control weight. Five (45%) females with microvascular complications had intentionally misused insulin to prevent weight gain. CONCLUSIONS An increase in BMI from adolescence to adulthood was associated with higher levels of concern over shape and weight and more intense dietary restraint, especially among females. Overt eating disorders were no more prevalent in these patients than in the general population, but milder forms of disordered eating were common and had implications for diabetes management. Insulin omission for weight control was frequent among females and may contribute to poor glycemic control and to risk of complications.
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Affiliation(s)
- K S Bryden
- University Department of Pediatrics, John Radcliffe Hospital, Oxford, U.K
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Fairburn CG, Norman PA, Welch SL, O'Connor ME, Doll HA, Peveler RC. A prospective study of outcome in bulimia nervosa and the long-term effects of three psychological treatments. Arch Gen Psychiatry 1995; 52:304-12. [PMID: 7702447 DOI: 10.1001/archpsyc.1995.03950160054010] [Citation(s) in RCA: 361] [Impact Index Per Article: 12.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Little is known about the longer-term outcome of bulimia nervosa and the distal effects of treatment. METHODS Prospective follow-up of subjects from two randomized controlled trials, involving a comparison of cognitive behavior therapy, behavior therapy, and focal interpersonal therapy. RESULTS Ninety percent (89/99) underwent reassessment by interview (mean [+/- SD] length of follow-up, 5.8 +/- 2.0 years). Almost half (46%) had a DSM-IV eating disorder; 19%, bulimia nervosa; 3%, anorexia nervosa; and 24%, eating disorder not otherwise specified. There was a low rate of other psychiatric disorders. Premorbid and paternal obesity predicted a poor outcome. While the three treatments did not differ with respect to the proportion of subjects with anorexia nervosa or bulimia nervosa at follow-up, they did differ once all forms of DSM-IV eating disorder were considered together. Those who had received cognitive behavior therapy or focal interpersonal therapy were doing markedly better than those who had received behavior therapy. CONCLUSIONS The longer-term outcome of bulimia nervosa depends on the nature of the treatment received. Patients who receive a treatment such as behavior therapy, which only has a short-lived effect, tend to do badly, whereas those who receive treatments such as cognitive behavior therapy or focal interpersonal therapy have a better prognosis.
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Affiliation(s)
- C G Fairburn
- Department of Psychiatry, University of Oxford Hospital, England
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Fairburn CG, Peveler RC, Jones R, Hope RA, Doll HA. Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to shape and weight. J Consult Clin Psychol 1993. [PMID: 8370866 DOI: 10.1037//0022-006x.61.4.696] [Citation(s) in RCA: 25] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Seventy-five patients with bulimia nervosa were treated with 1 of 3 short-term psychological treatments and were then entered into a closed 1-year period of follow-up. Pretreatment predictors of 3 measures of outcome were sought. Only 2 variables were significantly associated with outcome: attitudes toward shape and weight, and self-esteem. The nature of the relation between attitudinal disturbance and outcome was complex and unexpected. The data set was also used to test the major prediction of the cognitive view of bulimia nervosa, namely that among patients who have responded to treatment, the residual level of attitudinal disturbance will predict subsequent outcome. This prediction was confirmed.
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Affiliation(s)
- C G Fairburn
- Department of Psychiatry, Oxford University, United Kingdom
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Abstract
To evaluate the frequency of eating disorder features among women receiving treatment for an alcohol problem, 52 female attenders at an alcohol clinic were assessed using a standardized research clinical interview, and the findings compared with data on a general population sample. The results suggest that eating disorder features are overrepresented among women who present for treatment for an alcohol problem.
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Affiliation(s)
- A V Taylor
- University of Southampton, United Kingdom
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Fairburn CG, Peveler RC, Jones R, Hope RA, Doll HA. Predictors of 12-month outcome in bulimia nervosa and the influence of attitudes to shape and weight. J Consult Clin Psychol 1993; 61:696-8. [PMID: 8370866 DOI: 10.1037/0022-006x.61.4.696] [Citation(s) in RCA: 156] [Impact Index Per Article: 5.0] [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] [Indexed: 01/30/2023]
Abstract
Seventy-five patients with bulimia nervosa were treated with 1 of 3 short-term psychological treatments and were then entered into a closed 1-year period of follow-up. Pretreatment predictors of 3 measures of outcome were sought. Only 2 variables were significantly associated with outcome: attitudes toward shape and weight, and self-esteem. The nature of the relation between attitudinal disturbance and outcome was complex and unexpected. The data set was also used to test the major prediction of the cognitive view of bulimia nervosa, namely that among patients who have responded to treatment, the residual level of attitudinal disturbance will predict subsequent outcome. This prediction was confirmed.
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Affiliation(s)
- C G Fairburn
- Department of Psychiatry, Oxford University, United Kingdom
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Fairburn CG, Jones R, Peveler RC, Hope RA, O'Connor M. Psychotherapy and bulimia nervosa. Longer-term effects of interpersonal psychotherapy, behavior therapy, and cognitive behavior therapy. Arch Gen Psychiatry 1993; 50:419-28. [PMID: 8498876 DOI: 10.1001/archpsyc.1993.01820180009001] [Citation(s) in RCA: 365] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To determine whether cognitive behavior therapy (CBT) for bulimia nervosa has a specific therapeutic effect and determine whether a simplified behavioral treatment (BT) of CBT is as effective as the full treatment. DESIGN Randomized controlled trial involving three psychological treatments. Two planned comparisons, CBT with interpersonal psychotherapy (IPT), and CBT with BT. Closed 12-month follow-up period. Independent assessors. SETTING Secondary referral center. PATIENTS Seventy-five consecutively referred patients with bulimia nervosa. Patients with concurrent anorexia nervosa were excluded. INTERVENTIONS Cognitive behavior therapy, IPT, BT conducted on an individual outpatient basis. There were nineteen sessions over 18 weeks. Six experienced therapists administered all three treatments. There was no concurrent treatment. MAIN OUTCOME MEASURE Frequency of binge eating and purging. RESULTS High rate (48%) of attrition and withdrawal among the patients who received BT. Over follow-up, few patients undergoing BT met criteria for a good outcome (cessation of all forms of binge eating and purging). Patients in the CBT and IPT treatments made equivalent, substantial, and lasting changes across all areas of symptoms, although there were clear temporal differences in the pattern of response, with IPT taking longer to achieve its effects. CONCLUSIONS Bulimia nervosa may be treated successfully without focusing directly on the patient's eating habits and attitudes to shape and weight. Cognitive behavior therapy and IPT achieved equivalent effects through the operation of apparently different mediating mechanisms. A further comparison of CBT and IPT is warranted. The behavioral version of CBT was markedly less effective than the full treatment.
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Affiliation(s)
- C G Fairburn
- Oxford University, Department of Psychiatry, Warneford Hospital, United Kingdom
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Abstract
Seventy-five patients with bulimia nervosa were treated with cognitive behaviour therapy, behaviour therapy or interpersonal psychotherapy. The changes that occurred during treatment were assessed in a subsample of 38 patients. There was an immediate decrease in the frequency of binge-eating and purging (self-induced vomiting or laxative misuse). This continued for 4 wk in interpersonal psychotherapy and for 8 wk in the other two treatment conditions. There were no clear differences between the three treatments in the time course of their effects on a global measure of eating behaviour and attitudes or on measures of depression and self-esteem. The findings suggest that certain shared 'non-specific' properties of psychological treatments can have a substantial early effect on the eating behaviour of patients with bulimia nervosa. Indeed, patients with bulimia nervosa may be particularly likely to show non-specific treatment effects. Cognitive behaviour therapy and behaviour therapy appear to have an immediate influence on eating behaviour over and above these non-specific effects. The study gave no clues as to the mechanism of action of interpersonal psychotherapy.
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Affiliation(s)
- R Jones
- Oxford University Department of Psychiatry, Warneford Hospital, U.K
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Abstract
Self-care behaviour, knowledge about diabetes, and blood glucose control were studied in 113 young adults with Type 1 diabetes using a semi-structured interview, self-report questionnaires, and a biochemical measure (glycated haemoglobin). The majority of subjects followed their prescribed regimen reasonably accurately, but individuals followed different aspects of the regimen to different degrees. Subjects were more concerned with the avoidance of hypoglycaemia than with attainment of 'tight' blood glucose control. The blood glucose test level at which subjects took remedial action was the best single predictor of symptomatic control. Frequency of nocturnal polyuria appeared to be a reliable indicator of impaired metabolic control. Insulin omission or dose reduction for the purpose of body weight reduction was common among women, who also had worse blood glucose control than men. Elevated glycated haemoglobin levels were associated with higher alcohol consumption in men. Theoretical knowledge about diabetes management was only weakly associated with self-care behaviour and blood glucose control in this population. The blood glucose test result at which subjects take remedial action appears to be the most appropriate behavioural target for intervention to improve control in such subjects.
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Affiliation(s)
- R C Peveler
- Oxford University Department of Psychiatry, Warneford Hospital, UK
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Abstract
OBJECTIVE To determine the prevalence of clinical eating disorders and lesser degrees of disturbed eating in adolescents with IDDM and a matched sample of nondiabetic control subjects. RESEARCH DESIGN AND METHODS A cross-sectional survey of eating habits and attitudes conducted in 76 adolescents with IDDM, and age- and sex-matched nondiabetic control subjects. Eating disorder features were assessed by standardized research interview adapted for use with patients with diabetes (EDE). Glycemic control was assessed by GHb assay. RESULTS Adolescent girls with IDDM were heavier than nondiabetic female control subjects and were dieting more intensively to control their shape and weight. However, clinical eating disorders were no more common among adolescent girls with IDDM than among nondiabetic control subjects. Nine percent of the IDDM girls met diagnostic criteria for an operational version of "Eating disorder not otherwise specified." Fifteen percent had omitted or reduced their dose of insulin to influence their shape and weight. Eating disorder features and insulin misuse for shape and weight control were not found in IDDM or nondiabetic boys, and these two groups did not differ in their body weight. CONCLUSIONS Adolescent girls with IDDM are heavier than their nondiabetic counterparts and diet more intensively to control their shape and weight. Disordered eating habits and weight control behavior are common, but no more so in IDDM than in nondiabetic subjects. Insulin misuse for the purpose of shape and weight control is not restricted to subjects with a clinical eating disorder. Disordered eating is associated with impaired glycemic control.
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Affiliation(s)
- R C Peveler
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
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Abstract
The psychosocial adjustment of 30 siblings (aged 8-18 years) of children with diabetes mellitus was studied. Although most were younger than the diabetic child, 55% were closely involved in the dietary management and insulin treatment of the diabetes, yet many had only a limited understanding of the disease. Most were well-adjusted. However, low levels of self-esteem were apparent among some subjects, who did not fee free to question their parents about diabetes (30%), who identified themselves as the member of the family most likely to receive blame (33%), and who reported spending more time at home with their families than their peers (40%). Nine children (30%) worried about becoming ill themselves. None believed that having a child with diabetes in the family had impaired relationships in the home. Six siblings (20%) also described some positive effects of the illness, particularly enhanced family closeness.
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Affiliation(s)
- R Adams
- Oxford University, Department of Psychiatry, Warneford Hospital, UK
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Fairburn CG, Peveler RC, Davies B, Mann JI, Mayou RA. Eating disorders in young adults with insulin dependent diabetes mellitus: a controlled study. BMJ 1991; 303:17-20. [PMID: 1781827 PMCID: PMC1670295 DOI: 10.1136/bmj.303.6793.17] [Citation(s) in RCA: 155] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE To determine the prevalence of clinical eating disorders and lesser degrees of disturbed eating in young adults with insulin dependent diabetes and a matched sample of non-diabetic female controls. DESIGN Cross sectional survey of eating habits and attitudes in diabetic and non-diabetic subjects. SETTING Outpatient clinic catering for young adults with diabetes; community sample of non-diabetic women drawn from the lists of two general practices. SUBJECTS 100 patients with insulin dependent diabetes (54 women and 46 men) aged 17-25 and 67 non-diabetic women of the same age. MAIN OUTCOME MEASURES Eating habits and eating disorder psychopathology were assessed by standardised research interview adapted for the assessment of patients with diabetes (eating disorder examination). Glycaemic control was assessed by glycated haemoglobin assay. RESULTS In both non-diabetic and diabetic women disturbed eating was common, and in diabetic women the degree of disturbance was related to control of glycaemia. Twenty of the diabetic women (37%) had omitted or underused insulin to influence their weight. This behaviour was not restricted to those with a clinical eating disorder. None of the men showed any features of eating disorders, and none had misused insulin to influence their weight. CONCLUSIONS There was no evidence that clinical eating disorders are more prevalent in young women with diabetes than in non-diabetic women. Nevertheless, disturbed eating is common and is associated with poor control of glycaemia, and the misuse of insulin to influence body weight is also common in young women with diabetes.
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Affiliation(s)
- C G Fairburn
- University Department of Psychiatry, Warneford Hospital, Oxford
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Fairburn CG, Jones R, Peveler RC, Carr SJ, Solomon RA, O'Connor ME, Burton J, Hope RA. Three psychological treatments for bulimia nervosa. A comparative trial. Arch Gen Psychiatry 1991; 48:463-9. [PMID: 2021299 DOI: 10.1001/archpsyc.1991.01810290075014] [Citation(s) in RCA: 349] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The specificity and magnitude of the effects of cognitive behavior therapy in the treatment of bulimia nervosa were evaluated. Seventy-five patients who met strict diagnostic criteria were treated with either cognitive behavior therapy, a simplified behavioral version of this treatment, or interpersonal psychotherapy. Assessment was by interview and self-report questionnaire, and many aspects of functioning were evaluated. All three treatments resulted in an improvement in the measures of the psychopathology. Cognitive behavior therapy was more effective than interpersonal psychotherapy in modifying the disturbed attitudes to shape and weight, extreme attempts to diet, and self-induced vomiting. Cognitive behavior therapy was more effective than behavior therapy in modifying the disturbed attitudes to shape and weight and extreme dieting, but it was equivalent in other respects. The findings suggest that cognitive behavior therapy, when applied to patients with bulimia nervosa, operates through mechanisms specific to this treatment and is more effective than both interpersonal psychotherapy and a simplified behavioral version of cognitive behavior therapy.
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Affiliation(s)
- C G Fairburn
- Department of Psychiatry, Oxford University, Warneford Hospital, England
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Abstract
The Symptom Check List (SCL-90R) is a self-report questionnaire which is designed to be suitable for use as a psychiatric case-finding instrument, as a measure of symptom severity, and as a descriptive measure of psychopathology. Scores obtained using the instrument were compared with those obtained from the investigator-based interview, the Present State Examination, in two samples of patients: a sample of patients with chronic physical disease (diabetes mellitus) and a sample of patients with bulimia nervosa. There was good agreement between the two methods of measurement in both samples, suggesting that the SCL-90R performs well in the assessment of neurotic symptoms.
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Affiliation(s)
- R C Peveler
- Oxford University, Department of Psychiatry, Warneford Hospital
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Abstract
A case of anorexia nervosa occurring in a patient with diabetes mellitus is reported. The patient was successfully managed using a cognitive-behavioural treatment approach. The presence of diabetes necessitated certain modifications to the standard cognitive-behavioural treatment for anorexia nervosa, including self-monitoring of diabetic regimen behaviours, attention to the adequacy of glycaemic control, and advice about changes in insulin dosage. Cognitive restructuring techniques also had to address diabetes-related thoughts. The general applicability and cost-effectiveness of this type of approach for the treatment of patients with co-existing eating disorders and diabetes is discussed.
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Peveler RC, Bergel DH, Robinson JL, Sleight P. The effect of phenylephrine upon arterial pressure, carotid sinus radius and baroreflex sensitivity in the conscious greyhound. Clin Sci (Lond) 1983; 64:455-61. [PMID: 6831834 DOI: 10.1042/cs0640455] [Citation(s) in RCA: 37] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
1. A method for recording carotid sinus diameter in conscious dogs has been developed, using an ultrasound transit time technique. We have used this method to measure the distensibility of the carotid sinus in resting animals, and we have investigated the effect of injecting the vasoactive drug phenylephrine on the mechanical behaviour of the sinus wall. 2. Baroreflex sensitivity was measured in the dogs by the usual method of relating the slowing of the heart to the transient pressure rise induced by the injections of phenylephrine. 3. We have shown that phenylephrine directly reduces the radius of the carotid sinus during the measurements of baroreflex sensitivity. At a dose of 2-4 micrograms/kg, phenylephrine has an enhancing effect on the baroreflex response, possibly resulting from a modification of baroreceptor output.
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Bergel DH, Peveler RC, Robinson JL, Sleight P. The measurement of arterial pressure, carotid sinus radius and baroreflex sensitivity in the conscious greyhound [proceedings]. J Physiol 1979; 292:65P-66P. [PMID: 490402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
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