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Van Leeuwen E, Maund E, Woods C, Bowers H, Christiaens T, Kendrick T. Health care professional barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord 2024; 356:616-627. [PMID: 38640978 DOI: 10.1016/j.jad.2024.04.060] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 04/12/2024] [Accepted: 04/14/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Long-term antidepressant (AD) use, much longer than recommended, is very common and can lead to potential harms. OBJECTIVE To investigate the existing literature on perspectives of health professionals (HPs) regarding long-term AD treatment, focusing on barriers and facilitators to discontinuation. METHODS A systematic review with thematic synthesis. Eight electronic databases were searched until August 2023 including MEDLINE, PubMed, Embase, PsycINFO, CINAHL, AMED, Health Management Information Consortium, and the Networked Digital Library of Theses and Dissertation. RESULTS Thirteen studies were included in the review. Of these, nine focused on general practitioner perspectives, one on psychiatrist perspectives, and three on a mix of HPs perspectives. Barriers and facilitators to discontinuing long-term ADs emerged within eight themes, ordered chronologically based on HP considerations during an AD review: perception of AD use, fears, HP role and responsibility, HPs' perception of AD discontinuation, HPs' confidence regarding their ability to manage discontinuation, perceived patient readiness to stop, support from patient's trusted people, and support from other HPs. LIMITATIONS Coding and development of subthemes and themes was performed by one researcher and further developed through discussion within the research team. CONCLUSION Deprescribing long-term ADs is a challenging concept for HPs. The review found evidence that the barriers far outweigh the facilitators with fear of relapse as a main barrier. HP education, reassurance and confidence-building is essential to increase the initiation of the discontinuation process. Further research into the perspectives of pharmacists and mental health workers is needed as well as exploring the role of trusted people.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium; Department of Public Health and Primary Care, Ghent University, Belgium.
| | - Emma Maund
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Catherine Woods
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Hannah Bowers
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Belgium
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Health & Medical Education, University of Southampton, Southampton, United Kingdom
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Archer C, Kessler D, Lewis G, Araya R, Duffy L, Gilbody S, Lewis G, Kendrick T, Peters TJ, Wiles N. What predicts response to sertraline for people with depression in primary care? a secondary data analysis of moderators in the PANDA trial. PLoS One 2024; 19:e0300366. [PMID: 38722970 PMCID: PMC11081306 DOI: 10.1371/journal.pone.0300366] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 02/23/2024] [Indexed: 05/13/2024] Open
Abstract
PURPOSE Antidepressants are a first-line treatment for depression, yet many patients do not respond. There is a need to understand which patients have greater treatment response but there is little research on patient characteristics that moderate the effectiveness of antidepressants. This study examined potential moderators of response to antidepressant treatment. METHODS The PANDA trial investigated the clinical effectiveness of sertraline (n = 326) compared with placebo (n = 329) in primary care patients with depressive symptoms. We investigated 11 potential moderators of treatment effect (age, employment, suicidal ideation, marital status, financial difficulty, education, social support, family history of depression, life events, health and past antidepressant use). Using multiple linear regression, we investigated the appropriate interaction term for each of these potential moderators with treatment as allocated. RESULTS Family history of depression was the only variable with weak evidence of effect modification (p-value for interaction = 0.048), such that those with no family history of depression may have greater benefit from antidepressant treatment. We found no evidence of effect modification (p-value for interactions≥0.29) by any of the other ten variables. CONCLUSION Evidence for treatment moderators was extremely limited, supporting an approach of continuing discuss antidepressant treatment with all patients presenting with moderate to severe depressive symptoms.
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Affiliation(s)
- Charlotte Archer
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David Kessler
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Gemma Lewis
- Division of Psychiatry, University College London, London, United Kingdom
| | - Ricardo Araya
- Health Services and Population Research Department, King’s College London, London, United Kingdom
| | - Larisa Duffy
- Division of Psychiatry, University College London, London, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
| | - Tony Kendrick
- Faculty of Medicine, Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Tim J. Peters
- Bristol Dental School, University of Bristol, Bristol, United Kingdom
| | - Nicola Wiles
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Duffy L, Lewis G, Marston L, Kendrick T, Kessler D, Moore M, Wiles N, Lewis G. Clinical factors associated with relapse in depression in a sample of UK primary care patients who have been on long-term antidepressant treatment. Psychol Med 2024; 54:951-961. [PMID: 37753652 DOI: 10.1017/s0033291723002659] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/28/2023]
Abstract
BACKGROUND This paper investigates whether age of onset of depression, duration of the last episode, number of episodes, and residual symptoms of depression and anxiety are associated with depression relapse in primary care patients who have been on long-term maintenance antidepressant treatment and no longer meet ICD10 criteria for depression. METHODS An observational cohort using data from ANTLER (N = 478), a double-blind placebo-controlled trial. The primary outcome was time to relapse using the retrospective CIS-R. Participants were followed for 12 months. RESULTS Primary outcome was available for 468 participants. Time to relapse in those with more than five previous episodes of depression was shorter, hazard ratio (HR) 1.84 (95% confidence interval [CI] 1.23-2.75) compared to people with two episodes; HR 1.57 (95% CI 1.01-2.43) after adjustment. The residual symptoms of depression at baseline were also associated with increased relapse: HR 1.05 (95% CI 1.01-1.09) and HR 1.06 (95% CI 1.01-1.12) in the adjusted model. There was evidence of reduced rate of relapse in older age of onset group: HR 0.86 (95% CI 0.78-0.95); HR attenuated after adjustment HR 0.91 (95% CI 0.81-1.02). There was no evidence of an association between duration of the current episode and residual anxiety symptoms with relapse. CONCLUSIONS The number of previous episodes and residual symptoms of depression were associated with increased likelihood of relapse. These factors could inform joint decision making when patients are considering tapering off maintenance antidepressant treatment or considering other treatments to prevent relapse.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
| | - Louise Marston
- Research Dept. of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
- Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tony Kendrick
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael Moore
- Primary Care Research Centre, School of Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London W1 T 7NF, UK
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Geraghty AWA, Holt S, Chew-Graham CA, Santer M, Moore M, Kendrick T, Terluin B, Little P, Stuart B, Mistry M, Richards A, Smith D, Newman S, Rathod S, Bowers H, van Marwijk H. Distinguishing emotional distress from mental disorder: A qualitative exploration of the Four-Dimensional Symptom Questionnaire (4DSQ). Br J Gen Pract 2024:BJGP.2023.0574. [PMID: 38499297 DOI: 10.3399/bjgp.2023.0574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Primary care clinicians see people experiencing the full range of mental health problems. Determining when symptoms reflect disorder is complex. The Four-Dimensional Symptom Questionnaire (4DSQ) uniquely distinguishes general distress from depressive and anxiety disorders. It may support diagnostic conversations and targeting of treatment. AIM We aimed to explore peoples' experiences of completing the 4DSQ and their perceptions of their resulting score profile across distress, depression, anxiety and physical symptoms. DESIGN AND SETTING A qualitative study conducted in the UK with people recruited from primary care and community settings. METHOD Participants completed the 4DSQ then took part in semi-structured telephone interviews. They were interviewed about their experience of completing the 4DSQ, their perceptions of their scores across four dimensions, and the perceived utility if used with a clinician. Interviews were transcribed verbatim and data were analysed thematically. RESULTS Twenty-four interviews were conducted. Most participants found the 4DSQ easy to complete and reported that scores across the four dimensions aligned well with their symptom experience. Distinct scores for distress, depression and anxiety appeared to support improved self-understanding. Some valued the opportunity to discuss their scores and provide relevant context. Many felt the use of the 4DSQ with clinicians would be helpful and likely to support treatment decisions, although some were concerned about time-limited consultations. CONCLUSION Distinguishing general distress from depressive and anxiety disorders aligned well with people's experience of symptoms. Use of the 4DSQ as part of mental health consultations may support targeting of treatment and personalisation of care.
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Affiliation(s)
- Adam W A Geraghty
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Sian Holt
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Carolyn A Chew-Graham
- Keele University, Research Institute, Primary Care and Health Sciences, Keele, United Kingdom
- Midlands Partnership Foundation Trust
| | - Miriam Santer
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Michael Moore
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Tony Kendrick
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | | | - Paul Little
- University of Southampton, Primary Care Research Centre, Southampton, United Kingdom
| | - Beth Stuart
- Queen Mary University of London, London, United Kingdom
| | - Manoj Mistry
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Al Richards
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Debs Smith
- Cardiff University, Wales COVID-19 Evidence Centre, Division of Population Medicine, Cardiff, United Kingdom
| | - Sonia Newman
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Shanaya Rathod
- Southern Health NHS Foundation Trust, Southampton, United Kingdom
| | - Hannah Bowers
- University of Southampton, Southampton, United Kingdom
| | - Harm van Marwijk
- Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
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Kendrick T, Dowrick C, Lewis G, Moore M, Leydon GM, Geraghty AW, Griffiths G, Zhu S, Yao GL, May C, Gabbay M, Dewar-Haggart R, Williams S, Bui L, Thompson N, Bridewell L, Trapasso E, Patel T, McCarthy M, Khan N, Page H, Corcoran E, Hahn JS, Bird M, Logan MX, Ching BCF, Tiwari R, Hunt A, Stuart B. Patient-reported outcome measures for monitoring primary care patients with depression: the PROMDEP cluster RCT and economic evaluation. Health Technol Assess 2024; 28:1-95. [PMID: 38551155 PMCID: PMC11017630 DOI: 10.3310/plrq4216] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/02/2024] Open
Abstract
Background Guidelines on the management of depression recommend that practitioners use patient-reported outcome measures for the follow-up monitoring of symptoms, but there is a lack of evidence of benefit in terms of patient outcomes. Objective To test using the Patient Health Questionnaire-9 questionnaire as a patient-reported outcome measure for monitoring depression, training practitioners in interpreting scores and giving patients feedback. Design Parallel-group, cluster-randomised superiority trial; 1 : 1 allocation to intervention and control. Setting UK primary care (141 group general practices in England and Wales). Inclusion criteria Patients aged ≥ 18 years with a new episode of depressive disorder or symptoms, recruited mainly through medical record searches, plus opportunistically in consultations. Exclusions Current depression treatment, dementia, psychosis, substance misuse and risk of suicide. Intervention Administration of the Patient Health Questionnaire-9 questionnaire with patient feedback soon after diagnosis, and at follow-up 10-35 days later, compared with usual care. Primary outcome Beck Depression Inventory, 2nd edition, symptom scores at 12 weeks. Secondary outcomes Beck Depression Inventory, 2nd edition, scores at 26 weeks; antidepressant drug treatment and mental health service contacts; social functioning (Work and Social Adjustment Scale) and quality of life (EuroQol 5-Dimension, five-level) at 12 and 26 weeks; service use over 26 weeks to calculate NHS costs; patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale); and adverse events. Sample size The original target sample of 676 patients recruited was reduced to 554 due to finding a significant correlation between baseline and follow-up values for the primary outcome measure. Randomisation Remote computerised randomisation with minimisation by recruiting university, small/large practice and urban/rural location. Blinding Blinding of participants was impossible given the open cluster design, but self-report outcome measures prevented observer bias. Analysis was blind to allocation. Analysis Linear mixed models were used, adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering including practice as random effect. Quality of life and costs were analysed over 26 weeks. Qualitative interviews Practitioner and patient interviews were conducted to reflect on trial processes and use of the Patient Health Questionnaire-9 using the Normalization Process Theory framework. Results Three hundred and two patients were recruited in intervention arm practices and 227 patients were recruited in control practices. Primary outcome data were collected for 252 (83.4%) and 195 (85.9%), respectively. No significant difference in Beck Depression Inventory, 2nd edition, score was found at 12 weeks (adjusted mean difference -0.46, 95% confidence interval -2.16 to 1.26). Nor were significant differences found in Beck Depression Inventory, 2nd Edition, score at 26 weeks, social functioning, patient satisfaction or adverse events. EuroQol-5 Dimensions, five-level version, quality-of-life scores favoured the intervention arm at 26 weeks (adjusted mean difference 0.053, 95% confidence interval 0.013 to 0.093). However, quality-adjusted life-years over 26 weeks were not significantly greater (difference 0.0013, 95% confidence interval -0.0157 to 0.0182). Costs were lower in the intervention arm but, again, not significantly (-£163, 95% confidence interval -£349 to £28). Cost-effectiveness and cost-utility analyses, therefore, suggested that the intervention was dominant over usual care, but with considerable uncertainty around the point estimates. Patients valued using the Patient Health Questionnaire-9 to compare scores at baseline and follow-up, whereas practitioner views were more mixed, with some considering it too time-consuming. Conclusions We found no evidence of improved depression management or outcome at 12 weeks from using the Patient Health Questionnaire-9, but patients' quality of life was better at 26 weeks, perhaps because feedback of Patient Health Questionnaire-9 scores increased their awareness of improvement in their depression and reduced their anxiety. Further research in primary care should evaluate patient-reported outcome measures including anxiety symptoms, administered remotely, with algorithms delivering clear recommendations for changes in treatment. Study registration This study is registered as IRAS250225 and ISRCTN17299295. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 17/42/02) and is published in full in Health Technology Assessment; Vol. 28, No. 17. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Tony Kendrick
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Christopher Dowrick
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Glyn Lewis
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Michael Moore
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Geraldine M Leydon
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Adam Wa Geraghty
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Shihua Zhu
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Guiqing Lily Yao
- Leicester Clinical Trials Unit, University of Leicester, Leicester, UK
| | - Carl May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mark Gabbay
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Rachel Dewar-Haggart
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Samantha Williams
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Lien Bui
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Natalie Thompson
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Lauren Bridewell
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Emilia Trapasso
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Tasneem Patel
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Molly McCarthy
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Naila Khan
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Helen Page
- Department of Primary Care and Mental Health, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Emma Corcoran
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Jane Sungmin Hahn
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Molly Bird
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Mekeda X Logan
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Brian Chi Fung Ching
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Riya Tiwari
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Anna Hunt
- School of Primary Care, Population Health and Medical Education, University of Southampton, Southampton, UK
| | - Beth Stuart
- Centre for Evaluation and Methods, Wolfson Institute of Population Health, Faculty of Medicine and Dentistry, Queen Mary University of London, London, UK
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Kendrick T, Dowrick C, Lewis G, Moore M, Leydon G, Geraghty AWA, Griffiths G, Zhu S, Yao G, May C, Gabbay M, Dewar-Haggart R, Williams S, Bui L, Thompson N, Bridewell L, Trapasso E, Patel T, McCarthy M, Khan N, Page H, Corcoran E, Hahn JS, Bird M, Logan MX, Ching BCF, Tiwari R, Hunt A, Stuart B. Depression follow-up monitoring with the PHQ-9: open cluster-randomised controlled trial. Br J Gen Pract 2024:BJGP.2023.0539. [PMID: 38408790 DOI: 10.3399/bjgp.2023.0539] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/19/2024] [Indexed: 02/28/2024] Open
Abstract
BACKGROUND Outcome monitoring of depression is recommended but lacks evidence of patient benefit in primary care. AIM To test monitoring depression using the PHQ-9 questionnaire with patient feedback. DESIGN AND SETTING Open cluster-randomised controlled trial in 141 group practices. METHOD Adults with new depressive episodes were recruited through records searches and opportunistically. EXCLUSION CRITERIA dementia, psychosis, substance misuse, suicide risk. The PHQ-9 questionnaire was to be administered soon after diagnosis, and 10-35 days later. PRIMARY OUTCOME Beck Depression Inventory (BDI-II) score at 12 weeks. SECONDARY OUTCOMES BDI-II at 26 weeks; Work and Social Adjustment Scale and EuroQol EQ-5D-5L quality of life at 12 and 26 weeks; antidepressant treatment, mental health service use, adverse events, and Medical Informant Satisfaction Scale over 26 weeks. RESULTS 302 intervention arm patients were recruited and 227 controls. At 12 weeks 252 (83.4%) and 195 (85.9%) were followed-up respectively. Only 41% of intervention arm patients had a GP follow-up PHQ-9 recorded. There was no significant difference in BDI-II score at 12 weeks (mean difference -0.46; 95% CI -2.16,1.26), adjusted for baseline depression, baseline anxiety, sociodemographic factors, and clustering by practice). EQ-5D-5L quality of life scores were higher in the intervention arm at 26 weeks (adjusted mean difference 0.053; 95% CI 0.093,0.013). A clinically significant difference in depression at 26 weeks could not be ruled out. No significant differences were found in social functioning, adverse events, or satisfaction. In a per-protocol analysis, antidepressant use and mental health contacts were significantly greater in intervention arm patients with a recorded follow-up PHQ-9. CONCLUSIONS No evidence was found of improved depression outcome at 12 weeks from monitoring. The findings of possible benefits over 26 weeks warrant replication, investigating possible mechanisms, preferably with automated delivery of monitoring and more instructive feedback.
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Affiliation(s)
| | | | - Glyn Lewis
- University College London, London, United Kingdom
| | - Michael Moore
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Geraldine Leydon
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Adam W A Geraghty
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Gareth Griffiths
- University of Southampton Faculty of Medicine, CTU, Southampton, United Kingdom
| | - Shihua Zhu
- University of Southampton Faculty of Medicine, CTU, Southampton, United Kingdom
| | - Guiqing Yao
- University of Leicester, Department of Health Sciences, Leicester, United Kingdom
| | - Carl May
- London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Mark Gabbay
- University of Liverpool, Institute of Population Health Sciences, Liverpool, United Kingdom
| | - Rachel Dewar-Haggart
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Samantha Williams
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Lien Bui
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Natalie Thompson
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Lauren Bridewell
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | | | | | | | - Naila Khan
- University of Liverpool, Liverpool, United Kingdom
| | - Helen Page
- University of Liverpool, Liverpool, United Kingdom
| | | | | | - Molly Bird
- University College London, London, United Kingdom
| | | | | | - Riya Tiwari
- University of Southampton, Primary Care and Population Sciences, Southampton, United Kingdom
| | - Anna Hunt
- Liverpool John Moores University, Liverpool, United Kingdom
| | - Beth Stuart
- Queen Mary University of London, London, United Kingdom
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8
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Douglas S, Bovendeerd B, van Sonsbeek M, Manns M, Milling XP, Tyler K, Bala N, Satterthwaite T, Hovland RT, Amble I, Atzil-Slonim D, Barkham M, de Jong K, Kendrick T, Nordberg SS, Lutz W, Rubel JA, Skjulsvik T, Moltu C. A Clinical Leadership Lens on Implementing Progress Feedback in Three Countries: Development of a Multidimensional Qualitative Coding Scheme. Adm Policy Ment Health 2023:10.1007/s10488-023-01314-6. [PMID: 37917313 DOI: 10.1007/s10488-023-01314-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/12/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND Progress feedback, also known as measurement-based care (MBC), is the routine collection of patient-reported measures to monitor treatment progress and inform clinical decision-making. Although a key ingredient to improving mental health care, sustained use of progress feedback is poor. Integration into everyday workflow is challenging, impacted by a complex interrelated set of factors across patient, clinician, organizational, and health system levels. This study describes the development of a qualitative coding scheme for progress feedback implementation that accounts for the dynamic nature of barriers and facilitators across multiple levels of use in mental health settings. Such a coding scheme may help promote a common language for researchers and implementers to better identify barriers that need to be addressed, as well as facilitators that could be supported in different settings and contexts. METHODS Clinical staff, managers, and leaders from two Dutch, three Norwegian, and four mental health organizations in the USA participated in semi-structured interviews on how intra- and extra-organizational characteristics interact to influence the use of progress feedback in clinical practice, supervision, and program improvement. Interviews were conducted in the local language, then translated to English prior to qualitative coding. RESULTS A team-based consensus coding approach was used to refine an a priori expert-informed and literature-based qualitative scheme to incorporate new understandings and constructs as they emerged. First, this hermeneutic approach resulted in a multi-level coding scheme with nine superordinate categories and 30 subcategories. Second-order axial coding established contextually sensitive categories for barriers and facilitators. CONCLUSIONS The primary outcome is an empirically derived multi-level qualitative coding scheme that can be used in progress feedback implementation research and development. It can be applied across contexts and settings, with expectations for ongoing refinement. Suggestions for future research and application in practice settings are provided. Supplementary materials include the coding scheme and a detailed playbook.
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Affiliation(s)
- Susan Douglas
- Department of Leadership, Policy and Organizations, Vanderbilt University, Peabody College, 230 Appleton Place PMB #414, Nashville, TN, 37203-5721, USA.
| | - Bram Bovendeerd
- Department of Clinical Psychology and Experimental Psychopathology, Faculty of Behavioural and Social Sciences, University of Groningen, Groningen, the Netherlands
- Dimence, Center for Mental Health Care, Deventer, the Netherlands
| | | | - Mya Manns
- Department of Leadership, Policy and Organizations, Vanderbilt University, Peabody College, 230 Appleton Place PMB #414, Nashville, TN, 37203-5721, USA
| | - Xavier Patrick Milling
- Department of Leadership, Policy and Organizations, Vanderbilt University, Peabody College, 230 Appleton Place PMB #414, Nashville, TN, 37203-5721, USA
| | - Ke'Sean Tyler
- Department of Leadership, Policy and Organizations, Vanderbilt University, Peabody College, 230 Appleton Place PMB #414, Nashville, TN, 37203-5721, USA
| | | | - Tim Satterthwaite
- Department of Leadership, Policy and Organizations, Vanderbilt University, Peabody College, 230 Appleton Place PMB #414, Nashville, TN, 37203-5721, USA
| | - Runar Tengel Hovland
- Faculty of Health and Social Sciences, Western Norway University of Applied Sciences, Førde, Norway
- Department of Research and Innovation, Førde Hospital Trust, Førde, Norway
| | - Ingunn Amble
- Villa Sana - Centre for Work Health, Modum Bad, Norway
| | | | - Michael Barkham
- Clinical and Applied Psychology Unit, Department of Psychology, University of Sheffield, Sheffield, UK
| | - Kim de Jong
- Clinical Psychology Unit, Institute of Psychology, Leiden University, Leiden, the Netherlands
| | - Tony Kendrick
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | - Samuel S Nordberg
- Department of Behavioral Health, Reliant Medical Group, Worcester, MA, USA
| | - Wolfgang Lutz
- Department of Psychology, University of Trier, Trier, Germany
| | - Julian A Rubel
- Department of Psychology, Psychotherapy Research Lab, Justus Liebig University Giessen, Giessen, Germany
| | | | - Christian Moltu
- District General Hospital of Førde, Førde, Norway
- Department of Health and Caring Science, Western Norway University of Applied Science, Førde, Norway
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9
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Van Leeuwen E, Maund E, Kendrick T, Anthierens S, Woods C, Christiaens T. Health professionals' views on discontinuation of long-term antidepressants: a systematic review and thematic synthesis. Br J Gen Pract 2023; 73:bjgp23X733749. [PMID: 37479319 DOI: 10.3399/bjgp23x733749] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND Long-term antidepressant use, much longer than recommended by guidelines, may cause harmful effects and generate unnecessary costs. AIM To investigate health professionals (HPs) views of long-term antidepressant discontinuation and their barriers and facilitators. METHOD Systematic review and meta-synthesis. We included studies that used qualitative data collection and had data on HPs perceptions on (dis)continuing AD use. The review searched nine database sources until May 2022. Study quality was assessed using the CASP checklist and the COREQ criteria. A thematic synthesis was performed. RESULTS Thirteen studies were included in the review. Nine studies were of GPs' perspectives, one study of psychiatrists', and three of a mix of HPs. Barriers and facilitators to discontinuing long-term AD yielded eight themes, ordered chronologically according to the considerations that HPs make when they review a long-term AD: perception of AD use, fears, HP role and responsibility, HPs attitude towards discontinuation, HPs confidence regarding ability to stop AD, perceived patient readiness to stop, support from relatives and support from other HP. CONCLUSION Deprescribing long-term AD is a difficult and complex process for HPs. The review found evidence that the barriers far outweigh the facilitators. More education on the lack of evidence for the long-term effect of AD and the risks of long-term use, guidance on managing long-term use, and support for HPs and patients is needed to increase long-term AD discontinuation. Further research from an HP perspective other than GPs is required and should also explore how HPs can be supported in managing discontinuation ADs.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences & Unit General Practice, Department of Public Health and Primary Care, University, Ghent, Belgium
| | - Emma Maund
- Southampton Health Technology Assessments Centre, University of Southampton
| | - Tony Kendrick
- Primary Care, Population Sciences & Medical Education University of Southampton
| | - Sibyl Anthierens
- Department of Family Medicine and Population Health, University of Antwerp, Antwerp, Belgium
| | - Catherine Woods
- Primary Care, Population Sciences & Medical Education University of Southampton
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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10
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Buckman JEJ, Cohen ZD, O'Driscoll C, Fried EI, Saunders R, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, Eley T, Peel AJ, Rayner C, Kessler D, Wiles N, Lewis G, Pilling S. Predicting prognosis for adults with depression using individual symptom data: a comparison of modelling approaches. Psychol Med 2023; 53:408-418. [PMID: 33952358 PMCID: PMC9899563 DOI: 10.1017/s0033291721001616] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 03/08/2021] [Accepted: 04/12/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND This study aimed to develop, validate and compare the performance of models predicting post-treatment outcomes for depressed adults based on pre-treatment data. METHODS Individual patient data from all six eligible randomised controlled trials were used to develop (k = 3, n = 1722) and test (k = 3, n = 918) nine models. Predictors included depressive and anxiety symptoms, social support, life events and alcohol use. Weighted sum scores were developed using coefficient weights derived from network centrality statistics (models 1-3) and factor loadings from a confirmatory factor analysis (model 4). Unweighted sum score models were tested using elastic net regularised (ENR) and ordinary least squares (OLS) regression (models 5 and 6). Individual items were then included in ENR and OLS (models 7 and 8). All models were compared to one another and to a null model (mean post-baseline Beck Depression Inventory Second Edition (BDI-II) score in the training data: model 9). Primary outcome: BDI-II scores at 3-4 months. RESULTS Models 1-7 all outperformed the null model and model 8. Model performance was very similar across models 1-6, meaning that differential weights applied to the baseline sum scores had little impact. CONCLUSIONS Any of the modelling techniques (models 1-7) could be used to inform prognostic predictions for depressed adults with differences in the proportions of patients reaching remission based on the predicted severity of depressive symptoms post-treatment. However, the majority of variance in prognosis remained unexplained. It may be necessary to include a broader range of biopsychosocial variables to better adjudicate between competing models, and to derive models with greater clinical utility for treatment-seeking adults with depression.
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Affiliation(s)
- J. E. J. Buckman
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, London, UK
- iCope – Camden & Islington Psychological Therapies Services – Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, UK
| | - Z. D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, USA
| | - C. O'Driscoll
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, London, UK
| | - E. I. Fried
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - R. Saunders
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, London, UK
| | - G. Ambler
- Statistical Science, University College London, 1-19 Torrington Place, London, UK
| | - R. J. DeRubeis
- Department of Psychology, School of Arts and Sciences, 425 S. University Avenue, Philadelphia PA, USA
| | - S. Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, UK
| | - S. D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - T. Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - E. Watkins
- Department of Psychology, University of Exeter, Sir Henry Wellcome Building for Mood Disorders Research, Perry Road, Exeter, UK
| | - T.C. Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - A. J. Peel
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - C. Rayner
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - D. Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - N. Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Bristol, UK
| | - G. Lewis
- Division of Psychiatry, University College London, Maple House, London, UK
| | - S. Pilling
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, London, UK
- Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, UK
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11
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Essery R, Pollet S, Bradbury K, Western MJ, Grey E, Denison-Day J, Smith KA, Hayter V, Kelly J, Somerville J, Stuart B, Becque T, Zhang J, Slodkowska-Barabasz J, Mowbray F, Ferrey A, Yao G, Zhu S, Kendrick T, Griffin S, Mutrie N, Robinson S, Brooker H, Griffiths G, Robinson L, Rossor M, Ballard C, Gallacher J, Rathod S, Gudgin B, Phillips R, Stokes T, Niven J, Little P, Yardley L. Parallel randomized controlled feasibility trials of the "Active Brains" digital intervention to protect cognitive health in adults aged 60-85. Front Public Health 2022; 10:962873. [PMID: 36203694 PMCID: PMC9530972 DOI: 10.3389/fpubh.2022.962873] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Accepted: 08/30/2022] [Indexed: 01/24/2023] Open
Abstract
Introduction Multidomain interventions to address modifiable risk factors for dementia are promising, but require more cost-effective, scalable delivery. This study investigated the feasibility of the "Active Brains" digital behavior change intervention and its trial procedures. Materials and methods Active Brains aims to reduce cognitive decline by promoting physical activity, healthy eating, and online cognitive training. We conducted 12-month parallel-design randomized controlled feasibility trials of "Active Brains" amongst "lower cognitive scoring" (n = 180) and "higher cognitive scoring" (n = 180) adults aged 60-85. Results We collected 67.2 and 76.1% of our 12-month primary outcome (Baddeley verbal reasoning task) data for the "lower cognitive score" and "higher cognitive score" groups, respectively. Usage of "Active Brains" indicated overall feasibility and satisfactory engagement with the physical activity intervention content (which did not require sustained online engagement), but engagement with online cognitive training was limited. Uptake of the additional brief telephone support appeared to be higher in the "lower cognitive score" trial. Preliminary descriptive trends in the primary outcome data might indicate a protective effect of Active Brains against cognitive decline, but further investigation in fully-powered trials is required to answer this definitively. Discussion Whilst initial uptake and engagement with the online intervention was modest, it was in line with typical usage of other digital behavior change interventions, and early indications from the descriptive analysis of the primary outcome and behavioral data suggest that further exploration of the potential protective benefits of Active Brains are warranted. The study also identified minor modifications to procedures, particularly to improve online primary-outcome completion. Further investigation of Active Brains will now seek to determine its efficacy in protecting cognitive performance amongst adults aged 60-85 with varied levels of existing cognitive performance.
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Affiliation(s)
- Rosie Essery
- University of Southampton, Southampton, United Kingdom,*Correspondence: Rosie Essery
| | | | - Katherine Bradbury
- University of Southampton, Southampton, United Kingdom,NIHR ARC Wessex, Southampton, United Kingdom
| | | | | | | | | | | | - Joanne Kelly
- University of Southampton, Southampton, United Kingdom
| | | | - Beth Stuart
- University of Southampton, Southampton, United Kingdom,Queen Mary University of London, London, United Kingdom
| | - Taeko Becque
- University of Southampton, Southampton, United Kingdom
| | - Jin Zhang
- University of Southampton, Southampton, United Kingdom
| | | | | | - Anne Ferrey
- University of Oxford, Oxford, United Kingdom
| | - Guiqing Yao
- University of Leicester, Leicester, United Kingdom
| | - Shihua Zhu
- University of Southampton, Southampton, United Kingdom
| | - Tony Kendrick
- University of Southampton, Southampton, United Kingdom
| | | | | | | | | | - Gareth Griffiths
- NIHR Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | | | | | | | - John Gallacher
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Shanaya Rathod
- Southern Health NHS Foundation Trust, Southampton, United Kingdom
| | - Bernard Gudgin
- Patient and Public Involvement Contributor, University of Southampton, Southampton, United Kingdom
| | - Rosemary Phillips
- Patient and Public Involvement Contributor, University of Southampton, Southampton, United Kingdom
| | - Tom Stokes
- Patient and Public Involvement Contributor, University of Southampton, Southampton, United Kingdom
| | - John Niven
- Patient and Public Involvement Contributor, University of Southampton, Southampton, United Kingdom
| | - Paul Little
- University of Southampton, Southampton, United Kingdom
| | - Lucy Yardley
- University of Southampton, Southampton, United Kingdom,University of Bristol, Bristol, United Kingdom
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12
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Susan Collinson
- Homerton University Hospital NHS Foundation Trust, London, UK
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13
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Affiliation(s)
| | - Steve Pilling
- University College London, London, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Ifigeneia Mavranezouli
- University College London, London, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | - Odette Megnin-Viggars
- University College London, London, UK
- National Guideline Alliance, Royal College of Obstetricians and Gynaecologists, London, UK
| | | | - Hilary Eadon
- National Institute for Health and Care Excellence, London, UK
| | - Navneet Kapur
- University of Manchester, Manchester, UK
- Greater Manchester Mental Health and Social Care Trust, Manchester, UK
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14
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Buckman JEJ, Saunders R, Stott J, Cohen ZD, Arundell LL, Eley TC, Hollon SD, Kendrick T, Ambler G, Watkins E, Gilbody S, Kessler D, Wiles N, Richards D, Brabyn S, Littlewood E, DeRubeis RJ, Lewis G, Pilling S. Socioeconomic Indicators of Treatment Prognosis for Adults With Depression: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry 2022; 79:406-416. [PMID: 35262620 PMCID: PMC8908224 DOI: 10.1001/jamapsychiatry.2022.0100] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [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] [Indexed: 12/28/2022]
Abstract
Importance Socioeconomic factors are associated with the prevalence of depression, but their associations with prognosis are unknown. Understanding this association would aid in the clinical management of depression. Objective To determine whether employment status, financial strain, housing status, and educational attainment inform prognosis for adults treated for depression in primary care, independent of treatment and after accounting for clinical prognostic factors. Data Sources The Embase, International Pharmaceutical Abstracts, MEDLINE, PsycINFO, and Cochrane (CENTRAL) databases were searched from database inception to October 8, 2021. Study Selection Inclusion criteria were as follows: randomized clinical trials that used the Revised Clinical Interview Schedule (CIS-R; the most common comprehensive screening and diagnostic measure of depressive and anxiety symptoms in primary care randomized clinical trials), measured socioeconomic factors at baseline, and sampled patients with unipolar depression who sought treatment for depression from general physicians/practitioners or who scored 12 or more points on the CIS-R. Exclusion criteria included patients with depression secondary to a personality or psychotic disorder or neurologic condition, studies of bipolar or psychotic depression, studies that included children or adolescents, and feasibility studies. Studies were independently assessed against inclusion and exclusion criteria by 2 reviewers. Data Extraction and Synthesis Data were extracted and cleaned by data managers for each included study, further cleaned by multiple reviewers, and cross-checked by study chief investigators. Risk of bias and quality were assessed using the Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tools, respectively. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Individual Participant Data (PRISMA-IPD) reporting guidelines. Main Outcomes and Measures Depressive symptoms at 3 to 4 months after baseline. Results This systematic review and individual patient data meta-analysis identified 9 eligible studies that provided individual patient data for 4864 patients (mean [SD] age, 42.5 (14.0) years; 3279 women [67.4%]). The 2-stage random-effects meta-analysis end point depressive symptom scale scores were 28% (95% CI, 20%-36%) higher for unemployed patients than for employed patients and 18% (95% CI, 6%-30%) lower for patients who were homeowners than for patients living with family or friends, in hostels, or homeless, which were equivalent to 4.2 points (95% CI, 3.6-6.2 points) and 2.9 points (95% CI, 1.1-4.9 points) on the Beck Depression Inventory II, respectively. Financial strain and educational attainment were associated with prognosis independent of treatment, but unlike employment and housing status, there was little evidence of associations after adjusting for clinical prognostic factors. Conclusions and Relevance Results of this systematic review and meta-analysis revealed that unemployment was associated with a poor prognosis whereas home ownership was associated with improved prognosis. These differences were clinically important and independent of the type of treatment received. Interventions that address employment or housing difficulties could improve outcomes for patients with depression.
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Affiliation(s)
- Joshua E. J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
- iCope Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, United Kingdom
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Joshua Stott
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | | | - Laura-Louise Arundell
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Thalia C. Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Gareth Ambler
- Statistical Science, University College London, London, United Kingdom
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicola Wiles
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, Exeter, United Kingdom
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Robert J. DeRubeis
- University of Pennsylvania College of Arts and Sciences, Department of Psychology, Philadelphia
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
- Camden & Islington NHS Foundation Trust, London, United Kingdom
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15
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Clarke CS, Duffy L, Lewis G, Freemantle N, Gilbody S, Kendrick T, Kessler D, King M, Lanham P, Mangin D, Moore M, Nazareth I, Wiles N, Marston L, Hunter RM. Correction to: Cost-Utility Analysis of Discontinuing Antidepressants in England Primary Care Patients Compared with Long-Term Maintenance: The ANTLER Study. Appl Health Econ Health Policy 2022; 20:283. [PMID: 34893957 PMCID: PMC8847289 DOI: 10.1007/s40258-021-00708-7] [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] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Affiliation(s)
- Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.
| | - Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Simon Gilbody
- Department of Health Sciences and Hull York Medical School, University of York, York, UK
| | - Tony Kendrick
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Kessler
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Paul Lanham
- Patient and Public Involvement Collaborator, London, UK
| | - Derelie Mangin
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
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16
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Clarke CS, Duffy L, Lewis G, Freemantle N, Gilbody S, Kendrick T, Kessler D, King M, Lanham P, Mangin D, Moore M, Nazareth I, Wiles N, Marston L, Hunter RM. Cost-Utility Analysis of Discontinuing Antidepressants in England Primary Care Patients Compared with Long-Term Maintenance: The ANTLER Study. Appl Health Econ Health Policy 2022; 20:269-282. [PMID: 34748164 PMCID: PMC8847280 DOI: 10.1007/s40258-021-00693-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 10/19/2021] [Indexed: 05/10/2023]
Abstract
BACKGROUND Depression is a common mental health condition with considerable negative impact on health and well-being. Although antidepressants are recommended as first-line treatment, there is limited evidence regarding the cost effectiveness of long-term maintenance antidepressants for preventing relapse. OBJECTIVES Our objective was to calculate the mean incremental costs and quality-adjusted life-years (QALYs) over 12 months of discontinuing long-term antidepressant medication in well patients compared with maintenance, using patient-level trial data. METHODS We conducted a cost-utility analysis of 478 participants from 150 UK general practices recruited to a randomised, double-blind trial (ANTLER). QALYs were calculated from EQ-5D-5L and 12-Item Short Form survey (SF-12) results, with primary analysis using the EQ-5D-5L value set for England. Resource use was collected from primary care patient electronic medical records and self-completed questionnaires capturing mental-health-related resource use. Costs were calculated by applying standard UK unit costs to resource use. Adjustments were made for baseline variables. RESULTS Participants randomised to discontinuation had significantly worse utility scores at 3 months (- 0.032; 95% confidence interval [CI] - 0.053 to - 0.011) but no significant difference in QALYs (- 0.011; 95% CI - 0.026 to 0.003) or costs (£3.11; 95% CI - 41.28 to 47.50) at 12 months. The probability that discontinuation was cost effective compared with maintenance was 12.9% at a threshold of £20,000 per QALY gained. CONCLUSIONS Discontinuation of antidepressants was unlikely to be cost effective compared with maintenance for currently well patients on long-term antidepressants. However, this analysis provides no information on the wider impact of antidepressants. Our findings provide information on the potential impact of discontinuing long-term maintenance antidepressants and facilitate improving guidance for shared patient-clinician decision making. TRIAL REGISTRATION EudraCT number 2015-004210-26; ISRCTN number ISRCTN15969819.
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Affiliation(s)
- Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.
| | - Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
| | - Nick Freemantle
- Institute of Clinical Trials and Methodology, University College London, London, UK
| | - Simon Gilbody
- Department of Health Sciences and Hull York Medical School, University of York, York, UK
| | - Tony Kendrick
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Kessler
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Paul Lanham
- Patient and Public Involvement Collaborator, London, UK
| | - Derelie Mangin
- Department of Family Medicine, McMaster University, Hamilton, Canada
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Rachael Maree Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK
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17
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Buckman JEJ, Saunders R, Arundell LL, Oshinowo ID, Cohen ZD, O'Driscoll C, Barnett P, Stott J, Ambler G, Gilbody S, Hollon SD, Kendrick T, Watkins E, Eley TC, Skelton M, Wiles N, Kessler D, DeRubeis RJ, Lewis G, Pilling S. Life events and treatment prognosis for depression: A systematic review and individual patient data meta-analysis. J Affect Disord 2022; 299:298-308. [PMID: 34920035 PMCID: PMC9113943 DOI: 10.1016/j.jad.2021.12.030] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 11/10/2021] [Accepted: 12/12/2021] [Indexed: 01/15/2023]
Abstract
OBJECTIVE To investigate associations between major life events and prognosis independent of treatment type: (1) after adjusting for clinical prognostic factors and socio-demographics; (2) amongst patients with depressive episodes at least six-months long; and (3) patients with a first life-time depressive episode. METHODS Six RCTs of adults seeking treatment for depression in primary care met eligibility criteria, individual patient data (IPD) were collated from all six (n = 2858). Participants were randomized to any treatment and completed the same baseline assessment of life events, demographics and clinical prognostic factors. Two-stage random effects meta-analyses were conducted. RESULTS Reporting any major life events was associated with poorer prognosis regardless of treatment type. Controlling for baseline clinical factors, socio-demographics and social support resulted in minimal residual evidence of associations between life events and treatment prognosis. However, removing factors that might mediate the relationships between life events and outcomes reporting: arguments/disputes, problem debt, violent crime, losing one's job, and three or more life events were associated with considerably worse prognoses (percentage difference in 3-4 months depressive symptoms compared to no reported life events =30.3%(95%CI: 18.4-43.3)). CONCLUSIONS Assessing for clinical prognostic factors, social support, and socio-demographics is likely to be more informative for prognosis than assessing self-reported recent major life events. However, clinicians might find it useful to ask about such events, and if they are still affecting the patient, consider interventions to tackle problems related to those events (e.g. employment support, mediation, or debt advice). Further investigations of the efficacy of such interventions will be important.
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Affiliation(s)
- Joshua E J Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom; iCope - Camden & Islington Psychological Therapies Services, Camden & Islington NHS Foundation Trust, 4St Pancras Way, London NW1 0PE, United Kingdom.
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Laura-Louise Arundell
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Iyinoluwa D Oshinowo
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Zachary D Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA 90095, United States
| | - Ciaran O'Driscoll
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Phoebe Barnett
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Joshua Stott
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom
| | - Gareth Ambler
- Statistical Science, University College London, London WC1E 7HB, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York YO10 5DD, United Kingdom
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN 407817, United States
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton SO16 5ST, United Kingdom
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, EX4 4QG, United Kingdom
| | - Thalia C Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London SE5 8AF, United Kingdom
| | - Megan Skelton
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London SE5 8AF, United Kingdom
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Bristol, United Kingdom
| | - David Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, United Kingdom
| | - Robert J DeRubeis
- School of Arts and Sciences, Department of Psychology, University of Pennsylvania, Philadelphia, PA 19104-60185, United States
| | - Glyn Lewis
- Division of Psychiatry, University College London, London W1T 7NF, United Kingdom
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London WC1E 7HB, United Kingdom; Camden and Islington NHS Foundation Trust, St Pancras Hospital, 4St Pancras Way, London NW1 0PE United Kingdom
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18
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Duffy L, Clarke CS, Lewis G, Marston L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, King M, Lanham P, Mangin D, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Donkor Y, Hunt A, Pervin J, Lewis G. Antidepressant medication to prevent depression relapse in primary care: the ANTLER RCT. Health Technol Assess 2021; 25:1-62. [PMID: 34842135 DOI: 10.3310/hta25690] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND There has been a steady increase in the number of primary care patients receiving long-term maintenance antidepressant treatment, despite limited evidence of a benefit of this treatment beyond 8 months. OBJECTIVE The ANTidepressants to prevent reLapse in dEpRession (ANTLER) trial investigated the clinical effectiveness and cost-effectiveness of antidepressant medication in preventing relapse in UK primary care. DESIGN This was a Phase IV, double-blind, pragmatic, multisite, individually randomised parallel-group controlled trial, with follow-up at 6, 12, 26, 39 and 52 weeks. Participants were randomised using minimisation on centre, type of antidepressant and baseline depressive symptom score above or below the median using Clinical Interview Schedule - Revised (two categories). Statisticians were blind to allocation for the outcome analyses. SETTING General practices in London, Bristol, Southampton and York. PARTICIPANTS Individuals aged 18-74 years who had experienced at least two episodes of depression and had been taking antidepressants for ≥ 9 months but felt well enough to consider stopping their medication. Those who met an International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, diagnosis of depression or with other psychiatric conditions were excluded. INTERVENTION At baseline, participants were taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg. They were randomised to either remain on their current medication or discontinue medication after a tapering period. MAIN OUTCOME MEASURES The primary outcome was the time, in weeks, to the beginning of the first depressive episode after randomisation. This was measured by a retrospective Clinical Interview Schedule - Revised that assessed the onset of a depressive episode in the previous 12 weeks, and was conducted at 12, 26, 39 and 52 weeks. The depression-related resource use was collected over 12 months from medical records and patient-completed questionnaires. Quality-adjusted life-years were calculated using the EuroQol-5 Dimensions, five-level version. RESULTS Between 9 March 2017 and 1 March 2019, we randomised 238 participants to antidepressant continuation (the maintenance group) and 240 participants to antidepressant discontinuation (the discontinuation group). The time to relapse of depression was shorter in the discontinuation group, with a hazard ratio of 2.06 (95% confidence interval 1.56 to 2.70; p < 0.0001). By 52 weeks, relapse was experienced by 39% of those who continued antidepressants and 56% of those who discontinued antidepressants. The secondary analysis revealed that people who discontinued experienced more withdrawal symptoms than those who remained on medication, with the largest difference at 12 weeks. In the discontinuation group, 37% (95% confidence interval 28% to 45%) of participants remained on their randomised medication until the end of the trial. In total, 39% (95% confidence interval 32% to 45%) of participants in the discontinuation group returned to their original antidepressant compared with 20% (95% confidence interval 15% to 25%) of participants in maintenance group. The health economic evaluation demonstrated that participants randomised to discontinuation had worse utility scores at 3 months (-0.037, 95% confidence interval -0.059 to -0.015) and fewer quality-adjusted life-years over 12 months (-0.019, 95% confidence interval -0.035 to -0.003) than those randomised to continuation. The discontinuation pathway, besides giving worse outcomes, also cost more [extra £2.71 per patient over 12 months (95% confidence interval -£36.10 to £37.07)] than the continuation pathway, although the cost difference was not significant. CONCLUSIONS Patients who discontinue long-term maintenance antidepressants in primary care are at increased risk of relapse and withdrawal symptoms. However, a substantial proportion of patients can discontinue antidepressants without relapse. Our findings will give patients and clinicians an estimate of the likely benefits and harms of stopping long-term maintenance antidepressants and improve shared decision-making. The participants may not have been representative of all people on long-term maintenance treatment and we could study only a restricted range of antidepressants and doses. Identifying patients who will not relapse if they discontinued antidepressants would be clinically important. TRIAL REGISTRATION Current Controlled Trials ISRCTN15969819 and EudraCT 2015-004210-26. 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. 25, No. 69. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, London, UK
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nick Freemantle
- PRIMENT Clinical Trials Unit, University College London, London, UK.,Comprehensive Clinical Trials Unit, University College London, London, UK
| | - Simon Gilbody
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Tony Kendrick
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Michael King
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Paul Lanham
- Division of Psychiatry, University College London, London, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, Hamilton, ON, Canada.,Department of General Practice, University of Otago, Christchurch, New Zealand
| | - Michael Moore
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, London, UK.,PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Faye Bacon
- Division of Psychiatry, University College London, London, UK
| | - Molly Bird
- Division of Psychiatry, University College London, London, UK
| | - Sally Brabyn
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Alison Burns
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Yvonne Donkor
- Division of Psychiatry, University College London, London, UK
| | - Anna Hunt
- Primary Care Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Jodi Pervin
- Department of Health and Social Care Sciences, University of York, York, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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19
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Lewis G, Marston L, Duffy L, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, Mangin D, King M, Lanham P, Moore M, Nazareth I, Wiles N, Bacon F, Bird M, Brabyn S, Burns A, Clarke CS, Hunt A, Pervin J, Lewis G. Maintenance or Discontinuation of Antidepressants in Primary Care. N Engl J Med 2021; 385:1257-1267. [PMID: 34587384 DOI: 10.1056/nejmoa2106356] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [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: 11/19/2022]
Abstract
BACKGROUND Patients with depression who are treated in primary care practices may receive antidepressants for prolonged periods. Data are limited on the effects of maintaining or discontinuing antidepressant therapy in this setting. METHODS We conducted a randomized, double-blind trial involving adults who were being treated in 150 general practices in the United Kingdom. All the patients had a history of at least two depressive episodes or had been taking antidepressants for 2 years or longer and felt well enough to consider stopping antidepressants. Patients who had received citalopram, fluoxetine, sertraline, or mirtazapine were randomly assigned in a 1:1 ratio to maintain their current antidepressant therapy (maintenance group) or to taper and discontinue such therapy with the use of matching placebo (discontinuation group). The primary outcome was the first relapse of depression during the 52-week trial period, as evaluated in a time-to-event analysis. Secondary outcomes were depressive and anxiety symptoms, physical and withdrawal symptoms, quality of life, time to stopping an antidepressant or placebo, and global mood ratings. RESULTS A total of 1466 patients underwent screening. Of these patients, 478 were enrolled in the trial (238 in the maintenance group and 240 in the discontinuation group). The average age of the patients was 54 years; 73% were women. Adherence to the trial assignment was 70% in the maintenance group and 52% in the discontinuation group. By 52 weeks, relapse occurred in 92 of 238 patients (39%) in the maintenance group and in 135 of 240 (56%) in the discontinuation group (hazard ratio, 2.06; 95% confidence interval, 1.56 to 2.70; P<0.001). Secondary outcomes were generally in the same direction as the primary outcome. Patients in the discontinuation group had more symptoms of depression, anxiety, and withdrawal than those in the maintenance group. CONCLUSIONS Among patients in primary care practices who felt well enough to discontinue antidepressant therapy, those who were assigned to stop their medication had a higher risk of relapse of depression by 52 weeks than those who were assigned to maintain their current therapy. (Funded by the National Institute for Health Research; ANTLER ISRCTN number, ISRCTN15969819.).
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Affiliation(s)
- Gemma Lewis
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Louise Marston
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Larisa Duffy
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Nick Freemantle
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Simon Gilbody
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Rachael Hunter
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Tony Kendrick
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - David Kessler
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Dee Mangin
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Michael King
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Paul Lanham
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Michael Moore
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Irwin Nazareth
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Nicola Wiles
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Faye Bacon
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Molly Bird
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Sally Brabyn
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Alison Burns
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Caroline S Clarke
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Anna Hunt
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Jodi Pervin
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
| | - Glyn Lewis
- From the Division of Psychiatry, Faculty of Brain Sciences (Gemma Lewis, L.D., M.K., P.L., F.B., M.B., Glyn Lewis), the Research Department of Primary Care and Population Health and Priment Clinical Trials Unit (L.M., R.H., I.N., C.S.C.), and the Institute of Clinical Trials and Methodology (N.F.), University College London, London, the Department of Health Sciences and Hull York Medical School, University of York, York (S.G., S.B., J.P.), Primary Care Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton (T.K., M.M., A.H.), and Population Health Sciences (D.K.) and the Centre for Academic Mental Health (N.W., A.B.), Bristol Medical School, University of Bristol, Bristol - all in the United Kingdom; and the Department of Family Medicine, McMaster University, Hamilton, ON, Canada (D.M.)
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Essery R, Pollet S, Smith KA, Mowbray F, Slodkowska-Barabasz J, Denison-Day J, Hayter V, Bradbury K, Grey E, Western MJ, Milton A, Hunter C, Ferrey AE, Müller AM, Stuart B, Mutrie N, Griffin S, Kendrick T, Brooker H, Gudgin B, Phillips R, Stokes T, Niven J, Little P, Yardley L. Planning and optimising a digital intervention to protect older adults' cognitive health. Pilot Feasibility Stud 2021; 7:158. [PMID: 34407886 PMCID: PMC8371874 DOI: 10.1186/s40814-021-00884-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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] [Received: 03/31/2020] [Accepted: 07/09/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND By 2050, worldwide dementia prevalence is expected to triple. Affordable, scalable interventions are required to support protective behaviours such as physical activity, cognitive training and healthy eating. This paper outlines the theory-, evidence- and person-based development of 'Active Brains': a multi-domain digital behaviour change intervention to reduce cognitive decline amongst older adults. METHODS During the initial planning phase, scoping reviews, consultation with PPI contributors and expert co-investigators and behavioural analysis collated and recorded evidence that was triangulated to inform provisional 'guiding principles' and an intervention logic model. The following optimisation phase involved qualitative think aloud and semi-structured interviews with 52 older adults with higher and lower cognitive performance scores. Data were analysed thematically and informed changes and additions to guiding principles, the behavioural analysis and the logic model which, in turn, informed changes to intervention content. RESULTS Scoping reviews and qualitative interviews suggested that the same intervention content may be suitable for individuals with higher and lower cognitive performance. Qualitative findings revealed that maintaining independence and enjoyment motivated engagement in intervention-targeted behaviours, whereas managing ill health was a potential barrier. Social support for engaging in such activities could provide motivation, but was not desirable for all. These findings informed development of intervention content and functionality that appeared highly acceptable amongst a sample of target users. CONCLUSIONS A digitally delivered intervention with minimal support appears acceptable and potentially engaging to older adults with higher and lower levels of cognitive performance. As well as informing our own intervention development, insights obtained through this process may be useful for others working with, and developing interventions for, older adults and/or those with cognitive impairment.
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Affiliation(s)
- Rosie Essery
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK.
| | - Sebastien Pollet
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Kirsten A Smith
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Fiona Mowbray
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Joanna Slodkowska-Barabasz
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - James Denison-Day
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Victoria Hayter
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Katherine Bradbury
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK
| | | | | | - Alexander Milton
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Cheryl Hunter
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Anne E Ferrey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Andre Matthias Müller
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, 117549, Singapore.,Centre for Sport & Exercise Sciences, University of Malaya, Kuala Lumpur, Malaysia
| | - Beth Stuart
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Nanette Mutrie
- Physical Activity for Health Research Centre, University of Edinburgh, Edinburgh, UK
| | - Simon Griffin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | | | - Bernard Gudgin
- Public and Patient Involvement (PPI) representative, Southampton, UK
| | - Rosemary Phillips
- Public and Patient Involvement (PPI) representative, Southampton, UK
| | - Tom Stokes
- Public and Patient Involvement (PPI) representative, Southampton, UK
| | - John Niven
- Public and Patient Involvement (PPI) representative, Southampton, UK
| | - Paul Little
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Centre for Clinical and Community Applications of Health Psychology, University of Southampton, Southampton, UK. .,School of Psychological Science, University of Bristol, Bristol, UK.
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21
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Browning Carmo K, McCarron M, Kendrick T, Gallagher P, Roxburgh J, Berry A. Re Pathways and factors that influence time to definitive trauma care for injured children in New South Wales, Australia by Curtis et al. published in 2021. Injury 2021; 52:2483-2485. [PMID: 33766432 DOI: 10.1016/j.injury.2021.03.025] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 03/09/2021] [Indexed: 02/02/2023]
Affiliation(s)
- K Browning Carmo
- New South Wales Newborn & paediatric Emergency Transport Service, Australia; University of Sydney, Australia.
| | - M McCarron
- New South Wales Newborn & paediatric Emergency Transport Service, Australia; University of Sydney, Australia
| | - T Kendrick
- New South Wales Newborn & paediatric Emergency Transport Service, Australia
| | - P Gallagher
- New South Wales Newborn & paediatric Emergency Transport Service, Australia
| | - J Roxburgh
- New South Wales Newborn & paediatric Emergency Transport Service, Australia
| | - A Berry
- New South Wales Newborn & paediatric Emergency Transport Service, Australia
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22
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Bowers H, Kendrick T, van Ginneken N, Glowacka M, Williams S, Leydon GM, May C, Dowrick C, Moncrieff J, Johnson CF, Moore M, Laine R, Geraghty AWA. A Digital Intervention for Primary Care Practitioners to Support Antidepressant Discontinuation (Advisor for Health Professionals): Development Study. J Med Internet Res 2021; 23:e25537. [PMID: 34269688 PMCID: PMC8325079 DOI: 10.2196/25537] [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] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND The number of people receiving antidepressants has increased in the past 3 decades, mainly because of people staying on them longer. However, in many cases long-term treatment is not evidence based and risks increasing side effects. Additionally, prompting general practitioners (GPs) to review medication does not improve the rate of appropriate discontinuation. Therefore, GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. OBJECTIVE This study aims to develop a digital intervention to support practitioners in helping patients discontinue inappropriate long-term antidepressants (as part of a wider intervention package including a patient digital intervention and patient telephone support). METHODS A prototype digital intervention called Advisor for Health Professionals (ADvisor HP) was planned and developed using theory, evidence, and a person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, the development of guiding principles for design elements, and theoretical behavioral analyses. The intervention was then optimized through think-aloud qualitative interviews with health professionals while they were using the prototype intervention. RESULTS Think-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible to practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners and clarity about who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats because of time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how they would use ADvisor HP in practice, with some preferring to read the resource in its entirety and others wanting to dip in and out as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. CONCLUSIONS ADvisor HP is a digital intervention that has been developed using theory, evidence, and a person-based approach. The optimization work suggests that practitioners may find this tool to be useful in supporting the reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomized controlled trial is needed to examine the feasibility, effectiveness, and cost-effectiveness of the intervention.
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Affiliation(s)
- Hannah Bowers
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Nadja van Ginneken
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Marta Glowacka
- Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, United Kingdom
| | - Samantha Williams
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Geraldine M Leydon
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Carl May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Christopher Dowrick
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, United Kingdom
| | - Joanna Moncrieff
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, United Kingdom
| | - Chris F Johnson
- Pharmacy & Prescribing Support Unit, Pharmacy Services, NHS Greater Glasgow & Clyde, Glasgow, United Kingdom
| | - Michael Moore
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Rebecca Laine
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
| | - Adam W A Geraghty
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, United Kingdom
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23
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Buckman JEJ, Saunders R, Stott J, Arundell LL, O'Driscoll C, Davies MR, Eley TC, Hollon SD, Kendrick T, Ambler G, Cohen ZD, Watkins E, Gilbody S, Wiles N, Kessler D, Richards D, Brabyn S, Littlewood E, DeRubeis RJ, Lewis G, Pilling S. Role of age, gender and marital status in prognosis for adults with depression: An individual patient data meta-analysis. Epidemiol Psychiatr Sci 2021; 30:e42. [PMID: 34085616 PMCID: PMC7610920 DOI: 10.1017/s2045796021000342] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 11/21/2022] Open
Abstract
AIMS To determine whether age, gender and marital status are associated with prognosis for adults with depression who sought treatment in primary care. METHODS Medline, Embase, PsycINFO and Cochrane Central were searched from inception to 1st December 2020 for randomised controlled trials (RCTs) of adults seeking treatment for depression from their general practitioners, that used the Revised Clinical Interview Schedule so that there was uniformity in the measurement of clinical prognostic factors, and that reported on age, gender and marital status. Individual participant data were gathered from all nine eligible RCTs (N = 4864). Two-stage random-effects meta-analyses were conducted to ascertain the independent association between: (i) age, (ii) gender and (iii) marital status, and depressive symptoms at 3-4, 6-8, and 9-12 months post-baseline and remission at 3-4 months. Risk of bias was evaluated using QUIPS and quality was assessed using GRADE. PROSPERO registration: CRD42019129512. Pre-registered protocol https://osf.io/e5zup/. RESULTS There was no evidence of an association between age and prognosis before or after adjusting for depressive 'disorder characteristics' that are associated with prognosis (symptom severity, durations of depression and anxiety, comorbid panic disorderand a history of antidepressant treatment). Difference in mean depressive symptom score at 3-4 months post-baseline per-5-year increase in age = 0(95% CI: -0.02 to 0.02). There was no evidence for a difference in prognoses for men and women at 3-4 months or 9-12 months post-baseline, but men had worse prognoses at 6-8 months (percentage difference in depressive symptoms for men compared to women: 15.08% (95% CI: 4.82 to 26.35)). However, this was largely driven by a single study that contributed data at 6-8 months and not the other time points. Further, there was little evidence for an association after adjusting for depressive 'disorder characteristics' and employment status (12.23% (-1.69 to 28.12)). Participants that were either single (percentage difference in depressive symptoms for single participants: 9.25% (95% CI: 2.78 to 16.13) or no longer married (8.02% (95% CI: 1.31 to 15.18)) had worse prognoses than those that were married, even after adjusting for depressive 'disorder characteristics' and all available confounders. CONCLUSION Clinicians and researchers will continue to routinely record age and gender, but despite their importance for incidence and prevalence of depression, they appear to offer little information regarding prognosis. Patients that are single or no longer married may be expected to have slightly worse prognoses than those that are married. Ensuring this is recorded routinely alongside depressive 'disorder characteristics' in clinic may be important.
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Affiliation(s)
- J. E. J. Buckman
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
- iCope – Camden & Islington NHS Foundation Trust, St Pancras Hospital, LondonNW1 0PE, UK
| | - R. Saunders
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - J. Stott
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - L.-L. Arundell
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - C. O'Driscoll
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - M. R. Davies
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, LondonSE5 8AF, UK
| | - T. C. Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, LondonSE5 8AF, UK
| | - S. D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN37240, USA
| | - T. Kendrick
- Faculty of Medicine, Primary Care, Population Sciences and Medical Education, University of Southampton, SouthamptonSO16 5ST, UK
| | - G. Ambler
- Statistical Science, University College London, LondonWC1E 7HB, UK
| | - Z. D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - E. Watkins
- Department of Psychology, University of Exeter, ExeterEX4 4QG, UK
| | - S. Gilbody
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - N. Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, BristolBS8 2BN, UK
| | - D. Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - D. Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, ExeterEX1 2LU, UK
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Inndalsveien 28, 5063Bergen, Norway
| | - S. Brabyn
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - E. Littlewood
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - R. J. DeRubeis
- Department of Psychology, School of Arts and Sciences, 425 S. University Avenue, PhiladelphiaPA, 19104-60185, USA
| | - G. Lewis
- Division of Psychiatry, University College London, LondonW1T 7NF, UK
| | - S. Pilling
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
- Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
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24
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O'Driscoll C, Buckman JEJ, Fried EI, Saunders R, Cohen ZD, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Kessler D, Lewis G, Watkins E, Wiles N, Pilling S. The importance of transdiagnostic symptom level assessment to understanding prognosis for depressed adults: analysis of data from six randomised control trials. BMC Med 2021; 19:109. [PMID: 33952286 PMCID: PMC8101158 DOI: 10.1186/s12916-021-01971-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 03/23/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Depression is commonly perceived as a single underlying disease with a number of potential treatment options. However, patients with major depression differ dramatically in their symptom presentation and comorbidities, e.g. with anxiety disorders. There are also large variations in treatment outcomes and associations of some anxiety comorbidities with poorer prognoses, but limited understanding as to why, and little information to inform the clinical management of depression. There is a need to improve our understanding of depression, incorporating anxiety comorbidity, and consider the association of a wide range of symptoms with treatment outcomes. METHOD Individual patient data from six RCTs of depressed patients (total n = 2858) were used to estimate the differential impact symptoms have on outcomes at three post intervention time points using individual items and sum scores. Symptom networks (graphical Gaussian model) were estimated to explore the functional relations among symptoms of depression and anxiety and compare networks for treatment remitters and those with persistent symptoms to identify potential prognostic indicators. RESULTS Item-level prediction performed similarly to sum scores when predicting outcomes at 3 to 4 months and 6 to 8 months, but outperformed sum scores for 9 to 12 months. Pessimism emerged as the most important predictive symptom (relative to all other symptoms), across these time points. In the network structure at study entry, symptoms clustered into physical symptoms, cognitive symptoms, and anxiety symptoms. Sadness, pessimism, and indecision acted as bridges between communities, with sadness and failure/worthlessness being the most central (i.e. interconnected) symptoms. Connectivity of networks at study entry did not differ for future remitters vs. those with persistent symptoms. CONCLUSION The relative importance of specific symptoms in association with outcomes and the interactions within the network highlight the value of transdiagnostic assessment and formulation of symptoms to both treatment and prognosis. We discuss the potential for complementary statistical approaches to improve our understanding of psychopathology.
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Affiliation(s)
- C O'Driscoll
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK. ciaran.o'
| | - J E J Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- iCope - Camden & Islington Psychological Therapies Services, Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, NW1 0PE, UK.
| | - E I Fried
- Department of Clinical Psychology, Leiden University, Leiden, The Netherlands
| | - R Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - Z D Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, USA
| | - G Ambler
- Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
| | - R J DeRubeis
- School of Arts and Sciences, Department of Psychology, 425 S. University Avenue, Philadelphia, PA, 19104-60185, USA
| | - S Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK
| | - S D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - T Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - D Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - G Lewis
- Division of Psychiatry, University College London, Maple House, London, W1T 7NF, UK
| | - E Watkins
- Department of Psychology, University of Exeter, Sir Henry Wellcome Building for Mood Disorders Research, Perry Road, Exeter, EX4 4QG, UK
| | - N Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Bristol, UK
| | - S Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK
- Camden & Islington NHS Foundation Trust, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PE, UK
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25
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Buckman JEJ, Saunders R, O’Driscoll C, Cohen ZD, Stott J, Ambler G, Gilbody S, Hollon SD, Kendrick T, Watkins E, Wiles N, Kessler D, Chari N, White IR, Lewis G, Pilling S. Is social support pre-treatment associated with prognosis for adults with depression in primary care? Acta Psychiatr Scand 2021; 143:392-405. [PMID: 33548056 PMCID: PMC7610633 DOI: 10.1111/acps.13285] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Revised: 12/14/2020] [Accepted: 02/01/2021] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Depressed patients rate social support as important for prognosis, but evidence for a prognostic effect is lacking. We aimed to test the association between social support and prognosis independent of treatment type, and the severity of depression, and other clinical features indicating a more severe illness. METHODS Individual patient data were collated from all six eligible RCTs (n = 2858) of adults seeking treatment for depression in primary care. Participants were randomized to any treatment and completed the same baseline assessment of social support and clinical severity factors. Two-stage random effects meta-analyses were conducted. RESULTS Social support was associated with prognosis independent of randomized treatment but effects were smaller when adjusting for depressive symptoms and durations of depression and anxiety, history of antidepressant treatment, and comorbid panic disorder: percentage decrease in depressive symptoms at 3-4 months per z-score increase in social support = -4.14(95%CI: -6.91 to -1.29). Those with a severe lack of social support had considerably worse prognoses than those with no lack of social support: increase in depressive symptoms at 3-4 months = 14.64%(4.25% to 26.06%). CONCLUSIONS Overall, large differences in social support pre-treatment were associated with differences in prognostic outcomes. Adding the Social Support scale to clinical assessments may be informative, but after adjusting for routinely assessed clinical prognostic factors the differences in prognosis are unlikely to be of a clinically important magnitude. Future studies might investigate more intensive treatments and more regular clinical reviews to mitigate risks of poor prognosis for those reporting a severe lack of social support.
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Affiliation(s)
- Joshua E. J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE)Research Department of Clinical, Educational & Health PsychologyUniversity College LondonLondonUK,iCope – Camden & Islington Psychological Therapies Services – Camden & Islington NHS Foundation TrustLondonUK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE)Research Department of Clinical, Educational & Health PsychologyUniversity College LondonLondonUK
| | - Ciaran O’Driscoll
- Centre for Outcomes Research and Effectiveness (CORE)Research Department of Clinical, Educational & Health PsychologyUniversity College LondonLondonUK
| | - Zachary D. Cohen
- Department of PsychiatryUniversity of California Los AngelesLos AngelesCAUSA
| | - Joshua Stott
- Centre for Outcomes Research and Effectiveness (CORE)Research Department of Clinical, Educational & Health PsychologyUniversity College LondonLondonUK
| | - Gareth Ambler
- Statistical ScienceUniversity College LondonLondonUK
| | - Simon Gilbody
- Department of Health SciencesUniversity of YorkYorkUK
| | | | - Tony Kendrick
- Primary Care, Population Sciences and Medical EducationFaculty of MedicineUniversity of SouthamptonSouthamptonUK
| | | | - Nicola Wiles
- Centre for Academic Mental HealthPopulation Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - David Kessler
- Centre for Academic Primary CareDepartment of Population Health ScienceBristol Medical SchoolUniversity of BristolBristolUK
| | - Nomsa Chari
- Division of PsychiatryUniversity College LondonLondonUK
| | | | - Glyn Lewis
- Division of PsychiatryUniversity College LondonLondonUK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE)Research Department of Clinical, Educational & Health PsychologyUniversity College LondonLondonUK,Camden & Islington NHS Foundation TrustSt Pancras HospitalLondonUK
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Buckman JEJ, Saunders R, Cohen ZD, Barnett P, Clarke K, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, Wiles N, Kessler D, Richards D, Sharp D, Brabyn S, Littlewood E, Salisbury C, White IR, Lewis G, Pilling S. The contribution of depressive 'disorder characteristics' to determinations of prognosis for adults with depression: an individual patient data meta-analysis. Psychol Med 2021; 51:1068-1081. [PMID: 33849685 PMCID: PMC8188529 DOI: 10.1017/s0033291721001367] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/08/2021] [Accepted: 03/26/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. METHODS We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. RESULTS Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3-4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3-4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. CONCLUSIONS When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.
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Affiliation(s)
- Joshua E. J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
- iCope – Camden and Islington Psychological Therapies Services, Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA90095, USA
| | - Phoebe Barnett
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Katherine Clarke
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Gareth Ambler
- Statistical Science, University College London, LondonWC1E 7HB, UK
| | - Robert J. DeRubeis
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA19104-60185, USA
| | - Simon Gilbody
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN37240, USA
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, SouthamptonSO16 5ST, UK
| | - Edward Watkins
- Department of Psychology, University of Exeter, ExeterEX4 4QG, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, BristolBS8 2BN, UK
| | - David Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - David Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, ExeterEX1 2LU, UK
| | - Deborah Sharp
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | | | - Chris Salisbury
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - Ian R. White
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, LondonWC1V 6LJ, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, LondonW1T 7NF, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
- Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
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Van Leeuwen E, van Driel ML, Horowitz MA, Kendrick T, Donald M, De Sutter AI, Robertson L, Christiaens T. Approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. Cochrane Database Syst Rev 2021; 4:CD013495. [PMID: 33886130 PMCID: PMC8092632 DOI: 10.1002/14651858.cd013495.pub2] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [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: 12/18/2022]
Abstract
BACKGROUND Depression and anxiety are the most frequent indication for which antidepressants are prescribed. Long-term antidepressant use is driving much of the internationally observed rise in antidepressant consumption. Surveys of antidepressant users suggest that 30% to 50% of long-term antidepressant prescriptions had no evidence-based indication. Unnecessary use of antidepressants puts people at risk of adverse events. However, high-certainty evidence is lacking regarding the effectiveness and safety of approaches to discontinuing long-term antidepressants. OBJECTIVES To assess the effectiveness and safety of approaches for discontinuation versus continuation of long-term antidepressant use for depressive and anxiety disorders in adults. SEARCH METHODS We searched all databases for randomised controlled trials (RCTs) until January 2020. SELECTION CRITERIA We included RCTs comparing approaches to discontinuation with continuation of antidepressants (or usual care) for people with depression or anxiety who are prescribed antidepressants for at least six months. Interventions included discontinuation alone (abrupt or taper), discontinuation with psychological therapy support, and discontinuation with minimal intervention. Primary outcomes were successful discontinuation rate, relapse (as defined by authors of the original study), withdrawal symptoms, and adverse events. Secondary outcomes were depressive symptoms, anxiety symptoms, quality of life, social and occupational functioning, and severity of illness. DATA COLLECTION AND ANALYSIS We used standard methodological procedures as expected by Cochrane. MAIN RESULTS We included 33 studies involving 4995 participants. Nearly all studies were conducted in a specialist mental healthcare service and included participants with recurrent depression (i.e. two or more episodes of depression prior to discontinuation). All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness. Abrupt discontinuation Thirteen studies reported abrupt discontinuation of antidepressant. Very low-certainty evidence suggests that abrupt discontinuation without psychological support may increase risk of relapse (hazard ratio (HR) 2.09, 95% confidence interval (CI) 1.59 to 2.74; 1373 participants, 10 studies) and there is insufficient evidence of its effect on adverse events (odds ratio (OR) 1.11, 95% CI 0.62 to 1.99; 1012 participants, 7 studies; I² = 37%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of abrupt discontinuation on withdrawal symptoms (1 study) is very uncertain. None of these studies included successful discontinuation rate as a primary endpoint. Discontinuation by "taper" Eighteen studies examined discontinuation by "tapering" (one week or longer). Most tapering regimens lasted four weeks or less. Very low-certainty evidence suggests that "tapered" discontinuation may lead to higher risk of relapse (HR 2.97, 95% CI 2.24 to 3.93; 1546 participants, 13 studies) with no or little difference in adverse events (OR 1.06, 95% CI 0.82 to 1.38; 1479 participants, 7 studies; I² = 0%) compared to continuation of antidepressants, without specific assessment of withdrawal symptoms. Evidence about the effects of discontinuation on withdrawal symptoms (1 study) is very uncertain. Discontinuation with psychological support Four studies reported discontinuation with psychological support. Very low-certainty evidence suggests that initiation of preventive cognitive therapy (PCT), or MBCT, combined with "tapering" may result in successful discontinuation rates of 40% to 75% in the discontinuation group (690 participants, 3 studies). Data from control groups in these studies were requested but are not yet available. Low-certainty evidence suggests that discontinuation combined with psychological intervention may result in no or little effect on relapse (HR 0.89, 95% CI 0.66 to 1.19; 690 participants, 3 studies) compared to continuation of antidepressants. Withdrawal symptoms were not measured. Pooling data on adverse events was not possible due to insufficient information (3 studies). Discontinuation with minimal intervention Low-certainty evidence from one study suggests that a letter to the general practitioner (GP) to review antidepressant treatment may result in no or little effect on successful discontinuation rate compared to usual care (6% versus 8%; 146 participants, 1 study) or on relapse (relapse rate 26% vs 13%; 146 participants, 1 study). No data on withdrawal symptoms nor adverse events were provided. None of the studies used low-intensity psychological interventions such as online support or a changed pharmaceutical formulation that allows tapering with low doses over several months. Insufficient data were available for the majority of people taking antidepressants in the community (i.e. those with only one or no prior episode of depression), for people aged 65 years and older, and for people taking antidepressants for anxiety. AUTHORS' CONCLUSIONS Currently, relatively few studies have focused on approaches to discontinuation of long-term antidepressants. We cannot make any firm conclusions about effects and safety of the approaches studied to date. The true effect and safety are likely to be substantially different from the data presented due to assessment of relapse of depression that is confounded by withdrawal symptoms. All other outcomes are confounded with withdrawal symptoms. Most tapering regimens were limited to four weeks or less. In the studies with rapid tapering schemes the risk of withdrawal symptoms may be similar to studies using abrupt discontinuation which may influence the effectiveness of the interventions. Nearly all data come from people with recurrent depression. There is an urgent need for trials that adequately address withdrawal confounding bias, and carefully distinguish relapse from withdrawal symptoms. Future studies should report key outcomes such as successful discontinuation rate and should include populations with one or no prior depression episodes in primary care, older people, and people taking antidepressants for anxiety and use tapering schemes longer than 4 weeks.
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Affiliation(s)
- Ellen Van Leeuwen
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Mieke L van Driel
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Mark A Horowitz
- Division of Psychiatry, University College London, London, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Maria Donald
- Primary Care Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - An Im De Sutter
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Thierry Christiaens
- Clinical Pharmacology Unit, Department of Basic and Applied Medical Sciences, Ghent University, Ghent, Belgium
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Smith KA, Bradbury K, Essery R, Pollet S, Mowbray F, Slodkowska-Barabasz J, Denison-Day J, Hayter V, Kelly J, Somerville J, Zhang J, Grey E, Western M, Ferrey AE, Krusche A, Stuart B, Mutrie N, Robinson S, Yao GL, Griffiths G, Robinson L, Rossor M, Gallacher J, Griffin S, Kendrick T, Rathod S, Gudgin B, Phillips R, Stokes T, Niven J, Little P, Yardley L. The Active Brains Digital Intervention to Reduce Cognitive Decline in Older Adults: Protocol for a Feasibility Randomized Controlled Trial. JMIR Res Protoc 2020; 9:e18929. [PMID: 33216010 PMCID: PMC7718093 DOI: 10.2196/18929] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Revised: 08/04/2020] [Accepted: 08/16/2020] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND Increasing physical activity, improving diet, and performing brain training exercises are associated with reduced cognitive decline in older adults. OBJECTIVE In this paper, we describe a feasibility trial of the Active Brains intervention, a web-based digital intervention developed to support older adults to make these 3 healthy behavior changes associated with improved cognitive health. The Active Brains trial is a randomized feasibility trial that will test how accessible, acceptable, and feasible the Active Brains intervention is and the effectiveness of the study procedures that we intend to use in the larger, main trial. METHODS In the randomized controlled trial (RCT), we use a parallel design. We will be conducting the intervention with 2 populations recruited through GP practices (family practices) in England from 2018 to 2019: older adults with signs of cognitive decline and older adults without any cognitive decline. Trial participants were randomly allocated to 1 of 3 study groups: usual care, the Active Brains intervention, or the Active Brains website plus brief support from a trained coach (over the phone or by email). The main outcomes are performance on cognitive tasks, quality of life (using EuroQol-5D 5 level), Instrumental Activities of Daily Living, and diagnoses of dementia. Secondary outcomes (including depression, enablement, and health care costs) and process measures (including qualitative interviews with participants and supporters) will also be collected. The trial has been approved by the National Health Service Research Ethics Committee (reference 17/SC/0463). RESULTS Results will be published in peer-reviewed journals, presented at conferences, and shared at public engagement events. Data collection was completed in May 2020, and the results will be reported in 2021. CONCLUSIONS The findings of this study will help us to identify and make important changes to the website, the support received, or the study procedures before we progress to our main randomized phase III trial. TRIAL REGISTRATION International Standard Randomized Controlled Trial Number 23758980; http://www.isrctn.com/ISRCTN23758980. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/18929.
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Affiliation(s)
- Kirsten Ailsa Smith
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Katherine Bradbury
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Rosie Essery
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Sebastien Pollet
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Fiona Mowbray
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Joanna Slodkowska-Barabasz
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - James Denison-Day
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Victoria Hayter
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Jo Kelly
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Jane Somerville
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Jin Zhang
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Elisabeth Grey
- Department for Health, University of Bath, Bath, United Kingdom
| | - Max Western
- Department for Health, University of Bath, Bath, United Kingdom
| | - Anne E Ferrey
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
- NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Adele Krusche
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Nanette Mutrie
- Physical Activity for Health Research Centre, University of Edinburgh, Edinburgh, United Kingdom
| | - Sian Robinson
- NIHR Newcastle Biomedical Research Centre, Newcastle University and Newcastle upon Tyne NHS Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Guiqing Lily Yao
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - Louise Robinson
- Institute of Population Health Sciences, University of Newcastle, Newcastle upon Tyne, United Kingdom
| | - Martin Rossor
- Dementia Research Centre, University College London, London, United Kingdom
| | - John Gallacher
- Department of Psychiatry, University of Oxford, Oxford, United Kingdom
| | - Simon Griffin
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Shanaya Rathod
- Southern Health NHS Foundation Trust, Southampton, United Kingdom
| | - Bernard Gudgin
- Public and Patient Involvement (PPI) representative, University of Southampton, Southampton, United Kingdom
| | - Rosemary Phillips
- Public and Patient Involvement (PPI) representative, University of Southampton, Southampton, United Kingdom
| | - Tom Stokes
- Public and Patient Involvement (PPI) representative, University of Southampton, Southampton, United Kingdom
| | - John Niven
- Public and Patient Involvement (PPI) representative, University of Southampton, Southampton, United Kingdom
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, United Kingdom
| | - Lucy Yardley
- Centre for Community and Clinical Applications of Health Psychology, University of Southampton, Southampton, United Kingdom
- School of Psychological Science, University of Bristol, Bristol, United Kingdom
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Affiliation(s)
- Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Emma Maund
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Abstract
Antidepressant prescribing has increased year on year since the introduction of the selective serotonin reuptake inhibitors (SSRIs) in the 1980s. More than 10% of adults in England are now taking antidepressants for depression/anxiety, with a median length of treatment of more than 2 years, but antidepressants can cause side effects and withdrawal symptoms which increase with longer use. Surveys of antidepressant users suggest 30-50% have no evidence-based indication to continue, but coming off antidepressants is often difficult due to fears of relapse, withdrawal symptoms and a lack of psychological treatments to replace maintenance treatment and prevent relapse. GPs should not prescribe antidepressants routinely for mild depressive/anxiety symptoms. Patients starting antidepressants should be advised that they are to be taken for a limited period only, and that there is a risk of withdrawal problems on stopping them. Prescribers should actively review long-term antidepressant use and suggest coming off them slowly to patients who are well. The relationship between SSRI dose and serotonin transporter receptor occupancy suggests that hyperbolic tapering regimes may be helpful for patients with troubling withdrawal symptoms who cannot stop treatment within 4-8 weeks, and tapering strips can allow carefully titrated slower dose reduction over some months. Internet and telephone support to patients wanting to reduce their antidepressants is being trialled in the REDUCE programme. More research is needed to establish the incidence of withdrawal symptoms in representative samples of patients coming off antidepressants, and large randomised controlled trials are needed to test different tapering strategies.
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences & Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
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Jacobs R, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Gutacker N, Kasteridis P, Kendrick T, Mason A, Rice N, Ride J, Siddiqi N, Williams R. The association between primary care quality and health-care use, costs and outcomes for people with serious mental illness: a retrospective observational study. Health Serv Deliv Res 2020. [DOI: 10.3310/hsdr08250] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Serious mental illness, including schizophrenia, bipolar disorder and other psychoses, is linked with high disease burden, poor outcomes, high treatment costs and lower life expectancy. In the UK, most people with serious mental illness are treated in primary care by general practitioners, who are financially incentivised to meet quality targets for patients with chronic conditions, including serious mental illness, under the Quality and Outcomes Framework. The Quality and Outcomes Framework, however, omits important aspects of quality.
Objectives
We examined whether or not better quality of primary care for people with serious mental illness improved a range of outcomes.
Design and setting
We used administrative data from English primary care practices that contribute to the Clinical Practice Research Datalink GOLD database, linked to Hospital Episode Statistics, accident and emergency attendances, Office for National Statistics mortality data and community mental health records in the Mental Health Minimum Data Set. We used survival analysis to estimate whether or not selected quality indicators affect the time until patients experience an outcome.
Participants
Four cohorts of people with serious mental illness, depending on the outcomes examined and inclusion criteria.
Interventions
Quality of care was measured with (1) Quality and Outcomes Framework indicators (care plans and annual physical reviews) and (2) non-Quality and Outcomes Framework indicators identified through a systematic review (antipsychotic polypharmacy and continuity of care provided by general practitioners).
Main outcome measures
Several outcomes were examined: emergency admissions for serious mental illness and ambulatory care sensitive conditions; all unplanned admissions; accident and emergency attendances; mortality; re-entry into specialist mental health services; and costs attributed to primary, secondary and community mental health care.
Results
Care plans were associated with lower risk of accident and emergency attendance (hazard ratio 0.74, 95% confidence interval 0.69 to 0.80), serious mental illness admission (hazard ratio 0.67, 95% confidence interval 0.59 to 0.75), ambulatory care sensitive condition admission (hazard ratio 0.73, 95% confidence interval 0.64 to 0.83), and lower overall health-care (£53), primary care (£9), hospital (£26) and mental health-care costs (£12). Annual reviews were associated with reduced risk of accident and emergency attendance (hazard ratio 0.80, 95% confidence interval 0.76 to 0.85), serious mental illness admission (hazard ratio 0.75, 95% confidence interval 0.67 to 0.84), ambulatory care sensitive condition admission (hazard ratio 0.76, 95% confidence interval 0.67 to 0.87), and lower overall health-care (£34), primary care (£9) and mental health-care costs (£30). Higher general practitioner continuity was associated with lower risk of accident and emergency presentation (hazard ratio 0.89, 95% confidence interval 0.83 to 0.97) and ambulatory care sensitive condition admission (hazard ratio 0.77, 95% confidence interval 0.65 to 0.92), but not with serious mental illness admission. High continuity was associated with lower primary care costs (£3). Antipsychotic polypharmacy was not statistically significantly associated with the risk of unplanned admission, death or accident and emergency presentation. None of the quality measures was statistically significantly associated with risk of re-entry into specialist mental health care.
Limitations
There is risk of bias from unobserved factors. To mitigate this, we controlled for observed patient characteristics at baseline and adjusted for the influence of time-invariant unobserved patient differences.
Conclusions
Better performance on Quality and Outcomes Framework measures and continuity of care are associated with better outcomes and lower resource utilisation, and could generate moderate cost savings.
Future work
Future research should examine the impact of primary care quality on measures that capture broader aspects of health and functioning.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 25. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
| | - Lauren Aylott
- Expert by experience
- Hull York Medical School, York, UK
| | | | | | - Simon Gilbody
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | | | - Tony Kendrick
- Primary Care and Population Sciences, Aldermoor Health Centre, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Hull York Medical School, York, UK
- Department of Health Sciences, University of York, York, UK
- Bradford District Care NHS Foundation Trust, Bradford, UK
| | - Rachael Williams
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
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Kendrick T, Moore M, Leydon G, Stuart B, Geraghty AWA, Yao G, Lewis G, Griffiths G, May C, Dewar-Haggart R, Williams S, Zhu S, Dowrick C. Patient-reported outcome measures for monitoring primary care patients with depression (PROMDEP): study protocol for a randomised controlled trial. Trials 2020; 21:441. [PMID: 32471492 PMCID: PMC7257549 DOI: 10.1186/s13063-020-04344-9] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Accepted: 04/24/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Benefits to patients from reduced depression have been shown from monitoring progress with patient-reported outcome measures (PROMs) in psychological therapy and mental health settings. This approach has not yet been researched in the United Kingdom for primary care, which is where most people with depression are treated in the United Kingdom. METHODS This is a parallel-group cluster randomised trial with 1:1 allocation to intervention and control. Patients who are age 18+ years, with a new episode of depressive disorder/symptoms, meet the inclusion criteria. Patients with current depression treatment, comorbid dementia/psychosis/substance misuse/suicidal ideas are excluded. The intervention includes the Administration of Patient Health Questionnaire (PHQ-9) as a PROM within 2 weeks of diagnosis and at follow-up 4 weeks later. General practitioners are trained in interpreting scores and asked to take them into account in their treatment decisions. Patients are given written feedback on scores and suggested treatments. The primary outcome measure is Depression on the Beck Depression Inventory BDI-II at 12 weeks. Secondary outcomes include BDI-II at 26 weeks, changes in drug treatments and referrals, social functioning (Work & Social Adjustment Scale) and quality of life (EQ-5D) at 12 and 26 weeks, service use over 26 weeks (modified Client Services Receipt Inventory) to calculate NHS costs, and patient satisfaction at 26 weeks (Medical Informant Satisfaction Scale). The sample includes 676 total participants from 113 practices across three centres. Randomisation is achieved by computerised sequence generation. Blinding is impossible given the nature of the intervention (self-report outcome measures prevent rating bias). Differences at 12 and 26 weeks between intervention and controls in depression, social functioning and quality of life are analysed using linear mixed models, adjusted for socio-demographics, baseline depression, anxiety, and clustering, while including practice as a random effect. Patient satisfaction, quality of life (QALYs) and costs over 26 weeks will be compared between arms. Qualitative process analysis includes interviews with 15-20 GP/NPs and 15-20 patients per arm to reflect trial results and implementation issues, using Normalization Process Theory as a theoretical framework. DISCUSSION If PROMs are helpful in improving patient outcomes for depression even to a small extent, then they are likely to be good value for money, given their low cost. The benefits could be considerable, given that depression is common, disabling, and costly. TRIAL REGISTRATION ISRCTN no: 17299295. Registered 1st October 2018.
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK.
| | - Michael Moore
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Beth Stuart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Adam W A Geraghty
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Guiqing Yao
- Department of Health Sciences, University of Leicester, George Davies Centre, University Road Leicester, Leicester, LE1 7RH, UK
| | - Glyn Lewis
- Division of Psychiatry, Faculty of Brain Sciences, University College London, 6th Floor, Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton, Southampton General Hospital, Tremona Road, Southampton, SO16 6YD, UK
| | - Carl May
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH, UK
| | - Rachel Dewar-Haggart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Samantha Williams
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Shihua Zhu
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, L69 3GL, UK
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Kendrick T, Geraghty AWA, Bowers H, Stuart B, Leydon G, May C, Yao G, O'Brien W, Glowacka M, Holley S, Williams S, Zhu S, Dewar-Haggart R, Palmer B, Bell M, Collinson S, Fry I, Lewis G, Griffiths G, Gilbody S, Moncrieff J, Moore M, Macleod U, Little P, Dowrick C. REDUCE (Reviewing long-term antidepressant use by careful monitoring in everyday practice) internet and telephone support to people coming off long-term antidepressants: protocol for a randomised controlled trial. Trials 2020; 21:419. [PMID: 32448374 PMCID: PMC7245840 DOI: 10.1186/s13063-020-04338-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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] [Received: 03/24/2020] [Accepted: 04/23/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Around one in ten adults take antidepressants for depression in England, and their long-term use is increasing. Some need them to prevent relapse, but 30-50% could possibly stop them without relapsing and avoid adverse effects and complications of long-term use. However, stopping is not always easy due to withdrawal symptoms and a fear of relapse of depression. When general practitioners review patients on long-term antidepressants and recommend to those who are suitable to stop the medication, only 6-8% are able to stop. The Reviewing long-term antidepressant use by careful monitoring in everyday practice (REDUCE) research programme aims to identify safe and cost-effective ways of helping patients taking long-term antidepressants taper off treatment when appropriate. METHODS Design: REDUCE is a two-arm, 1:1 parallel group randomised controlled trial, with randomisation clustered by participating family practices. SETTING England and north Wales. POPULATION patients taking antidepressants for longer than 1 year for a first episode of depression or longer than 2 years for repeated episodes of depression who are no longer depressed and want to try to taper off their antidepressant use. INTERVENTION provision of 'ADvisor' internet programmes to general practitioners or nurse practitioners and to patients designed to support antidepressant withdrawal, plus three patient telephone calls from a psychological wellbeing practitioner. The control arm receives usual care. Blinding of patients, practitioners and researchers is not possible in an open pragmatic trial, but statistical and health economic data analysts will remain blind to allocation. OUTCOME MEASURES the primary outcome is self-reported nine-item Patient Health Questionnaire at 6 months for depressive symptoms. SECONDARY OUTCOMES depressive symptoms at other follow-up time points, anxiety, discontinuation of antidepressants, social functioning, wellbeing, enablement, quality of life, satisfaction, and use of health services for costs. SAMPLE SIZE 402 patients (201 intervention and 201 controls) from 134 general practices recruited over 15-18 months, and followed-up at 3, 6, 9 and 12 months. A qualitative process evaluation will be conducted through interviews with 15-20 patients and 15-20 practitioners in each arm to explore why the interventions were effective or not, depending on the results. DISCUSSION Helping patients reduce and stop antidepressants is often challenging for practitioners and time-consuming for very busy primary care practices. If REDUCE provides evidence showing that access to internet and telephone support enables more patients to stop treatment without increasing depression we will try to implement the intervention throughout the National Health Service, publishing practical guidance for professionals and advice for patients to follow, publicised through patient support groups. TRIAL REGISTRATION ISRCTN:12417565. Registered on 7 October 2019.
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Affiliation(s)
- Tony Kendrick
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK.
| | - Adam W A Geraghty
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Hannah Bowers
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Beth Stuart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Carl May
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Guiqing Yao
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - Wendy O'Brien
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Marta Glowacka
- Department for Rehabilitation and Sport Sciences, Faculty of Health and Social Sciences, Bournemouth University, Bournemouth, UK
| | - Simone Holley
- School of Psychology, Building 44 Highfield Campus, University of Southampton, Southampton, UK
| | - Samantha Williams
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Shihua Zhu
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Rachel Dewar-Haggart
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Bryan Palmer
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Margaret Bell
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Sue Collinson
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Imogen Fry
- School of Psychology, Building 44 Highfield Campus, University of Southampton, Southampton, UK
| | - Glyn Lewis
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Gareth Griffiths
- Southampton Clinical Trials Unit, University of Southampton and University Hospitals Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Simon Gilbody
- Department of Health Sciences, Seebohm Rowntree Building, University of York, York, UK
| | - Joanna Moncrieff
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Michael Moore
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Una Macleod
- Hull York Medical School, Allam Medical Building, University of Hull, Hull, UK
| | - Paul Little
- Primary Care, Population Sciences, and Medical Education, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
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Buckman JE, Saunders R, Cohen ZD, Clarke K, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, White IR, Lewis G, Pilling S. What factors indicate prognosis for adults with depression in primary care? A protocol for meta-analyses of individual patient data using the Dep-GP database. Wellcome Open Res 2020; 4:69. [PMID: 31815189 PMCID: PMC6880263 DOI: 10.12688/wellcomeopenres.15225.3] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/26/2020] [Indexed: 12/04/2022] Open
Abstract
Background: Pre-treatment severity is a key indicator of prognosis for those with depression. Knowledge is limited on how best to encompass severity of disorders. A number of non-severity related factors such as social support and life events are also indicators of prognosis. It is not clear whether this holds true after adjusting for pre-treatment severity as a) a depressive symptom scale score, and b) a broader construct encompassing symptom severity and related indicators: "disorder severity". In order to investigate this, data from the individual participants of clinical trials which have measured a breadth of "disorder severity" related factors are needed. Aims: 1) To assess the association between outcomes for adults seeking treatment for depression and the severity of depression pre-treatment, considered both as i) depressive symptom severity only and ii) "disorder severity" which includes depressive symptom severity and comorbid anxiety, chronicity, history of depression, history of previous treatment, functional impairment and health-related quality of life. 2) To determine whether i) social support, ii) life events, iii) alcohol misuse, and iv) demographic factors (sex, age, ethnicity, marital status, employment status, level of educational attainment, and financial wellbeing) are prognostic indicators of outcomes, independent of baseline "disorder severity" and the type of treatment received. Methods: Databases were searched for randomised clinical trials (RCTs) that recruited adults seeking treatment for depression from their general practitioners and used the same diagnostic and screening instrument to measure severity at baseline - the Revised Clinical Interview Schedule; outcome measures could differ between studies. Chief investigators of all studies meeting inclusion criteria were contacted and individual patient data (IPD) were requested. Conclusions: In total 15 RCTs met inclusion criteria. The Dep-GP database will include the 6271 participants from the 13 studies that provided IPD. This protocol outlines how these data will be analysed. Registration: PROSPERO CRD42019129512 (01/04/2019).
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Affiliation(s)
- Joshua E.J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Katherine Clarke
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Gareth Ambler
- Statistical Science, University College London, London, WC1E 7HB, UK
| | - Robert J. DeRubeis
- School of Arts and Sciences, Department of Psychology, University of Pennsylvania, Philadelphia, PA, 19104-60185, USA
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, 407817, USA
| | - Tony Kendrick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 5ST, UK
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, EX4 4QG, UK
| | - Ian R. White
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit, University College London, London, WC1V 6LJ, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, W1T 7NF, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
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Bowers HM, Kendrick T, Glowacka M, Williams S, Leydon G, May C, Dowrick C, Moncrieff J, Laine R, Nestoriuc Y, Andersson G, Geraghty AWA. Supporting antidepressant discontinuation: the development and optimisation of a digital intervention for patients in UK primary care using a theory, evidence and person-based approach. BMJ Open 2020; 10:e032312. [PMID: 32152159 PMCID: PMC7064123 DOI: 10.1136/bmjopen-2019-032312] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVES We aimed to develop a digital intervention to support antidepressant discontinuation in UK primary care that is scalable, accessible, safe and feasible. In this paper, we describe the development using a theory, evidence and person-based approach. DESIGN Intervention development using a theory, evidence and person-based approach. SETTING Primary Care in the South of England. PARTICIPANTS Fifteen participants with a range of antidepressant experience took part in 'think aloud' interviews for intervention optimisation. INTERVENTION Our digital intervention prototype (called 'ADvisor') was developed on the basis of a planning phase consisting of qualitative and quantitative reviews, an in-depth qualitative study, the development of guiding principles and a theory-based behavioural analysis. Our optimisation phase consisted of 'think aloud' interviews where the intervention was iteratively refined. RESULTS The qualitative systematic review and in-depth qualitative study highlighted the centrality of fear of depression relapse as a key barrier to discontinuation. The quantitative systematic review showed that psychologically informed approaches such as cognitive-behavioural therapy were associated with greater rates of discontinuation than simple advice to reduce. Following a behavioural diagnosis based on the behaviour change wheel, social cognitive theory provided a theoretical basis for the intervention. The intervention was optimised on the basis of think aloud interviews, where participants suggested they like the flexibility of the system and found it reassuring. Changes were made to the tone of the material and the structure was adjusted based on this qualitative feedback. CONCLUSIONS 'ADvisor' is a theory, evidence and person-based digital intervention designed to support antidepressant discontinuation. The intervention was perceived as helpful and reassuring in optimisation interviews. Trials are now needed to determine the feasibility, clinical and cost-effectiveness of this approach.
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Affiliation(s)
- Hannah M Bowers
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Marta Glowacka
- Faculty of Health and Social Sciences, Bournemouth University, Poole, UK
| | - Samantha Williams
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Carl May
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Chris Dowrick
- Institute of Population Health Sciences, University of Liverpool, Liverpool, UK
| | - Joanna Moncrieff
- Mental Health Sciences, University College London and North East London mental health trust, London, UK
| | - Rebecca Laine
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
| | - Yvonne Nestoriuc
- Department of Psychology, Helmet Schmidt University, Hamburg, Germany
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linkoping University, Linköping, Sweden
- Department of Clinical Neuroscience and Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Adam W A Geraghty
- Primary Care, Population Sciences and Medical Education, University of Southampton, Southampton, UK
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Geraghty AWA, Santer M, Beavis C, Williams SJ, Kendrick T, Terluin B, Little P, Moore M. 'I mean what is depression?' A qualitative exploration of UK general practitioners' perceptions of distinctions between emotional distress and depressive disorder. BMJ Open 2019; 9:e032644. [PMID: 31843841 PMCID: PMC6924803 DOI: 10.1136/bmjopen-2019-032644] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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] [Received: 06/28/2019] [Revised: 11/01/2019] [Accepted: 11/11/2019] [Indexed: 12/30/2022] Open
Abstract
OBJECTIVE Detection of depression is a key part of primary mental healthcare. However, determining whether depressive disorder is or is not present in primary care patients is complex. The aim of this qualitative study was to explore general practitioners' (GPs) perceptions of distinctions between emotional distress and depressive disorder. DESIGN Qualitative interview study. SETTING Face-to-face and telephone interviews with GPs from the South of England. PARTICIPANTS GPs working in UK primary care practices (n=21). METHOD Interviews followed a semi-structured interview guide, were audio recorded and transcribed. Data were analysed thematically. RESULTS Views were divergent when directly considering whether emotional distress could be distinguished from depressive disorder. Some GPs suggested a distinction was not possible as symptoms lay on a continuum, with severity as a proxy for disorder. Others focused on the difficulty of the distinction and were uncertain. Some GPs perceived a distinction and referred to emotional distress as more likely in the presence of a stressor with the absence of biological symptoms. It was also common for GPs to refer to endogenous and reactive depression when considering possible distinctions between distress and depressive disorder. CONCLUSIONS GPs' perceptions of when emotional symptoms reflect disorder varied greatly, with a broad range of views presented. Further research is needed to develop more consistent frameworks for understanding emotional symptoms in primary care.
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Affiliation(s)
- Adam W A Geraghty
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Charlotte Beavis
- Forth Valley Royal Hospital, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Samantha J Williams
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Berend Terluin
- Department of General Practice and Elderly Care Medicine, Amsterdam Public Health Research Institute, Amsterdam UMC, Vrije Universiteit Amsterdam, Amsterdam, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Medical Group, University of Southampton Medical School, Southampton, UK
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Duffy L, Lewis G, Ades A, Araya R, Bone J, Brabyn S, Button K, Churchill R, Croudace T, Derrick C, Dixon P, Dowrick C, Fawsitt C, Fusco L, Gilbody S, Harmer C, Hobbs C, Hollingworth W, Jones V, Kendrick T, Kessler D, Khan N, Kounali D, Lanham P, Malpass A, Munafo M, Pervin J, Peters T, Riozzie D, Robinson J, Salaminios G, Sharp D, Thom H, Thomas L, Welton N, Wiles N, Woodhouse R, Lewis G. Antidepressant treatment with sertraline for adults with depressive symptoms in primary care: the PANDA research programme including RCT. Programme Grants Appl Res 2019. [DOI: 10.3310/pgfar07100] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Despite a growing number of prescriptions for antidepressants (over 70 million in 2018), there is uncertainty about when people with depression might benefit from antidepressant medication and concern that antidepressants are prescribed unnecessarily.
Objectives
The main objective of the PANDA (What are the indications for Prescribing ANtiDepressAnts that will lead to a clinical benefit?) research programme was to provide more guidance about when antidepressants are likely to benefit people with depression. We aimed to estimate the minimal clinically important difference for commonly used self-administered scales for depression and anxiety, and to understand more about how patients respond to such assessments. We carried out an observational study of patients with depressive symptoms and a placebo-controlled randomised controlled trial of sertraline versus placebo to estimate the treatment effect in UK primary care. The hypothesis was that the severity and duration of symptoms were related to treatment response.
Design
The programme consisted of three phases. The first phase relied on the secondary analysis of existing data extracted from published trials. The second phase was the PANDA cohort study of patients with depressive symptoms who presented to primary care and were followed up 2, 4 and 6 weeks after a baseline assessment. Both quantitative and qualitative methods were used in the analysis. The third phase was a multicentre randomised placebo-controlled double-blind trial of sertraline versus placebo in patients presenting to primary care with depressive symptoms.
Setting
UK primary care in Bristol, London, Liverpool and York.
Participants
Patients aged 18–74 years who were experiencing depressive symptoms in primary care. Eligibility for the PANDA randomised controlled trial included that there was uncertainty about the benefits about treatment with an antidepressant.
Interventions
In the PANDA randomised controlled trial, patients were individually randomised to 100 mg daily of sertraline or an identical placebo. The PANDA cohort study was an observational study.
Main outcome measures
Depressive symptoms measured using the Patient Health Questionnaire were the primary outcome for the randomised controlled trial. Other outcomes included anxiety symptoms using the Generalised Anxiety Disorder-7; depressive symptoms using the Beck Depression Inventory, version 2; health-related quality of life; self-reported improvement; and cost-effectiveness.
Results
The secondary analysis of existing randomised controlled trials [GENetic and clinical Predictors Of treatment response in Depression (GenPod), TREAting Depression with physical activity (TREAD) and Clinical effectiveness and cost-effectiveness of cognitive Behavioural Therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care (CoBalT)] found evidence that the minimal clinically important difference increased as the initial severity of depressive symptoms rose. Our estimates of minimal clinically important difference were a 17% and 18% reduction in Beck Depression Inventory scores for GenPod and TREAD, respectively. In CoBalT, a 32% reduction corresponded to the minimal clinically important difference but the participants in this study had depression that had not responded to antidepressants. In the PANDA study cohort, and from our analyses in existing data, we found that the minimal clinically important difference varies considerably with the initial severity of depressive and anxiety symptoms. Expressing the minimal clinically important difference as a percentage reduction reduces this variation at higher scores, but at low scores the percentage reduction increased substantially. The results from the qualitative studies pointed out many limitations of the Patient Health Questionnaire-9 items in assessing change and recovery from depression. In the PANDA randomised controlled trial, there was no evidence that sertraline resulted in a reduction in depressive symptoms within 6 weeks of randomisation, but there was some evidence of a reduction by 12 weeks. However, sertraline led to a reduction in anxiety symptoms, an improvement of mental health-related quality of life and an increased likelihood of reporting improvement. The mean Patient Health Questionnaire-9 items score at 6 weeks was 7.98 (standard deviation 5.63) in the sertraline group and 8.76 (standard deviation 5.86) in the placebo group (5% relative reduction, 95% confidence interval –7% to 15%; p = 0.41). Of the secondary outcomes, there was strong evidence that sertraline reduced anxiety symptoms (Generalised Anxiety Disorder-7 score reduced by 17% (95% confidence interval 9% to 25%; p = 0.00005). Sertraline had a high probability (> 90%) of being cost-effective at 12 weeks. The PANDA randomised controlled trial found no evidence that treatment response or cost-effectiveness was related to severity or duration of depressive symptoms. The minimal clinically important difference estimates suggested that sertraline’s effect on anxiety, but not on depression, was likely to be clinically important.
Limitations
The results from the randomised controlled trial and the estimates of minimal clinically important difference were not sufficiently precise to provide specific clinical guidance for individuals. We had low power in testing whether or not initial severity and duration of depressive symptoms are related to treatment response.
Conclusions
The results of the trial support the use of sertraline and probably other selective serotonin reuptake inhibitors because of their action in reducing anxiety symptoms and the likelihood of longer-term benefit on depressive symptoms. Sertraline could be prescribed for anxiety symptoms that commonly occur with depression and many patients will experience a clinical benefit. The Patient Health Questionnaire-9 items and similar self-administered scales should not be used on their own to assess clinical outcome, but should be supplemented with further clinical assessment.
Future work
We need to examine the longer-term effects of antidepressant treatment. We need more precise estimates of the treatment effects and minimal clinically important difference at different severities to provide more specific guidance for individuals. However, the methods we have developed provide an approach towards providing such detailed guidance.
Trial registration
Current Controlled Trials ISRCTN84544741 and EudraCT number 2013-003440-22.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 7, No. 10. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, London, UK
| | - Anthony Ades
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Ricardo Araya
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jessica Bone
- Division of Psychiatry, University College London, London, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | | | - Rachel Churchill
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Tim Croudace
- School of Nursing and Health Studies, University of Dundee, Dundee, UK
| | | | - Padraig Dixon
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | | | - Louise Fusco
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Vivien Jones
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - David Kessler
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Naila Khan
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Daphne Kounali
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Lanham
- Patient and public involvement contributor, UK
| | - Alice Malpass
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus Munafo
- Department of Psychology and Integrated Epidemiology Unit, University of Bristol, Bristol, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - Tim Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Jude Robinson
- Department of Sociology, Social Policy and Criminology, University of Liverpool, Liverpool, UK
| | | | - Debbie Sharp
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Howard Thom
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Laura Thomas
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Wiles
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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Lewis G, Duffy L, Ades A, Amos R, Araya R, Brabyn S, Button KS, Churchill R, Derrick C, Dowrick C, Gilbody S, Fawsitt C, Hollingworth W, Jones V, Kendrick T, Kessler D, Kounali D, Khan N, Lanham P, Pervin J, Peters TJ, Riozzie D, Salaminios G, Thomas L, Welton NJ, Wiles N, Woodhouse R, Lewis G. The clinical effectiveness of sertraline in primary care and the role of depression severity and duration (PANDA): a pragmatic, double-blind, placebo-controlled randomised trial. Lancet Psychiatry 2019; 6:903-914. [PMID: 31543474 PMCID: PMC7029306 DOI: 10.1016/s2215-0366(19)30366-9] [Citation(s) in RCA: 64] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2019] [Revised: 07/26/2019] [Accepted: 08/13/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Depression is usually managed in primary care, but most antidepressant trials are of patients from secondary care mental health services, with eligibility criteria based on diagnosis and severity of depressive symptoms. Antidepressants are now used in a much wider group of people than in previous regulatory trials. We investigated the clinical effectiveness of sertraline in patients in primary care with depressive symptoms ranging from mild to severe and tested the role of severity and duration in treatment response. METHODS The PANDA study was a pragmatic, multicentre, double-blind, placebo-controlled randomised trial of patients from 179 primary care surgeries in four UK cities (Bristol, Liverpool, London, and York). We included patients aged 18 to 74 years who had depressive symptoms of any severity or duration in the past 2 years, where there was clinical uncertainty about the benefit of an antidepressant. This strategy was designed to improve the generalisability of our sample to current use of antidepressants within primary care. Patients were randomly assigned (1:1) with a remote computer-generated code to sertraline or placebo, and were stratified by severity, duration, and site with random block length. Patients received one capsule (sertraline 50 mg or placebo orally) daily for one week then two capsules daily for up to 11 weeks, consistent with evidence on optimal dosages for efficacy and acceptability. The primary outcome was depressive symptoms 6 weeks after randomisation, measured by Patient Health Questionnaire, 9-item version (PHQ-9) scores. Secondary outcomes at 2, 6 and 12 weeks were depressive symptoms and remission (PHQ-9 and Beck Depression Inventory-II), generalised anxiety symptoms (Generalised Anxiety Disorder Assessment 7-item version), mental and physical health-related quality of life (12-item Short-Form Health Survey), and self-reported improvement. All analyses compared groups as randomised (intention-to-treat). The study is registered with EudraCT, 2013-003440-22 (protocol number 13/0413; version 6.1) and ISRCTN, ISRCTN84544741, and is closed to new participants. FINDINGS Between Jan 1, 2015, and Aug 31, 2017, we recruited and randomly assigned 655 patients-326 (50%) to sertraline and 329 (50%) to placebo. Two patients in the sertraline group did not complete a substantial proportion of the baseline assessment and were excluded, leaving 653 patients in total. Due to attrition, primary outcome analyses were of 550 patients (266 in the sertraline group and 284 in the placebo group; 85% follow-up that did not differ by treatment allocation). We found no evidence that sertraline led to a clinically meaningful reduction in depressive symptoms at 6 weeks. The mean 6-week PHQ-9 score was 7·98 (SD 5·63) in the sertraline group and 8·76 (5·86) in the placebo group (adjusted proportional difference 0·95, 95% CI 0·85-1·07; p=0·41). However, for secondary outcomes, we found evidence that sertraline led to reduced anxiety symptoms, better mental (but not physical) health-related quality of life, and self-reported improvements in mental health. We observed weak evidence that depressive symptoms were reduced by sertraline at 12 weeks. We recorded seven adverse events-four for sertraline and three for placebo, and adverse events did not differ by treatment allocation. Three adverse events were classified as serious-two in the sertraline group and one in the placebo group. One serious adverse event in the sertraline group was classified as possibly related to study medication. INTERPRETATION Sertraline is unlikely to reduce depressive symptoms within 6 weeks in primary care but we observed improvements in anxiety, quality of life, and self-rated mental health, which are likely to be clinically important. Our findings support the prescription of SSRI antidepressants in a wider group of participants than previously thought, including those with mild to moderate symptoms who do not meet diagnostic criteria for depression or generalised anxiety disorder. FUNDING National Institute for Health Research.
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Affiliation(s)
- Gemma Lewis
- Division of Psychiatry, University College London, London, UK.
| | - Larisa Duffy
- Division of Psychiatry, University College London, London, UK
| | - Anthony Ades
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Rebekah Amos
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Ricardo Araya
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Simon Gilbody
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | | | - Vivien Jones
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - David Kessler
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Daphne Kounali
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Naila Khan
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, UK
| | - Paul Lanham
- School of Nursing and Health Studies, University of Dundee, Dundee, UK; Department of Liberal Arts, Durham University, Durham, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - Tim J Peters
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Derek Riozzie
- Centre for Reviews and Dissemination, University of York, York, UK
| | | | - Laura Thomas
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicky J Welton
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Nicola Wiles
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | - Glyn Lewis
- Division of Psychiatry, University College London, London, UK
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Buckman JE, Saunders R, Cohen ZD, Clarke K, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, White IR, Lewis G, Pilling S. What factors indicate prognosis for adults with depression in primary care? A protocol for meta-analyses of individual patient data using the Dep-GP database. Wellcome Open Res 2019; 4:69. [PMID: 31815189 PMCID: PMC6880263 DOI: 10.12688/wellcomeopenres.15225.2] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/24/2019] [Indexed: 02/15/2024] Open
Abstract
Background: Pre-treatment severity is a key indicator of prognosis for those with depression. Knowledge is limited on how best to encompass severity of disorders. A number of non-severity related factors such as social support and life events are also indicators of prognosis. It is not clear whether this holds true after adjusting for pre-treatment severity as a) a depressive symptom scale score, and b) a broader construct encompassing symptom severity and related indicators: "disorder severity". In order to investigate this, data from the individual participants of clinical trials which have measured a breadth of "disorder severity" related factors are needed. Aims: 1) To assess the association between outcomes for adults seeking treatment for depression and the severity of depression pre-treatment, considered both as i) depressive symptom severity only and ii) "disorder severity" which includes depressive symptom severity and comorbid anxiety, chronicity, history of depression, history of previous treatment, functional impairment and health-related quality of life. 2) To determine whether i) social support, ii) life events, iii) alcohol misuse, and iv) demographic factors (sex, age, ethnicity, marital status, employment status, level of educational attainment, and financial wellbeing) are prognostic indicators of outcomes, independent of baseline "disorder severity" and the type of treatment received. Methods: Databases were searched for randomised clinical trials (RCTs) that recruited adults seeking treatment for depression from their general practitioners and used the same diagnostic and screening instrument to measure severity at baseline - the Revised Clinical Interview Schedule; outcome measures could differ between studies. Chief investigators of all studies meeting inclusion criteria were contacted and individual patient data (IPD) were requested. Conclusions: In total 15 RCTs met inclusion criteria. The Dep-GP database will include the 6271 participants from the 13 studies that provided IPD. This protocol outlines how these data will be analysed. Registration: PROSPERO CRD42019129512 (01/04/2019).
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Affiliation(s)
- Joshua E.J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Katherine Clarke
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Gareth Ambler
- Statistical Science, University College London, London, WC1E 7HB, UK
| | - Robert J. DeRubeis
- School of Arts and Sciences, Department of Psychology, University of Pennsylvania, Philadelphia, PA, 19104-60185, USA
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, 407817, USA
| | - Tony Kendrick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 5ST, UK
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, EX4 4QG, UK
| | - Ian R. White
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit, University College London, London, WC1V 6LJ, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, W1T 7NF, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
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Ride J, Kasteridis P, Gutacker N, Doran T, Rice N, Gravelle H, Kendrick T, Mason A, Goddard M, Siddiqi N, Gilbody S, Williams R, Aylott L, Dare C, Jacobs R. Impact of family practice continuity of care on unplanned hospital use for people with serious mental illness. Health Serv Res 2019; 54:1316-1325. [PMID: 31598965 PMCID: PMC6863233 DOI: 10.1111/1475-6773.13211] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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] [Indexed: 12/28/2022] Open
Abstract
Objective To investigate whether continuity of care in family practice reduces unplanned hospital use for people with serious mental illness (SMI). Data Sources Linked administrative data on family practice and hospital utilization by people with SMI in England, 2007‐2014. Study Design This observational cohort study used discrete‐time survival analysis to investigate the relationship between continuity of care in family practice and unplanned hospital use: emergency department (ED) presentations, and unplanned admissions for SMI and ambulatory care‐sensitive conditions (ACSC). The analysis distinguishes between relational continuity and management/ informational continuity (as captured by care plans) and accounts for unobserved confounding by examining deviation from long‐term averages. Data Collection/Extraction Methods Individual‐level family practice administrative data linked to hospital administrative data. Principal Findings Higher relational continuity was associated with 8‐11 percent lower risk of ED presentation and 23‐27 percent lower risk of ACSC admissions. Care plans were associated with 29 percent lower risk of ED presentation, 39 percent lower risk of SMI admissions, and 32 percent lower risk of ACSC admissions. Conclusions Family practice continuity of care can reduce unplanned hospital use for physical and mental health of people with SMI.
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Affiliation(s)
- Jemimah Ride
- Health Economics Unit, Centre for Health Policy, Melbourne School of Population and Global Health, University of Melbourne, Parkville, Vic., Australia
| | | | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Tim Doran
- Department of Health Sciences, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Tony Kendrick
- Department of Primary Care, University of Southampton, Southampton, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Najma Siddiqi
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, York, UK.,Bradford District Care, NHS Foundation Trust, Bradford, UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | | | - Lauren Aylott
- Health Professions Education Unit, Hull York Medical School, York, UK
| | - Ceri Dare
- Service User, York, North Yorkshire, UK
| | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
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Kasteridis P, Ride J, Gutacker N, Aylott L, Dare C, Doran T, Gilbody S, Goddard M, Gravelle H, Kendrick T, Mason A, Rice N, Siddiqi N, Williams R, Jacobs R. Association Between Antipsychotic Polypharmacy and Outcomes for People With Serious Mental Illness in England. Psychiatr Serv 2019; 70:650-656. [PMID: 31109263 PMCID: PMC6890489 DOI: 10.1176/appi.ps.201800504] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [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] [Indexed: 11/30/2022]
Abstract
OBJECTIVE Although U.K. and international guidelines recommend monotherapy, antipsychotic polypharmacy among patients with serious mental illness is common in clinical practice. However, empirical evidence on its effectiveness is scarce. Therefore, the authors estimated the effectiveness of antipsychotic polypharmacy relative to monotherapy in terms of health care utilization and mortality. METHODS Primary care data from Clinical Practice Research Datalink, hospital data from Hospital Episode Statistics, and mortality data from the Office of National Statistics were linked to compile a cohort of patients with serious mental illness in England from 2000 to 2014. The antipsychotic prescribing profile of 17,255 adults who had at least one antipsychotic drug record during the period of observation was constructed from primary care medication records. Survival analysis models were estimated to identify the effect of antipsychotic polypharmacy on the time to first occurrence of each of three outcomes: unplanned hospital admissions (all cause), emergency department (ED) visits, and mortality. RESULTS Relative to monotherapy, antipsychotic polypharmacy was not associated with increased risk of unplanned hospital admission (hazard ratio [HR]=1.14; 95% confidence interval [CI]=0.98-1.32), ED visit (HR=0.95; 95% CI=0.80-1.14), or death (HR=1.02; 95% CI=0.76-1.37). Relative to not receiving antipsychotic medication, monotherapy was associated with a reduced hazard of unplanned admissions to the hospital and ED visits, but it had no effect on mortality. CONCLUSIONS The study results support current guidelines for antipsychotic monotherapy in routine clinical practice. However, they also suggest that when clinicians have deemed antipsychotic polypharmacy necessary, health care utilization and mortality are not affected.
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Affiliation(s)
- Panagiotis Kasteridis
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Jemimah Ride
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Nils Gutacker
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Lauren Aylott
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Ceri Dare
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Tim Doran
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Simon Gilbody
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Maria Goddard
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Hugh Gravelle
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Tony Kendrick
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Anne Mason
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Nigel Rice
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Najma Siddiqi
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Rachael Williams
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
| | - Rowena Jacobs
- Centre for Health Economics (Kasteridis, Ride, Gutacker, Goddard, Gravelle, Mason, Rice, Jacobs) and Department of Health Sciences (Doran, Gilbody, Siddiqi), University of York, York, England; Hull York Medical School, York, England (Aylott, Gilbody, Siddiqi); Primary Care and Population Sciences, University of Southampton, Southampton, England (Kendrick); Clinical Practice Research Datalink-Medicines and Healthcare Products Regulatory Agency, London (Williams). Mental health services consultant, York, United Kingdom (Dare)
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Bowers HM, Williams SJ, Geraghty AWA, Maund E, O'brien W, Leydon G, May CR, Kendrick T. Helping people discontinue long-term antidepressants: views of health professionals in UK primary care. BMJ Open 2019; 9:e027837. [PMID: 31278099 PMCID: PMC6615882 DOI: 10.1136/bmjopen-2018-027837] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE The aims of this paper were to identify, characterise and explain clinician factors that shape decision-making around antidepressant discontinuation in UK primary care. DESIGN Four focus groups and three interviews were conducted and analysed using thematic analysis. PARTICIPANTS Twenty-one general practitioners (GPs), four GP assistants, seven nurses and six community mental health team workers and psychotherapists took part in focus groups and interviews. SETTING Participants were recruited from seven primary care regions and two National Health Service Trusts providing community mental health services in the South of England. RESULTS Participants highlighted a number of barriers and enablers to discussing discontinuation with patients. They held a range of views around responsibility, with some suggesting it was the responsibility of the health professional (HP) to broach the subject, and others suggesting responsibility rested with the patients. HPs were concerned about destabilising the current situation, discussed how continuity and knowing the patient facilitated discontinuation talks, and discussed how confidence in their professional skills and knowledge affected whether they elected to raise discontinuation in consultations. CONCLUSIONS Findings indicate a need to consider support for HPs in the management of antidepressant medication and discussions of discontinuation in particular. They may also benefit from support around their fears of patient relapse and awareness of when and how to initiate discussions about discontinuation with their patients.
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Affiliation(s)
- Hannah M Bowers
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | - Samantha J Williams
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Adam W A Geraghty
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Emma Maund
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | - Wendy O'brien
- Primary Care and Population Sciences, University of Southampton Faculty of Medicine, Southampton, UK
| | | | - Carl R May
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Duffy L, Bacon F, Clarke CS, Donkor Y, Freemantle N, Gilbody S, Hunter R, Kendrick T, Kessler D, King M, Lanham P, Lewis G, Mangin D, Marston L, Moore M, Nazareth I, Wiles N, Lewis G. A randomised controlled trial assessing the use of citalopram, sertraline, fluoxetine and mirtazapine in preventing relapse in primary care patients who are taking long-term maintenance antidepressants (ANTLER: ANTidepressants to prevent reLapse in dEpRession): study protocol for a randomised controlled trial. Trials 2019; 20:319. [PMID: 31159856 PMCID: PMC6547591 DOI: 10.1186/s13063-019-3390-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [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] [Received: 12/07/2018] [Accepted: 05/02/2019] [Indexed: 01/08/2023] Open
Abstract
Background Antidepressants are used both for treating acute episodes and for prophylaxis to prevent future episodes of depression, also called maintenance treatment. This article describes the protocol for a randomised controlled trial (ANTLER: ANTidepressants to prevent reLapse in dEpRession) to investigate the clinical effectiveness and cost-effectiveness in UK primary care of continuing on long-term maintenance antidepressants compared with a placebo in preventing relapse of depression in those who have taken antidepressants for more than 9 months and who are currently well enough to consider stopping maintenance treatment. Methods/design The ANTLER trial is an individually randomised, double-blind, placebo-controlled trial in which participants are randomised to remain on active medication or to take an identical placebo after a tapering period of 2 months. Eligible participants are those who: are between the ages of 18 and 74 years; have had at least two episodes of depression; and have been taking antidepressants for 9 months or more and are currently taking citalopram 20 mg, sertraline 100 mg, fluoxetine 20 mg or mirtazapine 30 mg but are well enough to consider stopping their medication. The participants will be followed up at 6, 12, 26, 39 and 52 weeks. The primary outcome will be the time in weeks to the beginning of the first episode of depression after randomisation. This will be measured using a retrospective version of the Clinical Interview Schedule—Revised administered at 12, 26, 39 and 52 weeks. Secondary outcomes will include depressive and anxiety symptoms, adverse effects, withdrawal symptoms, emotional processing tasks, quality of life and the resources and costs used. We will also perform a cost-effectiveness analysis based on results of the trial. Discussion The ANTLER trial findings will inform primary care prescribing practice by providing a valid and generalisable estimate of the clinical effectiveness and cost-effectiveness of long-term maintenance treatment with antidepressants in UK primary care. Trial registration Controlled Trials ISRCTN Registry, ISRCTN15969819. Registered on 21 September 2015. Electronic supplementary material The online version of this article (10.1186/s13063-019-3390-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Larisa Duffy
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK.
| | - Faye Bacon
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Caroline S Clarke
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Yvonne Donkor
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Nick Freemantle
- Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Comprehensive Clinical Trials Unit, University College London, 90 High Holborn 2nd Floor, London, WC1V 6LJ, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree Building, Heslington, York, YO10 5DD, UK
| | - Rachael Hunter
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Tony Kendrick
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Michael King
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Paul Lanham
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Gemma Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
| | - Dee Mangin
- Department of Family Medicine, McMaster University, 1280 Main Street West, Hamilton, Ontario, L8S 4L8, Canada.,Department of General Practice, University of Otago, Christchurch, PO Box 4345, Christchurch, 8140, New Zealand
| | - Louise Marston
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Michael Moore
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, SO16 5ST, UK
| | - Irwin Nazareth
- Research Department of Primary Care and Population Health, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK.,Priment Clinical Trials Unit, University College London, UCL Medical School, Upper 3rd Floor, Royal Free Campus, Rowland Hill Street, London, NW3 2PF, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol, BS8 2BN, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, 6th Floor Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK
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Buckman JE, Saunders R, Cohen ZD, Clarke K, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, White IR, Lewis G, Pilling S. What factors indicate prognosis for adults with depression in primary care? A protocol for meta-analyses of individual patient data using the Dep-GP database. Wellcome Open Res 2019; 4:69. [PMID: 31815189 PMCID: PMC6880263 DOI: 10.12688/wellcomeopenres.15225.1] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/05/2019] [Indexed: 02/15/2024] Open
Abstract
Background: Pre-treatment severity is a key indicator of prognosis for those with depression. Knowledge is limited on how best to encompass severity of disorders. A number of non-severity related factors such as social support and life events are also indicators of prognosis. It is not clear whether this holds true after adjusting for pre-treatment severity as a) a depressive symptom scale score, and b) a broader construct encompassing symptom severity and related indicators: "disorder severity". In order to investigate this, data from the individual participants of clinical trials which have measured a breadth of "disorder severity" related factors are needed. Aims: 1) To assess the association between outcomes for adults seeking treatment for depression and the severity of depression pre-treatment, considered both as i) depressive symptom severity only and ii) "disorder severity" which includes depressive symptom severity and comorbid anxiety, chronicity, history of depression, history of previous treatment, functional impairment and health-related quality of life. 2) To determine whether i) social support, ii) life events, iii) alcohol misuse, and iv) demographic factors (sex, age, ethnicity, marital status, employment status, level of educational attainment, and financial wellbeing) are prognostic indicators of outcomes, independent of baseline "disorder severity" and the type of treatment received. Methods: Databases were searched for randomised clinical trials (RCTs) that recruited adults seeking treatment for depression from their general practitioners and used the same diagnostic and screening instrument to measure severity at baseline - the Revised Clinical Interview Schedule; outcome measures could differ between studies. Chief investigators of all studies meeting inclusion criteria were contacted and individual patient data (IPD) were requested. Conclusions: In total 13 RCTs were found to meet inclusion criteria. The Dep-GP database was formed from the 6271 participants. This protocol outlines how these data will be analysed. Registration: PROSPERO CRD42019129512 (01/04/2019).
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Affiliation(s)
- Joshua E.J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - Katherine Clarke
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
| | - Gareth Ambler
- Statistical Science, University College London, London, WC1E 7HB, UK
| | - Robert J. DeRubeis
- School of Arts and Sciences, Department of Psychology, University of Pennsylvania, Philadelphia, PA, 19104-60185, USA
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, 407817, USA
| | - Tony Kendrick
- Primary Care & Population Sciences, Faculty of Medicine, University of Southampton, Southampton, SO16 5ST, UK
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, EX4 4QG, UK
| | - Ian R. White
- Institute of Clinical Trials and Methodology, MRC Clinical Trials Unit, University College London, London, WC1V 6LJ, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, W1T 7NF, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, WC1E 7HB, UK
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Maund E, Dewar-Haggart R, Williams S, Bowers H, Geraghty AWA, Leydon G, May C, Dawson S, Kendrick T. Barriers and facilitators to discontinuing antidepressant use: A systematic review and thematic synthesis. J Affect Disord 2019; 245:38-62. [PMID: 30366236 DOI: 10.1016/j.jad.2018.10.107] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [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: 08/06/2018] [Revised: 09/24/2018] [Accepted: 10/16/2018] [Indexed: 01/31/2023]
Abstract
OBJECTIVE To explore patient and health professional views and experiences of antidepressant treatment with particular focus on barriers and facilitators to discontinuing use. DESIGN Systematic review with thematic synthesis DATA SOURCES: MEDLINE, PubMed, Embase, PsycINFO, CINAHL, AMED, Health Management Information Consortium, OpenGrey, and the Networked Digital Library of Theses and Dissertations from inception until February 2017. Updated searches were carried out in July 2018. ELIGIBILITY CRITERIA Primary studies, published in English, that used qualitative data collection and analysis, and had data on attitudes, beliefs, feelings, perceptions on continuing or discontinuing antidepressant use, of patients (aged 18 or above, who received treatment with antidepressants for at least 6 months) or any health professionals. DATA EXTRACTION One reviewer extracted data and assessed study quality, which was checked by a second reviewer. FINDINGS Twenty two papers were included in the review. A thematic synthesis was performed for patient perspectives only, due to insufficient data from a health professional perspective. The thematic synthesis yielded nine themes: (1) psychological and physical capabilities; (2) perception of antidepressants; (3) fears; (4) intrinsic motivators and goals; (5) the Doctor as a navigator to maintenance or discontinuation; (6) perceived cause of depression; (7) aspects of information that support decision-making; (8) significant others - a help or a hindrance; and (9) support from other health professionals. LIMITATIONS Coding and development of subthemes and themes was performed by one researcher and further developed through discussion between two researchers. CONCLUSIONS Barriers and facilitators to discontinuing antidepressant use are numerous and complex, and likely to require detailed conversations between patients and their general practitioners (GPs). These conversations are more likely to happen if GPs raise the issue of discontinuation. Further research from a health professional perspective including, but not limited to GPs, is needed.
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Affiliation(s)
- Emma Maund
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Rachel Dewar-Haggart
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Samantha Williams
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Hannah Bowers
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Adam W A Geraghty
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Geraldine Leydon
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
| | - Carl May
- Department of Health Services Research and Policy, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London WC1H 9SH, UK.
| | - Sarah Dawson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol BS8 2PS, UK.
| | - Tony Kendrick
- University of Southampton Primary Care & Population Sciences, Aldermoor Health Centre, Southampton SO16 5ST, UK.
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Maund E, Stuart B, Moore M, Dowrick C, Geraghty AWA, Dawson S, Kendrick T. Managing Antidepressant Discontinuation: A Systematic Review. Ann Fam Med 2019; 17:52-60. [PMID: 30670397 PMCID: PMC6342590 DOI: 10.1370/afm.2336] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Revised: 10/08/2018] [Accepted: 11/01/2018] [Indexed: 11/09/2022] Open
Abstract
PURPOSE We aimed to determine the effectiveness of interventions to manage antidepressant discontinuation, and the outcomes for patients. METHODS We conducted a systematic review with narrative synthesis and meta-analysis of studies published to March 2017. Studies were eligible for inclusion if they were randomized controlled trials, quasi-experimental studies, or observational studies assessing interventions to facilitate discontinuation of antidepressants for depression in adults. Our primary outcomes were antidepressant discontinuation and discontinuation symptoms. Secondary outcomes were relapse/recurrence; quality of life; antidepressant reduction; and sexual, social, and occupational function. RESULTS Of 15 included studies, 12 studies (8 randomized controlled trials, 2 single-arm trials, 2 retrospective cohort studies) were included in the synthesis. None were rated as having high risk for selection or detection bias. Two studies prompting primary care clinician discontinuation with antidepressant tapering guidance found 6% and 7% of patients discontinued, vs 8% for usual care. Six studies of psychological or psychiatric treatment plus tapering reported cessation rates of 40% to 95%. Two studies reported a higher risk of discontinuation symptoms with abrupt termination. At 2 years, risk of relapse/recurrence was lower with cognitive behavioral therapy plus taper vs clinical management plus taper (15% to 25% vs 35% to 80%: risk ratio = 0.34; 95% CI, 0.18-0.67; 2 studies). Relapse/recurrence rates were similar for mindfulness-based cognitive therapy with tapering and maintenance antidepressants (44% to 48% vs 47% to 60%; 2 studies). CONCLUSIONS Cognitive behavioral therapy or mindfulness-based cognitive therapy can help patients discontinue antidepressants without increasing the risk of relapse/recurrence, but are resource intensive. More scalable interventions incorporating psychological support are needed.
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Affiliation(s)
- Emma Maund
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Beth Stuart
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Michael Moore
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Christopher Dowrick
- Institute of Psychology Health and Society, University of Liverpool, Liverpool, United Kingdom
| | - Adam W A Geraghty
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
| | - Sarah Dawson
- Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Tony Kendrick
- Primary Care & Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, United Kingdom
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Ride J, Kasteridis P, Gutacker N, Kronenberg C, Doran T, Mason A, Rice N, Gravelle H, Goddard M, Kendrick T, Siddiqi N, Gilbody S, Dare CRJ, Aylott L, Williams R, Jacobs R. Do care plans and annual reviews of physical health influence unplanned hospital utilisation for people with serious mental illness? Analysis of linked longitudinal primary and secondary healthcare records in England. BMJ Open 2018; 8:e023135. [PMID: 30498040 PMCID: PMC6278786 DOI: 10.1136/bmjopen-2018-023135] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE To investigate whether two primary care activities that are framed as indicators of primary care quality (comprehensive care plans and annual reviews of physical health) influence unplanned utilisation of hospital services for people with serious mental illness (SMI). DESIGN, SETTING, PARTICIPANTS Retrospective observational cohort study using linked primary care and hospital records (Hospital Episode Statistics) for 5158 patients diagnosed with SMI between April 2006 and March 2014, who attended 213 primary care practices in England that contribute to the Clinical Practice Research Datalink GOLD database. OUTCOMES AND ANALYSIS Cox survival models were used to estimate the associations between two primary care quality indicators (care plans and annual reviews of physical health) and the hazards of three types of unplanned hospital utilisation: presentation to accident and emergency departments (A&E), admission for SMI and admission for ambulatory care sensitive conditions (ACSC). RESULTS Risk of A&E presentation was 13% lower (HR 0.87, 95% CI 0.77 to 0.98) and risk of admission to hospital for ACSC was 23% lower (HR 0.77, 95% CI 0.60 to 0.99) for patients with a care plan documented in the previous year compared with those without a care plan. Risk of A&E presentation was 19% lower for those who had a care plan documented earlier but not updated in the previous year (HR: 0.81, 95% CI 0.67 to 0.97) compared with those without a care plan. Risks of hospital admission for SMI were not associated with care plans, and none of the outcomes were associated with annual reviews. CONCLUSIONS Care plans documented in primary care for people with SMI are associated with reduced risk of A&E attendance and reduced risk of unplanned admission to hospital for physical health problems, but not with risk of admission for mental health problems. Annual reviews of physical health are not associated with risk of unplanned hospital utilisation.
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Affiliation(s)
- Jemimah Ride
- Centre for Health Economics, University of York, York, UK
| | | | - Nils Gutacker
- Centre for Health Economics, University of York, York, UK
| | - Christoph Kronenberg
- CINCH, University Duisburg-Essen, Essen, Germany
- Leibniz Science Campus Ruhr, Essen, Germany
- RWI – Leibniz-Institute for Economic Research, Essen, Germany
| | - Tim Doran
- Department of Health Sciences, The University of York, York, UK
| | - Anne Mason
- Centre for Health Economics, University of York, York, UK
| | - Nigel Rice
- Centre for Health Economics, University of York, York, UK
| | - Hugh Gravelle
- Centre for Health Economics, University of York, York, UK
| | - Maria Goddard
- Centre for Health Economics, University of York, York, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Najma Siddiqi
- Department of Health Sciences, The University of York, York, UK
| | - Simon Gilbody
- Department of Health Sciences, The University of York, York, UK
| | | | | | | | - Rowena Jacobs
- Centre for Health Economics, University of York, York, UK
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Kendrick T. Improve access to quality primary care for patients with anxiety or depression. Lancet 2018; 392:1308. [PMID: 30322576 DOI: 10.1016/s0140-6736(18)31888-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 08/08/2018] [Indexed: 10/28/2022]
Affiliation(s)
- Tony Kendrick
- Primary Care Group, Primary Care and Population Sciences, University of Southampton, Southampton, SO16 5ST, UK.
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Kendrick T, Marchant J, Tsang N, Nkazana K, McGeever J, Cooke E, Grant T. Humidified high flow therapy in paediatric patients referred for retrieval to the NSW newborn and paediatric emergency transport service (NETS). Aust Crit Care 2018. [DOI: 10.1016/j.aucc.2017.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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50
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Brien SB, Stuart B, Dickens AP, Kendrick T, Jordan RE, Adab P, Thomas M. Independent determinants of disease-related quality of life in COPD - scope for nonpharmacologic interventions? Int J Chron Obstruct Pulmon Dis 2018; 13:247-256. [PMID: 29386893 PMCID: PMC5765972 DOI: 10.2147/copd.s152955] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [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] [Indexed: 12/26/2022] Open
Abstract
Purpose Quality-of-life (QoL) scores in chronic obstructive pulmonary disease (COPD) have a weak relationship with physiologic impairment. We investigated factors associated with poor QoL, focusing on psychological measures potentially amenable to intervention. Patients and methods We utilized a pre-existing Birmingham (UK) COPD cohort to assess factors associated with QoL impairment (COPD Assessment Test [CAT] scores). Univariate and multivariate regression models were constructed from three categories of variables: demographic, lung function/COPD-related symptoms, and psychosocial/behavioral factors. Results Analyses were based on self-report questionnaire data from 735 participants. The multivariate model of variables independently associated with CAT included depression, dysfunctional breathing symptoms (Nijmegen score), and illness perception, in addition to COPD symptoms (wheeze, cough), exercise capacity, breathlessness, exacerbations, and deprivation; this model explained 72% of CAT score variation. In a dominance analysis assessing the relative contribution of variables, similar contributions were made by breathlessness (20.2%), illness perception (19.8%), dysfunctional breathing symptoms (17.5%), and depression (12.5%) with other variables contributing <5%. Conclusion Psychological factors significantly contribute to disease-specific QoL impairment in COPD, and potentially explain the mismatch between objective physiologic impairment and patients’ experience of their disease. Interventions targeting psychological factors, illness perception, and dysfunctional breathing should be assessed.
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Affiliation(s)
- Sarah B Brien
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire
| | - Beth Stuart
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire
| | - Andrew P Dickens
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Warwickshire, UK
| | - Tony Kendrick
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire
| | - Rachel E Jordan
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Warwickshire, UK
| | - Paymane Adab
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, Warwickshire, UK
| | - Mike Thomas
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, Hampshire
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