Case-finding instruments for depression. Two questions are as good as many

Evaluation of a Pilot Implementation to Integrate Alcohol-Related Care within Primary Care

Alcohol use is a major cause of disability and death worldwide. To improve prevention and treatment addressing unhealthy alcohol use, experts recommend that alcohol-related care be integrated into primary care (PC). However, few healthcare systems do so. To address this gap, implementation researchers and clinical leaders at Kaiser Permanente Washington partnered to design a high-quality Program of Sustained Patient-centered Alcohol-related Care (SPARC). Here, we describe the SPARC pilot implementation, evaluate its effectiveness within three large pilot sites, and describe the qualitative findings on barriers and facilitators. Across the three sites (N = 74,225 PC patients), alcohol screening increased from 8.9% of patients pre-implementation to 62% post-implementation (p < 0.0001), with a corresponding increase in assessment for alcohol use disorders (AUD) from 1.2 to 75 patients per 10,000 seen (p < 0.0001). Increases were sustained over a year later, with screening at 84.5% and an assessment rate of 81 patients per 10,000 seen across all sites. In addition, there was a 50% increase in the number of new AUD diagnoses (p = 0.0002), and a non-statistically significant 54% increase in treatment within 14 days of new diagnoses (p = 0.083). The pilot informed an ongoing stepped-wedge trial in the remaining 22 PC sites.

Study protocol for a comparative effectiveness trial of two models of perinatal integrated psychosocial assessment: the PIPA project

BACKGROUND

Studies examining psychosocial and depression assessment programs in maternity settings have not adequately considered the context in which psychosocial assessment occurs or how broader components of integrated care, including clinician decision-making aids, may optimise program delivery and its cost-effectiveness. There is also limited evidence relating to the diagnostic accuracy of symptom-based screening measures used in this context. The Perinatal Integrated Psychosocial Assessment (PIPA) Project was developed to address these knowledge gaps. The primary aims of the PIPA Project are to examine the clinical- and cost-effectiveness of two alternative models of integrated psychosocial care during pregnancy: 'care as usual' (the SAFE START model) and an alternative model (the PIPA model). The acceptability and perceived benefit of each model of care from the perspective of both pregnant women and their healthcare providers will also be assessed. Our secondary aim is to examine the psychometric properties of a number of symptom-based screening tools for depression and anxiety when used in pregnancy.

METHODS

This is a comparative-effectiveness study comparing 'care as usual' to an alternative model sequentially over two 12-month periods. Data will be collected from women at Time 1 (initial antenatal psychosocial assessment), Time 2 (2-weeks after Time 1) and from clinicians at Time 3 for each condition. Primary aims will be evaluated using a between-groups design, and the secondary aim using a within group design.

DISCUSSION

The PIPA Project will provide evidence relating to the clinical- and cost- effectiveness of psychosocial assessment integrated with electronic clinician decision making prompts, and referral options that are tailored to the woman's psychosocial risk, in the maternity care setting. It will also address research recommendations from the Australian (2011) and NICE (2015) Clinical Practice Guidelines.

TRIAL REGISTRATION

ACTRN12617000932369.

Improving recognition of anxiety and depression in rheumatoid arthritis: a qualitative study in a community clinic

BACKGROUND

Comorbid anxiety and depression are common in patients with rheumatoid arthritis (RA) but are often under-recognised and treated, contributing to worse outcomes. National Institute for Health and Care Excellence (NICE) recommends that patients with RA should be offered a holistic annual review, including an assessment of mood.

AIM

To explore patients' perspectives of anxiety and depression in RA and preferences for disclosure and management of mood problems.

DESIGN AND SETTING

Qualitative interview study with patients recruited from a nurse-led RA annual review clinic in the Midlands, England.

METHOD

Patients attending the clinic who scored ≥3 on the case-finding questions (PHQ-2 and GAD-2) were invited for interview. Data were analysed thematically using principles of constant comparison.

RESULTS

Participants recognised a connection between their RA and mood, though this was perceived variably. Some lacked candidacy for care, normalising their mood problems. Fear of stigmatisation, a lack of time, and the perception that clinicians prioritise physical over mental health problems recursively affected help-seeking. Good communication and continuity of care were perceived to be integral to disclosure of mood problems. Participants expressed a preference for psychological therapies, though they reported problems accessing care. Some perceived medication to be offered as a 'quick fix' and feared potential drug interactions.

CONCLUSION

Prior experiences can lead patients with RA and comorbid anxiety and depression to feel they lack candidacy for care. Provision of equal priority to mental and physical health problems by GPs and improved continuity of care could help disclosure of mood concerns. Facilitation of access to psychological therapies could improve outcomes for both mental and physical health problems.

CHOICE: Choosing Health Options In Chronic Care Emergencies

Background

Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation.

Objectives

The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs).

Design

A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team.

Setting

Primary care. Manchester and London.

Participants

People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff.

Results

Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling.

Limitations

The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD.

Conclusions

Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness.

Future work

The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

Funding

The National Institute for Health Research Programme Grants for Applied Research programme.

Student midwives' awareness, knowledge, and experiences of antenatal anxiety within clinical practice

OBJECTIVE

The current study aimed to explore student midwives' awareness, knowledge, and experiences of supporting women with antenatal anxiety (ANA) within clinical practice.

BACKGROUND

ANA is associated with negative outcomes for mother and baby. Midwives play a key role in the screening of antenatal mental health and care of women suffering from ANA.

METHODS

This study was conducted with student midwives at one UK university in the north-west of England. Twenty-five midwifery students completed a brief online survey informed by National Institute of Health and Care Excellence (NICE) guidelines. Of these, seven volunteered to participate in semi-structured interviews exploring the survey data. The interview topic guide was designed based on the findings of the survey.

RESULTS

Thematic analysis of the seven interviews revealed four overarching themes: Perpetuating factors, Barriers to care, Skills required in role and Suggestions for future directions. Midwives had a varied knowledge and understanding of ANA and expressed a desire to learn more about their role in supporting women with ANA.

CONCLUSION

Although a small study, the results highlight the need for education to be improved in order to best prepare student midwives for cases of ANA, with emphasis on integrating psychology and mental health information into teaching as well as time spent in clinical practice. Midwives are key in the screening of women for ANA and are in an ideal position to signpost for specialist care.

Inquiring about insomnia may facilitate diagnosis of depression in the primary care setting

AIM

Depression is often undiagnosed in primary care. Asking about sleep status is much easier than asking about mood. This study was conducted to examine the relation between insomnia and depression.

METHODS

New patients aged 35-64 years were recruited from internal medicine clinics in Japan. Self-administered questionnaires were employed. Depression was evaluated by the Zung Self-Rating Depression Scale and the Profile of Mood States. Sleep status was investigated using the Pittsburgh Sleep Quality Index. Likelihood ratios of insomnia for depression were calculated. To assess the relation between insomnia and depression independent of confounding factors, adjusted odds ratios (OR) and 95% confidence intervals (CI) were calculated using multiple logistic regression analyses.

RESULTS

Among 598 subjects, 153 (25.6%) were assessed as having depression. 'Very bad sleep quality, with difficulty falling asleep within 30 min ≥3 times/week' showed a positive likelihood ratio of 20.36 (95%CI, 2.53-164) while 'not very good sleep quality' had a negative likelihood ratio of 0.32 (95%CI, 0.14-0.72). Adjusted for sex, age, underlying diseases, major life events, lifestyle habits, and relationship problems, significant OR for depression were observed for 'difficulty falling asleep within 30 min ≥3 times/week' (OR, 2.53; 95%CI, 1.07-5.98), 'waking up in the middle of the night or early morning ≥3 times/week' (OR, 3.09; 95%CI, 1.58-6.05), and 'fairly bad sleep quality' (OR, 3.65; 95%CI, 1.34-9.96).

CONCLUSION

Inquiring about the weekly frequency of difficulty 'falling asleep within 30 min,' 'waking up in the middle of the night or early morning,' and 'sleep quality' may help to diagnose depression.

Physician Burnout and Well-Being: A Systematic Review and Framework for Action

BACKGROUND

Physician burnout in the United States has reached epidemic proportions and is rising rapidly, although burnout in other occupations is stable. Its negative impact is far reaching and includes harm to the burned-out physician, as well as patients, coworkers, family members, close friends, and healthcare organizations.

OBJECTIVE

The purpose of this review is to provide an accurate, current summary of what is known about physician burnout and to develop a framework to reverse its current negative impact, decrease its prevalence, and implement effective organizational and personal interventions.

DATA SOURCES

I completed a comprehensive MEDLINE search of the medical literature from January 1, 2000, through December 28, 2016, related to medical student and physician burnout, stress, depression, suicide ideation, suicide, resiliency, wellness, and well-being. In addition, I selectively reviewed secondary articles, books addressing the relevant issues, and oral presentations at national professional meetings since 2013.

STUDY SELECTION

Healthcare organizations within the United States were studied.

RESULTS

The literature review is presented in 5 sections covering the basics of defining and measuring burnout; its impact, incidence, and causes; and interventions and remediation strategies.

CONCLUSIONS

All US medical students, physicians in training, and practicing physicians are at significant risk of burnout. Its prevalence now exceeds 50%. Burnout is the unintended net result of multiple, highly disruptive changes in society at large, the medical profession, and the healthcare system. Both individual and organizational strategies have been only partially successful in mitigating burnout and in developing resiliency and well-being among physicians. Two highly effective strategies are aligning personal and organizational values and enabling physicians to devote 20% of their work activities to the part of their medical practice that is especially meaningful to them. More research is needed.

A bespoke mobile application for the longitudinal assessment of depression and mood during pregnancy: protocol of a feasibility study

INTRODUCTION

Depression is a common mental health disorder during pregnancy, with important consequences for mothers and their children. Despite this, it goes undiagnosed and untreated in many women attending antenatal care. Smartphones could help support the prompt identification of antenatal depression in this setting. In addition, these devices enable the implementation of ecological momentary assessment techniques, which could be used to assess how mood is experienced during pregnancy. With this study, we will assess the feasibility of using a bespoke mobile application (app) running on participants' own handsets for the longitudinal (6 months) monitoring of antenatal mood and screening of depression.

METHODS AND ANALYSIS

We will use a randomised controlled study design to compare two types of assessment strategies: retrospective + momentary (consisting of the Edinburgh Postnatal Depression Scale plus five momentary and two contextual questions), and retrospective (consisting of the Edinburgh Postnatal Depression Scale only). We will assess the impact that these strategies have on participant adherence to a prespecified sampling protocol, dropout rates and timeliness of data completion. We will evaluate differences in acceptance of the technology through a short quantitative survey and open-ended questions. We will also assess the potential effect that momentary assessments could have on retrospective data. We will attempt to identify any patterns in app usage through the analysis of log data.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the National Research Ethics Service Committee South East Coast-Surrey on 15 April 2016 as a notice of substantial amendment to the original submission (9 July 2015) under the Research Ethics Committee (REC) reference 15/LO/0977. This study is being sponsored by Imperial College London under the reference number 15IC2687 and has been included in the UK Clinical Research Network Study Portfolio under the Central Portfolio Management System number 19280. The findings of this study will be disseminated through academic peer-reviewed publications, poster presentations and abstracts at academic and professional conferences, discussion with peers, and social media. The findings of this study will also inform the PhD theses of JSMB and KD.

Implementation of depression screening in antenatal clinics through tablet computers: results of a feasibility study

Background

Mobile devices may facilitate depression screening in the waiting area of antenatal clinics. This can present implementation challenges, of which we focused on survey layout and technology deployment.

Methods

We assessed the feasibility of using tablet computers to administer a socio-demographic survey, the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to 530 pregnant women attending National Health Service (NHS) antenatal clinics across England. We randomised participants to one of two layout versions of these surveys: (i) a scrolling layout where each survey was presented on a single screen; or (ii) a paging layout where only one question appeared on the screen at any given time.

Results

Overall, 85.10% of eligible pregnant women agreed to take part. Of these, 90.95% completed the study procedures. Approximately 23% of participants answered Yes to at least one Whooley question, and approximately 13% of them scored 10 points of more on the EPDS. We observed no association between survey layout and the responses given to the Whooley questions, the median EPDS scores, the number of participants at increased risk of self-harm, and the number of participants asking for technical assistance. However, we observed a difference in the number of participants at each EPDS scoring interval (p = 0.008), which provide an indication of a woman’s risk of depression. A scrolling layout resulted in faster completion times (median = 4 min 46 s) than a paging layout (median = 5 min 33 s) (p = 0.024). However, the clinical significance of this difference (47.5 s) is yet to be determined.

Conclusions

Tablet computers can be used for depression screening in the waiting area of antenatal clinics. This requires the careful consideration of clinical workflows, and technology-related issues such as connectivity and security. An association between survey layout and EPDS scoring intervals needs to be explored further to determine if it corresponds to a survey layout effect. Future research needs to evaluate the effect of this type of antenatal depression screening on clinical outcomes and clinic workflows.

Trial registration

This study was registered in ClinicalTrials.gov under the identifier NCT02516982 on 20 July 2015.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-017-0459-8) contains supplementary material, which is available to authorized users.

Supporting women with postpartum anxiety: exploring views and experiences of specialist community public health nurses in the UK

Anxiety is common among postpartum women and can have adverse effects on mother's and child's somatic and psychological health if left untreated. In the UK, nurses or midwifes with a specialisation in community public health nursing, also called health visitors (HVs), work with families who have children younger than 5 years of age and are therefore in a key position to identify and support women with postpartum mental health issues. Until recently, postpartum mental health support provided by HVs mainly focused on identifying and managing depression, but the updated clinical guidance by the National Institute for Health and Care Excellence also includes guidance regarding screening and psychological interventions for perinatal anxiety. This study therefore aimed to explore HVs' experiences of supporting women with postpartum anxiety and their views on currently available care. Using a qualitative approach, in-depth semi-structured interviews were conducted with 13 HVs from the UK between May and October 2015. Participants were interviewed in person at their workplace or on the phone/Skype. Using thematic analysis, four main themes emerged: identification and screening issues; importance of training; service usage; and status of current service provision. Women with postpartum anxiety were commonly encountered by HVs in their clinical practice and described as often heavily using their or other related healthcare services, which puts additional strain on HVs' already heavy workload. Issues with identifying and screening for postpartum anxiety were raised and the current lack of perinatal mental health training for HVs was highlighted. In addition, HVs described a current lack of good perinatal mental health services in general and specifically for anxiety. The study highlights the need for HV perinatal mental health training in general and postpartum anxiety specifically, as well as better coverage of specialist mental health services and the need for development of interventions targeted at postpartum anxiety.

Effect of Acupressure, Acupuncture and Moxibustion in Women With Pregnancy-Related Anxiety and Previous Depression: A Preliminary Study

Background

In this preliminary study, we examined the effect of acupressure, acupuncture and moxibustion (oriental treatments) to prevent of the relapse/deterioration of perinatal depression in women with pregnancy-related anxiety and previous depression.

Methods and results

Between 2014 and 2016, there were 48 women with pregnancy-related anxiety and previous depression who had delivery at ≥ 22 weeks’ gestation in our institute. Of these, oriental treatments were performed in eight and two women (totally 10, 21%) during pregnancy and postpartum, respectively. One of the 10 (10%) who received oriental treatments admitted depressive symptoms during pregnancy or postpartum, while 18 of the rest 38 who did not receive oriental treatments admitted depressive symptoms (47%, P = 0.065).

Conclusion

The oriental treatments may be useful for pregnant women who need perinatal mental health care.

Screening for Depressive and Anxiety Symptoms During Pregnancy and Postpartum at a Japanese Perinatal Center

BACKGROUND

We examined the current status of depressive and anxiety symptoms in Japanese women during pregnancy and postpartum.

METHODS

We asked 220 Japanese women who gave birth to singleton babies at term to answer the two self-administered questionnaires (Whooley's two questions and two-item generalized anxiety disorder scale) at first, second and third trimester of pregnancy and 1 month after delivery.

RESULTS

The rates of women with depressive symptoms were common during the first trimester of pregnancy (25%) and the postpartum (17%), while the women with anxiety symptoms were common during the first trimester of pregnancy (36%). Eight percent women had histories of mental disorders, and 95% of them showed depressive and/or anxiety symptoms somewhere during pregnancy. Of the women who had depressive symptoms during postpartum, 86% showed depressive and/or anxiety symptoms somewhere during pregnancy.

CONCLUSION

Screening for depressive and anxiety symptoms during pregnancy was suggested to be useful to detect high risk women of postpartum depression.

Depression screening using health questionnaires in patients receiving oral isotretinoin for acne vulgaris

Isotretinoin is used to treat severe and recalcitrant acne. Possible side effects include depression, suicide, and suicidal ideation; however, other studies suggest isotretinoin may improve mood and quality of life. Although iPLEDGE consenting warns about the risk of depression and suicidal ideation, there is no recommendation for screening tools. The patient health questionnaire-2 and the patient health questionnaire-9 are validated instruments that enable dermatologists to efficiently screen for depression before and after isotretinoin is initiated.

Validation of the Whooley questions for antenatal depression and anxiety among low-income women in urban South Africa

Background/objective

In South Africa, approximately 40% of women suffer from depression during pregnancy. Although perinatal depression and anxiety are significant public health problems impacting maternal and infant morbidity and mortality, no routine mental health screening programmes exist in the country. A practical, accurate screening tool is needed to identify cases in these busy, resource-scarce settings.

Method

A convenience sample of 145 women between 22 and 28 weeks gestation was recruited from Rahima Moosa Hospital antenatal clinic in Johannesburg. All women completed a biographical interview, the Edinburgh Postnatal Depression Scale (EPDS), the Whooley questions and a structured clinical interview.

Results

The results demonstrate the sensitivity and specificity of the Whooley questions and the EPDS in identifying depression, anxiety and stress disorders of varying severity. The importance of personal, social and cultural context in influencing the content and expression of these common perinatal conditions was also identified.

Discussion and conclusion

The validity of the Whooley questions in the context of urban South Africa, and the importance of ensuring clinical interviews to supplement any screening tools, is emphasised.

Influence of intimate partner violence on mental status in Japanese women during the first trimester of pregnancy

OBJECTIVE

We examined the relation between intimate partner violence (IVP) and maternal mental status such as depression and anxiety.

METHODS

Between April 2016 and October 2016, we asked all Japanese women during the first trimester of pregnancy to answer the three self-administered questionnaires to screen IVP and depressive and anxiety symptoms.

RESULTS

There were 19 women who had a high score in the modified Violence Against Women Screen (VAWS) (4.1%, IPV group) and 408 women who had a score 0 (86.8%, control group). Overall, the rate of the women with depressive, anxiety, and depressive plus anxiety symptoms were 21.3, 31.5, and 16.0%, respectively. The rate of depressive and/or anxiety symptoms in the IPV group were significantly higher than those in the control group (Odds ratio = 5.02 and 7.40, p < .01 by X² test).

CONCLUSIONS

The significant adverse effect of IPV on maternal mental status seemed to be observed in Japanese women during the first trimester of pregnancy.

Presentation of Coping Strategies Associated with Physical and Mental Health During Health Check-ups

We identified coping behaviors during regular health check-ups and examined whether they were related to physical and mental health. We assessed coping strategies with the Brief COPE scale in 201 people who underwent a regular health check-up in a clinic. We found several significant relationships between coping and physical/psychological conditions presented in health check-up: Humor and systolic blood pressure, Substance use and high-density lipoprotein cholesterol, Venting and low-density lipoprotein cholesterol, Self-blame and depression, and Behavioral disengagement and sleep disorder. By evaluating coping strategies and screening depression as part of a regular health check-up, General practitioner can provide psychological intervention such as cognitive behavioral therapy which may improve both mental and physical health of the people.

Comparison of diagnostic performance of Two-Question Screen and 15 depression screening instruments for older adults: systematic review and meta-analysis

BackgroundScreening for depression in older adults is recommended.AimsTo evaluate the diagnostic accuracy of the Two-Question Screen for older adults and compare it with other screening instruments for depression.MethodWe undertook a literature search for studies assessing the diagnostic performance of depression screening instruments in older adults. Combined diagnostic accuracy including sensitivity and specificity were the primary outcomes. Potential risks of bias and the quality of studies were also assessed.ResultsA total of 46 506 participants from 132 studies were identified evaluating 16 screening instruments. The majority of studies (63/132) used various versions of the Geriatric Depression Scale (GDS) and 6 used the Two-Question Screen. The combined sensitivity and specificity for the Two-Question Screen were 91.8% (95% CI 85.2-95.6) and 67.7% (95% CI 58.1-76.0), respectively; the diagnostic performance area under the curve (AUC) was 90%. The Two-Question Screen showed comparable performance with other instruments, including clinician-rated scales. The One-Question Screen showed the lowest diagnostic performance with an AUC of 78%. In subgroup analysis, the Two-Question Screen also had good diagnostic performance in screening for major depressive disorder.ConclusionsThe Two-Question Screen is a simple and short instrument for depression screening. Its diagnostic performance is comparable with other instruments and, therefore, it would be favourable to use it for older adult screening programmes.

The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

BACKGROUND

This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes.

METHODS AND FINDINGS

We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire-2 for depression, a two-item Generalized Anxiety Disorder-2 questionnaire for anxiety, and a question about current pain intensity [0-10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]).

CONCLUSIONS

In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group.

TRIAL REGISTRATION

ISRCTN registry ISRCTN40721988.

Using the Edinburgh Postnatal Depression Scale for women and men-some cautionary thoughts

The objective of the study was to critically consider some of the possible limitations in the Edinburgh Depression Scale (EDS), given that great emphasis is put on the results of this measure within both clinical and research fields. Using findings and discussion points from other studies, as well as from a critical analysis of issues by the authors based upon their clinical and research experience, possible limitations with the scale in nine areas are discussed. Possible limitations include the following: (1) ambiguous items, (2) exclusion of certain types of distress, (3) scoring difficulties, (4) low positive predictive value, (5) frequent use of incorrect cut-off scores, (6) a vast array of validated cut-off scores, (7) validation against a questionable gold-standard, (8) limited anxiety detection and of depressive symptoms in men, and (9) many screen positive women only have transient distress. While the EDS has unquestionably been an extremely valuable instrument in aiding in the recognition of the importance of perinatal mental health, users of the scale should be aware that it, like other measures, has limitations. We discuss possible strategies to overcome these limitations and describe a recent scale that has been developed to surmount these shortcomings more effectively.

Association of excessive daytime sleepiness with migraine and headache frequency in the general population

BACKGROUND

Some previous studies have postulated an association between migraine and excessive daytime sleepiness (EDS). This study evaluated the association of EDS with migraine and headache frequency in a general population, after adjusting for potential confounding variables.

METHODS

The study was a postal survey of a random age and gender-stratified sample of 40,000 persons aged 20 to 80 years old drawn by the National Population Register in Norway. The questionnaire included questions about migraine, headache, the Epworth sleepiness scale (ESS) and various comorbidities. EDS was defined as ESS > 10. The association of EDS and migraine/headache were analysed by bivariate and multivariable logistic regression analyses.

RESULTS

A total of 21,177 persons responded to the ESS and were included in the analyses. The odds ratio (OR) for EDS was increased for migraineurs (1.42 (95% CI 1.31─1.54), p < 0.001) compared to non-migraineurs; however, this finding was not significant after adjustment for a number of possible confounders. EDS increased with increasing headache frequency, with an OR of 2.74 (95% CI 2.05─3.65), p < 0.001) for those with headache on >179 days per year compared to those without headache in multivariable analysis.

CONCLUSIONS

In a general population, the odds for EDS increased significantly with the headache frequency, irrespective of migraine status. EDS was not associated with reported migraine in multivariable analysis.

Subthreshold Depression and Clinically Significant Depression in an Italian Population of 70-74-Year-Olds: Prevalence and Association with Perceptions of Self

Estimates of depressive disorders in the elderly vary depending on how cases are defined. We estimated the prevalence of subthreshold depression (SD) and clinically significant depression (D) in a population of 70–74-year-olds. We also looked for associations with sociodemographic factors and perceptions of self. Participants underwent a multidimensional assessment (social, medical, and neuropsychological). The estimated prevalence of SD was 15.71% (95% CI: 13.70–17.72), while that of D was 5.58% (95% CI: 4.31–6.85). Multinomial logistic regression analysis revealed that female gender and dissatisfaction with family relationships were related to SD and D. A self-perception of physical age as older than actual age (but not comorbidity) and greater self-perceived stress caused by negative life events both increased the probability of SD. The likelihood of D was decreased in those who perceived their own health as good, whereas a self-perception of mental age as older than actual age and dissatisfaction with relationships with friends were both significantly associated with D. Both SD and D emerged as key problems in our population. Female gender and self-perceptions of various characteristics, which can be explored through simple questions, are associated with late-life depression in elderly people independently of their actual physical condition and other characteristics.

Gambling problems among patients in primary care: a cross-sectional study of general practices

BACKGROUND

Primary care is an important context for addressing health-related behaviours, and may provide a setting for identification of gambling problems.

AIM

To indicate the extent of gambling problems among patients attending general practices, and explore settings or patient groups that experience heightened vulnerability.

DESIGN AND SETTING

Cross-sectional study of patients attending 11 general practices in Bristol, South West England.

METHOD

Adult patients (n = 1058) were recruited from waiting rooms of practices that were sampled on the basis of population characteristics. Patients completed anonymous questionnaires comprising measures of mental health problems (for example, depression) and addictive behaviours (for example, risky alcohol use). The Problem Gambling Severity Index (PGSI) measured gambling problems, along with a single-item measure of gambling problems among family members. Estimates of extent and variability according to practice and patient characteristics were produced.

RESULTS

There were 0.9% of all patients exhibiting problem gambling (PGSI ≥5), and 4.3% reporting problems that were low to moderate in severity (PGSI 1-4). Around 7% of patients reported gambling problems among family members. Further analyses indicated that rates of any gambling problems (PGSI ≥1) were higher among males and young adults, and more tentatively, within a student healthcare setting. They were also elevated among patients exhibiting drug use, risky alcohol use, and depression.

CONCLUSION

There is need for improved understanding of the burden of, and responses to, patients with gambling problems in general practices, and new strategies to increase identification to facilitate improved care and early intervention.

Characteristics and Etiologies of Chronic Scrotal Pain: A Common but Poorly Understood Condition

Chronic scrotal pain (CSP) is a common and debilitating condition, but the underlying characteristics and etiology of CSP are poorly understood. The objective of this study is to identify the characteristic and etiologies of CSP. Men presenting for management of CSP completed a standardized questionnaire and underwent a complete physical examination. From Feb 2014 to Sep 2015, a total of 131 men (mean age 43) with CSP were studied. The CSP was of long duration (mean of 4.7 ± 5.95 years) and dramatically affected men's lives, with adverse effects on normal activities (71.%), ability to work (51.90%), and sexual functioning (61.8%). 50.4% felt depressed on most days, and 67.17% felt either unhappy or terrible with their present condition. Physical examination revealed that the epididymis was the most common tender area found in 70/131 men (53.43%), though a musculoskeletal source for the pain was found in 9.9%. Neuropathic changes were found in 30%. For close to half of the men (43.5%) we were unable to identify any potential cause for the CSP. This study characterizes the dramatic impact that CSP has on the lives of men, while providing an understanding of the common etiologies.

Discovering pockets of complexity: Socioeconomic status, stress exposure, and the nuances of the health gradient

One of the most pervasive statements about stratification and health identifies the strong inverse relationship-or gradient-between socioeconomic status (SES) and poor health. We elaborate on the ways that the SES-based gradient in stress exposure contributes to nuances in the SES-health association. In analyses of the 2008 National Study of the Changing Workforce, we find some evidence that the inverse association between SES and health outcomes is finely graded-but several 'pockets of complexity' emerge. First, education and income have different associations with health and well-being. Second, those associations depend on the outcome being assessed. Education is more influential for predicting anxiety and poor health than for depression or life dissatisfaction, while income is more influential for predicting depression and, to a lesser extent, life dissatisfaction. Third, different patterns of explanation or suppression reflect resource advantage or stress of higher status dynamics. Some impactful stressors that people encounter-especially job pressure and work-family conflict-are not neatly graded in ways that corroborate the conventional SES-health narrative. Instead, these mask the size of the overall health differences between lower versus higher SES groups. Our mapping of the SES gradient in stressors extends that story and complicates the conventional view of the association between SES and health/well-being.

Primary care Screening Questionnaire for Depression: reliability and validity of a new four-item tool

BACKGROUND

Unidentified depression in primary care is a public health concern, globally. There is a need for brief, valid and easily administered tools in primary care.

AIMS

To estimate reliability and validity of the newly developed Primary care Screening Questionnaire for Depression (PSQ4D), a four-item tool, with 'yes' or 'no' options.

METHOD

PSQ4D was administered verbally (time required, <1 min) by primary care physicians to adult outpatients (n=827) in six primary care settings in Kerala, India. A psychiatrist evaluated each patient on the same day, using ICD-10 Diagnostic Criteria for Research, based on unstructured clinical interview.

RESULTS

The Cronbach's alpha for internal consistency reliability was 0.80; kappa coefficient for test-retest reliability was 0.9 and that for interrater reliability was 0.72. At a score ≥2, sensitivity was 0.96, specificity was 0.87, positive predictive value was 0.74, negative predictive value was 0.98, positive likelihood ratio was 7.4 and negative likelihood ratio was 0.05.

CONCLUSIONS

When physician administered, PSQ4D has good reliability. At a cut-off score of ≥2, it has high sensitivity and specificity to identify depressive disorder in primary care.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Prevalence of stressful life events during pregnancy and its association with postpartum depressive symptoms

Experiencing stressful life events (SLEs) has negative consequences for both mother and infant. This study examined the predictive contributions of (1) experiences of each SLE separately and its association with postpartum depressive symptoms (PDS), (2) experiences of cumulative number of SLEs and PDS, and (3) the cumulative experiences of SLEs across three domains (relational, financial, physical health). Georgia's Pregnancy Risk Assessment Monitoring System data were obtained from 2004 to 2011. Chi-square tests and a combination of weighted logistic regression models were conducted to predict self-reported PDS. Odds ratios (OR) and 95 % confidence intervals (CI) were reported. A total of 10,231 women were included in the analysis; 15 % of the mothers reported PDS. Arguments with partner, trouble paying bills, and separation/divorce significantly predicted increased odds of PDS. Increased odds of PDS were observed with increasing numbers of cumulative SLEs. Experiencing high stress in any domain significantly predicted PDS with the highest predictor being high stress across all domains, followed by experiencing a combination of high relational and financial stress. SLEs were associated with reporting PDS among new mothers in Georgia. It is important to assess for SLEs during prenatal care and provide resources aimed at reducing the impact of SLEs.

Psychosomatic aspects of vitiligo

Vitiligo is a chronic common skin disease. The asymptomatic hypopigmented cutaneous lesions are considered by many health care professionals as a cosmetic problem only; however, vitiligo can have a major psychosocial impact on patients' lives. We review some of the factors responsible for this impact, such as the general public's wrong perception of the disease, feelings and emotional responses from patients, how stressful events can act as triggers of the disease, stigmatization experiences suffered by the patients, the prevalence of psychiatric morbidity, the effects on relationships and sex life, how quality of life in adults and children is impaired, and how treatment can improve it.

Chronic symptoms in a representative sample of community-dwelling older people: a cross-sectional study in Switzerland

OBJECTIVES

The burden of multiple diagnoses is well documented in older people, but less is known about chronic symptoms, many of which are even not brought to medical attention. This study aimed to determine the prevalence of chronic symptoms, their relationships with disability in basic activities of daily living (BADL) and quality of life (QoL), and their public health impact.

DESIGN

A large cross-sectional population-based study.

SETTING

Community in 2 regions of French-speaking Switzerland.

PARTICIPANTS

Community-dwelling older adults aged 68 years and older in 2011 (N=5300).

OUTCOMES

Disability in BADL defined as difficulty or help needed with any of dressing, bathing, eating, getting in/out of bed or an arm chair, and using the toilet. Overall QoL dichotomised as favourable (ie, excellent or very good) or unfavourable (ie, good, fair or poor). Disturbance by any of the following 14 chronic symptoms for at least 6 months: joint pain, back pain, chest pain, dyspnoea, persistent cough, swollen legs, memory gaps, difficulty concentrating, difficulty making decisions, dizziness/vertigo, skin problems, stomach/intestine problems, urinary incontinence and impaired sexual life.

RESULTS

Only 17.1% of participants did not report being disturbed by any of these chronic symptoms. Weighted prevalence ranged from 3.1% (chest pain) to 47.7% (joint pain). Most chronic symptoms were significantly associated with disability in BADL or unfavourable QoL, with substantial gender differences. The number of chronic symptoms was significantly associated with disability in BADL and unfavourable QoL, with gradients suggesting dose-response relationships. Joint pain and back pain had the highest population attributable fractions.

CONCLUSIONS

Chronic symptoms are highly prevalent in older people, and are associated with disability in BADL and unfavourable QoL, particularly when multiple chronic symptoms co-occur. Owing to their high public health impact, musculoskeletal chronic symptoms represent good targets for preventive interventions.

Association between Physical Frailty and Quality of Life in a Representative Sample of Community-Dwelling Swiss Older People

OBJECTIVE

Though the association between physical frailty and health is well established, little is known about its association with other domains of quality of life (QoL). This study investigated the association between physical frailty and multiple domains of QoL in community-dwelling older people.

DESIGN

Cross-sectional study.

SETTING AND PARTICIPANTS

Data of the 2011 annual assessment of 927 older people (age 73-77 years) from the Lc65+ cohort study were used.

MEASUREMENTS

Physical frailty was assessed by Fried's five criteria: 'shrinking'; 'weakness'; 'poor endurance, exhaustion'; 'slowness'; and 'low activity'. QoL was assessed using 28 items yielding a QoL score and seven domain-specific QoL subscores (Feeling of safety; Health and mobility; Autonomy; Close entourage; Material resources; Esteem and recognition; and Social and cultural life). Low QoL (QoL score or QoL subscores in the lowest quintile) was used as dependent variable in logistic regression analyses adjusted for age and sex (model 1), and additionally for socioeconomic (model 2) and health (model 3) covariates.

RESULTS

Physical frailty was associated with a low QoL score, as well as decreased QoL subscores in all seven specific domains, even after adjusting for socio-economic covariates. However, when performing additional adjustment for health covariates, only the domain Health and mobility remained significantly associated with physical frailty. Among each specific Fried's criteria, 'slowness' had the strongest association with a low QoL score.

CONCLUSION

Physical frailty is associated with all QoL domains, but these associations are largely explained by poor health characteristics. Longitudinal studies are needed to better understand temporal relationships between physical frailty, health and QoL.

Telotristat Ethyl, a Tryptophan Hydroxylase Inhibitor for the Treatment of Carcinoid Syndrome

Purpose

Preliminary studies suggested that telotristat ethyl, a tryptophan hydroxylase inhibitor, reduces bowel movement (BM) frequency in patients with carcinoid syndrome. This placebo-controlled phase III study evaluated telotristat ethyl in this setting.

Patients and Methods

Patients (N = 135) experiencing four or more BMs per day despite stable-dose somatostatin analog therapy received (1:1:1) placebo, telotristat ethyl 250 mg, or telotristat ethyl 500 mg three times per day orally during a 12-week double-blind treatment period. The primary end point was change from baseline in BM frequency. In an open-label extension, 115 patients subsequently received telotristat ethyl 500 mg.

Results

Estimated differences in BM frequency per day versus placebo averaged over 12 weeks were –0.81 for telotristat ethyl 250 mg ( P < .001) and ‒0.69 for telotristat ethyl 500 mg ( P < .001). At week 12, mean BM frequency reductions per day for placebo, telotristat ethyl 250 mg, and telotristat ethyl 500 mg were –0.9, –1.7, and –2.1, respectively. Responses, predefined as a BM frequency reduction ≥ 30% from baseline for ≥ 50% of the double-blind treatment period, were observed in 20%, 44%, and 42% of patients given placebo, telotristat ethyl 250 mg, and telotristat ethyl 500 mg, respectively. Both telotristat ethyl dosages significantly reduced mean urinary 5-hydroxyindole acetic acid versus placebo at week 12 ( P < .001). Mild nausea and asymptomatic increases in gamma-glutamyl transferase were observed in some patients receiving telotristat ethyl. Follow-up of patients during the open-label extension revealed no new safety signals and suggested sustained BM responses to treatment.

Conclusion

Among patients with carcinoid syndrome not adequately controlled by somatostatin analogs, treatment with telotristat ethyl was generally safe and well tolerated and resulted in significant reductions in BM frequency and urinary 5-hydroxyindole acetic acid.

Symptom Overlap and Screening for Symptoms of Attention-Deficit/Hyperactivity Disorder and Psychosis Risk in Help-Seeking Psychiatric Patients

Symptoms of attention-deficit/hyperactivity disorder (ADHD) and psychosis risk share features which might represent an early vulnerability marker for schizophrenia. Early detection of individuals with this symptomatic overlap is relevant and may assist clinicians in their decision making for diagnosis and treatment. This study sought to analyze the capability of different instruments in the screening of patients for ADHD symptoms or at psychosis risk, assess their classification accuracy, and describe the extent of symptoms overlap between them. 243 adult patients completed one instrument screening for ADHD and two instruments screening for psychosis risk symptoms [Adult ADHD Self-Report Scale Symptom Checklist (ASRS-v1.1); Prodromal Questionnaire Brief Version (PQ-16); Self-Screen Prodrome (SPro)]. The ability of these instruments to distinguish between the symptomaticity of these patients appears modest. The most satisfactory scale to identify subjects at psychosis risk was SPro with its subscale psychosis risk. ASRS-v1.1 showed good reliability in assessing individuals as not having ADHD symptoms and had higher probability to achieve its own and the cut-off of another questionnaire. Subjects having symptoms of psychosis risk and ADHD showed elevated symptomatology. Reliable instruments capable of separating ADHD symptoms from those of psychosis risk are needed to better identify the symptomatic overlap of this two conditions.

Poststroke Depression: A Scientific Statement for Healthcare Professionals From the American Heart Association/American Stroke Association

Poststroke depression (PSD) is common, affecting approximately one third of stroke survivors at any one time after stroke. Individuals with PSD are at a higher risk for suboptimal recovery, recurrent vascular events, poor quality of life, and mortality. Although PSD is prevalent, uncertainty remains regarding predisposing risk factors and optimal strategies for prevention and treatment. This is the first scientific statement from the American Heart Association on the topic of PSD. Members of the writing group were appointed by the American Heart Association Stroke Council's Scientific Statements Oversight Committee and the American Heart Association's Manuscript Oversight Committee. Members were assigned topics relevant to their areas of expertise and reviewed appropriate literature, references to published clinical and epidemiology studies, clinical and public health guidelines, authoritative statements, and expert opinion. This multispecialty statement provides a comprehensive review of the current evidence and gaps in current knowledge of the epidemiology, pathophysiology, outcomes, management, and prevention of PSD, and provides implications for clinical practice.

Association Between Learning Environment Interventions and Medical Student Well-being: A Systematic Review

IMPORTANCE

Concerns exist about the current quality of undergraduate medical education and its effect on students' well-being.

OBJECTIVE

To identify best practices for undergraduate medical education learning environment interventions that are associated with improved emotional well-being of students.

DATA SOURCES

Learning environment interventions were identified by searching the biomedical electronic databases Ovid MEDLINE, EMBASE, the Cochrane Library, and ERIC from database inception dates to October 2016. Studies examined any intervention designed to promote medical students' emotional well-being in the setting of a US academic medical school, with an outcome defined as students' reports of well-being as assessed by surveys, semistructured interviews, or other quantitative methods.

DATA EXTRACTION AND SYNTHESIS

Two investigators independently reviewed abstracts and full-text articles. Data were extracted into tables to summarize results. Study quality was assessed by the Medical Education Research Study Quality Instrument (MERQSI), which has a possible range of 5 to 18; higher scores indicate higher design and methods quality and a score of 14 or higher indicates a high-quality study.

FINDINGS

Twenty-eight articles including at least 8224 participants met eligibility criteria. Study designs included single-group cross-sectional or posttest only (n = 10), single-group pretest/posttest (n = 2), nonrandomized 2-group (n = 13), and randomized clinical trial (n = 3); 89.2% were conducted at a single site, and the mean MERSQI score for all studies was 10.3 (SD, 2.11; range, 5-13). Studies encompassed a variety of interventions, including those focused on pass/fail grading systems (n = 3; mean MERSQI score, 12.0), mental health programs (n = 4; mean MERSQI score, 11.9), mind-body skills programs (n = 7; mean MERSQI score, 11.3), curriculum structure (n = 3; mean MERSQI score, 9.5), multicomponent program reform (n = 5; mean MERSQI score, 9.4), wellness programs (n = 4; mean MERSQI score, 9.0), and advising/mentoring programs (n = 3; mean MERSQI score, 8.2).

CONCLUSIONS AND RELEVANCE

In this systematic review, limited evidence suggested that some specific learning environment interventions were associated with improved emotional well-being among medical students. However, the overall quality of the evidence was low, highlighting the need for high-quality medical education research.

Association of Postpartum Predischarge Depot-Medroxyprogesterone Acetate with In-Hospital Breastfeeding Initiation

OBJECTIVE

The primary aim of this study was to examine the association between postpartum predischarge depot-medroxyprogesterone acetate (ppDMPA) and in-hospital breastfeeding initiation, and the secondary exploratory aim was to determine if any racial disparities are associated with ppDMPA receipt or its relationship to breastfeeding initiation.

MATERIALS AND METHODS

We conducted a cross-sectional retrospective chart review of maternal and newborn records at a large urban academic medical center. Variables extracted included in-hospital feeding choice, obstetrical and sociodemographic variables, infant characteristics, and ppDMPA receipt. The association of ppDMPA and maternal-child characteristics with breastfeeding initiation was examined using logistic regression analysis.

RESULTS

Among singleton live births of 919 mother-infant pairs (76.5% African American [AA]), 67% initiated breastfeeding (34% exclusive and 33% mixed) and 31.4% received ppDMPA. Breastfeeding rates differed significantly between AA (60.7%) and non-AA mothers (86.6%), and ppDMPA also differed significantly between AA (37.6%) and non-AA mothers (11.6%). Adjusting for other independent predictors, mothers who received ppDMPA were 1.5 times more likely not to initiate breastfeeding if AA, and 5.2 times more likely not to initiate breastfeeding if non-AA.

CONCLUSIONS

ppDMPA receipt was independently associated with decreased rates of breastfeeding initiation. Although more AA mothers received ppDMPA than non-AA, the association of ppDMPA with breastfeeding noninitiation was stronger in non-AA than in AA mothers. Future research should examine this question prospectively to ascertain if there is a cause-effect relationship and should address both physiological effects and social perceptions.

Predicting three-month functional outcomes after an ED visit for acute low back pain

BACKGROUND

Nearly 30% of patients who present to an ED with acute, new onset, low back pain (LBP) report LBP-related functional impairment three months later. These patients are at risk of chronic LBP, a highly debilitating condition. It has been reported previously that functional impairment, depression, and psychosomatic symptomatology at the index visit are associated with poor LBP outcomes. We wished to replicate those findings in a cohort of ED patients, and also to determine if clinical features present at one week follow-up could predict three-month outcomes in individual patients.

METHODS

This was a planned analysis of data from a randomized comparative effectiveness study of three analgesic combinations conducted in one ED. Patients were followed by telephone one week and three months post-ED visit. The primary outcome was a three-month Roland-Morris Disability Questionnaire (RMDQ) score >0, indicating the presence of LBP-related functional impairment. At the index visit, we measured functional impairment (using the RMDQ), depressive symptomatology (using the Patient Health Questionnaire depression module), and psychosomatic features (using the 5-item Cassandra scale). At the one-week follow-up, we ascertained the presence or absence of LBP. We built a logistic regression model in which all the predictors were entered and retained in the model, in addition to socio-demographic variables and dummy variables controlling for investigational medication. Results are reported as adjusted odds ratios (adjOR) with 95% CI. To determine if statistically significant associations could be used to predict three-month outcomes in individual patients, we then calculated positive and negative likelihood ratios [LR(+) and LR(-)] with 95% CI for those independent variables associated with the primary outcome.

RESULTS

Of 295 patients who completed the study, 14 (5%) were depressed and 18 (6%) reported psychosomatic symptoms. The median index visit RMDQ score was 19 (IQR: 17, 21) indicating substantial functional impairment. One week after the ED visit, 193 (65%) patients reported presence of LBP. 294 patients provided a three-month RMDQ score, 88 of whom (30%, 95% CI: 25, 35%) reported a score >0. Neither depression (adjOR 0.7 [95% CI 0.2, 3.1]), psychosomatic symptomatology (adjOR 0.5 [95% CI 0.1, 2.0]), nor index visit functional impairment (adjOR 1.0 [95% CI 1.0, 1.1]) were associated with three-month outcome. Pain at one week was strongly and independently associated with the three-month outcome when examined at the group level (adjOR 4.0 [95% CI 2.1, 7.7]). However, likelihood ratios for pain or its absence at one-week were insufficiently robust to be clinically useful in predicting three-month outcomes in individual patients (LR+: 1.4 [95% CI: 1.3, 1.7]; LR-: 0.4 [95% CI: 0.2, 0.6]).

CONCLUSIONS

In spite of a strong association at the group level between presence of LBP at one week and functional impairment at three months, when used to predict outcomes in individual patients, presence of pain failed to discriminate with clinically meaningful utility between acute LBP patients destined to have a favorable versus unfavorable three-month outcome.

Depressive Symptoms, Cardiac Disease Severity, and Functional Status in Patients With Coronary Artery Disease (from the Heart and Soul Study)

Patient-reported health status is highly valued as a key measure of health care quality, yet little is known about the extent to which it is determined by subjective perception compared with objective measures of disease severity. We sought to compare the associations of depressive symptoms and objective measures of cardiac disease severity with perceived functional status in patients with stable coronary artery disease. We assessed depressive symptoms, severity of cardiovascular disease, and perceived functional status in a cross-sectional study of 1,023 patients with stable coronary artery disease. We compared the extent to which patient-reported functional status was influenced by depressive symptoms versus objective measures of disease severity. We then evaluated perceived functional status as a predictor of subsequent cardiovascular hospitalizations during 8.8 years of follow-up. Patients with depressive symptoms were more likely to report poor functional status than those without depressive symptoms (44% vs 17%; p <0.001). After adjustment for traditional risk factors and co-morbid conditions, independent predictors of poor functional status were depressive symptoms (odds ratio [OR] 2.68, 95% confidence interval [CI] 1.89 to 3.79), poor exercise capacity (OR 2.30, 95% CI 1.65 to 3.19), and history of heart failure (OR 1.61, 95% CI 1.12 to 2.29). Compared with patients who had class I functional status, those with class II functional status had a 96% greater rate (hazard ratio 1.96, 95% CI 1.15 to 3.34) and those with class III or IV functional status had a 104% greater rate (hazard ratio 2.04, 95% CI 1.12 to 3.73) of hospitalization for HF, adjusted for baseline demographic characteristics, co-morbidities, cardiac disease severity, and depressive symptoms. In conclusion, depressive symptoms and cardiac disease severity were independently associated with patient-reported functional status. This suggests that perceived functional status may be as strongly influenced by depressive symptoms as it is by cardiovascular disease severity.

Depression: an exploratory parallel-group randomised controlled trial of Antenatal guided self help for WomeN (DAWN): study protocol for a randomised controlled trial

BACKGROUND

Depression is a common antenatal mental disorder and is associated with an increased risk of adverse effects on the fetus and significant morbidity for the mother; if untreated it can also continue into the post-natal period and affect mother-infant interactions. There has been little research evaluating the effectiveness or cost-effectiveness of antenatal psychological interventions for antenatal depression, particularly for mild to moderate disorders. International guidelines recommend a stepped care approach starting with Guided Self Help, and the aim of this exploratory trial is to investigate Guided Self Help modified for pregnancy.

METHODS

The DAWN trial is an exploratory randomised controlled trial of the effectiveness and cost-effectiveness of antenatal Guided Self Help, modified for pregnancy and delivered by National Health Service Psychological Wellbeing Practitioners. Antenatal Guided Self Help, in addition to usual care, is compared with usual care for pregnant women diagnosed with mild to moderate depression and mixed anxiety and depression, using the Structured Clinical Interview for DSM-IV Disorders. Modifications for pregnancy include perinatal mental health training, addressing pregnancy-specific worries and including sections on health issues in pregnancy and planning for parenthood. Women allocated to Guided Self Help will be seen for up to eight sessions by a Psychological Wellbeing Practitioner (including an initial assessment session); there will also be an appointment at 12 weeks after delivery. Research measures including the Edinburgh Postnatal Depression Scale (primary outcome) and other measures of depression, anxiety, quality of life and service use will be collected from women before random allocation, 14 weeks after random allocation and at 12 weeks after delivery. Potential psychological mechanisms of the intervention will be explored using the Pregnancy-Related Thoughts Questionnaire and the Metacognitive Awareness Questionnaire.

DISCUSSION

The DAWN trial is the first exploratory trial to investigate the efficacy of antenatal Guided Self Help for pregnant women with mild to moderate depression meeting DSM-IV diagnostic criteria. Recruitment started January 2015 and is expected to be completed by July 2016.

TRIAL REGISTRATION

ISRCTN registry: ISRCTN83768230 . Registered on 8 August 2014.

Prenatal predictors of postpartum depression and postpartum depressive symptoms in Mexican mothers: a longitudinal study

Prospective studies on the predictors of postpartum depression (PPD) in Latin America are scarce, which is a matter of importance, since the significance of PPD risk factors may vary according to the level of development of a country, the types of measurement and the time periods assessed. This study identifies the prenatal predictors for PPD (diagnostic interview) and postpartum depressive symptoms (PPDS) (self-report scale) in Mexican mothers at 6 weeks and 6 months postpartum. Two hundred and ten women were interviewed using the Structured Clinical Interview (SCID-I), Patient Health Questionnaire (PHQ-9) and various risk factor scales. Univariate logistic regressions showed that social support, marital satisfaction, life events, a history of psychopathology, anxiety symptoms, depressive symptoms, the traditional female role, previous miscarriages/termination of pregnancy and unplanned/unwanted pregnancy were significant predictors for both PPD and PPDS at both assessment times in the postpartum. Education, age, marital status, income, occupation, parity, C-section and resilience were significant for only one of the measurements and/or at just one assessment time. General findings replicate a high- and low-income country observed psychosocial risk profile and confirm a sociodemographic and obstetric profile of vulnerability that is more prevalent in resource-constrained countries. PPD constitutes a high burden for new mothers, particularly for those living in low-middle-income countries who face social disadvantages (such as low educational attainment and income).

Using health psychology to help patients: common mental health disorders and psychological distress

This article provides an overview of how health psychology can be used by nurses to help patients experiencing common mental health problems and psychological distress. Mental health problems are common and are associated with poor outcomes, especially for patients with comorbid physical health conditions. Mental health problems are associated with unhealthy behaviours such as smoking, physical inactivity, overeating and excessive alcohol use, which will result in poorer outcomes for patients. Consideration of a patient's psychological health is therefore important for all nurses providing holistic care. Awareness of the symptoms of psychological distress, good communication skills and simple screening instruments can be used by nurses to assess patients' mental health. The cognitive and behavioural risk factors associated with depression and anxiety are also explored, as an understanding of these can help nurses to provide appropriate care.

Who is actually asked about their mental health in pregnancy and the postnatal period? Findings from a national survey

BACKGROUND

Pregnancy and the postnatal period is a period of potential vulnerability for women and families. It is UK policy that all women are asked about their mental health and wellbeing early in pregnancy and following the birth to help detect potential problems and prevent serious adverse outcome. However, identification of mental health problems in pregnancy may be less than 50 %. The aim of the study was to find out which women are asked about their mood and mental health during pregnancy and postnatally, and about offer and uptake of treatment.

METHODS

Secondary analysis of a national maternity survey carried out in 2014 which asked about sociodemographic factors, care in pregnancy, childbirth, and the postnatal period with specific questions on emotional and mental health.

RESULTS

The usable response rate to the survey was 47 % (4571 women). Most women recalled being asked about their mental health in pregnancy (82 %) and in the postnatal period (90 %). However, antenatally, Asian and older women were less likely to be asked and to be offered treatment. In the postnatal period, differences were more marked. Non-white women, those living in more deprived areas, and those who had received less education were less likely to be asked about their mental health, to be offered treatment, and to receive support. Women with a trusting relationship with their midwife were more likely to be asked about their mental health.

CONCLUSION

The inequities described in this study suggest that the inverse care law is operating in relation to this aspect of maternity care. Those women most likely to be in need of support and treatment are least likely to be offered it and may be at risk of serious adverse outcomes.

Burnout and Alcohol Abuse/Dependence Among U.S. Medical Students

PURPOSE

To explore the relationship between alcohol abuse/dependence with burnout and other forms of distress among a national cohort of medical students.

METHOD

In 2012, the authors completed a national survey of medical students from the American Medical Association's Physician Masterfile containing validated items assessing alcohol abuse/dependence, burnout, depression, suicidality, quality of life (QOL), and fatigue. Descriptive and comparative statistical analyses were computed, including chi-square and multivariate logistic regression, to determine relationships between variables.

RESULTS

Of the 12,500 students, 4,402 (35.2%) responded. Of these, 1,411 (32.4%) met diagnostic criteria for alcohol abuse/dependence. Students who were burned out (P = .01), depressed (P = .01), or reported low mental (P =.03) or emotional (P = .016) QOL were more likely to have alcohol abuse/dependence. Emotional exhaustion and depersonalization domains of burnout were strongly associated with alcohol abuse/dependence. On multivariate analysis, burnout (OR 1.20; 95% CI 1.05-1.37; P < .01), having $50,000 to $100,000 (OR 1.21 versus < $50,000; CI 1.02-1.44; P < .05) or > $100,000 (OR 1.27 versus < $50,000; CI 1.08-1.48; P < .01) of educational debt, being unmarried (OR 1.89; CI 1.57-2.27; P < .001), and being younger (for every five years, OR 1.15; CI 1.02-1.28; P = .01) were independently associated with increased risk for alcohol abuse/dependence.

CONCLUSIONS

Burnout was strongly related to alcohol abuse/dependence among sampled medical students and increased educational debt predicted a higher risk. A multifaceted approach addressing burnout, medical education costs, and alcohol use is needed.

Perceptions of Support Among Older Adults With HIV

Social support becomes an increasingly significant resource for people as they age, particularly those living with chronic illnesses. Previous research has shown that older adults with HIV do not receive adequate emotional and instrumental assistance from their informal support networks. This study examined what factors contribute to older HIV-positive adults'perceptions of inadequate emotional and instrumental support. Regression analyses showed that physical strain and the number of comorbid illnesses were significant predictors of instrumental and emotional support adequacy. Specifically, participants who reported greater numbers of comorbid illnesses and higher levels of physical strain were more likely to report that they received adequate support. Curiously, those with fewer health complaints reported greater need for emotional and instrumental support. The aging HIV-positive population, largely disconnected from traditional informal support networks, relies on formal care providers. This dependence on an increasingly overburdened health care system may be a result of isolation and stigma.

Behavioural activation written self-help to improve mood, wellbeing and quality of life in people with dementia supported by informal carers (PROMOTE): a study protocol for a single-arm feasibility study

BACKGROUND

Increases in life expectancy have resulted in a global rise in dementia prevalence. Dementia is associated with poor wellbeing, low quality of life and increased incidence of mental health difficulties such as low mood or depression. However, currently, there is limited access to evidence-based psychological interventions for people with dementia experiencing low mood and poor wellbeing. Behavioural activation-based self-help, supported by informal carers and guided by mental health professionals, may represent an effective and acceptable solution.

METHODS/DESIGN

The present study is a phase II (feasibility) single-arm trial informed by the Medical Research Council complex interventions research methods framework. Up to 50 dementia participant/informal carer dyads will be recruited from a variety of settings including primary care, dementia-specific health settings and community outreach. People living with dementia will receive behavioural activation-based self-help and be supported by their informal carer who has received training in the skills required to support the self-help approach. In turn, during the use of the intervention, the informal carer will be guided by mental health professionals to help them work through the materials and problem solve any difficulties. Consistent with the objectives of feasibility studies, outcomes relating to recruitment from different settings, employment of different recruitment methods, attrition, data collection procedures, clinical delivery and acceptability of the intervention will be examined. Clinical outcomes for people with dementia (symptoms of depression and quality of life) and informal carers (symptoms of depression and anxiety, carer burden and quality of life) will be measured pre-treatment and at 3 months post-treatment allocation.

DISCUSSION

This study will examine the feasibility and acceptability of a novel behavioural activation-based self-help intervention designed to promote wellbeing and improve low mood in people living with dementia, alongside methodological and procedural uncertainties associated with research-related procedures. As determined by pre-specified progression criteria, if research procedures and the new intervention demonstrate feasibility and acceptability, results will then be used to inform the design of a pilot randomised controlled trial (RCT) to specifically examine remaining methodological uncertainties associated with recruitment into a randomised controlled design.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN42017211.