Predictors and moderators of the response of adults with intellectual disabilities and depression to behavioural activation and guided self-help therapies

BACKGROUND

No previous studies have reported predictors and moderators of outcome of psychological therapies for depression experienced by adults with intellectual disabilities (IDs). We investigated baseline variables as outcome predictors and moderators based on a randomised controlled trial where behavioural activation was compared with guided self-help.

METHODS

This study was an exploratory secondary data analysis of data collected during a randomised clinical trial. Participants (n = 161) were randomised to behavioural activation or guided self-help and followed up for 12 months. Pre-treatment variables were included if they have previously been shown to be associated with an increased risk of having depression in adults with IDs or have been reported as a potential predictor or moderator of outcome of treatment for depression with psychological therapies. The primary outcome measure, the Glasgow Depression Scale for Adults with Learning Disabilities (GDS-LD), was used as the dependant variable in mixed effects regression analyses testing for predictors and moderators of outcome, with baseline GDS-LD, treatment group, study centre and antidepressant use as fixed effects, and therapist as a random effect.

RESULTS

Higher baseline anxiety (mean difference in outcome associated with a 1 point increase in anxiety 0.164, 95% confidence interval [CI] 0.031, 0.297; P = 0.016), lower performance intelligence quotient (IQ) (mean difference in outcome associated with a 1 point increase in IQ 0.145, 95% CI 0.009, 0.280; P = 0.037) and hearing impairment (mean difference 3.449, 95% CI 0.466, 6.432; P = 0.024) were predictors of poorer outcomes, whilst greater severity of depressive symptoms at baseline (mean difference in outcome associated with 1 point increase in depression -0.160, 95% CI -0.806, -0.414; P < 0.001), higher expectation of change (mean difference in outcome associated with a 1 point increase in expectation of change -1.013, 95% CI -1.711, -0.314; p 0.005) and greater percentage of therapy sessions attended (mean difference in outcome with 1 point increase in percentage of sessions attended -0.058, 95% CI -0.099, -0.016; P = 0.007) were predictors of more positive outcomes for treatment after adjusting for randomised group allocation. The final model included severity of depressive and anxiety symptoms, lower WASI performance IQ subscale, hearing impairment, higher expectation of change and percentage of therapy sessions attended and explained 35.3% of the variance in the total GDS-LD score at 12 months (R2  = 0.353, F4, 128  = 17.24, P < 0.001). There is no evidence that baseline variables had a moderating effect on outcome for treatment with behavioural activation or guided self-help.

CONCLUSIONS

Our results suggest that baseline variables may be useful predictors of outcomes of psychological therapies for adults with IDs. Further research is required to examine the value of these potential predictors. However, our findings suggest that therapists consider how baseline variables may enable them to tailor their therapeutic approach when using psychological therapies to treat depression experienced by adults with IDs.

[Historical observations on shoulder dystocia. 1) From the origin to Jacquemier]

The result of a literature survey on shoulder dystocia from year 1609 to 1860 are presented. Operative maneuvers for the resolution of dystocia were mainly examined, as well as the development of knowledge about the pathogenetic mechanism of this serious complication.

NK-1 antagonist reduces colonic inflammation and oxidative stress in dextran sulfate-induced colitis in rats

Although substance P (SP) has been implicated as a mediator of neurogenic inflammation in the small intestine, little information is available regarding the role of SP in the pathogenesis of chronic ulcerative colitis. In this study, our aim was to investigate whether the intraperitoneal administration of a nonpeptide neurokinin-1 (NK-1) antagonist, CP-96345, which antagonizes the binding of SP to its NK-1 receptor, results in the attenuation of colonic inflammation induced in rats by 5% dextran sodium sulfate (DSS) in drinking water for 10 days compared with an inactive enantiomer, CP-96344. Disease activity was assessed daily for 10 days, after which colonic tissue damage was scored and myeloperoxidase activity and colon and urinary 8-isoprostanes were measured. Animals receiving DSS exhibited marked physical signs of colitis by day 5 compared with controls. Chronic administration of the NK-1 antagonist significantly reduced the disease activity index, mucosal myeloperoxidase activity, colonic tissue damage score, and mucosal and urinary levels of 8-isoprostanes compared with inactive enantiomer- or vehicle-injected (saline) animals receiving DSS alone. These data indicate that the administration of an NK-1 antagonist can attenuate colonic inflammation and oxidative stress and suggest a novel therapeutic approach in the treatment of chronic ulcerative colitis.

Dysphonia, an uncommon symptom of systemic neurotoxic envenomation by Vipera aspis bite. Report of two cases

Two cases of Vipera aspis bites with severe envenomation in which, among other neurotoxic signs, dysphonia was observed, with alteration of the pitch of the voice are described. This uncommon symptom has never been reported in envenomation by European adders. It is pointed out that bites of European vipers should never be underestimated as severe envenomation may develop.

A case of intestinal infarction following Vipera aspis bite

A case of Vipera aspis bite followed by severe envenomation, shock, neurotoxic symptoms, myoglobinuria and coagulation disorders with thrombosis of the iliac vessels and intestinal infarction is described. A right hemicolectomy had to be performed. Treatment is described in detail. European adder bites may cause, although uncommonly, severe envenoming with unusual symptoms. The attending doctor must be prepared to face unusual diagnostic and therapeutic problems.

Accreditation of prior learning: is it worth it? An evaluation of a pilot scheme

Accreditation of Prior Learning (APL) is a relatively new process for both students and colleges of nursing and claims to offer many benefits (Open University 1990, Fox et al 1992). This paper describes the findings of a study undertaken to determine students' experiences of the APL process and their perceptions of how the APL process developed them. A sample of 14 students reported on the use of APL to obtain academic credit for a Level I Welsh National Board Framework Module. The results indicated both some difficulties and benefits associated with using the APL process. The majority of students experienced difficulty in reflecting on prior learning and practice. This seemed to be due in part to the students' reluctance to value their clinical learning experiences. Many of the sample also reported difficulty in maintaining motivation over the period of time allocated to complete the APL process. All the students undertook the process in their own time and had to submit the module summative assignment in addition to the APL evidence required. These factors may have further influenced motivational levels. Clear positive outcomes were that APL was felt to be a worthwhile process, even increasing self-esteem for some individuals. It also enabled students to develop reflective writing skills and to value clinical experience. Recommendations were made to both facilitate and enhance the APL experience for future students, and to promote critical reflection within the nursing profession as a whole.

Comparison of values of antibody to Bordetella pertussis antigens in young German and American men

Pertussis is well controlled in the United States by routine childhood immunization. In contrast, this disease is endemic and epidemic in Germany because routine immunization has not been implemented. To gain information relating to the epidemiology of Bordetella pertussis infections, we examined the prevalence and magnitude of B. pertussis agglutinins and of IgG and IgA antibodies (detected by enzyme-linked immunosorbent assay) to four B. pertussis antigens--lymphocytosis-promoting factor, filamentous hemagglutinin, pertactin, and fimbriae-2--in the sera of 119 American university students and 119 German military recruits of similar age. Geometric mean titers of agglutinins and geometric mean values for IgG antibodies to the four antigens were two- to threefold higher in sera from the American students than in sera from German recruits. In contrast, the geometric mean IgA values and the percentage of subjects with detectable IgA antibodies to the four antigens were similar in the two populations. Since IgA antibody results mainly from infection and not from immunization, our data suggest that B. pertussis infections are common among both American and German young adults despite the marked difference in rates of clinical pertussis in the two countries.

The effects of ambient NO2 on lung function in primary schoolchildren

The effect of ambient NO2 on lung function was investigated in a sample of 423 schoolchildren. At each of four locations NO2 was monitored continuously. Over a 6-month period from January to June 1990 two surveys were performed and spirometry recorded each time for each child. Linear regression was used to estimate the effect of NO2 for different time intervals preceding lung function testing. A decrease of NO2 between surveys was significantly associated with a higher forced vital capacity (FVC) at the second survey. For each microgram/m3 NO2 decrease the model predicted an increase in FVC of 1.5 ml [for the 2-hr mean (P < 0.05)] and 3.1 ml [for the 12-hr mean (P < 0.01)]. We conclude that even at NO2 levels below current air-quality standards children demonstrate significant changes in lung function.