Aidan Searle

Facilitated physical activity as a treatment for depressed adults: randomised controlled trial

Objective To investigate the effectiveness of facilitated physical activity as an adjunctive treatment for adults with depression presenting in primary care. Design Pragmatic, multicentre, two arm parallel randomised controlled trial. Setting General practices in Bristol and Exeter. Participants 361 adults aged 18-69 who had recently consulted their general practitioner with symptoms of depression. All those randomised had a diagnosis of an episode of depression as assessed by the clinical interview schedule-revised and a Beck depression inventory score of 14 or more. Interventions In addition to usual care, intervention participants were offered up to three face to face sessions and 10 telephone calls with a trained physical activity facilitator over eight months. The intervention was based on theory and aimed to provide individually tailored support and encouragement to engage in physical activity. Main outcome measures The primary outcome was self reported symptoms of depression, assessed with the Beck depression inventory at four months post-randomisation. Secondary outcomes included use of antidepressants and physical activity at the four, eight, and 12 month follow-up points, and symptoms of depression at eight and 12 month follow-up. Results There was no evidence that participants offered the physical activity intervention reported improvement in mood by the four month follow-up point compared with those in the usual care group; adjusted between group difference in mean Beck depression inventory score −0.54 (95% confidence interval −3.06 to 1.99; P=0.68). Similarly, there was no evidence that the intervention group reported a change in mood by the eight and 12 month follow-up points. Nor was there evidence that the intervention reduced antidepressant use compared with usual care (adjusted odds ratio 0.63, 95% confidence interval 0.19 to 2.06; P=0.44) over the duration of the trial. However, participants allocated to the intervention group reported more physical activity during the follow-up period than those allocated to the usual care group (adjusted odds ratio 2.27, 95% confidence interval 1.32 to 3.89; P=0.003). Conclusions The addition of a facilitated physical activity intervention to usual care did not improve depression outcome or reduce use of antidepressants compared with usual care alone. Trial registration Current Controlled Trials ISRCTN16900744.

Psychosocial and clinical determinants of compliance with occlusion therapy for amblyopic children

Aims The objective of this study was to determine the extent that psychosocial and clinical variables influence parental compliance with occlusion therapy (eye patching) in children with amblyopia.Methods Children (n = 151) receiving occlusion therapy (eye patching) for the treatment of amblyopia were recruited from five orthoptic clinics in Bristol, UK. Parents completed a questionnaire based on Rogers’ (1983) Protection Motivation Theory (PMT). The parents (n = 105) were also followed up 2 months later. Clinical data, including measures of visual acuity, were also recorded. Compliance with eye patching was assessed through self-report accounts of parents. Stepwise regression analyses were used to determine the factors predictive of compliance with eye patching.Results Self-reported compliance with eye patching at study entry revealed that only 54% of parents were achieving orthoptists’ recommendations to patch their child. Perceived self-efficacy was positively associated with compliance and perceived prohibition of the child’s activities were negatively associated with compliance. At follow-up, past behaviour accounted for the largest proportion of explained variance in patching behaviour followed by response efficacy, and prohibition of the child’s activities.Conclusion The present findings may serve to inform interventions aimed at enhancing current orthoptic practice to improve compliance in amblyopic children. The importance of ‘self-efficacy’ and past behaviour suggests that consultations with parents exhibiting higher levels of success with patching may elicit strategies that could be shared with parents experiencing difficulties with patching their children. In addition, it is possible that the perceived efficacy of the treatment could be enhanced if orthoptists emphasised evidence of improvements in visual acuity which may, in turn, foster the maintenance of eye patching.

Habitual prospective memory in elderly patients with Type 2 diabetes: implications for medication adherence

Habitual prospective memory (HPM) may be important in medication adherence. The present study utilized a computer-based task of HPM to (1) examine the relationship between HPM performance and medication adherence and (2) explore whether, and under what conditions, HPM could be enhanced. Forty-eight elderly diabetic patients were randomly allocated to one of four HPM task conditions: no cue, visual cue, auditory cue or dual cue (auditory and visual cue) to aid performance. Medication adherence was monitored for at least 10 days using electronic dose event monitors. HPM task performance was optimal in the dual cue condition and there was some evidence of a relationship between HPM task performance and indices of medication adherence.

A pragmatic randomised controlled trial to evaluate the cost-effectiveness of a physical activity intervention as a treatment for depression: the treating depression with physical activity (TREAD) trial.

OBJECTIVE The TREAting Depression with physical activity (TREAD) study investigated the cost-effectiveness of a physical activity intervention, in addition to usual general practitioner care, as a treatment for people with depression. DESIGN An individually randomised, pragmatic, multicentre randomised controlled trial with follow-up at 4, 8 and 12 months. A subset of participants took part in a qualitative study that investigated the acceptability and perceived benefits of the intervention. SETTING General practices in the Bristol and Exeter areas. PARTICIPANTS Aged 18-69 years with an International Statistical Classification of Diseases and Related Health Problems, 10th Edition (ICD-10) diagnosis of depression and scoring ≥ 14 on the Beck Depression Inventory (BDI). Those who were unable to complete self-administered questionnaires in English, with medical contraindications to physical activity or with psychosis, bipolar disorder or serious drug abuse were excluded. INTERVENTIONS We devised an intervention designed to encourage choice and autonomy in the adoption of physical activity. It consisted of up to three face-to-face and ten telephone contacts delivered by a trained physical activity facilitator over an 8-month period. MAIN OUTCOME MEASURES The primary outcome was the BDI score measured at 4 months. Secondary outcomes included depressive symptoms over the 12 months and quality of life, antidepressant use and level of physical activity. RESULTS The study recruited 361 patients, with 182 randomised to the intervention arm and 179 to the usual care arm; there was 80% retention at the 4-month follow-up. The intervention group had a slightly lower BDI score at 4 months [-0.54, 95% confidence interval (CI) -3.06 to 1.99] but there was no evidence that the intervention improved outcome for depression. Neither was there any evidence to suggest a difference in the prescription of or self-reported use of antidepressants. However, the amount of physical activity undertaken by those who had received the intervention was increased (odds ratio 2.3, 95% CI 1.3 to 3.9) and was sustained beyond the end of the intervention. From a health-care perspective, the intervention group was more costly than the usual care group, with the cost of the intervention £220 per person on average. It is therefore extremely unlikely that the intervention is cost-effective as a treatment for depression using current willingness-to-pay thresholds. CONCLUSIONS This physical activity intervention is very unlikely to lead to any clinical benefit in terms of depressive symptoms or to be a cost-effective treatment for depression. Previous research has reported some benefit and there are three possible reasons for this discrepancy: first, even though the intervention increased self-reported physical activity, the increase in activity was not sufficiently large to lead to a measurable influence; second, only more vigorous activity might be of benefit; and third, previous studies had recruited individuals with a pre-existing commitment to physical activity. Future research is needed to identify and explain the mechanisms by which depression might be effectively treated, including, in particular, specific guidance on the optimum type, intensity and duration of physical activity required to produce a therapeutic effect. TRIAL REGISTRATION Current Controlled Trials ISRCTN16900744. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 16, No. 10. See the HTA programme website for further project information.

Psychological factors and inflammatory bowel disease: A review of a decade of literature

The present review examines the English-language literature published between the years 1990 and 2000 concerning psychological factors and their relationship with the course of Inflammatory bowel disease (IBD). The literature is concerned with: (1) the relationship between psychological stress and symptom exacerbation or relapse in patients with IBD; (2) the relationship between psychological distress (anxiety, depression) and symptomatology of IBD; and (3) the impact of psychological treatment of IBD. Methodology of the studies was critically examined and two main conclusions are made. First, there is a trend emerging such that daily hassles are more significantly associated with exacerbation of symptoms in IBD than major life events. The second conclusion, which is less secure as a result of a lack of appropriate research, is that such increases in disease activity appear to influence mood and this is demonstrated in the intensity of anxiety and depression experienced by participants. It is, therefore, tentatively suggested that a bi-phasic process is evident where perceived stress, typically in the form of daily hassles, increases disease activity which in turn induces psychological distress in IBD patients. The implications of the findings are discussed with reference to future research methodology.

Predicting adherence to eye patching in children with amblyopia: An application of protection motivation theory

OBJECTIVES This study reports an application of protection motivation theory (PMT) to the prediction of parental adherence to eye patching recommendations for children with amblyopia over a 2-month period. The study also considered the role of past behaviour in PMT. DESIGN AND METHODS A total of 151 parents of children with amblyopia who were attending follow-up appointments for orthoptic treatment participated. They completed questionnaires based on PMT to assess their beliefs about amblyopia and eye patching. Of the parents, 105 were contacted again at 2-month follow-up to obtain a measure of adherence to the recommended treatment for their child. RESULTS PMT was found to be predictive of adherence intentions and behaviour at 2-month follow-up. Regression analyses revealed perceived vulnerability, response efficacy and self-efficacy to be significant predictors of protection motivation, whereas perceived vulnerability and response costs were significant predictors of adherence behaviour. Past adherence behaviour was found to have a direct effect on future adherence behaviour over and above the influence of PMT. CONCLUSIONS The results are discussed in relation to the sufficiency of PMTas a model of adherence behaviour. The practical implications for attempts to increase adherence to eye patching among children with amblyopia are outlined.

Do patients’ beliefs about type 2 diabetes differ in accordance with complications: An investigation into diabetic foot ulceration and retinopathy

Background: Previous research has examined patients’ beliefs in diabetes and how these beliefs may affect patient outcomes. However, changes in symptoms and complications are a common feature of diabetes, and these can significantly alter the patient’s “disease experience.” However, no consideration has been given to how beliefs about diabetes vary according to the complications patients have. Purpose: The present study was designed to compare the beliefs of 22 patients with diabetic foot ulcers and 22 age- and gender-matched patients with diabetic retinopathy, and 22 age- and gender-matched controls with type 2 diabetes but without either complication. Methods: Beliefs about diabetes were assessed with the Revised Illness Perception Questionnaire (IPQ-R; Moss-Morris et al., 2002). Results: Patients with foot ulcers held a greater belief in personal control of diabetes, but perceived treatment control was lower than that of diabetic controls without serious complications (p < .05). Patients with foot ulcers also demonstrated less illness coherence than patients with retinopathy and diabetic controls (p < .01) and also perceived their diabetes to be more cyclical in nature (p < .01). Conclusion. Differences were found in diabetic patients’ beliefs according to their complications. Future interventions should consider how the complications associated with diabetes may affect patients’ beliefs and subsequent emotional and behavioral responses to the disease.

Participants’ experiences of facilitated physical activity for the management of depression in primary care

A qualitative study was conducted within a randomised trial of facilitated physical activity for depression based on Self-Determination Theory and motivational interviewing. Interviews were held with 19 participants at 4 months, and 12 participants were re-interviewed 8 months later. The interviews were analysed in accordance with Grounded Theory using framework. Themes consisted of the following: relationship with the physical activity facilitators, mode of facilitation, impact of contact with physical activity facilitator/assimilation and future plans, change in activity, and effectiveness of physical activity facilitator techniques. Engagement in physical activity was enhanced within an autonomy-supportive environment.

Reducing the burden of chronic wounds: Prevention and management of the diabetic foot in the context of clinical guidelines:

Objectives: Chronic wounds such as diabetic foot and venous leg ulcers are a major burden for health services. Our programme was developed to explore the psychological and behavioural factors that may influence both the incidence of chronic wounds and their progression. The present article focuses on two particular aspects of the programme: patient knowledge of diabetic foot ulceration and factors influencing foot-related behaviour in patients with and without foot ulcers; and patient and podiatrist perspectives of consultations for diabetic foot ulcers. Methods: Two independent qualitative studies were undertaken: one with diabetic patients without a history of ulceration; and the other with diabetic patients with active ulceration and podiatrists treating these patients. Results: We found that patients may find it difficult understanding the rationale underlying prevention and treatment of foot ulcers; ulcerated patients may find it difficult to engage in the management of their foot ulcer outside consultations; and some podiatrists feel frustrated and unsupported in their attempts at empowering and building partnerships with patients. Conclusion: Patient and practitioner factors may contribute to the effective implementation of clinical guidelines regarding education, partnership building and shared decision-making. These findings are discussed in relation to patient education, partnership building and shared decision-making as recommended in NICE guidelines.

Clinical directors’ views of centralisation and commissioning of cleft services in the UK

BackgroundTo determine the views of Clinical Directors working in the United Kingdom (U.K.) Cleft Service with regard to centralisation, commissioning and impact on cleft service provision.MethodsIn-depth qualitative interviews were conducted with 11 Clinical Directors representing regional cleft services. Interviews were transcribed verbatim, a coding frame was developed by two researchers and transcripts were coded using a thematic, ‘interpretive’ approach.ResultsClinical Directors perceived the commissioning of cleft services in the U.K. to be dependent upon historical agreements and individual negotiation despite service centralisation. Furthermore, Clinical Directors perceived unfairness in the commissioning and funding of cleft services and reported inconsistencies in funding models and service costs that have implications for delivering an equitable cleft service with an effective Multidisciplinary Team.ConclusionsNational Health Service (NHS) commissioning bodies can learn lessons from the centralisation of cleft care. Clinical Directors’ accounts of their relationships with specialist commissioning bodies and their perspectives of funding cleft services may serve to increase parity and improve the commissioning of cleft services in the U.K.