Cassandra Kenning

The Effect of Complex Interventions on Depression and Anxiety in Chronic Obstructive Pulmonary Disease: Systematic Review and Meta-Analysis

Background Depression and anxiety are very common in people with chronic obstructive pulmonary disease (COPD) and are associated with excess morbidity and mortality. Patients prefer non-drug treatments and clinical guidelines promote non-pharmacological interventions as first line therapy for depression and anxiety in people with long term conditions. However the comparative effectiveness of psychological and lifestyle interventions among COPD patients is not known. We assessed whether complex psychological and/or lifestyle interventions are effective in reducing symptoms of anxiety and depression in patients with COPD. We then determined what types of psychological and lifestyle interventions are most effective. Methods and Findings Systematic review of randomised controlled trials of psychological and/or lifestyle interventions for adults with COPD that measured symptoms of depression and/or anxiety. CENTRAL, Medline, Embase, PsychINFO, CINAHL, ISI Web of Science and Scopus were searched up to April 2012. Meta-analyses using random effects models were undertaken to estimate the average effect of interventions on depression and anxiety. Thirty independent comparisons from 29 randomised controlled trials (n = 2063) were included in the meta-analysis. Overall, psychological and/or lifestyle interventions were associated with small reductions in symptoms of depression (standardised mean difference −0.28, 95% confidence interval −0.41 to −0.14) and anxiety (standardised mean difference −0.23, 95% confidence interval −0.38 to −0.09). Multi-component exercise training was the only intervention subgroup associated with significant treatment effects for depression (standardised mean difference −0.47, 95% confidence interval −0.66 to −0.28), and for anxiety (standardised mean difference −0.45, 95% confidence interval −0.71 to −0.18). Conclusions Complex psychological and/or lifestyle interventions that include an exercise component significantly improve symptoms of depression and anxiety in people with COPD. Furthermore, multi-component exercise training effectively reduces symptoms of anxiety and depression in all people with COPD regardless of severity of depression or anxiety, highlighting the importance of promoting physical activity in this population.

Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity

BackgroundPrimary care is increasingly focussed on the care of people with two or more long-term conditions (multimorbidity). The UK Department of Health strategy for long term conditions is to use self-management support for the majority of patients but there is evidence of limited engagement among primary care professionals and patients with multimorbidity. Furthermore, multimorbidity is more common in areas of socioeconomic deprivation but deprivation may act as a barrier to patient engagement in self-management practices.BackgroundEffective self-management is considered critical to meet the needs of people living with long term conditions but achieving this is a significant challenge in patients with multimorbidity. This study aimed to explore patient and practitioner views on factors influencing engagement in self-management in the context of multimorbidity.MethodsA qualitative study using individual semi-structured interviews with 20 patients and 20 practitioners drawn from four general practices in Greater Manchester situated in areas of high and low social deprivation.Patients were purposively sampled on socioeconomic deprivation (defined by Index of Multiple Deprivation (IMD) score), number and type of long term conditions (2 or more of: coronary heart disease, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease and depression), age and gender. Practitioners were sampled by deprivation status of the practice area; role (i.e. salaried GP, GP principal, practice nurse); and number of years’ experience. Interviews were audio-recorded and transcribed verbatim. Analysis used a thematic approach based on Framework.ResultsThree main factors were identified as influencing patient engagement in self-management: capacity (access and availability of socio-economic resources and time; knowledge; and emotional and physical energy), responsibility (the degree to which patients and practitioners agreed about the division of labour about chronic disease management, including self-management) and motivation (willingness to take-up types of self-management practices). Socioeconomic deprivation negatively impacted on all three factors. Motivation was especially reduced in the presence of mental and physical multimorbidity.ConclusionFull engagement in self-management practices in multimorbidity was only present where patients’ articulated a sense of capacity, responsibility, and motivation. Patient `know-how’ or interpretive capacity to self-manage multimorbidity is potentially an important precursor to responsibility and motivation, and might be a critical target for intervention. However, individual and social resources are needed to generate capacity, responsibility, and motivation for self-management, pointing to a balanced role for health services and wider enabling networks.

Primary care practitioner and patient understanding of the concepts of multimorbidity and self-management: A qualitative study.

Objectives: The aim of this article is to offer insight into how professionals and patients understand and experience multimorbidity and how these accounts differ, and how they affect attitudes and engagement with self-management. Methods: Semi-structured interviews with 20 primary healthcare practitioners and 20 patients with at least 2 long-term conditions (including coronary heart disease, diabetes, osteoarthritis, chronic obstructive pulmonary disease and depression). Thematic analysis was used, and themes were identified using an open-coding method. Results: Practitioners associated multimorbidity with complexity and uncertainty in the clinic, leading to emotional strain and ‘heart sink’. Patient accounts differed. Some described multimorbidity as problematic when it exacerbated their symptoms and caused emotional and psychological strain. Others did not perceive multimorbidity as problematic. Self-management was seen by practitioners and patients to be a key element of managing multiple conditions, but drivers for prompting and engaging in self-management differed between patients and practitioners. Conclusion: This study suggests that recommendations for clinical practice for multimorbid patients should take into account the gap in perceptions between practitioner and patients about experiences of multimorbidity. Not least, practice would need to reflect the tension between practitioners’ and patients’ accounts about the role and benefits of self-management in the presence of multimorbidity.

Development of a multimorbidity illness perceptions scale (MULTIPleS).

Background Illness perceptions are beliefs about the cause, nature and management of illness, which enable patients to make sense of their conditions. These perceptions can predict adjustment and quality of life in patients with single conditions. However, multimorbidity (i.e. patients with multiple long-term conditions) is increasingly prevalent and a key challenge for future health care delivery. The objective of this research was to develop a valid and reliable measure of illness perceptions for multimorbid patients. Methods Candidate items were derived from previous qualitative research with multimorbid patients. Questionnaires were posted to 1500 patients with two or more exemplar long-term conditions (depression, diabetes, osteoarthritis, coronary heart disease and chronic obstructive pulmonary disease). Data were analysed using factor analysis and Rasch analysis. Rasch analysis is a modern psychometric technique for deriving unidimensional and intervally-scaled questionnaires. Results Questionnaires from 490 eligible patients (32.6% response) were returned. Exploratory factor analysis revealed five potential subscales ‘Emotional representations’, ‘Treatment burden’, ‘Prioritising conditions’, ‘Causal links’ and ‘Activity limitations’. Rasch analysis led to further item reduction and the generation of a summary scale comprising of items from all scales. All scales were unidimensional and free from differential item functioning or local independence of items. All scales were reliable, but for each subscale there were a number of patients who scored at the floor of the scale. Conclusions The MULTIPleS measure consists of five individual subscales and a 22-item summary scale that measures the perceived impact of multimorbidity. All scales showed good fit to the Rasch model and preliminary evidence of reliability and validity. A number of patients scored at floor of each subscale, which may reflect variation in the perception of multimorbidity. The MULTIPleS measure will facilitate research into the impact of illness perceptions on adjustment, clinical outcomes, quality of life, and costs in patients with multimorbidity.

Does patient experience of multimorbidity predict self-management and health outcomes in a prospective study in primary care?

Background. There is a need to better understand the mechanisms which lead to poor outcomes in patients with multimorbidity, especially those factors that might be amenable to intervention. Objective. This research aims to explore what factors predict self-management behaviour and health outcomes in patients with multimorbidity in primary care in the UK. Methods. A prospective study design was used. Questionnaires were mailed out to 1460 patients with multimorbidity. Patients were asked to complete a range of self-report measures including measures of multimorbidity, measures of their experience of multimorbidity and service delivery and outcomes (three measures of self-management: behaviours, Self-monitoring and Insight and medication adherence; and a measure of self-reported health). Results. In total, 36% (n = 499) of patients responded to the baseline survey and 80% of those respondents completed follow-up. Self-management behaviour at 4 months was predicted by illness perceptions around the consequences of individual conditions. Self-monitoring and Insight at 4 months was predicted by patient experience of ‘Hassles’ in health services. Self-reported medication adherence at 4 months was predicted by health status, Self-monitoring and Insight and ‘Hassles’ in health services. Perceived health status at 4 months was predicted by age and patient experience of multimorbidity. Conclusions. This research shows that different factors, particularly around patients’ experiences of health care and control over their treatment, impact on various types of self-management. Patient experience of multimorbidity was not a critical predictor of self-management but did predict health status in the short term. The findings can help to develop and target interventions that might improve outcomes in patients with multimorbidity.

Learning disabilities and educational needs of juvenile offenders

This article is based on a study that was commissioned by the Youth Justice Board for England and Wales. We report on the learning profiles and education needs of a cohort of young offenders who were recruited for the study. The research was a national cross‐sectional survey of 301 young offenders who were resident in custodial settings or attending youth offending teams in the community. The young people were assessed using the WASI and the WORD measures to obtain psychometric information (IQ scores and reading/reading comprehension ages). One in five (20%) young people met the ICD‐10 criteria for mental retardation (IQ<70), while problems with reading (52%) and reading comprehension (61%) were common. Verbal IQ scores were found to be significantly lower than performance IQ scores, particularly in male offenders. It is clear from these results that a large proportion of juvenile offenders have a learning disability, as characterised by an IQ<70 and significantly low reading and reading comprehension ages. The underlying aetiology of this association is less clear and may be a consequence of both an increased prevalence of neurocognitive deficits and the impact of poor schooling. There is some evidence that developmental pathways may be different for boys compared with girls.

Cognitive behaviour therapy for adolescent offenders with mental health problems in custody

Many studies have identified high levels of mental health problems among adolescents in custody and there is increasing evidence that mental health problems in this population are associated with further offending and mental health problems into adulthood. Despite recent improvements in mental health provision within custodial settings there is little evidence of structured interventions being offered or of their effectiveness being evaluated. A cognitively based intervention was developed and offered to adolescents with a variety of mental health problems in different secure settings, and the outcomes compared with a control group. Although this small-scale study did not identify significant differences in outcomes for the two groups, both recruitment and retention in therapy were good, and potential candidates were not excluded on the basis of learning difficulties or co-morbidity. The study demonstrated the viability of a delivering cognitively based intervention for common mental health problems within secure settings.

Self-management interventions in patients with long-term conditions: a structured review of approaches to reporting inclusion, assessment, and outcomes in multimorbidity

Background Multimorbidity has many potential implications for healthcare delivery, but a particularly important impact concerns the validity of trial evidence underpinning clinical guidelines for individual conditions. Objective To review how authors of published trials of self-management interventions reported inclusion criteria, sample descriptions, and consideration of the impact of multimorbidity on trial outcomes. Methods We restricted our analysis to a small number of exemplar long-term conditions: type 2 diabetes mellitus, coronary heart disease, and chronic obstructive pulmonary disease. We focussed our search on published Cochrane reviews. Data were extracted from the trials on inclusion/exclusion, sample description, and impact on outcomes. Results Eleven reviews consisting of 164 unique trials were identified. Sixty percent of trials reported excluding patients with forms of multimorbidity. Reasons for exclusion were poorly described or defined. Reporting of multimorbidity within the trials was poor, with only 35% of trials reporting on multimorbidity in their patient samples. Secondary analyses, exploring the impact of multimorbidity, were very rare. Conclusions The importance of multimorbidity in trials is only going to become more important over time, but trials often exclude patients with multimorbidity, and reporting of multimorbidity in trials including such patients is generally poor. This limits judgements about the external validity of the results for clinical populations. A consistent approach to the conduct and reporting of secondary analyses of the effects of multimorbidity on outcomes, using current best-practice guidance, could lead to a rapid development of the evidence base.

Barriers and facilitators in accessing dementia care by ethnic minority groups: a meta-synthesis of qualitative studies

BackgroundIt is estimated that there are about 25,000 people from UK ethnic minority groups with dementia. It is clear that there is an increasing need to improve access to dementia services for all ethnic groups to ensure that everyone has access to the same potential health benefits. The aim was to systematically review qualitative studies and to perform a meta-synthesis around barriers and facilitators to accessing care for dementia in ethnic minorities.MethodsDatabases were searched to capture studies on barriers and facilitators to accessing care for dementia in ethnic minorities. Analysis followed the guidelines for meta-ethnography. All interpretations of data as presented by the authors of the included papers were extracted and grouped into new themes.ResultsSix hundred and eighty four papers were identified and screened. Twenty eight studies were included in the meta-synthesis. The analysis developed a number of themes and these were incorporated into two overarching themes: ‘inadequacies’ and ‘cultural habitus’.ConclusionsThe two overarching themes lend themselves to interventions at a service level and a community level which need to happen in synergy.Trial registrationThe review was registered with PROSPERO: CRD42016049326.

Dementia in UK South Asians: a scoping review of the literature

Objective Over 850 000 people live with dementia in the UK. A proportion of these people are South Asians, who make up over 5% of the total UK population. Little is known about the prevalence, experience and treatment of dementia in the UK South Asian population. The aim of this scoping review is to identify dementia studies conducted in the UK South Asian population to highlight gaps in the literature which need to be addressed in future research. Method Databases were systematically searched using a comprehensive search strategy to identify studies. A methodological framework for conducting scoping reviews was followed. An extraction form was developed to chart data and collate study characteristics and findings. Studies were then grouped into six categories: prevalence and characteristics; diagnosis validation and screening; knowledge, understanding and attitudes; help-seeking; experience of dementia; service organisation and delivery. Results A total of 6483 studies were identified, 27 studies were eligible for inclusion in the scoping review. We found that studies of prevalence, diagnosis and service organisation and delivery in UK South Asians are limited. We did not find any clinical trials of culturally appropriate interventions for South Asians with dementia in the UK. The existing evidence comes from small-scale service evaluations and case studies. Conclusions This is the first scoping review of the literature to identify priority areas for research to improve care for UK South Asians with dementia. Future research should first focus on developing and validating culturally appropriate diagnostic tools for the UK South Asians and then conducting high-quality epidemiological studies in order to accurately identify the prevalence of dementia in this group. The cultural adaptation of interventions for dementia and testing in randomised controlled trials is also vital to ensure that there are appropriate treatments available for the UK South Asians to access.