Christine Bundy

Predictors of drop-out from an outpatient cardiac rehabilitation programme:

Objective: To investigate the prevalence and predictors of early drop-out from a cardiac rehabilitation programme and also whether completers and drop-out patients differed in relation to their illness cognitions, gender and psychological distress and quality of life. Design: A six-week outpatient cardiac rehabilitation programme. Setting: A university teaching hospital. Subjects: One hundred and eighty-nine patients were recruited from a consecutive series of outpatient referrals prior to a six-week comprehensive cardiac rehabilitation programme. Outcome measures: The revised Illness Perception Questionnaire, Quality of Life after Myocardial Infarction Questionnaire and the Hospital Anxiety and Depression Scale. Results: One hundred and forty-seven cardiac patients completed the cardiac rehabilitation programme. Forty-two (22%) patients dropped out in the first two weeks. Factors predicting early drop-out were female gender, younger age, higher Hospital Anxiety Depression Scale score, lower illness perception consequences and higher illness perception personal control and lower illness perception treatment control (all P < 0.05). Conclusion: Over a fifth of the patients did not complete this typical cardiac rehabilitation programme. Female patients are more likely to drop out from cardiac rehabilitation than men. Psychological distress, younger age and lower perceptions of consequences, higher perception personal control and lower illness perception of treatment control were predictors of early drop-out from a cardiac rehabilitation programme.

Talking about depression: A qualitative study of barriers to managing depression in people with long term conditions in primary care

BackgroundThe risk of depression is increased in people with long term conditions (LTCs) and is associated with poorer patient outcomes for both the depressive illness and the LTC, but often remains undetected and poorly managed. The aim of this study was to identify and explore barriers to detecting and managing depression in primary care in people with two exemplar LTCs: diabetes and coronary heart disease (CHD).MethodsQualitative in-depth interviews were conducted with 19 healthcare professionals drawn predominately from primary care, along with 7 service users and 3 carers (n = 29). One focus group was then held with a set of 6 healthcare professionals and a set of 7 service users and 1 carer (n = 14). Interviews and the focus group were digitally recorded, transcribed verbatim, and analysed independently. The two data sets were then inspected for commonalities using a constant comparative method, leading to a final thematic framework used in this paper.ResultsBarriers to detecting and managing depression in people with LTCs in primary care exist: i) when practitioners in partnership with patients conceptualise depression as a common and understandable response to the losses associated with LTCs - depression in the presence of LTCs is normalised, militating against its recognition and treatment; ii) where highly performanced managed consultations under the terms of the Quality and Outcomes Framework encourage reductionist approaches to case-finding in people with CHD and diabetes, and iii) where there is uncertainty among practitioners about how to negotiate labels for depression in people with LTCs in ways that might facilitate shared understanding and future management.ConclusionDepression was often normalised in the presence of LTCs, obviating rather than facilitating further assessment and management. Furthermore, structural constraints imposed by the QOF encouraged reductionist approaches to case-finding for depression in consultations for CHD and diabetes. Future work might focus on how interventions that draw on the principles of the chronic care model, such as collaborative care, could support primary care practitioners to better recognise and manage depression in patients with LTCs.

The long-term benefits of cardiac rehabilitation on depression, anxiety, physical activity and quality of life.

AIMS To investigate the long-term benefits of a six-week comprehensive cardiac rehabilitation programme on physical activity, psychological well-being and quality of life in patients with coronary heart disease. BACKGROUND Cardiac rehabilitation (CR) in short term improves exercise capacity and quality of life in patients with cardiac disease. However, the long-term benefits of CR are inconclusive. DESIGN A prospective CR programme with repeated measures follow-up over 12 months. METHODS A six-week outpatient cardiac rehabilitation programme was conducted including 147 patients with coronary heart disease. Patients completed the physical activity energy expenditure (seven-day recall activity), MacNew Heart Disease Health-Related Quality of Life (MacNew) and Hospital Anxiety and Depression scale (HADs) at baseline, six weeks, six and 12 months. RESULTS One hundred and five (71%) patients (76 male) mean age of 61.8 (SD 9.7) completed the four-measurement points. Analysis of variance revealed that total energy expenditure (F (2, 231) = 131, p < 0.001), HADs (F (2, 237) = 19.3, p < 0.001), depression score (F (2, 235) = 21.06, p < 0.001), anxiety score (F (2,237) = 17.02, p < 0.001) and MacNew (F (2, 197) = 77.02, p < 0.001) were all statistically significant over time. Bonferroni pairwise follow-up confirmed significant positive differences (p < 0.05) between baseline values and all subsequent measures over time. Depression was independently explained in 22% of the variance in quality of life at 6 or 12 months. The energy expenditure was significantly higher for men compared to women (F (1, 103) = 31, p < 0.001). CONCLUSION A six-week cardiac rehabilitation programme is beneficial in improving quality of life, physical activity status, anxiety and depression. These benefits were maintained at 12 months. Elevated levels of depression were associated with impaired quality of life. RELEVANCE TO CLINICAL PRACTICE All relevant health care staff should be aware of the benefits of CR and routinely refer and encourage patients with cardiac disease to attend a cardiac rehabilitation programme. Depression and anxiety intervention strategies should be incorporated in cardiac rehabilitation programmes.

The diabetes educator : trying hard, but must concentrate more on behaviour

Current guidelines state that education is fundamental to help people with diabetes modify their lifestyle and prevent ill health and early death. However, many people with diabetes are not receiving adequate education. There is a widespread assumption that transferring knowledge will improve health outcomes but there is little empirical support for this assertion. Indeed, knowledge and behaviour are poorly correlated. Knowledge may be a necessary condition but is rarely a sufficient condition for behaviour change. Single interventions, cognitive or behavioural, have had disappointing results, unsurprisingly given the complexity of human behaviour. The most effective interventions are multifaceted and include education, behavioural and psychosocial elements, and target lifestyle change and factors such as self‐efficacy and empowerment. We advocate that educational interventions should have multiple components. They should aim to improve patients’ sense of self‐efficacy and empowerment, and build attitudes towards diabetes that will support the lifestyle changes needed for successful self‐management. These conclusions have implications for future research and clinical practice.

Characteristics of Psychological Interventions That Improve Depression in People With Coronary Heart Disease: A Systematic Review and Meta-Regression

Objective Despite previous intervention trials, it is unclear which psychological treatments are most effective for people with coronary heart disease (CHD). We have conducted a systematic review with meta-regression to identify the characteristics of psychological interventions that improve depression and depressive symptoms among people with CHD. Methods Searches of multiple electronic databases up to March 2012 were conducted, supplemented by hand-searching of identified reviews and citation tracing of eligible studies. Studies were included if they reported a randomized controlled trial of a psychological intervention for people with CHD and included depression as an outcome. Data on main effects and characteristics of interventions were extracted from eligible studies. Standardized mean differences (SMDs) were calculated for each study and pooled using random-effects models. Random-effects multivariate meta-regression was performed to identify treatment characteristics associated with improvements in depression. Results Sixty-four independent treatment comparisons were identified. Psychological interventions improved depression, although the effect was small (SMD = 0.18, p < .001). Problem solving (SMD = 0.34), general education (SMD = 0.19), skills training (SMD = 0.25), cognitive-behavioral therapy (CBT; SMD = 0.23), and relaxation (SMD = 0.15) had small effects on CHD patients who were recruited irrespective of their depression status. Among high-quality trials of depressed CHD patients, only CBT showed significant but small effects (SMD = 0.31). When entered into multivariable analysis, no individual treatment component significantly improved depression. Conclusions CBT and problem solving should be considered for inclusion in future treatment developments and randomized controlled trials. However, the effects are small in magnitude, and there is room to develop new interventions that may be more effective.

Understanding Why People with Type 1 Diabetes Do Not Attend for Specialist Advice: A Qualitative Analysis of the Views of People with Insulin-dependent Diabetes Who Do Not Attend Diabetes Clinic:

Attendance at diabetes clinic is associated with improved medical outcome, however, significant numbers of people with type 1 diabetes choose not to attend. In order to understand the reasons underlying this decision, qualitative interviews were carried out with 12 long-term non-attenders. Three distinct groups emerged differing in terms of their cognitive and emotional responses to diabetes and their coping strategies: (1) the ‘High fear’ group; (2) the ‘Patient as expert’ group; and (3) the ‘Low motivation’ group. These differences should be recognized and suitable approaches developed to ensure that all people with diabetes are able to accept appropriate specialist support.

The effects of group motivational interviewing and externalizing conversations for adolescents with Type-1 diabetes

There is a generally appreciated need for psychosocial interventions to help adolescents with Type-1 diabetes cope more effectively with their diabetes, but guidance literature is scarce. We hypothesized perceptions and coping with diabetes could be changed using group motivational interviewing (MI) and externalizing conversations (EC). This paper reports qualitative research findings from a preliminary study of group MI - EC intervention for adolescents with Type-1 diabetes. Twenty adolescents with poorly controlled diabetes were allocated to treatment and control conditions. Treatment consisted of EC and MI over six 1-h weekly sessions. Control consisted of usual care. Participants completed semi-structured questionnaires assessing their perceptions and management of diabetes before, after and 6 months after the intervention. Questionnaires compiled for the study were analysed using content analysis. The treatment group shifted their perceptions of diabetes. They felt less threatened, had more feelings of control and acceptance. Consequences of having diabetes were seen as having a less restrictive influence on their lifestyle than previously. From this exploratory analysis we tentatively conclude this innovative group intervention led to an adaptive shift in illness perception. We are planning a larger RCT to investigate the relationship between shifts in perception and better diabetes management.

Illness representations in patients with multimorbid long-term conditions: Qualitative study

Most research on illness representations explores how patients view single conditions, but many patients report more than one long-term condition (known as multimorbidity). It is not known how multimorbidity impacts on patient illness representations. This exploratory qualitative study examined patients’ representations of multimorbid long-term conditions and sought to assess how models of illness representation might need modification in the presence of multimorbidity. We explored two major issues: (1) the impact of multimorbidity on patient representations of their individual conditions and (2) the representation of multimorbidity itself. Twenty eight adults with at least two long-term conditions (mean of 4) were interviewed. The presence of multimorbidity impacted on patient illness representations in relation to the dimensions of identity, perceived cause, coherence and consequences. Representations of multimorbidity itself concerned representations of the burden of medication and perceived priorities among conditions and synergies and antagonisms between conditions and their management. The results have implications for the measurement of multimorbidity (through scales such as the Illness Perception Questionnaire) and the use of illness representations in the design and delivery of interventions to improve health behaviour and outcomes of patients with multiple long-term conditions.

Adherence to medication in patients with psoriasis: a systematic review

Background  Psoriasis is a life‐long inflammatory condition that can impact on quality of life, psychological and social functioning. Previous literature suggests patient dissatisfaction with psoriasis management; however, little is known about people’s specific experiences of health care consultations.

Using the IPQ and PMDI to predict regular diabetes care-seeking among patients with Type 1 diabetes

OBJECTIVES The objectives were, first, to identify factors associated with regular diabetes care-seeking and, second, to compare the performance of the Illness Perception Questionnaire (IPQ) and a modified version of the Personal Models of Diabetes Interview (PMDI) in predicting care-seeking. METHOD This was a cross-sectional study involving 42 patients who had not attended hospital diabetes clinic for a period of 18 months or more and 42 matched controls receiving specialist care. Differences in illness representations between clinic attenders and non-attenders were examined. Due to the variability in care-seeking between non-attenders (ranging from no contact with health professionals to regular general practitioners care), participants were then reclassified for further analyses into those receiving regular care from either hospital diabetes clinic or general practice (n = 52) and those receiving no regular care (n = 32). RESULTS Patients not seeking regular care held more negative views of the control, course and consequences of diabetes than those who received regular care. Regression analyses showed that the most important construct was treatment effectiveness. Treatment effectiveness (PMDI) and control (IPQ) dimensions were associated with clinic attendance. PMDI constructs of treatment effectiveness, threat and worries were associated with regular care-seeking. CONCLUSIONS IPQ and PMDI results were generally consistent. In order to understand diabetes care-seeking behaviour it is important to measure beliefs about the benefits of treatment recommendations in addition to those of the disease itself. Emotional and cognitive responses to diabetes should be assessed.