Deborah Sharp

Intellectual Problems Shown by 11‐year‐old Children Whose Mothers Had Postnatal Depression

The aim of the study was to examine long-term sequelae in the children of mothers who were depressed at 3 months postpartum. In a community sample from two general practices in South London. 149 women were given psychiatric interviews at 3 months postpartum and 132 of their children (89 %) were tested at 11 years of age. The children of women who were depressed at 3 months postpartum had significantly lower IQ scores. They also had attentional problems and difficulties in mathematical reasoning. and were more likely than other children to have special educational needs. Boys were more severely affected than girls, with the sex difference most pronounced on Performance IQ. The links between postnatal depression and the childrens intellectual problems were not mediated by parental IQ and were not accounted for by measures of social disadvantage nor by the mothers later mental health problems. Breastfeeding did not remove the effect of the mothers illness on Full Scale IQ, but exerted its own influence on Verbal IQ and appeared to mediate the link with mathematical ability. The findings show that adverse experiences in infancy predict cognitive ability and academic performance a decade later.

Therapist-delivered internet psychotherapy for depression in primary care: a randomised controlled trial

BACKGROUND Despite strong evidence for its effectiveness, cognitive-behavioural therapy (CBT) remains difficult to access. Computerised programs have been developed to improve accessibility, but whether these interventions are responsive to individual needs is unknown. We investigated the effectiveness of CBT delivered online in real time by a therapist for patients with depression in primary care. METHODS In this multicentre, randomised controlled trial, 297 individuals with a score of 14 or more on the Beck depression inventory (BDI) and a confirmed diagnosis of depression were recruited from 55 general practices in Bristol, London, and Warwickshire, UK. Participants were randomly assigned, by a computer-generated code, to online CBT in addition to usual care (intervention; n=149) or to usual care from their general practitioner while on an 8-month waiting list for online CBT (control; n=148). Participants, researchers involved in recruitment, and therapists were masked in advance to allocation. The primary outcome was recovery from depression (BDI score <10) at 4 months. Analysis was by intention to treat. This trial is registered, number ISRCTN 45444578. FINDINGS 113 participants in the intervention group and 97 in the control group completed 4-month follow-up. 43 (38%) patients recovered from depression (BDI score <10) in the intervention group versus 23 (24%) in the control group at 4 months (odds ratio 2.39, 95% CI 1.23-4.67; p=0.011), and 46 (42%) versus 26 (26%) at 8 months (2.07, 1.11-3.87; p=0.023). INTERPRETATION CBT seems to be effective when delivered online in real time by a therapist, with benefits maintained over 8 months. This method of delivery could broaden access to CBT. FUNDING BUPA Foundation.

Evaluation of computer based clinical decision support system and risk chart for management of hypertension in primary care: randomised controlled trial

Abstract Objectives: To investigate the effect of a computer based clinical decision support system and a risk chart on absolute cardiovascular risk, blood pressure, and prescribing of cardiovascular drugs in hypertensive patients. Design: Cluster randomised controlled trial. Setting: 27 general practices in Avon. Participants: 614 patients aged between 60 and 79 years with high blood pressure. Interventions: Patients were randomised to computer based clinical decision support system plus cardiovascular risk chart; cardiovascular risk chart alone; or usual care. Main outcome measures: Percentage of patients in each group with a five year cardiovascular risk≥10%, systolic blood pressure, diastolic blood pressure, prescribing of cardiovascular drugs. Results: Patients in the computer based clinical decision support system and chart only groups were no more likely to have cardiovascular risk reduced to below 10% than patients receiving usual care. Patients in the computer based clinical decision support group were more likely to have a cardiovascular risk≥10% than chart only patients, odds ratio 2.3 (95% confidence interval 1.1 to 4.8). The chart only group had significantly lower systolic blood pressure compared with the usual care group (difference in means−4.6 mm Hg (95% confidence interval−8.4 to−0.8). Reduction of diastolic blood pressure did not differ between the three groups. The chart only group were twice as likely to be prescribed two classes of cardiovascular drugs and over three times as likely to be prescribed three or more classes of drugs compared with the other groups. Conclusions: The computer based clinical decision support system did not confer any benefit in absolute risk reduction or blood pressure control and requires further development and evaluation before use in clinical care can be recommended. Use of chart guidelines are associated with a potentially important reduction in systolic blood pressure.

Clinical features of colorectal cancer before diagnosis: a population-based case–control study

Most colorectal cancers are diagnosed after the onset of symptoms. However, the risk of colorectal cancer posed by particular symptoms is largely unknown, especially in unselected populations like primary care. This was a population-based case–control study in all 21 general practices in Exeter, Devon, UK, aiming to identify and quantify the prediagnostic features of colorectal cancer. In total, 349 patients with colorectal cancer, aged 40 years or more, and 1744 controls, matched by age, sex and general practice, were studied. The full medical record for 2 years before diagnosis was coded using the International Classification of Primary Care-2. We calculated odds ratios for variables independently associated with cancer, using multivariable conditional logistic regressions, and then calculated the positive predictive values of these variables, both individually and in combination. In total, 10 features were associated with colorectal cancer before diagnosis. The positive predictive values (95% confidence interval) of these were rectal bleeding 2.4% (1.9, 3.2); weight loss 1.2% (0.91, 1.6); abdominal pain 1.1% (0.86, 1.3); diarrhoea 0.94% (0.73, 1.1); constipation 0.42% (0.34, 0.52); abnormal rectal examination 4.0% (2.4, 7.4); abdominal tenderness 1.1% (0.77, 1.5); haemoglobin <10.0 g dl−1 2.3% (1.6, 3.1); positive faecal occult bloods 7.1% (5.1, 10); blood glucose>10 mmol l−1 0.78% (0.51, 1.1): all P<0.001. Earlier diagnosis of colorectal cancer may be possible using the predictive values for single or multiple symptoms, physical signs or test results.

Antenatal depression predicts depression in adolescent offspring: Prospective longitudinal community-based study

BACKGROUND Depression is familial. Evidence shows that untreated postnatal depression is associated with adverse outcomes for the child. Few studies have traced prospectively the course of maternal depression through pregnancy, the postnatal period and the following 16 years in relation to adolescent offspring depression. METHOD The sample was recruited from two general practice antenatal clinics. Of 151 mother-child dyads followed from pregnancy to 16 years, information on the course of maternal depression and on depression in adolescent offspring was available for 127 (84%). RESULTS Two-thirds (82/125) of the women had been depressed during the 17-year time period, with the majority (54/82) experiencing more than one episode. A third of the women were depressed in pregnancy (41/124). Over half of these women (23/41) had consulted a doctor about their mental health prior to being pregnant and almost 90% (35/39) had further episodes during the childs lifetime. 14% (18/127) of the adolescent offspring were diagnosed with a depressive disorder at 16 years. Every depressed adolescent had been exposed to maternal depression. The risk of depression for the 16-year-olds exposed to antenatal depression was 4.7 times greater than for offspring not so exposed. The effect of antenatal depression was mediated by repeated exposure. LIMITATIONS The number of study participants is small and limited to an inner-city population. Only depression spectrum diagnoses in the adolescent offspring have been considered. CONCLUSIONS Detection of depression in pregnancy identifies mothers at risk of further depressive episodes and a group of children who are at risk of depression in adolescence.

Pathways to Violence in the Children of Mothers Who Were Depressed Postpartum

The impact of postnatal depression on a childs risk for violent behavior was evaluated in an urban British community sample (N=122 families). Mothers were interviewed during pregnancy, at 3 months postpartum, and when the child was 1, 4, and 11 years of age. Mothers, teachers, and children reported on violent symptoms at age 11. Structural equation modeling revealed that the childs violence was predicted by the mothers postnatal depression even when her depression during pregnancy, her later history of depression, and family characteristics were taken into account. Violence was associated with symptoms of attention-deficit/hyperactivity disorder and problems with anger management. Children were most violent if mothers had been depressed at 3 months and at least once thereafter.

Identification and Referral to Improve Safety (IRIS) of women experiencing domestic violence with a primary care training and support programme: a cluster randomised controlled trial

BACKGROUND Most clinicians have no training about domestic violence, fail to identify patients experiencing abuse, and are uncertain about management after disclosure. We tested the effectiveness of a programme of training and support in primary health-care practices to increase identification of women experiencing domestic violence and their referral to specialist advocacy services. METHODS In this cluster randomised controlled trial, we selected general practices in two urban primary care trusts, Hackney (London) and Bristol, UK. Practices in which investigators from this trial were employed or those who did not use electronic records were excluded. Practices were stratified by proportion of female doctors, postgraduate training status, number of patients registered, and percentage of practice population on low incomes. Within every primary care trust area, we randomised practices with a computer-minimisation programme with a random component to intervention or control groups. The intervention programme included practice-based training sessions, a prompt within the medical record to ask about abuse, and a referral pathway to a named domestic violence advocate, who also delivered the training and further consultancy. The primary outcome was recorded referral of patients to domestic violence advocacy services. The prespecified secondary outcome was recorded identification of domestic violence in the electronic medical records of the general practice. Poisson regression analyses accounting for clustering were done for all practices receiving the intervention. Practice staff and research associates were not masked and patients were not aware they were part of a study. This study is registered at Current Controlled Trials, ISRCTN74012786. FINDINGS We randomised 51 (61%) of 84 eligible general practices in Hackney and Bristol. Of these, 24 received a training and support programme, 24 did not receive the programme, and three dropped out before the trial started. 1 year after the second training session, the 24 intervention practices recorded 223 referrals of patients to advocacy and the 24 control practices recorded 12 referrals (adjusted intervention rate ratio 22·1 [95% CI 11·5-42·4]). Intervention practices recorded 641 disclosures of domestic violence and control practices recorded 236 (adjusted intervention rate ratio 3·1 [95% CI 2·2-4·3). No adverse events were recorded. INTERPRETATION A training and support programme targeted at primary care clinicians and administrative staff improved referral to specialist domestic violence agencies and recorded identification of women experiencing domestic violence. Our findings reduce the uncertainty about the benefit of training and support interventions in primary care settings for domestic violence and show that screening of women patients for domestic violence is not a necessary condition for improved identification and referral to advocacy services. FUNDING Health Foundation.

Diet or diet plus physical activity versus usual care in patients with newly diagnosed type 2 diabetes: the Early ACTID randomised controlled trial

BACKGROUND Lifestyle changes soon after diagnosis might improve outcomes in patients with type 2 diabetes mellitus, but no large trials have compared interventions. We investigated the effects of diet and physical activity on blood pressure and glucose concentrations. METHODS We did a randomised, controlled trial in southwest England in adults aged 30-80 years in whom type 2 diabetes had been diagnosed 5-8 months previously. Participants were assigned usual care (initial dietary consultation and follow-up every 6 months; control group), an intensive diet intervention (dietary consultation every 3 months with monthly nurse support), or the latter plus a pedometer-based activity programme, in a 2:5:5 ratio. The primary endpoint was improvement in glycated haemoglobin A(1c)(HbA(1c)) concentration and blood pressure at 6 months. Analysis was done by intention to treat. This study is registered, number ISRCTN92162869. FINDINGS Of 593 eligible individuals, 99 were assigned usual care, 248 the diet regimen, and 246 diet plus activity. Outcome data were available for 587 (99%) and 579 (98%) participants at 6 and 12 months, respectively. At 6 months, glycaemic control had worsened in the control group (mean baseline HbA(1c) percentage 6·72, SD 1·02, and at 6 months 6·86, 1·02) but improved in the diet group (baseline-adjusted difference in percentage of HbA(1c) -0·28%, 95% CI -0·46 to -0·10; p=0·005) and diet plus activity group (-0·33%, -0·51 to -0·14; p<0·001). These differences persisted to 12 months, despite less use of diabetes drugs. Improvements were also seen in bodyweight and insulin resistance between the intervention and control groups. Blood pressure was similar in all groups. INTERPRETATION An intensive diet intervention soon after diagnosis can improve glycaemic control. The addition of an activity intervention conferred no additional benefit. FUNDING Diabetes UK and the UK Department of Health.

Randomised controlled trial of Alexander Technique lessons, exercise, and massage (ATEAM) for chronic and recurrent back pain

Objective To determine the effectiveness of lessons in the Alexander technique, massage therapy, and advice from a doctor to take exercise (exercise prescription) along with nurse delivered behavioural counselling for patients with chronic or recurrent back pain. Design Factorial randomised trial. Setting 64 general practices in England. Participants 579 patients with chronic or recurrent low back pain; 144 were randomised to normal care, 147 to massage, 144 to six Alexander technique lessons, and 144 to 24 Alexander technique lessons; half of each of these groups were randomised to exercise prescription. Interventions Normal care (control), six sessions of massage, six or 24 lessons on the Alexander technique, and prescription for exercise from a doctor with nurse delivered behavioural counselling. Main outcome measures Roland Morris disability score (number of activities impaired by pain) and number of days in pain. Results Exercise and lessons in the Alexander technique, but not massage, remained effective at one year (compared with control Roland disability score 8.1: massage −0.58, 95% confidence interval −1.94 to 0.77, six lessons −1.40, −2.77 to −0.03, 24 lessons −3.4, −4.76 to −2.03, and exercise −1.29, −2.25 to −0.34). Exercise after six lessons achieved 72% of the effect of 24 lessons alone (Roland disability score −2.98 and −4.14, respectively). Number of days with back pain in the past four weeks was lower after lessons (compared with control median 21 days: 24 lessons −18, six lessons −10, massage −7) and quality of life improved significantly. No significant harms were reported. Conclusions One to one lessons in the Alexander technique from registered teachers have long term benefits for patients with chronic back pain. Six lessons followed by exercise prescription were nearly as effective as 24 lessons. Trial registration National Research Register N0028108728. How does the Alexander Technique work? What are the authors findings about the clinical and cost effectiveness of the treatment? Watch this video to find out (12 mins). 10.1136/bmj.a884V1

What are the clinical features of lung cancer before the diagnosis is made? A population based case-control study

Background: Over 38 000 new cases of lung cancer occur each year in the UK. Most are diagnosed after initial presentation to primary care, but the relative importance of the various clinical features is largely unknown. Methods: A population based case-control study was undertaken in all 21 general practices in Exeter, Devon, UK (population 128 700). 247 primary lung cancers were studied in subjects aged over 40 years diagnosed between 1998 and 2002 and 1235 controls matched by age, sex and general practice. The entire primary care record for 2 years before diagnosis was coded using the International Classification of Primary Care-2. Univariable and multivariable conditional logistic regression analyses were used to identify and quantify clinical features independently associated with lung cancer. The main outcome measures were odds ratios and positive predictive values for these variables. Results: Seven symptoms (haemoptysis, loss of weight, loss of appetite, dyspnoea, thoracic pain, fatigue and cough), one physical sign (finger clubbing), and two abnormal investigation results (thrombocytosis and abnormal spirometry) were associated with lung cancer in multivariable analyses, as was cigarette smoking. After excluding variables reported in the final 180 days before diagnosis, haemoptysis, dyspnoea and abnormal spirometry remained independently associated with cancer. Conclusions: This study provides an evidence base for selection of patients for investigation of possible lung cancer, both for clinicians and for developers of guidelines.