Helen Baxter

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.

The attitudes of 'tomorrow's doctors' towards mental illness and psychiatry : changes during the final undergraduate year

To compare the efficacy of two teaching styles, didactic teaching and problem based learning, in producing enduring change in final‐year medical students’ attitudes towards psychiatry and mental illness.

Prevalence of epilepsy and associated health service utilization and mortality among patients with intellectual disability.

We considered the prevalence of epilepsy and associated health service utilization for a population with intellectual disability. Registers for epilepsy and intellectual disability were created using a range of datasets. Of 1,595 people with an intellectual disability, 257 (16.1%) had epilepsy. Standardized activity ratios were 3.07 (95% CI 3.00 to 3.15), 2.03 (95% CI 1.94 to 2.11), and 3.09 (95% CI 2.78 to 3.41) for inpatients, outpatients, and accident and emergency, respectively. After excluding epilepsy-related inpatient admissions, we found the standardized activity ratio was 2.55 (2.48 to 2.62). Institutionalized patients were less likely to be admitted than were those in the community (standardized activity ratio = 0.63 (95% CI 0.54 to 0.73). Patients with intellectual disability and co-existing epilepsy used secondary care services more frequently than did those with intellectual disability only.

Is fast access to general practice all that should matter? A discrete choice experiment of patients' preferences.

OBJECTIVES To determine the relative importance of factors that influence patient choice in the booking of general practice appointments for two health problems. METHODS Two discrete choice experiments incorporated into a survey of general practice patients and qualitative methods to support survey development. RESULTS An overall response of 94% (1052/1123) was achieved. Factors influencing the average respondents choice of appointment, in order of importance, were: seeing a doctor of choice; booking at a convenient time of day; seeing any available doctor; and having an appointment sooner rather than later (acute, low worry condition). This finding was the same for an ongoing, high worry condition but in addition the duration of the appointment was also of (small) value. Patients traded off speed of access for more convenient appointment times (a willingness to wait an extra 2.5-3 days longer to get a convenient time slot for an acute low worry/ongoing, high worry condition, respectively). However, contrary to expectation, patients were willing to trade off speed of access for continuity of care (e.g. willingness to wait five days longer to see the doctor of their choice for an acute, low worry condition). Preferences varied by a persons gender, work and carer status. CONCLUSIONS Patients hold strong preferences for the way general practice appointment systems are managed. Contrary to current policy on improving access to primary care patients value a more complex mix of factors than fast access at all costs. It is important that policy-makers and practices take note of these preferences.

The effectiveness of staff support: evaluating Active Support training using a conditional probability approach

Active Support, a package of procedures which includes activity planning, support planning, and training on providing effective assistance, was introduced in five community residences serving 19 adults with severe mental retardation following a multiple baseline design. Real-time observational data were collected on the level of assistance residents received from staff and their engagement in activity. Active Support was shown in a companion paper (Jones et al., 1999) to increase the levels of assistance residents received and their engagement in activity. Increased assistance was particularly experienced by the behaviorally less able and the disparity in activity between the more and less able was reduced. In the analysis presented here, the effectiveness of assistance was evaluated before and after Active Support training by calculating the likelihood of engagement occurring given the occurrence of assistance. This likelihood was represented by the statistic, Yules Q. Yules Q significantly increased following Active Support training, an increase that was maintained at follow-up. The increased effectiveness of assistance was related to other research findings on the relationship between staff: resident interaction patterns and resident behavior.

A general practice-based prevalence study of epilepsy among adults with intellectual disabilities and of its association with psychiatric disorder, behaviour disturbance and carer stress

BACKGROUND Although the elevated occurrence of epilepsy in people with intellectual disabilities (ID) is well recognized, the nature of seizures and their association with psychopathology and carer strain are less clearly understood. The aims were to determine the prevalence and features of epilepsy in a community-based population of adults with ID, and to explore whether the presence of epilepsy was associated with greater psychopathology or carer strain. METHODS Data were collected on the age, gender, place of residence, adaptive and challenging behaviour, social abilities and psychiatric status of 318 adults from 40 general practices, together with the degree of malaise and strain of family carers. For participants with epilepsy, a nurse collected information on seizures, investigations, treatment and carer concerns by interview. Association between epilepsy and psychiatric morbidity, challenging behaviour and caregiver malaise or strain, was explored by comparing those with epilepsy with a comparison group matched on adaptive behaviour. RESULTS Fifty-eight participants (18%) had epilepsy: 26% were seizure free, but 34% had extremely poorly controlled seizures. Earlier onset and seizure frequency were associated with adaptive behaviour. Carer concerns were related to seizure frequency and a history of injury. There were no significant differences in psychopathology, carer malaise or caregiver strain between the matched epilepsy and non-epilepsy groups. CONCLUSIONS This study supports the high occurrence and chronicity of epilepsy among people with ID. While psychopathology and carer strain is common within this population, underlying disability-related factors appear to be more important than the presence of epilepsy per se.

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.

Pharmacological and psychotherapeutic interventions for management of obsessive-compulsive disorder in adults: a systematic review and network meta-analysis

Summary Background Several interventions are available for management of obsessive-compulsive disorder in adults, but few studies have compared their relative efficacy in a single analysis. We aimed to simultaneously compare all available treatments using both direct and indirect data. Methods In this systematic review and network meta-analysis, we searched the two controlled trials registers maintained by the Cochrane Collaboration Common Mental Disorders group for trials published up to Feb 16, 2016. We selected randomised controlled trials in which an active psychotherapeutic or pharmacological intervention had been used in adults with obsessive-compulsive disorder. We allowed all comorbidities except for schizophrenia or bipolar disorder. We excluded studies that focused exclusively on treatment-resistant patient populations defined within the same study. We extracted data from published reports. The primary outcome was symptom severity as measured by the Yale-Brown Obsessive Compulsive Scale. We report mean differences with 95% credible intervals compared with placebo. This study is registered with PROSPERO, number CRD42012002441. Findings We identified 1480 articles in our search and included 53 articles (54 trials; 6652 participants) in the network meta-analysis. Behavioural therapy (mean difference −14·48 [95% credible interval −18·61 to −10·23]; 11 trials and 287 patients), cognitive therapy (−13·36 [–18·40 to −8·21]; six trials and 172 patients), behavioural therapy and clomipramine (−12·97 [–19·18 to −6·74]; one trial and 31 patients), cognitive behavioural therapy and fluvoxamine (−7·50 [–13·89 to −1·17]; one trial and six patients), cognitive behavioural therapy (−5·37 [–9·10 to −1·63]; nine trials and 231 patients), clomipramine (−4·72 [–6·85 to −2·60]; 13 trials and 831 patients), and all SSRIs (class effect −3·49 [95% credible interval −5·12 to −1·81]; 37 trials and 3158 patients) had greater effects than did drug placebo. Clomipramine was not better than were SSRIs (−1·23 [–3·41 to 0·94]). Psychotherapeutic interventions had a greater effect than did medications, but a serious limitation was that most psychotherapeutic trials included patients who were taking stable doses of antidepressants (12 [80%] of the 15 psychotherapy trials explicitly allowed antidepressants). Interpretation A range of interventions is effective in the management of obsessive-compulsive disorder, but considerable uncertainty and limitations exist regarding their relative efficacy. Taking all the evidence into account, the combination of psychotherapeutic and psychopharmacological interventions is likely to be more effective than are psychotherapeutic interventions alone, at least in severe obsessive-compulsive disorder. Funding National Institute for Health Research.

Mentally disordered parricide and stranger killers admitted to high-security care. 1: A descriptive comparison

Parricide is an uncommon crime, so that many of the descriptive studies suffer from methodological shortcomings of small sample sizes and a non-representative ascertainment. We describe a consecutive series of mentally disordered offenders convicted of parricide who were admitted to high-security care and we compare their index characteristics with a group convicted of killing one or more strangers. The main findings were that the parricides were more likely to suffer from schizophrenia but less likely to have had a disrupted childhood and criminal history, as compared with those who had killed a stranger. Those in the parricide group had made a previous attack on their victim in 40% of cases. Overall, the study confirmed some of the differences that one might expect between these two groups of homicides, which had entirely different relationships to their victims.

Use of interpreters in individual psychotherapy

Objective: This paper was written after one of the authors treated a case by individual therapy using an interpreter, as patient and therapist spoke different languages. There is little literature on this subject, and this paper describes our findings and recommendations for using this approach. Method: A 15-year-old Chinese, Cantonese-speaking in-patient in Hong Kong was treated with individual psychodynamic psychotherapy by an English- speaking Caucasian psychotherapist. The Chinese interpreter attended each session, and therapy was supervised by a bilingual Chinese supervisor. The alternative was to not carry out any therapy, as there was no other therapist available. Results: The patient was treated for a total of 32 sessions. Issues involving language and culture differences between therapist and patient, issues of therapy in a triadic situation involving group dynamics, and specific therapy difficulties raised by the presence of the interpreter are discussed. Conclusion: Therapy was not as effective as hoped, but the patient made some improvements. Finding a suitable interpreter is difficult and their role must be well defined. A bilingual supervisor is also needed to monitor the translation as well as supervising the therapist. Psychotherapy through an interpreter is feasible but not ideal.