Kerrie Clover

Postcards from the EDge project: randomised controlled trial of an intervention using postcards to reduce repetition of hospital treated deliberate self poisoning

Abstract Objective To determine whether an intervention using postcards (postcards from the EDge project) reduces repetitions of hospital treated deliberate self poisoning. Design Randomised controlled trial. Setting Regional referral service for general hospital treated deliberate self poisoning in Newcastle, Australia. Participants 772 patients aged over 16 years with deliberate self poisoning. Intervention Non-obligatory intervention using eight postcards over 12 months along with standard treatment compared with standard treatment alone. Main outcome measures Proportion of patients with one or more repeat episodes of deliberate self poisoning and the number of repeat episodes for deliberate self poisoning per person in 12 months. Results The proportion of repeaters with deliberate self poisoning in the intervention group did not differ significantly from that in the control group (57/378, 15.1%, 95% confidence interval 11.5% to 18.7% v 68/394, 17.3%, 13.5% to 21.0%: difference between groups -2%, -7% to 3%). In unadjusted analysis the number of repetitions were significantly reduced (incidence risk ratio 0.55, 0.35 to 0.87). Conclusion A postcard intervention reduced repetitions of deliberate self poisoning, although it did not significantly reduce the proportion of individual repeaters.

Postcards from the EDge: 24-month outcomes of a randomised controlled trial for hospital-treated self-poisoning

BACKGROUND Repetition of hospital-treated self-poisoning and admission to psychiatric hospital are both common in individuals who self-poison. AIMS To evaluate efficacy of postcard intervention after 5 years. METHOD A randomised controlled trial of individuals who have self-poisoned: postcard intervention (eight in 12 months) plus treatment as usual v. treatment as usual. Our primary outcomes were self-poisoning admissions and psychiatric admissions (proportions and event rates). RESULTS There was no difference between groups for any repeat-episode self-poisoning admission (intervention group: 24.9%, 95% CI 20.6-29.5; control group: 27.2%, 95% CI 22.8-31.8) but there was a significant reduction in event rates (incidence risk ratio (IRR) = 0.54, 95% CI 0.37-0.81), saving 306 bed days. There was no difference for any psychiatric admission (intervention group: 38.1%, 95% CI 33.1-43.2; control group: 35.5%, 95% CI 30.8-40.5) but there was a significant reduction in event rates (IRR = 0.66, 95% CI 0.47-0.91), saving 2565 bed days. CONCLUSIONS A postcard intervention halved self-poisoning events and reduced psychiatric admissions by a third after 5 years. Substantial savings occurred in general hospital and psychiatric hospital bed days.

Development and validation of the PCQ: A questionnaire to measure the psychological consequences of screening mammography

We have developed a reliable and valid questionnaire to measure the psychological consequences of screening mammography. The questionnaire measures the effect of screening on an individuals functioning on emotional, social, and physical life domains. Content validity was ensured by extensive review of the relevant literature, discussion with professionals and interviews with attenders at a pilot Breast X-ray Screening Program in Melbourne, Australia. Discriminant validity was assessed by having expert judges sort items into dimensions which they appeared to be measuring. Acceptable levels of concordance (above 80%) with a priori classifications were found. Concurrent validity was demonstrated by comparison of subscale scores of 53 attenders at the Breast X-ray Program with an independent interview assessment of dysfunction on each of the emotional, social and physical dimensions. There was over 79% agreement between interview scores and questionnaire scores for each dimension. Construct validity was confirmed by showing that subscale scores varied in predicted ways. For women who were recalled for further investigation, scores on each subscale measuring negative consequences, were higher at the recall clinic than at screening clinic (emotional: t = -7.28; df = 70; P less than 0.001; physical: t = -2.53; df = 70; P = 0.014; social: t = -2.49; df = 70; P = 0.015). The internal consistency of all subscales was found to be acceptable. This questionnaire is potentially useful for assessing the psychological consequences of the screening process and should have wide application.

Meta-analysis of screening and case finding tools for depression in cancer: Evidence based recommendations for clinical practice on behalf of the Depression in Cancer Care consensus group

BACKGROUND To examine the validity of screening and case-finding tools used in the identification of depression as defined by an ICD10/DSM-IV criterion standard. METHODS We identified 63 studies involving 19 tools (in 33 publications) designed to help clinicians identify depression in cancer settings. We used a standardized rating system. We excluded 11 tools without at least two independent studies, leaving 8 tools for comparison. RESULTS Across all cancer stages there were 56 diagnostic validity studies (n=10,009). For case-finding, one stem question, two stem questions and the BDI-II all had level 2 evidence (2a, 2b and 2c respectively) and given their better acceptability we gave the stem questions a grade B recommendation. For screening, two stem questions had level 1b evidence (with high acceptability) and the BDI-II had level 2c evidence. For every 100 people screened in advanced cancer, the two questions would accurately detect 18 cases, while missing only 1 and correctly reassure 74 with 7 falsely identified. For every 100 people screened in non-palliative settings the BDI-II would accurately detect 17 cases, missing 2 and correctly re-assure 70, with 11 falsely identified as cases. The main cautions are the reliance on DSM-IV definitions of major depression, the large number of small studies and the paucity of data for many tools in specific settings. CONCLUSIONS Although no single tool could be offered unqualified support, several tools are likely to improve upon unassisted clinical recognition. In clinical practice, all tools should form part of an integrated approach involving further follow-up, clinical assessment and evidence based therapy.

Depression Screening in Stroke A Comparison of Alternative Measures With the Structured Diagnostic Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (Major Depressive Episode) as Criterion Standard

Background and Purpose— Screening tools for depression and psychological distress commonly used in medical settings have not been well validated in stroke populations. We aimed to determine the accuracy of common screening tools for depression or distress in detecting caseness for a major depressive episode compared with a clinician-administered structured clinical interview for Diagnostic and Statistical Manual of Mental Disorders Fourth Edition as the gold standard. Methods— Seventy-two participants ≥3 weeks poststroke underwent a diagnostic interview for major depressive episode and completed the Patient Health Questionnaire-2 and -9, Hospital Anxiety and Depression Scale, Beck Depression Inventory-II, Distress Thermometer, and Kessler-10. Internal consistency, sensitivity, specificity, likelihood ratios, and posttest probabilities were calculated. Each measure was validated against the gold standard using receiver operating characteristic curves with comparison of the area under the curve for all measures. Results— Internal consistency ranged from acceptable to excellent for all measures (Cronbach &agr;=0.78–0.94). Areas under the curve (95% CI) for the Patient Health Questionnaire-2, Patient Health Questionnaire-9, Hospital Anxiety and Depression Scale depression and total score, Beck Depression Inventory-II, and Kessler-10 ranged from 0.80 (0.69–0.89) for the Kessler-10 to 0.89 (0.79–0.95) for the Beck Depression Inventory-II with no significant differences between measures. The Distress Thermometer had an area under the curve (95% CI) of 0.73 (0.61–0.83), significantly smaller than the Beck Depression Inventory-II (P<0.05). Conclusions— Apart from the Distress Thermometer, selected scales performed adequately in a stroke population with no significant difference between measures. The Patient Health Questionnaire-2 would be the most useful single screen given free availability and the shortest number of items.

Compliance in the treatment of hypertension : a need for action

Compliance is commonly defined as the extent to which a persons behavior coincides with medical or health advice. There is evidence that noncompliance is a common problem with many medications, including antihypertensive treatment. Since noncompliance can have serious adverse effects on patient health it is important that practitioners make use of available strategies for increasing compliance. This paper considers aspects of the literature concerning noncompliance with antihypertensive medications and presents a number of strategies that practitioners can use to increase compliance. These include strategies for increasing patient recall of information and for implementing reminder systems. There is some evidence that eliciting social support can aid compliance as can presenting information about side effects. The importance of prescribing the simplest possible dosage regimen is emphasized.

Why do oncology outpatients who report emotional distress decline help

Many patients who experience distress do not seek help, and little is known about the reasons for this. We explored the reasons for declining help among patients who had significant emotional distress.

Evidence for interventions to improve psychological outcomes in people with head and neck cancer: a systematic review of the literature

PurposeIn addition to cancer-related distress, people with head and neck cancer (HNC) endure facial disfigurement and difficulties with eating and communication. High rates of alcohol use and socio-economic disadvantage raise concerns that patients with HNC may be less likely than others to participate in and adhere to psychological interventions. This article aims to inform future practice and research by reviewing the evidence in support of psychological interventions for this patient group.MethodsWe searched CENTRAL, Medline, Embase, PsycINFO and CINAHL in December 2009. Relevant studies were rated for internal and external validity against the criteria of the Agency for Healthcare Research and Quality (AHRQ) US Preventive Services Task Force. Wherever possible, outcomes were evaluated using effect sizes to confirm statistically significant results and enable comparison between studies. Meta-analysis was planned according to criteria in the Cochrane Handbook for Systematic Reviews. Levels of evidence for each intervention type were evaluated using AHRQ criteria.ResultsNine studies met inclusion criteria. One study was rated ‘good’ for internal validity and four for external validity. Psycho-education and/or cognitive–behavioural therapy were evaluated by seven studies, and communication skills training and a support group by one study each. Significant heterogeneity precluded meta-analysis. Based on a study-by-study review, there was most support for psycho-education, with three out of five studies finding at least some effect.ConclusionsResearch to date suggests it is feasible to recruit people with HNC to psychological interventions and to evaluate their progress through repeated-outcome measures. Evidence for interventions is limited by the small number of studies, methodological problems, and poor comparability. Future interventions should target HNC patients who screen positive for clinical distress and be integrated into standard care.

Is my patient suffering clinically significant emotional distress? Demonstration of a probabilities approach to evaluating algorithms for screening for distress

Goals of workScreening oncology patients for clinically significant emotional distress is a recommended standard of care in psycho-oncology. However, principles regarding the interpretation of screening and diagnostic tests developed in other areas of medicine have not been widely applied in psycho-oncology. This paper explores the application of the concepts of likelihood ratios and post-test probabilities to the interpretation of psychological screening instruments and demonstrates the development of an algorithm for screening for emotional distress and common psychopathology.Materials and methodsThree hundred forty oncology/haematology outpatients at the Calvary Mater Newcastle, Australia completed the Distress Thermometer (DT), the PSYCH-6 subscale of the Somatic and Psychological Health Report and the Kessler-10 scale. The Hospital Anxiety and Depression Scale (HADS) (cutoff 15+) was used as the gold standard.Main resultsLikelihood ratios showed that a score over threshold on the DT was 2.77 times more likely in patients who were cases on the HADS. These patients had a 53% post-test probability of being cases on the HADS compared with the pretest probability of 29%. Adding either the PSYCH-6 (3+) or the Kessler-10 (22+) to the DT (4+) significantly increased this post-test probability to 94% and 92%, respectively. The significance of these improvements was confirmed by logistic regression analysis.ConclusionsThis study demonstrated the application of probability statistics to develop an algorithm for screening for distress in oncology patients. In our sample, a two-stage screening algorithm improved appreciably on the performance of the DT alone to identify distressed patients. Sequential administration of a very brief instrument followed by selective use of a longer inventory may save time and increase acceptability.

Effectiveness of QUICATOUCH: a computerised touch screen evaluation for pain and distress in ambulatory oncology patients in Newcastle, Australia

To describe the change in pain and distress over time to demonstrate the effectiveness of the QUICATOUCH program in an outpatient oncology population.