Melanie Chalder

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 impact of co-located NHS walk-in centres on emergency departments

Objectives: To determine the impact of establishing walk-in centres alongside emergency departments (EDs) on attendance rates, visit duration, process, costs and outcome of care. Methods: Eight hospitals with co-located EDs and walk-in centres were compared with eight matched EDs without walk-in centres. Site visits were conducted. Routine data about attendance numbers and use of resources were analysed. A random sample of records of patients attending before and after the opening of walk-in centres was also assessed. Patients who had not been admitted to hospital were sent a postal questionnaire. Results: At most sites, the walk-in centres did not have a distinct identity and there were few differences in the way services were provided compared with control sites. Overall, there was no evidence of an increase in attendance at sites with walk-in centres, but considerable variability across sites was found. The proportion of patients managed within the 4 h National Health Service target improved at sites both with and without walk-in centres. There was no evidence of any difference in reconsultation rates, costs of care or patient outcomes at sites with or without walk-in centres. Conclusions: Most hospitals in this study implemented the walk-in centre concept to a very limited extent. Consequently, there was no evidence of any effect on attendance rates, process, costs or outcome of care.

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.

Comparing care at walk-in centres and at accident and emergency departments: an exploration of patient choice, preference and satisfaction

Objectives: To explore the impact of establishing walk-in centres alongside emergency departments on patient choice, preference and satisfaction. Methods: A controlled, mixed-method study comparing 8 emergency departments with co-located walk-in centres with the same number of “traditional” emergency departments. This paper focuses on the results of a cross-sectional questionnaire survey of users. Results: Survey data demonstrated that patients were frequently unable to distinguish between being treated at a walk-in centre or at an accident and emergency (A&E) department and, even where this was the case, opportunities to exercise choice about their preferred care provider were often limited. Few made an active choice to attend a co-located walk-in centre. Patients attending walk-in centres were just as likely to be satisfied overall with the care they received as their counterparts who were treated in the co-located A&E facility, although walk-in centre users reported greater satisfaction with some specific aspects of their care and consultation. Conclusions: Whereas one of the key policy goals underpinning the co-location of walk-in centres next to an A&E department was to provide patients with more options for accessing healthcare and greater choice, leading in turn to increased satisfaction, this evaluation was able to provide little evidence to support this. The high percentage of patients expressing a preference for care in an established emergency department compared with that in a new walk-in centre facility raises questions for future policy development. Further consideration should therefore be given to the role that A&E-focused walk-in centres play in the Department of Health’s current policy agenda, as far as patient choice is concerned.

Participants’ experiences of facilitated physical activity for the management of depression in primary care

A qualitative study was conducted within a randomised trial of facilitated physical activity for depression based on Self-Determination Theory and motivational interviewing. Interviews were held with 19 participants at 4 months, and 12 participants were re-interviewed 8 months later. The interviews were analysed in accordance with Grounded Theory using framework. Themes consisted of the following: relationship with the physical activity facilitators, mode of facilitation, impact of contact with physical activity facilitator/assimilation and future plans, change in activity, and effectiveness of physical activity facilitator techniques. Engagement in physical activity was enhanced within an autonomy-supportive environment.

Physical activity as a treatment for depression: the TREAD randomised trial protocol

BackgroundDepression is one of the most common reasons for consulting a General Practitioner (GP) within the UK. Whilst antidepressants have been shown to be clinically effective, many patients and healthcare professionals would like to access other forms of treatment as an alternative or adjunct to drug therapy for depression. A recent systematic review presented some evidence that physical activity could offer one such option, although further investigation is needed to test its effectiveness within the context of the National Health Service.The aim of this paper is to describe the protocol for a randomised, controlled trial (RCT) designed to evaluate an intervention developed to increase physical activity as a treatment for depression within primary care.Methods/designThe TREAD study is a pragmatic, multi-centre, two-arm RCT which targets patients presenting with a new episode of depression. Patients were approached if they were aged 18-69, had recently consulted their GP for depression and, where appropriate, had been taking antidepressants for less than one month. Only those patients with a confirmed diagnosis of a depressive episode as assessed by the Clinical Interview Schedule-Revised (CIS-R), a Beck Depression Inventory (BDI) score of at least 14 and informed written consent were included in the study. Eligible patients were individually randomised to one of two treatment groups; usual GP care or usual GP care plus facilitated physical activity. The primary outcome of the trial is clinical symptoms of depression assessed using the BDI four months after randomisation. A number of secondary outcomes are also measured at the 4-, 8- and 12-month follow-up points including quality of life, attitude to and involvement in physical activity and antidepressant use/adherence. Outcomes will be analysed on an intention-to-treat (ITT) basis and will use linear and logistic regression models to compare treatments.DiscussionThe results of the trial will provide information about the effectiveness of physical activity as a treatment for depression. Given the current prevalence of depression and its associated economic burden, it is hoped that TREAD will provide a timely contribution to the evidence on treatment options for patients, clinicians and policy-makers.Trial registration: ISRCTN 16900744

Can a health forecasting service offer COPD patients a novel way to manage their condition

Objectives: The UK Meteorological Office (Met Office) has developed a health forecasting service for chronic obstructive pulmonary disease (COPD) patients, combining a rule-based model predicting risk based on environmental conditions with an anticipatory care intervention providing information on self-management and warnings via an interactive telephone call. Our aim was to explore the acceptability and utility of such a service to patients with COPD and its perceived impact on their behaviour and disease management. Methods: A cross-sectional questionnaire survey of service users drawn from 189 general practices in England, Scotland and Wales at the end of the winter of 2007/8. Results: Completed questionnaires were received from 3288 COPD patients, representing a response rate of 40%. Eighty-five percent of those returning a questionnaire reported at least one exacerbation during the study period and 8% had been admitted to hospital on one occasion or more. The majority of respondents deemed the information pack (comprising a booklet and thermometers) useful while the automated calls were generally said to be convenient, easy to understand and reassuring. Those less satisfied with the service felt they were already sufficiently aware of the prevailing weather conditions or felt more detailed information was needed. Most benefit was reported by those patients who were willing to be pro-active in the management of their condition, with the service encouraging 36% of respondents to seek a repeat prescription, 28% to reread their information pack and 12% to consult their GP for worsening of symptoms. Conclusions: Patients found the automated interactive calling, combined with a health risk forecast, both viable and useful, welcoming the information and tools it offered. In many cases, it added to patients’ understanding of their illness and promoted better self-management. Future research should focus on the potential impact of the service in terms of health outcomes and cost-effectiveness.

Republished research: Facilitated physical activity as a treatment for depressed adults: randomised controlled trial

Study question Does facilitated physical activity provide an effective treatment for adults with depression presenting in primary care? Summary answer Although trial participants receiving the physical activity intervention in addition to usual care reported increased physical activity compared with those receiving usual care alone, there was no evidence to suggest that the intervention brought about any improvement in depressive symptoms or reduction in antidepressant use. What is known and what this paper adds Numerous studies have reported the positive effects of physical activity, but most of the current evidence originates from small non-clinical samples using interventions that are not practicable in a healthcare setting. Our results indicate that offering patients a facilitated physical activity intervention is not an effective strategy for reducing symptoms of depression, although it increased self reported physical activity and sustained this effect over 12 months.

A systematic review to identify and assess the effectiveness of alternatives for people over the age of 65 who are at risk of potentially avoidable hospital admission

Background/objectives There are some older patients who are ‘at the decision margin’ of admission. This systematic review sought to explore this issue with the following objective: what admission alternatives are there for older patients and are they safe, effective and cost-effective? A secondary objective was to identify the characteristics of those older patients for whom the decision to admit to hospital may be unclear. Design Systematic review of controlled studies (April 2005–December 2016) with searches in Medline, Embase, Cinahl and CENTRAL databases. The protocol is registered at PROSPERO (CRD42015020371). Studies were assessed using Cochrane risk of bias criteria, and relevant reviews were assessed with the AMSTAR tool. The results are presented narratively and discussed. Setting Primary and secondary healthcare interface. Participants People aged over 65 years at risk of an unplanned admission. Interventions Any community-based intervention offered as an alternative to admission to an acute hospital. Primary and secondary outcomes measures Reduction in secondary care use, patient-related outcomes, safety and costs. Results Nineteen studies and seven systematic reviews were identified. These recruited patients with both specific conditions and mixed chronic and acute conditions. The interventions involved paramedic/emergency care practitioners (n=3), emergency department-based interventions (n=3), community hospitals (n=2) and hospital-at-home services (n=11). Data suggest that alternatives to admission appear safe with potential to reduce secondary care use and length of time receiving care. There is a lack of patient-related outcomes and cost data. The important features of older patients for whom the decision to admit is uncertain are: age over 75 years, comorbidities/multi-morbidities, dementia, home situation, social support and individual coping abilities. Conclusions This systematic review describes and assesses evidence on alternatives to acute care for older patients and shows that many of the options available are safe and appear to reduce resource use. However, cost analyses and patient preference data are lacking.