Nicola J Wiles

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.

Active exercise, education, and cognitive behavioral therapy for persistent disabling low back pain: A randomized controlled trial

Study Design. A randomized controlled trial. Objectives. To determine 1) whether, among patients with persistent disabling low back pain (LBP), a group program of exercise and education using a cognitive behavioral therapy (CBT) approach, reduces pain and disability over a subsequent 12-month period; 2) the cost-effectiveness of the intervention; and 3) whether a priori preference for type of treatment influences outcome. Summary of Background Data. There is evidence that both exercise and CBT delivered in specialist settings is effective in improving LBP. There is a lack of evidence on whether such interventions, delivered by trained individuals in primary care, result in improved outcomes. Methods. The study was conducted in nine family medical practices in East Cheshire, UK. Patients 18 to 65 years of age, consulting with LBP, were recruited; those still reporting LBP 3 months after the initial consultation were randomized between the two trial arms. The intervention arm received a program of eight 2-hour group exercise session over 6 weeks comprising active exercise and education delivered by physiotherapists using a CBT approach. Both arms received an educational booklet and audio-cassette. The primary outcome measures were pain (0–100 Visual Analogue Scale) and disability (Roland and Morris Disability Scale; score 0–24). Results. A total of 196 subjects (84%) completed follow-up 12 months after the completion of the intervention program. The intervention showed only a small and nonsignificant effect at reducing pain (−3.6 mm; 95% confidence interval, −8.5, 1.2 mm) and disability (−0.6 score; 95% confidence interval, −1.6, 0.4). The cost of the intervention was low with an incremental cost-effectiveness ratio of £5000 (U.S.

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

8650) per quality adjusted life year. In addition, patients allocated to the intervention that had expressed a preference for it had clinically important reductions in pain and disability. Conclusions. This intervention program produces only modest effects in reducing LBP and disability over a 1-year period. The observation that patient preference for treatment influences outcome warrants further investigation.

'Junk food' diet and childhood behavioural problems: results from the ALSPAC cohort.

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.

Is socioeconomic status in early life associated with drug use? A systematic review of the evidence

Background/Objectives:To determine whether a ‘junk food’ diet at age 4½ is associated with behavioural problems at age 7.Subjects/Methods:Data on approximately 4000 children participating in the Avon Longitudinal Study of Parents and Children, a birth cohort recruited in Avon, UK in 1991/92 were used. Behavioural problems were measured at age 7 using the Strengths and Difficulties Questionnaire (SDQ; maternal completion). Total difficulties and scores for the five sub-scales (hyperactivity, conduct and peer problems, emotional symptoms and pro-social behaviour) were calculated. Principal components analysis of dietary data (frequency of consumption of 57 foods/drinks) collected at age 4½ by maternal report was used to generate a ‘junk food’ factor. Data on confounders were available from questionnaires.Results:A one standard deviation increase in ‘junk food’ intake at age 4½ years was associated with increased hyperactivity at age 7 (odds ratio: 1.19; 95% confidence interval: 1.10, 1.29). This persisted after adjustment for confounders including intelligence quotient score (odds ratio: 1.13; 95% confidence interval: 1.01, 1.15). There was little evidence to support an association between ‘junk food’ intake and overall behavioural difficulties or other sub-scales of the SDQ.Conclusions:Children eating a diet high in ‘junk food’ in early childhood were more likely to be in the top 33% on the SDQ hyperactivity sub-scale at age 7. This may reflect a long-term nutritional imbalance, or differences in parenting style. This finding requires replication before it can provide an avenue for intervention.

Predictors of persistent neck pain after whiplash injury

AIM To conduct a systematic review of longitudinal studies that examined the association between childhood socioeconomic status (SES) and illegal drug use in later life. DESIGN AND METHODS Systematic search with an agreed list of search items was used to identify all longitudinal population-based studies that examined the association between childhood SES and later drug use. These included MEDLINE (1966-2005), EMBASE (1990-2005), CINAHL (1982-2005) and PsychInfo (1806-2005), and specialist databases of the Lindesmith Library, Drugscope and Addiction Abstracts. Foreign-language papers were included. Abstracts were screened independently by two reviewers. If there was disagreement to accept or reject the abstract, then a third reviewer acted as arbiter. Data were extracted by one of the authors. RESULTS Eleven relevant papers were identified (two birth cohorts and nine papers on school-aged cohorts). There was consistent evidence to support an association between lower childhood SES and later drug use, primarily cannabis use. However, few studies examined cannabis dependence, and studies of more problematic forms of drug use gave contradictory results. DISCUSSION AND CONCLUSIONS We found consistent, though weak, evidence to support the assumption that childhood disadvantage is associated with later cannabis use. Further research is needed to clarify this issue and to inform future policies and public health messages.

The timing of maternal depressive symptoms and child cognitive development: a longitudinal study

Objective: To establish the aetiological influences of persistent neck pain following a motor vehicle collision and to construct a model for use in the emergency department for identifying patients at high risk of persistent symptoms. Design: Prospective cohort study. Patients recruited from hospital emergency departments were sent a questionnaire to gather information on various exposures. They were followed up at 1, 3, and 12 months to identify those with persistent symptoms. Main outcome measure: Persistent neck pain (pain at 1, 3, and 12 months after collision). Results: The baseline survey included 765 patients. Subsequently, 480 completed a questionnaire at each follow up time point, of whom 128 (27%) reported neck pain on each occasion. Few collision specific factors predicted persistent neck pain. In contrast, a high level of general psychological distress, pre-collision history of widespread body pain, type of vehicle, whiplash associated symptoms, and initial neck disability best predicted the persistence of symptoms. Furthermore, these factors, in combination, accounted for more than a fivefold increase in the risk of persistent neck pain. Conclusion: The greatest predictors of persistent neck pain following a motor vehicle collision relate to psychological distress and aspects of pre-collision health rather than to various attributes of the collision itself. With these factors, and those relating to initial injury severity, it is possible to identify a subgroup of patients presenting with neck pain with the highest risk of persistent symptoms. Thus, it is possible to identify whiplash patients with a poor prognosis and to provide closer follow up and specific attention to management in these individuals.

Cost-effectiveness of therapist-delivered online cognitive–behavioural therapy for depression: randomised controlled trial

BACKGROUND   Maternal depression is known to be associated with impairments in child cognitive development, although the effect of timing of exposure to maternal depression is unclear. METHODS   Data collected for the Avon Longitudinal Study of Parents and Children, a longitudinal study beginning in pregnancy, included self-report measures of maternal depression the Edinburgh Postnatal Depression Scale, completed on 6 occasions up to 3 years of age, and IQ of the index child (WISC) measured at aged 8 years. We used these data to assign women to 8 groups according to whether depression occurred in the antenatal, postnatal, preschool period, any combination of these times, or not at all. We compared a model comprising all patterns of depression (saturated model) with models nested within this to test whether there is a relationship between depression and child cognitive development and, if so, whether there is a sensitive period. We then investigated the relationship with child IQ for each model, following adjustment for confounders. RESULTS   Six thousand seven hundred and thirty-five of 13,615 children from singleton births (49.5%, of eligible core sample) attended a research clinic at 8 years and completed a WISC with a score ≥ 70. A total of 5,029 mothers of these children had completed mood assessments over the 3 time periods. In unadjusted analyses, all three sensitive period models were as good as the saturated model, as was an accumulation model. Of the sensitive period models, only that for antenatal exposure was a consistently better fit than the accumulation model. After multiple imputation for missing data (to n = 6,735), there was no effect of postnatal depression on child IQ independent of depression at other times [-0.19 IQ points, 95% confidence interval (CI) -1.5 to 1.1 points]. There was an effect of antenatal depression (-3.19 IQ points, 95% CI: -4.33 to -2.06) which attenuated following adjustment (-0.64 IQ points, 95% CI: -1.68 to 0.40). CONCLUSIONS   The postnatal period is not a sensitive one for the effect of maternal depression on child cognitive development.

The impact of recurrent abdominal pain: predictors of outcome in a large population cohort.

BACKGROUND Therapist-delivered online cognitive-behavioural therapy (CBT) has been found to be effective for depression in primary care. AIMS To determine the cost-effectiveness of online CBT compared with usual care. METHOD Economic evaluation at 8 months alongside a randomised controlled trial. Cost to the National Health Service (NHS), personal costs, and the value of lost productivity, each compared with outcomes based on the Beck Depression Inventory and quality-adjusted life-years (QALYs). Incremental analysis indicated the NHS cost per QALY gain. RESULTS Online CBT was more expensive than usual care, although the outcomes for the CBT group were better. Cost per QALY gain based on complete case data was £17,173, and £10,083 when missing data were imputed. CONCLUSIONS Online CBT delivered by a therapist in real time is likely to be cost-effective compared with usual care if society is willing to pay at least £20,000 per QALY; it could be a useful alternative to face-to-face CBT.

Polymorphism of the 5-HT transporter and response to antidepressants: randomised controlled trial.

Aim: Recurrent abdominal pain is one of the commonest complaints of childhood, affecting approximately 10% of children at any one time. This study aims to describe the outcome of recurrent abdominal pain amongst 6‐year‐old children, and to identify risk factors (in both the children and their parents), which predict these outcomes.