Rachel Hayes

Effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse or recurrence (PREVENT): a randomised controlled trial

BACKGROUND Individuals with a history of recurrent depression have a high risk of repeated depressive relapse or recurrence. Maintenance antidepressants for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to medication. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce risk of relapse or recurrence compared with usual care, but has not yet been compared with maintenance antidepressant treatment in a definitive trial. We aimed to see whether MBCT with support to taper or discontinue antidepressant treatment (MBCT-TS) was superior to maintenance antidepressants for prevention of depressive relapse or recurrence over 24 months. METHODS In this single-blind, parallel, group randomised controlled trial (PREVENT), we recruited adult patients with three or more previous major depressive episodes and on a therapeutic dose of maintenance antidepressants, from primary care general practices in urban and rural settings in the UK. Participants were randomly assigned to either MBCT-TS or maintenance antidepressants (in a 1:1 ratio) with a computer-generated random number sequence with stratification by centre and symptomatic status. Participants were aware of treatment allocation and research assessors were masked to treatment allocation. The primary outcome was time to relapse or recurrence of depression, with patients followed up at five separate intervals during the 24-month study period. The primary analysis was based on the principle of intention to treat. The trial is registered with Current Controlled Trials, ISRCTN26666654. FINDINGS Between March 23, 2010, and Oct 21, 2011, we assessed 2188 participants for eligibility and recruited 424 patients from 95 general practices. 212 patients were randomly assigned to MBCT-TS and 212 to maintenance antidepressants. The time to relapse or recurrence of depression did not differ between MBCT-TS and maintenance antidepressants over 24 months (hazard ratio 0·89, 95% CI 0·67-1·18; p=0·43), nor did the number of serious adverse events. Five adverse events were reported, including two deaths, in each of the MBCT-TS and maintenance antidepressants groups. No adverse events were attributable to the interventions or the trial. INTERPRETATION We found no evidence that MBCT-TS is superior to maintenance antidepressant treatment for the prevention of depressive relapse in individuals at risk for depressive relapse or recurrence. Both treatments were associated with enduring positive outcomes in terms of relapse or recurrence, residual depressive symptoms, and quality of life. FUNDING National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme, and NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula.Solitary median maxillary central incisor (SMMCI) is a rare dental anomaly characterized by a symmetric central incisor of normal size, developed and erupted precisely in the midline of the maxilla in both primary and permanent dentitions. SMMCI may occur alone or be associated with other midline structures defects of the body or other systemic disorders. The best known association is holoprosencephaly (HPE). This paper reported a case of SMMCI that companied with other midline structures defects of the body.

Efficacy of Mindfulness-Based Cognitive Therapy in Prevention of Depressive Relapse: An Individual Patient Data Meta-analysis From Randomized Trials

IMPORTANCE Relapse prevention in recurrent depression is a significant public health problem, and antidepressants are the current first-line treatment approach. Identifying an equally efficacious nonpharmacological intervention would be an important development. OBJECTIVE To conduct a meta-analysis on individual patient data to examine the efficacy of mindfulness-based cognitive therapy (MBCT) compared with usual care and other active treatments, including antidepressants, in treating those with recurrent depression. DATA SOURCES English-language studies published or accepted for publication in peer-reviewed journals identified from EMBASE, PubMed/Medline, PsycINFO, Web of Science, Scopus, and the Cochrane Controlled Trials Register from the first available year to November 22, 2014. Searches were conducted from November 2010 to November 2014. STUDY SELECTION Randomized trials of manualized MBCT for relapse prevention in recurrent depression in full or partial remission that compared MBCT with at least 1 non-MBCT treatment, including usual care. DATA EXTRACTION AND SYNTHESIS This was an update to a previous meta-analysis. We screened 2555 new records after removing duplicates. Abstracts were screened for full-text extraction (S.S.) and checked by another researcher (T.D.). There were no disagreements. Of the original 2555 studies, 766 were evaluated against full study inclusion criteria, and we acquired full text for 8. Of these, 4 studies were excluded, and the remaining 4 were combined with the 6 studies identified from the previous meta-analysis, yielding 10 studies for qualitative synthesis. Full patient data were not available for 1 of these studies, resulting in 9 studies with individual patient data, which were included in the quantitative synthesis. RESULTS Of the 1258 patients included, the mean (SD) age was 47.1 (11.9) years, and 944 (75.0%) were female. A 2-stage random effects approach showed that patients receiving MBCT had a reduced risk of depressive relapse within a 60-week follow-up period compared with those who did not receive MBCT (hazard ratio, 0.69; 95% CI, 0.58-0.82). Furthermore, comparisons with active treatments suggest a reduced risk of depressive relapse within a 60-week follow-up period (hazard ratio, 0.79; 95% CI, 0.64-0.97). Using a 1-stage approach, sociodemographic (ie, age, sex, education, and relationship status) and psychiatric (ie, age at onset and number of previous episodes of depression) variables showed no statistically significant interaction with MBCT treatment. However, there was some evidence to suggest that a greater severity of depressive symptoms prior to treatment was associated with a larger effect of MBCT compared with other treatments. CONCLUSIONS AND RELEVANCE Mindfulness-based cognitive therapy appears efficacious as a treatment for relapse prevention for those with recurrent depression, particularly those with more pronounced residual symptoms. Recommendations are made concerning how future trials can address remaining uncertainties and improve the rigor of the field.

The role of facial orientation in newborn infants’ preference for attractive faces

Several previous experiments have found that newborn and young infants will spend more time looking at attractive faces when these are shown paired with faces judged by adults to be unattractive. Two experimental conditions are described whose aim was to find whether the ‘attractiveness effect’ is affected by the orientation of the facial stimuli. Pairs of attractive and less attractive faces (as judged by adults) were shown to newborn infants (mean age 2 days 20.5 hours), where each pair was presented both upright and inverted through 180°. In the former (upright) condition, but not the latter (inverted) condition, the infants looked longer at the attractive faces, and the difference in attractiveness preference between the conditions was statistically significant. These findings are clear evidence that infants’ early representation of faces contains information about faces that is orientation-specific. The results are discussed in terms of innate facial representations and rapid learning about faces in the hours from birth.

Intermodal perception at birth: Intersensory redundancy guides newborn infants’ learning of arbitrary auditory−visual pairings

In this study the ability of newborn infants to learn arbitrary auditory–visual associations in the absence versus presence of amodal (redundant) and contingent information was investigated. In the auditory-noncontingent condition 2-day-old infants were familiarized to two alternating visual stimuli (differing in colour and orientation), each accompanied by its ‘own’ sound: when the visual stimulus was presented the sound was continuously presented, independently of whether the infant looked at the visual stimulus. In the auditory-contingent condition the auditory stimulus was presented only when the infant looked at the visual stimulus: thus, presentation of the sound was contingent upon infant looking. On the post-familiarization test trials attention recovered strongly to a novel auditory–visual combination in the auditory-contingent condition, but remained low, and indistinguishable from attention to the familiar combination, in the auditory-noncontingent condition. These findings are a clear demonstration that newborn infants’ learning of arbitrary auditory–visual associations is constrained and guided by the presence of redundant (amodal) contingent information. The findings give strong support to Bahrick’s theory of early intermodal perception.

Developmental change in form categorization in early infancy.

Three experiments utilizing the familiarization/novelty-preference procedure were conducted to examine the form categorization abilities of newborn and 3- to 4- month-old infants. In the first two experiments, newborn infants discriminated between individual exemplars chosen from different form categories (Expt 1) and from within a form category (Expt 2). In Expt 3, older infants provided evidence of having formed individuated categorical representations for circles, crosses, squares and triangles, whereas newborn infants did not. However, newborn performance was consistent with the formation of broader categorical representations for open versus closed classes of form (i.e. crosses vs. circles, squares and triangles). The results are discussed in terms of a possible differentiation-based developmental change from broad-to-narrow (or global-to-basic) in the perceptual category representations formed by young infants.

The effectiveness and cost-effectiveness of mindfulness-based cognitive therapy compared with maintenance antidepressant treatment in the prevention of depressive relapse/recurrence: results of a randomised controlled trial (the PREVENT study)

BACKGROUND Individuals with a history of recurrent depression have a high risk of repeated depressive relapse/recurrence. Maintenance antidepressant medication (m-ADM) for at least 2 years is the current recommended treatment, but many individuals are interested in alternatives to m-ADM. Mindfulness-based cognitive therapy (MBCT) has been shown to reduce the risk of relapse/recurrence compared with usual care but has not yet been compared with m-ADM in a definitive trial. OBJECTIVES To establish whether MBCT with support to taper and/or discontinue antidepressant medication (MBCT-TS) is superior to and more cost-effective than an approach of m-ADM in a primary care setting for patients with a history of recurrent depression followed up over a 2-year period in terms of preventing depressive relapse/recurrence. Secondary aims examined MBCTs acceptability and mechanism of action. DESIGN Single-blind, parallel, individual randomised controlled trial. SETTING UK general practices. PARTICIPANTS Adult patients with a diagnosis of recurrent depression and who were taking m-ADM. INTERVENTIONS Participants were randomised to MBCT-TS or m-ADM with stratification by centre and symptomatic status. Outcome data were collected blind to treatment allocation and the primary analysis was based on the principle of intention to treat. Process studies using quantitative and qualitative methods examined MBCTs acceptability and mechanism of action. MAIN OUTCOMES MEASURES The primary outcome measure was time to relapse/recurrence of depression. At each follow-up the following secondary outcomes were recorded: number of depression-free days, residual depressive symptoms, quality of life, health-related quality of life and psychiatric and medical comorbidities. RESULTS In total, 212 patients were randomised to MBCT-TS and 212 to m-ADM. The primary analysis did not find any evidence that MBCT-TS was superior to m-ADM in terms of the primary outcome of time to depressive relapse/recurrence over 24 months [hazard ratio (HR) 0.89, 95% confidence interval (CI) 0.67 to 1.18] or for any of the secondary outcomes. Cost-effectiveness analysis did not support the hypothesis that MBCT-TS is more cost-effective than m-ADM in terms of either relapse/recurrence or quality-adjusted life-years. In planned subgroup analyses, a significant interaction was found between treatment group and reported childhood abuse (HR 1.89, 95% CI 1.06 to 3.38), with delayed time to relapse/recurrence for MBCT-TS participants with a more abusive childhood compared with those with a less abusive history. Although changes in mindfulness were specific to MBCT (and not m-ADM), they did not predict outcome in terms of relapse/recurrence at 24 months. In terms of acceptability, the qualitative analyses suggest that many people have views about (dis)/continuing their ADM, which can serve as a facilitator or a barrier to taking part in a trial that requires either continuation for 2 years or discontinuation. CONCLUSIONS There is no support for the hypothesis that MBCT-TS is superior to m-ADM in preventing depressive relapse/recurrence among individuals at risk for depressive relapse/recurrence. Both treatments appear to confer protection against relapse/recurrence. There is an indication that MBCT may be most indicated for individuals at greatest risk of relapse/recurrence. It is important to characterise those most at risk and carefully establish if and why MBCT may be most indicated for this group. TRIAL REGISTRATION Current Controlled Trials ISRCTN26666654. FUNDING This project was funded by the NIHR Health Technology Assessment programme and the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care South West Peninsula and will be published in full in Health Technology Assessment; Vol. 19, No. 73. See the NIHR Journals Library website for further project information.

The role of perceptual and cognitive processes in addition–subtraction studies with 5-month-old infants

After a brief familiarization period to either one or two toys 5-month-olds gave a clear preference for perceptually novel displays, suggesting that replicable findings of greater looking at an unexpected arithmetic outcome in addition/subtraction experiments cannot easily be attributed to simple familiarity preferences.

The reliability and validity of the pupil behaviour questionnaire: a child classroom behaviour assessment tool

ABSTRACT This paper assesses the reliability and validity of the teacher-completed Pupil Behaviour Questionnaire (PBQ), by comparing it to the already extensively validated teacher-completed Strengths and Difficulties Questionnaire (SDQ). Participants included 2074 primary school children participating in a universal school-based trial and 41 vulnerable children who were taking part in a study exploring the impact of exclusion from school. Exploratory factor analysis results (first factor accounts for 80.8% of the variation in the items) and the high Cronbach’s alpha value of 0.85 indicate that the PBQ consists of one substantive factor/dimension. Strong correlations between the total PBQ score and the conduct sub-scale (Spearman’s correlation coefficient (rs) = 0.67) and total difficulties score (rs = 0.59) of the SDQ indicate convergent validity. This study suggests that the PBQ is a reliable measure, and provides some evidence of validity. Further work is needed to test the PBQ in an older, more diverse populations and to measure sensitivity to change.

'How I Feel About My School': The construction and validation of a measure of wellbeing at school for primary school children.

There is a growing focus on child wellbeing and happiness in schools, but we lack self-report measures for very young children. Three samples (N = 2345) were combined to assess the psychometric properties of the How I Feel About My School (HIFAMS) questionnaire, which was designed for children aged 4–8 years. Test–retest reliability was moderate (intraclass correlation coefficient = .62). HIFAMS assessed a single concept and had moderate internal consistency (Cronbach’s alpha values from .62 to .67). There were low correlations between scores on the child-reported HIFAMS and parent and teacher reports. Children at risk of exclusion had significantly lower HIFAMS scores than the community sample (mean difference = 2.4; 95% confidence interval (CI) = [1.6, 3.2]; p < .001). Schools contributed only 4.5% of the variability in HIFAMS score, the remaining 95.5% reflecting pupil differences within schools. Girls’ scores were 0.37 units (95% CI = [0.16, 0.57]; p < .001) higher than boys, while year group and deprivation did not predict HIFAMS score. HIFAMS is a promising measure that demonstrates moderate reliability and discriminates between groups even among very young children.

Classroom behaviour management strategies in response to problematic behaviours of primary school children with special educational needs: views of special educational needs coordinators

Children identified with special educational needs (SEN) and behavioural difficulties present extra challenges to educators and require additional supports in school. This paper presents views from special educational needs coordinators (SENCos) on various strategies used by educators to support children identified with SEN and problematic behaviours. The data were collected from telephone interviews with six SENCos from the UK’s South West Peninsula. The SENCos were invited to participate because their school was participating in a cluster-randomised trial of a teacher classroom management course (Incredible Years). Using thematic analysis to analyse the data, this paper illustrates strategies deemed by SENCos to be successful in the support of children identified with SEN. The management strategies generated by participating SENCos were then mapped onto those taught as part of the classroom management course for comparison. Findings indicate that strategies from the training programme appear to be appropriate for children identified with both SEN and behavioural difficulties.