Sandra Jumbe

Validation of post-traumatic stress disorder (PTSD) and complex PTSD using the International Trauma Questionnaire

The 11th version of the International Classification of Diseases (ICD‐11) has proposed two related trauma diagnoses: Post‐traumatic stress disorder (PTSD) and Complex PTSD (CPTSD). Using a newly developed, disorder‐specific measure of PTSD and CPTSD called the International Trauma Questionnaire (ITQ) the current study will (i) assess the factorial validity of ICD‐11 PTSD and CPTSD; (ii) provide the first test of the discriminant validity of these constructs; and (iii) provide the first comparison of ICD‐11, and Diagnostic and Statistical Manual, Fifth Edition (DSM‐5), PTSD diagnostic rates using disorder‐specific measures.

High Prevalence of Untreated Depression in Patients Accessing Low-Vision Services

News about untreatable sight loss is devastating. Clinicians have an important role to play in determining when and how information is provided, gauging how effectively patients are likely to cope, and recognizing when someone needs to access treatment for their psychological distress. It is true that some resilient individuals are able to adjust, eventually, to their new situation, but many others find the myriad of practical problems associated with sight loss and worry about the future overwhelming, their psychological wellbeing suffers, and many sink into chronic depression. Depression is common in those with a visual impairment and particularly so in those seeking help at low vision rehabilitation clinics, but just how prevalent is it and are people getting the help they need? Large-scale epidemiologic studies indicate that about 13% of people with a visual impairment have significant depressive symptoms, about 3 times greater than in the general population. In those accessing low vision rehabilitation clinics the prevalence is known to be higher at about 30%. However, these estimates should be treated with caution. Small sample sizes and volunteers rather than consecutive attendees may underestimate the scale of the problem because people with depression are less likely to volunteer. The data in this report are from the Depression in Visual Impairment Trial (DEPVIT), a multicenter, randomized controlled trial that screened >1000 consecutive attendees at low vision rehabilitation clinics in Britain (ISRCTN46824140). Two important aims of the study were to estimate the prevalence of significant depressive symptoms in consecutive attendees at National Health Service (NHS) funded low vision rehabilitation services in Britain and to identify the proportion currently accessing treatments for depression. Participants were consecutive adult patients attending 1 of 16 low vision rehabilitation services in Britain between November 2011 and March 2014. Fourteen of the services were provided in a primary care setting in Wales and the others were hospital-based services in London. All of the clinics gave a routine preassessment survey to all patients before their clinic visit. The survey included the Geriatric Depression Scale (GDS-15) to quantify depressive symptoms, a short version of the National Eye Institute Visual Function Questionnaire (7-item NEI-VFQ) and a single question from the Short Form Health Survey to assess overall health. To ensure that data collection was standardized across centers, clinicians attended a 1-day training event to improve their understanding of depression and all study procedures. For those who consented, information on date of birth, gender, ethnicity, medical illness, time since vision loss first identified, primary ocular diagnosis, corrected Early Treatment Diabetic Retinopathy Study logarithm of the minimum angle of resolution acuity and threshold reading ability (Bailey-Lovie Word Reading Chart) was recorded at the clinic. In line with the large-scale Medical Research Council assessment of older adults study, we adopted the relatively conservative cutoff score of !6 on the GDS-15 to identify those with significant depressive symptoms. People who screened positive for depressive symptoms were also asked if they were receiving treatment for their low mood. Data were analyzed on STATA Ver 12. The prevalence of depressive symptoms together with 95% CIs was computed by the exact binomial method. Ethical approval was obtained from the NHS National Research Ethics Service (11/WA/0014). During the 30-month recruitment period, a total of 1323 consecutive adult patients attended the low vision rehabilitation clinics. Of these, consenting patients 1008 (76.2%) provided complete datasets. The mean (SD) age of consenting patients was 74.4 (16.1) years, 61.7% were women, and 52.8% had a diagnosis of age-related macular degeneration. Overall, the prevalence of significant depressive symptoms, as measured by a GDS-15 score of!6, was 43% (95% CI, 40%e46%). And, of those who screened positive for significant depressive symptoms, 74.8% (95% CI, 79.2%e70.7%) were not being treated for their depression. Table 1 (available at www.aaojournal.org) describes the prevalence of significant depressive symptoms according to study location and patient characteristics. Interestingly, a regression analysis indicated that the prevalence of significant depressive symptoms was not related to visual acuity or to the time since sight loss was first identified. Figure 1 describes the prevalence of significant depressive symptoms as a function of time since the onset of sight loss and it seems that depression does not resolve over time. However, because this was a cross-sectional study, we cannot rule out the possible effects of time. The prevalence of clinically significant depressive symptoms in 43% of those seeking help for sight loss in Britain is striking. To put the findings into perspective, 45% of those with a diagnosis of cancer who are about to undergo chemotherapy have clinically significant depressive features. Clearly, people seeking help for their visual problems are a high-risk group for depression, but the fact that three-quarters of those who screened positive were not receiving any form of treatment suggests that depression is being routinely overlooked in this vulnerable group. We are only aware of 2 low vision services in Britain that screen people regularly for depression. People are not getting the help they need. Addressing a patient’s needs should include more than improving their acuity or other aspect of visual function. Depression is a major cause of disability in its own right; it reduces the effectiveness of low vision rehabilitation interventions, quality of life, and even life expectancy. Depression is a medical condition, treatments can be effective, and screening is relatively straightforward. In Britain, the National Institute for Health and Clinical Excellence (NICE) recommend screening high risk groups by Ophthalmology Volume 123, Number 2, February 2016

Depression in Visual Impairment Trial (DEPVIT): A Randomized Clinical Trial of Depression Treatments in People With Low Vision

PURPOSE The purpose of this study was to compare two interventions for depression, problem solving treatment (PST) and referral to the patients physician, with a waiting-list control group in people with sight loss and depressive symptoms. METHODS This was an assessor-masked, exploratory, multicenter, randomized clinical trial, with concurrent economic analysis. Of 1008 consecutive attendees at 14 low-vision rehabilitation centers in Britain, 43% (n = 430) screened positive for depressive symptoms on the Geriatric Depression Scale and 85 of these attendees participated in the trial. Eligible participants were randomized in the ratio 1:1:1 to PST, referral to their physician, or a waiting-list control arm. PST is a manualized talking intervention delivered by a trained therapist who teaches people over six to eight sessions to implement a seven-step method for solving their problems. Referral to the physician involved sending a referral letter to the persons physician, encouraging him or her to consider treatment according to the stepped care protocol recommended by the U.K.s National Institute of Health and Care Excellence. The primary outcome was change in depressive symptoms (6 months after baseline) as determined by the Beck Depression Inventory. RESULTS At 6 months, Beck Depression Inventory scores reduced by 1.05 (SD 8.85), 2.11 (SD 7.60), and 2.68 (SD 7.93) in the waiting-list control, referral, and PST arms, respectively. The cost per patient of the PST intervention was £1176 in Wales and £1296 in London. CONCLUSIONS Depressive symptoms improved most in the PST group and least in the control group. However, the change was small and the uncertainty of the measurements relatively large.

Contrasting Views of the Post-bariatric Surgery Experience between Patients and their Practitioners: a Qualitative Study

BackgroundThe superiority of obesity surgery for improving medical and weight outcomes in severely obese patients when compared to other weight loss interventions remains undisputed. However, knowledge about the psychological impact of the procedure on patients’ lives is limited. Systematic reviews indicate persisting psychological distress after surgery compared to control groups especially longer term, suggesting the need for postoperative psychological support and assessment. Research literature also infers limited knowledge regarding the postoperative patient experience of obesity surgery. This may form a barrier in health practitioners’ understanding of these patients’ ongoing needs.MethodsTen patients who had obesity surgery two or more years ago and eight obesity surgery practitioners were recruited within hospital settings and individually interviewed by the researcher to capture their accounts of the postoperative experience. Concordance between the two groups was explored to gauge awareness of patients’ subsequent health needs.ResultsThematic analysis of transcribed interviews elicited a key finding around ‘post-surgical cliffs in patient care’ within a heavily structured service. Participants reported some unmet needs, namely, psychological aftercare to facilitate adjustment following drastic weight loss and excess skin, acceptance of their non-obese self and perceived stigma. The impact of contrasting views of success between patients and practitioners on postoperative care within the service context was highlighted.ConclusionsObesity surgery is a great weight loss catalyst for severe obesity. However, lack of psychological aftercare may threaten early gains in health outcomes over the longer term. More qualitative and quantitative studies are needed to validate current study results.

Psychological Aspects of Bariatric Surgery as a Treatment for Obesity

Purpose of ReviewLittle is known about the psychological effects on life after bariatric surgery despite the high prevalence of psychological disorders in candidates seeking this procedure. Our review discusses the literature around the psychological impact of bariatric surgery, exploring whether the procedure addresses underlying psychological conditions that can lead to morbid obesity and the effect on eating behaviour postoperatively.Recent FindingsFindings show that despite undisputed significant weight loss and improvements in comorbidities, current literature suggests some persisting disorder in psychological outcomes like depression and body image for patients at longer term follow-up, compared to control groups. Lack of postoperative psychological monitoring and theoretical mapping limits our understanding of reasons behind these findings.SummaryReframing bariatric approaches to morbid obesity to incorporate psychological experience postoperatively would facilitate understanding of psychological aspects of bariatric surgery and how this surgical treatment maps onto the disease trajectory of obesity.

Equipping community pharmacy workers as agents for health behaviour change : developing and testing a theory-based smoking cessation intervention.

Objective To develop a complex intervention for community pharmacy staff to promote uptake of smoking cessation services and to increase quit rates. Design Following the Medical Research Council framework, we used a mixed-methods approach to develop, pilot and then refine the intervention. Methods Phase I: We used information from qualitative studies in pharmacies, systematic literature reviews and the Capability, Opportunity, Motivation—Behaviour framework to inform design of the initial version of the intervention. Phase II: We then tested the acceptability of this intervention with smoking cessation advisers and assessed fidelity using actors who visited pharmacies posing as smokers, in a pilot study. Phase III: We reviewed the content and associated theory underpinning our intervention, taking account of the results of the earlier studies and a realist analysis of published literature. We then confirmed a logic model describing the intended operation of the intervention and used this model to refine the intervention and associated materials. Setting Eight community pharmacies in three inner east London boroughs. Participants 12 Stop Smoking Advisers. Intervention Two, 150 min, skills-based training sessions focused on communication and behaviour change skills with between session practice. Results The pilot study confirmed acceptability of the intervention and showed preliminary evidence of benefit; however, organisational barriers tended to limit effective operation. The pilot data and realist review pointed to additional use of Diffusion of Innovations Theory to seat the intervention in the wider organisational context. Conclusions We have developed and refined an intervention to promote smoking cessation services in community pharmacies, which we now plan to evaluate in a randomised controlled trial. Trial registration number UKCRN ID 18446, Pilot.

Creating a theoretically-grounded, gamified health app: lessons from developing the Cigbreak smoking cessation smartphone game (Preprint)

Background Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps. Objective This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app. Methods A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers. Results Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend. Conclusions A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.