Wendy Macdonald

Identifying psychosocial interventions that improve both physical and mental health in patients with diabetes: A systematic review and meta-analysis

OBJECTIVE Patients with diabetes suffer high rates of mental health problems, and this combination is associated with poor outcomes. Although effective treatments exist for both diabetes and mental health problems, delivering services for physical and mental health problems separately ignores their interaction and may be inefficient. This systematic review sought to identify psychosocial interventions that could improve both the physical and mental health of patients with diabetes. RESEARCH DESIGN AND METHODS Studies were identified from the following databases: CENTRAL, MEDLINE, Excerpta Medica (EMBASE), Psychinfo, and Cumulative Index to Nursing and Allied Health Literature (CINAHL). The review included randomized controlled trials in patients with type 1 and type 2 diabetes who received psychosocial interventions and where both mental health and physical health outcomes were reported. Data were extracted on study quality, the content and process of interventions, and outcomes. RESULTS Eighty-five eligible comparisons were identified, of which 49 reported sufficient data for analysis. Psychosocial interventions modestly improved A1C (standardized mean difference −0.29 [95% CI −0.37 to −0.21]) and mental health outcomes (−0.16 [−0.25 to −0.07]). However, there was a limited association between the effects on A1C and mental health, and no intervention characteristics predicted benefit on both outcomes. CONCLUSIONS Managing physical and mental health in long-term conditions are increasingly important. The review did not identify types of interventions that consistently provide benefits for both physical and mental health. Developing such interventions remains an important challenge. The findings have implications for understanding the interaction between physical and mental health problems and for the coordination of care.

The clinical effectiveness of guided self-help versus waiting-list control in the management of anxiety and depression: A randomized controlled trial

BACKGROUND There are significant barriers to accessing effective psychological therapy in primary care resulting from a lack of suitably trained therapists to meet current demand. More efficient service delivery using minimal interventions (such as bibliotherapy) provided by paraprofessional therapists may be one method of overcoming these problems, and is the subject of attention in the UK and elsewhere. A randomized trial was conducted to test the clinical effectiveness of this model. Assistant psychologists delivered a guided self-help intervention to patients with anxiety and depression who were currently waiting for psychological therapy. METHOD A total of 114 patients were randomized either to guided self-help or a waiting-list control group. All patients were followed up 3 months later, prior to starting conventional psychological therapy. Measures included self-reported adherence to the intervention, anxiety and depressive symptoms, social functioning and patient satisfaction. RESULTS Adherence to the guided self-help intervention was acceptable and patients reported satisfaction with the intervention. However, there were no statistically significant differences between groups in anxiety and depression symptoms at 3 months. CONCLUSIONS The results demonstrate that this model of guided self-help did not provide additional benefit to patients on a waiting list for psychological therapy. The results are considered in the context of possible internal and external validity threats, and compared with previous trials of minimal interventions. The implications of the results for the design of future minimal interventions are considered.

What is the relationship between diabetes and depression? A qualitative meta-synthesis of patient experience of co-morbidity:

Aims: To develop an explanatory framework concerning patient experience of diabetes and depression and the relationship between these disorders; to better understand how interventions and health services should be delivered for this group of patients. Methods: The study used meta-synthesis. Published qualitative studies were identified using a structured search, and themes synthesized across studies to develop a new explanatory framework. Results: Searches of three databases identified 5506 papers, and 22 were included. Diagnosis of diabetes and the impact of symptoms on functioning were associated with varied psychological reactions, not all of which are negative, and the concept of ‘depression’ only captures aspects of the experience. Similarly, the relationship between diabetes and relationships with professionals and family were variable, with relationships serving as both a buffer of the effects of diabetes and potentially as a cause of further difficulties for patients. Depression and other psychological states were significant barriers to effective coping. Definition of ‘self’ emerged as a key potential moderator of the relationship between depression and diabetes. Conclusions: The variability in psychological reactions to diabetes suggested three key clinical implications, reflecting increasing levels of complexity for practitioners.

Illness representations in patients with multimorbid long-term conditions: Qualitative study

Most research on illness representations explores how patients view single conditions, but many patients report more than one long-term condition (known as multimorbidity). It is not known how multimorbidity impacts on patient illness representations. This exploratory qualitative study examined patients’ representations of multimorbid long-term conditions and sought to assess how models of illness representation might need modification in the presence of multimorbidity. We explored two major issues: (1) the impact of multimorbidity on patient representations of their individual conditions and (2) the representation of multimorbidity itself. Twenty eight adults with at least two long-term conditions (mean of 4) were interviewed. The presence of multimorbidity impacted on patient illness representations in relation to the dimensions of identity, perceived cause, coherence and consequences. Representations of multimorbidity itself concerned representations of the burden of medication and perceived priorities among conditions and synergies and antagonisms between conditions and their management. The results have implications for the measurement of multimorbidity (through scales such as the Illness Perception Questionnaire) and the use of illness representations in the design and delivery of interventions to improve health behaviour and outcomes of patients with multiple long-term conditions.

Child and Adolescent Mental Health interface work with primary services: A survey of NHS provider trusts

BACKGROUND We document the extent, nature and predictors of interface work between secondary Child and Adolescent Mental Health (CAMHS) and primary services, through structured questionnaires sent to all Trusts with CAMHS in England (returned by 124/150 or 83%). RESULTS Two-thirds of CAMHS reported training and education to primary care services, about one-third a structured consultation service, one-fifth reported undertaking outpatient clinics in primary care settings and joint casework. One-third had developed primary mental health worker posts. Multiple regression analysis identified firstly specialist clinics within CAMHS, and secondly CAMHS size, as the strongest predictors of interface work across agencies. Interface work thus grows with more developed, larger CAMHS.

What makes a successful volunteer Expert Patients Programme tutor? Factors predicting satisfaction, productivity and intention to continue tutoring of a new public health workforce in the United Kingdom

OBJECTIVES Better management of chronic conditions is a challenge for public health policy. The Expert Patients Programme was introduced into the United Kingdom to improve self-care in people with long-term conditions. To deliver self-care courses, the programme relies on the recruitment and continued commitment to delivering the courses of volunteer lay tutors who have long-term conditions. Ensuring the tutor workforce is productive, satisfied in their role and retained long-term is central to the viability of the programme. This exploratory study aimed to determine what factors predict productivity, intention to continue tutoring, and satisfaction in a sample of volunteer tutors from the Expert Patients Programme. METHODS A cross-sectional survey of 895 tutors was carried out and 518 (58%) responded. The questionnaire was designed to describe the characteristics, productivity, intention to continue tutoring, and satisfaction of tutors. Multiple linear regression analyses were used to examine the determinants of productivity, intention to continue tutoring, and satisfaction, such as patient demographics, attitudes, physical and mental health, mastery and self-esteem. RESULTS Attitudes relating to personal goals, and better health were significant predictors of satisfaction with the tutor role. Only a small proportion of the variance in productivity was accounted for, and tutors were more likely to be productive when they were single, homeowners, car owners, and had lower scores on the depression scale. Overall satisfaction and personal goals were predictors of intention to continue tutoring. CONCLUSION Demographic factors, health measures and attitudes each predicted different aspects of the experience of work conducted by the volunteer tutors. The results should prove useful for planning interventions to enhance the success of this new workforce initiative. PRACTICE IMPLICATIONS Attempts to increase participation in courses by people from deprived backgrounds are likely to be enhanced if tutors come from similar backgrounds. This study demonstrated that material advantage and attitudes that value personal goals were predictors of satisfaction and productivity in the tutor role. Specific incentives and strategies may be required to recruit and support tutors from more marginalised groups in order to ensure equitable access to effective self-care support for all.

Prisoner perspectives on managing long term conditions: A qualitative study

This paper explores the perceptions of prisoners to the barriers and opportunities for managing long term conditions in a prison setting. A qualitative study using semi‐structured interviews was conducted with prisoners from two local prisons in England. All the prisoners involved in the study had a long term condition and were attending an Expert Patients Programme (EPP) course, a lay‐led self care programme. A number of themes emerge from the data in relation to the impact prison has had on lifestyle and control of long term conditions. The structured prison regime allowed some to regain control over previously chaotic lifestyles but the lack of access to a healthy diet and exercise facilities as well as lack of opportunities to practice new health behaviours learnt whilst in prison, prevented a healthier lifestyle being adopted. Another main theme was in relation to the ability of prisoners to negotiate access to health care services and professionals. The study found a number of pre‐existing factors which would need to be addressed if prisoners were to become fully engaged in future health initiatives, such as EPP.