Recent Submissions

  • Are dental-related psychological variables important for dental attendance in China? A cross-sectional study

    Topcu, Gogem (2021)
    OBJECTIVEDental services are expanding in China, yet there is little evidence available on the dental-related psychological factors contributing to the uptake of dental services. Our study explored whether beliefs, anxiety, and cognitions significantly differ across different levels of attendance, and whether dental-related psychological variables can independently predict dental attendance in Chinese adults. We also explored the extent to which cognitions and beliefs relate to attendance as a function of dental anxiety.METHODIn our cross-sectional study 480 adult participants in China completed a questionnaire including dental attendance and measures of dental-related psychological variables (dental cognitions, beliefs, anxiety, and fear of dental pain).RESULTSOnly 25.8% of participants visited the dentist regularly. There was a significant difference for all dental-related psychological variables (p < 0.001), across all three levels of dental attendance (never; irregularly or regularly attend). Thus, fear of dental pain and dental anxiety are higher, and cognitions and beliefs are more negative, for those who have less favorable dental service utilization. All these variables, except fear of dental pain, were also independent predictors of dental attendance (p < 0.05). Moreover, how individuals think, and what they believe, about the dentist (and the dental context) were only partially explained through dental anxiety. Thus, beliefs (β = 0.579, SE = 0.035, p < 0.001) and cognitions (β = 0.594, SE = 0.045, p < 0.001) are impacting on dental attendance, mostly independent of whether the individual is anxious.CONCLUSIONOur preliminary findings show dental-related psychological factors are related to dental attendance and these should be explored further in a larger sample.
  • The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety

    Malins, Samuel; Morriss, Richard K.; Schroder, Thomas; Brown, Paula; Boycott, Naomi (2021)
    Objectives Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA. Design This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity. Methods Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments. Results Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes. Conclusions Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.
  • Screening male prisoners for depression and anxiety with the PHQ-9 and GAD-7 at NHS HealthchecK: patterns of symptoms and caseness threshold

    Packham, Chris; Williams, Marie; Kaul, Adarsh; Morriss, Richard K. (2021)
    BACKGROUNDScreening for depression and anxiety disorders has been proposed in prison populations but little is known about caseness thresholds on commonly used self-report measures in relation to core symptoms, risk factors and symptom patterns.METHODA cross-sectional prevalence survey measured depression and anxiety caseness (threshold scores > 10 and > 15 on PHQ-9 and GAD-7 and diagnostic algorithm on PHQ-9) in 1205 male prisoners aged 35-74 years eligible for an NHS Healthcheck from six English prisons. Caseness scores were compared with the presence or absence of daily core symptoms of depression and generalised anxiety disorder (GAD), demographic, prison and cardiovascular risk factors. Cluster analysis was applied to PHQ-9 and GAD-7 items in prisoners scoring > 10 on PHQ-9.RESULTS453(37.6%) and 249(20.7%) prisoners scored > 10 and > 15 respectively on PHQ-9; 216 (17.9%) had a depressive episode on the PHQ-9 algorithm; 378(31.4%) and 217(18.0%) scored > 10 and > 15 on GAD-7 respectively. Daily core items for depression were scored in 232(56.2%) and 139(74.3%) prisoners reaching > 10 and > 15 respectively on PHQ-9; daily core anxiety items in 282(74.9%) and 179(96.3%) reaching > 10 and > 15 on GAD-7. Young age, prison and previous high alcohol intake were associated with > 15 on the PHQ-9. Cluster analysis showed a cluster with core symptoms of depression, slowness, restlessness, suicidality, poor concentration, irritability or fear. Altered appetite, poor sleep, lack of energy, guilt or worthlessness belonged to other clusters and may not be indicative of depression.CONCLUSIONSIn male prisoners > 35 years, a score of > 10 on the PHQ-9 over diagnoses depressive episodes but a score of > 10 on the GAD-7 may detect cases of GAD more efficiently. Further research utilising standardised psychiatric interviews is required to determine whether the diagnostic algorithm, a higher cut-off on the PHQ-9 or the profile of symptoms on the PHQ-9 and GAD-7 used singly or in combination may be used to screen depressive episodes efficiently in prisoners.
  • The Oxford Agoraphobic Avoidance Scale

    Jones, Julia; O'Regan, Eileen (2021)
    Background Agoraphobic avoidance of everyday situations is a common feature in many mental health disorders. Avoidance can be due to a variety of fears, including concerns about negative social evaluation, panicking, and harm from others. The result is inactivity and isolation. Behavioural avoidance tasks (BATs) provide an objective assessment of avoidance and in situ anxiety but are challenging to administer and lack standardisation. Our aim was to draw on the principles of BATs to develop a self-report measure of agoraphobia symptoms. Method The scale was developed with 194 patients with agoraphobia in the context of psychosis, 427 individuals in the general population with high levels of agoraphobia, and 1094 individuals with low levels of agoraphobia. Factor analysis, item response theory, and receiver operating characteristic analyses were used. Validity was assessed against a BAT, actigraphy data, and an existing agoraphobia measure. Test–retest reliability was assessed with 264 participants. Results An eight-item questionnaire with avoidance and distress response scales was developed. The avoidance and distress scales each had an excellent model fit and reliably assessed agoraphobic symptoms across the severity spectrum. All items were highly discriminative (avoidance: a = 1.24–5.43; distress: a = 1.60–5.48), indicating that small increases in agoraphobic symptoms led to a high probability of item endorsement. The scale demonstrated good internal reliability, test–retest reliability, and validity. Conclusions The Oxford Agoraphobic Avoidance Scale has excellent psychometric properties. Clinical cut-offs and score ranges are provided. This precise assessment tool may help focus attention on the clinically important problem of agoraphobic avoidance.
  • A case management occupational health model to facilitate earlier return to work of NHS staff with common mental health disorders: a feasibility study

    Griffiths, Amanda (2021)
    Background: The NHS is the biggest employer in the UK. Depression and anxiety are common reasons for sickness absence among staff. Evidence suggests that an intervention based on a case management model using a biopsychosocial approach could be cost-effective and lead to earlier return to work for staff with common mental health disorders. Objective: The objective was to assess the feasibility and acceptability of conducting a trial of the clinical effectiveness and cost-effectiveness of an early occupational health referral and case management intervention to facilitate the return to work of NHS staff on sick leave with any common mental health disorder (e.g. depression or anxiety). Design: A multicentre mixed-methods feasibility study with embedded process evaluation and economic analyses. The study comprised an updated systematic review, survey of care as usual, and development of an intervention in consultation with key stakeholders. Although this was not a randomised controlled trial, the study design comprised two arms where participants received either the intervention or care as usual. Participants: Participants were NHS staff on sick leave for 7 or more consecutive days but less than 90 consecutive days, with a common mental health disorder. Intervention: The intervention involved early referral to occupational health combined with standardised work-focused case management. Control/comparator: Participants in the control arm received care as usual. Primary outcome: The primary outcome was the feasibility and acceptability of the intervention, study processes (including methods of recruiting participants) and data collection tools to measure return to work, episodes of sickness absence, workability (a worker’s functional ability to perform their job), occupational functioning, symptomatology and cost-effectiveness proposed for use in a main trial. Results: Forty articles and two guidelines were included in an updated systematic review. A total of 49 of the 126 (39%) occupational health providers who were approached participated in a national survey of care as usual. Selected multidisciplinary stakeholders contributed to the development of the work-focused case management intervention (including a training workshop). Six NHS trusts (occupational health departments) agreed to take part in the study, although one trust withdrew prior to participant recruitment, citing staff shortages. At mixed intervention sites, participants were sequentially allocated to each arm, where possible. Approximately 1938 (3.9%) NHS staff from the participating sites were on sick leave with a common mental health disorder during the study period. Forty-two sick-listed NHS staff were screened for eligibility on receipt of occupational health management referrals. Twenty-four (57%) participants were consented: 11 (46%) received the case management intervention and 13 (54%) received care as usual. Follow-up data were collected from 11 out of 24 (46%) participants at 3 months and 10 out of 24 (42%) participants at 6 months. The case management intervention and case manager training were found to be acceptable and inexpensive to deliver. Possible contamination issues are likely in a future trial if participants are individually randomised at mixed intervention sites. Harms: No adverse events were reported. Limitations: The method of identification and recruitment of eligible sick-listed staff was ineffective in practice because uptake of referral to occupational health was low, but a new targeted method has been devised. Conclusion: All study questions were addressed. Difficulties raising organisational awareness of the study coupled with a lack of change in occupational health referral practices by line managers affected the identification and recruitment of participants. Strategies to overcome these barriers in a main trial were identified. The case management intervention was fit for purpose and acceptable to deliver in the NHS.
  • Cognitive-behavioural therapy for a variety of conditions: an overview of systematic reviews and panoramic meta-analysis

    das Nair, Roshan (2021)
    Background: Cognitive-behavioural therapy aims to increase quality of life by changing cognitive and behavioural factors that maintain problematic symptoms. A previous overview of cognitive-behavioural therapy systematic reviews suggested that cognitive-behavioural therapy was effective for many conditions. However, few of the included reviews synthesised randomised controlled trials. Objectives: This project was undertaken to map the quality and gaps in the cognitive-behavioural therapy systematic review of randomised controlled trial evidence base. Panoramic meta-analyses were also conducted to identify any across-condition general effects of cognitive-behavioural therapy. Data sources: The overview was designed with cognitive-behavioural therapy patients, clinicians and researchers. The Cochrane Library, MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Child Development & Adolescent Studies, Database of Abstracts of Reviews of Effects and OpenGrey databases were searched from 1992 to January 2019. Review methods: Study inclusion criteria were as follows: (1) fulfil the Centre for Reviews and Dissemination criteria; (2) intervention reported as cognitive-behavioural therapy or including one cognitive and one behavioural element; (3) include a synthesis of cognitive-behavioural therapy trials; (4) include either health-related quality of life, depression, anxiety or pain outcome; and (5) available in English. Review quality was assessed with A MeaSurement Tool to Assess systematic Reviews (AMSTAR)-2. Reviews were quality assessed and data were extracted in duplicate by two independent researchers, and then mapped according to condition, population, context and quality. The effects from high-quality reviews were pooled within condition groups, using a random-effect panoramic meta-analysis. If the across-condition heterogeneity was I-2 < 75%, we pooled across conditions. Subgroup analyses were conducted for age, delivery format, comparator type and length of follow-up, and a sensitivity analysis was performed for quality. Results: A total of 494 reviews were mapped, representing 68% (27/40) of the categories of the International Classification of Diseases, Eleventh Revision, Mortality and Morbidity Statistics. Most reviews (71%, 351/494) were of lower quality. Research on older adults, using cognitive-behavioural therapy preventatively, ethnic minorities and people living outside Europe, North America or Australasia was limited. Out of 494 reviews, 71 were included in the primary panoramic meta-analyses. A modest effect was found in favour of cognitive-behavioural therapy for health-related quality of life (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.05 to 0.50, I-2 = 32%), anxiety (standardised mean difference 0.30, 95% confidence interval 0.18 to 0.43, prediction interval -0.28 to 0.88, I-2 = 62%) and pain (standardised mean difference 0.23, 95% confidence interval 0.05 to 0.41, prediction interval -0.28 to 0.74, I-2 = 64%) outcomes. All condition, subgroup and sensitivity effect estimates remained consistent with the general effect. A statistically significant interaction effect was evident between the active and non-active comparator groups for the health-related quality-of-life outcome. A general effect for depression outcomes was not produced as a result of considerable heterogeneity across reviews and conditions. Limitations: Data extraction and analysis were conducted at the review level, rather than returning to the individual trial data. This meant that the risk of bias of the individual trials could not be accounted for, but only the quality of the systematic reviews that synthesised them. Conclusion: Owing to the consistency and homogeneity of the highest-quality evidence, it is proposed that cognitive-behavioural therapy can produce a modest general, across-condition benefit in health-related quality-of-life, anxiety and pain outcomes. Future work: Future research should focus on how the modest effect sizes seen with cognitive-behavioural therapy can be increased, for example identifying alternative delivery formats to increase adherence and reduce dropout, and pursuing novel methods to assess intervention fidelity and quality. Study registration: This study is registered as PROSPERO CRD42017078690.
  • A direct-to-public peer support program (Big White Wall) versus web-based information to aid the self-management of depression and anxiety: Results and challenges of an automated randomized controlled trial

    Morriss, Richard K.; Kaylor-Hughes, Catherine; Rawsthorne, Mat; Simpson, Sandra; Guo, Boliang; James, Marilyn; Williams, Laura (2021)
    Background: Effective help for depression and anxiety reaches a small proportion of people who might benefit from it. The scale of the problem suggests the need for effective, safe web-based public health services delivered directly to the public. One model, the Big White Wall (BWW), offers peer support at low cost. As these interventions are delivered digitally, we tested whether a randomized controlled trial (RCT) intervention could also be fully delivered and evaluated digitally. Objective: This study aims to determine the reach, feasibility, acceptability, baseline costs, and outcomes of a public health campaign for an automated RCT of the BWW, providing digital peer support and information, compared with a standard website used by the National Health Service Moodzone (MZ), to people with probable mild-to-moderate depression and anxiety disorder. The primary outcome was the change in self-rated well-being at 6 weeks, measured using the Warwick-Edinburgh Mental Well-Being Scale. Methods: An 18-month campaign was conducted across Nottinghamshire, the United Kingdom (target population 914,000) to advertise the trial directly to the public through general marketing, web-based and social media sources, health services, other public services, and third-sector groups. The population reach of this campaign was examined by the number of people accessing the study website and self-registering to the study. A pragmatic, parallel-group, single-blind RCT was then conducted using a fully automated trial website in which eligible participants were randomized to receive either 6 months of access to BWW or signposted to MZ. Those eligible for participation were aged >16 years with probable mild-to-moderate depression or anxiety disorders. Results: Of 6483 visitors to the study website, 1510 (23.29%) were eligible. Overall, 790 of 1510 (52.32%) visitors participated. Of 790 visitors, 397 (50.3%) were randomized to BWW and 393 (49.7%) to MZ. Their mean age was 38 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, and 47.4% (271/572) had no contact with health services in the previous 3 months. We estimated 3-month productivity losses of £1001.01 (95% CI 868.75-1133.27; US $1380.79; 95% CI 1198.35-1563.23) per person for those employed. Only 16.6% (131/790) participants completed the primary outcome assessment. There were no differences in the primary or secondary outcomes between the 2 groups. Conclusions: Most participants reached and those eligible for this trial of digital interventions were White women not in recent contact with health services and whose productivity losses represent a significant annual societal burden. A fully automated RCT recruiting directly from the public failed to recruit and retain sufficient participants to test the clinical effectiveness of this digital intervention, primarily because it did not personally engage participants and explain how these unfamiliar interventions might benefit them.
  • Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive behavioral thearpy for severe health anxiety

    Malins, Samuel; Morriss, Richard K.; Schroder, Thomas; Brown, Paula; Boycott, Naomi (2020)
    There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which Cognitive-Behavioural Therapy (CBT) is a frontline treatment. However, it is unclear what interaction-types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction-types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: An individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction-types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorised and rated. The scores were then compared to ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions amongst those with greater outcome-improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared to the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes, and made more contributions to structuring interactions at initial sessions. Conclusion. Specific early interaction-types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.
  • Mental health recovery for survivors of modern slavery: Grounded theory study protocol

    Wright, Nicola; Brookes, Caroline; Jordan, Melanie; Slade, Mike (2020)
    Introduction Slavery and human trafficking are crimes involving the violation of human rights and refer to exploitative situations where an individual cannot refuse or leave due to threats, coercion or abuse of power. Activities involving slavery include forced labour exploitation, forced sexual exploitation, forced marriage and servitude. Epidemiological studies show high levels of mental health need and poor provision of appropriate support for survivors. What mental health recovery means to victims/survivors and how it could be promoted is under-researched. Methods and analysis A grounded theory study based on individual interviews will be undertaken. Survivors across the UK will be identified and recruited from non-governmental organisations and via social media. As per grounded theory methodology, data collection and analysis will be undertaken concurrently and recruitment will continue until theoretical saturation is reached. It is anticipated that approximately 30 participants will be recruited. Interviews will be audio recorded, transcribed verbatim and uploaded to NVivo V.11. The constant comparative method will be used to analyse the data, in order to produce a theoretical framework for mental health recovery that is grounded in the experiences of survivors. Ethics and dissemination Ethical approval has been obtained from the Faculty of Medicine and Health Sciences Ethics Committee at the University of Nottingham. The findings of the study will be disseminated to academic, professional and survivor-based audiences to inform future policy developments and the provision of mental health recovery support to this population. © 2020 Author(s). Published by BMJ.
  • Differential effects of cranial electrotherapy stimulation on changes in anxiety and depression symptoms over time in patients with generalized anxiety disorder

    Morriss, Richard K. (2020)
    Background: Cranial electrotherapy stimulation (CES) is a safe and well-tolerated 6-12 week treatment that is clinically and cost effective on both anxiety and depression symptoms resulting in sustained remission of these symptoms at 12 and 24 weeks in generalized anxiety disorder (GAD) patients. The aim of the current report was to explore whether the effectiveness of CES was related to its effects on depression or anxiety over time METHODS: A consecutive sample of 161 eligible patients with GAD was recruited from two publicly funded services in England while they waited for individual cognitive behaviour therapy (CBT) after failing to achieve remission on the GAD-7 with computerised CBT. They received 60 minutes per day Alpha-Stim CES for 6-12 weeks. Outcomes were changes in PHQ-9, GAD-7 score from baseline to 4, 6, 8, 12 and 24 weeks. Latent variable cross-lagged panel analysis permitted an analysis of the differential effects of anxiety and depression with CES treatment over time.Results: Anxiety at baseline significantly predicted depression at week 4 (standardized regression weight = .40, p<0.001). Depression at week 12 significantly predicted anxiety at week 24 (standardized regression weight = .28, p<0.05).Limitations: Not a randomized controlled trial but further analysis of a prospective observational cohort. High rates of loss to follow up by 24 weeks.Conclusion: Sustained effectiveness required a CES response to anxiety symptoms in first 4 weeks and improvement in depression symptoms by 12 weeks.
  • Anxiety Gremlins: mixed methods sequential explanatory evaluation of a CBT group intervention for children

    Redstone, Lucy (2020)
    Although research evidence supports the efficacy of cognitive behavioural therapy (CBT) for anxiety in children, it is important to examine practice-based evidence of effectiveness in typical clinical contexts. This study evaluated a CBT group intervention - 'Anxiety Gremlins' - for childhood anxiety. Participants were 36 children (19 boys, 17 girls) aged 8-13, referred for anxiety symptoms at a UK NHS service. The 8-session intervention included six child sessions (2 h) and two parent sessions (1 h). Self-report outcome measures of anxiety symptoms, life functioning and therapeutic relationships were used to measure change pre- and post-intervention. Semi-structured interviews were conducted with group facilitators and analysed through deductive content analysis to identify barriers and facilitators to change. No substantive differences were found between aggregated scores on pre-versuspost-intervention outcome measures. Reliable change in anxiety symptoms was identified in 10 children (31%), with five improvers and five deteriorators. Interviews with facilitators identified disruption in group flow, lack of facilitator time to prepare and reflect, and the complexity of clients as hindering factors. Children meeting like-minded peers to share their stories and high engagement in the therapeutic process were helpful factors. Anxiety Gremlins did not demonstrate effectiveness on outcome measures, and this contrasted with clinical opinion. Recommendations were made for the service to revisit the intervention content and the method for recruiting children to the group - as complexity/co-morbidity was linked to poorer outcomes. Future research could explore fidelity to an adapted intervention and include interviews with children and their parents. Key learning aims After reading this paper the reader should be able to: (1) Understand how instances of CBT practice can be robustly evaluated using a mixed-methods approach, including analyses of change at both group and individual levels. (2) Understand critical considerations when adapting 'evidence-based' CBT interventions for routine practice. (3) Appreciate that aggregative group-level analyses can mask clinically important differences in individual CBT outcomes.
  • A longitudinal cohort study to explore the relationship between depression, anxiety and academic performance among Emirati university students

    Davies, E. Bethan; Glazebrook, Cris (2020)
    BACKGROUND: Many university students experience depression and anxiety, both of which have been shown to affect cognitive function. However, the impact of these emotional difficulties on academic performance is unclear. This study aims to determine the prevalence of depression and anxiety in university students in United Arab Emirates (UAE). It further seeks to explore the relationship between emotional difficulties and students' academic performance. METHODS: This longitudinal study recruited 404 students (aged 17-25 years) attending one UAE university (80.4% response rate). At baseline, participants completed a paper-based survey to assess socio-economic factors and academic performance, including most recent grade point average (GPA) and attendance warnings. PHQ-9 and GAD-7 scales were used to assess depressive and anxiety symptoms. At six-month follow-up, 134 participants (33.3%) provided details of their current GPA. RESULTS: Over a third of students (34.2%; CIs 29.7-38.9%) screened for possible major depressive disorder (MDD; PHQ-9 ≥ 10) but less than a quarter (22.3%; CIs 18.2-26.3%) screened for possible generalized anxiety disorder (GAD; GAD-7 ≥ 10). The Possible MDD group had lower GPAs (p = 0.003) at baseline and were less satisfied with their studies (p = 0.015). The MDD group also had lower GPAs at follow-up (p = 0.035). The Possible GAD group had lower GPAs at baseline (p = 0.003) but did not differ at follow-up. The relationship between GAD group and GPA was moderated by gender with female students in the Possible GAD group having lower GPAs (p < 0.001) than females in the Non-GAD group. Male students in the Possible GAD group had non-significantly higher GPA scores. Higher levels of both depression and anxiety symptoms scores were associated with lower GPAs at baseline. PHQ-9 scores, but not GAD-7 scores, independently predicted lower GPA scores at follow-up (p = 0.006). This relationship was no longer statistically significant after controlling for baseline GPA (p < 0.09). CONCLUSION: This study confirms previous findings that around a third of university students are likely to be experiencing a depressive disorder at any one time. Furthermore, it provides important evidence regarding the negative impacts of emotional difficulties on students' academic performance. The results support the need to consider the mental health of students who are struggling academically and highlight the importance of signposting those students to appropriate support, including evidence-based therapies.
  • Long term effect of gender affirming hormone treatment on depression and anxiety symptoms in transgender people: A prospective cohort study

    Aldridge, Zoe; Patel, Shireen; Guo, Boliang; Nixon, Elena; Bouman, Walter P.; Arcelus, Jon (2020)
    BACKGROUNDCross-sectional studies show that transgender people are more likely than cisgender people to experience depression and anxiety before Gender Affirming Hormone Treatment (GAHT). However, the effect of GAHT on mental health in transgender people, and the role of other factors that may have a predictive effect, is poorly explored.OBJECTIVESUsing a longitudinal methodology, this study investigated the effect of 18 months GAHT on depression and anxiety symptomatology and the predictors on mental health outcomes in a large population of transgender people.MATERIALS AND METHODSParticipants (n=178) completed a socio-demographic questionnaire, the Hospital Anxiety and Depression Scale (HADS), the Multidimensional Scale of Perceived Social Support (MSPSS) and the Autism Spectrum Quotient Short Version (AQ-short) at pre-assessment (T0) and at 18 months after initiation of GAHT (T1).RESULTSFrom T0 to T1, symptomatology was significantly decreased for depression (P <0.001) and non-significantly reduced for anxiety (P=0.37). Scores on the MSPSS predicted reduction in depression, while scores on the AQ-short predicted reduction in anxiety.DISCUSSIONGAHT reduces symptoms of depression which are predicted by having higher levels of social support. Although anxiety symptoms also reduce the changes are not significant and high levels of anxiety still remain post GAHT.CONCLUSIONSThese results highlight the important mental health benefits of GAHT. Support services (professional, third sector or peer-support) aiming at increasing social support for transgender individuals should be made available.
  • The acceptability and usability of digital health interventions for adults with depression, anxiety, and somatoform disorders: Qualitative systematic review and meta-synthesis

    Patel, Shireen; Malins, Samuel; Wright, Nicola; Rowley, Emma; Young, Emma; Sampson, Stephanie; Morriss, Richard K. (2020)
    Background: The prevalence of mental health disorders continues to rise, with almost 4% of the world population having an anxiety disorder and almost 3.5% having depression in 2017. Despite the high prevalence, only one-third of people with depression or anxiety receive treatment. Over the last decade, the use of digital health interventions (DHIs) has risen rapidly as a means of accessing mental health care and continues to increase. Although there is evidence supporting the effectiveness of DHIs for the treatment of mental health conditions, little is known about what aspects are valued by users and how they might be improved. Objective: This systematic review aimed to identify, appraise, and synthesize the qualitative literature available on service users' views and experiences regarding the acceptability and usability of DHIs for depression, anxiety, and somatoform disorders. Methods: A systematic search strategy was developed, and searches were run in 7 electronic databases. Qualitative and mixed methods studies published in English were included. A meta-synthesis was used to interpret and synthesize the findings from the included studies. Results: A total of 24 studies were included in the meta-synthesis, and 3 key themes emerged with descriptive subthemes. The 3 key themes were initial motivations and approaches to DHIs, personalization of treatment, and the value of receiving personal support in DHIs. The meta-synthesis suggests that participants' initial beliefs about DHIs can have an important effect on their engagement with these types of interventions. Personal support was valued very highly as a major component of the success of DHIs. The main reason for this was the way it enabled individual personalization of care. Conclusions: Findings from the systematic review have implications for the design of future DHIs to improve uptake, retention, and outcomes in DHIs for depression, anxiety, and somatoform disorders. DHIs need to be personalized to the specific needs of the individual. Future research should explore whether the findings could be generalized to other health conditions
  • Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database

    Butler, Debbie; Hollis, Chris P.; Morriss, Richard K. (2020)
    BACKGROUNDAntidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care.METHODSThe study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years).RESULTSIn total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%).CONCLUSIONSThe results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.
  • Incidence of depression and first-line antidepressant therapy in people with obesity and depression in primary care

    Morriss, Richard K. (2020)
    Objective: The aim of this study was to describe the age- and gender-specific incidence of depression, the dose-response relationship between BMI and risk of depression (Cox proportional hazards), and antidepressant drug prescribing in adults with overweight or obesity. Methods: A retrospective electronic health record study using the Clinical Practice Research Datalink was conducted to identify adults with overweight and obesity (≥ 18 years) with incident depression (no prior depression diagnosis in their records), followed up from 2000 to 2019. Results: Among 519,513 adults, incidence of depression was 9.2 per 1,000 person-years and was higher in women and in 40- to 59-year-old men who had severe obesity. Compared with having overweight, the hazard of depression increased with each BMI category as follows: 1.13 (30-34 kg/m2; 95% CI: 1.10-1.16), 1.34 (35-39 kg/m2; 1.29-1.40), 1.51 (40-44 kg/m2; 1.41-1.61), and 1.67 (45-49 kg/m2; 1.48-1.87), attenuating at BMI 50+ kg/m2 (1.54; 2.91-1.84). Antidepressants were prescribed as first-line therapy in two-thirds (66.3%) of cases. Prescriptions for fluoxetine reduced over time (20.4% [2000]; 8.8% [2018]), and prescriptions for sertraline increased (4.3% [2000]; 38.9% [2018]). Conclusions: We recommend guidance on antidepressant drug prescribing and specific services for people with obesity and depression that address both symptoms and behaviors. © 2020 The Obesity Society
  • Brief training in psychological assessment and interventions skills for cancer care staff: A mixed methods evaluation of deliberate practice techniques

    Malins, Samuel; Levene, Jo; Biswas, Sanchia (2020)
    OBJECTIVE: Unaddressed anxiety and depression is common among cancer patients and has significant adverse consequences. Cancer staff training is recommended for psychological assessment and interventions to address depression and anxiety, to increase access to psychosocial oncology care. However, psychological skills training has a poor track-record for improving clinical effectiveness. "Deliberate practice", receiving feedback on therapeutic micro-skills and rehearsing modifications, can enhance clinical effectiveness. This study applied deliberate practice to maximise benefits of brief psychological skills training for cancer care staff. METHOD: Seventeen one-day training workshops were provided to 263 cancer care staff, aiming to improve confidence in assessing anxiety and depression, and delivering problem-solving therapy. Training used deliberate practice methods at the expense of didactic lecturing. Staff confidence was assessed in key teaching domains using pre-post confidence ratings. Anonymous comments from 152 training attendees were examined using thematic analysis. RESULTS: One-day psychological skills training significantly improved cancer staff confidence in assessment of anxiety and depression, and delivery of brief psychological interventions. Thematic analysis indicated that focusing on practical skills was valued by participants and contributed to staff commitments to change practice. However, some participants felt the one-day training was over-filled and would be better delivered over more days. CONCLUSION: Similar results can be achieved by providing psychological skills training on a single-day, as compared to an established five-day programme, by abbreviating didactic teaching and focusing time on deliberate practice of skills. Training may increase the likelihood of changes in practice, but more training time may be required for maximum benefit. This article is protected by copyright. All rights reserved.
  • Clinical and economic outcomes of remotely delivered Cognitive Behavior Therapy for repeat unscheduled care users with severe health anxiety: A multi-center randomized controlled trial

    Morriss, Richard K.; Patel, Shireen; Malins, Samuel; Guo, Boliang; Higton, Fred; Brown, Paula; Cope, Naomi; Kaylor-Hughes, Catherine; Simpson, Jayne; Stubley, Michelle (2019)
    Background: Repeat users of unscheduled health care with severe health anxiety may be challenging to engage in psychological help and incur high service costs. We investigated whether clinical and economic outcomes were improved by offering Remote Cognitive Behaviour Therapy using videoconferencing or telephone (RCBT) compared to Treatment As Usual (TAU). Methods: A single-blind, parallel group, multi-centre randomised controlled trial (RCT) was undertaken in primary and general hospital care. Participants were aged >18 years with >2 unscheduled healthcare contacts within 12 months and clinically severe health anxiety > 18 on the Health Anxiety Inventory (HAI). Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI from baseline to six months on an intention-totreat basis. Results: 156 (33%) participants were recruited out of 470 who were eligible. 78 were randomised to TAU and 78 to RCBT with data available for 112 participants (72%) at six months. Compared to TAU, RCBT significantly reduced health anxiety at six months (mean change difference HAI - 2.81; 95% CI -5.11, -0.50; p=.017), 9 and 12 months with significant improvements in general health, depression and generalised anxiety. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group. Conclusions: Remotely delivered CBT may reduce health anxiety and cost and may be a promising intervention for repeat users of unscheduled care with severe health anxiety.
  • Using smart-messaging to enhance mindfulness-based cognitive therapy for cancer patients: A mixed methods proof of concept evaluation

    Malins, Samuel; Biswas, Sanchia; Sweeney, Timothy; Levene, Jo (2019)
    OBJECTIVE Depression and anxiety lead to reduced treatment adherence, poorer quality of life, and increased care costs amongst cancer patients. Mindfulness-Based Cognitive Therapy (MBCT) is an effective treatment, but dropout reduces potential benefits. Smart-message reminders can prevent dropout and improve effectiveness. However, smart-messaging is untested for MBCT in cancer. This study evaluates smart-messaging to reduce dropout and improve effectiveness in MBCT for cancer patients with depression or anxiety. METHODS Fifty-one cancer patients attending MBCT in a psycho-oncology service were offered a smart-messaging intervention, which reminded them of prescribed between-session activities. Thirty patients accepted smart-messaging and 21 did not. Assessments of depression and anxiety were taken at baseline, session-by-session and one-month follow-up. Logistic regression and multilevel modelling compared the groups on treatment completion and clinical effectiveness. Fifteen post-treatment patient interviews explored smart-messaging use. RESULTS The odds of programme completion were eight times greater for patients using smart-messaging compared with non-users, controlling for age, gender, baseline depression, and baseline anxiety (OR = 7.79, 95% CI 1.75 to 34.58, p = .007). Smart-messaging users also reported greater improvement in depression over the programme (B = -2.33, SEB = .78, p = .004), when controlling for baseline severity, change over time, age, and number of sessions attended. There was no difference between groups in anxiety improvement (B = -1.46, SEB = .86, p = .097). In interviews, smart-messaging was described as a motivating reminder and source of personal connection. CONCLUSIONS Smart-messaging may be an easily integrated telehealth intervention to improve MBCT for cancer patients.
  • Clinical effectiveness and cost minimisation model of Alpha-Stim cranial electrotherapy stimulation in treatment seeking patients with moderate to severe generalised anxiety disorder

    Morriss, Richard K. (2019)
    BACKGROUND: Cranial electrotherapy stimulation (CES) is a well-tolerated neuromodulation treatment with demonstrated trial efficacy in anxiety disorders. The aim of the current study was to demonstrate its clinical and cost effectiveness during and after CES in people with generalised anxiety disorder (GAD) who had not responded to low intensity psychological treatment in a routine health service. METHODS: Consecutive sample of eligible patients with GAD waiting for individual cognitive behaviour therapy (CBT) selected from two publicly funded services in England. They received 60 min per day Alpha-Stim CES for 6-12 weeks. Primary outcome was remission on the GAD-7 scale at 12 and 24 weeks. Cost effectiveness was examined using a cost minimisation model of direct health costs. RESULTS: Of 161 patients recruited, 72 (44.7%) and 77 (47.8%) achieved remission on the GAD-7 at 12 and 24 weeks respectively with 122 (75.8%) receiving at least 6 weeks CES. Mean (sd) GAD-7 score at baseline significantly improved from 15.77 (3.21) to 8.92 (5.42) and 8.99 (6.18) at 12 and 24 weeks respectively (p < 0.001). 80 (49.7%) participants required further individual CBT. CES provided a saving of pound540.88 per patient (95% CI - pound327.12, pound648.69). LIMITATIONS: Participants were not randomised and there was no control group. Only 48 (29.9%) participants completed every assessment. CONCLUSION: In patients with generalised anxiety disorder not responding to low intensity psychological treatment, 6-12 weeks daily Alpha Stim CES may be effective after treatment and 3 months later, thereby reducing the need for individual CBT and saving health costs.

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