Recent Submissions

  • Primary care depression advice clinic

    Ludvigsen, Anna; Nixon, Neil L. (2019)
    Aims and Objectives: The aim of the Depression Advice Clinic (DAC) was to provide timely specialist advice on depression management within a primary care setting for individuals suffering from treatment resistant or recurrent depression. Method(s): The clinic was located in a primary care centre and offered one-off 90 minute assessments to patients referred by their GPs. Patients were seen by a senior psychiatry trainee who conducted a comprehensive psychiatric history, examination, diagnosis and bio-psycho-social formulation. Following discussion with the supervising consultant psychiatrist a letter with recommendations for next step treatments was sent to patient and their GP. The clinic employed one full time senior trainee, a consultant psychiatrist at 12.5% full time equivalent and an administrator at 25% full time equivalent as well as incurring overheads for consultation room rental. Result(s): During the 12 month operational period 127 referrals were received and 124 assessment appointments were offered. The mean wait for assessment was 23 days (in secondary care this is closer to 70 days) and the completed assessment rate was 92% (in local audit of secondary care services this was 81%). Following initial assessment 96% patients were discharged to their GP with advice on lifestyle, self-care and next step pharmacological and psychotherapeutic management option. 4% of patients were transferred directly to secondary/ tertiary care psychiatry, for reasons including severity, risk or initiation of medications that could not be carried out in primary care (e.g. Lithium). Discussion(s): The DAC achieved its aim of providing timely assessment and advice for people suffering from persistent or recurrent depression with most patients being seen much sooner than they would have had they been referred to secondary care. There were also some surprising, and potentially significant, findings from the clinic: more men were referred to the clinic than would have been expected to be seen in secondary services and one third of patients referred with an existing diagnosis of depression had this diagnosis changed following assessment (primarily to one of the anxiety disorders). Each of the patients referred from the DAC into secondary and tertiary care disclosed that they had made plans to end their life which they had concealed form their families and GPs and that being seen in the clinic had prevented them from acting on their plans. Conclusion(s): Referral rates, completed appointment rates and stakeholder feedback suggest that the DAC was an operationally feasible way of working across primary, secondary and tertiary care, whilst also being acceptable to GPs and patients. It is estimated that the average cost per completed suicide for those of working age in England is 1.67m. Since at least three patients reported that being seen in the clinic had prevented them from ending their lives the DAC was also a cost effective way of decreasing the mortality and morbidity resulting from chronic and recurring depression.
  • Depressive symptoms, social support, and health-related quality of life: A community-based study in Shanghai, China

    Crawford, Paul; Kane, Eddie (2021)
    BACKGROUNDDepressive symptoms erode both physical and mental aspects of health-related quality of life (HRQoL). Social support (SS) may improve HRQoL through its direct effects or buffering effects. The association among depressive symptoms, SS, and HRQoL has been studied in specific groups, but research in the general adult population remains limited. This study examined the association among depressive symptoms, SS, and HRQoL, including exploring whether SS (including its three dimensions: subjective SS, objective SS and support utilization) mediated or moderated the relationship between depressive symptoms and HRQoL among community-based adults.METHODSWe conducted a cross-sectional survey in six communities in Shanghai, China, and 1642 adult participants with complete information on depressive symptoms and/or SS, and HRQoL were included. Linear regression analysis was used to investigate the association among depressive symptoms, SS, and HRQoL. In addition, we explored the mediating and moderating role of SS in the relationship between depressive symptoms and HRQoL.RESULTSMore depressive symptoms were associated with lower physical HRQoL (B = -0.64, p < .001) and lower mental HRQoL (B = -0.83, p < .001). SS (B = 0.07, p = .02), specifically subjective SS (B = 0.09, p = .03), was positively related to mental HRQoL. After adjusting for covariates, we found no evidence for a mediating role of SS in the relationship between depressive symptoms and HRQoL, while SS (subjective SS and objective SS) moderated the association between depressive symptoms and mental HRQoL.LIMITATIONSDue to the low voluntary participation rate of employees, participants represented approximately 50% of the individuals approached, thus limiting the generalizability of our findings. Data collected through self-report scales could lead to information bias.CONCLUSIONSSS does not appear to underlie the relationship between depressive symptoms and HRQoL. However, interventions to increase SS (in particular, subjective SS and objective SS) should be studied to determine whether they may be beneficial in alleviating the adverse impact of depressive symptoms on mental HRQoL.
  • Multicentre randomised controlled trial of a group psychological intervention for postnatal depression in British mothers of South Asian origin (ROSHNI-2): study protocol

    Morriss, Richard K. (2022)
    Background In the UK, postnatal depression is more common in British South Asian women than White Caucasion women. Cognitive–behavioural therapy (CBT) is recommended as a first-line treatment, but there is little evidence for the adaptation of CBT for postnatal depression to ensure its applicability to different ethnic groups. Aims To evaluate the clinical and cost-effectiveness of a CBT-based positive health programme group intervention in British South Asian women with postnatal depression. Method We have designed a multicentre, two-arm, partially nested, randomised controlled trial with 4- and 12-month follow-up, comparing a 12-session group CBT-based intervention (positive health programme) plus treatment as usual with treatment as usual alone, for British South Asian women with postnatal depression. Participants will be recruited from primary care and appropriate community venues in areas of high South Asian density across the UK. It has been estimated that randomising 720 participants (360 into each group) will be sufficient to detect a clinically important difference between a 55% recovery rate in the intervention group and a 40% recovery rate in the treatment-as-usual group. An economic analysis will estimate the cost-effectiveness of the positive health programme. A qualitative process evaluation will explore barriers and enablers to study participation and examine the acceptability and impact of the programme from the perspective of British South Asian women and other key stakeholders.
  • The impact of data from remote measurement technology on the clinical practice of healthcare professionals in depression, epilepsy and multiple sclerosis: survey

    Andrews, Jacob A.; Craven, Michael P.; Morriss, Richard K.; Hollis, Chris P. (2021)
    BACKGROUNDA variety of smartphone apps and wearables are available both to help patients monitor their health and to support health care professionals (HCPs) in providing clinical care. As part of the RADAR-CNS consortium, we have conducted research into the application of wearables and smartphone apps in the care of people with multiple sclerosis, epilepsy, or depression.METHODSWe conducted a large online survey study to explore the experiences of HCPs working with patients who have one or more of these conditions. The survey covered smartphone apps and wearables used by clinicians and their patients, and how data from these technologies impacted on the respondents' clinical practice. The survey was conducted between February 2019 and March 2020 via a web-based platform. Detailed statistical analysis was performed on the answers.RESULTSOf 1009 survey responses from HCPs, 1006 were included in the analysis after data cleaning. Smartphone apps are used by more than half of responding HCPs and more than three quarters of their patients use smartphone apps or wearable devices for health-related purposes. HCPs widely believe the data that patients collect using these devices impacts their clinical practice. Subgroup analyses show that views on the impact of this data on different aspects of clinical work varies according to whether respondents use apps themselves, and, to a lesser extent, according to their clinical setting and job role.CONCLUSIONSUse of smartphone apps is widespread among HCPs participating in this large European survey and caring for people with epilepsy, multiple sclerosis and depression. The majority of respondents indicate that they treat patients who use wearables and other devices for health-related purposes and that data from these devices has an impact on clinical practice.
  • 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.
  • Recent advances in electroconvulsive therapy and physical treatments for depression

    Waite, Jonathan (2021)
    This article gives an update for practitioners on recent developments in the use of electroconvulsive therapy (ECT) and related treatment modalities in the contemporary treatment of depression in the UK. Details are provided on new information on the efficacy and side-effects of ECT both in research studies and in the real world, together with recent research on ECT's mode of delivery. There is a focus on the safe administration of ECT in clinical practice. An update on the regulatory framework for ECT in the UK is provided, together with up-to-date information on the legal situation regarding its prescription. Finally, brief summaries of the current position for other neuromodulatory treatment modalities are given.
  • 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.
  • Safety of antidepressants in a primary care cohort of adults with obesity and depression

    Morriss, Richard K. (2021)
    BACKGROUNDObesity, depressive disorders and antidepressant drugs are associated with increased mortality, cardiovascular disease, diabetes, fractures and falls. We explored outcomes associated with the most commonly prescribed antidepressants in overweight or obese people with depression.METHODS AND FINDINGSWe identified a cohort of overweight or obese adults (≥18 years) in primary care from the UK Clinical Practice Research Datalink, linked with hospital and mortality data, between 1 January 2000 and 31 December 2016 who developed incident depression to January 2019. Cox proportional hazards models and 99% confidence intervals were used to estimate hazard ratios (HR) for mortality, cardiovascular disease, diabetes, and falls/fractures associated with exposure to selective serotonin reuptake inhibitors (SSRIs), tricyclic (TCA)/other, combination antidepressants, citalopram, fluoxetine, sertraline, amitriptyline and mirtazapine, adjusting for potential confounding variables. In 519,513 adults, 32,350 (9.2 per 1,000 years) displayed incident depression and 21,436 (66.3%) were prescribed ≥1 antidepressant. Compared with no antidepressants, all antidepressant classes were associated with increased relative risks of cardiovascular disorders [SSRI HR: 1.32 (1.14-1.53), TCA/Other HR: 1.26 (1.01-1.58)], and diabetes (any type) [SSRI HR: 1.28 (1.10-1.49), TCA/Other: 1.52 (1.19-1.94)]. All commonly prescribed antidepressants except citalopram were associated with increased mortality compared with no antidepressants. However, prescription ≥1 year of ≥40mg citalopram was associated with increased mortality and falls/fractures and ≥1 year 100mg sertraline with increased falls/fractures.CONCLUSIONSIn overweight/obese people with depression, antidepressants may be overall and differentially associated with increased risks of some adverse outcomes. Further research is required to exclude indication bias and residual confounding.
  • 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.
  • Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data

    Schneider, Justine (2021)
    BACKGROUND: Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS: We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS: We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION: The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING: Japan Society for the Promotion of Science.
  • How can we estimate QALYs based on PHQ-9 scores? Equipercentile linking analysis of PHQ-9 and EQ-5D

    Schneider, Justine (2021)
    BACKGROUNDQuality-adjusted life years (QALYs) are widely used to measure the impact of various diseases on both the quality and quantity of life and in their economic valuations. It will be clinically important and informative if we can estimate QALYs based on measurements of depression severity.OBJECTIVETo construct a conversion table from the Patient Health Questionnaire-9 (PHQ-9), the most frequently used depression scale in recent years, to the Euro-Qol Five Dimensions Three Levels (EQ-5D-3L), one of the most commonly used instruments to assess QALYs.METHODSWe obtained individual participant data of randomised controlled trials of internet cognitive-behavioural therapy which had administered depression severity scales and the EQ-5D-3L at baseline and at end of treatment. Scores from depression scales were all converted into the PHQ-9 according to the validated algorithms. We used equipercentile linking to establish correspondences between the PHQ-9 and the EQ-5D-3L.FINDINGSIndividual-level data from five trials (total N=2457) were available. Subthreshold depression (PHQ-9 scores between 5 and 10) corresponded with EQ-5D-3L index values of 0.9-0.8, mild major depression (10-15) with 0.8-0.7, moderate depression (15-20) with 0.7-0.5 and severe depression (20 or higher) with 0.6-0.0. A five-point improvement in PHQ-9 corresponded approximately with an increase in EQ-5D-3L score by 0.03 and a ten-point improvement by approximately 0.25.CONCLUSIONS AND CLINICAL IMPLICATIONSThe conversion table between the PHQ-9 and the EQ-5D-3L scores will enable fine-grained assessment of burden of depression at its various levels of severity and of impacts of its various treatments.
  • Psychometric properties of the five facets mindfulness questionnaire in moderate-to-severe, persistent depression

    Sweeney, Timothy; Morriss, Richard K.; Nixon, Elena; Guo, Boliang; Callaghan, Patrick (2021)
    ObjectivesMindfulness has been increasingly incorporated into modern psychotherapies and healthcare services. The importance of psychometrically quantifying the construct of mindfulness has become paramount. One of the most reliable and valid instruments for the assessment of different aspects of dispositional mindfulness is the Five Facets Mindfulness Questionnaire (FFMQ). However, the psychometric properties of the FFMQ are yet to be tested in individuals with high levels of persistent depression. This study therefore investigated the psychometric properties of the FFMQ in a clinical sample with moderate-to-severe, persistent depression.MethodsThe data of 187 participants recruited from a funded randomised controlled trial were utilised. Internal consistency was assessed and construct validity was examined with confirmatory factor analyses (CFA) and by statistically correlating the FFMQ to measures of depression, self-compassion, rumination and experiential avoidance.ResultsFindings supported the internal consistency of the FFMQ. CFA fit indices indicated that all correlated and hierarchical models fitted the data acceptably, with results slightly favouring the correlated model. Contrary to predictions however, individual facet loadings showed that the facet Observe loaded strongly onto an overarching factor of mindfulness, whilst Nonjudge loaded marginally. Nonjudge further showed a non-significant correlation with depression. However, exploratory post hoc analysis presented findings inconsistent with CFA.ConclusionsIn a sample of severely depressed individuals, psychometric investigation of the validity of the FFMQ highlighted contradictory findings relating to “Nonjudge”. Whilst such findings potentially challenge the validity of the FFMQ for use in its current structure in this sample, further investigation with a larger population is warranted.Trial RegistrationClinicalTrials.gov (NCT01047124) and the ISRCTN registry (ISRCTN10963342) (PsycInfo Database Record (c) 2021 APA, all rights reserved) (Source: journal abstract)
  • Informing the development of a digital health platform through universal points of care: Qualitative survey study

    Craven, Michael P.; Andrews, Jacob A.; Morriss, Richard K.; Hollis, Chris P. (2020)
    BACKGROUNDEpilepsy, multiple sclerosis (MS), and depression are chronic conditions where technology holds potential in clinical monitoring and self-management. Over 5 years, the Remote Assessment of Disease and Relapse - Central Nervous System (RADAR-CNS) consortium has explored the application of remote measurement technology (RMT) to the management and self-management of patients in these clinical areas. The consortium is large and includes clinical and nonclinical researchers as well as a patient advisory board.OBJECTIVEThis formative development study aimed to understand how consortium members viewed the potential of RMT in epilepsy, MS, and depression.METHODSIn this qualitative survey study, we developed a methodological tool, universal points of care (UPOC), to gather views on the potential use, acceptance, and value of a novel RMT platform across 3 chronic conditions (MS, epilepsy, and depression). UPOC builds upon use case scenario methodology, using expert elicitation and analysis of care pathways to develop scenarios applicable across multiple conditions. After developing scenarios, we elicited views on the potential of RMT in these different scenarios through a survey administered to 28 subject matter experts, consisting of 16 health care practitioners; 5 health care services researchers; and 7 people with lived experience of MS, epilepsy, or depression. Survey results were analyzed thematically and using an existing framework of factors describing links between design and context.RESULTSThe survey elicited potential beneficial applications of the RADAR-CNS RMT system as well as patient, clinical, and nonclinical requirements of RMT across the 3 conditions of interest. Potential applications included recognition of early warning signs of relapse from subclinical signals for MS, seizure precipitant signals for epilepsy, and behavior change in depression. RMT was also thought to have the potential to overcome the problem of underreporting, which is especially problematic in epilepsy, and to allow the capture of secondary symptoms that are not generally collected in MS, such as mood.CONCLUSIONSRespondents suggested novel and unanticipated uses of RMT, including the use of RMT to detect emerging side effects of treatment, enable behavior change for sleep regulation and activity, and offer a way to include family and other carers in a care network, which could assist with goal setting. These suggestions, together with others from this and related work, will inform the development of the system for its eventual application in research and clinical practice. The UPOC methodology was effective in directing respondents to consider the value of health care technologies in condition-specific experiences of everyday life and working practice.
  • The bi-factor structure of the 17-item Hamilton Depression Rating Scale in persistent major depression; dimensional measurement of outcome

    Nixon, Neil L.; Guo, Boliang; Garland, Anne; Kaylor-Hughes, Catherine; Nixon, Elena; Morriss, Richard K. (2020)
    BACKGROUNDThe 17-item Hamilton Depression Rating Scale (HDRS17) is used world-wide as an observer-rated measure of depression in randomised controlled trials (RCTs) despite continued uncertainty regarding its factor structure. This study investigated the dimensionality of HDRS17 for patients undergoing treatment in UK mental health settings with moderate to severe persistent major depressive disorder (PMDD).METHODSExploratory Structural Equational Modelling (ESEM) was performed to examine the HDRS17 factor structure for adult PMDD patients with HDRS17 score ≥16. Participants (n = 187) were drawn from a multicentre RCT conducted in UK community mental health settings evaluating the outcomes of a depression service comprising CBT and psychopharmacology within a collaborative care model, against treatment as usual (TAU). The construct stability across a 12-month follow-up was examined through a measurement equivalence/invariance (ME/I) procedure via ESEM.RESULTSESEM showed HDRS17 had a bi-factor structure for PMDD patients (baseline mean (sd) HDRS17 22.6 (5.2); 87% PMDD >1 year) with an overall depression factor and two group factors: vegetative-worry and retardation-agitation, further complicated by negative item loading. This bi-factor structure was stable over 12 months follow up. Analysis of the HDRS6 showed it had a unidimensional structure, with positive item loading also stable over 12 months.CONCLUSIONSIn this cohort of moderate-severe PMDD the HDRS17 had a bi-factor structure stable across 12 months with negative item loading on domain specific factors, indicating that it may be more appropriate to multidimensional assessment of settled clinical states, with shorter unidimensional subscales such as the HDRS6 used as measures of change.
  • 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.
  • 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.
  • Connectivity guided theta burst transcranial magnetic stimulation versus repetitive transcranial magnetic stimulation for treatment-resistant moderate to severe depression: study protocol for a randomised double-blind controlled trial (BRIGhTMIND)

    Morriss, Richard K.; Webster, Lucy; Briley, Paul M.; Iwabuchi, Sarina J.; James, Marilyn; Kaylor-Hughes, Catherine; Lankappa, Sudheer; Liddle, Peter F.; Thomson, Louise (2020)
    INTRODUCTIONThe BRIGhTMIND study aims to determine the clinical effectiveness, cost-effectiveness and mechanism of action of connectivity guided intermittent theta burst stimulation (cgiTBS) versus standard repetitive transcranial magnetic stimulation (rTMS) in adults with moderate to severe treatment resistant depression.METHODS AND ANALYSISThe study is a randomised double-blind controlled trial with 1:1 allocation to either 20 sessions of (1) cgiTBS or (2) neuronavigated rTMS not using connectivity guidance. A total of 368 eligible participants with a diagnosis of current unipolar major depressive disorder that is both treatment resistant (defined as scoring 2 or more on the Massachusetts General Hospital Staging Score) and moderate to severe (scoring >16 on the 17-item Hamilton Depression Rating Scale (HDRS-17)), will be recruited from primary and secondary care settings at four treatment centres in the UK. The primary outcome is depression response at 16 weeks (50% or greater reduction in HDRS-17 score from baseline). Secondary outcomes include assessments of self-rated depression, anxiety, psychosocial functioning, cognition and quality of life at 8, 16 and 26 weeks postrandomisation. Cost-effectiveness, patient acceptability, safety, mechanism of action and predictors of response will also be examined.ETHICS AND DISSEMINATIONEthical approval was granted by East Midlands Leicester Central Research Ethics Committee (ref: 18/EM/0232) on 30 August 2018. The results of the study will be published in relevant peer-reviewed journals, and then through professional and public conferences and media. Further publications will explore patient experience, moderators and mediators of outcome and mechanism of action.TRIAL REGISTRATION NUMBERISRCTN19674644.
  • 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

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