• A cluster randomised controlled trial to determine the clinical effectiveness and cost-effectiveness of classroom-based cognitive-behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents

      Taylor, John A.; Sayal, Kapil (2013)
      Background: Depression in adolescents is a significant problem that impairs everyday functioning and increases the risk of severe mental health disorders in adulthood. Although this is a major problem, relatively few adolescents with, or at risk of developing, depression are identified and referred for treatment. This suggests the need to investigate alternative approaches whereby preventative interventions are made widely available in schools. Objective: To investigate the clinical effectiveness and cost-effectiveness of classroom-based cognitive- behavioural therapy (CBT) in reducing symptoms of depression in high-risk adolescents. Design: Cluster randomised controlled trial. Year groups (n = 28) randomly allocated on a 1: 1: 1 basis to one of three trial arms once all schools were recruited and balanced for number of classes, number of students, Personal, Social and Health Education (PSHE) lesson frequency, and scheduling of PSHE. Setting: Year groups 8 to 11 (ages 12-16 years) in mixed-sex secondary schools in the UK. Data were collected between 2009 and 2011. Participants: Young people who attended PSHE at participating schools were eligible (n = 5503). Of the 5030 who agreed to participate, 1064 (21.2%) were classified as 'high risk': 392 in the classroom-based CBT arm, 374 in the attention control PSHE arm and 298 in the usual PSHE arm. Primary outcome data on the high-risk group at 12 months were available for classroom-based CBT (n = 296), attention control PSHE (n = 308) and usual PSHE (n = 242). Interventions: The Resourceful Adolescent Programme (RAP) is a focused CBT-based intervention adapted for the UK (RAP-UK) and delivered by two facilitators external to the school. Control groups were usual PSHE (usual school curriculum delivered by teachers) and attention control (usual school PSHE with additional support from two facilitators). Interventions were delivered universally to whole classes. Primary outcomes: Clinical effectiveness: symptoms of depression [Short Mood and Feelings Questionnaire (SMFQ)] in adolescents at high risk of depression 12 months from baseline. Cost-effectiveness: incremental cost-effectiveness ratios (ICERs) based on SMFQ score and quality-adjusted life-years (from European Quality of Life-5 Dimensions scores) between baseline and 12 months. Process evaluation: reach, attrition and qualitative feedback from service recipients and providers. Results: SMFQ scores had decreased for high-risk adolescents in all trial arms at 12 months, but there was no difference between arms [classroom-based CBT vs. usual PSHE adjusted difference in means 0.97, 95% confidence interval (CI) -0.34 to 2.28; classroom-based CBT vs. attention control PSHE -0.63, 95% CI -1.99 to 0.73]. Costs of interventions per child were estimated at 41.96 for classroom-based CBT and 34.45 for attention control PSHE. Fieller's method was used to obtain a parametric estimate of the 95% CI for the ICERs and construct the cost-effectiveness acceptability curve, confirming that classroom-based CBT was not cost-effective relative to the controls. Reach of classroom-based CBT was good and attrition was low (median 80% attending > 60% of sessions), but feedback indicated some difficulties with acceptability and sustainability. Conclusions: Classroom-based CBT, attention control PSHE and usual PSHE produced similar outcomes. Classroom-based CBT may result in increased self-awareness and reporting of depressive symptoms. Classroom-based CBT was not shown to be cost-effective. While schools are a convenient way of reaching a wide range of young people, implementing classroom-based CBT within schools is challenging, particularly with regard to fitting programmes into a busy timetable, the lack of value placed on PSHE, and difficulties engaging with teachers and young people. Wider use of classroom-based depression prevention programmes should not be undertaken without further research. If universal preventative approaches are to be pursued, their clinical effectiveness and cost-effectiveness with younger children (aged 10-11 yea s), before the incidence of depression increases, should be investigated. Alternatively, the clinical effectiveness of indicated school-based programmes targeting those already displaying symptoms of depression should be investigated. © Queen's Printer and Controller of HMSO 2013.
    • A comparison of the screening potential of the geriatric depression scale (GDS) and the hospital anxiety and depression scale (HADS) in diagnosing depression at a geriatric day hospital setting

      Das, Sujata (2010)
      Background Depression is a common condition in older people affecting approximately 10% of elderly people of all age groups living at home (Morgan et al 1987). Some studies suggest that prevalence is higher in those with medical conditions. There are several screening tools used in diagnosing depression, but it is unknown which tool is most effective in a setting such as the Medical Geriatric Day Hospital. Aim of this study was to compare the usefulness of two commonly used screening tools; the Geriatric Depression Scale (GDS) and the Hospital Anxiety and Depression Scale (HADS), by employing the Diagnostic and Statistical manual (DSM IV) as the "gold standard" method of diagnosing depression. Method Consecutive patients aged over 65 years attending the Medical Geriatric Day Hospital were recruited. GDS (15) and HADS were administered by a trained nurse. An independent Old Age Psychiatrist, blinded to the screening tool results, performed the DSM IV assessment in a standardised manner. Results 101 participants (58 women) were recruited. Mean age (SD; range) of the study population was 79.4 (6.7; 65-93) years. Prevalence of depression in the studied population using the DSM IV was 22.8%. Sensitivities and specificities(95%CI) of the GDS (15) in diagnosing depression were 78.3%(70.3-86.3) and 73.0%(64.4-81.6) and those of HADS were 69.6%(60.6-78.6) and 78.2%(70.1-86.3) respectively. Positive predictive values for GDS (15) and HADS were 46.2%(36.5-55.9) and 48.5%(38.7-57.7) and the negative predictive values were 91.9%(86.6-97.2) and 89.7%(83.8-95.6) respectively. False positive rates were 53.8%(44.1-63.5) and 51.5%(41.8-61.2) and false negative rates were 8.1%(2.8-13.4) and 10.3%(4.4-16.2) respectively. Conclusions Both GDS (15) and HADS had a relatively high negative predictive value suggesting that they may have value in ruling out depression. However the false positive rates mean that patients screened positive in both tools require a more comprehensive assessment as approximately half will not have depression. The two screening tools performed similarly.
    • A large scale pragmatic validation of the HADS for major depression in an ethnically diverse cancer population

      Baker-Glenn, Elena A. (2010)
      OBJECTIVES: There is considerable interest in the accuracy of the Hospital Anxiety and Depression Scale in cancer. The HADS is the single most commonly applied tool for depression, tested to date in 22 analyses against major depressive disorder (MDD). However, only one previous study had a sample size over 300 (Walker et al. 2007 J Psychosom Res 63: 83-91). METHOD: We analysed data collected from Leicester Cancer Centre from 2007-2009 involving approximately 1000 people approached by a research nurse, research physician and two therapeutic radiographers. The researcher applied DSMIV criteria of major depressive disorder (MDD). We collated full data on 690 patient assessments of whom 12.9% had MDD, 121 were palliative and 115 (16.7%) were from ethnic minorities (largely British South Asian of India descent). RESULTS: Sensitivity and specificity were as follows HADS-A 87.6%/72.3; HADS-D 86.5%/80.1% and HADS-T 95.5%/76.3%. The AUC was highest for HADS-T > HADS-D > HADS-A. In ethnic minorities sensitivity and specificity were as follows HADS-A 93.1%/66.3%; HADS-D 86.2%/65.1% and HADS-T 96.6%/66.3%. AUC was poor for the HADS-D from the ethnic group and HADS-A/HADS-T were preferred. There was no difference by cancer stage. CONCLUSIONS: This is the largest validation study of the HADS in cancer and suggests that in an ethnically diverse population the HADS-T may be the optimal version based on accuracy alone; regardless of cancer stage. The HADS-D may have weaker validity in patients from ethnic minority populations.
    • A qualitative process evaluation of classroom-based cognitive behaviour therapy to reduce adolescent depression

      Taylor, John A.; Sayal, Kapil (2014)
      Small scale trials indicate that classroom-based Cognitive Behaviour Therapy (CBT) for adolescents has good reach and can help prevent depression. However, under more diverse everyday conditions, such programmes tend not to show such positive effects. This study examined the process of implementing a classroom-based CBT depression prevention programme as part of a large (n = 5,030) randomised controlled trial across eight UK secondary schools which was not found to be effective (PROMISE, ISRCTN19083628). The views of young people (n = 42), teachers (n = 12) and facilitators (n = 16) involved in the Resourceful Adolescent Programme (RAP) were obtained via focus groups and interviews which were thematically analysed. The programme was considered to be well structured and contain useful content, particularly for younger pupils. However, challenges associated with implementation were its age appropriateness for all year groups, its perceived lack of flexibility, the consistency of quality of delivery, the competing demands for teacher time and a culture where academic targets were prioritised over personal, social and health education. Whilst schools are convenient locations for introducing such programmes and allow good reach, the culture around improving well-being of young people in schools, increasing engagement with teachers and young people and sustaining such programmes are issues that need addressing.
    • A survey of the prescribing of selective serotonin reuptake inhibitors by psychiatrists

      Lawton, John D.; Naik, Prakash (1995)
      Questionnaires were sent to 92 doctors asking them aspects of their antidepressant prescribing; 72 returned them. Sixty had prescribed selective serotonin reuptake inhibitors (SSRIs) in the previous year. The ratio of SSRIs to all antidepressants prescribed in the previous year exceeded 40% in only eight doctors. Inability to tolerate and failure to respond to established antidepressants were the most common indications for prescribing SSRIs. Side effects and cost were the most common reasons deterring doctors from prescribing SSRIs. SSRIs being new products and doubtS regarding their efficacy were factors that were significantly more likely to deter 'doctors of other grades' than consultants from prescribing them. Fluoxetine and paroxetine were the most frequently prescribed SSRIs.
    • A systematic review of studies of depression prevalence in university students

      Adams, Clive E.; Glazebrook, Cris (2013)
      Background: Depression is a common health problem, ranking third after cardiac and respiratory diseases as a major cause of disability. There is evidence to suggest that university students are at higher risk of depression, despite being a socially advantaged population, but the reported rates have shown wide variability across settings. Purpose: To explore the prevalence of depression in university students. Method: PubMed, PsycINFO, BioMed Central and Medline were searched to identify studies published between 1990 and 2010 reporting on depression prevalence among university students. Searches used a combination of the terms depression, depressive symptoms, depressive disorders, prevalence, university students, college students, undergraduate students, adolescents and/or young adults. Studies were evaluated with a quality rating. Results: Twenty-four articles were identified that met the inclusion and exclusion criteria. Reported prevalence rates ranged from 10% to 85% with a weighted mean prevalence of 30.6%. Conclusions: The results suggest that university students experience rates of depression that are substantially higher than those found in the general population. Study quality has not improved since 1990. © 2012 Elsevier Ltd.
    • 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
    • Acceptability of online self-help to people with depression: Users' views of MoodGYM versus informational websites

      Schneider, Justine (2014)
      Background: Little is known about the factors that influence acceptability of and adherence to online psychological interventions. Evidence is needed to guide further development of promising programs. Objective: Our goal was to investigate users' views of two online approaches to self-help for depression: computerized cognitive behavior therapy (cCBT) and informational websites, in a workplace context. Computerized CBT offers an inexpensive and accessible alternative to face-to-face therapy, and employers have an interest in reducing the working time lost to depression or stress. Yet little is known about how employees, who have actual experience of using online approaches, judge the intervention as a process. Methods: The qualitative data reported here were collected within an online randomized controlled trial whose participants had diagnosable depression. The experimental intervention was a 5-week cCBT program called MoodGYM, and the control condition was five informational websites about mental health. Data were collected via online questionnaires. There was no evidence of the superiority of either in terms of treatment outcomes. In parallel, using brief rating scales and open-ended questions designed for this purpose, we examined the relative acceptability of each approach over time, including perceptions of cCBT compared to seeing a health care professional. Results: At least 60% of participants held online therapy to be at least as acceptable as seeing a professional about mental health issues, and they were more likely to retain this opinion over time if they used the interactive program, MoodGYM, rather than informational websites alone. Barriers to cCBT use fell into four categories: intrinsic, intrapersonal problems; extrinsic technical problems; generic issues mostly pertaining to perceptions of cCBT; and specific issues about the intervention or control condition. These indicate strategies for improving engagement. Conclusions: As first-aid for mild to moderate mental health problems, evidence-based computerized approaches have broad acceptability. This could be increased by attending to the barriers noted here and by proactively managing users' expectations at individual and organizational levels. The findings have implications for occupational health providers and others addressing the needs of working-age adults with depression. They also raise methodological issues for online research. (PsycINFO Database Record (c) 2016 APA, all rights reserved)
    • Alterations in effective connectivity anchored on the insula in major depressive disorder

      Iwabuchi, Sarina J.; Liddle, Elizabeth B.; Liddle, Peter F.; Palaniyappan, Lena (2014)
      Recent work has identified disruption of several brain networks involving limbic and cortical regions that contribute to the generation of diverse symptoms of major depressive disorder (MDD). Of particular interest are the networks anchored on the right anterior insula, which binds the cortical and limbic regions to enable key functions that integrate bottom-up and top-down information in emotional and cognitive processing. Emotional appraisal has been linked to a presumed hierarchy of processing, from sensory percepts to affective states. But it is unclear whether the network level dysfunction seen in depression relates to a breakdown of this presumed hierarchical processing system from sensory to higher cognitive regions, mediated by core limbic regions (e.g. insula). In 16 patients with current MDD, and 16 healthy controls, we investigated differences in directional influences between anterior insula and the rest of the brain using resting-state functional magnetic resonance imaging (fMRI) and Granger-causal analysis (GCA), using anterior insula as a seed region. Results showed a failure of reciprocal influence between insula and higher frontal regions (dorsomedial prefrontal cortex) in addition to a weakening of influences from sensory regions (pulvinar and visual cortex) to the insula. This suggests dysfunction of both sensory and putative self-processing regulatory loops centered around the insula in MDD. For the first time, we demonstrate a network-level processing defect extending from sensory to frontal regions through insula in depression. Within limitations of inferences drawn from GCA of resting fMRI, we offer a novel framework to advance targeted network modulation approaches to treat depression.; Copyright © 2014 Elsevier B.V. and ECNP. All rights reserved.
    • An experimental study exploring the impact of vignette gender on the quality of university students' mental health first aid for peers with symptoms of depression

      Davies, E. Bethan; Morriss, Richard K.; Glazebrook, Cris (2016)
      BACKGROUND: University students have high rates of depression, and friends are often the most commonly-used source of support for emotional distress in this population. This study aimed to explore students' ability to provide effective support for their peers with depressive symptoms and the factors influencing the quality of their mental health first aid (MHFA) skills, including students' gender, course of study, and gender of student experiencing depression. METHODS: Via an online survey, students at two British universities (N = 483) were quasi-randomly allocated to view a video vignette of either a male or female student depicting symptoms of depression. An open-ended question probed MHFA actions they would take to help the vignette character, which were rated using a standardised scoring scheme based on MHFA guidelines. RESULTS: Students reported low MHFA scores (mean 2.89, out of possible 12). The most commonly reported action was provision of support and information, but only eight (1.6%) students stated an intention to assess risk of harm. Those studying clinically non-relevant degrees with limited mental health content reported poorer MHFA (p = <0.001) and were less confident about their ability to support a friend with depression (p = 0.04). There was no main effect of vignette gender, but within the group of students on non-relevant courses the male vignette received significantly poorer MHFA than the female vignette (p = 0.02). A significant three-way interaction found that male participants studying non-relevant degrees who viewed a male vignette had poorer MHFA compared to females studying non-relevant degrees who viewed the female vignette (p = 0.005). CONCLUSIONS: Most students lack the necessary MHFA skills to support friends suffering from symptoms of depression, or to help them get appropriate support and prevent risk of harm. Students on courses which do not include mental health related content are particularly ill-equipped to support male students, with male students receiving the poorest quality MHFA from fellow male students on these courses. MHFA training has the potential to improve outcomes for students with depression, and could have a valuable role in reducing the excess risk of harm seen in male students.
    • An investigation of the factors associated with an increased risk of psychological morbidity in burn injured patients

      Tedstone, Josephine E. (1998)
      Previous research aimed at identifying factors that increase the risk of major burns patients experiencing psychological problems post-burn has generally ignored the potential role of psychological factors. In a prospective study, patients with burn injuries ranging from < 1 per cent up to 40 per cent were interviewed within 2 weeks of sustaining the burn and followed up at ca 3 months post-burn in order to assess the effects of both non-psychological and psychological factors on their subsequent mental health. The factors investigated included burn related information, demographic information, previous psychiatric history, levels of psychological morbidity at 2 weeks post-burn, responsibility for the injury, previous life events, compensation claims and factors from the coping literature including appraisal, coping strategies and coping efficacy. Forward stepwise multiple regression analyses were used to investigate the relationships between these factors and subsequent mental health. Post-burn psychological morbidity was strongly associated with psychological factors including levels of psychological morbidity in the first 2 weeks of sustaining the injury and factors from the coping literature.;
    • An investigation of the prevalence of psychological morbidity in burn-injured patients

      Tedstone, Josephine E. (1997)
      Research on the psychological impact of burn injuries has concentrated on major burns, while small burns have been largely neglected. In a prospective study, 45 patients with burn injuries ranging from 1 per cent or less up to 40 per cent total body surface area were assessed using semi-structured interviews within 2 weeks of sustaining the burn, and followed-up at approximately 3 months postburn to investigate the prevalence of mental health problems. The prevalence of clinically significant levels of anxiety, intrusions and avoidance remained similar at 2 weeks and 3 months postburn, however, the prevalence of depression and Post Traumatic Stress Disorder (PTSD) increased 6- and 4-times, respectively, by 3 months. Patients with small burn injuries of 1 per cent or less also experienced clinically significant levels of psychological difficulties postburn. The implications for the identification of patients at risk of future psychological morbidity are discussed.;
    • Antidepressant drugs and generic counselling for treatment of major depression in primary care: Randomised trial with patient preference arms

      Bedi, Navjot; Duggan, Conor (2001)
      Objectives: To compare the efficacy of antidepressant drugs and generic counselling for treating mild to moderate depression in general practice. To determine whether the outcomes were similar for patients with randomly allocated treatment and those expressing a treatment preference. Design: Randomised controlled trial, with patient preference arms. Follow up at 8 weeks and 12 months and abstraction of GP case notes. Setting: 31 general practices in Trent region. Participants: Patients aged 18-70 who met research diagnostic criteria for major depression; 103 patients were randomised and 220 patients were recruited to the preference arms. Main outcome measures: Difference in mean Beck depression inventory score; time to remission; global outcome assessed by a psychiatrist using all data sources; and research diagnostic criteria. Results: At 12 months there was no difference between the mean Beck scores in the randomised arms. Combining the randomised and patient preference groups, the difference in Beck scores was 0.4 (95% confidence interval -2.7 to 3.5). Patients choosing counselling did better than those randomised to it (mean difference in Beck score 4.6, 0.0 to 9.2). There was no difference in the psychiatrist's overall assessment of outcome between any of the groups. 221/265(83%) of participants with a known outcome had a remission. Median time to remission was shorter in the group randomised to antidepressants than the other three groups (2 months upsilon 3 months). 33/221 (15%) patients had a relapse. Conclusions: Generic counselling seems to be as effective as antidepressant treatment for mild to moderate depressive illness, although patients receiving antidepressants may recover more quickly. General practitioners should allow patients to have their preferred treatment.
    • Antidepressant use and risk of adverse outcomes in people aged 20-64 years: cohort study using a primary care database

      Morriss, Richard K. (2018)
      BACKGROUNDAntidepressants are one of the most commonly prescribed medications in young and middle-aged adults, but there is relatively little information on their safety across a range of adverse outcomes in this age group. This study aimed to assess associations between antidepressant treatment and several adverse outcomes in people aged 20-64 years diagnosed with depression.METHODSWe conducted a cohort study in 238,963 patients aged 20-64 years registered with practices across the UK contributing to the QResearch primary care database. Only patients with a first diagnosis of depression were included. Outcomes were falls, fractures, upper gastrointestinal bleed, road traffic accidents, adverse drug reactions and all-cause mortality recorded during follow-up. Cox proportional hazards models were used to estimate hazard ratios associated with antidepressant exposure adjusting for potential confounding variables.RESULTSDuring 5 years of follow-up, 4651 patients had experienced a fall, 4796 had fractures, 1066 had upper gastrointestinal bleeds, 3690 had road traffic accidents, 1058 had experienced adverse drug reactions, and 3181 patients died. Fracture rates were significantly increased for selective serotonin reuptake inhibitors (adjusted hazard ratio 1.30, 95% CI 1.21-1.39) and other antidepressants (1.28, 1.11-1.48) compared with periods when antidepressants were not used. All antidepressant drug classes were associated with significantly increased rates of falls. Rates of adverse drug reactions were significantly higher for tricyclic and related antidepressants (1.54, 1.25-1.88) and other antidepressants (1.61, 1.22-2.12) compared with selective serotonin reuptake inhibitors. Trazodone was associated with a significantly increased risk of upper gastrointestinal bleed. All-cause mortality rates were significantly higher for tricyclic and related antidepressants (1.39, 1.22-1.59) and other antidepressants (1.26, 1.08-1.47) than for selective serotonin reuptake inhibitors over 5 years but not 1 year, and were significantly reduced after 85 or more days of treatment with selective serotonin reuptake inhibitors. Mirtazapine was associated with significantly increased mortality rates over 1 and 5 years of follow-up.CONCLUSIONSSelective serotonin reuptake inhibitors had higher rates of fracture than tricyclic and related antidepressants but lower mortality and adverse drug reaction rates than the other antidepressant drug classes. The association between mirtazapine and increased mortality merits further investigation. These risks should be carefully considered and balanced against potential benefits for individual patients when the decision to prescribe an antidepressant is made.
    • Antidepressants for people with both schizophrenia and depression

      Furtado, Vivek (2002)
      Background: Depressive symptoms, often of substantial severity, are found in 50% of newly diagnosed suffers of schizophrenia and 33% of people with chronic schizophrenia who have relapsed. Depression is associated with dysphoria, disability, reduction of motivation to accomplish tasks and the activities of daily living, an increased duration of illness and more frequent relapses. Objectives: To determine the clinical effects of antidepressant medication for the treatment of depression in people who also suffer with schizophrenia. Search methods: We undertook electronic searches of the Cochrane Schizophrenia Group's Register (October 2000), ClinPsych (1988-2000), The Cochrane Library (Issue 3, 2000), EMBASE (1980-2000) and MEDLINE (1966-2000). This was supplemented by citation searching, personal contact with authors and pharmaceutical companies. We updated this search January 2013 and added 71 new trials to the awaiting assessment section. Selection criteria: All randomised clinical trials that compared antidepressant medication with placebo for people with schizophrenia or schizoaffective disorder who were also suffering from depression. Data collection and analysis: Data were independently selected and extracted. For homogeneous dichotomous data the fixed effects risk difference (RD), the 95% confidence intervals (CI) and, where appropriate, the number needed to treat (NNT) were calculated on an intention-to-treat basis. For continuous data, reviewers calculated weighted mean differences. Statistical tests for heterogeneity were also undertaken. Main results: Eleven studies met the inclusion criteria. All were small, and randomised fewer than 30 people to each group. Most included people after the most acute phase of psychosis and investigated a wide range of antidepressants. The quality of reporting varied a great deal. For the outcome of 'no important clinical response' antidepressants were significantly better than placebo (n=209, 5 RCTs, summary risk difference fixed effects -0.26, 95% CI -0.39 to -0.13, NNT 4 95% CI 3 to 8). The depression score at the end of the trial, as assessed by the Hamilton Rating Scale (HAM-D), seemed to suggest that using antidepressants was beneficial, but this was only statistically significant when a fixed effects model was used (n=261, 6 RCTs, WMD fixed effects -2.2 95% CI -3.8 to -0.6; WMD random effects -2.1 95% CI -5.04 to 0.84). There was no evidence that antidepressant treatment led to a deterioration of psychotic symptoms in the included trials. Heterogeneous data on 'any adverse effect' are equivocal (n=110, 2 RCTs, RD fixed 0.11 CI -0.03 to 0.25, Chi square 7.5, df=1, p=0.0062). In one small study extrapyramidal adverse effects were reported less often by those allocated to antidepressant (n=52, 1 RCT, RD fixed -0.28 CI -0.5 to -0.04). Only about 10% of people left these studies by 12 weeks. There was no apparent difference between those allocated placebo and those given an antidepressant (n=426, 10 RCTs, RD fixed 0.04 CI -0.02 to 0.1). Authors' conclusions: Overall, the literature was of poor quality, and only a small number of trials made useful contributions. Though our results provide some evidence to indicate that antidepressants may be beneficial for people with depression and schizophrenia, the results, at best, are likely to overestimate the treatment effect, and, at worst, could merely reflect selective reporting of statistically significant results and publication bias. At present, there is no convincing evidence to support or refute the use of antidepressants in treating depression in people with schizophrenia. We need further well-designed, conducted and reported research to determine the best approach towards treating depression in people with schizophrenia. Note: the 71 citations in the awaiting classification section of the review may alter the conclusions of the review once assessed.<br/>Copyright &#xa9; 2013 The Cochrane Collaboration.
    • Anxiety, depression and PTSD symptoms in relatives of ICU patients: A review of the literature

      Tedstone, Josephine E. (2004)
      Studies using designated, reliable and valid mental health questionnaires or structured clinical interviews measuring anxiety, depression or post traumatic stress disorder (PTSD) in family members of adult intensive care patients were reviewed with reference to design, measures used and main findings. The majority described anxiety levels, which may be initially high, but reduce significantly after discharge. Existing characteristics of relatives, patient characteristics and elements of the ICU environment may all predispose family members to high levels of initial anxiety. Some interventions to reduce anxiety in the short term have been successful, and elements of these methods could be incorporated into routine family care in ICU. There is a lack of research investigating the long-term mental health of relatives who continue to care for patients some months after discharge.
    • Assessing effectiveness of treatment of depression in primary care: Partially randomised preference trial

      Duggan, Conor (2000)
      Background: There is a mismatch between the wish of a patient with depression to have counselling and the prescription of antidepressants by the doctor. Aims: To determine whether counselling is as effective as antidepressants for depression in primary care and whether allowing patients to choose their treatment affects their response. Method: A partially randomised preference trial, with patients randomised to either antidepressants or counselling or given their choice of either treatment. The treatment and follow-up were identical in the randomised and patient preference arms. Results: There were 103 randomised and 220 preference patients in the trial. We found: No differences in the baseline characteristics of the randomised and preference groups; that the two treatments were equally effective at 8 weeks, both for the randomised group and when the randomised and patient preference groups for a particular treatment were combined; and that expressing a preference for either treatment conferred no additional benefit on outcome. Conclusions: These data challenge several assumptions about the most appropriate treatment for depression in a primary care setting. Declaration of interest: None. The NHS Executive, Trent, funded the study.
    • Assessment and immediate management of patients with medically unexplained symptoms in primary care

      Morriss, Richard K. (2009)
      Medically unexplained symptoms (MUS) are physical symptoms that doctors cannot explain by organic pathology, which distress or impair the functioning of the patient. Patients with MUS account for around 50% more visits to primary care doctors, one-third more secondary care contacts than patients without MUS. MUS are often precipitated or exacerbated by psychosocial stress, depression and anxiety. Primary care consultations can take the form of a contest between the patient with MUS and the doctors: the doctor tries to reassure the patient, the patient provides more evidence of their distress or information that challenges the authority of the doctor, and the consultation often ends in collusion with an investigation, prescription, or referral that neither patient nor doctor is content with. Patients with MUS seek doctors who take their concerns seriously and legitimize their complaints. They do not necessarily expect a cure, but they seek an alliance to help them understand their health problems. Provision of emotional support, modification of symptom beliefs, explanations linking physical problems to psychosocial issues when they are relevant, antidepressants, and graded exercise for some types of MUS seem to be worth trying by doctors for patients with MUS. A four-stage model to help doctors manage MUS is provided. Some patients with chronic MUS and high consultation behaviour will require regular consultations with a single doctor who restricts the use of investigations, prescriptions, and referrals. Cognitive behavioural therapy may be helpful for patients with MUS who are willing to seek further psychological help. © 2009 Elsevier Ltd. All rights reserved.
    • Association between mirtazapine use and serious self-harm in people with depression: an active comparator cohort study using UK electronic health records

      Morriss, Richard K.; Butler, Debbie; Hollis, Chris P. (2022)
      Background Studies report an increased risk of self-harm or suicide in people prescribed mirtazapine compared with other antidepressants.Objectives To compare the risk of serious self-harm in people prescribed mirtazapine versus other antidepressants as second-line treatments.Design and setting Cohort study using anonymised English primary care electronic health records, hospital admission data and mortality data with study window 1 January 2005 to 30 November 2018.Participants 24 516 people diagnosed with depression, aged 18–99 years, initially prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine, a different SSRI, amitriptyline or venlafaxine.Main outcome measures Hospitalisation or death due to deliberate self-harm. Age–sex standardised rates were calculated and survival analyses were performed using inverse probability of treatment weighting to account for baseline covariates.Results Standardised rates of serious self-harm ranged from 3.8/1000 person-years (amitriptyline) to 14.1/1000 person-years (mirtazapine). After weighting, the risk of serious self-harm did not differ significantly between the mirtazapine group and the SSRI or venlafaxine groups (HRs (95% CI) 1.18 (0.84 to 1.65) and 0.85 (0.51 to 1.41) respectively). The risk was significantly higher in the mirtazapine than the amitriptyline group (3.04 (1.36 to 6.79)) but was attenuated after adjusting for dose.Conclusions There was no evidence for a difference in risk between mirtazapine and SSRIs or venlafaxine after accounting for baseline characteristics. The higher risk in the mirtazapine versus the amitriptyline group might reflect residual confounding if amitriptyline is avoided in people considered at risk of self-harm.Clinical implications Addressing baseline risk factors and careful monitoring might improve outcomes for people at risk of serious self-harm.No data are available. Data used in the study were provided under licence by CPRD (www.cprd.com) and cannot be shared by the authors. All code lists and the statistical code (in the form of Stata do-files) used to prepare and analyse the data are available on Zenodo.org (https://doi.org/10.5281/zenodo.4779024).