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Smoking tobacco is regarded as an epiphenomenon in patients with schizophrenia when it may be causal. We aimed to examine whether smoking status is related to the onset of schizophrenia or the broader diagnosis of non-affective psychosis, including schizophrenia.
We used data from The Health Improvement Network primary care database to identify people aged 15–24 between 1 January 2004 and 31 December 2009. We followed them until the earliest of: first diagnosis of schizophrenia (or psychosis), patient left the practice, practice left THIN, patient died or 31 December 2014.
In men, incidence rates for schizophrenia per 100 000 person years at risk were higher in smoking initiators (non-smoker who became a smoker during the study) than in non-smokers (adjusted IRR 1.94; 95% CI 1.29–2.91) and higher still in smokers (adjusted IRR 3.32; 95% CI 2.67–4.14). Among women, the incidence rate of schizophrenia was higher in smokers than in non-smokers (adjusted IRR 1.50; 95% CI 1.06–2.12), but no higher in smoking initiators than non-smokers. For non-affective psychosis, the pattern was similar for men but more evident in women where psychosis incidence rates were higher in smoking initiators (adjusted IRR 1.90; 95% CI 1.40–2.56) and in smokers (adjusted IRR 2.13; 95% CI 1.76–2.57) than in non-smokers.
We found an important and strong association between smoking and incidence of schizophrenia. Smoking may increase risk through as yet unknown pathways or smoking may share genetic risk with schizophrenia and non-affective psychoses.
Depression is one of the most common mental disorders in people with advanced cancer. Although cognitive–behavioural therapy (CBT) has been shown to be effective for depression in people with cancer, it is unclear whether this is the case for people with advanced cancer and depression.
We sought to determine whether CBT is more clinically effective than treatment as usual (TAU) for treating depression in people with advanced cancer (trial registration number ISRCTN07622709).
A multi-centre, parallel-group single-blind randomised controlled trial comparing TAU with CBT (plus TAU). Participants (n = 230) with advanced cancer and depression were randomly allocated to (a) up to 12 sessions of individual CBT or (b) TAU. The primary outcome measure was the Beck Depression Inventory-II (BDI-II). Secondary outcome measures included the Patient Health Questionnaire-9, the Eastern Cooperative Oncology Group Performance Status, and Satisfaction with Care.
Multilevel modelling, including complier-average intention-to-treat analysis, found no benefit of CBT. CBT delivery was proficient, but there was no treatment effect (−0.84, 95% CI −2.76 to 1.08) or effects for secondary measures. Exploratory subgroup analysis suggested an effect of CBT on the BDI-II in those widowed, divorced or separated (−7.21, 95% CI −11.15 to −3.28).
UK National Institute for Health and Care Excellence (NICE) guidelines recommend CBT for treating depression. Delivery of CBT through the Improving Access to Psychological Therapies (IAPT) programme has been advocated for long-term conditions such as cancer. Although it is feasible to deliver CBT through IAPT proficiently to people with advanced cancer, this is not clinically effective. CBT for people widowed, divorced or separated needs further exploration. Alternate models of CBT delivery may yield different results.
Recent media reports have focused on the large increase in antidepressants dispensed in England. We investigated this, focusing on selective serotonin reuptake inhibitors (SSRIs).
To examine the rate of initiation of SSRIs over time and changes over time in the duration of prescribing episodes.
We estimated initiation and duration of SSRI prescribing from 7 025 802 individuals aged over 18 years and registered with a general practice that contributed data to The Health Improvement Network.
Rates of SSRI initiation increased from 1.03 per 100 person-years in 1995 to 2.15 in 2001, but remained stable from then to 2012. The median duration of prescribing episodes increased from 112 to 169 days for episodes starting in 1995 to 2010.
Despite media reports describing an increasing rate of antidepressant prescribing, SSRI initiation rates have stabilised since 2001. However, our results suggest that individuals who take SSRIs are receiving treatment for longer.
In this issue, El Marroun et al suggest an association between prenatal selective serotonin reuptake inhibitor (SSRI) exposure and autistic traits in children, as well as an association with prenatal depressive symptoms. However, SSRIs may be mere markers of severity of underlying illnesses and it may be premature to reach such conclusions about effects of treatment. Studies like this raise concerns as this may fuel further anxiety and guilt among women who are faced with depression in pregnancy and possibly leave some women without treatment.
Psychological distress, defined as symptoms of depression and anxiety, is an increasingly important public health issue in developing countries. Little is known about the extent to which adverse dietary factors are associated with psychological distress in South Asians. Our aim was to compare the associations of diet and psychological distress in men and women in Goa, India.
Cross-sectional study of consecutive attendees in nine urban and rural general practices in Goa, India in 2004–2005. All participants completed an FFQ on their dietary intake in a typical week. Psychological distress was measured using the Kessler Psychological Distress Scale (K10), a WHO-validated screening instrument.
Consecutive attendees (n 1512; 601 men and 911 women) aged 30 to 75 years participated. Moderate and high scores of psychological distress were detected in significantly more women than men (eighty-eight men v. 264 women, unadjusted OR = 0·39; 95 % CI 0·29, 0·52). Those who ate one or more portions of fish weekly had nearly half the prevalence of distress in both sexes (women, OR = 0·52; 95 % CI 0·29, 0·91; men, OR = 0·50; 95 % CI 0·25, 0·99) and this was independent of age, marital status, education, income, religion and living alone.
Psychological distress is significantly lower with fish intake in both sexes. Further longitudinal work is needed to establish temporal relationships. Addressing psychological distress is becoming an increasingly significant public health priority in both high- and low-income countries.
Factors associated with depression are usually identified from cross-sectional studies.
We explore the relative roles of onset and recovery in determining these associations.
Hazard ratios for onset and recovery were estimated for 39 risk factors from a cohort study of 10 045 general practice attendees whose depression status was assessed at baseline, 6 and 12 months.
Risk factors have a stronger relative effect on the rate of onset than recovery. The strongest risk factors for both onset and maintenance of depression tend to be time-dependent. With the exception of female gender the strength of a risk factor's effect on onset is highly predictive of its impact on recovery.
Preventive measures will achieve a greater reduction in the prevalence of depression than measures designed to eliminate risk factors post onset. The strength of time-dependent risk factors suggests that it is more productive to focus on proximal rather than distal factors.
There is a paucity of data describing how general practitioners (GPs) label or record depression.
To determine incidence and sociodemographic variation in GP-recorded depression diagnoses and depressive symptoms.
Annual incidence rates calculated using data from 298 UK general practices between 1996 and 2006, adjusted for year of diagnosis, gender, age and deprivation.
Incidence of diagnosed depression fell from 22.5 to 14.0 per 1000 person-years at risk (PYAR) from 1996 to 2006. The incidence of depressive symptoms rose threefold from 5.1 to 15.5 per 1000 PYAR. Combined incidence of diagnoses and symptoms remained stable. Diagnosed depression and symptoms were more common in women and in more deprived areas.
Depression recorded by general practitioners has lower incidence rates than depression recorded in epidemiological studies, although there are similar associations with gender and deprivation. General practitioners increasingly use symptoms rather than diagnostic labels to categorise people's illnesses. Studies using standardised diagnostic instruments may not be easily comparable with clinical practice.
There is evidence that the prevalence of common mental disorders varies
To compare prevalence of common mental disorders in general practice
attendees in six European countries.
Unselected attendees to general practices in the UK, Spain, Portugal,
Slovenia, Estonia and The Netherlands were assessed for major depression,
panic syndrome and other anxiety syndrome. Prevalence of DSM–IV major
depression, other anxiety syndrome and panic syndrome was compared
between the UK and other countries after taking account of differences in
demographic factors and practice consultation rates.
Prevalence was estimated in 2344 men and 4865 women. The highest
prevalence for all disorders occurred in the UK and Spain, and lowest in
Slovenia and The Netherlands. Men aged 30–50 and women aged 18–30 had the
highest prevalence of major depression; men aged 40–60 had the highest
prevalence of anxiety, and men and women aged 40–50 had the highest
prevalence of panic syndrome. Demographic factors accounted for the
variance between the UK and Spain but otherwise had little impact on the
significance of observed country differences.
These results add to the evidence for real differences between European
countries in prevalence of psychological disorders and show that the
burden of care on general practitioners varies markedly between
Depression is prevalent, costly and often undertreated.
To test the hypothesis that people with low socio-economic status are least likely to receive and adhere to evidence-based treatments for depression, after controlling for clinical need.
Individuals with an ICD-10 depressive episode in the past 12 months (n = 866) were recruited from 7271 attendees in 36 general practices in England and Wales. Depressive episodes were identified using the 12-month Composite International Diagnostic Interview. Treatment receipt and adherence were assessed by structured interview, and rated using evidence-based criteria.
We identified 332 individuals (38.3%) who received and adhered to evidence-based treatment. There were few socio-economic differences in treatment allocation. Although those without educational qualifications were least likely to receive psychological treatments (OR = 0.55, 95% CI 0.34–0.89, P = 0.02), this association was not statistically significant after adjusting for depression severity.
We found no evidence of inverse care in the treatment of moderate and severe depression in primary care in England and Wales.
Undertreatment of depression in primary care is common. Efforts to address this tend to overlook the role of patient attitudes. Our aim was to validate and describe responses to a questionnaire about attitudes to depression and its treatment in a sample with experience of moderate and severe depressive episodes.
Cross-sectional survey of 866 individuals with a confirmed history of an ICD-10 depressive episode in the 12 months preceding interview, recruited from 7271 consecutive general practitioner (GP) attendees in 36 general practices in England and Wales. Attitudes to and beliefs about depression were assessed using a 19-item self-report questionnaire.
Factor analysis resulted in a three-factor solution: factor 1, depression as a disabling, permanent state; factor 2, depression as a medical condition responsive to support; and factor 3, antidepressants are addictive and ineffective. Participants who received and adhered to antidepressant medication and disclosed their depression to family and friends had significantly lower scores on factors 1 and 3 but higher scores on factor 2.
People with moderate or severe depressive episodes have subtle and divergent views about this condition, its outcome, and appropriate help. Such beliefs should be considered in primary care as they may significantly impact on help seeking and adherence to treatment.
Primary care research networks are fundamental to developing primary care-based research. A significant amount of their work is with locally organized projects. Working effectively with externally funded trials is another crucial way to inform the evidence base. There is little information on how trial teams may best work with multiple networks. We examined factors that might assist and impede collaboration between an externally funded trial and networks by exploring the systems networks used to assess externally approved trials. A large RCT was used as an example of an external trial. Networks were identified in areas where the trial could provide the intervention. Eighteen networks were sent standard letters asking for information about contacts and assessment procedures. We examined how long it took to identify a liaison person, what processes were used to assess the trial and how long these processes took. Sixteen of 18 networks (89%) agreed to work with the trial. Most networks provided initial information within a month of being contacted. There was no standard process for approving externally funded trials. The time taken to gain final approval varied from one week to three months. There is enthusiasm among networks to work with externally funded studies. It is feasible and can be successful, but current systems for approval are variable and often time-consuming. A defined turnaround time and central mechanism for approving trials could result in greater engagement of external trials with networks and an increased likelihood of a successful research.
Despite concern about the incidence of coronary heart disease (CHD) in people with severe mental illness (SMI), there is little systematic research on CHD risk factors in this population.
To compare the main risk factors for CHD in people with and without SMI in primary care, to investigate the role of socio-economic variables, and to examine any association between antipsychotic medication and CHD risk.
In total, 75 of 182 general practice patients with SMI and 150 of 313 such patients without SMI attended the interview. SMI was associated with: raised 10-year CHD risk scores (OR= 1.8, 95% CI 1.0–3.1); high-density-lipoprotein (HDL)-cholesterol levels <l.0 mmol/l (OR=4.0, 95% CI 1.5–10.7); raised cholesterol/HDL-cholesterol ratios (OR=1.8, 95% CI 1.0–3.2); diabetes mellitus (OR=3.8, 95% CI 1.1–13.3) and smoking (OR=3.0, 95% CI 1.7–3.4). These associations varied significantly with age. Adjustment for unemployment did not fully explain the associations.
Excess risk factors for CHD are not wholly accounted for by medication or socio-economic deprivation. There is an urgent need for CHD screening and for relevant interventions for smoking cessation and diabetes, as well as advice on diet and exercise, in patients with SMI.
This trial evaluated the feasibility, acceptability and effectiveness of a structured approach to the management of schizophrenia in general practice.
All patients with non-affective psychosis (mainly schizophrenia) in four inner-city general practices were recruited. A check-list and a set of outcome measures were used by the general practitioner and the practice nurses. Information on attendances at the general practice and psychiatric out-patient departments was also collected.
Two practices took part in the intervention and two served as control practices. Sixty-seven patients with non-affective psychosis were identified. Thirty-three (81%) of the 41 patients in the two intervention practices attended the initial assessment by the doctor and nurse, but only 13 (32%) attended the first review assessment. The attendance for the second review, after six months, was six out of 15 (40%) in one practice, but rose to 16 out of 18 (89%) in the other practice. Significant improvements were recorded in the intervention group on the Global Assessment Scale (GAS) and the Behaviour, Speech and Other Syndromes (BSO) subscore of the Present State Examination (PSE). The absolute risk reduction and relative risk reduction as a result of the intervention as measured by the GAS scores, was 29% (95% CI 4% to 54%) and 36% (95% CI 5% to 66%), respectively, and in the case of the BSO subscores of the PSE, this was 23% (95% CI – 1.8% to 47.2%) and 28% (95% CI – 2.2% to 57%), respectively. For one patient to show an improvement in GAS and BSO scores 3.5 patients (95% CI 1.85 to 25) and 4.3 patients (95% CI – 55 to 2.1), respectively, would need to receive the intervention. There was a significant increase in consultation rates for patients in the intervention practices.
Health surveillance of patients with non-affective psychosis is possible in general practice.