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UK Biobank is a well-characterised cohort of over 500 000 participants including genetics, environmental data and imaging. An online mental health questionnaire was designed for UK Biobank participants to expand its potential.
Describe the development, implementation and results of this questionnaire.
An expert working group designed the questionnaire, using established measures where possible, and consulting a patient group. Operational criteria were agreed for defining likely disorder and risk states, including lifetime depression, mania/hypomania, generalised anxiety disorder, unusual experiences and self-harm, and current post-traumatic stress and hazardous/harmful alcohol use.
A total of 157 366 completed online questionnaires were available by August 2017. Participants were aged 45–82 (53% were ≥65 years) and 57% women. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status. Lifetime depression was a common finding, with 24% (37 434) of participants meeting criteria and current hazardous/harmful alcohol use criteria were met by 21% (32 602), whereas other criteria were met by less than 8% of the participants. There was extensive comorbidity among the syndromes. Mental disorders were associated with a high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The UK Biobank questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed because of selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
UK Biobank is a well-characterised cohort of over 500 000 participants that offers unique opportunities to investigate multiple diseases and risk factors.
An online mental health questionnaire completed by UK Biobank participants was expected to expand the potential for research into mental disorders.
An expert working group designed the questionnaire, using established measures where possible, and consulting with a patient group regarding acceptability. Case definitions were defined using operational criteria for lifetime depression, mania, anxiety disorder, psychotic-like experiences and self-harm, as well as current post-traumatic stress and alcohol use disorders.
157 366 completed online questionnaires were available by August 2017. Comparison of self-reported diagnosed mental disorder with a contemporary study shows a similar prevalence, despite respondents being of higher average socioeconomic status than the general population across a range of indicators. Thirty-five per cent (55 750) of participants had at least one defined syndrome, of which lifetime depression was the most common at 24% (37 434). There was extensive comorbidity among the syndromes. Mental disorders were associated with high neuroticism score, adverse life events and long-term illness; addiction and bipolar affective disorder in particular were associated with measures of deprivation.
The questionnaire represents a very large mental health survey in itself, and the results presented here show high face validity, although caution is needed owing to selection bias. Built into UK Biobank, these data intersect with other health data to offer unparalleled potential for crosscutting biomedical research involving mental health.
Declaration of interest
G.B. received grants from the National Institute for Health Research during the study; and support from Illumina Ltd. and the European Commission outside the submitted work. B.C. received grants from the Scottish Executive Chief Scientist Office and from The Dr Mortimer and Theresa Sackler Foundation during the study. C.S. received grants from the Medical Research Council and Wellcome Trust during the study, and is the Chief Scientist for UK Biobank. M.H. received grants from the Innovative Medicines Initiative via the RADAR-CNS programme and personal fees as an expert witness outside the submitted work.
Neurodevelopmental abnormalities are common in children with CHD and are the highest-priority concerns for parents and professionals following cardiac surgery in childhood. There is no additional routine monitoring of development for children with CHD in the United Kingdom; hence, neurodevelopmental concerns may be detected late, precluding early referral and intervention.
An early recognition tool – the “Brief Developmental Assessment” – was developed using quality improvement methodology involving several iterations and rounds of pilot testing. Our requirements were for a tool covering important developmental domains and practicable for use within inpatient and outpatient settings by paediatric cardiac health professionals who are non-developmental specialists, without specialised equipment and which involved direct observation, as well as parental report.
Items were included in the tool based on existing developmental measures, covering the domains of gross and fine motor skills, daily living skills, communication, socialisation, and general understanding. Items were developed for five age bands – 0–16 weeks, 17–34 weeks, 35–60 weeks, 15 months–2.9 years, and 3–4.9 years – and the final versions included a traffic light scoring system for identifying children with possible delay in any or all domains. Preliminary testing indicated excellent inter-rater reliability, an ability to detect children with a diagnosis known to be associated with developmental delay, and largely acceptable internal reliability.
We report the evolution and preliminary testing of an early recognition tool for assessing the development of children with heart disease; this was encouraging and sufficiently good to support further validation in a larger study.
This audit will be relevant to all psychiatrists, though those working in and with services for early intervention in psychosis (EI) will find it especially useful.
EI is a key component of modern mental health services in England (Department of Health, 2000). It involves the specialist support of people with first-episode psychosis aged 14–35 years and their families and comprises three concepts: the early detection of psychosis; a reduction in the duration of untreated psychosis; the importance of the first 3–5 years following onset (the critical period) for later biological, psychological and social outcomes.
The Mental Health Policy Implementation Guide (PIG) (Department of Health, 2001) provides a model for EI. On the basis of this model, the Department of Health specified eight minimum fidelity criteria against which providers could self-assess local EI services. These were expanded to give ten standards against which services were assessed in this audit:
▸ stand-alone service model
▸ dedicated consultant psychiatrist input
▸ full age range (14–35 years)
▸ care provided for up to 3 years
▸ assertive community outreach work
▸ extended opening hours
▸ case-loads of 10–15 per care coordinator
▸ adolescent provision
▸ primary care referral
▸ designated access to acute beds.
These criteria are included in the Department of Health's autumn assessment local delivery plan (LDP) returns (see also Tiffin & Glover, 2007).
Service managers within EI teams should ensure there is a system in place to document minimum data on all patients under their care and that operational descriptors accurately describe the service model. Information on patient age, referral source and interventions received were obtained from patient case files. Service managers should therefore be able to provide the data required within the audit ‘window’. A bespoke tool was used in the present audit, but an EI audit pro forma is available online as part of the LDP autumn assessment to assist efficiency of data collection and analysis (http://www.ic.nhs.uk/services/ mental-health/mental-health-minimum-dataset-mhmds).
Morbidity is defined as a state of being unhealthy or of experiencing an aspect of health that is “generally bad for you”, and postoperative morbidity linked to paediatric cardiac surgery encompasses a range of conditions that may impact the patient and are potential targets for quality assurance.
As part of a wider study, a multi-disciplinary group of professionals aimed to define a list of morbidities linked to paediatric cardiac surgery that was prioritised by a panel reflecting the views of both professionals from a range of disciplines and settings as well as parents and patients.
We present a set of definitions of morbidity for use in routine audit after paediatric cardiac surgery. These morbidities are ranked in priority order as acute neurological event, unplanned re-operation, feeding problems, the need for renal support, major adverse cardiac events or never events, extracorporeal life support, necrotising enterocolitis, surgical site of blood stream infection, and prolonged pleural effusion or chylothorax. It is recognised that more than one such morbidity may arise in the same patient and these are referred to as multiple morbidities, except in the case of extracorporeal life support, which is a stand-alone constellation of morbidity.
It is feasible to define a range of paediatric cardiac surgical morbidities for use in routine audit that reflects the priorities of both professionals and parents. The impact of these morbidities on the patient and family will be explored prospectively as part of a wider ongoing, multi-centre study.
Early intervention services (EIS) comprise low-stigma, youth-friendly mental health teams for young people undergoing first-episode psychosis (FEP). Engaging with the family of the young person is central to EIS policy and practice.
By analysing carers' accounts of their daily lives and affective challenges during a relative's FEP against the background of wider research into EIS, this paper explores relationships between carers' experiences and EIS.
Semi-structured longitudinal interviews with 80 carers of young people with FEP treated through English EIS.
Our data suggest that EIS successfully aid carers to support their relatives, particularly through the provision of knowledge about psychosis and medications. However, paradoxical ramifications of these user-focused engagements also emerge; they risk leaving carers' emotions unacknowledged and compounding an existing lack of help-seeking.
By focusing on EIS's engagements with carers, this paper draws attention to an urgent broader question: as a continuing emphasis on care outside the clinic space places family members at the heart of the care of those with severe mental illness, we ask: who can, and should, support carers, and in what ways?
Individual placement and support (IPS) is effective in helping patients return to work but is poorly implemented because of clinical ambivalence and fears of relapse.
To assess whether a motivational intervention (motivational interviewing) directed at clinical staff to address ambivalence about employment improved patients' occupational outcomes.
Two of four early intervention teams that already provided IPS were randomised to receive motivational interviewing training for clinicians, focused on attitudinal barriers to employment. The trial was registered with the International Standard Randomised Controlled Trial Register (ISRCTN71943786).
Of 300 eligible participants, 159 consented to the research. Occupational outcomes were obtained for 134 patients (85%) at 12-month follow-up. More patients in the intervention teams than in the IPS-only teams achieved employment by 12 months (29/68 v. 12/66). A random effects logistic regression accounting for clustering by care coordinator, and adjusted for participants' gender, ethnicity, educational and employment history and clinical status scores, confirmed superiority of the intervention (odds ratio = 4.3, 95% CI 1.5–16.6).
Employment outcomes were enhanced by addressing clinicians' ambivalence about their patients returning to work.
In order to optimise care of the adult patients with complex congenital heart disease, there is a need to develop recommendations for interventions. This document is the work of representatives of the three relevant societies and provides recommendations for institutions and operators performing cardiac interventions in these patients.
One of the key questions of primary importance to global agriculture and food security is how to optimize sustainable intensification to balance competing demands on land for food and energy production, while ensuring the provision of ecosystem services and maintaining or increasing yields. Integrating trees and agriculture through agroforestry has been attracting increasing interest as an agroecological approach to sustainable intensification. Trees have traditionally been important elements of temperate agricultural systems around the world, but there has been increasing separation of agriculture, forestry and nature over the past few decades. This paper discusses what we can learn from traditional agroforestry systems to help develop modern systems that integrate ecological farming and agroecological advances to achieve sustainable intensification. We also discuss the existing barriers to wider adoption of agroforestry, and identify how these barriers can be overcome to promote agroforestry as a mainstream land-use system.
Meeting the needs for a growing world population calls for multifunctional land use, which can meet the multiple demands of food and fuel production, environmental and biodiversity protection, and has the capacity for adaptation or resilience to climate change. Agroforestry, a land-use system that integrates trees and shrubs with crops and/or livestock production, has been identified by the International Assessment of Agricultural Knowledge, Science and Technology for Development (IAASTD) as a ‘win–win’ approach that balances the production of commodities (food, feed, fuel, fiber, etc.) with non-commodity outputs such as environmental protection and cultural and landscape amenities. Evidence is now coming to light that supports the promotion of agroforestry in temperate developed countries as a sustainable alternative to the highly industrialized agricultural model with its associated negative environmental externalities. This paper reviews this evidence within the ‘ecosystem services’ framework to evaluate agroforestry as part of a multifunctional working landscape in temperate regions. Establishing trees on agricultural land can help to mitigate many of the negative impacts of agriculture, for example by regulating soil, water and air quality, supporting biodiversity, reducing inputs by natural regulation of pests and more efficient nutrient cycling, and by modifying local and global climates. The challenge now lies in promoting the adoption of agroforestry as a mainstream land use through research, dissemination of information and policy changes.
Poor weight gain is common in infants after Stage I Norwood operation and can negatively impact outcomes.
The purpose of this study was to examine the impact of feeding strategy on interstage weight gain.
In a multi-centre study, 158 infants discharged following the Norwood operation were enrolled prospectively. Weight and feeding data were obtained at 2-week intervals. Differences between feeding regimens in average daily weight gain and change in weight-for-age z-score between Stage I discharge and Stage II surgery were examined.
Discharge feeding regimens were oral only in 52%, oral with tube supplementation in 33%, and by nasogastric/gastrostomy tube only in 15%. There were significant differences in the average daily interstage weight gain among the feeding groups – oral only 25.0 grams per day, oral/tube 21.4 grams per day, and tube only 22.3 grams per day – p = 0.019. Tube-only-fed infants were significantly older at Stage II (p = 0.004) and had a significantly greater change in weight-for-age z-score (p = 0.007). The overall rate of weight gain was 16–32 grams per day, similar to infant norms. The rate of weight gain declined over time, with earlier decline observed for oral- and oral/tube-fed infants (less than 15 grams per day at 5.4 months) in comparison with tube-only-fed infants (less than 15 grams per day at 8.6 months).
Following Stage I Norwood, infants discharged on oral feeding had better average daily weight gain than infants with tube-assisted feeding. The overall weight gain was within the normal limits in all feeding groups, but the rate of weight gain decreased over time, with an earlier decline in infants fed orally.
Between 1982 and 1996 a group of rock-cut votive reliefs was discovered during archaeological survey in Pisidia under the direction of Stephen Mitchell and the sponsorship of the British Institute (of Archaeology) at Ankara. The types represented include a horseman deity, perhaps Kakasbos, the Dioscuri with ‘goddess’ and the moon-god Men. The reliefs are discussed according to their cults and iconography, and their contribution to art and religion both locally and beyond. As a religious phenomenon, they are further considered in relation to both regional traditions and empire-wide practices. It is suggested that reliefs of this type, that are associated with the protection of mortals, should also be viewed as part of the history of devotional art and added to discussions of rock art that extend beyond the Greek and Roman worlds. A detailed catalogue of the reliefs, organised by iconographic type, concludes the article.