Reducing patient delay with symptoms of acute coronary syndrome:a research protocol for a systematic review of previous interventions to investigate which behaviour change techniques are associated with effective interventions

Introduction: Delay to presentation with symptoms of acute coronary syndrome (ACS) is common meaning many fail to achieve optimal benefit from treatments. Interventions have had variable success in reducing delay. Evidence suggests inclusion of behaviour change techniques (BCTs) may improve effectiveness of interventions but this has not yet been systematically evaluated. Data from other time-critical conditions may be relevant.Methods and analysis: A systematic review will be undertaken to identify which BCTs are associated with effective interventions to reduce patient delay (or prompt rapid help-seeking) among people with time-critical conditions (eg, chest pain, ACS, lumps, stroke, cancer and meningitis). A systematic search of a wide range of databases (including Cochrane Library, MEDLINE, EMBASE, CINAHL, PsycInfo) and grey literature will be undertaken to identify all relevant intervention studies (randomised controlled trials, controlled clinical trials and cohort studies). Two independent reviewers will screen abstracts to identify relevant studies, apply inclusion criteria to full papers, assess methodological quality and extract data.Primary outcome measure: Change in patient decision time BCTs reported in each of the included studies will be categorised and presented according to the latest reliable taxonomy. Results of included studies will be synthesised, exploring relationships between inclusion of each BCT and effectiveness of the overall intervention. Where possible, means and SDs for differences in delay time will be calculated and combined within meta-analyses to derive a standardised mean difference and 95% CI. Analysis of (1) all time-critical and (2) ACS-only interventions will be undertaken

Dose-response effects of selective serotonin reuptake inhibitor monotherapy for the treatment of depression: systematic review of reviews and meta-narrative synthesis

Objective: To assess and clarify the relations between selective serotonin reuptake inhibitor (SSRI) dose efficacy, acceptability (early treatment discontinuation (dropouts)), and tolerability (reported adverse drug effects), and critically evaluate methods previously used to examine SSRI dose-response effects for the treatment of depression in adults.Design: Systematic review of reviews and meta-narrative synthesis.Data sources: Embase, Medline, PsycINFO, Scopus, and the Cochrane Collaboration library, from 1975 to December 2021. Reference lists of national depression treatment guidelines were systemically searched by hand.Eligibility criteria for selecting studies: Reviews assessing SSRI monotherapy dose-response effects for the treatment of depression in adults (age ≥18 years) reporting efficacy, acceptability, or tolerability. Reviews meeting inclusion criteria had a high degree of heterogeneity, due to methodological diversity; therefore, a meta-narrative synthesis approach was applied. Standard daily doses were defined as 20 mg citalopram, fluoxetine, paroxetine; 50 mg sertraline; and 10 mg escitalopram. Risk of bias was assessed using the Risk of Bias in Systematic Reviews tool, in line with Cochrane recommendations.Results: The search identified 9138 records; 387 full text reports were assessed for eligibility, 42 of which matched the inclusion criteria. The majority, 83% (n=35), of reviews included data for studies with a duration of ≤12 weeks (ie, the acute phase of depression treatment). Of 39 reviews assessing efficacy, the majority (n=26) indicated that individual SSRIs and SSRI class demonstrated flat dose-response effects; standard doses were optimal for efficacy. Acceptability or tolerability were assessed in 28 reviews. Higher than standard daily doses were associated with higher dropout rates and a greater incidence of adverse drug effects (eg, nausea, sexual dysfunction, fatigue, anxiety). Despite a range of methods being reported, there was an overall consensus regarding SSRI dose related efficacy, dropouts, and adverse drug effects.Conclusion: Standard daily doses of SSRIs for the treatment of depression in adults provide a favourable balance between efficacy, acceptability, and tolerability. Patients are encouraged to talk to their prescriber or community pharmacist if they experience adverse effects or have any concerns about their drug treatments

Understanding the attitudes and acceptability of extra-genital Chlamydia testing in young women: evaluation of a feasibility study

BackgroundChlamydia trachomatis (C. trachomatis) is the most common bacterial sexually transmitted infection in the UK. Recent studies suggest that in addition to the genital tract, C. trachomatis is found in the throat and rectum, suggesting the number of infections is under-reported. There is an urgent need to study the impact of extending diagnosis to include extra-genital samples; however, there is a lack of evidence on the acceptability of asking young women to provide these samples.MethodA mixed methods single group feasibility study explored the acceptability of combined genital and extra-genital testing in young women aged 16–25 years consecutively attending a sexual health centre in Edinburgh, Scotland. Young women were asked to complete a self- administered anonymous questionnaire whether they would be willing to give self-taken throat and ano-rectal samples. Interviews with women (n = 20) willing to self-sample were conducted before and after self-sampling, and these explored the underlying reasons behind their decision, and feelings about the tests.ResultsOf 500 women recruited to the study, 422 (84.4%) women provided sufficient data for analysis. From completed questionnaires, 86.3% of respondents reported willingness to self-sample from the throat. Willingness of ano-rectal self-sampling was lower (59.1%), particularly in women under 20 ( < 20 years: 44.4%; ≥20 years, 68.2%). Willingness of ano-rectal self-sampling was higher in women who had more sexual partners in the last 6 months (0 partners, 48.3%, n = 14, 3 or more partners, 67.4%, n = 60) and in those who have previous experience of a positive test for a sexually transmitted infection (STI) (positive: 64.5%; negative: 57%). Interviewed women suggested that a lack of knowledge of STIs, embarrassment and lack of confidence in the ability to carry out the sampling were barriers towards acceptability.ConclusionsIn this study, self-sampling of throat samples is largely acceptable; however, the acceptability of taking an ano-rectal sample for C. trachomatis testing in young women was lower in younger women. The study suggests further research to investigate the acceptability of extra-genital testing as an addition to routine C. trachomatis testing, and whether this increases detection and prevents infective sequelae for women

Defining and assessing vulnerability within law enforcement and public health organisations: a scoping review

Background Historically, police departments focused solely on criminal justice issues. Recently, there has been a dynamic shift in focus, with Law Enforcement professional groups assuming more responsibility for tackling mental health and distress-related issues (that may arise because of mental health related problems and learning disabilities) alongside Public Health departments. While Law Enforcement has become a ‘last line of support’ and an increasing partner in mental health support, there is partnership working between law enforcement, psychology, and health professions in training and mental health service delivery. The term vulnerability is frequently used across Law Enforcement and Public Health (LEPH) to identify those in need of these services. Effective vulnerability assessment is therefore expected to prevent unintentional harmful health and criminal justice consequences and manage the negative impact of such in cases where prevention is not possible. This scoping review aimed to identify how vulnerability is defined and assessed across LEPH organisations. Results Vulnerability is context-specific from a Law Enforcement perspective, and person-specific from a Public Health perspective. Definitions of vulnerability are at best fragmented, while models for assessing vulnerability lack uniformity across LEPH. The implications are two-fold. For “vulnerable groups”, the lack of an evidence-based definition and assessment model could prevent access to relevant LEPH services, exacerbating issues of multiple vulnerabilities, co-morbidity, and/or dual diagnosis. All could inadvertently enable social exclusion of vulnerable groups from political discourse and policy interventions. The lack of consistency regarding vulnerability may result in reactive crisis responses as opposed to proactive preventative measures. Conclusions This scoping review exposes the complexities associated with defining and assessing vulnerability from a LEPH perspective, which are perceived and prioritised differently across the organizations. Future research must bridge this gap. Building on the establishment of a definition of vulnerability within the empirical literature, researchers ought to engage with service users, LEPH staff, and those engaged in policy making to craft effective vulnerability definitions and assessment models. Only through evidence based, co-produced definitions and assessment models for vulnerability can we ensure that best-practice, but also meaningful and feasible practice, in vulnerability assessment can be achieved

Co-creation of five key research priorities across Law Enforcement and Public Health: A methodological example

IntroductionLaw enforcement professions now assume more responsibility for tackling mental health issues alongside public health colleagues than ever before. The term ‘vulnerability’ is frequently used within Law Enforcement and Public Health (LEPH) to identify those requiring emergency mental health care. However, there are ongoing challenges within LEPH to determine whose responsibility this is.AimTo co-create the most important priorities for LEPH research in Scotland.MethodThe paper describes a collaborative workshop which brought together an Expert Advisory Group (EAG) of 26 senior stakeholders, from academia, policing, mental health nursing, psychiatry, paramedics, emergency medicine, people with lived experience, policy makers, and third sector.ResultsThe five key priorities included: vulnerability; mental health crisis; decision making around assessment and triage across professional groups and professional roles; peer support and organisational well-being; and information and data sharing.DiscussionThe paper discusses the EAG group event as a co-production process, focusing on how key LEPH research priorities were derived.Implications for PracticeThis paper demonstrates the inextricable link between co-production and co-creation of value via EAG group consensus on LEPH research priorities. Shared vision and professional will is not enough to ensure progress: there must also be shared policy, knowledge, and access

‘Doing the right thing’: factors influencing GP prescribing of antidepressants and prescribed doses

Background: Antidepressant prescribing continues to increase, with 5-16% of adults receiving antidepressants annually. Total prescribing growth is due in part to increased long-term use, greater selective serotonin re-uptake inhibitor (SSRI) use and the use of higher SSRI doses. Evidence does not support routine use of higher SSRI doses for depression treatment, and factors influencing the use of such doses are not well known. The aim of this study was to explore factors influencing GPs’ use of antidepressants and their doses to treat depression.Methods: Semi-structured interviews with a purposive sample of 28 practising GPs; sampled by antidepressant prescribing volume, practice size and deprivation level. A topic guide drawing on past literature was used with enough flexibility to allow additional themes to emerge. Interviews were audio-recorded and transcribed verbatim.Framework analysis was employed. Constant comparison and disconfirmation were carried out across transcripts,with data collection being interspersed with analysis by three researchers. The thematic framework was thensystematically applied to the data and conceptualised into an overarching explanatory model.Results: Depression treatment involved ethical and professional imperatives of ‘doing the right thing’ for individuals by striving to achieve the ‘right care fit’. This involved medicalised and non-medicalised patient-centred approaches.Factors influencing antidepressant prescribing and doses varied over time from first presentation, to antidepressant initiation and longer-term treatment. When faced with distressed patients showing symptoms of moderate to severe depression GPs were confident prescribing SSRIs which they considered as safe and effective medicines, andethically and professionally appropriate.Many GPs were unaware that higher doses lacked greater efficacy and onset of action occurred within 1-2 weeks,preferring to wait 8-12 weeks before increasing or switching. Ongoing pressures to maintain prescribing (e.g. fear of depression recurrence), few perceived continuation problems (e.g. lack of safety concerns) and lack of proactive medication review (e.g. patients only present in crisis), all combine to further drive antidepressant prescribing growth over time.Conclusions: GPs strive to ‘do the right thing’ to help people. Antidepressants are only a single facet of depression treatment. However, increased awareness of drug limitations and regular proactive reviews may help optimise care