Stroke Survivors Who Score below Threshold on Standard Depression Measures May Still Have Negative Cognitions of Concern

Background and Purpose— There has been an increase in screening for depression in the physically ill. We explored whether important negative cognitions may be missed by conventional approaches to screening for depression in 2 independently conducted stroke studies with similar methods. Methods— The Auckland Regional Community Stroke (ARCOS) study was a prospective, population-based stroke incidence study conducted in Auckland, New Zealand, for 12 months in 2002 to 2003. The Stroke Outcomes Study was a prospective, hospital cohort study conducted in Leeds and Bradford, United Kingdom, for 33 months in 2002 to 2005. Symptoms of abnormal mood were assessed at 6 months in ARCOS with a single simple question, “Do you often feel sad and depressed?” and the 28-item General Health Questionnaire administered as part of a structured interview and in the Stroke Outcomes Study with the 28-item General Health Questionnaire and a single question about depressed mood taken from the Present State Examination. Results— Mood data were available at 6 months from 770 ARCOS and 492 Stroke Outcomes Study participants. A significant proportion (up to 28%) of people who did not meet study criteria for depression reported important negative cognitions such as hopelessness, worthlessness, or suicidality. People who were older, dependent in activities of daily living, or not partnered were more likely to report negative cognitions. Conclusions— Important negative cognitions, including suicidal thoughts, may be missed when people are screened for depression after stroke. Screening alone is not an adequate substitute for a sensitive exploration of the psychological impact of stroke on the survivor

Self-harm with suicidal and non-suicidal intent in young people in sub-Saharan Africa: a systematic review

Background: Self-harm, whether attributed to suicidal or non-suicidal motives, is associated with several poor outcomes in young people, including eventual suicide. Much of our understanding of self-harm in young people is based on literature from Europe (particularly, the UK), North America, and Australia. We aimed to synthesise the available evidence on prevalence, the commonly reported self-harm methods, correlates, risk and protective factors, and reasons for self-harm, in adolescents (aged 10–25 years) in sub-Saharan Africa. Method: We searched MEDLINE, PsycINFO, PubMed, African Journals OnLine, and African Index Medicus for records from 1950 through August 2019, without language restrictions. We supplemented the database searches by searching relevant portals for postgraduate theses, reference harvesting, contacting authors for unpublished studies, and hand searching relevant print sources. We applied narrative synthesis to the evidence. Results: Seventy-four studies from 18 sub-Saharan African countries met the inclusion criteria. The median lifetime prevalence estimate was 10·3% (interquartile range [IQR] 4·6% – 16·1%); median 12-month prevalence estimate was 16·9% (IQR: 11·5% – 25·5%); median 6-month prevalence estimate was 18·2% (IQR: 12·7% – 21·8%); and the median 1-month prevalence estimate was 3·2% (IQR: 2·5–14·8%). Studies from Western sub-Saharan Africa reported the highest 12-month prevalence estimates (median = 24·3%; IQR = 16·9% – 27·9%). Clinical samples commonly reported overdose, whereas self-cutting was most commonly reported in non-clinical samples. Academic failure, sexual, emotional, and physical abuse, romantic relationship problems, family conflict, depression, and previous self-harm were identified as key correlates of self-harm. No study reported protective factors against self-harm. Conclusion: Variation in estimates was explained by small sample sizes and variation in definitions and measures used. Exploration of associations, risks and protective factors was based upon concepts and measures derived from high income countries. More detailed and culturally sensitive research is needed to understand the context-specific risks and protective factors for self-harm in adolescents in sub-Saharan Africa

Good practice or positive action? Using Q methodology to identify competing views on improving gender equality in academic medicine

Objectives: The number of women entering medicine has increased significantly, yet women are still under-represented at senior levels in academic medicine. To support the gender equality action plan at one School of Medicine, this study sought to (1) identify the range of viewpoints held by staff on how to address gender inequality and (2) identify attitudinal barriers to change. Design: Q methodology. 50 potential interventions representing good practice or positive action, and addressing cultural, organisational and individual barriers to gender equality, were ranked by participants according to their perception of priority. Setting: The School of Medicine at the University of Leeds, UK. Participants: Fifty-five staff members were purposively sampled to represent gender and academic pay grade. Results: Principal components analysis identified six competing viewpoints on how to address gender inequality. Four viewpoints favoured positive action interventions: (1) support careers of women with childcare commitments, (2) support progression of women into leadership roles rather than focus on women with children, (3) support careers of all women rather than just those aiming for leadership, and (4) drive change via high-level financial and strategic initiatives. Two viewpoints favoured good practice with no specific focus on women by (5) recognising merit irrespective of gender and (6) improving existing career development practice. No viewpoint was strongly associated with gender, pay grade or role; however, latent class analysis identified that female staff were more likely than male to prioritise the setting of equality targets. Attitudinal barriers to the setting of targets and other positive action initiatives were identified, and it was clear that not all staff supported positive action approaches. Conclusions: The findings and the approach have utility for those involved in gender equality work in other medical and academic institutions. However, the impact of such initiatives needs to be evaluated in the longer term

Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm.

BACKGROUND:Social problem-solving is one technique used to help reduce incidence of self-harm. Our study evaluated the feasibility and acceptability of the adaptation and implementation of a brief Problem-Solving Training (PST) intervention to reduce self-harm in prisons. METHODS:The process involved i) adaptation of the training materials using focus groups with prison staff and prisoners, ii) training frontline prison staff to use the skills, and iii) implementation of the skills with prisoners at risk of self-harm. Qualitative interviews were conducted with prison staff, prisoners and field researchers and were analysed using a thematic framework to produce a model of the barriers and facilitators to the process. RESULTS:We conducted 43 interviews across three prison sites. The interviews included 19 prison staff, 18 prisoners and six field researcher meetings. The adaptation to the training and intervention materials were well received. The findings identified the need to support training using a collaborative and flexible approach. Prisoner engagement was affected by their own personal circumstances and by a range of contextual issues relating to the prison environment. Implementation of the skills by prison staff were hindered by resource constraints, the prison environment and staff attitudes. CONCLUSIONS:We found that it was feasible to adapt an existing intervention and contextualise it within the prison environment. Although we could train large numbers of staff it was deemed unfeasible for staff to implement the problem-solving skills to prisoners at risk of self-harm. Prisoners who engaged with the intervention reported a range of benefits. Alternative implementation mechanisms to tackle the contextual barriers proposed by staff and prisoners included delivery of the intervention using an educational setting and/or use of a prisoner peer-led scheme

New models of care: a liaison psychiatry service for medically unexplained symptoms and frequent attenders in primary care

Aims and method: This paper describes the process of setting up and the early results from a new liaison psychiatry service in primary care for people identified as frequent general practice attenders with long-term conditions or medically unexplained symptoms. Using a rapid evidence synthesis, we identified existing service models, mechanisms to identify and refer patients, and outcomes for the service. Considering this evidence, with local contingencies we defined options and resources. We agreed a model to set up a service in three diverse general practices. An evaluation explored the feasibility of the service and of collecting data for clinical, service and economic outcomes. Results: High levels of patient and staff satisfaction, and reductions in the utilisation of primary and secondary healthcare, with associated cost savings are reported. Clinical implications: A multidisciplinary liaison psychiatry service integrated in primary care is feasible and may be evaluated using routinely collected data

A qualitative synthesis of factors influencing maintenance of lifestyle behaviour change in individuals with high cardiovascular risk

Management of cardiovascular risk factors includes commitment from patients to adhere to prescribed medications and adopt healthy lifestyles. Unfortunately many fail to take up and maintain the four key healthy behaviours (not smoking, having a balanced diet, limiting alcohol consumption and being more active). Five factors (beliefs, knowledge, transport and other costs, emotions, and friends and family support) are known to predict uptake of lifestyle behaviour change. The key factors influencing maintenance of healthy lifestyles are not known but would be helpful to support the development of relapse prevention programmes for this population. Our review aimed to clarify the main patient perceived factors thought to influence maintenance of changed healthy lifestyles. ; We performed a systematic review of qualitative observational studies and applied the principles of content synthesis and thematic analysis to extract reported factors (barriers and facilitators) considered by individuals to be influential in maintaining changed healthy lifestyle behaviours. Factors were then organised into an existing framework of higher order categories which was followed by an analysis of the interrelationships between factors to identify key themes. ; Twenty two studies met our inclusion criteria. Participants reported barriers and facilitators within 13 categories, the majority of which were facilitators. The most commonly reported influences were those relating to social support (whether provided formally or informally), beliefs (about the self or the causes and management of poor health, and the value of maintaining lifestyle behaviours), and other psychological factors (including attitude, thinking and coping styles, and problem solving skills). Physical activity was the most commonly investigated behaviour in four categories, but overall, the main barriers and facilitators were related to a range of behaviours. Through analysis of the interrelationships between factors within categories, ‘social support’, ‘education and knowledge’, and ‘beliefs and emotions’ were all considered key themes. ; Our review suggests that for the most part, factors that influence lifestyle change are also important for maintaining healthy behaviours. This indicates that addressing these barriers and facilitators within lifestyle support programmes would also be of value in the longer-term

Longer-term effectiveness of systemic family therapy compared with treatment as usual for young people after self-harm: An extended follow up of pragmatic randomised controlled trial

Background: Self-harm in adolescents is common and repetition frequent. Evidence for effective interventions to reduce self-harm is limited. Long term follow-up of existing studies is rare. Methods: Extended follow up, from 18 to at least 36-months, of the SHIFT trial: a pragmatic, multi-centre, individually-randomised, controlled trial involving young people (11–17) who had self-harmed at least twice and presented to Child & Adolescent Mental Health Services (CAMHS). SHIFT evaluated manualised family therapy (FT) versus treatment as usual (TAU) in reducing repetition of self-harm leading to hospital attendance 18 months post-randomisation. We obtained ONS mortality data, adult mental health data, and further details of hospital attendance from routine Hospital Episode Statistics (HES) data plus researcher follow-up. We assessed longer-term differences in outcome using multivariable Cox Proportional Hazards regression analysis, and assessed all-cause mortality and morbidity relating to hospital attendances for reasons other than self-harm. Study registration: ISRCTN 59793150 Outcomes: The original sample of 832 were randomised between April 2010 and December 2013. Extended follow-up continued until February 2017 for a median 55·4 months (range 0–82·5 months), providing post 18-month data for 804 (96·6%) participants, of whom 785 (94·4%) had a minimum of 36-months follow-up. There was no evidence of a between-group difference in the primary outcome during the extended follow-up period (Hazard Ratio (HR) 1·03; 95% CI: 0·83, 1·28; p-value=0·78), consistent with our findings in the original trial with 18 months follow-up (HR 1·14, 95% CI 0·87, 1·49; p-value 0·33). There was a reduced rate of self-harm in older participants aged 15–17 (HR 0·7, 95% CI 0·56, 0·88), as compared with those aged 11–14; and significantly increased rates of self-harm in participants whose index episode combined self-injury and poisoning (HR 1·8, 95% CI 1·2, 2·7). Two deaths were reported during the extended follow up period. Interpretation: For adolescents referred to CAMHS after self-harm, having self-harmed at least once before, trial FT confers no benefits over TAU in reducing subsequent hospitalisation for self-harm over 18 months or 36 months. Funding: NIHR HTA Reference: 07/33/0

Lifestyle referral assessment in an acute cardiology setting: study protocol for a randomized controlled feasibility trial.

BACKGROUND: Lifestyle and behaviour change are important factors in the prevention of cardiovascular disease and reduction of premature mortality. Public health initiatives have focused on opportunities for healthcare staff to deliver lifestyle advice routinely in primary and secondary care but there is no consistent approach to onward referrals and the rate of uptake of advice remains low. We do not know if advice is more effective in supporting behaviour change when a systematic approach is taken that includes identification of barriers to change, directing patients toward services, referral to services, and feedback on outcome. METHODS AND DESIGN: This is a single-centre, randomized, unblinded feasibility trial in an acute hospital setting which aims to assess the feasibility of a definitive trial and provide proof of concept for the systematic delivery of individualized lifestyle advice in patients managed through an acute cardiology in-patient service.Patients will be recruited before discharge and randomized to two groups. A control group will receive the usual lifestyle assessment and referral, while an intervention group will receive the usual assessment plus the new individualized lifestyle assessment and referral. The new assessment will inform assignment of each patient to one of three categories based on personal barriers to change. Patients may be referred to a formal lifestyle-change programme, through the 'Leeds Let's Change' website, or they may be guided in self-management, using goal setting, or they may be assigned to a 'deferment' category, for reassessment at follow-up. These latter patients will be given a contact card for the 'Leeds Let's Change' service. DISCUSSION: Lifestyle change is an important mechanism for improving health and wellbeing across the population but there are widely acknowledged difficulties in addressing lifestyle factors with patients and supporting behaviour change. A systematic approach to assessment would facilitate audit and provide an indicator of the quality of care. The new assessment template has been designed to be quick and easy to use in practice and could, for example, be added to a primary care consultation or form part of a nursing discharge assessment in an acute setting. TRIAL REGISTRATION: Current Controlled Trials ISRCTN41781196

Randomised controlled trial of a psychotherapeutic intervention to improve quality of life and other outcomes in people who repeatedly self-harm : FReSH START study protocol

Background Self-harm is a major public health challenge and repeated self-harm is common in those attending hospital following an episode. Evidence suggests psychological interventions could help people who self-harm, but few definitive studies have assessed their clinical and cost-effectiveness. Repeated self-harm is associated with poor quality of life, depression, suicide and increased health service costs which justify the development of psychotherapeutic interventions tailored for people with repeated self-harm. Methods FReSH START is a multicentre individually 1:1 randomised controlled trial evaluating the clinical and cost-effectiveness of standard care plus psychological therapy or standard care alone for adults (>=18 years) presenting at an emergency department (ED) with repeated self-harm. Recruiting 630 participants, it includes an internal pilot, economic evaluation and process evaluation. The intervention will be delivered by mental health staff working in acute settings, with experience of assessing and managing risk in people presenting to emergency services with self-harm. Staff will be trained and supervised to deliver one of three specially adapted therapies: psychodynamic interpersonal therapy, cognitive behavioural therapy, or acceptance and commitment therapy. Participants allocated to the intervention will receive one of the adapted therapies according to therapist allocation for up to 6 months via 12 weekly, one to one, 45-50 minute sessions. The primary outcome is quality of life measured by the Clinical Outcomes in Routine Evaluation Outcome Measure at 12 months post-randomisation. Secondary outcomes include suicidal intent, depression, and cost-effectiveness. Data are collected using hospital attendance records and online/postal/telephone questionnaires at 6 and 12 months post-randomisation, with resource use additionally collected at 3 and 9 months). Discussion This protocol outlines a randomised controlled trial to investigate whether modified therapies are cost-effective and improve quality of life for people who repeatedly self-harm. Few interventions are proven to be deliverable in the NHS for this population. This study is strengthened by the involvement of qualified mental health workers experienced in managing risk as therapists