Racial discrimination and health: a prospective study of ethnic minorities in the United Kingdom

BACKGROUND: Racism has been linked with poor health in studies in the United States. Little is known about prospective associations between racial discrimination and health outcomes in the United Kingdom (UK). METHODS: Data were from 4883 ethnic minority (i.e. non-white) participants in the UK Household Longitudinal Study. Perceived discrimination in the last 12 months on the basis of ethnicity or nationality was reported in 2009/10. Psychological distress, mental functioning, life satisfaction, self-rated health, physical functioning and reports of limiting longstanding illness were assessed in 2009/10 and 2011/12. Linear and logistic regression analyses adjusted for age, sex, income, education and ethnicity. Prospective analyses also adjusted for baseline status on the outcome being evaluated. RESULTS: Racial discrimination was reported by 998 (20.4%) of the sample. Cross-sectionally, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness (odds ratio (OR) = 1.78, 95% confidence interval (CI) 1.49; 2.13) and fair/poor self-rated health (OR = 1.50; 95% CI 1.24; 1.82) than those who did not report racial discrimination. Racial discrimination was associated with greater psychological distress (B = 1.11, 95% CI 0.88; 1.34), poorer mental functioning (B = - 3.61; 95% CI -4.29; - 2.93), poorer physical functioning (B = - 0.86; 95% CI -1.50; - 0.27), and lower life satisfaction (B = - 0.40, 95% CI -0.52; - 0.27). Prospectively, those who reported racial discrimination had a greater likelihood on average of limiting longstanding illness (OR = 1.31, 95% CI 1.01; 1.69) and fair/poor self-rated health (OR = 1.30; 95% CI 1.00; 1.69), than those who did not report racial discrimination. Racial discrimination was associated increased psychological distress (B = 0.52, 95% CI 0.20; 0.85) and poorer mental functioning (B = - 1.77; 95% CI -2.70; - 0.83) over two-year follow-up, adjusting for baseline scores. CONCLUSIONS: UK adults belonging to ethnic minority groups who perceive racial discrimination experience poorer mental and physical health than those who do not. These results highlight the need for effective interventions to combat racial discrimination in order to reduce inequalities in health

Authors' Response to Peer Reviews of “Using Structural Equation Modelling in Routine Clinical Data on Diabetes and Depression: Observational Cohort Study”

Background: Large data sets comprising routine clinical data are becoming increasingly available for use in health research. These data sets contain many clinical variables that might not lend themselves to use in research. Structural equation modelling (SEM) is a statistical technique that might allow for the creation of “research-friendly” clinical constructs from these routine clinical variables and therefore could be an appropriate analytic method to apply more widely to routine clinical data. Objective: SEM was applied to a large data set of routine clinical data developed in East London to model well-established clinical associations. Depression is common among patients with type 2 diabetes, and is associated with poor diabetic control, increased diabetic complications, increased health service utilization, and increased health care costs. Evidence from trial data suggests that integrating psychological treatment into diabetes care can improve health status and reduce costs. Attempting to model these known associations using SEM will test the utility of this technique in routine clinical data sets. Methods: Data were cleaned extensively prior to analysis. SEM was used to investigate associations between depression, diabetic control, diabetic care, mental health treatment, and Accident & Emergency (A&E) use in patients with type 2 diabetes. The creation of the latent variables and the direction of association between latent variables in the model was based upon established clinical knowledge. Results: The results provided partial support for the application of SEM to routine clinical data. Overall, 19% (3106/16,353) of patients with type 2 diabetes had received a diagnosis of depression. In line with known clinical associations, depression was associated with worse diabetic control (β=.034, P<.001) and increased A&E use (β=.071, P<.001). However, contrary to expectation, worse diabetic control was associated with lower A&E use (β=–.055, P<.001) and receipt of mental health treatment did not impact upon diabetic control (P=.39). Receipt of diabetes care was associated with better diabetic control (β=–.072, P<.001), having depression (β=.018, P=.007), and receiving mental health treatment (β=.046, P<.001), which might suggest that comprehensive integrated care packages are being delivered in East London. Conclusions: Some established clinical associations were successfully modelled in a sample of patients with type 2 diabetes in a way that made clinical sense, providing partial evidence for the utility of SEM in routine clinical data. Several issues relating to data quality emerged. Data improvement would have likely enhanced the utility of SEM in this data set

The impact of a brief gratitude intervention on subjective well-being, biology and sleep

This randomised controlled experiment tested whether a brief subjective well-being (SWB) intervention would have favourable effects on cardiovascular and neuroendocrine function and on sleep. We compared 2 weeks of a gratitude intervention with an active control (everyday events reporting) and no treatment conditions in 119 young women. The treatment elicited increases in hedonic well-being, optimism and sleep quality along with decreases in diastolic blood pressure. Improvements in SWB were correlated with increased sleep quality and reductions in blood pressure, but there were no relationships with cortisol. This brief intervention suggests that SWB may contribute towards lower morbidity and mortality through healthier biological function and restorative health behaviours

Vitamin D and the risk of treatment-resistant and atypical depression: A Mendelian randomization study

Observational evidence has implicated vitamin D levels as a risk factor in major depressive disorder (MDD). Confounding or reverse causation may be driving these observed associations, with studies using genetics indicating little evidence of an effect. However, genetic studies have relied on broad definitions of depression. The genetic architecture of different depression subtypes may vary since MDD is a highly heterogenous condition, implying potentially diverging requirements in therapeutic approaches. We explored the associations between vitamin D and two subtypes of MDD, for which evidence of a causal link could have the greatest clinical benefits: treatment-resistant depression (TRD) and atypical depression (AD). We used a dual approach, combining observational data with genetic evidence from polygenic risk scores (PRS) and two-sample Mendelian randomization (MR), in the UK Biobank. There was some evidence of a weak association between vitamin D and both incident TRD (Ncases = 830) and AD (Ncases = 2366) in observational analyses, which largely attenuated when adjusting for confounders. Genetic evidence from PRS and two-sample MR, did not support a causal link between vitamin D and either TRD (Ncases = 1891, OR = 1.01 [95%CI 0.78, 1.31]) or AD (Ncases = 2101, OR = 1.04 [95%CI 0.80, 1.36]). Our comprehensive investigations indicated some evidence of an association between vitamin D and TRD/AD observationally, but little evidence of association when using PRS and MR, mirroring findings of genetic studies of vitamin D on broad depression phenotypes. Results do not support further clinical trials of vitamin D in these MDD subtypes but do not rule out that small effects may exist that require larger samples to detect

The effects of six-day SSRI administration on diurnal cortisol secretion in healthy volunteers

RATIONALE: Hyperactivity of the hypothalamic-pituitary-adrenal (HPA) axis has been widely reported in depression, and evidence suggests that selective serotonin reuptake inhibitors (SSRIs) might exert their therapeutic effects through altering cortisol secretion. OBJECTIVE: This study assessed the effects of SSRI administration on diurnal cortisol secretion in healthy volunteers. METHODS: Sixty-four healthy men and women were randomised to receive either 10 mg escitalopram or placebo for six days in a double-blind fashion. On day six of medication, saliva samples were obtained at home for measurement of diurnal cortisol parameters (cortisol slope, cortisol awakening response, total daily cortisol output). RESULTS: Women receiving escitalopram had significantly steeper cortisol slopes across the day compared with those receiving placebo (F(1, 36) = 7.54, p = 0.009). This alteration in cortisol slope was driven by increases in waking cortisol levels (F(1, 35) = 9.21, p = 0.005). Escitalopram did not have any significant effect on the cortisol awakening response or the total daily cortisol output. CONCLUSIONS: Flattened cortisol slopes have been seen in depression. The results of this study suggest that escitalopram might exert its therapeutic effect in women in part through correction of a flattened diurnal cortisol rhythm

The combined association of depression and socioeconomic status with length of post-operative hospital stay following coronary artery bypass graft surgery: data from a prospective cohort study.

To understand the association between pre-operative depression symptoms, including cognitive and somatic symptom subtypes, and length of post-operative stay in patients undergoing coronary artery bypass graft (CABG) surgery, and the role of socioeconomic status (SES)

Depression, C-reactive protein and length of post-operative hospital stay in coronary artery bypass graft surgery patients.

This study aimed to explore the role of C-reactive protein (CRP) in mediating the association between greater pre-operative depression symptoms and longer post-operative length of stay in patients undergoing coronary artery bypass graft (CABG) surgery. We used a sample of 145 elective CABG patients and measured depression symptoms using the Beck Depression Inventory (BDI) prior to surgery and collected baseline measures of CRP. Participants were followed up during their in-hospital stay to measure early (1-3days post-surgery) and persistent (4-8days post-surgery) CRP responses to surgery. We found that compared with participants with low depression symptoms, those with elevated depression symptoms (BDI>10) prior to CABG were at increased odds of a hospital stay of greater than one week (OR 3.51, 95% CI 1.415-8.693, p=0.007) and that greater persistent CRP responses mediated this association. Further work is needed to explore the exact physiological pathways through which depression and CRP interact to affect recovery in CABG patients

The Impact of Caregiving Burden on Mental Well-Being in Coronary Artery Bypass Graft Surgery Caregivers: The Mediatory Role of Perceived Social Support.

An increase in caregiver burden and a decrease in social support have both been identified as predictors of poor caregiver psychological distress. However, little is known about the role of these factors in coronary artery bypass graft (CABG) caregivers. The purpose of this study was to investigate whether change in perceived social support from pre to post surgery mediated the relationship between change in caregiver burden and caregiver depressive symptoms and subjective well-being post surgery. A sample of 101 caregivers of elective CABG patients were assessed 28 days before and 62 days after patients' surgery. Caregivers completed the Oberst Burden Scale, the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Instrument, the Beck Depression Inventory, and the Control, Autonomy, Self-Realisation, and Pleasure (CASP-19) scale. Simple mediation analyses showed that change in social support significantly mediated both the relationship between change in caregiver burden and post-surgery depressive symptoms (unstandardised β = 0.041, 95% CI (0.005, 0.112)) and the relationship between change in caregiver burden and post-surgery subjective well-being (unstandardised β = 0.071, 95% CI (0.001, 0.200)). Psychological interventions aimed at the CABG caregiver population should promote social support to deal with the increase of caregivers' tasks and demands after the patients' surgery

Cost-effectiveness of hydroxychloroquine versus placebo for hand osteoarthritis: economic evaluation of the HERO trial

Background: An economic evaluation alongside the Hydroxychloroquine Effectiveness in Reducing symptoms of hand Osteoarthritis (HERO) trial was undertaken to assess the cost-effectiveness of hydroxychloroquine compared with placebo for symptomatic treatment of hand osteoarthritis for patients with at least moderate hand pain and inadequate response to current therapies. Methods: A trial-based cost–utility analysis was undertaken from the perspective of the UK National Health Service and Personal Social Services over a 12-month time horizon, using evidence from 248 participants included in the HERO trial, conducted in England. Patient-level data were collected prospectively over a 12-month period, using participant-completed questionnaires and investigator forms, to collect healthcare utilisation, costs and quality-adjusted life years (QALYs) using the EQ-5D-5L. The base-case analysis was conducted on an intention-to-treat basis and used multiple imputation methods to deal with missing data. Results were presented in terms of incremental cost-effectiveness ratios (incremental cost per QALY) and net health benefit, with uncertainty surrounding the findings explored using cost-effectiveness acceptability curves. Results: The base-case analysis estimated slightly lower costs on average (−£11.80; 95% confidence interval (CI) −£15.60 to −£8.00) and marginally fewer QALYs (−0.0052; 95% CI −0.0057 to −0.0047) for participants in the hydroxychloroquine group versus placebo group at 12 months. The resulting incremental cost-effectiveness ratio of £2,267 per QALY lost indicated that although costs were saved, health-related quality of life was lost. Even assuming symmetrical preferences regarding losses and gains for health benefits, the findings do not fall within the cost-effective region. Similar findings arose for analyses conducted from the societal perspective and using complete cases only. Conclusions: This economic evaluation indicates that hydroxychloroquine is unlikely to provide a cost-effective pain relief option for improving health-related quality of life in adult patients with moderate-to-severe hand osteoarthritis