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1.  The prevalence and correlates of alcohol use and alcohol use disorders: a population based study in Colombo, Sri Lanka 
BMC Psychiatry  2015;15:158.
Background
Alcohol use is increasing in non-Western countries. However, the effects of this increase on the prevalence of alcohol use disorders (AUD) remains unknown, particularly in South Asia. This study aimed to estimate the prevalence of alcohol use and AUD in the Colombo District, Sri Lanka. Environmental risk factors and psychiatric correlates were also examined.
Methods
The Composite International Diagnostic Interview was used to assess alcohol use and psychiatric disorders in a population based sample of 6014 twins and singletons in the Colombo region of Sri Lanka.
Results
Lifetime alcohol use on 12 or more occasions was estimated at 63.1 % (95 % CI: 61.3-64.9) in men and 3.7 % (95 % CI: 3.0-4.3) in women. Prevalence of lifetime alcohol abuse and alcohol dependence in men was 6.2 % (95 % CI: 5.3-7.1) and 4.0 % (95 % CI: 3.3-4.7) respectively. Lower standard of living was independently associated with alcohol use and dependence but not abuse. Significant associations between lifetime AUD and other psychiatric disorders were observed.
Conclusions
Lower prevalence of alcohol use and AUD was observed compared to Western countries. Prevalence of alcohol use and AUD were higher than previous reports. Socio-demographic and environmental risk factors appear to be similar across cultures as were associations between AUD and other psychiatric disorders.
doi:10.1186/s12888-015-0549-z
PMCID: PMC4499892  PMID: 26169683
Alcohol use; Alcohol use disorders; Sri Lanka; Comorbidity
2.  Validation of the SCOFF Questionnaire for Eating Disorders in a Multiethnic General Population Sample 
Introduction
This study aimed to validate the SCOFF, an eating disorders (ED) screening questionnaire, in a multiethnic general population sample of adults.
Method
A two-stage design was employed using the South East London Community Health Study phases I and II data. A total of 1,669 participants were screened using the SCOFF in SELCoHI, and 145 were administrated an ED clinical interview in SELCoHII. We explored the diagnostic validity of the questionnaire restricting to the 145 individuals with the clinical questionnaire.
Results
Sensitivity and specificity of the SCOFF were 53.7 and 93.5%, respectively.
Conclusion
The SCOFF showed good levels of specificity but low sensitivity, resulting in a high percentage of false negatives. Given the low sensitivity found in our sample the SCOFF is likely to be a suboptimal measure for the identification of ED in the community. © 2014 The Authors International Journal of Eating Disorders Published by Wiley Periodicals, Inc. (Int J Eat Disord 2015; 48:312–316)
doi:10.1002/eat.22373
PMCID: PMC4407952  PMID: 25504212
SCOFF; eating disorders; diagnostic validity
3.  Developing a new model for patient recruitment in mental health services: a cohort study using Electronic Health Records 
BMJ Open  2014;4(12):e005654.
Objectives
To develop a new model for patient recruitment that harnessed the full potential of Electronic Health Records (EHRs). Gaining access to potential participants’ health records to assess their eligibility for studies and allow an approach about participation (‘consent for contact’) is ethically, legally and technically challenging, given that medical data are usually restricted to the patient's clinical team. The research objective was to design a model for identification and recruitment to overcome some of these challenges as well as reduce the burdensome (and/or time consuming) gatekeeper role of clinicians in determining who is appropriate or not to participate in clinical research.
Setting
Large secondary mental health services context, UK.
Participants
2106 patients approached for ‘consent for contact’. All patients in different services within the mental health trust are gradually and systematically being approached by a member of the clinical care team using the ‘consent for contact’ model. There are no exclusion criteria.
Primary and secondary outcome measures
Provision of ‘consent for contact’.
Results
A new model (the South London and Maudsley NHS Trust Consent for Contact model (SLaM C4C)) for gaining patients’ consent to contact them about research possibilities, which is built around a de-identified EHR database. The model allows researchers to contact potential participants directly. Of 2106 patients approached by 25 October 2013, nearly 3 of every 4 gave consent for contact (1560 patients; 74.1%).
Conclusions
The SLaM C4C model offers an effective way of expediting recruitment into health research through using EHRs. It reduces the gatekeeper function of clinicians; gives patients greater autonomy in decisions to participate in research; and accelerates the development of a culture of active research participation. More research is needed to assess how many of those giving consent for contact subsequently consent to participate in particular research studies.
doi:10.1136/bmjopen-2014-005654
PMCID: PMC4256538  PMID: 25468503
MENTAL HEALTH; PSYCHIATRY
4.  Trauma, post-traumatic stress disorder and psychiatric disorders in a middle-income setting: prevalence and comorbidity 
The British Journal of Psychiatry  2014;205(5):383-389.
Background
Most studies of post-traumatic stress disorder (PTSD) in low- and middle-income countries (LMICs) have focused on ‘high-risk’ populations defined by exposure to trauma.
Aims
To estimate the prevalence of post-traumatic stress disorder (PTSD) in a LMIC, the conditional probability of PTSD given a traumatic event and the strength of associations between traumatic events and other psychiatric disorders.
Method
Our sample contained a mix of 3995 twins and 2019 non-twins. We asked participants about nine different traumatic exposures, including the category ‘other’, but excluding sexual trauma.
Results
Traumatic events were reported by 36.3% of participants and lifetime PTSD was present in 2.0%. Prevalence of non-PTSD lifetime diagnosis was 19.1%. Of people who had experienced three or more traumatic events, 13.3% had lifetime PTSD and 40.4% had a non-PTSD psychiatric diagnosis.
Conclusions
Despite high rates of exposure to trauma, this population had lower rates of PTSD than high-income populations, although the prevalence might have been slightly affected by the exclusion of sexual trauma. There are high rates of non-PTSD diagnoses associated with trauma exposure that could be considered in interventions for trauma-exposed populations. Our findings suggest that there is no unique relationship between traumatic experiences and the specific symptomatology of PTSD.
doi:10.1192/bjp.bp.113.141796
PMCID: PMC4217028  PMID: 25257062
5.  Seeking informal and formal help for mental health problems in the community: a secondary analysis from a psychiatric morbidity survey in South London 
BMC Psychiatry  2014;14:275.
Background
Only 30-35% of people with mental health problems seek help from professionals. Informal help, usually from friends, family and religious leaders, is often sought but is under-researched. This study aimed to contrast patterns of informal and formal help-seeking using data from a community psychiatric morbidity survey (n=1692) (South East London Community Health (SELCOH) Study).
Methods
Patterns of help-seeking were analysed by clinical, sociodemographic and socioeconomic indicators. Factors associated with informal and formal help-seeking were investigated using logistic regression. Cross-tabulations examined informal help-seeking patterns from different sources.
Results
‘Cases’ (n = 386) were participants who had scores of ≥ 12 on the Revised Clinical Interview Schedule (CIS-R), indicating a common mental disorder. Of these, 40.1% had sought formal help, (of whom three-quarters (29%) had also sought informal help), 33.6% had sought informal help only and only 26.3% had sought no help. When controlling for non-clinical variables, severity, depression, suicidal ideas, functioning and longstanding illnesses were associated with formal rather than informal help-seeking. Age and ethnic group influenced sources of informal help used. Younger people most frequently sought informal help only whereas older people tended to seek help from their family. There were ethnic group differences in whether help was sought from friends, family or religious leaders.
Conclusions
This study has shown how frequently informal help is used, whether in conjunction with formal help or not. Among the ‘cases’, over 60% had sought informal help, whether on its own or together with formal help. Severity was associated with formal help-seeking. Patterns of informal help use have been found. The use and effectiveness of informal help merit urgent research.
doi:10.1186/s12888-014-0275-y
PMCID: PMC4195997  PMID: 25292287
Informal help; Formal help-seeking; Depression; Functioning; Friends; Family; Community psychiatric survey; Mental health
6.  Fluoxetine versus other types of pharmacotherapy for depression 
Background
Depression is common in primary care and it is associated with marked personal, social and economic morbidity, and creates significant demands on service providers in terms of workload. Treatment is predominantly pharmaceutical or psychological. Fluoxetine, the first of a group of antidepressant (AD) agents known as selective serotonin reuptake inhibitors (SSRIs), has been studied in many randomised controlled trials (RCTs) in comparison with tricyclic (TCA), heterocyclic and related ADs, and other SSRIs. These comparative studies provided contrasting findings. In addition, systematic reviews of RCTs have always considered the SSRIs as a group, and evidence applicable to this group of drugs might not be applicable to fluoxetine alone. The present systematic review assessed the efficacy and tolerability profile of fluoxetine in comparison with TCAs, SSRIs and newer agents.
Objectives
To determine the efficacy of fluoxetine, compared with other ADs, in alleviating the acute symptoms of depression, and to review its acceptability.
Search methods
Relevant studies were located by searching the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDANCTR), the Cochrane Central Register of Controlled Trials (CENTRAL), Medline (1966-2004) and Embase (1974-2004). Non-English language articles were included.
Selection criteria
Only RCTs were included. For trials which have a crossover design only results from the first randomisation period were considered.
Data were independently extracted by two reviewers using a standard form. Responders to treatment were calculated on an intention-to-treat basis: drop-outs were always included in this analysis. When data on drop-outs were carried forward and included in the efficacy evaluation, they were analysed according to the primary studies; when dropouts were excluded from any assessment in the primary studies, they were considered as treatment failures. Scores from continuous outcomes were analysed including patients with a final assessment or with the last observation carried forward. Tolerability data were analysed by calculating the proportion of patients who failed to complete the study and who experienced adverse reactions out of the total number of randomised patients. The primary analyses used a fixed effects approach, and presented Peto Odds Ratio (Peto OR) and Standardised Mean Difference (SMD).
Main results
On a dichotomous outcome fluoxetine was less effective than dothiepin (Peto OR: 2.09, 95% CI 1.08 to 4.05), sertraline (Peto OR: 1.40, 95% CI 1.11 to 1.76), mirtazapine (Peto OR: 1.64, 95% CI 1.01 to 2.65) and venlafaxine (Peto OR: 1.40, 95% CI 1.15 to 1.70). On a continuous outcome, fluoxetine was more effective than ABT-200 (Standardised Mean Difference (SMD) random effects: - 1.85, 95% CI - 2.25 to - 1.45) and milnacipran (SMD random effects: - 0.38, 95% CI - 0.71 to - 0.06); conversely, it was less effective than venlafaxine (SMD random effect: 0.11, 95% CI 0.00 to 0.23), however these figures were of borderline statistical significance.
Fluoxetine was better tolerated than TCAs considered as a group (Peto OR: 0.78, 95% CI 0.68 to 0.89), and was better tolerated in comparison with individual ADs, in particular than amitriptyline (Peto OR: 0.64, 95% CI 0.47 to 0.85) and imipramine (Peto OR: 0.79, 95% CI 0.63 to 0.99), and among newer ADs than ABT-200 (Peto OR: 0.21, 95% CI 0.10 to 0.41), pramipexole (Peto OR: 0.20, 95% CI 0.08 to 0.47) and reboxetine (Peto OR: 0.61, 95% CI 0.40 to 0.94).
Authors’ conclusions
There are statistically significant differences in terms of efficacy and tolerability between fluoxetine and certain ADs, but the clinical meaning of these differences is uncertain, and no definitive implications for clinical practice can be drawn. From a clinical point of view the analysis of antidepressants’ safety profile (adverse effect and suicide risk) remains of crucial importance and more reliable data about these outcomes are needed. Waiting for more robust evidence, treatment decisions should be based on considerations of clinical history, drug toxicity, patient acceptability, and cost. We need for large, pragmatic trials, enrolling heterogeneous populations of patients with depression to generate clinically relevant information on the benefits and harms of competitive pharmacological options. A meta-analysis of individual patient data from the randomised trials is clearly necessary.
doi:10.1002/14651858.CD004185.pub2
PMCID: PMC4163961  PMID: 16235353
Antidepressive Agents [therapeutic use]; Antidepressive Agents, Second-Generation [*therapeutic use]; Antidepressive Agents, Tricyclic [therapeutic use]; Depression [*drug therapy]; Fluoxetine [*therapeutic use]; Randomized Controlled Trials as Topic; Serotonin Uptake Inhibitors [*therapeutic use]; Humans
7.  Mini-Mental State Examination as a Predictor of Mortality among Older People Referred to Secondary Mental Healthcare 
PLoS ONE  2014;9(9):e105312.
Background
Lower levels of cognitive function have been found to be associated with higher mortality in older people, particularly in dementia, but the association in people with other mental disorders is still inconclusive.
Methods and Findings
Data were analysed from a large mental health case register serving a geographic catchment of 1.23 million residents, and associations were investigated between cognitive function measured by the Mini-Mental State Examination (MMSE) and survival in patients aged 65 years old and over. Cox regressions were carried out, adjusting for age, gender, psychiatric diagnosis, ethnicity, marital status, and area-level socioeconomic index. A total of 6,704 subjects were involved, including 3,368 of them having a dementia diagnosis and 3,336 of them with depression or other diagnoses. Descriptive outcomes by Kaplan-Meier curves showed significant differences between those with normal and impaired cognitive function (MMSE score<25), regardless of a dementia diagnosis. As a whole, the group with lower cognitive function had an adjusted hazard ratio (HR) of 1.42 (95% CI: 1.28, 1.58) regardless of diagnosis. An HR of 1.23 (95% CI: 1.18, 1.28) per quintile increment of MMSE was also estimated after confounding control. A linear trend of MMSE in quintiles was observed for the subgroups of dementia and other non-dementia diagnoses (both p-values<0.001). However, a threshold effect of MMSE score under 20 was found for the specific diagnosis subgroups of depression.
Conclusion
Current study identified an association between cognitive impairment and increased mortality in older people using secondary mental health services regardless of a dementia diagnosis. Causal pathways between this exposure and outcome (for example, suboptimal healthcare) need further investigation.
doi:10.1371/journal.pone.0105312
PMCID: PMC4153564  PMID: 25184819
8.  The Effect of Clozapine on Premature Mortality: An Assessment of Clinical Monitoring and Other Potential Confounders 
Schizophrenia Bulletin  2014;41(3):644-655.
Clozapine can cause severe adverse effects yet it is associated with reduced mortality risk. We test the hypothesis this association is due to increased clinical monitoring and investigate risk of premature mortality from natural causes. We identified 14 754 individuals (879 deaths) with serious mental illness (SMI) including schizophrenia, schizoaffective and bipolar disorders aged ≥ 15 years in a large specialist mental healthcare case register linked to national mortality tracing. In this cohort study we modeled the effect of clozapine on mortality over a 5-year period (2007–2011) using Cox regression. Individuals prescribed clozapine had more severe psychopathology and poorer functional status. Many of the exposures associated with clozapine use were themselves risk factors for increased mortality. However, we identified a strong association between being prescribed clozapine and lower mortality which persisted after controlling for a broad range of potential confounders including clinical monitoring and markers of disease severity (adjusted hazard ratio 0.4; 95% CI 0.2–0.7; p = .001). This association remained after restricting the sample to those with a diagnosis of schizophrenia or those taking antipsychotics and after using propensity scores to reduce the impact of confounding by indication. Among individuals with SMI, those prescribed clozapine had a reduced risk of mortality due to both natural and unnatural causes. We found no evidence to indicate that lower mortality associated with clozapine in SMI was due to increased clinical monitoring or confounding factors. This is the first study to report an association between clozapine and reduced risk of mortality from natural causes.
doi:10.1093/schbul/sbu120
PMCID: PMC4393681  PMID: 25154620
clozapine; mortality; clinician contact; schizophrenia; schizoaffective disorder; bipolar affective disorder
9.  Social networks, social support and psychiatric symptoms: social determinants and associations within a multicultural community population 
Purpose
Little is known about how social networks and social support are distributed within diverse communities and how different types of each are associated with a range of psychiatric symptoms. This study aims to address such shortcomings by: (1) describing the demographic and socioeconomic characteristics of social networks and social support in a multicultural population and (2) examining how each is associated with multiple mental health outcomes.
Methods
Data is drawn from the South East London Community Health Study; a cross-sectional study of 1,698 adults conducted between 2008 and 2010.
Results
The findings demonstrate variation in social networks and social support by socio-demographic factors. Ethnic minority groups reported larger family networks but less perceived instrumental support. Older individuals and migrant groups reported lower levels of particular network and support types. Individuals from lower socioeconomic groups tended to report less social networks and support across the indicators measured. Perceived emotional and instrumental support, family and friend network size emerged as protective factors for common mental disorder, personality dysfunction and psychotic experiences. In contrast, both social networks and social support appear less relevant for hazardous alcohol use.
Conclusions
The findings both confirm established knowledge that social networks and social support exert differential effects on mental health and furthermore suggest that the particular type of social support may be important. In contrast, different types of social network appear to impact upon poor mental health in a more uniform way. Future psychosocial strategies promoting mental health should consider which social groups are vulnerable to reduced social networks and poor social support and which diagnostic groups may benefit most.
doi:10.1007/s00127-014-0943-8
PMCID: PMC4464053  PMID: 25106666
Social support; Social networks; Mental health; London; UK
10.  ‘You feel you've been bad, not ill’: Sick doctors’ experiences of interactions with the General Medical Council 
BMJ Open  2014;4(7):e005537.
Objective
To explore the views of sick doctors on their experiences with the General Medical Council (GMC) and their perception of the impact of GMC involvement on return to work.
Design
Qualitative study.
Setting
UK.
Participants
Doctors who had been away from work for at least 6 months with physical or mental health problems, drug or alcohol problems, GMC involvement or any combination of these, were eligible for inclusion into the study. Eligible doctors were recruited in conjunction with the Royal Medical Benevolent Fund, the GMC and the Practitioner Health Programme. These organisations approached 77 doctors; 19 participated. Each doctor completed an in-depth semistructured interview. We used a constant comparison method to identify and agree on the coding of data and the identification of central themes.
Results
18 of the 19 participants had a mental health, addiction or substance misuse problem. 14 of the 19 had interacted with the GMC. 4 main themes were identified: perceptions of the GMC as a whole; perceptions of GMC processes; perceived health impacts and suggested improvements. Participants described the GMC processes they experienced as necessary, and some elements as supportive. However, many described contact with the GMC as daunting, confusing and anxiety provoking. Some were unclear about the role of the GMC and felt that GMC communication was unhelpful, particularly the language used in correspondence. Improvements suggested by participants included having separate pathways for doctors with purely health issues, less use of legalistic language, and a more personal approach with for example individualised undertakings or conditions.
Conclusions
While participants recognised the need for a regulator, the processes employed by the GMC and the communication style used were often distressing, confusing and perceived to have impacted negatively on their mental health and ability to return to work.
doi:10.1136/bmjopen-2014-005537
PMCID: PMC4120406  PMID: 25034631
MENTAL HEALTH; QUALITATIVE RESEARCH; OCCUPATIONAL & INDUSTRIAL MEDICINE
11.  Predicting outcome following psychological therapy in IAPT (PROMPT): a naturalistic project protocol 
BMC Psychiatry  2014;14:170.
Background
Depression and anxiety are highly prevalent and represent a significant and well described public health burden. Whilst first line psychological treatments are effective for nearly half of attenders, there remain a substantial number of patients who do not benefit. The main objective of the present project is to establish an infrastructure platform for the identification of factors that predict lack of response to psychological treatment for depression and anxiety, in order to better target treatments as well as to support translational and experimental medicine research in mood and anxiety disorders.
Methods/design
Predicting outcome following psychological therapy in IAPT (PROMPT) is a naturalistic observational project that began patient recruitment in January 2014. The project is currently taking place in Southwark Psychological Therapies Service, an Improving Access to Psychological Therapies (IAPT) service currently provided by the South London and Maudsley NHS Foundation Trust (SLaM). However, the aim is to roll-out the project across other IAPT services. Participants are approached before beginning treatment and offered a baseline interview whilst they are waiting for therapy to begin. This allows us to test for relationships between predictor variables and patient outcome measures. At the baseline interview, participants complete a diagnostic interview; are asked to give blood and hair samples for relevant biomarkers, and complete psychological and social questionnaire measures. Participants then complete their psychological therapy as offered by Southwark Psychological Therapies Service. Response to psychological therapy will be measured using standard IAPT outcome data, which are routinely collected at each appointment.
Discussion
This project addresses a need to understand treatment response rates in primary care psychological therapy services for those with depression and/or anxiety. Measurement of a range of predictor variables allows for the detection of bio-psycho-social factors which may be relevant for treatment outcome. This will enable future clinical decision making to be based on the individual needs of the patient in an evidence-based manner. Moreover, the identification of individuals who fail to improve following therapy delivered by IAPT services could be utilised for the development of novel interventions.
doi:10.1186/1471-244X-14-170
PMCID: PMC4057910  PMID: 24910361
12.  Decision-making capacity for treatment in psychiatric and medical in-patients: cross-sectional, comparative study† 
The British Journal of Psychiatry  2013;203(6):461-467.
Background
Is the nature of decision-making capacity (DMC) for treatment significantly different in medical and psychiatric patients?
Aims
To compare the abilities relevant to DMC for treatment in medical and psychiatric patients who are able to communicate a treatment choice.
Method
A secondary analysis of two cross-sectional studies of consecutive admissions: 125 to a psychiatric hospital and 164 to a medical hospital. The MacArthur Competence Assessment Tool - Treatment and a clinical interview were used to assess decision-making abilities (understanding, appreciating and reasoning) and judgements of DMC. We limited analysis to patients able to express a choice about treatment and stratified the analysis by low and high understanding ability.
Results
Most people scoring low on understanding were judged to lack DMC and there was no difference by hospital (P = 0.14). In both hospitals there were patients who were able to understand yet lacked DMC (39% psychiatric v. 13% medical in-patients, P<0.001). Appreciation was a better ‘test’ of DMC in the psychiatric hospital (where psychotic and severe affective disorders predominated) (P<0.001), whereas reasoning was a better test of DMC in the medical hospital (where cognitive impairment was common) (P = 0.02).
Conclusions
Among those with good understanding, the appreciation ability had more salience to DMC for treatment in a psychiatric setting and the reasoning ability had more salience in a medical setting.
doi:10.1192/bjp.bp.112.123976
PMCID: PMC3844898  PMID: 23969482
13.  Gender differences in the association between adiposity and probable major depression: a cross-sectional study of 140,564 UK Biobank participants 
BMC Psychiatry  2014;14:153.
Background
Previous studies on the association between adiposity and mood disorder have produced contradictory results, and few have used measurements other than body mass index (BMI). We examined the association between probable major depression and several measurements of adiposity: BMI, waist circumference (WC), waist-hip-ratio (WHR), and body fat percentage (BF%).
Methods
We conducted a cross-sectional study using baseline data on the sub-group of UK Biobank participants who were assessed for mood disorder. Multivariate logistic regression models were used, adjusting for potential confounders including: demographic and life-style factors, comorbidity and psychotropic medication.
Results
Of the 140,564 eligible participants, evidence of probable major depression was reported by 30,145 (21.5%). The fully adjusted odds ratios (OR) for obese participants were 1.16 (95% confidence interval (CI) 1.12, 1.20) using BMI, 1.15 (95% CI 1.11, 1.19) using WC, 1.09 (95% CI 1.05, 1.13) using WHR and 1.18 (95% CI 1.12, 1.25) using BF% (all p < 0.001). There was a significant interaction between adiposity and gender (p = 0.001). Overweight women were at increased risk of depression with a dose response relationship across the overweight (25.0-29.9 kg/m2), obese I (30.0-34.9 kg/m2), II (35.0-39.9 kg/m2) and III (≥40.0 kg/m2) categories; fully adjusted ORs 1.14, 1.20, 1.29 and 1.48, respectively (all p < 0.001). In contrast, only obese III men had significantly increased risk of depression (OR 1.29, 95% CI 1.08, 1.54, p = 0.006).
Conclusion
Adiposity was associated with probable major depression, irrespective of the measurement used. The association was stronger in women than men. Physicians managing overweight and obese women should be alert to this increased risk.
doi:10.1186/1471-244X-14-153
PMCID: PMC4050096  PMID: 24884621
Adiposity; Obesity; Depression; Mental health; Mood disorder; UK Biobank
14.  Adversity, cannabis use and psychotic experiences: evidence of cumulative and synergistic effects 
The British Journal of Psychiatry  2014;204(5):346-353.
Background
There is robust evidence that childhood adversity is associated with an increased risk of psychosis. There is, however, little research on intervening factors that might increase or decrease risk following childhood adversity.
Aims
To investigate main effects of, and synergy between, childhood abuse and life events and cannabis use on odds of psychotic experiences.
Method
Data on psychotic experiences and childhood abuse, life events and cannabis use were collected from 1680 individuals as part of the South East London Community Health Study (SELCoH), a population-based household survey.
Results
There was strong evidence that childhood abuse and number of life events combined synergistically to increase odds of psychotic experiences beyond the effects of each individually. There was similar, but weaker, evidence for cannabis use (past year).
Conclusions
Our findings are consistent with the hypothesis that childhood abuse creates an enduring vulnerability to psychosis that is realised in the event of exposure to further stressors and risk factors.
doi:10.1192/bjp.bp.113.134452
PMCID: PMC4006086  PMID: 24627297
15.  Concepts of mental capacity for patients requesting assisted suicide: a qualitative analysis of expert evidence presented to the Commission on Assisted Dying 
BMC Medical Ethics  2014;15:32.
Background
In May 2013 a new Assisted Dying Bill was tabled in the House of Lords and is currently scheduled for a second reading in May 2014. The Bill was informed by the report of the Commission on Assisted Dying which itself was informed by evidence presented by invited experts.
This study aims to explore how the experts presenting evidence to the Commission on Assisted Dying conceptualised mental capacity for patients requesting assisted suicide and examine these concepts particularly in relation to the principles of the Mental Capacity Act 2005.
Methods
This study was a secondary qualitative analysis of 36 transcripts of oral evidence and 12 pieces of written evidence submitted by invited experts to the Commission on Assisted Dying using a framework approach.
Results
There was agreement on the importance of mental capacity as a central safeguard in proposed assisted dying legislation. Concepts of mental capacity, however, were inconsistent. There was a tendency towards a conceptual and clinical shift toward a presumption of incapacity. This appeared to be based on the belief that assisted suicide should only be open to those with a high degree of mental capacity to make the decision.
The ‘boundaries’ around the definition of mental capacity appeared to be on a continuum between a circumscribed legal ‘cognitive’ definition of capacity (in which most applicants would be found to have capacity unless significantly cognitively impaired) and a more inclusive definition which would take into account wider concepts such as autonomy, rationality, voluntariness and decision specific factors such as motivation for decision making.
Conclusion
Ideas presented to the Commission on Assisted Dying about mental capacity as it relates to assisted suicide were inconsistent and in a number of cases at variance with the principles of the Mental Capacity Act 2005. Further work needs to be done to establish a consensus as to what constitutes capacity for this decision and whether current legal frameworks are able to support clinicians in determining capacity for this group.
doi:10.1186/1472-6939-15-32
PMCID: PMC3998063  PMID: 24755362
Assisted suicide; Mental capacity; Qualitative
16.  Job Strain, Health and Sickness Absence: Results from the Hordaland Health Study 
PLoS ONE  2014;9(4):e96025.
Objectives
While it is generally accepted that high job strain is associated with adverse occupational outcomes, the nature of this relationship and the causal pathways involved are not well elucidated. We aimed to assess the association between job strain and long-term sickness absence (LTSA), and investigate whether any associations could be explained by validated health measures.
Methods
Data from participants (n = 7346) of the Hordaland Health Study (HUSK), aged 40–47 at baseline, were analyzed using multivariate Cox regression to evaluate the association between job strain and LTSA over one year. Further analyses examined whether mental and physical health mediated any association between job strain and sickness absence.
Results
A positive association was found between job strain and risk of a LTSA episode, even controlling for confounding factors (HR = 1.64 (1.36–1.98); high job strain exposure accounted for a small proportion of LTSA episodes (population attributable risk 0.068). Further adjustments for physical health and mental health individually attenuated, but could not fully explain the association. In the fully adjusted model, the association between high job strain and LTSA remained significant (HR = 1.30 (1.07–1.59)).
Conclusion
High job strain increases the risk of LTSA. While our results suggest that one in 15 cases of LTSA could be avoided if high job strain were eliminated, we also provide evidence against simplistic causal models. The impact of job strain on future LTSA could not be fully explained by impaired health at baseline, which suggests that factors besides ill health are important in explaining the link between job strain and sickness absence.
doi:10.1371/journal.pone.0096025
PMCID: PMC3995988  PMID: 24755878
17.  Investigating Exposure to Violence and Mental Health in a Diverse Urban Community Sample: Data from the South East London Community Health (SELCoH) Survey 
PLoS ONE  2014;9(4):e93660.
Background
General population surveys have seldom examined violence as a multidimensional concept and in relation to an array of mental disorders.
Methods
Data from the South East London Community Health Study was used to examine the prevalence, overlap and distribution of proximal witnessed, victimised and perpetrated violence and their association with current mental disorders. We further investigated the cumulative effect of lifetime exposure to violence on current mental disorders. Unadjusted and adjusted (for confounders and violence) models were examined.
Results
In the last twelve months, 7.4% reported witnessing violence, 6.3% victimisation and 3.2% perpetration of violence. There was a significant overlap across violence types, with some shared correlates across the groups such as being younger and male. Witnessing violence in the past year was associated with current common mental disorders (CMD) and post-traumatic stress disorder (PTSD) symptoms. Proximal perpetration was associated with current CMD, PTSD symptoms and past 12 months drug use; whereas proximal victimisation was associated with lifetime and past 12 months drug use. Lifetime exposure to two or more types of violence was associated with increased risk for all mental health outcomes, suggesting a cumulative effect.
Conclusion
Exposure to violence needs to be examined in a multi-faceted manner: i) as discrete distal and proximal events, which may have distinct patterns of association with mental health and ii) as a concept with different but overlapping dimensions, thus also accounting for possible cumulative effects.
doi:10.1371/journal.pone.0093660
PMCID: PMC3972242  PMID: 24691206
18.  A cohort study on mental disorders, stage of cancer at diagnosis and subsequent survival 
BMJ Open  2014;4(1):e004295.
Objectives
To assess the stage at cancer diagnosis and survival after cancer diagnosis among people served by secondary mental health services, compared with other local people.
Setting
Using the anonymised linkage between a regional monopoly secondary mental health service provider in southeast London of four London boroughs, Croydon, Lambeth, Lewisham and Southwark, and a population-based cancer register, a historical cohort study was constructed.
Participants
A total of 28 477 cancer cases aged 15+ years with stage of cancer recorded at diagnosis were identified. Among these, 2206 participants had been previously assessed or treated in secondary mental healthcare before their cancer diagnosis and 125 for severe mental illness (schizophrenia, schizoaffective or bipolar disorders).
Primary and secondary outcome measures
Stage when cancer was diagnosed and all-cause mortality after cancer diagnosis among cancer cases registered in the geographical area of southeast London.
Results
Comparisons between people with and without specific psychiatric diagnosis in the same residence area for risks of advanced stage of cancer at diagnosis and general survival after cancer diagnosed were analysed using logistic and Cox models. No associations were found between specific mental disorder diagnoses and beyond local spread of cancer at presentation. However, people with severe mental disorders, depression, dementia and substance use disorders had significantly worse survival after cancer diagnosis, independent of cancer stage at diagnosis and other potential confounders.
Conclusions
Previous findings of associations between mental disorders and cancer mortality are more likely to be accounted for by differences in survival after cancer diagnosis rather than by delayed diagnosis.
doi:10.1136/bmjopen-2013-004295
PMCID: PMC3913023  PMID: 24477317
Cancer Stage at Diagnosis; Case Register Linkage; Severe Mental Illness; Survival
19.  Depression and decision-making capacity for treatment or research: a systematic review 
BMC Medical Ethics  2013;14:54.
Background
Psychiatric disorders can pose problems in the assessment of decision-making capacity (DMC). This is so particularly where psychopathology is seen as the extreme end of a dimension that includes normality. Depression is an example of such a psychiatric disorder. Four abilities (understanding, appreciating, reasoning and ability to express a choice) are commonly assessed when determining DMC in psychiatry and uncertainty exists about the extent to which depression impacts capacity to make treatment or research participation decisions.
Methods
A systematic review of the medical ethical and empirical literature concerning depression and DMC was conducted. Medline, EMBASE and PsycInfo databases were searched for studies of depression and consent and DMC. Empirical studies and papers containing ethical analysis were extracted and analysed.
Results
17 publications were identified. The clinical ethics studies highlighted appreciation of information as the ability that can be impaired in depression, indicating that emotional factors can impact on DMC. The empirical studies reporting decision-making ability scores also highlighted impairment of appreciation but without evidence of strong impact. Measurement problems, however, looked likely. The frequency of clinical judgements of lack of DMC in people with depression varied greatly according to acuity of illness and whether judgements are structured or unstructured.
Conclusions
Depression can impair DMC especially if severe. Most evidence indicates appreciation as the ability primarily impaired by depressive illness. Understanding and measuring the appreciation ability in depression remains a problem in need of further research.
doi:10.1186/1472-6939-14-54
PMCID: PMC4029430  PMID: 24330745
Depression; Depressive disorder; Depressed; Decision-making; Informed consent; Competence; Mental competency; Mental capacity
20.  Prevalence and Characteristics of Probable Major Depression and Bipolar Disorder within UK Biobank: Cross-Sectional Study of 172,751 Participants 
PLoS ONE  2013;8(11):e75362.
Objectives
UK Biobank is a landmark cohort of over 500,000 participants which will be used to investigate genetic and non-genetic risk factors for a wide range of adverse health outcomes. This is the first study to systematically assess the prevalence and validity of proposed criteria for probable mood disorders within the cohort (major depression and bipolar disorder).
Methods
This was a descriptive epidemiological study of 172,751 individuals assessed for a lifetime history of mood disorder in relation to a range of demographic, social, lifestyle, personality and health-related factors. The main outcomes were prevalence of a probable lifetime (single) episode of major depression, probable recurrent major depressive disorder (moderate), probable recurrent major depressive disorder (severe), probable bipolar disorder and no history of mood disorder (comparison group). Outcomes were compared on age, gender, ethnicity, socioeconomic status, educational attainment, functioning, self-reported health status, current depressive symptoms, neuroticism score, smoking status and alcohol use.
Results
Prevalence rates for probable single lifetime episode of major depression (6.4%), probable recurrent major depression (moderate) (12.2%), probable recurrent major depression (severe) (7.2%) and probable bipolar disorder (1.3%) were comparable to those found in other population studies. The proposed diagnostic criteria have promising validity, with a gradient in evidence from no mood disorder through major depression and probable bipolar disorder in terms of gender distribution, socioeconomic status, self-reported health rating, current depressive symptoms and smoking.
Significance
The validity of our proposed criteria for probable major depression and probable bipolar disorder within this cohort are supported by these cross-sectional analyses. Our findings are likely to prove useful as a framework for a wide range of future genetic and non-genetic studies.
doi:10.1371/journal.pone.0075362
PMCID: PMC3839907  PMID: 24282498
21.  Are Reports of Psychological Stress Higher in Occupational Studies? A Systematic Review across Occupational and Population Based Studies 
PLoS ONE  2013;8(11):e78693.
Objectives
The general health questionnaire (GHQ) is commonly used to assess symptoms of common mental disorder (CMD). Prevalence estimates for CMD caseness from UK population studies are thought to be in the range of 14–17%, and the UK occupational studies of which we are aware indicate a higher prevalence. This review will synthesise the existing research using the GHQ from both population and occupational studies and will compare the weighted prevalence estimates between them.
Methods
We conducted a systematic review and meta-analysis to examine the prevalence of CMD, as assessed by the GHQ, in all UK occupational and population studies conducted from 1990 onwards.
Results
The search revealed 65 occupational papers which met the search criteria and 15 relevant papers for UK population studies. The weighted prevalence estimate for CMD across all occupational studies which used the same version and cut-off for the GHQ was 29.6% (95% confidence intervals (CIs) 27.3–31.9%) and for comparable population studies was significantly lower at 19.1% (95% CIs 17.3–20.8%). This difference was reduced after restricting the studies by response rate and sampling method (23.9% (95% CIs 20.5%–27.4%) vs. 19.2% (95 CIs 17.1%–21.3%)).
Conclusions
Counter intuitively, the prevalence of CMD is higher in occupational studies, compared to population studies (which include individuals not in employment), although this difference narrowed after accounting for measures of study quality, including response rate and sampling method. This finding is inconsistent with the healthy worker effect, which would presume lower levels of psychological symptoms in individuals in employment. One explanation is that the GHQ is sensitive to contextual factors, and it seems possible that symptoms of CMD are over reported when participants know that they have been recruited to a study on the basis that they belong to a specific occupational group, as in nearly all “stress” surveys.
doi:10.1371/journal.pone.0078693
PMCID: PMC3817075  PMID: 24223840
22.  Risk factors for Post Traumatic Stress Disorder amongst United Kingdom Armed Forces personnel 
Psychological medicine  2008;38(4):511-522.
Background
Understanding the factors which increase the risk of PTSD for military personnel is important. This study aims to investigate the relative contribution of pre-deployment, peri-deployment, and post deployment variables to the prevalence of post traumatic stress symptoms in UK Armed Forces personnel who have been deployed in Iraq since 2003.
Method
Data are drawn from stage 1 of a retrospective cohort study comparing a random sample of UK military personnel deployed to the 2003 Iraq War with a control group who were not deployed to the initial phase of war fighting (response rate 61%). The analyses are limited to 4762 regular service individuals who responded and who deployed to Iraq since 2003.
Results
Post traumatic stress symptoms were associated with lower rank, being unmarried, low educational attainment and a history of childhood adversity. Exposure to potentially traumatising events was associated with post traumatic stress symptoms. Appraisals of the experience as involving threat to life or that work in theatre was above an individual’s trade and experience were strongly associated with post traumatic stress symptoms Low morale, poor social support within the unit and non-receipt of a homecoming brief were associated with greater risk of post traumatic stress symptoms.
Conclusions
These results support that there are modifiable occupational factors which may influence an individual’s risk of PTSD. Personal appraisal of threat to life during the trauma emerged as the strongest predictor of symptoms, and therefore interventions focused on reinstating a sense of control are an important focus for treatment.
doi:10.1017/S0033291708002778
PMCID: PMC3785135  PMID: 18226287
24.  The prevalence of depression in rheumatoid arthritis: a systematic review and meta-analysis 
Rheumatology (Oxford, England)  2013;52(12):2136-2148.
Objective. There is substantial uncertainty regarding the prevalence of depression in RA. We conducted a systematic review aiming to describe the prevalence of depression in RA.
Methods. Web of Science, PsycINFO, CINAHL, Embase, Medline and PubMed were searched for cross-sectional studies reporting a prevalence estimate for depression in adult RA patients. Studies were reviewed in accordance with the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines and a meta-analysis was performed.
Results. A total of 72 studies, including 13 189 patients, were eligible for inclusion in the review. Forty-three methods of defining depression were reported. Meta-analyses revealed the prevalence of major depressive disorder to be 16.8% (95% CI 10%, 24%). According to the PHQ-9, the prevalence of depression was 38.8% (95% CI 34%, 43%), and prevalence levels according to the HADS with thresholds of 8 and 11 were 34.2% (95% CI 25%, 44%) and 14.8% (95% CI 12%, 18%), respectively. The main influence on depression prevalence was the mean age of the sample.
Conclusion. Depression is highly prevalent in RA and associated with poorer RA outcomes. This suggests that optimal care of RA patients may include the detection and management of depression.
doi:10.1093/rheumatology/ket169
PMCID: PMC3828510  PMID: 24003249
depression; rheumatoid arthritis; prevalence; meta-analysis; systematic review
25.  Chronic fatigue syndrome 
BMJ Clinical Evidence  2011;2011:1101.
Introduction
Chronic fatigue syndrome (CFS) affects between 0.006% and 3% of the population depending on the criteria of definition used, with women being at higher risk than men.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for chronic fatigue syndrome? We searched: Medline, Embase, The Cochrane Library, and other important databases up to March 2010 (Clinical Evidence reviews are updated periodically; please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 46 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antidepressants, cognitive behavioural therapy (CBT), corticosteroids, dietary supplements, evening primrose oil, galantamine, graded exercise therapy, homeopathy, immunotherapy, intramuscular magnesium, oral nicotinamide adenine dinucleotide, and prolonged rest.
Key Points
Chronic fatigue syndrome is characterised by severe, disabling fatigue, and other symptoms including musculoskeletal pain, sleep disturbance, impaired concentration, and headaches. CFS affects between 0.006% and 3% of the population depending on the criteria used, with women being at higher risk than men.
Graded exercise therapy has been shown to effectively improve measures of fatigue and physical functioning. Educational interventions with encouragement of graded exercise (treatment sessions, telephone follow-ups, and an educational package explaining symptoms and encouraging home-based exercise) improve symptoms more effectively than written information alone.
CBT is effective in treating chronic fatigue syndrome in adults. CBT may also be beneficial when administered by therapists with no specific experience of chronic fatigue syndrome, but who are adequately supervised.In adolescents, CBT can reduce fatigue severity and improve school attendance compared with no treatment.
We don't know how effective antidepressants, corticosteroids, and intramuscular magnesium are in treating chronic fatigue syndrome. Antidepressants should be considered in people with affective disorders, and tricyclics in particular have potential therapeutic value because of their analgesic properties.
Interventions such as dietary supplements, evening primrose oil, oral nicotinamide adenine dinucleotide, homeopathy, and prolonged rest have not been studied in enough detail in RCTs for us to draw conclusions on their efficacy.
Based on a single large RCT galantamine seems no better than placebo at improving symptoms of chronic fatigue syndrome.
Although there is some RCT evidence that immunotherapy can improve symptoms compared with placebo, it is associated with considerable adverse effects, and should therefore probably not be offered as a treatment for chronic fatigue.
PMCID: PMC3275316  PMID: 21615974

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