Socio-demographic variation in diagnosis of and prescribing for common mental illnesses among children and young people during the COVID-19 pandemic: time series analysis of primary care electronic health records.

BACKGROUND: The impact of the COVID-19 pandemic on the mental health of children and young people (CYP) has been widely reported. Primary care electronic health records were utilised to examine trends in the diagnosing, recording and treating of these common mental disorders by ethnicity and social deprivation in Greater Manchester, England. METHODS: Time-series analyses conducted using Greater Manchester Care Record (GMCR) data examined all diagnosed episodes of anxiety disorders and depression and prescribing of anxiolytics and antidepressants among patients aged 6-24 years. The 41-month observation period was split into three epochs: Pre-pandemic (1/2019-2/2020); Pandemic Phase 1 (3/2020-6/2021); Pandemic Phase 2 (7/2021-5/2022). Rate ratios for all CYP specific to sex, age, ethnicity, and neighbourhood-level Indices of Multiple Deprivation (IMD) quintile were modelled using negative binomial regression. RESULTS: Depression and anxiety disorder rates were highest in females, CYP aged 19-24, and White and 'Other' ethnic groups. During Pandemic Phase 1, rates for these diagnoses fell in all demographic subgroups and then rose to similar levels as those recorded pre-pandemic. In Pandemic Phase 2, rates in Black and Mixed-ethnicity females rose to a significantly greater degree (by 54% and 62%, respectively) than those in White females. Prescribing rates increased throughout the study period, with significantly greater rises observed in non-White females and males. The temporal trends were mostly homogeneous across deprivation quintiles. CONCLUSION: The observed fluctuations in frequency of recorded common mental illness diagnoses likely reflect service accessibility and patients' differential propensities to consult as well as changing levels of distress and psychopathology in the population. However, psychotropic medication prescribing increased throughout the observation period, possibly indicating a sustained decline in mental health among CYP, and also clinicians' responses to problems presented. The comparatively greater increases in frequencies of diagnosis recording and medication prescribing among ethnic minority groups warrants further investigation.

Trajectories of distress and recovery, secondary stressors and social cure processes in people who used the resilience hub after the Manchester Arena bombing.

BACKGROUND: Terrorist incidents lead to a range of mental health outcomes for people affected, sometimes extending years after the event. Secondary stressors can exacerbate them, and social support can provide mitigation and aid recovery. There is a need to better understand distress and mitigating factors among survivors of the Manchester Arena attack in 2017. AIMS: We explored three questions. First, what experiences of distress did participants report? Second, how might secondary stressors have influenced participants' psychosocial recoveries? Third, what part has social support played in the relationships between distress and participants' recovery trajectories? METHOD: We conducted a cross-sectional online survey of a convenience sample of survivors of the Manchester Arena bombing (N = 84) in January 2021 (3 years 8 months post-incident), and a longitudinal study of the same participants' scores on mental health measures over 3 years from September 2017. RESULTS: Survivors' mental well-being scores in early 2021 were significantly lower than general population norms. Longitudinal follow-up provided evidence of enduring distress. Secondary stressors, specifically disruptions to close relationships, were associated with greater post-event distress and slower recovery. We found an indirect relationship between identifying with, and receiving support from, others present at the event and mental well-being >3 years later. CONCLUSIONS: The Arena attack has had an enduring impact on mental health, even in survivors who had a mild response to the event. The quality of close relationships is pivotal to long-term outcome. Constructive support from family and friends, and people with shared experiences, are key to social cure processes that facilitate coping and recovery.

Use of antimicrobial dressings in England and the association with published clinical guidance: interrupted time series analysis.

OBJECTIVES: In healthcare systems, practices and products of unproven value and cost-effectiveness can decrease value and increase waste. Using the management of complex wounds, this study investigates temporal trends in the use of antimicrobials dressings, places this in the context of available evidence and discusses the potential impacts on the UK National Health Service (NHS). DESIGN: Secondary descriptive and interrupted time series (ITS) analysis of NHS prescription data. SETTING: Prescribing Cost Analysis (PCA) details all NHS prescriptions dispensed in the community in England. INTERVENTIONS: An ITS design was used to compare annual changes in the expenditure and use of antimicrobial and non-antimicrobial dressings before and after the publication of the 'intervention' of key evidence-based Scottish Intercollegiate Guidelines Network (SIGN) guidance in 2010. PRIMARY AND SECONDARY OUTCOME MEASURES: Trends in use and expenditure of antimicrobial dressings in relation to published clinical guidance. RESULTS: There was a large increase in the prescribing of, and expenditure on, antimicrobial wound dressings between 1997 and 2016. In 1997, the total number of dressings prescribed was 5 792 700; increasing to 11 447 102 in 2009 with expenditure increasing from £1 960 386 to £32 841 263. During the year of the SIGN intervention (2010), there was a significant drop in the use of silver but there was no consistent ongoing reduction from 2011 to 2015. CONCLUSIONS: Prescribing data can be used to identify products of unproven benefit, which also impose a significant financial burden. This study quantifies the huge increase in the use of antimicrobial wound dressings over a 20-year period despite the lack of compelling evidence to support their routine use. There is some suggestion, however that the use and expenditure decreased after the publication of key guidance. Routine data can be used to as part of more systematic efforts to increase value and reduce waste in health systems.

The Health and Occupation Research Network: An Evolving Surveillance System.

Vital to the prevention of work-related ill-health (WRIH) is the availability of good quality data regarding WRIH burden and risks. Physician-based surveillance systems such as The Health and Occupation Research (THOR) network in the UK are often established in response to limitations of statutory, compensation-based systems for addressing certain epidemiological aspects of disease surveillance. However, to fulfil their purpose, THOR and others need to have methodologic rigor in capturing and ascertaining cases. This article describes how data collected by THOR and analogous systems can inform WRIH incidence, trends, and other determinants. An overview of the different strands of THOR research is provided, including methodologic advancements facilitated by increased data quantity/quality over time and the value of the research outputs for informing Government and other policy makers. In doing so, the utility of data collected by systems such as THOR to address a wide range of research questions, both in relation to WRIH and to wider issues of public and social health, is demonstrated.

The influence of prior training on GPs' attitudes to sickness absence certification post-fit note.

UNLABELLED: Aim To investigate the attitudes to health and work of general practitioners (GPs) with training in occupational medicine (OM) compared with non-OM trained GPs, since the introduction of the fit note. BACKGROUND: Changes to the UK sickness certification system since 2010 and the introduction of the fit note required GPs to change their focus to what patients can do, rather than what they cannot do in relation to work. In an effort to reduce the UK sickness absence burden, GPs completion of the fit note should help to keep people in work, or assist patients to return to work as quickly as possible after a period of absence. METHODS: Questionnaire data were collected via the 7th National General Practitioner Worklife Survey. Findings Results indicate that responses from GPs who had undertaken training in OM, and GPs having received some form of work and health training in the 12-month period before the study were associated with significantly more positive attitudes to patients' returning to work and to the fit note. This study reveals evidence of a difference between trained and non-trained GPs in their attitude to the fit note, and to work and health generally. Further work investigating the effect of specific training in OM on the management and recognition of ill-health by GPs is recommended.

Work-related sickness absence negotiations: GPs' qualitative perspectives.

BACKGROUND: GPs can find their role as issuers of sickness certification problematic, particularly in trying to maintain a balance between certifying absence and preserving the doctor-patient relationship. Little research has been published on consultations in which sickness absence has been certified. AIM: To explore negotiations between GPs and patients in sickness absence certification, including how occupational health training may affect this process. METHOD: A qualitative study was undertaken with GPs trained in occupational health who also participate in a UK wide surveillance scheme studying work-related ill-health. Telephone interviews were conducted with 31 GPs who had reported cases with associated sickness absence. RESULTS: Work-related sickness absence and patients' requests for a 'sick note' vary by diagnosis. Some GPs felt their role as patient advocate was of utmost importance, and issue certificates on a patient's request, whereas others offer more resistance through a greater understanding of issues surrounding work and health acquired through occupational health training. GPs felt that their training helped them to challenge beliefs about absence from work being beneficial to patients experiencing ill-health; they felt better equipped to consider patients' fitness for work, and issued fewer certificates as a result of this. CONCLUSION: Complex issues surround GPs' role in the sickness-certification process, particularly when determining the patient's ability to work while maintaining a healthy doctor-patient relationship. This study demonstrates the potential impact of occupational health training for GPs, particularly in light of changes to the medical statement introduced in 2010.

Time-sampled versus continuous-time reporting for measuring incidence.

BACKGROUND: Accuracy of incidence estimates may be affected by biases that depend on frequency of approach to reporters and reporting window length. A time-sampling strategy enables infrequent approaches with short windows but has never been evaluated. METHODS: A randomized crossover trial compared incidence estimates of work-related diseases using time-sampled versus continuous-time reporting. Physicians were randomly allocated either to report every month (12/12) in 2004 and for 1 randomly chosen month (1/12) in 2005, or to the reverse sequence. Numbers of new cases of work-related disease reported per reporter per month for 1/12 and 12/12 reporting periods were compared. RESULTS: Response rates were high (87%). Withdrawal from the study was higher under 12/12 reporting. The rate ratio for 1/12 versus 12/12 reporting was 1.26 (95% confidence interval = 1.11-1.42). Rates declined gradually in the 12/12 groups over the year, consistent with reporting fatigue. CONCLUSIONS: Increased frequency of data collection may reduce incidence estimates.

Continuing professional development in occupational medicine for general practitioners.

BACKGROUND: The Health and Occupation Reporting (THOR) network for general practitioners (GPs) offers free online continuing professional development (CPD) to contributing GPs. Use of this resource by members is relatively low. Non-uptake is most frequently attributed to lack of time. AIMS: The primary aim was to assess the effects of changes made to educational material, available online to GPs participating in THOR-GP, 1 year after a needs assessment which informed the changes. The secondary aim, developed from the findings of the original study, was to compare contributing GPs who undertake work in occupational medicine, with those who do not, in terms of uptake of the educational material and of educational need. METHODS: GPs participating in THOR-GP, who responded to a questionnaire to assess their use of THOR-GP's website for CPD, were sent a follow-up questionnaire 1 year after the original survey. Both questionnaires comprised scales derived from the syllabus for the Diploma of the Faculty of Occupational Medicine and questions about attitudes to CPD in occupational medicine. RESULTS: No change was found in uptake of or rating of components of the website, following modification. Responders worked on average seven sessions per week in general practice and 1.5 sessions in occupational medicine. GPs working in occupational medicine reported greater confidence in some subject areas than GPs not currently working in occupational medicine and were also more likely to engage in CPD activity within the specialty of occupational medicine. CONCLUSIONS: Undertaking work in occupational medicine increases confidence in the subject and stimulates the use of related educational facilities.

Work-related ill health in general practice, as reported to a UK-wide surveillance scheme.

GPs with training in occupational medicine report cases of work-related ill health and sickness absence to The Health and Occupation Reporting network in General Practice (THOR-GP) using an online webform. This report describes the data reported in 2006 and 2007. GPs mainly reported musculoskeletal disorders and mental ill-health. A much larger proportion of the mental ill-health cases were sickness-absence certified, making up 55.9% of the total days certified. Musculoskeletal disorders are the most frequently reported diagnoses of work-related ill health, but mental ill-health is responsible for most work-related sickness absence.

CPD for GPs using the THOR-GP website.

BACKGROUND: An estimated 3200 UK general practitioners (GPs) practise occupational medicine on a sessional basis. AIM: To assess the educational needs of GPs practising occupational medicine and participating in The Health and Occupational Reporting (THOR) network. METHODS: A questionnaire survey of GPs participating in a national reporting scheme, recording occupational ill-health from general practice (THOR-GP). The questionnaire used scales derived from the syllabus for the Diploma of the Faculty of Occupational Medicine to assess the use of the THOR-GP website for continuing professional development (CPD). Questions were also asked concerning the attitudes and experience of these doctors to CPD in occupational medicine. RESULTS: The response rate was 73% (213/291). Only 22% of responders used the THOR-GP website for CPD. Lack of time was the most frequently cited reason for not using the site. The topics provided on the website which were rated least interesting also appeared as requests for further information in questionnaire returns. CONCLUSION: Online learning has the potential to fulfil the needs of GPs practising occupational medicine. The designers of material for online learning should actively manage and modify the material available in response to educational needs. Further research is required into the clinical and business outcomes of online learning for these doctors.

The incidence of work-related illness in the UK health and social work sector: The Health and Occupation Reporting network 2002-2003.

BACKGROUND: In the United Kingdom, The Health and Occupation Reporting network (THOR) collects incidence data on work-related illness. THOR data show that the health and social work sector generates a high proportion of case reports. This study analyses the most recent data for the health and social work sector, from 2002 to 2003. METHODS: Cases returned to the Occupational Physicians Reporting Activity (OPRA) scheme and three other specialist schemes (Surveillance of Occupational Stress and Mental Illness, Musculoskeletal Occupational Surveillance Scheme and occupational skin surveillance) were analysed. Estimates of incidence rates for stress-related illness, musculoskeletal disorders and skin disease were calculated using two denominators. RESULTS: In this period, 23% (11,016/47,437) of all estimated cases in THOR were in health and social work sector employees. In OPRA, in the health and social work sector, annual average incidence rates per 100,000 calculated using Labour Force Survey (LFS) data as the denominator were 51.2 for mental illness, 35.9 for musculoskeletal disorders and 10.4 for skin disease; using McDonald's data as the denominator the corresponding rates were 119.5, 83.7 and 24.3. In the specialist THOR schemes, annual average incidence rates per 100,000 using LFS data as the denominator were 18.4 (mental illness), 6.1 (musculoskeletal disorders) and 15.3 (skin disease). CONCLUSIONS: Our results highlight the importance of collecting information on incident cases and denominators, to allow calculation of occupational disease rates. The higher incidence of mental illness (compared with musculoskeletal and skin disorders) in this employment sector merits further investigation.

A study of work-related musculoskeletal case reports to The Health and Occupation Reporting network (THOR) from 2002 to 2003.

BACKGROUND: Occupational musculoskeletal disorders are frequently seen by occupational physicians and rheumatologists, and there are well-established UK-based schemes set-up for reporting these conditions. An apparent fall in case reporting for work-related musculoskeletal disorders in Great Britain to The Health and Occupation Reporting network (THOR) was observed from 2002 to 2003. AIMS: To investigate changes in case reporting for musculoskeletal disorders sent by occupational physicians to Occupational Physicians Reporting Activity (OPRA) and by rheumatologists to Musculoskeletal Occupational Surveillance Scheme (MOSS) between 2002 and 2003. METHODS: Musculoskeletal cases returned by more than 800 physicians from Great Britain reporting to OPRA and MOSS in 2002-2003 were analysed. Changes in reporting are described at individual physician and group levels in: numbers of participants, levels of response, and numbers of case reports by disease category and major occupational and industrial groups. RESULTS: In 2002-2003, musculoskeletal disease was the most frequently reported major disease category in OPRA. Between 2002 and 2003, the proportion of musculoskeletal case reporting fell by 37% in OPRA, and 7% in MOSS. This fall was seen in many disease categories, across a wide range of occupations and industries. In OPRA, the greatest fall in reporting (74%) was for the category Raynaud's/Hand-Arm Vibration Syndrome/Vibration White Finger. CONCLUSIONS: The fall in occupational musculoskeletal case reporting between 2002 and 2003 cannot be explained by internal factors within the reporting system. This observation highlights the need for systematic investigation of trends in case reporting for work-related ill-health.