Socio-Economic Deprivation and Symptom Burden in UK Hospice Patients with Advanced Cancer-Findings from a Longitudinal Study.

Socio-economic deprivation is known to impact on cancer diagnosis, treatment and access to services, but little is known of the impact of socio-economic deprivation on symptom burden in patients with advanced cancer. Patients with advanced cancer attending hospice day services were recruited into a 24 week longitudinal study. An area-based index of social deprivation was collected along with depression and symptom burden at baseline, 8, 16 and 24 weeks. Of the 595 patients included, with an age range of 33-89 years and a mean age of 68 years, 67% were female, and 37% were diagnosed with cancer in the last 12 months. Twenty nine percent lived in one of the most deprived 20% of neighbourhoods. Patients living in the most socio-economically deprived areas were significantly likely to report receiving insufficient information regarding their cancer at diagnosis (p = 0.007), greater pain (p = 0.02), moderate to severe depression (p = 0.04) and higher global symptom burden (p = 0.04). This study is the first to report that patients with advanced cancer attending hospice services, living in the most deprived neighbourhoods experience significantly greater symptom burden, notably depression and pain. We recommend using patient outcome measures in order to provide targeted support and thereby reduce the increased symptom burden that socio-economically disadvantaged patients experience at the end of life.

Pilot randomised controlled trial of focused narrative intervention for moderate to severe depression in palliative care patients: DISCERN trial.

BACKGROUND: Depression is poorly detected and sub-optimally managed in palliative care patients, and few trials of psychosocial interventions have been carried out in this group of patients. AIMS: A pilot trial to determine the effect of a focused narrative intervention on depression in palliative care patients when used in addition to usual care. DESIGN: Patients scoring 10 or higher on Patient Health Questionnaire-9 randomised to focused narrative intervention in addition to usual care or usual care only and followed up at 2, 4 and 6 weeks. A reduction of five points on Patient Health Questionnaire-9 was regarded as clinically significant response to treatment. SETTING/PARTICIPANTS: Palliative care patients aged over 18 recruited from hospice day care services - exclusion criteria included an estimated prognosis of 6 weeks or less, cognitive impairment and unable to understand written or spoken English. RESULTS: Out of 57 participating patients (71% female), with mean age 65.1 years (range 36-88 years), 33 patients were randomised to the intervention and 24 to usual care only. Mean Patient Health Questionnaire-9 score at baseline was 16.4. Patients receiving intervention had greater reduction in Patient Health Questionnaire-9 score at 6-week follow-up ( p = 0.04). Median survival was 157 days for intervention and 102 days for control group patients ( p = 0.07). CONCLUSION: This pilot trial suggests a focused narrative intervention in palliative care patients with moderate to severe depression can reduce depression scores more than usual care alone. Patients receiving intervention appeared to have longer survival. These results support the need for a fully powered trial.

Beliefs of people taking antidepressants about the causes of their own depression.

BACKGROUND: The beliefs of people receiving treatment about the causes of their own mental health problems are researched less often than the causal beliefs of the public, but have important implications for relationships with prescribers, treatment choices and recovery. METHOD: An online survey on a range of beliefs about depression, and experiences with antidepressants, was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants. RESULTS: Six of 17 beliefs about the causes of their own depression were endorsed by more than half the sample: chemical imbalance, family stress, work stress, heredity, relationship problems and distressing events in childhood. There were some marked differences in content, structure and level of conviction of beliefs about one׳s own depression and the sample׳s previously published beliefs about depression in general. There were also significant differences between the beliefs of demographic groupings. Regression analyses revealed that self-reported effectiveness of the antidepressants was positively associated with bio-genetic causal beliefs. The quality of the relationship with the prescribing doctor was positively related to a belief in chemical imbalance as a cause and negatively related to a belief in unemployment as a cause. LIMITATIONS: The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression. CONCLUSIONS: People experiencing depression hold complex, multifactorial and idiosyncratic sets of beliefs about the causes of their own depression, apparently based at least in part on their own life experiences and circumstances. Exploring those beliefs may enhance the doctor-patient relationship and selection of appropriate treatment modality.

Beliefs of people taking antidepressants about causes of depression and reasons for increased prescribing rates.

BACKGROUND: Public beliefs about the causes of mental health problems are related to desire for distance and pessimism about recovery, and are therefore frequently studied. The beliefs of people receiving treatment are researched less often. METHOD: An online survey on causal beliefs about depression and experiences with antidepressants was completed by 1829 New Zealand adults prescribed anti-depressants in the preceding five years, 97.4% of whom proceeded to take antidepressants. RESULTS: The most frequently endorsed of 17 causal beliefs were family stress, relationship problems, loss of loved one, financial problems, isolation, and abuse or neglect in childhood. Factor analysis produced three factors: 'bio-genetic', 'adulthood stress' and 'childhood adversity'. The most strongly endorsed explanations for increases in antidepressant prescribing invoked improved identification, reduced stigma and drug company marketing. The least strongly endorsed was 'Anti-depressants are the best treatment'. Regression analyses revealed that self-reported efficacy of the antidepressants was positively associated with bio-genetic causal beliefs, negatively associated with childhood adversity beliefs and unrelated to adulthood stress beliefs. The belief that 'People cannot׳ get better by themselves even if they try' was positively associated with bio-genetic beliefs. LIMITATIONS: The convenience sample may have been biased towards a favourable view of bio-genetic explanations, since 83% reported that the medication reduced their depression. CONCLUSIONS: Clinicians׳ should consider exploring patients׳ causal beliefs. The public, even when taking antidepressants, continues to hold a multi-factorial causal model of depression with a primary emphasis on psycho-social causes. A three factor model of those beliefs may lead to more sophisticated understandings of relationships with stigma variables.

Determinants of care seeking for children with pneumonia and diarrhea in Guatemala: implications for intervention strategies.

OBJECTIVES: We identified barriers to care seeking for pneumonia and diarrhea among rural Guatemalan children. METHODS: A population-based survey was conducted twice from 2008 to 2009 among 1605 households with children younger than 5 years. A 14-day calendar recorded episodes of carer-reported pneumonia (n = 364) and diarrhea (n = 481), and formal (health services, public, private) and informal (neighbors, traditional, local shops, pharmacies) care seeking. RESULTS: Formal care was sought for nearly half of severe pneumonias but only for 27% within 2 days of onset, with 31% and 18%, respectively, for severe diarrhea. In multivariable analysis, factors independently associated with formal care seeking were knowing the Community Emergency Plan, mother's perception of illness severity, recognition of World Health Organization danger signs, distance from the health center, and having someone to care for family in an emergency. CONCLUSIONS: Proximal factors associated with recognizing need for care were important in determining formal care, and were strongly linked to social determinants. In addition to specific action by the health system with an enhanced community health worker role, a systems approach can help ensure barriers are addressed among poorer and more remote homes.

Inequalities in immunisation and breast feeding in an ethnically diverse urban area: cross-sectional study in Manchester, UK.

OBJECTIVES: To examine inequalities in immunisation and breast feeding by ethnic group and their relation to relative deprivation. DESIGN: Cross-sectional study. SETTING: Manchester, UK. PARTICIPANTS: 20 203 children born in Manchester (2002-2007), who had been coded as of white, mixed, Indian, Pakistani, Bangladeshi and black or black British ethnicity in the Child Health System database. MAIN OUTCOME MEASURES: Breast feeding at 2 weeks post partum; uptake of triple vaccine (diphtheria, pertussis and tetanus) at 16 weeks post partum; uptake of the measles, mumps and rubella vaccine (MMR) by the age of 2. RESULTS: Black or black British infants had the highest rates of breast feeding at 2 weeks post partum (89%), and South Asian infants had the highest triple and MMR vaccination rates (Indian, 95%, 96%; Pakistani 95%, 95%; Bangladeshi 96%, 95%) after area level of deprivation, parity, parenthood status and age had been controlled for. White infants were least likely to be breast fed at 2 weeks post partum (36%), and to be vaccinated with triple (92%) and MMR vaccines (88%). Within the white ethnic group, lower percentages of immunisation and breast feeding were significantly associated with living in a deprived area and with increasing parity. This was not found within black or black British and Pakistani ethnic groups. DISCUSSION: Practices that are protective of child health were consistently less likely to be adopted by white mothers living in deprived areas. Methods of health education and service delivery that are designed for the general population are unlikely to be successful in this context, and evidence of effective interventions needs to be established.

Patient, clinician, and general practice factors in long-term certified sickness.

AIMS: To investigate the association of patient, clinician, and general practice factors with long-term certified sickness absence. METHODS: Analysis of a sickness certification database constructed via the use of carbonized sick notes by clinicians at nine general practices in the north-west of England. A total of 3,385 patient sickness episodes certified by 44 general practitioners (GPs) were included in the analysis. Three logistic regression models were constructed in order to estimate independent effects of the patient, GP, and the general practice on risk of long-term (>28 weeks) incapacity. RESULTS: The logistic regression models explained a maximum of 27% of the variation in long-term certified sickness. The diagnostic reason for the sickness episode explained over 18% of variance, while clinician and general practice effects explained only 3.4% and 2.3% respectively. In all models, older patient age and an episode within the mild mental disorder (MMD) diagnostic category significantly increased the risk of long-term work incapacity. CONCLUSIONS: The study results imply that, rather than basing 'return to work' interventions on identification of individual patient/claimant characteristics or on GP training initiatives, it may be more productive to focus upon a more diagnosis-based approach within primary care itself. Interventions aiming to reduce mild mental disorder-related work incapacity should be given priority.

The influence of GP and patient gender interaction on the duration of certified sickness absence.

BACKGROUND: Little research has focused upon how GP and patient gender interact to influence the outcome of consultation. In particular, no UK studies have investigated the effect of gender interaction on the duration of patients' certified sickness. OBJECTIVE: To investigate associations between the four GP-patient gender interaction categories and patient risk of intermediate or long-term work incapacity. DESIGN: Use of carbonized sickness certificates to collect routine sick note data over a 12-month collection period. SETTING: Nine general practices in the Mersey Primary Care R&D Consortium. SUBJECTS: A total of 3906 patients, certified sick by 67 GPs (including 45 GP principals). MAIN OUTCOME MEASURES: The effect of gender interaction was measured against two outcomes: intermediate (6-28 week) and long-term (28 weeks or over) periods of certified sickness. RESULTS: After univariate and multivariate analyses, it was discovered that certification of male patients by male GPs was significantly associated with increased prevalence of intermediate (6-28 week) certified sickness outcomes, compared with females certified by females (OR=1.38 P=0.009). This result was replicated in the subgroup of patients with mild mental disorder-related sickness absence. However, no association was demonstrated between gender interaction and long-term (>or=28 week) outcome, in the total patient group or within diagnostic subcategories. CONCLUSION: GP and patient gender appear to have most impact upon sickness certification in the intermediate period. This period is already recognized as the optimum time for interventions to prevent onset of long-term incapacity, particularly in cases where the cause of sickness absence is reversible (as in psychological-related certified sickness absence). Further research is needed (particularly focusing upon attitudes and content of consultations) in order to shed more light on the gender differences found in this study.

Depression in men attending a rural general practice: factors associated with prevalence of depressive symptoms and diagnosis.

BACKGROUND: Doctors are less likely to diagnose depression in men than in women. Little research has been conducted to explore the underlying reasons for this in rural settings, or to compare primary care doctors' and male patients' ratings of perceived depression. AIMS: To identify symptomatic and socio-demographic correlates of depression in men attending a rural practice, and to compare and contrast general practitioners' and patients' assessments of depression. METHOD: All male patients of working age attending a rural general practice over a 12-month period were invited to participate. RESULTS: Men reporting recent "chest pain" or "feeling tired/little energy", expressing low job enjoyment or with a previous diagnosis of depression were more likely to be scored above threshold on the Hospital Anxiety and Depression Scale-Depression sub-scale. There was little agreement between the doctors and their male patients about the degree of perceived depression. CONCLUSIONS: Educational interventions aimed at addressing the diagnosis of depression in men should take greater account of factors within a particular social setting.

Why are patients in clinical trials of heart failure not like those we see in everyday practice?

BACKGROUND/OBJECTIVES: Evidence-based research has been criticized for not being relevant to the real world of patient care in the community, mainly because participants in research studies are dissimilar to those typically seen in every day practice. This article examines recruitment difficulties, and identifies the main reasons why patients with heart failure declined to participate in a research trial. METHODS: Postal survey of potential trial participants (n=667), at time of recruitment. Analysis of (1) clinical and sociodemographic characteristics of respondents and nonrespondents to survey, and decliners and consenters to participation in a randomized controlled trial. RESULTS: No significant differences were found between respondents and nonrespondents in respect to sociodemographic or clinical variables. Males (OR=1.58, CI=1.04-2.41), younger patients (OR=1.05, CI=1.03-1.08), and those prescribed an angiotensin converting enzyme (ACE) inhibitor (OR=1.68, CI=1.10-2.57) were significantly more likely to consent to participate. Main reasons for nonparticipation were perceptions of being too old, too unwell, or too busy. CONCLUSIONS: Explanations of the purpose of research need to counter against perceptions among participants and clarify the benefits and disadvantages of participating in an intervention study when unwell. Study design should recognize that many elderly patients have busy lives and caring responsibilities. Financial support for participation should be considered.