Generational differences in mental health trends in the twenty-first century.

Given the observed deterioration in mental health among Australians over the past decade, this study investigates to what extent this differs in people born in different decades-i.e., possible birth cohort differences in the mental health of Australians. Using 20 y of data from a large, nationally representative panel survey (N = 27,572), we find strong evidence that cohort effects are driving the increase in population-level mental ill-health. Deteriorating mental health is particularly pronounced among people born in the 1990s and seen to a lesser extent among the 1980s cohort. There is little evidence that mental health is worsening with age for people born prior to the 1980s. The findings from this study highlight that it is the poorer mental health of Millennials that is driving the apparent deterioration in population-level mental health. Understanding the context and changes in society that have differentially affected younger people may inform efforts to ameliorate this trend and prevent it continuing for emerging cohorts.

The Motivational Determinants of Human Action, Their Neural Bases and Functional Impact in Adolescents With Obsessive-Compulsive Disorder.

Background: Establishing the motivational influences on human action is essential for understanding choice and decision making in health and disease. Here we used tests of value-based decision making, manipulating both predicted and experienced reward values to assess the motivational control of goal-directed action in healthy adolescents and those with obsessive-compulsive disorder (OCD). Methods: After instrumental training on a two action-two outcome probabilistic task, adolescents (n = 21) underwent Pavlovian conditioning using distinct stimuli predicting either the instrumental outcomes, a third outcome, or nothing. We then assessed functional magnetic resonance imaging during choice tests in which we varied the predicted value, using specific and general Pavlovian-instrumental transfer, and the experienced value, using outcome devaluation. To establish functional significance, we tested a matched cohort of adolescents with OCD (n = 20). Results: In healthy adolescents, both predicted and experienced values influenced the performance of goal-directed actions, mediated by distinct orbitofrontal-striatal circuits involving the lateral orbitofrontal cortex (OFC) and medial OFC, respectively. However, in adolescents with OCD, choice was insensitive to changes in either predicted or experienced values. These impairments were related to hypoactivity in the lateral OFC and hyperactivity in the medial OFC during specific Pavlovian-instrumental transfer and hypoactivity in the anterior prefrontal cortex, caudate nucleus, and their connectivity in the devaluation test. Conclusions: We found that predicted and experienced values exerted a potent influence on the performance of goal-directed actions in adolescents via distinct orbitofrontal- and prefrontal-striatal circuits. Furthermore, the influence of these motivational processes was severely blunted in OCD, as was the functional segregation of circuits involving medial and lateral OFC, producing dysregulated action control.

Bayesian network modelling to identify on-ramps to childhood obesity.

BACKGROUND: When tackling complex public health challenges such as childhood obesity, interventions focused on immediate causes, such as poor diet and physical inactivity, have had limited success, largely because upstream root causes remain unresolved. A priority is to develop new modelling frameworks to infer the causal structure of complex chronic disease networks, allowing disease "on-ramps" to be identified and targeted. METHODS: The system surrounding childhood obesity was modelled as a Bayesian network, using data from The Longitudinal Study of Australian Children. The existence and directions of the dependencies between factors represent possible causal pathways for childhood obesity and were encoded in directed acyclic graphs (DAGs). The posterior distribution of the DAGs was estimated using the Partition Markov chain Monte Carlo. RESULTS: We have implemented structure learning for each dataset at a single time point. For each wave and cohort, socio-economic status was central to the DAGs, implying that socio-economic status drives the system regarding childhood obesity. Furthermore, the causal pathway socio-economic status and/or parental high school levels → parental body mass index (BMI) → child's BMI existed in over 99.99% of posterior DAG samples across all waves and cohorts. For children under the age of 8 years, the most influential proximate causal factors explaining child BMI were birth weight and parents' BMI. After age 8 years, free time activity became an important driver of obesity, while the upstream factors influencing free time activity for boys compared with girls were different. CONCLUSIONS: Childhood obesity is largely a function of socio-economic status, which is manifest through numerous downstream factors. Parental high school levels entangle with socio-economic status, and hence, are on-ramp to childhood obesity. The strong and independent causal relationship between birth weight and childhood BMI suggests a biological link. Our study implies that interventions that improve the socio-economic status, including through increasing high school completion rates, may be effective in reducing childhood obesity prevalence.

The comparative mental health of Australian doctors before and during COVID-19: A population-based approach.

OBJECTIVE: Occupational surveys of doctors consistently show higher rates of depression and anxiety than reported in general population surveys, findings replicated in all other occupational groups, suggesting potential selection bias. We evaluated the comparative mental health of different occupations in Australia from the same sampling frame over the past 6 years and assessed whether COVID-19 differentially affected different occupational groups. METHODS: We analysed six annual data waves (2015-2020) from the nationally representative 'Household, Income, and Labour Dynamics in Australia' study. Mental health (Mental Health Inventory-5 from the 36-Item Short Form Survey) and life satisfaction scores of doctors over this period were compared with five other professions and all other employees. Regression models were adjusted for age, gender, income and work hours. Two-way analysis of variance examined the comparative changes in mental health among occupations between 2019 and after exposure to the COVID-19 pandemic in late 2020. RESULTS: The sample of 15,174 employed respondents included 106 doctors. The 5-year mean mental health score for doctors (M = 78.7; SD = 13.1) was significantly higher than that for teachers (M = 75.6; SD = 14.9), nurses and midwives (M = 76.6; SD = 15.9), lawyers (M = 74.2; SD = 16.1), accountants (M = 74.2; SD = 16.5) and all other employed respondents (M = 73.1, SD = 16.7) (p < 0.001). Cognitive wellbeing comparisons were similar. There were no significant changes in professionals' mental health over this period except for an improvement in engineers and a decline for teachers. From 2019 to 2020, all occupations suffered mental health declines without any significant inter-occupational differences. CONCLUSION: Australian doctors identified from a population-based sample rather than occupational surveys reported better levels of mental health and greater life satisfaction than most professions prior to COVID-19 without experiencing the worsening seen in the general employed population over the past 5 years. From 2020, there was a mental health decline in all of the employed population, not disproportionately affecting doctors. Although over-representing Australian trained general practitioners, the results from both this sample and other tentative findings challenge the discourse in medical advocacy, but need more formal comparative studies to confirm.

Trajectories of psychological distress over multiple COVID-19 lockdowns in Australia.

The impact of the global COVID-19 pandemic, including the indirect effect of policy responses, on psychological distress has been the subject of much research. However, there has been little consideration of how the prevalence of psychological distress changed with the duration and repetition of lockdowns, or the rate of resolution of psychological distress once lockdowns ended. This study describes the trajectories of psychological distress over multiple lockdowns during the first two years of the pandemic across five Australian states for the period May 2020 to December 2021 and examines whether psychological distress trajectories varied as a function of time spent in lockdown, or time since lockdown ended. A total of N = 574,306 Australian adults completed Facebook surveys over 611 days (on average 940 participants per day). Trajectories of psychological distress (depression and anxiety) were regressed on lockdown duration and time since lockdown ended. Random effects reflecting the duration of each lockdown were included to account for varying effects on psychological distress associated with lockdown length. The prevalence of psychological distress was higher during periods of lockdown, more so for longer lockdowns relative to shorter lockdowns. Psychological distress increased rapidly over the first ten weeks of lockdowns spanning at least twelve weeks, though less rapidly for short lockdowns of three weeks or less. Psychological distress levels tended to stabilise, or even decrease, after ten consecutive weeks of lockdown. After lockdown restrictions were lifted, psychological distress rapidly subsided but did not return to pre-lockdown levels within four weeks, although continued to decline afterwards. In Australia short lockdowns of pre-announced durations were associated with slower rises in psychological distress. Lockdowns may have left some temporary residual population effect, but we cannot discern whether this reflects longer term trends in increasing psychological distress. However, the findings do re-emphasise the resilience of individuals to major life stressors.

Impact of e-cigarette retail displays on attitudes to smoking and vaping in children: an online experimental study.

OBJECTIVES: To estimate the impact of electronic cigarette (e-cigarette) retail display exposure on attitudes to smoking and vaping (susceptibility to tobacco smoking and using e-cigarettes, and perceptions of the harms of smoking and e-cigarette use). DESIGN: Between-subjects randomised experiment using a 2 (e-cigarette retail display visibility: high vs low)×2 (proportion of e-cigarette images: 75% vs 25%) factorial design. SETTING: Online via the Qualtrics survey platform. PARTICIPANTS: UK children aged 13-17 years (n=1034), recruited through a research agency. INTERVENTION: Participants viewed 12 images of retail displays that contained e-cigarette display images or unrelated product images. E-cigarette display images were either high or low visibility, based on a conspicuousness score. Participants were randomised to one of four groups, with e-cigarette display visibility and proportion of e-cigarette images, compared with images of unrelated products, manipulated: (1) 75% e-cigarettes, high visibility; (2) 25% e-cigarettes, high visibility; (3) 75% e-cigarettes, low visibility; (4) 25% e-cigarettes, low visibility. MAIN OUTCOME MEASURES: The primary outcome was susceptibility to smoking (among never smokers only). Secondary outcomes were susceptibility to using e-cigarettes (among never vapers only), and perceptions of smoking and e-cigarette harm (all participants). RESULTS: Neither e-cigarette retail display visibility, nor the proportion of e-cigarette images displayed, appeared to influence susceptibility to smoking (visibility: OR=0.84, 95% CI 0.62 to 1.13, p=0.24; proportion: OR=1.34, 95% CI 1.00 to 1.82, p=0.054 (reference: low visibility, not susceptible)).Planned subgroup analyses indicated that exposure to a higher proportion of e-cigarette images increased susceptibility to smoking among children who visited retail stores more regularly (n=524, OR=1.59, 95% CI 1.04 to 2.43, p=0.034), and those who passed the attention check (n=880, OR=1.43, 95% CI 1.03 to 1.98, p=0.031).In addition, neither e-cigarette retail display visibility nor the proportion of e-cigarette images displayed, appeared to influence susceptibility to using e-cigarettes (visibility: OR=1.07, 95% CI 0.80 to 1.43, p=0.65; proportion: OR=1.22, 95% CI 0.91 to 1.64, p=0.18).Greater visibility of e-cigarette retail displays reduced perceived harm of smoking (mean difference (MD)=-0.19, 95% CI -0.34 to -0.04, p=0.016). There was no evidence that the proportion of e-cigarette images displayed had an effect (MD=-0.07, 95% CI -0.22 to 0.09, p=0.40).Perceived harm of e-cigarette use did not appear to be affected by e-cigarette retail display visibility (MD=-0.12, 95% CI -0.28 to 0.05, p=0.16) or by the proportion of e-cigarette images displayed (MD=-0.10, 95% CI -0.26 to 0.07, p=0.24). CONCLUSIONS: There is no evidence in the full sample to suggest that children's susceptibility to smoking is increased by exposure to higher visibility e-cigarette retail displays, or to a higher proportion of e-cigarette images. However, for regular store visitors or those paying more attention, viewing a higher proportion of e-cigarette images increased susceptibility to smoking. In addition, viewing higher visibility e-cigarette images reduced perceived harm of smoking. A review of the current regulatory discrepancy between tobacco and e-cigarette point-of-sale marketing is warranted. TRIAL REGISTRATION NUMBER: ISRCTN18215632.

Effect of health warning labels on motivation towards energy-dense snack foods: Two experimental studies.

Health warning labels (HWLs) show promise in reducing motivation towards energy-dense snack foods. Understanding the underlying mechanisms could optimise their effectiveness. In two experimental studies in general population samples (Study 1 n = 90; Study 2 n = 1382), we compared the effects of HWLs and irrelevant aversive labels (IALs) on implicit (approach) motivation towards unhealthy snacks, using an approach-avoidance task (Study 1), and a manikin task (Study 2). We also assessed explicit motivation towards unhealthy snacks using food selection tasks. We examined whether labelling effects on motivation arose from the creation of outcome-dependent associations between the food and its health consequences or from simple, non-specific aversive associations. Both label types reduced motivation towards snack foods but only when the label was physically present. HWLs and IALs showed similar effects on implicit motivation, although HWLs reduced explicit motivation more than IALs. Thus, aversive HWLs appear to act both through low level associative mechanisms affecting implicit motivation, and by additionally emphasizing explicit causal links to health outcomes thereby affecting explicitly motivated choice behaviours.

Evaluation of a mental health screening tool using cross-sectional surveys in a workplace setting.

OBJECTIVES: The Brief Health Check (BHC) is a health screener used by the Get Healthy at Work programme, which identifies workers with chronic disease risk and provides them with advice and referrals to support services. The BHC was revised to include mental health to provide a holistic approach to workplace health. This study aimed to evaluate the acceptability and appropriateness of the revised BHC by comparing the results around psychological distress and future risk with previous research, and a participant feedback survey. METHOD: Data collection took place between October 2018 and May 2019. The study used data that were collected as part of programme delivery, as well as a participant feedback survey that was administered after the health check was completed. RESULTS: BHCs were completed by n=912 workers, out of which, n=238 completed the feedback survey. The mean Distress Questionnaire 5 score was 10.5, and 10% of participants met the threshold for 'high' future risk. The feedback survey revealed that the majority of participants found the mental health advice to be useful (76%), agreed with their mental health distress and risk ratings (92%-94%) and most intended on using the referred services (62%-68%). CONCLUSION: The findings around mental health risk were comparable to previous findings in employed samples. The inclusion of mental health assessments, advice and referral pathways into the BHC was found to be acceptable and the subsequent referrals were appropriate, indicating that this approach could be scaled up and implemented to help address worker's mental ill health.

The Neural Bases of Action-Outcome Learning in Humans.

From an associative perspective the acquisition of new goal-directed actions requires the encoding of specific action-outcome (AO) associations and, therefore, sensitivity to the validity of an action as a predictor of a specific outcome relative to other events. Although competitive architectures have been proposed within associative learning theory to achieve this kind of identity-based selection, whether and how these architectures are implemented by the brain is still a matter of conjecture. To investigate this issue, we trained human participants to encode various AO associations while undergoing functional neuroimaging (fMRI). We then degraded one AO contingency by increasing the probability of the outcome in the absence of its associated action while keeping other AO contingencies intact. We found that this treatment selectively reduced performance of the degraded action. Furthermore, when a signal predicted the unpaired outcome, performance of the action was restored, suggesting that the degradation effect reflects competition between the action and the context for prediction of the specific outcome. We used a Kalman filter to model the contribution of different causal variables to AO learning and found that activity in the medial prefrontal cortex (mPFC) and the dorsal anterior cingulate cortex (dACC) tracked changes in the association of the action and context, respectively, with regard to the specific outcome. Furthermore, we found the mPFC participated in a network with the striatum and posterior parietal cortex to segregate the influence of the various competing predictors to establish specific AO associations.SIGNIFICANCE STATEMENT Humans and other animals learn the consequences of their actions, allowing them to control their environment in a goal-directed manner. Nevertheless, it is unknown how we parse environmental causes from the effects of our own actions to establish these specific action-outcome (AO) relationships. Here, we show that the brain learns the causal structure of the environment by segregating the unique influence of actions from other causes in the medial prefrontal and anterior cingulate cortices and, through a network of structures, including the caudate nucleus and posterior parietal cortex, establishes the distinct causal relationships from which specific AO associations are formed.

Electronic cigarette and smoking paraphernalia point of sale displays: an observational study in England.

BACKGROUND: Tobacco point of sale (POS) retail displays are banned in many countries, including in England, due in part to evidence linking them to greater susceptibility to smoking in children. There is no equivalent ban on displays of electronic cigarettes (e-cigarettes) or smoking paraphernalia (eg, cigarette lighters) in England, which are often positioned alongside covered tobacco storage units. This observational study describes the visibility and placement of e-cigarette and smoking paraphernalia POS displays in major tobacco retailers in two cities in England to inform future research examining their possible links to susceptibility to tobacco smoking, particularly in children. METHODS: Researchers visited all small- and large-format stores of four supermarket chains and a randomly selected sample of convenience stores, in Bristol and Cambridge. A standardised checklist was used to create a total visibility score for POS displays of (a) e-cigarettes and (b) smoking paraphernalia, plus other measures of visibility and placement. These were described for the total sample and compared between areas of low, medium, and high deprivation using general linear models adjusting for store location and store type. RESULTS: The visibility checklist was completed in 133 of 166 stores (80% completion rate). Both e-cigarette and smoking paraphernalia POS displays were present in 96% of stores. POS displays were highly visible across all stores: mean (SD) total visibility scores, out of 17, were 14.7 (1.8) for e-cigarettes and 12.7 (1.8) for smoking paraphernalia. There was no clear evidence of differences in visibility by area of deprivation. CONCLUSION: E-cigarette and smoking paraphernalia POS displays are near ubiquitous and highly visible in major tobacco retailers in two cities in England. The impact of these displays on tobacco smoking in children and adults is unknown, meriting urgent research to assess their effect on susceptibility to tobacco smoking in children.

Size and shape of plates and size of wine glasses and bottles: impact on self-serving of food and alcohol.

BACKGROUND: The physical properties of tableware could influence selection and consumption of food and alcohol. There is considerable uncertainty, however, around the potential effects of different sizes and shapes of tableware on how much food and alcohol people self-serve. These studies aimed to estimate the impact of: 1. Plate size and shape on amount of food self-served; 2.Wine glass and bottle size on amount of wine self-poured. METHODS: 140 adults participated in two laboratory studies-each using randomised within-subjects factorial designs-where they self-served food (Study 1) and wine (Study 2): Study 1: 3 plate sizes (small; medium; large) × 2 plate shapes (circular; square). Study 2: 3 wine glass sizes (small; medium; large) × 2 wine bottle sizes (75 cl; 50 cl). RESULTS: Study 1: There was a main effect of plate size: less was self-served on small (76 g less, p < 0.001) and medium (41 g less, p < 0.001) plates, compared to large plates. There was no evidence for a main effect of plate shape (p = 0.46) or a size and shape interaction (p = 0.47). Study 2: There was a main effect of glass size: less was self-served in small (34 ml less, p < 0.001) and medium (17 ml less, p < 0.001) glasses, compared to large glasses. There was no evidence of a main effect of bottle size (p = 0.20) or a glass and bottle size interaction (p = 0.18). CONCLUSIONS: Smaller tableware (i.e. plates and wine glasses) decreases the amount of food and wine self-served in an initial serving. Future studies are required to generate estimates on selection and consumption in real world settings when numerous servings are possible. Protocol registration information: OSF ( https://osf.io/dj3c6/ ) and ISRCTN ( https://doi.org/10.1186/ISRCTN66774780 ).

Detecting Heterogeneity of Intervention Effects Using Analysis and Meta-analysis of Differences in Variance Between Trial Arms.

BACKGROUND: Randomized controlled trials (RCTs) with continuous outcomes usually only examine mean differences in response between trial arms. If the intervention has heterogeneous effects, then outcome variances will also differ between arms. Power of an individual trial to assess heterogeneity is lower than the power to detect the same size of main effect. METHODS: We describe several methods for assessing differences in variance in trial arms and apply them to a single trial with individual patient data and to meta-analyses using summary data. Where individual data are available, we use regression-based methods to examine the effects of covariates on variation. We present an additional method to meta-analyze differences in variances with summary data. RESULTS: In the single trial, there was agreement between methods, and the difference in variance was largely due to differences in prevalence of depression at baseline. In two meta-analyses, most individual trials did not show strong evidence of a difference in variance between arms, with wide confidence intervals. However, both meta-analyses showed evidence of greater variance in the control arm, and in one example, this was perhaps because mean outcome in the control arm was higher. CONCLUSIONS: Using meta-analysis, we overcame low power of individual trials to examine differences in variance using meta-analysis. Evidence of differences in variance should be followed up to identify potential effect modifiers and explore other possible causes such as varying compliance.

Cigarette pack size and consumption: an adaptive randomised controlled trial.

BACKGROUND: Observational evidence suggests that cigarette pack size - the number of cigarettes in a single pack - is associated with consumption but experimental evidence of a causal relationship is lacking. The tobacco industry is introducing increasingly large packs, in the absence of maximum cigarette pack size regulation. In Australia, the minimum pack size is 20 but packs of up to 50 cigarettes are available. We aimed to estimate the impact on smoking of reducing cigarette pack sizes from ≥25 to 20 cigarettes per pack. METHOD: A two-stage adaptive parallel group RCT in which Australian smokers who usually purchase packs containing ≥25 cigarettes were randomised to use only packs containing either 20 (intervention) or their usual packs (control) for four weeks. The primary outcome, the average number of cigarettes smoked per day, was measured through collecting all finished cigarette packs, labelled with the number of cigarettes participants smoked. An interim sample size re-estimation was used to evaluate the possibility of detecting a meaningful difference in the primary outcome. RESULTS: The interim analysis, conducted when 124 participants had been randomised, suggested 1122 additional participants needed to be randomised for sufficient power to detect a meaningful effect. This exceeded pre-specified criteria for feasible recruitment, and data collection was terminated accordingly. Analysis of complete data (n = 79) indicated that the mean cigarettes smoked per day was 15.9 (SD = 8.5) in the intervention arm and 16.8 (SD = 6.7) among controls (difference - 0.9: 95%CI = - 4.3, 2.6). CONCLUSION: It remains unclear whether reducing cigarette pack sizes from ≥25 to 20 cigarettes reduces cigarette consumption. Importantly, the results of this study provide no evidence that capping cigarette pack sizes would be ineffective at reducing smoking. The limitations identified in this study can inform a more efficient RCT, which is urgently required to address the dearth of experimental evidence on the impact of large cigarette pack sizes on smoking. TRIAL REGISTRATION: https://doi.org/10.1186/ISRCTN34202533.

Lagged Association between Climate Variables and Hospital Admissions for Pneumonia in South Africa.

Pneumonia is a leading cause of hospitalization in South Africa. Climate change could potentially affect its incidence via changes in meteorological conditions. We investigated the delayed effects of temperature and relative humidity on pneumonia hospital admissions at two large public hospitals in Limpopo province, South Africa. Using 4062 pneumonia hospital admission records from 2007 to 2015, a time-varying distributed lag non-linear model was used to estimate temperature-lag and relative humidity-lag pneumonia relationships. Mean temperature, relative humidity and diurnal temperature range were all significantly associated with pneumonia admissions. Cumulatively across the 21-day period, higher mean daily temperature (30 °C relative to 21 °C) was most strongly associated with a decreased rate of hospital admissions (relative rate ratios (RR): 0.34, 95% confidence interval (CI): 0.14-0.82), whereas results were suggestive of lower mean daily temperature (12 °C relative to 21 °C) being associated with an increased rate of admissions (RR: 1.27, 95%CI: 0.75-2.16). Higher relative humidity (>80%) was associated with fewer hospital admissions while low relative humidity (<30%) was associated with increased admissions. A proportion of pneumonia admissions were attributable to changes in meteorological variables, and our results indicate that even small shifts in their distributions (e.g., due to climate change) could lead to substantial changes in their burden. These findings can inform a better understanding of the health implications of climate change and the burden of hospital admissions for pneumonia now and in the future.

Straight-sided beer and cider glasses to reduce alcohol sales for on-site consumption: A randomised crossover trial in bars.

BACKGROUND: Straight-sided glasses can slow the rate of lager consumption in a laboratory setting compared with curved glasses. Slower drinking rates may lower overall alcohol consumption. Glass shape is therefore a potential target for intervention. The aim of this randomised crossover trial was to estimate the impact of serving draught beer and cider in straight-sided glasses, compared with usual, predominantly curved glasses, on alcohol sales for on-site consumption in bars. METHODS: Twenty-four bars in England completed two intervention periods (A) and two control periods (B) in a randomised order: 1) BABA; 2) BAAB; 3) ABBA; or 4) ABAB. Each period lasted two weeks and involved serving draught beer and cider in either straight-sided glasses (A) or the venue's usual glasses (≥75% curved; B). The primary outcome was the mean volume (in litres) of draught beer and cider sold weekly, compared between A and B periods using a paired-samples t-test on aggregate data. A regression model adjusted for season, order, special events, and busyness. FINDINGS: Mean weekly volume sales of draught beer and cider was 690·9 L (SD 491·3 L) across A periods and 732·5 L (SD 501·0 L) across B periods. The adjusted mean difference (A minus B) was 8·9 L per week (95% CI -45·5 to 63·3; p = 0·737). INTERPRETATION: This study provides no clear evidence that using straight-sided glasses, compared with usual, predominantly curved glasses, reduces the volume of draught beer and cider sold for on-site consumption in bars.

Is continuity of primary care declining in England? Practice-level longitudinal study from 2012 to 2017.

BACKGROUND: Continuity of care is a core principle of primary care related to improved patient outcomes and reduced healthcare costs. Evidence suggests continuity of care in England is declining. AIM: To confirm reports of declining continuity of care, explore differences in decline according to practice characteristics, and examine associations between practice populations or appointment provision and changes in continuity of care. DESIGN AND SETTING: Longitudinal design on GP Patient Survey data reported annually in June or July from 2012 to 2017, whereby the unit of analysis was English general practices that existed in 2012. METHOD: Linear univariable and bivariable multilevel models were used to determine decline in average annual percentage of patients having a preferred GP and seeing this GP 'usually' according to practicelevel continuity of care, rural/urban location, and deprivation. Associations between percentage of patients having a preferred GP or seeing this GP usually and patients' experiences with the appointment system and practice population characteristics were modelled. RESULTS: In 2012, 56.7% of patients had a preferred GP, which had declined by 9.4 percentage points (pp) (95% CI = -9.6 to -9.2) by 2017. Of patients with a preferred GP, 66.4% saw that GP 'usually' in 2012; this had declined by 9.7 pp (95% CI = -10.0 to -9.4) by 2017. This decline was visible in all types of practices, irrespective of baseline continuity, rural/urban location, or level of deprivation. At practice level, an increase over time in the percentage of patients reporting good overall experience of making appointments was associated with an increase in both the percentage of patients having a preferred GP and those able to see that GP 'usually'. CONCLUSION: Patients reported a steady decline in continuity of care over time, which should concern clinicians and policymakers. Ability of practices to offer patients a satisfactory appointment system could partly counteract this decline.

Amphetamine use and psychiatric admissions: a 10-year perspective.

OBJECTIVE: We aimed to (i) describe the 10-year trend in admissions associated with amphetamine use, (ii) describe the distinguishing characteristics of people with an amphetamine-related diagnosis (ARD) and (iii) examine predictors of repeated admissions among people with an ARD. METHOD: We conducted a retrospective cohort study. We (i) counted the number of admissions with an ARD and evaluated any trends, and using univariate and multivariate tests, (ii) compared those who had an ARD with those who did not and (iii) compared those with an ARD who had one, two to four, and five or more admissions. RESULTS: Admissions associated with amphetamine use increased between 2009 and 2015. Those with an ARD had significant differences in demographics, diagnosis and pattern of service use relative to those without an ARD. Amongst those with an ARD, a higher number of admissions was positively associated with a schizophrenia diagnosis but inversely associated with a transient psychotic disorder diagnosis. CONCLUSIONS: The increase in admissions associated with amphetamine use indicates that people with an ARD posed major demands on inpatient services. Targeting amphetamine treatment to those with psychotic disorders, both schizophrenia and transient psychotic disorders, may reduce hospital-related costs and re-admissions.

Equity-specific effects of interventions to promote physical activity among middle-aged and older adults: results from applying a novel equity-specific re-analysis strategy.

BACKGROUND: Reducing inequalities in physical activity (PA) and PA-associated health outcomes is a priority for public health. Interventions to promote PA may reduce inequalities, but may also unintentionally increase them. Thus, there is a need to analyze equity-specific intervention effects. However, the potential for analyzing equity-specific effects of PA interventions has not yet been sufficiently exploited. The aim of this study was to set out a novel equity-specific re-analysis strategy tried out in an international interdisciplinary collaboration. METHODS: The re-analysis strategy comprised harmonizing choice and definition of outcomes, exposures, socio-demographic indicators, and statistical analysis strategies across studies, as well as synthesizing results. It was applied in a collaboration of a convenience sample of eight European PA intervention studies in adults aged ≥45 years. Weekly minutes of moderate-to-vigorous PA was harmonized as outcome. Any versus no intervention was harmonized as exposure. Gender, education, income, area deprivation, and marital status were harmonized as socio-demographic indicators. Interactions between the intervention and socio-demographic indicators on moderate-to-vigorous PA were analyzed using multivariable linear regression and random-effects meta-analysis. RESULTS: The collaborative experience shows that the novel re-analysis strategy can be applied to investigate equity-specific effects of existing PA interventions. Across our convenience sample of studies, no consistent pattern of equity-specific intervention effects was found. Pooled estimates suggested that intervention effects did not differ by gender, education, income, area deprivation, and marital status. CONCLUSIONS: To exploit the potential for equity-specific effect analysis, we encourage future studies to apply the strategy to representative samples of existing study data. Ensuring sufficient representation of 'hard to reach' groups such as the most disadvantaged in study samples is of particular importance. This will help to extend the limited evidence required for the design and prioritization of future interventions that are most likely to reduce health inequalities.

Health warning labels and alcohol selection: a randomised controlled experiment in a naturalistic shopping laboratory.

BACKGROUND AND AIMS: Health warning labels (HWLs) on tobacco products reduce smoking. There is an absence of evidence concerning the impact of alcohol HWLs on selection or purchasing in naturalistic settings. Using a commercial-standard naturalistic shopping laboratory, this study aimed to estimate the impact on selection of alcoholic drinks of HWLs describing adverse health consequences of excessive alcohol consumption. DESIGN: A between-subjects randomised experiment with three groups was conducted: group 1: image-and-text HWL; group 2: text-only HWL; group 3: no HWL. SETTING: A commercial-standard naturalistic shopping laboratory in the United Kingdom. PARTICIPANTS: Adults (n = 399, 55% female) over the age of 18 years, who purchased beer or wine weekly to drink at home. INTERVENTIONS: Participants were randomised to one of three groups varying in the HWL displayed on the packaging of the alcoholic drinks: (i) image-and-text HWL (n = 135); (ii) text-only HWL (n = 129); (iii) no HWL (n = 135). Participants completed a shopping task, selecting items from a range of alcoholic and non-alcoholic drinks, and snacks. MEASUREMENT: The primary outcome was the proportion of alcoholic drinks selected. Secondary outcomes included HWL ratings on negative emotional arousal and label acceptability. FINDINGS: There was no clear evidence of a difference in the HWL groups for the percentage of drinks selected that were alcoholic compared to no HWL (44%): image-and-text HWL: 46% (odds ratio [OR] = 1.08, 95% confidence interval [CI] = 0.82, 1.42); text-only HWL: 41% (OR = 0.87, 95% CI = 0.67, 1.14). Concordant with there being no difference between groups, there was extreme evidence in favour of the null hypothesis (Bayes factor [BF] < 0.01). Negative emotional arousal was higher (P < 0.001) and acceptability lower (P < 0.001) in the image-and-text HWL group, compared to the text-only HWL group. CONCLUSIONS: In a naturalistic shopping laboratory, there was no evidence that health warning labels describing the adverse health consequences of excessive alcohol consumption changed selection behaviour.

High-dose baclofen attenuates insula activation during anticipatory anxiety in treatment-seeking alcohol dependant individuals: Preliminary findings from a pharmaco-fMRI study.

The GABA B agonist, baclofen, has been shown to reduce alcohol consumption in patients with alcohol use disorder and also those with comorbid anxiety. This study aimed to evaluate the effect of baclofen versus placebo on the BOLD response during an anticipatory anxiety fMRI task in treatment seeking alcohol patients. Participants included 28 alcohol dependant individuals who had received daily baclofen 30 mg (n = 10), 75 mg (n = 8) or placebo (n = 10) for at least 2 week on a randomized controlled trial (Morley, Leung et al. 2013, Morley, Baillie et al. 2018). Using functional magnetic resonance imaging (fMRI), we examined threat cue-elicited neural activation during a threat reactivity task 120 min following administration of BAC (30 mg or 75 mg) or placebo. Whole-brain analyses revealed no significant differences between the combined BAC doses versus PL. However, there were significant decreases in anticipatory threat cue-elicited activation observed in BAC 75 mg/day compared to PL participants in the insula. In response to threat cues, high dose (75 mg/day) baclofen administration attenuates activation in the insula and inferior frontal gyrus, relative to placebo. These preliminary findings suggests that modulating emotional regulation and attentional allocation during high threat stimuli may be mediated by GABA B receptors and may be a potential mechanism of action for baclofen's beneficial treatment effects for alcohol use disorder.