Perceiving and expressing feelings through actions in relation to individual differences in empathic traits: the Action and Feelings Questionnaire (AFQ).

Empathy is usually conceived of as independent of the non-verbal behaviors which mediate its experience, though embodied cognition theory predicts that individual differences in action representation will affect empathic traits. The "Actions and Feelings Questionnaire" (AFQ) was designed to capture individual differences in self-awareness of own and others' actions, particularly those associated with feelings, which we predicted would correlate with levels of empathic traits. A pilot 30-item questionnaire included items on perceptual sensitivity to action, imitation, action imagery, and gestural and facial expression. It was completed by a sample of 278 adults (mean age 21.2 years; 189 females, 89 males) along with the 15-item Empathic Quotient (EQ) Questionnaire. Total scores on the final 18-item questionnaire showed strong internal coherence (Cronbach's alpha of 0.81) and test-retest reliability (ICC=0.88), marked effect of sex and highly significant correlation with EQ. The questionnaire was administered to participants in an fMRI study investigating the neural correlates of facial imitation. Total AFQ score correlated with activity in somatosensory cortex, insula, anterior cingulate, and visual cortex. The AFQ shows promise as a brief and simple self-report measure sensitive to variability in the self-awareness of actions associated with feelings. It suggests that much of the variability of empathic traits in typical populations is accounted for by variance in this capacity. We suggest that being more empathic really is about being "touchy-feely," and this questionnaire provides a novel measure of action-based empathy.

Restarting antidepressant treatment following early discontinuation--a primary care database study.

BACKGROUND: Many patients in primary care stop antidepressant treatment after only one prescription, so do not benefit from treatment. Some patients who stop initial antidepressant treatment go on to restart it, but neither the incidence of restarting nor the probability that patients who restart treatment subsequently complete an adequate course of treatment is known. OBJECTIVE: To examine subsequent antidepressant use in patients who discontinued treatment after only one antidepressant prescription. METHODS: We used a primary care database (over 1.2 million records) to study patients who commenced treatment with an eligible antidepressant between April 2007 and March 2008 and who stopped treatment for at least 1 month after the first prescription. We examined their subsequent antidepressant prescriptions to estimate the probability of restarting antidepressant treatment, the likelihood of continuing subsequent treatment and the patient characteristics associated with these. RESULTS: Out of 24817 patients, 6952 (28%) patients discontinued antidepressant treatment after the first prescription. The cumulative probability of restarting treatment after early discontinuation was 8.6% (95% confidence interval [CI] 8.0-9.3) after 1 month off-treatment, and 24.1% (22.9-25.2) after 9 months off-treatment. The probability of those who restarted treatment continuing for 6 months or more was 29.3% (26.5-32.5). CONCLUSIONS: Few patients who stop antidepressant treatment after the first prescription subsequently complete an adequate treatment course within the next year. Initiatives to promote adherence to appropriate antidepressant treatment should begin during the first prescription.

A comparison of three methods of assessing differential item functioning (DIF) in the Hospital Anxiety Depression Scale: ordinal logistic regression, Rasch analysis and the Mantel chi-square procedure.

PURPOSE: It is important for clinical practice and research that measurement scales of well-being and quality of life exhibit only minimal differential item functioning (DIF). DIF occurs where different groups of people endorse items in a scale to different extents after being matched by the intended scale attribute. We investigate the equivalence or otherwise of common methods of assessing DIF. METHOD: Three methods of measuring age- and sex-related DIF (ordinal logistic regression, Rasch analysis and Mantel χ(2) procedure) were applied to Hospital Anxiety Depression Scale (HADS) data pertaining to a sample of 1,068 patients consulting primary care practitioners. RESULTS: Three items were flagged by all three approaches as having either age- or sex-related DIF with a consistent direction of effect; a further three items identified did not meet stricter criteria for important DIF using at least one method. When applying strict criteria for significant DIF, ordinal logistic regression was slightly less sensitive. CONCLUSIONS: Ordinal logistic regression, Rasch analysis and contingency table methods yielded consistent results when identifying DIF in the HADS depression and HADS anxiety scales. Regardless of methods applied, investigators should use a combination of statistical significance, magnitude of the DIF effect and investigator judgement when interpreting the results.

The monitoring of longer term prescriptions of antidepressants: observational study in a primary care setting.

BACKGROUND: There is little evidence to guide the frequency of review for patients taking antidepressants in the longer term. OBJECTIVES: To measure the frequency with which patients on longer term courses of antidepressants have their treatment monitored in primary care and to identify patient characteristics associated with the frequency of monitoring. METHODS: A cohort of patients who were receiving antidepressants continuously for at least two years was identified from four general practices. Data were collected from patients' general medical records. The dates of all GP consultations and whether they included a documented review of antidepressant therapy were recorded, along with patient characteristics hypothesized to influence the frequency of monitoring. RESULTS: The frequency of antidepressant review consultations and proportion of participants being reviewed during a specific year of antidepressant therapy decreased with increasing year of antidepressant therapy. Individuals who receive antidepressants for an overt mental health reason; undergo more dose and drug changes; and who are referred to the community mental health team have their antidepressant therapy reviewed more often during the first five years of antidepressant therapy. CONCLUSION: As many patients on longer term courses of antidepressants are not being appropriately reviewed, a 'chronic disease management approach' to depression in primary care is advocated.

MADRS symptom subtypes in ECT-treated depressed patients: relationship to response and subsequent ECT.

OBJECTIVE: This study aimed to explore the relationship of Montgomery-Åsberg Depression Rating Scale (MADRS) symptom subtypes with response to electroconvulsive therapy (ECT) and subsequent ECT treatment within 12 months. METHODS: A consecutive sample of 414 patients with depression receiving ECT in the North East of Scotland was assessed by retrospective chart review. Response rate was defined as greater than or equal to 50% decrease in pretreatment total MADRS score or a posttreatment total MADRS less than or equal to 10. Principal component analyses were conducted on a sample with psychotic features (n = 124) and a sample without psychotic features (n = 290). Scores on extracted factor subscales, clinical and demographic characteristics were assessed for association with response and subsequent ECT treatment within 12 months. Where more than 1 variable was associated with response or subsequent ECT, logistic regression analysis was applied. RESULTS: MADRS symptom subtypes formed 3 separate factors in both samples. Logistic regression revealed older age and high "Despondency" subscale score predicted response in the nonpsychotic group. Older age alone predicted response in the group with psychotic features. Nonpsychotic patients subsequently re-treated with ECT were older than those not prescribed subsequent ECT. No association of variables emerged with subsequent ECT treatment in the group with psychotic features. Being of older age and the presence of psychotic features predicted response. Presence of psychotic features alone predicted subsequent retreatment. CONCLUSIONS: Subscale scores of the MADRS are of limited use in predicting which patients with depression will respond to ECT, with the exception of "Despondency" subscale scores in patients without psychotic features.

Socioeconomic status of patients receiving electroconvulsive therapy.

This study describes the relationship between socioeconomic deprivation and electroconvulsive therapy (ECT) prescription and outcomes. Two research questions are addressed in this study: (1) Does the rate of ECT prescription increase with deprivation? and (2) Does deprivation influence ECT outcomes? Electroconvulsive therapy outcomes, of consecutive patients from Aberdeen, were compared across socioeconomic groups determined by the Scottish Index of Multiple Deprivation (SIMD) quintiles. A primary care sample, invited to complete the Hospital Anxiety and Depression Scale (HADS), was used for comparison. The proportion of patients in the most affluent quintile (32%) was greater than that in the least affluent (9%): this reflects the distribution of the local population, unlike the prevalence of depressive disorder, as demonstrated in our primary care group. Severity of depressive symptoms in patients receiving ECT was no different across the socioeconomic groups: before ECT (χ = 8.056; df = 4; P = 0.09), after ECT (χ = 6.035; df = 4; P = 0.197); nor was the total change in score (χ = 4.367; df = 4; P = 0.359). There were no differences among the SIMD quintiles for the number of ECT treatments administered (χ = 6.076; df = 4; P = 0.194) or the number of courses of ECT each patient had during contact with the service (χ = 6.505; df = 4; P = 0.164).Socioeconomic deprivation has no effect on the rate of ECT prescription or treatment outcomes despite a higher proportion of patients with severe depressive symptoms in the least affluent groups in a local community sample.

Continuity and monitoring of antidepressant therapy in a primary care setting.

BACKGROUND: Little is currently known about the continuity and monitoring of antidepressant treatment at individual patient level in primary care. AIMS: To assess continuity of antidepressant therapy in a UK primary care setting at the individual patient level and whether this therapy is conducted with appropriate review. Methods A systematic analysis was undertaken in two general practices in Aberdeen, Scotland of primary care records of adults initiated on an antidepressant for a new episode of depression or anxiety within a 12-month period and followed up for three years. Demographic and clinical details were recorded. Uni- and multivariate analyses were performed. Results The sample consisted of 191 patients. Median duration of treatment for the first episode was 180 (inter-quartile range (IQR)=60, 429) days, with 29% of patients receiving an antidepressant for 60 days or less. Age and previous receipt of antidepressants contributed significantly to predicting treatment duration (p <0.01); effect size (R(2) =0.1). The median interval between antidepressant review consultations increased progressively with increasing treatment duration. There were no significant predictors of frequency of antidepressant review. Conclusion Depression management could be improved by assertive review (and better characterisation) of patients who discontinue early; and by scheduled reassessment of treatment in the second and subsequent years of continuation therapy.

Exploring Patient Safety Culture in a Kuwaiti Secondary Care Setting: A qualitative study.

OBJECTIVES: Qualitative studies can improve understanding of patient safety culture (PSC), which has been relatively neglected by researchers in the Gulf Cooperation Council context. This study employed a qualitative approach to explore healthcare staff and patients' perceptions of PSC and how it can be improved. METHODS: This qualitative study was conducted in a public hospital in Kuwait. Individual face-to-face interviews were used to understand the experience of healthcare staff and patients concerning PSC. After obtaining the required ethical approvals, maximum variation sampling was used. Interviews were recorded and transcribed. The analysis was inductive and thematic. RESULTS: A total of 51 participants were included in this study (35 healthcare professionals and 16 patients). Data analysis revealed four overarching themes relevant to the research question: (1) workload; (2) communication; (3) environmental constraints; and (4) incident reporting. These issues were interrelated in practice. Kuwaiti and non-Kuwaiti participants held different views, particularly about the response to errors and expatriate staff members' clinical skills. CONCLUSION: This study revealed multiple factors related to workload, communication, healthcare environment and incident reporting, which hindered the promotion of positive PSC in the included department. The presence of numerous constraints suggests that multiple interventions which target both individual and organisational levels should be implemented.

Emotional self-awareness in autism: A meta-analysis of group differences and developmental effects.

LAY ABSTRACT: Autistic people are thought to have difficulties with identifying and understanding their own emotions. This is referred to as emotional self-awareness. It is important to study emotional self-awareness as people who are more able to understand their own emotions, whether they are autistic or not, are more able to respond to them appropriately, as well as to identify them in other people. It has not yet been confirmed whether autistic people have difficulties with emotional self-awareness, or if any reported difficulties are actually due to the way in which emotional self-awareness is measured in autistic people. If these difficulties do exist, it is also not known when these difficulties emerge. In this research, we reviewed 47 existing studies that measured emotional self-awareness in autistic and non-autistic adults and children. We also compared studies that measured emotional self-awareness in different ways. We found that autistic adults did seem to have poorer emotional self-awareness compared to their neurotypical peers. However, this was not the case with autistic children of age 12 years and below. Instead, differences in emotional self-awareness only seemed to emerge during adolescence. Moreover, these difficulties seemed to increase with age. These results suggest that difficulties with emotional self-awareness may not be inherent in autism. Instead, they may emerge alongside the greater social and mental health difficulties that are experienced by many autistic people during adolescence. We therefore suggest that it is important to find out more about, and subsequently support, the emotional self-awareness difficulties that autistic adolescents may encounter.

Autistic traits predict underestimation of emotional abilities.

People vary in their self-awareness of their own emotions, and this may predict psychological well-being. Evidence suggests that emotional self-awareness is diminished in autism, but these findings may be biased by self-report or confounded by verbal intelligence. To address this issue, we developed the emotional consistency (EC) task, measuring emotional self-awareness through consistency in emotional decision-making. In the EC-Task, we showed participants pairs of emotional images, asking them to judge which evoked the more intense emotional experience. The logical consistency of decision making, based on transitive relationships between stimuli, reflects precision of judgment of experience of emotional intensity, which in turn reflects emotional self-awareness. Emotional consistency significantly correlated with lower self-reported alexithymia but not autistic traits. Instead, autistic traits predicted greater discrepancy between EC-Task performance and self-reported difficulties identifying feelings. Participants with higher autistic traits were more likely to underestimate their emotional self-awareness, possibly because of greater metacognitive difficulties and negative self-beliefs. Our study suggests emotional self-awareness is not diminished in autism and provides a novel method to investigate this issue. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Cross-Cultural Differences and Psychometric Properties of the Japanese Actions and Feelings Questionnaire (J-AFQ).

Aims: We aimed to assess the psychometric properties of a Japanese version of the Actions and Feelings Questionnaire (J-AFQ), an 18-item self-report measure of non-verbal emotional communication, as well as to examine its transcultural properties. Methods: The J-AFQ was administered to 500 Japanese adults (age 20-49, 250 male), alongside the Japanese Broad Autism Phenotype Questionnaire (BAPQ-J) and Empathy Quotient (EQ-J). These were compared to a group of 597 British and Irish participants (age 16-18, 148 male). J-AFQ was assessed in terms of validity by confirmatory factor analysis and convergence with BAPQ-J and EQ-J using Pearson correlation. Internal consistency and differential item functioning (DIF) were assessed and compared between Japanese and UK/Irish participants. Results: Reversed worded items (RWIs) showed poor item-total correlations but excluding these left a 13-item version of the J-AFQ with good internal consistency and content validity. Consistent with the English version, J-AFQ scores correlated with EQ and lower BAPQ scores. However, comparing across cultures, J-AFQ scores were significantly lower in the Japanese sample, and there was evidence of important DIF by country in over half of the J-AFQ items Conclusion: Cultural differences in attitudes to self-report, as well as increased acquiescence to RWI's also seen in previous studies, limit the value of the 18-item instrument in Japanese culture. However, the 13-item J-AFQ is a valid and reliable measure of motor empathy, which, alongside the English version, offers promise for research in motor cognition and non-verbal emotional communication across cultures.

Different Aspects of Emotional Awareness in Relation to Motor Cognition and Autism Traits.

Emotion is inherently embodied, formulated through bodily sensation, as well as expressed and regulated through action. Both expressing one's own emotions and understanding the emotional actions of others are common areas of difficulty in autism. Moreover, reduced emotional awareness is also thought to be problematic in autism, and such difficulties may be mediated by impaired motor cognition. We aimed to examine how intensity of emotional experience and ability to differentiate between one's own emotions relates to motor empathy and autistic traits. We hypothesized that greater motor cognition would be associated with greater emotional intensity and more refined emotion differentiation. Participants from the general population (N = 160) completed the Actions and Feelings Questionnaire (AFQ), a self-report measure assessing motor cognition, alongside the Broad Autism Phenotype Questionnaire and an emotion elicitation task. Motor cognition was significantly associated with more intense emotional experiences but not with ability to differentiate between similar emotions. Autistic traits, particularly social aloofness, predicted less emotion differentiation and lower scores on the animation subscale of the AFQ. We suggest that whereas as intensity of experience may be dependent on sensorimotor representation of emotions, differentiation requires additional cognitive functions such as language understanding. A dissociation between awareness of intensity and differentiation may be critical for understanding emotional difficulties in autism.

Psychometric comparison of PHQ-9 and HADS for measuring depression severity in primary care.

BACKGROUND: The 2004 National Institute for Health and Clinical Excellence (NICE) guidelines highlight the importance of assessing severity of depression in primary care. AIM: To assess the psychometric properties of the Patient Health Questionnaire (PHQ-9) and the depression subscale of the Hospital Anxiety and Depression Scale (HADS-D) for measuring depression severity in primary care. DESIGN OF STUDY: Psychometric assessment. SETTING: Thirty-two general practices in Grampian, Scotland. METHOD: Consecutive patients referred to a primary care mental health worker completed the PHQ-9 and HADS at baseline (n = 1063) and at the end of treatment (n = 544). Data were analysed to assess reliability, robustness of factor structure, convergent/discriminant validity, convergence of severity banding, and responsiveness to change. RESULTS: Both scales demonstrated high internal consistency at baseline and end of treatment (PHQ-9 alpha = 0.83 and 0.92; HADS-D alpha = 0.84 and 0.89). One factor emerged each for the PHQ-9 (explaining 42% of variance) and HADS-D (explaining 52% of variance). Both scales converged more with each other than with the HADS anxiety (HADS-A) subscale at baseline (P<0.001) and at end of treatment (P = 0.01). Responsiveness to change was similar: effect size for PHQ-9 = 0.99 and for the HADS-D = 1. The HADS-D and PHQ-9 differed significantly in categorising severity of depression, with the PHQ-9 categorising a greater proportion of patients with moderate/severe depression (P<0.001). CONCLUSION: The HADS-D and PHQ-9 demonstrated reliability, convergent/discriminant validity, and responsiveness to change. However, they differed considerably in how they catergorised severity. Given that treatment decisions are made on the basis of severity, further work is needed to assess the validity of the scales' severity cut-off bands.

Dates of birth and seasonal changes in well-being among 4904 subjects completing the seasonal pattern assessment questionnaire.

BACKGROUND: Abnormal distributions of birthdates, suggesting intrauterine aetiological factors, have been found in several psychiatric disorders, including one study of out-patients with Seasonal Affective Disorder (S.A.D.). We investigated birthdate distribution in relation to seasonal changes in well-being among a cohort who had completed the Seasonal Pattern Assessment Questionnaire (SPAQ). METHOD: A sample of 4904 subjects, aged 16 to 64, completed the SPAQ. 476 were cases of S.A.D. on the SPAQ and 580 were cases of sub-syndromal S.A.D. (S-S.A.D.). 92 were interview confirmed cases of S.A.D. Months and dates of birth were compared between S.A.D. cases and all others, between S.A.D. and S-S.A.D. cases combined and all others, and between interview confirmed cases and all others. Seasonality, as measured through seasonal fluctuations in well-being on the Global Seasonality Scores (GSS) of the SPAQ, was compared for all subjects by month and season of birth. RESULTS: There was no evidence of an atypical pattern of birthdates for subjects fulfilling criteria for S.A.D., for the combined S.A.D./S-S.A.D. group or for interview confirmed cases. There was also no relationship between seasonality on the GSS and month or season of birth. LIMITATIONS: Diagnoses of S.A.D. made by SPAQ criteria are likely to be overinclusive. CONCLUSION: Our findings differ from studies of patients with more severe mood disorders, including psychiatric out-patients with S.A.D. The lack of association between seasonality and birthdates in our study adds credence to the view that the aetiology of S.A.D. relates to separable factors predisposing to affective disorders and to seasonality.

The Actions and Feelings Questionnaire in Autism and Typically Developed Adults.

Impaired motor cognition may underpin empathy problems in autism. The actions and feelings questionnaire (AFQ), designed to examine individual differences in motor cognition, was completed fully by 1391 adults, of whom 326 reported a diagnosis of an autism spectrum condition (ASC). A confirmatory factor analysis supported a 3 factor model. The AFQ total and 'feelings' subscale scores correlated highly with the EQ and ROC curves were similar. Our findings suggest that individual differences in empathic traits are heavily accounted for by variance in mechanisms that serve sensorimotor learning (motor cognition) in relation to emotional states. The AFQ is a self-report tool that provides a valid indicator of autism status in adult populations.

Obesity in individuals with schizophrenia: a case controlled study in Scotland.

BACKGROUND: Despite extensive clinical concern about rates of obesity in patients with schizophrenia, there is little evidence of the extent of this problem at a population level. AIMS: To estimate levels of obesity in a national population sample by comparing patients with schizophrenia with matched controls. METHOD: We calculated levels of obesity for each patient with schizophrenia from the national Primary Care Clinical Informatics Unit database (n=4658) matched with age, gender and neighbourhood controls. RESULTS: We demonstrated a significant increased obesity hazard for the schizophrenia group using Cox regression analysis, with odds ratio (OR) of 1.94 (95% CI 1.81-2.10) (under the assumption of missing body mass index (BMI) indicating non-obesity) and OR=1.68 (95% CI 1.55-1.81) where no assumptions were made for missing BMI data. CONCLUSIONS: People with schizophrenia are at increased risk of being obese compared with controls matched by age, gender and practice attended. Priority should be given to research which aims to reduce weight and increase activity in those with schizophrenia. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

The Patient Centered Assessment Method (PCAM): integrating the social dimensions of health into primary care.

BACKGROUND: Social dimensions of health are known to contribute to what is often termed "patient complexity," which is particularly common among patients with multimorbidity. Health-care professionals require tools to help them identify and manage these aspects of patient needs. OBJECTIVES: To examine: (i) the Patient Centered Assessment Method (PCAM), a tool for assessing patient complexity in ways that are sensitive to the biopsychosocial dimensions of health, in primary care settings in Scotland; (ii) the impact of the PCAM on referral patterns and its perceived value; and (iii) the PCAM's perceived applicability for use in a complex patient population. DESIGN: Two studies are described: (i) a mixed-methods prospective cohort study of the implementation of the PCAM in primary care clinics; and (ii) a qualitative exploratory study that evaluated the value of the PCAM in a complex patient population. RESULTS: Use of the PCAM did not impact patient satisfaction or perception of practitioners' empathy, but it did increase both the number of onward referrals per referred patient (9-12%) and the proportion of referrals to non-medical services addressing psychological, social, and lifestyle needs. Nurses valued the PCAM, particularly its ability to help them address psychological and social domains of patients' lives, and found it to be highly relevant for use in populations with known high complexity. CONCLUSIONS: The PCAM represents a feasible approach for assessing patient needs with consideration to the social dimensions of health, and allows practitioners to refer patients to a broader range of services to address patient complexity.

Psychometric properties of the 16-item Quick Inventory of Depressive Symptomatology: a systematic review and meta-analysis.

Effective management of depression is predicated upon reliable assessment. The Quick Inventory of Depressive Symptomatology (QIDS) is a depression severity scale with both self-rated (QIDS-SR16) and clinician-rated (QIDS-C16) versions. Although widely used in research, the psychometric properties of the QIDS16 have not been systematically reviewed. We performed a systematic review of studies of the psychometric properties (factor structure, internal consistency, convergent validity, discriminant validity, test-retest reliability and responsiveness to change) of the QIDS-SR16 or QIDS-C16. Six databases were searched: MEDLINE, EMBASE, PsycINFO, CinAHL, Web of Science and the Cochrane Central Register of Controlled Trials. Findings were summarised, bias assessed and correlations with reference standards were pooled. 37 studies (17,118 participants) were included in the review. Both versions of the QIDS16 were unidimensional. Cronbach's alpha ranged from 0.69 to 0.89 for the QIDS-SR16 and 0.65 to 0.87 for the QIDS-C16. The QIDS-SR16 correlated moderately to highly with several depression severity scales. Seven studies were pooled where QIDS-SR16 was correlated with the HRSD-17 (r = 0.76, CI 0.69, 0.81) in patients diagnosed with depression. Four studies examined convergent validity with the QIDS-C16. Four studies examined discriminant validity, for the QIDS-SR16 alone. Eighteen studies had at least one author who was a co-author of the original QIDS16 study. Most studies were conducted in the USA (n = 26). The QIDS-SR16 and the QIDS-C16 are unidimensional rating scales with acceptable internal consistency. To justify the use of the QIDS16 scale in clinical practice, more research is needed on convergent and discriminant validity, and in populations outside the USA.

Seasonal affective disorder and social deprivation in Aberdeen.

BACKGROUND: Unlike non-seasonal depression, there is some evidence that seasonal affective disorder (SAD) is more common among more affluent socioeconomic groups. METHODS: In primary care settings in Aberdeen, 4557 subjects had previously completed a Seasonal Pattern Assessment Questionnaire (SPAQ). From the subjects' postcodes they were allocated a Carstairs score which placed them in one of seven categories of socioeconomic deprivation. These categories were compared with regard to seasonal pathology from the SPAQ ratings. RESULTS: Complete postcodes and Carstairs scores were established for 3772 (83%) of the 4557 subjects. No statistically significant relationship between socioeconomic deprivation and SPAQ ratings was detected. LIMITATIONS: The study population was an affluent one relative to Scotland as a whole which may have reduced the likelihood of a positive finding. The study was conducted 7 years after the census on which postcode deprivation scores were calculated, and changes therein may have occurred. CONCLUSIONS: SAD either has no relationship to social deprivation or is associated with affluence and this distinguishes it from non-seasonal depression.

Efficacy and tolerability of antidepressants for sub-threshold depression and for mild major depressive disorder.

BACKGROUND: It is commonly assumed that robust evidence exists for the lack of efficacy of antidepressants at the milder end of the depression severity spectrum. In light of specific limitations of existing reviews, we assess if antidepressants are efficacious and tolerable for sub-threshold or mild major depressive disorder (MDD). METHOD: Systematic review and meta-analysis of randomised controlled trials of adults with sub-threshold depression or mild MDD (initial baseline symptom severity of HRSD≤20) comparing an antidepressant with placebo or treatment as usual (TAU) however defined. A pre-specified protocol was published (Prospero reference: CRD42013004505). RESULTS: 8 trials were included: 5 trials (453 participants) of sub-threshold depression and 3 trials (502 participants) of mild MDD. Trials of sub-threshold depression exhibited low risk of bias whereas those of mild MDD exhibited high risk. Two trials of sub-threshold depression were pooled (n=102) to assess efficacy and favoured antidepressants over placebo statistically but the difference was small and unlikely to be clinically meaningful: mean difference -1.39 (-2.41, -0.36). Due to heterogeneity, no trials of mild MDD could be pooled for efficacy. There was no difference between antidepressant treatment and placebo for drop out due to adverse events. The maximum proportion in those receiving antidepressants dropping out due to adverse events was 17%, with indication of a dose effect. LIMITATIONS: Not all data from identified trials could be included in the meta-analyses due to a lack of availability of relevant data. CONCLUSION: There is insufficient evidence to support or contest the efficacy of antidepressant medication for sub-threshold depression or mild MDD. More trials, with adequate follow up, are required to address this question.