Ethnic inequalities among NHS staff in England: workplace experiences during the COVID-19 pandemic.

OBJECTIVES: This study aims to determine how workplace experiences of National Health Service (NHS) staff varied by ethnicity during the COVID-19 pandemic and how these experiences are associated with mental and physical health at the time of the study. METHODS: An online Inequalities Survey was conducted by the Tackling Inequalities and Discrimination Experiences in Health Services study in collaboration with NHS CHECK. This Inequalities Survey collected measures relating to workplace experiences (such as personal protective equipment (PPE), risk assessments, redeployments and discrimination) as well as mental health (Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder 7 (GAD-7)), and physical health (PHQ-15) from NHS staff working in the 18 trusts participating with the NHS CHECK study between February and October 2021 (N=4622). RESULTS: Regression analysis of this cross-sectional data revealed that staff from black and mixed/other ethnic groups had greater odds of experiencing workplace harassment (adjusted OR (AOR) 2.43 (95% CI 1.56 to 3.78) and 2.38 (95% CI 1.12 to 5.07), respectively) and discrimination (AOR 4.36 (95% CI 2.73 to 6.96) and 3.94 (95% CI 1.67 to 9.33), respectively) compared with white British staff. Staff from black ethnic groups also had greater odds than white British staff of reporting PPE unavailability (AOR 2.16 (95% CI 1.16 to 4.00)). Such workplace experiences were associated with negative physical and mental health outcomes, though this association varied by ethnicity. Conversely, understanding employment rights around redeployment, being informed about and having the ability to inform redeployment decisions were associated with lower odds of poor physical and mental health. CONCLUSIONS: Structural changes to the way staff from ethnically minoritised groups are supported, and how their complaints are addressed by leaders within the NHS are urgently required.

Impact of the COVID-19 pandemic on hospital episodes for falls and fractures associated with new-onset disability and frailty in England: a national cohort study.

BACKGROUND: Older people with frailty are at risk of harm from immobility or isolation, yet data about how COVID-19 lockdowns affected them are limited. Falls and fractures are easily measurable adverse outcomes correlated with frailty. We investigated whether English hospital admission rates for falls and fractures varied from the expected trajectory during the COVID-19 pandemic, and how these varied by frailty status. METHODS: NHS England Hospital Episode Statistics Admitted Patient Care data were analysed for observed versus predicted outcome rates for 24 January 2020 to 31 December 2021. An auto-regressive integrated moving average time-series model was trained using falls and fracture incidence data from 2013 to 2018 and validated using data from 2019. Models included national and age-, sex- and region-stratified forecasts. Outcome measures were hospital admissions for falls, fractures, and falls and fractures combined. Frailty was defined using the Hospital Frailty Risk Score. RESULTS: 144,148,915 pre-pandemic hospital admissions were compared with 42,267,318 admissions after pandemic onset. For the whole population, falls and fracture rates were below predicted for the first period of national lockdown, followed by a rapid return to rates close to predicted. Thereafter, rates followed expected trends. For people living with frailty, however, falls and fractures increased above expected rates during periods of national lockdown and remained elevated throughout the study period. Effects of frailty were independent of age. CONCLUSIONS: People living with frailty experienced increased fall and fracture rates above expected during and following periods of national lockdown. These remained persistently elevated throughout the study period.

When a test is more than just a test: Findings from patient interviews and survey in the trial of a technology to measure antidepressant medication response (the PReDicT Trial).

BACKGROUND: A RCT of a novel intervention to detect antidepressant medication response (the PReDicT Test) took place in five European countries, accompanied by a nested study of its acceptability and implementation presented here. The RCT results indicated no effect of the intervention on depression at 8 weeks (primary outcome), although effects on anxiety at 8 weeks and functioning at 24 weeks were found. METHODS: The nested study used mixed methods. The aim was to explore patient experiences of the Test including acceptability and implementation, to inform its use within care. A bespoke survey was completed by trial participants in five countries (n = 778) at week 8. Semi-structured interviews were carried out in two countries soon after week 8 (UK n = 22, Germany n = 20). Quantitative data was analysed descriptively; for qualitative data, thematic analysis was carried out using a framework approach. Results of the two datasets were interrogated together. OUTCOMES: Survey results showed the intervention was well received, with a majority of participants indicating they would use it again, and it gave them helpful extra information; a small minority indicated the Test made them feel worse. Qualitative data showed the Test had unexpected properties, including: instigating a process of reflection, giving participants feedback on progress and new understanding about their illness, and making participants feel supported and more engaged in treatment. INTERPRETATION: The qualitative and quantitative results are generally consistent. The Test's unexpected properties may explain why the RCT showed little effect, as properties were experienced across both trial arms. Beyond the RCT, the qualitative data sheds light on measurement reactivity, i.e., how measurements of depression can impact patients.

The risk of all-cause and cause-specific mortality in people prescribed mirtazapine: an active comparator cohort study using electronic health records.

BACKGROUND: Studies have reported an increased risk of mortality among people prescribed mirtazapine compared to other antidepressants. The study aimed to compare all-cause and cause-specific mortality between adults prescribed mirtazapine or other second-line antidepressants. METHODS: This cohort study used English primary care electronic medical records, hospital admission records, and mortality data from the Clinical Practice Research Datalink (CPRD), for the period 01 January 2005 to 30 November 2018. It included people aged 18-99 years with depression first prescribed a selective serotonin reuptake inhibitor (SSRI) and then prescribed mirtazapine (5081), a different SSRI (15,032), amitriptyline (3905), or venlafaxine (1580). Follow-up was from starting to stopping the second antidepressant, with a 6-month wash-out window, censoring at the end of CPRD follow-up or 30 November 2018. Age-sex standardised rates of all-cause mortality and death due to circulatory system disease, cancer, or respiratory system disease were calculated. Survival analyses were performed, accounting for baseline characteristics using inverse probability of treatment weighting. RESULTS: The cohort contained 25,598 people (median age 41 years). The mirtazapine group had the highest standardised mortality rate, with an additional 7.8 (95% confidence interval (CI) 5.9-9.7) deaths/1000 person-years compared to the SSRI group. Within 2 years of follow-up, the risk of all-cause mortality was statistically significantly higher in the mirtazapine group than in the SSRI group (weighted hazard ratio (HR) 1.62, 95% CI 1.28-2.06). No significant difference was found between the mirtazapine group and the amitriptyline (HR 1.18, 95% CI 0.85-1.63) or venlafaxine (HR 1.11, 95% CI 0.60-2.05) groups. After 2 years, the risk was significantly higher in the mirtazapine group compared to the SSRI (HR 1.51, 95% CI 1.04-2.19), amitriptyline (HR 2.59, 95% CI 1.38-4.86), and venlafaxine (HR 2.35, 95% CI 1.02-5.44) groups. The risks of death due to cancer (HR 1.74, 95% CI 1.06-2.85) and respiratory system disease (HR 1.72, 95% CI 1.07-2.77) were significantly higher in the mirtazapine than in the SSRI group. CONCLUSIONS: Mortality was higher in people prescribed mirtazapine than people prescribed a second SSRI, possibly reflecting residual differences in other risk factors between the groups. Identifying these potential health risks when prescribing mirtazapine may help reduce the risk of mortality.

Mental health of people with multiple sclerosis during the COVID-19 outbreak: A prospective cohort and cross-sectional case-control study of the UK MS Register.

BACKGROUND: People with MS (pwMS) have had higher rates of anxiety and depression than the general population before the COVID-19 pandemic, placing them at higher risk of experiencing poor psychological wellbeing during the pandemic. OBJECTIVE: To assess mental health and its social/lifestyle determinants in pwMS during the first wave of the outbreak in the United Kingdom. METHODS: This is a community-based, prospective longitudinal cohort and cross-sectional case-control online questionnaire study. It includes 2010 pwMS from the UK MS Register and 380 people without MS. RESULTS: The Hospital Anxiety and Depression Scale scores of pwMS for anxiety and depression during the outbreak did not change from the previous year. PwMS were more likely to have anxiety (using General Anxiety Disorder-7) and/or depression (using Patient Health Questionnaire-9) than controls during the outbreak (OR: 2.14, 95% CI: 1.58-2.91). PwMS felt lonelier (OR: 1.37, 95% CI: 1.04-1.80) reported worse social support (OR: 1.90, 95% CI: 1.18-3.07) and reported worsened exercise habits (OR: 1.65, 95% CI: 1.18-2.32) during the outbreak than controls. CONCLUSION: Early in the pandemic, pwMS remained at higher risk of experiencing anxiety and depression than the general population. It is important that multidisciplinary teams improve their support for the wellbeing of pwMS, who are vulnerable to the negative effects of the pandemic on their lifestyle and social support.

Comparing the number and length of primary care consultations in people with and without intellectual disabilities and health needs: observational cohort study using electronic health records.

BACKGROUND: In the United Kingdom, 15-min appointments with the general practitioner (GP) are recommended for people with complex health conditions, including intellectual disabilities and health needs, but we do not know whether this happens. AIMS: We compared number and length of primary care consultations (GP, nurse, other allied health, other) for people with and without intellectual disabilities and health needs. METHODS: Linked primary care data from the Clinical Practice Research Datalink (CPRD) in England were used to investigate face-to-face and telephone primary care consultations in 2017-2019. Health needs investigated were: epilepsy; incontinence; severe visual/hearing impairments; severe mobility difficulties; cerebral palsy; and percutaneous endoscopic gastrostomy feeding. Age and gender-standardized consultation rates per year (Poisson), duration of consultations, and the proportion of "long consultations" (≥15 min) were reported. RESULTS: People with intellectual disabilities (n = 7,794) had 1.9 times as many GP consultations per year as those without (n = 176,807; consultation rate ratio = 1.87 [95% confidence interval 1.86-1.89]). Consultation rates with nurses and allied healthcare professionals were also twice as high. Mean GP consultation time was 9-10 min regardless of intellectual disability/health need status. Long GP consultations were less common in people with intellectual disabilities (18.2% [17.8-18.7] vs. 20.9% [20.8-21.0]). Long consultations with practice nurses were more common in people with health needs, particularly severe visual loss. CONCLUSIONS: People with intellectual disabilities and/or health needs tend to have more, rather than longer, GP consultations compared with the rest of the population. We recommend further investigation into the role of practice nurses to support people with intellectual disabilities and health needs.

Mental health and other factors associated with work productivity after injury in the UK: multicentre cohort study.

INTRODUCTION: Mental health conditions are a major contributor to productivity loss and are common after injury. This study quantifies postinjury productivity loss and its association with preinjury and postinjury mental health, injury, demographic, health, social and other factors. METHODS: Multicentre, longitudinal study recruiting hospitalised employed individuals aged 16-69 years with unintentional injuries, followed up at 1, 2, 4 and 12 months. Participants completed questionnaires on injury, demographic factors, health (including mental health), social factors, other factors and on-the-job productivity upon return to work (RTW). ORs were estimated for above median productivity loss using random effects logistic regression. RESULTS: 217 adults had made an RTW at 2, 4 or 12 months after injury: 29% at 2 months, 66% at 4 months and 83% at 12 months. Productivity loss reduced over time: 3.3% of working time at 2 months, 1.7% at 4 months, 1% at 12 months. Significantly higher productivity loss was associated with preinjury psychiatric conditions (OR 21.40, 95% CI 3.50 to 130.78) and post-traumatic stress avoidance symptoms at 1 month (OR for 1-unit increase in score 1.15, 95% CI 1.07 to 1.22). Significantly lower productivity loss was associated with male gender (OR 0.32, 95% CI 0.14 to 0.74), upper and lower limb injuries (vs other body regions, OR 0.15, 95% CI 0.03 to 0.81) and sports injuries (vs home, OR 0.18, 95% CI 0.04 to 0.78). Preinjury psychiatric conditions and gender remained significant in analysis of multiply imputed data. CONCLUSIONS: Unintentional injury results in substantial productivity loss. Females, those with preinjury psychiatric conditions and those with post-traumatic stress avoidance symptoms experience greater productivity loss and may require additional support to enable successful RTW.

NHS Health Check Programme: a qualitative study of prison experience.

BACKGROUND: NHS Health Checks began in England in 2009 and were subsequently introduced into English prisons. Uptake has been patchy and there is limited understanding about factors that may limit or enhance uptake in prison settings. Uptake of this programme is a key policy in reducing the risk of cardiovascular disease and death in these settings. METHOD: Semi-structured focus groups were conducted with groups of prisoners (attendees and non-attendees to the health check), prison healthcare staff, custodial staff and ex-prisoners (n = 50). Participants were asked about their awareness and experiences of the NHS Health Check Programme in prison. RESULTS: All groups highlighted barriers for not attending a health check appointment, such as poor accessibility to the healthcare department, stigma and fear. The majority of participants expressed a lack of awareness and discussed common misconceptions regarding the health check programme. Methods of increasing the uptake of health checks through group-based approaches and accessibility to healthcare were suggested. CONCLUSIONS: This study reports on prisoner, staff and ex-prisoner perspectives on the implementation of NHS Health Checks within a restrictive prison environment. These findings have potentially substantial implications for successful delivery of care within offender healthcare services.

The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety.

OBJECTIVES: Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA. DESIGN: This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity. METHODS: Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments. RESULTS: Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes. CONCLUSIONS: Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.

Service user experiences of care recommendations from the 2014 NICE guideline for bipolar disorder: a survey.

Clinical guidelines for mental health disorders produced by the National Institute of Care Excellence (NICE) emphasise a recovery-based approach clinical care with collaborative decision-making. The aim of the study was to explore service user experience of collaborative decision-making and recovery focussed care in relation to a NICE clinical guideline for bipolar disorder four years after publication. Participants with a clinical diagnosis of bipolar disorder were recruited from adult mental health services in four specialist mental health NHS Trusts through health professional or self-referral following advertisement. An online or written survey was designed with service user input to cover 40 NICE recommendations on recovery based or collaborative care. Participants completed the survey anonymously and independent of any health professional involvement. Of 222 participants, 72 (33.5%) reported to a great extent care was delivered in line with a positive recovery message; 55 (25.5%) reported that not much or no care was recovery based. Only four items (10%) on medication or the offer of crisis services were endorsed as collaborative decision-making with a health professional by >70% service users. Most decision-making in relation to the NICE clinical guideline for bipolar disorder was not delivered collaboratively and only some care was recovery focussed.

Screening male prisoners for depression and anxiety with the PHQ-9 and GAD-7 at NHS Healthcheck: patterns of symptoms and caseness threshold.

BACKGROUND: Screening for depression and anxiety disorders has been proposed in prison populations but little is known about caseness thresholds on commonly used self-report measures in relation to core symptoms, risk factors and symptom patterns. METHOD: A cross-sectional prevalence survey measured depression and anxiety caseness (threshold scores > 10 and > 15 on PHQ-9 and GAD-7 and diagnostic algorithm on PHQ-9) in 1205 male prisoners aged 35-74 years eligible for an NHS Healthcheck from six English prisons. Caseness scores were compared with the presence or absence of daily core symptoms of depression and generalised anxiety disorder (GAD), demographic, prison and cardiovascular risk factors. Cluster analysis was applied to PHQ-9 and GAD-7 items in prisoners scoring > 10 on PHQ-9. RESULTS: 453(37.6%) and 249(20.7%) prisoners scored > 10 and > 15 respectively on PHQ-9; 216 (17.9%) had a depressive episode on the PHQ-9 algorithm; 378(31.4%) and 217(18.0%) scored > 10 and > 15 on GAD-7 respectively. Daily core items for depression were scored in 232(56.2%) and 139(74.3%) prisoners reaching > 10 and > 15 respectively on PHQ-9; daily core anxiety items in 282(74.9%) and 179(96.3%) reaching > 10 and > 15 on GAD-7. Young age, prison and previous high alcohol intake were associated with > 15 on the PHQ-9. Cluster analysis showed a cluster with core symptoms of depression, slowness, restlessness, suicidality, poor concentration, irritability or fear. Altered appetite, poor sleep, lack of energy, guilt or worthlessness belonged to other clusters and may not be indicative of depression. CONCLUSIONS: In male prisoners > 35 years, a score of > 10 on the PHQ-9 over diagnoses depressive episodes but a score of > 10 on the GAD-7 may detect cases of GAD more efficiently. Further research utilising standardised psychiatric interviews is required to determine whether the diagnostic algorithm, a higher cut-off on the PHQ-9 or the profile of symptoms on the PHQ-9 and GAD-7 used singly or in combination may be used to screen depressive episodes efficiently in prisoners.

Study protocol for a randomised placebo-controlled trial of pramipexole in addition to mood stabilisers for patients with treatment resistant bipolar depression (the PAX-BD study).

BACKGROUND: Treatment Resistant Bipolar Depression (TRBD) is a major contributor to the burden of disease associated with Bipolar Disorder (BD). Treatment options for people experiencing bipolar depression are limited to three interventions listed by National Institute for Health and Care: lamotrigine, quetiapine and olanzapine, of which the latter two are often not well tolerated. The majority of depressed people with BD are therefore prescribed antidepressants despite limited efficacy. This demonstrates an unmet need for additional interventions. Pramipexole has been shown to improve mood symptoms in animal models of depression, in people with Parkinson's Disease and two proof of principle trials of pramipexole for people with BD who are currently depressed. METHODS: The PAX-BD study, funded by the United Kingdom (UK) National Institute for Health Research, aims to extend previous findings by assessing the efficacy, safety and health economic impact of pramipexole in addition to mood stabilisers for patients with TRBD. A randomised, double-blind, placebo controlled design is conducted in a naturalistic UK National Health Service setting. An internal pilot study to examine feasibility and acceptability of the study design is included. Participants with TRBD are screened from National Health Service secondary care services in up to 40 mental health trusts in the UK, with the aim of recruiting approximately 414 participants into a pre-randomisation phase to achieve a target of 290 randomised participants. Primary safety and efficacy measures are at 12 weeks following randomisation, with follow up of participants to 52 weeks. The primary outcome is depressive symptoms as measured by Quick Inventory for Depressive Symptomatology - Self Report. Secondary outcomes include changes in anxiety, manic symptoms, tolerability, acceptability, quality of life and cost-effectiveness. Outcome measures are collected remotely using self-report tools implemented online, and observer-rated assessments conducted via telephone. ANCOVA will be used to examine the difference in rating scale scores between treatment arms, and dependent on compliance in completion of weekly self-report measures. A mixed effects linear regression model may also be used to account for repeated measures. TRIAL REGISTRATION: ISRCTN72151939. Registered on 28 August 2019, http://www.isrctn.com/ISRCTN72151939 Protocol Version: 04-FEB-2021, Version 9.0.

Correction: A Direct-to-Public Peer Support Program (Big White Wall) Versus Web-Based Information to Aid the Self-management of Depression and Anxiety: Results and Challenges of an Automated Randomized Controlled Trial.

[This corrects the article DOI: 10.2196/23487.].

A Direct-to-Public Peer Support Program (Big White Wall) Versus Web-Based Information to Aid the Self-management of Depression and Anxiety: Results and Challenges of an Automated Randomized Controlled Trial.

BACKGROUND: Effective help for depression and anxiety reaches a small proportion of people who might benefit from it. The scale of the problem suggests the need for effective, safe web-based public health services delivered directly to the public. One model, the Big White Wall (BWW), offers peer support at low cost. As these interventions are delivered digitally, we tested whether a randomized controlled trial (RCT) intervention could also be fully delivered and evaluated digitally. OBJECTIVE: This study aims to determine the reach, feasibility, acceptability, baseline costs, and outcomes of a public health campaign for an automated RCT of the BWW, providing digital peer support and information, compared with a standard website used by the National Health Service Moodzone (MZ), to people with probable mild-to-moderate depression and anxiety disorder. The primary outcome was the change in self-rated well-being at 6 weeks, measured using the Warwick-Edinburgh Mental Well-Being Scale. METHODS: An 18-month campaign was conducted across Nottinghamshire, the United Kingdom (target population 914,000) to advertise the trial directly to the public through general marketing, web-based and social media sources, health services, other public services, and third-sector groups. The population reach of this campaign was examined by the number of people accessing the study website and self-registering to the study. A pragmatic, parallel-group, single-blind RCT was then conducted using a fully automated trial website in which eligible participants were randomized to receive either 6 months of access to BWW or signposted to MZ. Those eligible for participation were aged >16 years with probable mild-to-moderate depression or anxiety disorders. RESULTS: Of 6483 visitors to the study website, 1510 (23.29%) were eligible. Overall, 790 of 1510 (52.32%) visitors participated. Of 790 visitors, 397 (50.3%) were randomized to BWW and 393 (49.7%) to MZ. Their mean age was 38 (SD 13.8) years, 81.0% (640/790) were female, 93.4% (738/790) were White, and 47.4% (271/572) had no contact with health services in the previous 3 months. We estimated 3-month productivity losses of £1001.01 (95% CI 868.75-1133.27; US $1380.79; 95% CI 1198.35-1563.23) per person for those employed. Only 16.6% (131/790) participants completed the primary outcome assessment. There were no differences in the primary or secondary outcomes between the 2 groups. CONCLUSIONS: Most participants reached and those eligible for this trial of digital interventions were White women not in recent contact with health services and whose productivity losses represent a significant annual societal burden. A fully automated RCT recruiting directly from the public failed to recruit and retain sufficient participants to test the clinical effectiveness of this digital intervention, primarily because it did not personally engage participants and explain how these unfamiliar interventions might benefit them. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) 12673428; https://www.isrctn.com/ISRCTN12673428. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.2196/resprot.8061.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety.

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Incidence and prevalence of primary care antidepressant prescribing in children and young people in England, 1998-2017: A population-based cohort study.

BACKGROUND: The use of antidepressants in children and adolescents remains controversial. We examined trends over time and variation in antidepressant prescribing in children and young people in England and whether the drugs prescribed reflected UK licensing and guidelines. METHODS AND FINDINGS: QResearch is a primary care database containing anonymised healthcare records of over 32 million patients from more than 1,500 general practices across the UK. All eligible children and young people aged 5-17 years in 1998-2017 from QResearch were included. Incidence and prevalence rates of antidepressant prescriptions in each year were calculated overall, for 4 antidepressant classes (selective serotonin reuptake inhibitors [SSRIs], tricyclic and related antidepressants [TCAs], serotonin and norepinephrine reuptake inhibitors [SNRIs], and other antidepressants), and for individual drugs. Adjusted trends over time and differences by social deprivation, region, and ethnicity were examined using Poisson regression, taking clustering within general practitioner (GP) practices into account using multilevel modelling. Of the 4.3 million children and young people in the cohort, 49,434 (1.1%) were prescribed antidepressants for the first time during 20 million years of follow-up. Males made up 52.0% of the cohorts, but only 34.1% of those who were first prescribed an antidepressant in the study period. The largest proportion of the cohort was from London (24.4%), and whilst ethnicity information was missing for 39.5% of the cohort, of those with known ethnicity, 75.3% were White. Overall, SSRIs (62.6%) were the most commonly prescribed first antidepressant, followed by TCAs (35.7%). Incident antidepressant prescribing decreased in 5- to 11-year-olds from a peak of 0.9 in females and 1.6 in males in 1999 to less than 0.2 per 1,000 for both sexes in 2017, but incidence rates more than doubled in 12- to 17-year-olds between 2005 and 2017 to 9.7 (females) and 4.2 (males) per 1,000 person-years. The lowest prescription incidence rates were in London, and the highest were in the South East of England (excluding London) for all sex and age groups. Those living in more deprived areas were more likely to be prescribed antidepressants after adjusting for region. The strongest trend was seen in 12- to 17-year-old females (adjusted incidence rate ratio [aIRR] 1.12, 95% confidence interval [95% CI] 1.11-1.13, p < 0.001, per deprivation quintile increase). Prescribing rates were highest in White and lowest in Black adolescents (aIRR 0.32, 95% CI 0.29-0.36, p < 0.001 [females]; aIRR 0.32, 95% CI 0.27-0.38, p < 0.001 [males]). The 5 most commonly prescribed antidepressants were either licensed in the UK for use in children and young people (CYP) or included in national guidelines. Limitations of the study are that, because we did not have access to secondary care prescribing information, we may be underestimating the prevalence and misidentifying the first antidepressant prescription. We could not assess whether antidepressants were dispensed or taken. CONCLUSIONS: Our analysis provides evidence of a continuing rise of antidepressant prescribing in adolescents aged 12-17 years since 2005, driven by SSRI prescriptions, but a decrease in children aged 5-11 years. The variation in prescribing by deprivation, region, and ethnicity could represent inequities. Future research should examine whether prescribing trends and variation are due to true differences in need and risk factors, access to diagnosis or treatment, prescribing behaviour, or young people's help-seeking behaviour.

Secondary care specialist visits made by children and young people prescribed antidepressants in primary care: a descriptive study using the QResearch database.

BACKGROUND: Antidepressants may be used to manage a number of conditions in children and young people including depression, anxiety, and obsessive-compulsive disorder. UK guidelines for the treatment of depression in children and young people recommend that antidepressants should only be initiated following assessment and diagnosis by a child and adolescent psychiatrist. The aim of this study was to summarise visits to mental health specialists and indications recorded around the time of antidepressant initiation in children and young people in UK primary care. METHODS: The study used linked English primary care electronic health records and Hospital Episode Statistics secondary care data. The study included 5-17-year-olds first prescribed antidepressants between January 2006 and December 2017. Records of visits to paediatric or psychiatric specialists and potential indications (from a pre-specified list) were extracted. Events were counted if recorded less than 12 months before or 6 months after the first antidepressant prescription. Results were stratified by first antidepressant type (all, selective serotonin reuptake inhibitors (SSRIs), tricyclic and related antidepressants) and by age group (5-11 years, 12-17 years). RESULTS: In total, 33,031 5-17-year-olds were included. Of these, 12,149 (37%) had a record of visiting a paediatrician or a psychiatric specialist in the specified time window. The majority of recorded visits (7154, 22%) were to paediatricians. Of those prescribed SSRIs, 5463/22,130 (25%) had a record of visiting a child and adolescent psychiatrist. Overall, 17,972 (54%) patients had a record of at least one of the pre-specified indications. Depression was the most frequently recorded indication (12,501, 38%), followed by anxiety (4155, 13%). CONCLUSIONS: The results suggest many children and young people are being prescribed antidepressants without the recommended involvement of a relevant specialist. These findings may justify both greater training for GPs in child and adolescent mental health and greater access to specialist care and non-pharmacological treatments. Further research is needed to explore factors that influence how and why GPs prescribe antidepressants to children and young people and the real-world practice barriers to adherence to clinical guidelines.

Preventing relapse with personalized smart-messaging after cognitive behavioural therapy: A proof-of-concept evaluation.

OBJECTIVES: Cognitive behavioural therapy (CBT) can improve symptoms of anxiety and depression, but also reduces the risk of future relapse after therapy completion. However, current CBT relapse prevention methods are resource-intensive and can be limited in clinical practice. This paper investigates a personalized means of reducing relapse using smart-messaging in two settings: research and routine care. DESIGN: Study 1 presents a cohort study comparing a cohort of smart-messaging users versus non-users. Study 2 presents time series follow-up data from a case series of smart-messaging users from clinical practice. METHODS: Fifteen of 56 CBT completers who participated in a trial for the treatment of health anxiety wrote advice they would want if in future they were doing well, experiencing early warning signs of relapse, or experiencing full relapse. Following CBT, participants received weekly text-message requests to rate their well-being. Dependent upon their response, participants received tailored advice they had written, appropriate to the well-being level reported after recovery from health anxiety. Smart-messaging was also trialled in a routine practice sample of 14 CBT completers with anxiety and depression. RESULTS: Across a 12-month follow-up, participants receiving smart-messaging showed greater health improvements than those who did not. Well-being scores showed stability between CBT completion and 6-month follow-up among routine care patients. CONCLUSIONS: These findings suggest that a low-intensity, personalized relapse prevention method can have a clinical benefit following CBT for common mental health problems. PRACTITIONER POINTS: Post-treatment outcomes may be improved using personalized smart-messaging to prevent relapse following cognitive behavioural therapy (CBT) for health anxiety. In clinical practice, post-treatment smart-messaging can be well-used by patients and may help maintain stable well-being in the 6 months after CBT ends. This evidence supports the clinical utility of a brief tailored digital intervention, which can be integrated within routine clinical practice with minimal therapist input. Overall, longer-term post-CBT outcomes may be improved by integrating a smart-messaging intervention at the end of therapy.

Health Care Professionals' Views on Using Remote Measurement Technology in Managing Central Nervous System Disorders: Qualitative Interview Study.

BACKGROUND: Remote measurement technologies (RMT) can be used to collect data on a variety of bio-behavioral variables, which may improve the care of patients with central nervous system disorders. Although various studies have explored their potential, prior work has highlighted a knowledge gap in health care professionals' (HCPs) perceptions of the value of RMT in clinical practice. OBJECTIVE: This study aims to understand HCPs' perspectives on using RMT in health care practice for the care of patients with depression, epilepsy, or multiple sclerosis (MS). METHODS: Semistructured interviews were conducted with 26 multidisciplinary primary and secondary care HCPs who care for patients with epilepsy, depression, or MS. Interviews were transcribed verbatim and analyzed using thematic analysis. RESULTS: A total of 8 main themes emerged from the analysis: (1) potential clinical value of RMT data; (2) when to use RMT in care pathways; (3) roles of health care staff who may use RMT data; (4) presentation and accessibility of data; (5) obstacles to successful use of RMT; (6) limits to the role of RMT; (7) empowering patients; and (8) considerations around alert-based systems. CONCLUSIONS: RMT could add value to the system of care for patients with central nervous system disorders by providing clinicians with graphic summaries of data in the patient record. Barriers of both technical and human nature should be considered when using these technologies, as should the limits to the benefits they can offer.

The Acceptability and Usability of Digital Health Interventions for Adults With Depression, Anxiety, and Somatoform Disorders: Qualitative Systematic Review and Meta-Synthesis.

BACKGROUND: The prevalence of mental health disorders continues to rise, with almost 4% of the world population having an anxiety disorder and almost 3.5% having depression in 2017. Despite the high prevalence, only one-third of people with depression or anxiety receive treatment. Over the last decade, the use of digital health interventions (DHIs) has risen rapidly as a means of accessing mental health care and continues to increase. Although there is evidence supporting the effectiveness of DHIs for the treatment of mental health conditions, little is known about what aspects are valued by users and how they might be improved. OBJECTIVE: This systematic review aimed to identify, appraise, and synthesize the qualitative literature available on service users' views and experiences regarding the acceptability and usability of DHIs for depression, anxiety, and somatoform disorders. METHODS: A systematic search strategy was developed, and searches were run in 7 electronic databases. Qualitative and mixed methods studies published in English were included. A meta-synthesis was used to interpret and synthesize the findings from the included studies. RESULTS: A total of 24 studies were included in the meta-synthesis, and 3 key themes emerged with descriptive subthemes. The 3 key themes were initial motivations and approaches to DHIs, personalization of treatment, and the value of receiving personal support in DHIs. The meta-synthesis suggests that participants' initial beliefs about DHIs can have an important effect on their engagement with these types of interventions. Personal support was valued very highly as a major component of the success of DHIs. The main reason for this was the way it enabled individual personalization of care. CONCLUSIONS: Findings from the systematic review have implications for the design of future DHIs to improve uptake, retention, and outcomes in DHIs for depression, anxiety, and somatoform disorders. DHIs need to be personalized to the specific needs of the individual. Future research should explore whether the findings could be generalized to other health conditions.