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    ABSTRACT: Previous research has described distinctive features for anxious and nonanxious forms of major depression. The concept of "mixed anxiety depression disorder" (MADD) refers to a milder degree of the anxious form of depression, since the depressive symptoms fall short of the number required for a diagnosis of major depression. It is argued that this can be thought of as a subclinical form of anxious depression, rather than a separate disorder in its own right. In view of its substantial prevalence in general medical settings, its associated disability and its public health importance, it deserves to be recognized, and seen as being continuous with the more severe forms of anxious depression. It will therefore be included in the Field Trials of the version of the ICD-11 (where ICD is the International Classification of Disease) intended for primary care. It is argued that current anxiety, depression (without anxiety), and anxious depression would cover most of the psychologically distressed patients seen in general medical settings, using a pseudodimensional system.
    Depression and Anxiety 04/2014; 31(4). DOI:10.1002/da.22206
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    ABSTRACT: The feasibility of implementation is insufficiently considered in clinical guideline development, leading to human and financial resource wastage. To develop (a) an empirically based standardised measure of the feasibility of complex interventions for use within mental health services and (b) reporting guidelines to facilitate feasibility assessment. A focused narrative review of studies assessing implementation blocks and enablers was conducted with thematic analysis and vote counting used to determine candidate items for the measure. Twenty purposively sampled studies (15 trial reports, 5 protocols) were included in the psychometric evaluation, spanning different interventions types. Cohen's kappa (κ) was calculated for interrater reliability and test-retest reliability. In total, 95 influences on implementation were identified from 299 references. The final measure - Structured Assessment of FEasibility (SAFE) - comprises 16 items rated on a Likert scale. There was excellent interrater (κ = 0.84, 95% CI 0.79-0.89) and test-retest reliability (κ = 0.89, 95% CI 0.85-0.93). Cost information and training time were the two influences least likely to be reported in intervention papers. The SAFE reporting guidelines include 16 items organised into three categories (intervention, resource consequences, evaluation). A novel approach to evaluating interventions, SAFE supplements efficacy and health economic evidence. The SAFE reporting guidelines will allow feasibility of an intervention to be systematically assessed.
    The British journal of psychiatry: the journal of mental science 12/2013; 204(4). DOI:10.1192/bjp.bp.113.128314
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    ABSTRACT: Background There is a well-established link between physical activity and psychological wellbeing, but less evidence on whether it can increase comfort in disclosure of mental health problems and help to reduce the perceived stigma of mental illness. Aims To investigate whether exercise projects, funded by the time to change anti-stigma programme to reduce mental health-related stigma and discrimination in England, can improve (1) wellbeing, (2) participation in physical activity, (3) readiness to disclose mental health problems or (4) perceived reduction in levels of stigma and discrimination. Methods Participants of exercise projects run in routine community settings by local Mind and Rethink Mental Illness associations completed the Warwick-Edinburgh Mental Well-being Scale (WEMWBS) and questions addressing the other three outcomes at baseline and three month follow-up (N = 2663 baseline; N = 531 three month follow-up). Results There was significant improvement at three months on the WEMWBS (t(386) = -7.64, p = <0.001, r = 0.36); readiness to disclose (χ(2)(1) = 10.86, p = 0.001) and participation in physical activity outside of the project (χ(2)(1) = 12.01, p = 0.001). Conclusions Community-based exercise projects have the potential to produce multifaceted positive outcomes for people with mental health problems; however, more methodologically robust studies are needed to adequately determine the effects of exercise.
    Journal of Mental Health 12/2013; 22(6):519-27. DOI:10.3109/09638237.2013.841874
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    ABSTRACT: Compulsory admission to psychiatric hospitals may be distressing, disruptive to patients and families, and associated with considerable cost to the health service. Improved patient experience and cost reductions could be realised by providing cost-effective crisis planning services. Economic evaluation within a multi-centre randomised controlled trial comparing Joint Crisis Plans (JCP) plus treatment as usual (TAU) to TAU alone for patients aged over 16, with at least one psychiatric hospital admission in the previous two years and on the Enhanced Care Programme Approach register. JCPs, containing the patient's treatment preferences for any future psychiatric emergency, are a form of crisis intervention that aim to mitigate the negative consequences of relapse, including hospital admission and use of coercion. Data were collected at baseline and 18-months after randomisation. The primary outcome was admission to hospital under the Mental Health Act. The economic evaluation took a service perspective (health, social care and criminal justice services) and a societal perspective (additionally including criminal activity and productivity losses). The addition of JCPs to TAU had no significant effect on compulsory admissions or total societal cost per participant over 18-months follow-up. From the service cost perspective, however, evidence suggests a higher probability (80%) of JCPs being the more cost-effective option. Exploration by ethnic group highlights distinct patterns of costs and effects. Whilst the evidence does not support the cost-effectiveness of JCPs for White or Asian ethnic groups, there is at least a 90% probability of the JCP intervention being the more cost-effective option in the Black ethnic group. The results by ethnic group are sufficiently striking to warrant further investigation into the potential for patient gain from JCPs among black patient groups. Current Controlled Trials ISRCTN11501328.
    PLoS ONE 11/2013; 8(11):e74210. DOI:10.1371/journal.pone.0074210
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    ABSTRACT: Objective: The "Like Minds, Like Mine" anti-stigma and discrimination programme has been running in New Zealand since 1997. We aimed to investigate the nature and degree of anticipated and experienced discrimination reported by people with mental illness, and their views on whether the campaign was contributing to reductions in stigma and discrimination. Methods: Questionnaires were sent to randomly selected people who were representative of those who had recently used mental health services in New Zealand. The measure used was the modified Discrimination and Stigma Scale (DISC-12), adding questions on the effect of "Like Minds, Like Mine", and also assessing overall changes in discrimination in the previous 5 years. Results: A total of 1135 participants completed the questionnaire. This included 225 Ma-ori, 196 Pacific, and 152 Asian persons. Over half of all participants reported improvement in discrimination over the previous 5 years, and 48% thought that the "Like Minds Like Mine" programme had assisted in reducing discrimination "moderately" or "a lot". Nevertheless, a clear majority (89%) reported experiencing at least "a little" unfair treatment in the previous 12 months due to their mental health problems. The primary source of both positive and negative discrimination was the family. Many (57%) participants had concealed or hidden their mental health problems from others, and 33% had stopped themselves from applying for work because they anticipated discrimination. Conclusions: Family, friendship, and social life were the most common areas of discrimination reported by the participants; however, many believed the overall level of discrimination had reduced over the previous 5 years. Overall, these results characterize the nature of stigma and discrimination anticipated and experienced by people with mental health problems and indicate modest but clear and positive recent progress in their reduction.
    Australian and New Zealand Journal of Psychiatry 11/2013; 48(4). DOI:10.1177/0004867413512687

  • Age and Ageing 11/2013; 43(1). DOI:10.1093/ageing/aft179
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    ABSTRACT: Many mental health service users delay disclosing to employers or never do so due to previous experience of, or anticipation of discrimination. However, non-disclosure precludes requesting 'reasonable workplace adjustments'. Service users may experience conflicting needs and values in deciding whether to disclose. No evidence-based interventions exist to support this decision. A decision aid (CORAL, or COnceal or ReveAL) to support mental health service users in reaching disclosure decisions was developed and subjected to preliminary evaluation (n=15). The majority found the decision aid quick (60%) and relevant (60%) and would recommend it (80%). Eighty percent reported that they would definitely or probably use it in making disclosure decisions. Forty percent each were positive or neutral on its ease of use. Semi-structured interviews revealed a demand for more information on the legal implications of disclosure. The mean level of 'decisional conflict' regarding disclosure reduced from 52.0 to 35.5 and mean Stage of Decision-making Scale score from 4.6 to 4.3. The results suggest that the CORAL decision aid is feasible, relevant and valuable in supporting decisions about disclosing a mental illness to an employer. The decision aid could be deployed in routine care without significant resource implications.
    Patient Education and Counseling 11/2013; 94(2). DOI:10.1016/j.pec.2013.10.008
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    ABSTRACT: It is important to seek cost-effective methods of improving the care and outcome of those with serious mental illnesses. User-held records, where the person with the illness holds all or some personal information relating to the course and care of their illness, are now the norm in some clinical settings. Their value for those with severe mental illnesses is unknown. To evaluate the effects of personalised, accessible, user-held clinical information for people with a severe mental illness (defined as psychotic illnesses). We updated previous searches by searching the Cochrane Schizophrenia Group Trials Register in August 2011. This register is compiled by systematic searches of major databases, and handsearches of journals and conference proceedings. We included all relevant randomised controlled trials (RCTs) that:i. have recruited adult participants with a diagnosis of a severe mental illness (specifically psychotic illnesses and severe mood disorders such as bipolar and depression with psychotic features); andii. compared any personalised and accessible clinical information held by the user beyond standard care to standard information routinely held such as appointment cards and generic information on diagnosis, treatment or services available. Study selection and data extraction were undertaken independently by two authors and confirmed and checked by a third. We contacted authors of trials for additional and missing data. Where possible, we calculated risk ratios (RR) and 95% confidence intervals (CI). We used a random-effects model. We assessed risk of bias for included studies and created a 'Summary of findings' table using GRADE. Four RCTs (n = 607) of user-held records versus treatment as usual met the inclusion criteria. When the effect of user-held records on psychiatric hospital admissions was compared with treatment as usual in four studies, the pooled treatment effect showed no significant impact of the intervention and was of very low magnitude (n = 597, 4 RCTs, RR 0.99 CI 0.71 to 1.38, moderate quality evidence). Similarly, there was no significant effect of the intervention in three studies which investigated compulsory psychiatric hospital admissions (n = 507, 4 RCTs, RR 0.64 CI 0.37 to 1.10, moderate quality evidence). Other outcomes including satisfaction and mental state were investigated but pooled estimates were not obtainable due to skewed or poorly reported data, or only being investigated by one study. Two outcomes (violence and death) were not investigated by the included studies. Two important randomised studies are ongoing. The evidence gap remains regarding user-held, personalised, accessible clinical information for people with psychotic illnesses for many of the outcomes of interest. However, based on moderate quality evidence, this review suggests that there is no effect of the intervention on hospital or outpatient appointment use for individuals with psychotic disorders. The number of studies is low, however, and further evidence is required to ascertain whether these results are mediated by the type of intervention, such as involvement of a clinical team or the type of information included.
    Cochrane database of systematic reviews (Online) 10/2013; 10(10):CD001711. DOI:10.1002/14651858.CD001711.pub2
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    ABSTRACT: Many mental health service users delay or avoid disclosing their condition to employers because of experience, or anticipation, of discrimination. However, non-disclosure precludes the ability to request 'reasonable adjustments'. There have been no intervention studies to support decision-making about disclosure to an employer. To determine whether the decision aid has an effect that is sustained beyond its immediate impact; to determine whether a large-scale trial is feasible; and to optimise the designs of a larger trial and of the decision aid. In this exploratory randomised controlled trial (RCT) in London, participants were randomly assigned to use of a decision aid plus usual care or usual care alone. Follow-up was at 3 months. Primary outcomes were: (a) stage of decision-making; (b) decisional conflict; and (c) employment-related outcomes (trial registration number: NCT01379014). We recruited 80 participants and interventions were completed for 36 out of 40 in the intervention group; in total 71 participants were followed up. Intention-to-treat analysis showed that reduction in decisional conflict was significantly greater in the intervention group than among controls (mean improvement -22.7 (s.d. = 15.2) v. -11.2 (s.d. = 18.1), P = 0.005). More of the intervention group than controls were in full-time employment at follow-up (P = 0.03). The observed reduction in decisional conflict regarding disclosure has a number of potential benefits which next need to be tested in a definitive trial.
    The British journal of psychiatry: the journal of mental science 09/2013; 203(5). DOI:10.1192/bjp.bp.113.128470
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    ABSTRACT: Patient and public involvement in health research, including mental health research, is promoted by research funders in England. However, it is poorly conceptualised. One argument is that patient and public involvement in research is an ethical imperative because those who research is for should have a stake in how it is done. This could be developed through concepts of citizenship and democratic science. More strongly, it can be argued that changing the knowledge producers will change knowledge itself. Starting with feminist standpoint epistemology, it is argued that a political conceptualisation best captures the new knowledge that marginalised health groups can produce.
    Journal of Health Psychology 09/2013; 19(1). DOI:10.1177/1359105313500249
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