Paul Walters

Dorset HealthCare University NHS Foundation Trust, Bournemouth, England, United Kingdom

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Publications (34)91.26 Total impact

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    ABSTRACT: Patients can report positive effects of myocardial infarction. It is unknown whether these effects are sustained or what factors influence adaptation. To explore primary care patients' perceptions of the effect of coronary heart disease and to identify possible modifiable predictors of adaptation. Cross-sectional, sub-study of UPBEAT cohort participants. Patients were recruited from coronary heart disease Registers in South London General Practices. 548 participants were asked "Has having heart disease changed your life? If so, was that change for the better, worse, both or neither?" Participants were asked to explain their response; explanations were subjected to content analysis. Associations between response and lifestyle, demographic, mood and coronary heart disease variables were tested. Respondents (394 male, 72%) were aged 27-98 years and had had heart disease for a mean of 12.4 SD±8.4 years. 120 (22%) reported that life was better and 200 (37%) said it was worse. The explanations of those who said 'better' were categorised as 'Healthier Living', 'Recognised Mortality' and 'Stress Reduction'. For those saying 'worse', categories were 'Restricted Lifestyle', 'Recognised Mortality', 'Loss and Burden'. More anxiety symptoms (RRR 1.56, 95% CI 1.12, 2.17), lower functional status (RRR 2.46, 95% CI 1.21, 4.98) and self-reported chest pain (RRR 2.24, 95% CI 1.34, 3.77) were associated with saying 'worse'. Many primary care patients are ambivalent to the effects of coronary heart disease, but some report positive effects. Negative perceptions are associated with reported functional impairment, chest pain and anxiety, but not illness severity or patient characteristics. Future work will track the implications of these perceptions, but nurses managing patients with coronary heart disease should consider these effects as they may be modifiable predictors of adaptation.
    International journal of nursing studies 04/2014; · 1.91 Impact Factor
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    ABSTRACT: An association between depression and coronary heart disease is now accepted but there has been little primary care research on this topic. The UPBEAT-UK studies are centred on a cohort of primary patients with coronary heart disease assessed every six months for up to four years. The aim of this research was to determine the prevalence and associations of depression in this cohort at baseline.
    PLoS ONE 01/2014; 9(6):e98342. · 3.73 Impact Factor
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    ABSTRACT: Depression is common in people with coronary heart disease (CHD) and associated with worse outcome. This study explored the acceptability and feasibility of procedures for a trial and for an intervention, including its potential costs, to inform a definitive randomized controlled trial (RCT) of a nurse-led personalised care intervention for primary care CHD patients with current chest pain and probable depression.
    PLoS ONE 01/2014; 9(6):e98704. · 3.73 Impact Factor
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    ABSTRACT: Adults with severe mental illness (i.e. schizophrenia or other related psychotic disorders and bipolar disorder) can be at greater risk of cancer than those without severe mental illness (SMI). Early detection of cancer through screening is effective in improving patient outcomes including death. However, people with SMI are less likely than others to take up available cancer screening. To determine the effectiveness of interventions targeted at adults with SMI, or their carers or health professionals, and aimed at increasing the uptake of cancer screening tests for which the adults with SMI are eligible. We searched electronically the Cochrane Schizophrenia Group's Register (25th October 2012). All randomised controlled trials (RCTs) of interventions, targeted towards adults with SMI or their carers or health professionals, to encourage uptake of cancer screening tests for which the adults with SMI were eligible. Two review authors independently screened titles and abstracts and assessed these against the inclusion criteria. We did not find any trials that met the inclusion criteria. A comprehensive search showed that currently there is no RCT evidence for any method of encouraging cancer screening uptake in people with SMI. No specific approach can therefore be recommended. High-quality, large-scale RCTs are needed urgently to help address the disparity between people with SMI and others in cancer screening uptake.
    Cochrane database of systematic reviews (Online) 07/2013; 7:CD009641. · 5.70 Impact Factor
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    ABSTRACT: BACKGROUND: The prevalence of depression in people with coronary heart disease (CHD) is high but little is known about patients' own perceptions and experiences of this. This study aimed to explore (i) primary care (PC) patients' perceptions of links between their physical condition and mental health, (ii) their experiences of living with depression and CHD and (iii) their own self-help strategies and attitudes to current PC interventions for depression. METHOD: Qualitative study using consecutive sampling, in-depth interviews and thematic analysis using a process of constant comparison. 30 participants from the UPBEAT-UK cohort study, with CHD and symptoms of depression. All participants were registered on the General Practitioner (GP) primary care, coronary register. RESULTS: A personal and social story of loss underpinned participants' accounts of their lives, both before and after their experience of having CHD. This theme included two interrelated domains: interpersonal loss and loss centred upon health/control issues. Strong links were made between CHD and depression by men who felt emasculated by CHD. Weaker links were made by participants who had experienced distressing life events such as divorce and bereavement or were living with additional chronic health conditions (i.e. multimorbidity). Participants also felt 'depressed' by the 'medicalisation' of their lives, loneliness and the experience of ageing and ill health. Just under half the sample had consulted their GP about their low mood and participants were somewhat ambivalent about accessing primary care interventions for depression believing the GP would not be able to help them with complex health and social issues. Talking therapies and interventions providing the opportunity for social interaction, support and exercise, such as Cardiac Rehabilitation, were thought to be helpful whereas anti-depressants were not favoured. CONCLUSIONS: The experiences and needs of patients with CHD and depression are diverse and include psycho-social issues involving interpersonal and health/control losses. In view of the varying social and health needs of patients with CHD and depression the adoption of a holistic, case management approach to care is recommended together with personalised support providing the opportunity for patients to develop and achieve life and health goals, where appropriate.
    BMC Family Practice 03/2013; 14(1):38. · 1.61 Impact Factor
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    ABSTRACT: People with coronary heart disease (CHD) are at heightened risk of depression, and this co-occurrence of conditions is associated with poorer outcomes including raised mortality. This study compares the diagnostic accuracy of two depression case finding instruments in CHD patients relative to a diagnostic standard, the revised Clinical Interview Schedule (CIS-R). The Patient Health Questionnaire (PHQ-9), the Hospital Anxiety and Depression Scale depression subscale (HADS-D) and the CIS-R depression module were administered to 803 patients identified from the CHD registers of GP practices in Greater London. Of 730 recruited patients without previously identified depression, 32 (4.4%) met ICD-10 depressive episode criteria according to the CIS-R. For the PHQ-9 and HADS-D lower cut-points than those routinely recommended were associated with improved case identifying properties. The PHQ-9 appeared the superior instrument using a cut-point of ≥8 (sensitivity=94%; specificity=84%). Using categorical scoring the PHQ-9 was 59% sensitive and 95% specific. For the HADS-D using cut-point ≥5, sensitivity was 81% and specificity was 77%. Areas under the curves (AUC) (standard error) were 0.95 (0.01) and 0.88 (0.02) for the PHQ-9 and HADS-D, and 0.91 (0.02) for PHQ-9 using the categorical algorithm. Statistically significant differences between AUCs of the PHQ-9 and the HADS-D favoured the former. Severity ratings compared across measures indicated inconsistency between recommended bandings: the PHQ-9 categorised a larger proportion of participants with mild and moderate depression. This is the first large-scale investigation of the accuracy of these commonly used measures within a primary care CHD population. Our results suggest that although both scales have acceptable abilities and can be used as case identification instruments for depression in patients with CHD, the PHQ-9 appeared diagnostically superior. Importantly, optimal cut-off points for depression identification in this population appear to differ from standard values, and severity ratings differ between these measures.
    PLoS ONE 01/2013; 8(10):e78493. · 3.73 Impact Factor
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    ABSTRACT: To explore characteristics associated with, and prevalence of, low health literacy in patients recruited to investigate the role of depression in patients on General Practice (GP) Coronary Heart Disease (CHD) registers (the Up-Beat UK study). Cross-sectional cohort. The health literacy measure was the Rapid Estimate of Health Literacy in Medicine (REALM). Univariable analyses identified characteristics associated with low health literacy and compared health service use between health literacy statuses. Those variables where there was a statistically significant/borderline significant difference between health literacy statuses were entered into a multivariable model. 16 General Practices in South London, UK. Inclusion: patients >18 years, registered with a GP and on a GP CHD register. Exclusion: patients temporarily registered. REALM. Of the 803 Up-Beat cohort participants, 687 (85.55%) completed the REALM of whom 106 (15.43%) had low health literacy. Twenty-eight participants could not be included in the multivariable analysis due to missing predictor variable data, leaving a sample of 659. The variables remaining in the final model were age, gender, ethnicity, Indices of Multiple Deprivation score, years of education, employment; body mass index and alcohol intake, and anxiety scores (Hospital Anxiety and Depression Scale). Univariable analysis also showed that people with low health literacy may have more, and longer, practice nurse consultations than people with adequate health literacy. There is a disadvantaged group of people on GP CHD registers with low health literacy. The multivariable model showed that patients with low health literacy have significantly higher anxiety levels than people with adequate health literacy. In addition, the univariable analyses show that such patients have more, and longer, consultations with practice nurses. We will collect 4-year longitudinal cohort data to explore the impact of health literacy in people on GP CHD registers and the impact of health literacy on health service use.
    BMJ Open 01/2013; 3(1). · 1.58 Impact Factor
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    ABSTRACT: BACKGROUND: Depression is common in coronary heart disease (CHD) and increases the incidence of coronary symptoms and death in CHD patients. Interventions feasible for use in primary care are needed to improve both mood and cardiac outcomes. The UPBEAT-UK programme of research has been funded by the NHS National Institute for Health Research (NIHR) to explore the relationship between CHD and depression and to develop a new intervention for use in primary care. METHODS: Using the Medical Research Council (MRC) guidelines for developing and evaluating complex interventions, we conducted a systematic review and qualitative research to develop a primary care-based nurse-led intervention to improve mood and cardiac outcomes in patients with CHD and depression. Iterative literature review was used to synthesise our empirical work and to identify evidence and theory to inform the intervention. RESULTS: We developed a primary care-based nurse-led personalised care intervention which utilises elements of case management to promote self management. Following biopsychosocial assessment, a personalised care plan is devised. Nurses trained in behaviour change techniques facilitate patients to address the problems important to them. Identification and utilisation of existing resources is promoted. Nurse time is conserved through telephone follow up. CONCLUSIONS: Application of the MRC framework for complex interventions has allowed us to develop an evidence based intervention informed by patient and clinician preferences and established theory. The feasibility and acceptability of this intervention is now being tested further in an exploratory trial.
    BMC Family Practice 12/2012; 13(1):119. · 1.61 Impact Factor
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    ABSTRACT: Community studies reveal people with coronary heart disease (CHD) are twice as likely to be depressed as the general population and that this co-morbidity negatively affects the course and outcome of both conditions. There is evidence for the efficacy of collaborative care and case management for depression treatment, and whilst NICE guidelines recommend these approaches only where depression has not responded to psychological, pharmacological, or combined treatments, these care approaches may be particularly relevant to the needs of people with CHD and depression in the earlier stages of stepped care in primary care settings. This pilot randomised controlled trial will evaluate whether a simple intervention involving a personalised care plan, elements of case management and regular telephone review is a feasible and acceptable intervention that leads to better mental and physical health outcomes for these patients. The comparator group will be usual general practitioner (GP) care.81 participants have been recruited from CHD registers of 15 South London general practices. Eligible participants have probable major depression identified by a score of ≥8 on the Hospital Anxiety and Depression Scale depression subscale (HADS-D) together with symptomatic CHD identified using the Modified Rose Angina Questionnaire.Consenting participants are randomly allocated to usual care or the personalised care intervention which involves a comprehensive assessment of each participant's physical and mental health needs which are documented in a care plan, followed by regular telephone reviews by the case manager over a 6-month period. At each review, the intervention participant's mood, function and identified problems are reviewed and the case manager uses evidence based behaviour change techniques to facilitate achievement of goals specified by the patient with the aim of increasing the patient's self efficacy to solve their problems.Depressive symptoms measured by HADS score will be collected at baseline and 1, 6- and 12 months post randomisation. Other outcomes include CHD symptoms, quality of life, wellbeing and health service utilisation. This practical and patient-focused intervention is potentially an effective and accessible approach to the health and social care needs of people with depression and CHD in primary care. ISRCTN21615909.
    BMC Psychiatry 06/2012; 12:58. · 2.23 Impact Factor
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    ABSTRACT: Depression is common in coronary heart disease (CHD). Affected patients have an increased incidence of coronary symptoms and death. Little is known about how best to manage primary care patients with both CHD and depression. This study is part of the UPBEAT-UK programme of research and was designed to understand general practitioners' (GPs) and practice nurses' (PNs) views and experience of managing depression in CHD. Individual in-depth interviews with 10 GPs and 12 PNs in South East London. Data were analysed using constant comparison. GPs and PNs had similar views. Distress following diagnosis or a cardiac event was considered to resolve spontaneously; if it endured or became severe it was treated as depression. GPs and PNs felt that psychosocial problems contributed to depression in patients with CHD. However, uncertainty was expressed as to their perceived role and responsibility in addressing these. In this respect, depression in patients with CHD was considered similar to depression in other patients and no coherent management approach specific for depression in CHD was identified. An individualised approach was favoured, but clinicians were unsure how to achieve this in the face of conflicting patient preferences and the treatment options they considered available. GPs and PNs view depression in CHD similarly to depression uncomplicated by physical illness. However, uncertainty exists as to how best to manage depression associated psychosocial issues. Personalised interventions are needed which account for individual need and which enable and encourage clinicians and patients to make use of existing resources to address the psychosocial factors which contribute to depression.
    BMC Family Practice 01/2012; 13:1. · 1.61 Impact Factor
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    ABSTRACT: Depression in primary care is common but under-recognized and suboptimally managed. Health professionals' attitudes are likely to play an important part in their recognition and management of depression. To pool findings from studies using the Depression Attitude Questionnaire (DAQ) to provide greater detail of clinicians' attitudes and the measure's psychometric properties. Electronic databases and grey literature were searched for relevant studies. Data from eligible studies were requested and pooled analysis conducted. Twenty studies were eligible and data were obtained from 12 of these involving GPs (n = 1543) and nurses (n = 984). Responses showed strong disagreement that depression is due to ageing or weakness. European GPs were more positive about depression treatments than UK GPs; nurses were more favourable about psychotherapy than GPs. UK GPs especially strongly opposed notions that depression is best managed by psychiatrists. Trends over time indicated increasing acknowledgement of psychological therapies and the nurse's role in depression management. Factor analysis indicated that many DAQ items fitted weakly within an overall model. The most parsimonious solution involved two factors: a positive view of depression and its treatment response and professional confidence in depression management. Individual DAQ items appear to measure key aspects of clinicians' attitudes to depression, and item responses indicate important differences between professions and geographical settings as well as changes over time. There are problems with the DAQ as a scale: its internal consistency is weak, and several items appear specific to particular professions or service structures, indicating that this questionnaire should be revised.
    Family Practice 09/2011; 29(2):121-30. · 1.83 Impact Factor
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    ABSTRACT: Current management in primary care of depression, with or without comorbid physical illness, has been found to be suboptimal. We therefore conducted a systematic review to identify clinician perceived barriers to and facilitators for good depression care. We conducted a systematic literature search to identify qualitative and quantitative studies published in the UK since 2000 of GPs' and practice nurses' attitudes to the management of depression. We used principles from meta-ethnography to identify common and refuted themes across studies. We identified 7 qualitative and 10 quantitative studies; none concerned depression and co-morbid physical illness of any kind. The studies of managing patients with a primary diagnosis of depression indicated that GPs and PNs are unsure of the exact nature of the relationship between mood and social problems and of their role in managing it. Among some clinicians, ambivalent attitudes to working with depressed people, a lack of confidence, the use of a limited number of management options and a belief that a diagnosis of depression is stigmatising complicate the management of depression. Detection and management of depression is considered complex. In particular, primary care clinicians need guidance to address the social needs of depressed patients. It is not known whether the same issues are important when managing depressed people with co-morbid physical illness.
    BMC Family Practice 06/2011; 12:47. · 1.61 Impact Factor
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    ABSTRACT: Coronary heart disease and depression are both common health problems and by 2020 will be the two leading causes of disability worldwide. Depression has been found to be more common in patients with coronary heart disease but the nature of this relationship is uncertain. In the United Kingdom general practitioners are now being remunerated for case-finding for depression in patients with coronary heart disease, however it is unclear how general practitioners should manage these patients. We aim to explore the relationship between coronary heart disease and depression in a primary care population and to develop an intervention for patients with coronary heart disease and depression. This programme of research will consist of 4 inter-related studies. A 4 year prospective cohort study of primary care patients with coronary heart disease will be conducted to explore the relationship between coronary heart disease and depression. Within this, a nested case-control biological study will investigate genetic and blood-biomarkers as predictors of depression in this sample. Two qualitative studies, one of patients' perspectives of treatments for coronary heart disease and co-morbid depression and one of primary care professionals' views on the management of patients with coronary heart disease and depression will inform the development of an intervention for this patient group. A feasibility study for a randomised controlled trial will then be conducted. This study will provide information on the relationship between coronary heart disease and depression that will allow health services to determine the efficiency of case-finding for depression in this patient group. The results of the cohort study will also provide information on risk factors for depression. The study will provide evidence on the efficacy and feasibility of a joint patient and professional led intervention and data necessary to plan a definitive randomised controlled trial of the intervention.
    BMC Family Practice 01/2011; 12:38. · 1.61 Impact Factor
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    ABSTRACT: Asthma and depression are common health problems in primary care. Evidence of a relationship between asthma and depression is conflicting. to determine 1. The incidence rate and incidence rate ratio of depression in primary care patients with asthma compared to those without asthma, and 2. The standardized mortality ratio of depressed compared to non-depressed patients with asthma. A historical cohort and nested case control study using data derived from the United Kingdom General Practice Research Database. 11,275 incident cases of asthma recorded between 1/1/95 and 31/12/96 age, sex and practice matched with non-cases from the database (ratio 1:1) and followed up through the database for 10 years. 1,660 cases were matched by date of asthma diagnosis with 1,660 controls. number of cases diagnosed with depression, the number of deaths over the study period. The rate of depression in patients with asthma was 22.4/1,000 person years and without asthma 13.8 /1,000 person years. The incident rate ratio (adjusted for age, sex, practice, diabetes, cardiovascular disease, cerebrovascular disease, smoking) was 1.59 (95% CI 1.48-1.71). The increased rate of depression was not associated with asthma severity or oral corticosteroid use. It was associated with the number of consultations (odds ratio per visit 1.09; 95% CI 1.07-1.11). The age and sex adjusted standardized mortality ratio for depressed patients with asthma was 1.87 (95% CI: 1.54-2.27). Asthma is associated with depression. This was not related to asthma severity or oral corticosteroid use but was related to service use. This suggests that a diagnosis of depression is related to health seeking behavior in patients with asthma. There is an increased mortality rate in depressed patients with asthma. The cause of this needs further exploration. Consideration should be given to case-finding for depression in this population.
    PLoS ONE 01/2011; 6(6):e20750. · 3.73 Impact Factor
  • P. Walters, E. Barley, R. Simmonds, D. Rose
    Journal of Affective Disorders - J AFFECT DISORDERS. 01/2010; 122.
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    Jed Boardman, Paul Walters
    British Journal of General Practice 03/2009; 59(559):76-8. · 1.83 Impact Factor
  • Mark Haddad, Paul Walters, André Tylee
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    ABSTRACT: The majority of patients with mental health problems are treated solely within primary care. This article discusses the epidemiology, diagnosis, and management of mood disorders in primary care. Factors influencing recognition, the use of screening instruments, and somatization are discussed. The article also outlines the latest recommendations for the management of depression in primary care using a stepped care model.
    Psychiatry. 02/2009; 8(2):71–75.
  • Paul Walters, Mark Ashworth, André Tylee
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    ABSTRACT: Antidepressant prescribing should reflect need. The Quality and Outcomes Framework has provided an opportunity to explore factors affecting antidepressant prescribing in UK general practice. To explore the relationship between physical illness, social deprivation, ethnicity, practice characteristics and the volume of antidepressants prescribed in primary care. This was an ecological study using data derived from the Quality and Outcomes Framework, the Informatics Collaboratory of the Social Sciences, and Prescribing Analyses and CosT data for 2004-2005. Associations were examined using linear regression modelling. Socio-economic status, ethnic density, asthma, chronic obstructive pulmonary disease and epilepsy explained 44% of the variance in the volume of antidepressants prescribed. Lower volumes of antidepressants are prescribed in areas with high densities of Black or Asian people. This may suggest disparities in provision of care. Chronic respiratory disease and epilepsy may have a more important association with depression in primary care than previously thought.
    The British Journal of Psychiatry 10/2008; 193(3):235-9. · 6.61 Impact Factor

Publication Stats

215 Citations
91.26 Total Impact Points

Institutions

  • 2012–2014
    • Dorset HealthCare University NHS Foundation Trust
      Bournemouth, England, United Kingdom
  • 2010–2014
    • ICL
      Londinium, England, United Kingdom
  • 2013
    • City University London
      • School of Health Sciences
      Londinium, England, United Kingdom
  • 2007–2013
    • King's College London
      • • Florence Nightingale School of Nursing and Midwifery
      • • Department of Health Service and Population Research
      London, ENG, United Kingdom
  • 2005
    • Ain Shams University
      Al Qāhirah, Al Qāhirah, Egypt
  • 2003–2004
    • UK Department of Health
      Londinium, England, United Kingdom