Depression: Creed F

Spiller R, Aziz Q, Creed F, Emmanuel A, Houghton L, Hungin P, Jones R, Kumar D, Rubin G, Trudgill N, Whorwell P, Anonymous00175. · Wolfson Digestive Diseases Centre, University of Nottingham, Nottingham, UK. · Gut. · Pubmed #17488783 No free full text.

Abstract: BACKGROUND: IBS affects 5-11% of the population of most countries. Prevalence peaks in the third and fourth decades, with a female predominance. AIM: To provide a guide for the assessment and management of adult patients with irritable bowel syndrome. METHODS: Members of the Clinical Services Committee of The British Society of Gastroenterology were allocated particular areas to produce review documents. Literature searching included systematic searches using electronic databases such as Pubmed, EMBASE, MEDLINE, Web of Science, and Cochrane databases and extensive personal reference databases. RESULTS: Patients can usefully be classified by predominant bowel habit. Few investigations are needed except when diarrhoea is a prominent feature. Alarm features may warrant further investigation. Adverse psychological features and somatisation are often present. Ascertaining the patients' concerns and explaining symptoms in simple terms improves outcome. IBS is a heterogeneous condition with a range of treatments, each of which benefits a small proportion of patients. Treatment of associated anxiety and depression often improves bowel and other symptoms. Randomised placebo controlled trials show benefit as follows: cognitive behavioural therapy and psychodynamic interpersonal therapy improve coping; hypnotherapy benefits global symptoms in otherwise refractory patients; antispasmodics and tricyclic antidepressants improve pain; ispaghula improves pain and bowel habit; 5-HT(3) antagonists improve global symptoms, diarrhoea, and pain but may rarely cause unexplained colitis; 5-HT(4) agonists improve global symptoms, constipation, and bloating; selective serotonin reuptake inhibitors improve global symptoms. CONCLUSIONS: Better ways of identifying which patients will respond to specific treatments are urgently needed.

Dickens C, Creed F. · No affiliation provided · Rheumatology (Oxford). · Pubmed #11752500 links to  free full text

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Creed F. · No affiliation provided · Heart. · Pubmed #10490547 links to  free full text

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Jones MP, Crowell MD, Olden KW, Creed F. · Feinberg School of Medicine, Northwestern University, Chicago, IL 60611-2908, USA. · Psychosomatics. · Pubmed #17329601 links to  free full text

Abstract: Functional gastrointestinal disorders (FGID) are common conditions, with well-established diagnostic criteria. They are associated with impaired health-related quality of life and increased societal and healthcare costs. Their symptoms are probably related to altered 5-HT transmission and central processing of noxious visceral stimuli. Evaluation and treatment are best formulated using a biopsychosocial model that integrates gut function with psychosocial assessment. Psychological therapies may improve overall well-being and appear to help patients without significant psychiatric comorbidity. Antidepressants help comorbid anxiety and depressive disorders and have primary efficacy in improving the symptoms of FGID. Finally, there is a need for greater involvement of psychiatrists in both the evaluation and treatment of patients with FGID as well as the education and training of practitioners caring for these patients.

Sheps DS, Creed F, Clouse RE. · University of Florida and the Malcom Randall VA Medical Center, P.O. Box 100181, Gainesville, FL 100181-0181, USA. · Psychosom Med. · Pubmed #15564350 links to  free full text

Abstract: OBJECTIVE: To describe factors influencing chest pain expression in patients with cardiac or noncardiac disease. METHODS: The authors conducted a case presentation and review of literature. RESULTS: Causes of chest pain are diverse. Psychologic factors influence chest pain expression commonly in patients with or without cardiac disease. CONCLUSIONS: Physicians and other therapists must be aware of psychologic influences on chest pain expression to provide optimal treatment to their patients.

Marshall M, Crowther R, Almaraz-Serrano A, Creed F, Sledge W, Kluiter H, Roberts C, Hill E, Wiersma D, Bond GR, Huxley P, Tyrer P. · University of Manchester, Guild Trust, Preston, UK. · Health Technol Assess. · Pubmed #11532238 links to  free full text

Abstract: ***ACUTE DAY HOSPITAL VERSUS ADMISSION FOR ACUTE PSYCHIATRIC DISORDERS*** BACKGROUND: Inpatient treatment is an expensive way of caring for people with acute psychiatric disorders. It has been proposed that many of those currently treated as inpatients could be cared for in acute psychiatric day hospitals. OBJECTIVE: The aim of this review was to assess the effectiveness and feasibility of day hospital versus inpatient care for people with acute psychiatric disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials of day hospital versus inpatient care for people with acute psychiatric disorders. Studies were excluded if they were primarily concerned with elderly people, children, or patients with a diagnosis of organic brain disease or substance abuse. METHODS - DATA SOURCES: We searched the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: Data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risk (RR) and 95% confidence intervals (CIs) were calculated for dichotomous data. Weighted or standardised means were calculated for continuous data. Day hospital trials tend to present similar outcomes in slightly different formats, making it difficult to synthesise the data. Individual patient data were therefore sought so that outcomes could be re-analysed using a common format. RESULTS: Nine trials met the inclusion criteria (involving 1568 randomised patients and 2268 assessed for suitability of day hospital treatment). Individual patient data were obtained for four trials (involving 594 people). A sensitivity analysis of combined data suggested that day hospital treatment was feasible for at worst 23.2% (n = 2268; 95% CI, 21.2 to 25.2) and at best 37.5% (n = 1768; 95% CI, 35.2 to 39.8) of those currently admitted to inpatient care. Individual patient data from three trials showed no difference in the number of days in hospital (combining day hospital days and inpatient days) between day hospital patients and controls (n = 465; weighted mean difference (WMD) = -0.38 days/ month; 95% CI, -1.32 to 0.55). However, compared with controls, patients randomised to day hospital care spent significantly more days in day hospital care (n = 265; WMD = 2.34 days/month; 95% CI, 1.97 to 2.70) and significantly fewer days in inpatient care (n = 265; WMD = -2.75 days/month; 95% CI, -3.63 to -1.87). There was no difference between readmission rates for day hospital and control patients (n = 667; RR = 0.91; 95% CI, 0.72 to 1.15). Individual patient data from three trials showed a significant time-treatment interaction, indicating a more rapid improvement in mental state (n = 407; c2 = 9.66; p = 0.002), but not social functioning (n = 295; c2 = 0.006; p = 0.941) amongst day hospital patients. Four of five trials demonstrated that day hospital care was cheaper than inpatient care (with overall cost reductions ranging from 20.9% to 36.9%). CONCLUSIONS: Acute day hospitals are an attractive option in situations where demand for inpatient care is high and facilities exist that are suitable for conversion. They are a less attractive option when demand for inpatient care is low and where effective alternatives already exist. The interpretation of day hospital research would be enhanced if future trials made use of the common set of outcome measures used in this review. It is important to examine how acute day hospital care can be most effectively integrated into a modern community-based psychiatric service. ***VOCATIONAL REHABILITATION FOR PEOPLE WITH SEVERE MENTAL DISORDERS*** BACKGROUND: People who are disabled by severe mental disorders experience high rates of unemployment, but most want to work. Prevocational training (PVT) is the traditional approach to helping such people to return to work. PVT assumes that a period of preparation is required before those with a severe mental disorder can enter into competitive employment. Supported Employment (SEm) is a new approach that places clients in competitive employment without extended preparation. Both PVT and SEm are widely practised, but it is unclear which is the most effective. OBJECTIVES: The overall objective of this review was to assess the effectiveness of PVT and SEm relative to each other and to standard care (in hospital or the community) for people with severe mental disorders. In addition, the review examined the effectiveness of: (1) special types of PVT ("clubhouse" model) and SEm (individual placement and support model); and (2) modifications for enhancing PVT (e.g. payment or psychological interventions). METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials (RCTs) examining the effectiveness of vocational rehabilitation approaches (PVT and SEm or modifications) for people of working age and suffering from a severe mental disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Schizophrenia Group's specialised register, MEDLINE, EMBASE, CINAHL and PsycLIT, and the reference lists of all identified studies and review articles. Researchers who were active in the field were approached in order to identify unpublished studies. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. Continuous data were excluded if they were collected by using an unpublished scale or were based on a subset of items from a scale. METHODS - DATA SYNTHESIS: For all comparisons, the primary outcome was the number of clients who were in competitive employment at various time points. Secondary outcomes were: other employment outcomes, clinical outcome and costs. The relative risk (RR) and number-needed-to-treat (NNT) were calculated for the relevant categorical outcomes. Continuous data were either presented as in the original trial reports or, where possible, combined across trials as a standardised mean difference score. RESULTS: Eighteen RCTs of reasonable quality were identified: PVT versus hospital controls, three RCTs, n = 172; PVT versus community controls, five RCTs, n = 1204; modified PVT, four RCTs, n = 423; SEm versus community controls, one RCT, n = 256; and SEm versus PVT, five RCTs, n = 491). The main finding was that, on the primary outcome (number in competitive employment), SEm was significantly more effective than PVT at all time points (e.g. at 12 months, SEm 34% employed, PVT 12% employed; RR of not being in competitive employment = 0.76, 95% confidence interval 0.69 to 0.84, NNT = 4.5). Clients in SEm also earned more and worked more hours per month than those in PVT. CONCLUSIONS: The main finding was that SEm was more effective than PVT for patients suffering from a severe mental disorder who wanted to work. There was no evidence that PVT was more effective than standard community care or hospital care. The implication of these findings is that people suffering from mental disorders who want to work should be offered the option of SEm. Commissioning agencies would be justified in encouraging vocational rehabilitation (VR) providers to develop more SEm schemes. From a research perspective, the cost-effectiveness of SEm should be examined in larger multicentre trials, both within and outside the USA. There is a case for countries outside the USA to survey their existing VR services to determine the extent to which the most effective interventions are being offered. ***DAY HOSPITAL VERSUS OUTPATIENT CARE FOR PATIENTS WITH PSYCHIATRIC DISORDERS*** BACKGROUND: This review considers the use of day hospitals as an alternative to outpatient care. Two typesof day hospital provision are covered: "day treatment programmes" and "day care centres". Day treatment programmes are day hospitals that are used to enhance the treatment of patients with anxiety or depressive disorders who have failed to respond to outpatient care. Day care centres are day hospitals that offer structured support to patients with long-term severe mental disorders who would otherwise be treated in an outpatient clinic. OBJECTIVES: There were two objectives: first, to assess the effectiveness of day treatment programmes versus outpatient care for people with non-psychotic disorders; and, secondly, to assess the effectiveness of day care centres versus outpatient care for people with severe long-term disorders. METHODS - STUDY SELECTION: Eligible studies were randomised controlled trials comparing day hospital care (either a day treatment programme or a day care centre) with outpatient care. Studies were ineligible if they were largely restricted to patients who were aged under 18 or over 65 years or who had a primary diagnosis of substance abuse or organic brain disorder. METHODS - DATA SOURCES: Relevant trials were identified from searches of the Cochrane Controlled Trials Register, MEDLINE, EMBASE, CINAHL, PsycLIT, and the reference lists of all identified studies and review articles. Researchers were approached to identify unpublished studies. Trialists were asked to provide individual patient data. METHODS - DATA EXTRACTION: All data were extracted independently by two reviewers and cross-checked. METHODS - DATA SYNTHESIS: Relative risks and 95% confidence intervals were calculated for dichotomous data. Standardised mean differences were calculated for continuous data. RESULTS: There was evidence from two of the five trials identified suggesting that day treatment programmes were superior to continuing outpatient care in terms of improving psychiatric symptoms. There was no evidence to suggest that day treatment programmes were better or worse than outpatient care on any other clinical or social outcome variable or on costs. (ABSTRACT TRUNCATED)

Creed F. · Department of Psychological Medicine, Manchester Royal Infirmary, United Kingdom. · Am J Med. · Pubmed #10588176 No free full text.

Abstract: This article reviews the evidence that psychiatric disorders have an adverse influence on the outcome of irritable bowel syndrome (IBS) and relates this to the close relationship between psychological symptoms and severity of abdominal pain, bloating, and diarrhea. Therefore, accurate measurement of psychological symptoms may be an important aspect of trial design for IBS therapy. The importance of psychological distress and health anxiety in differentiating "consulters" and "nonconsulters" for IBS is reviewed. The consequences of excluding from a trial people with certain types of psychiatric disorder or with a known past history of sexual abuse are considered.

Guthrie E, Barlow J, Fernandes L, Ratcliffe J, Read N, Thompson DG, Tomenson B, Creed F, Anonymous00236. · School of Psychiatry and Behavioural Science, University of Manchester, Manchester, UK. · Psychosom Med. · Pubmed #15272106 links to  free full text

Abstract: OBJECTIVE: Reduced tolerance to rectal distension has been regarded as a biological marker for irritable bowel syndrome (IBS), but longitudinal studies are few. This study determined whether change in tolerance to rectal distension after psychological treatments was associated with: 1) change in abdominal pain; 2) change in psychological symptoms; 3) a reported history of sexual abuse. METHODS: Participants completed a visual analogue scale of abdominal pain, SCL-90 and Hamilton rating scale of depression; discomfort threshold to rectal distension was determined using a double random staircase protocol. These were measured at entry to a trial of psychotherapy or paroxetine (selective serotonin reuptake inhibitor antidepressant) and 3 months later (N = 52). Analysis of change scores were adjusted for treatment group and baseline values. RESULTS: Increased tolerance to distension after treatment was associated with reduction in depression (r = -0.37, p =.008) but not abdominal pain. Patients who reported prior sexual abuse showed greater increase in tolerance than the remainder (changes in volume threshold: -24.7 ml [SEM = 12.1] vs. 3.6 ml [SEM = 6.2], adjusted p =.045; changes in pressure threshold: -4.7 [SEM = 1.7] mm Hg vs. 0.96 [SEM=0.9], adjusted p =.005). Multiple regression indicated that reduction in depression score and a reported history of sexual abuse were independently associated with improved tolerance to distension. CONCLUSIONS: In patients with severe IBS, increased tolerance to rectal distension after psychological treatment is significantly associated with improved depression and reported sexual abuse. These results suggest that in some patients with severe IBS psychological rather than biological processes are primarily responsible for reduced tolerance to rectal distension.

Derbyshire SW, Jones AK, Creed F, Starz T, Meltzer CC, Townsend DW, Peterson AM, Firestone L. · Department of Anesthesiology and Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, 15213, USA. · Neuroimage. · Pubmed #11969326 No free full text.

Abstract: Changes in regional cerebral blood flow (rCBF) have previously been demonstrated in a number of cortical and subcortical regions, including the cerebellum, midbrain, thalamus, lentiform nucleus, and the insula, prefrontal, anterior cingulate, and parietal cortices, in response to experimental noxious stimuli. Increased anterior cingulate responses in patients with chronic regional pain and depression to noxious stimulation distant from the site of clinical pain have been observed. We suggested that this may represent a generalized hyperattentional response to noxious stimuli and may apply to other types of chronic regional pain. Here these techniques are extended to a group of patients with nonspecific chronic low back pain. Thirty-two subjects, 16 chronic low back pain patients and 16 controls, were studied using positron emission tomography. Thermal stimuli, corresponding to the experience of hot, mild, and moderate pain, were delivered to the back of the subject's right hand using a thermal probe. Each subject had 12 measurements of rCBF, 4 for each stimulus. Correlation of rCBF with subjective pain experience revealed similar responses across groups in the cerebellum, midbrain (including the PAG), thalamus, insula, lentiform nucleus, and midcingulate (area 24') cortex. These regions represented the majority of activations for this study and those recorded by other imaging studies of pain. Although some small differences were observed between the groups these were not considered sufficient to suggest abnormal nociceptive processing in patients with nonspecific low back pain.

Dickens C, Jayson M, Sutton C, Creed F. · Department of Psychiatry, Manchester University, UK. · Psychosomatics. · Pubmed #11110112 links to  free full text

Abstract: Previous studies have shown a positive association between pain and depression, though evidence supporting a direct link between these two variables is less robust. Using a placebo-controlled trial, the authors examined the analgesic and antidepressant efficacy of paroxetine (20 mg) in chronic low back pain sufferers. The authors examined the associations among pain, depression, disability, and illness attitudes. Paroxetine showed no effects on pain or depression compared with placebo; however, subjects randomized to paroxetine were more likely to reduce concomitant analgesic medication. The cross-sectional association of depression and pain at baseline (r = 0.2, P = 0.02) was weaker than the association between depression and disability (r = 0.3, P = 0.004). Similarly, the association of change in depression scores with change in pain (r = 0.25, P = 0.016) was weaker than change between depression and disability (r = 0.49, P<0.0005). Whereas the relationship between pain and depression became nonsignificant when disability and illness attitudes were controlled, the relationship between depression and disability remained highly significant when pain and illness attitudes were controlled. These data are consistent with the association between pain and depression being wholly modulated by disability and illness attitudes, with no direct relationship between pain and depression.

Guthrie E, Moorey J, Margison F, Barker H, Palmer S, McGrath G, Tomenson B, Creed F. · School of Psychiatry and Behavioural Sciences, University of Manchester, England. · Arch Gen Psychiatry. · Pubmed #10359466 links to  free full text

Abstract: BACKGROUND: It is known that a small number of patients with mental health problems have chronic disorders and account for a disproportionate amount of mental health costs. This randomized controlled trial evaluated the cost-effectiveness of psychodynamic-interpersonal therapy vs treatment as usual in patients with mental health problems who were unresponsive to usual treatment. METHOD: Subjects (N = 110) with nonpsychotic disorders unresponsive to 6 months of routine specialist mental health treatment were enrolled in a randomized controlled trial. Sixty-three percent were women, the mean age was 41.4 years, the median duration of illness was 5 years, 68% were unemployed or receiving state benefits because of illness, and 75.5% had a depressive illness. Intervention patients received 8 weekly sessions of psychodynamic-interpersonal psychotherapy. Control patients received usual care from their psychiatrist. Outcome measures included ratings of psychological distress and health status and a detailed economic evaluation. Analysis was conducted on an intent-to-treat basis. RESULTS: Subjects randomized to psychotherapy had a significantly greater improvement than controls in psychological distress and social functioning 6 months after the trial. Baseline treatment costs were similar for both groups. Subjects who received psychotherapy showed significant reductions in the cost of health care utilization in the 6 months after treatment compared with controls. The extra cost of psychotherapy was recouped within 6 months through reductions in health care use. CONCLUSION: These preliminary findings suggest that brief psychodynamic-interpersonal therapy may be cost-effective relative to usual care for patients with enduring nonpsychotic symptoms who are not helped by conventional psychiatric treatment.

Rahman A, Ahmed M, Sikander S, Malik A, Tomenson B, Creed F. · University of Liverpool, Alder Hey Children's NHS Foundation Trust, Liverpool, UK. · J Affect Disord. · Pubmed #19135262 No free full text.

Abstract: BACKGROUND: The prevalence of depression is very high among adult women in Pakistan but it is not known whether such a high prevalence occurs in younger women. We aimed to assess the prevalence and correlates of depression in 16 to 18-year old unmarried women in Pakistan. METHOD: Population-based survey of all 16 to 18-year old unmarried women in one rural community in Rawalpindi District, Punjab, Pakistan. Depressive disorder and psychological distress were assessed using the Structured Clinical Interview for DSM-IV Disorders (SCID) and Self-Reporting Questionnaire (SRQ) respectively. RESULTS: 337 eligible women were identified of whom 321 (95%) were interviewed. Fourteen (4.4%) had depressive disorder; one third scored 9 or more on SRQ. On multivariate analysis a high SRQ score was associated with childhood experience of poverty, father's education, stressful life events, disturbed family relationships and mother's depression. LIMITATIONS: The sample was derived from one rural community only and the results should be generalised with caution. CONCLUSION: Depressive disorder is not common in young women in rural Pakistan though distress appears common and is associated with early and recent adversity and family difficulties. These results suggest future work might aim to understand onset and prevent chronic depression.

Pitceathly C, Maguire P, Fletcher I, Parle M, Tomenson B, Creed F. · CRUK Psychological Medicine Group, Stanley House, Christie Hospital, Manchester, UK. · Ann Oncol. · Pubmed #19126633 No free full text.

Abstract: BACKGROUND: We tested whether a brief psychological intervention could prevent anxiety or depressive disorders among newly diagnosed cancer patients. PATIENTS AND METHODS: Patients free of anxiety or depressive disorder were randomised to receive immediate intervention (start of cancer treatment), delayed intervention (8 weeks after starting treatment) or usual care. They were stratified according to risk of developing anxiety or depressive disorders. Primary outcome was measured using a standardised psychiatric interview to detect any anxiety or depressive disorder at 6 and 12 months following the cancer diagnosis. Analyses used conditional odds logistic regression models adjusting for age, gender, concerns and past history to compare outcome of all intervention patients with usual care. RESULTS: A total of 465 patients were recruited. In all, 313 (79%) of the 397 well enough to be interviewed completed the study. At 12 months, there was no difference between the groups receiving the intervention and usual care [odds ratio (OR) = 0.69, 95% confidence interval (CI) 0.41-1.17, P = 0.17]. In high-risk patients, those who received the intervention were less likely to develop an anxiety or depressive disorder compared with those who received usual care (OR = 0.54, 95% CI 0.29-1.00, P = 0.050). In low-risk patients, there was no difference (OR = 1.50, 95% CI 0.51-4.43, P = 0.47). CONCLUSION: A brief intervention, delivered by nonspecialists, promoted adjustment among newly diagnosed cancer patients at high risk of developing anxiety or depressive disorders.

Ismail K, Thomas SM, Maissi E, Chalder T, Schmidt U, Bartlett J, Patel A, Dickens CM, Creed F, Treasure J. · Instituteof Psychiatry, King's College London, Weston Education Centre, London, United Kingdom. · Ann Intern Med. · Pubmed #19017589 links to  free full text

Abstract: BACKGROUND: Although psychological issues can interfere with diabetes care, the effectiveness of psychological treatments in improving diabetes outcomes is uncertain. OBJECTIVE: To determine whether motivational enhancement therapy with or without cognitive behavior therapy improves glycemic control in type 1 diabetes compared with usual care. DESIGN: Randomized, controlled trial. SETTING: 8 diabetes centers in London and Manchester, United Kingdom. PATIENTS: 344 adults with type 1 diabetes for longer than 2 years, with hemoglobin A(1c) levels of 8.2% to 15%, and without complications or severe comorbid disease. INTERVENTION: Nurse-delivered motivational enhancement therapy (4 sessions over 2 months), motivational enhancement therapy plus cognitive behavior therapy (12 sessions over 6 months), or usual care. MEASUREMENTS: 12-month change in hemoglobin A(1c) levels (primary outcome), hypoglycemic events, depression, quality of life, fear of hypoglycemia, diabetes self-care activities, and body mass index (secondary outcomes). RESULTS: In an analysis including all randomly assigned patients, the 12-month change in hemoglobin A(1c) levels compared with usual care was -0.46% (95% CI, -0.81% to -0.11%) in the motivational enhancement therapy plus cognitive behavior therapy group and -0.19% (CI, -0.53% to 0.16%) in the motivational enhancement therapy group alone. There was no evidence of treatment effects on secondary outcomes. LIMITATIONS: Of 1659 screened patients, only 507 were eligible and 344 participated. Data on the primary outcome were unavailable for 11.3% of the participants. Study design did not permit distinction of the additive effect of cognitive behavior therapy plus motivational enhancement therapy from the effect of greater intensity and duration of the combined intervention compared with the motivational enhancement therapy alone. CONCLUSION: Nurse-delivered motivational enhancement therapy and cognitive behavior therapy is feasible for adults with poorly controlled type 1 diabetes. Combined therapy results in modest 12-month improvement in hemoglobin A(1c) levels compared with usual care, but motivational enhancement therapy alone does not.

Rahman A, Malik A, Sikander S, Roberts C, Creed F. · School of Population, Community, and Behavioural Sciences, University of Liverpool, Liverpool, UK. · Lancet. · Pubmed #18790313 links to  free full text

Abstract: BACKGROUND: The treatment of perinatal depression is a public-health priority because of its high prevalence and association with disability and poor infant development. We integrated a cognitive behaviour therapy-based intervention into the routine work of community-based primary health workers in rural Pakistan and assessed the effect of this intervention on maternal depression and infant outcomes. METHODS: We randomly assigned 40 Union Council clusters in rural Rawalpindi, Pakistan, in equal numbers to intervention or control. Married women (aged 16-45 years) in their third trimester of pregnancy with perinatal depression were eligible to participate. In the intervention group, primary health workers were trained to deliver the psychological intervention, whereas in the control group untrained health workers made an equal number of visits to the depressed mothers. The primary outcomes were infant weight and height at 6 months and 12 months, and secondary outcome was maternal depression. The interviewers were unaware of what group the participants were assigned to. Analysis was by intention to treat. The study is registered as ISRCTN65316374. FINDINGS: The number of clusters per group was 20, with 463 mothers in the intervention group and 440 in the control group. At 6 months, 97 (23%) of 418 and 211 (53%) of 400 mothers in the intervention and control groups, respectively, met the criteria for major depression (adjusted odds ratio (OR) 0.22, 95% CI 0.14 to 0.36, p<0.0001). These effects were sustained at 12 months (111/412 [27%] vs 226/386 [59%], adjusted OR 0.23, 95% CI 0.15 to 0.36, p<0.0001). The differences in weight-for-age and height-for-age Z scores for infants in the two groups were not significant at 6 months (-0.83 vs -0.86, p=0.7 and -2.03 vs -2.16, p=0.3, respectively) or 12 months (-0.64 vs -0.8, p=0.3 and -1.10 vs -1.36, p=0.07, respectively). INTERPRETATION: This psychological intervention delivered by community-based primary health workers has the potential to be integrated into health systems in resource-poor settings.

Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F. · Department of Psychiatry, University of Manchester, University Place, Oxford Road, Manchester M13 9PL, UK. · Gen Hosp Psychiatry. · Pubmed #18774424 No free full text.

Abstract: OBJECTIVE: To test the hypothesis that negative perceptions about heart disease at the time of the myocardial infarction (MI) were associated with the onset of new episodes of depression following MI. METHOD: We recruited 269 subjects admitted following first MI and monitored their depression status over the subsequent 12 months. At baseline, we recorded demographic information, family and personal history of cardiac disease and severity of MI; subjective health beliefs were assessed using the Illness Perceptions Questionnaire (IPQ). We assessed depression at baseline, 6 and 12 months following MI using a standardised questionnaire, validated in this population against a semistructured research interview. RESULTS: In the days following MI, patients who subsequently developed depression were more likely to anticipate that their heart disease would last a long time (P=.012) and was unlikely to be cured (P=.038). Controlling for potential confounding variables, scores on the IPQ remained associated with subsequent depression (P = .036), with anticipation that heart disease would last a long time [odds ratio (OR)=2.7, P=.013] and that heart disease could be cured (OR=0.45, P=.048) showing strongest association. CONCLUSIONS: Negative perceptions about heart disease in the days following admission to hospital with first MI are associated with the development of subsequent new episodes of depression.

Gater R, Tomenson B, Percival C, Chaudhry N, Waheed W, Dunn G, Macfarlane G, Creed F. · Psychiatry Research Group, University of Manchester, Rawnsley Building, Manchester Royal Infirmary, Manchester, UK. · Soc Psychiatry Psychiatr Epidemiol. · Pubmed #18726242 No free full text.

Abstract: INTRODUCTION: We compared depression, social stress and treatment in people of Pakistani origin and white Europeans living in an UK city. METHOD: In a population-based two-phase sample of 1,856 adults we interviewed 651 (77%) of eligible participants, using the schedule for clinical assessment in neuropsychiatry and life events and difficulties schedule. We identified 216 people with depressive and 208 with subthreshold disorder; after 6-months we re-interviewed 398 (94% response). RESULTS: Depressive disorder was more common in Pakistani women only (31.1% [24.1-38.0] vs.19.3% [14.1-24.5]) and persisted more often in Pakistanis over 50 years of age (90 vs.66%, P = 0.023). New episodes of depressive disorder occurred in 17% of participants who had subthreshold disorder at baseline in each ethnic group. Persistent depression in the Pakistani group was associated with continuing problems of disabling physical illness and close relationships. Treatment was limited and not associated with persistent depression. CONCLUSIONS: Persistent depressive disorder in older people of Pakistani origin is associated with potentially remediable factors.

Stewart RC, Kauye F, Umar E, Vokhiwa M, Bunn J, Fitzgerald M, Tomenson B, Rahman A, Creed F. · Department of Community Health, College of Medicine, Blantyre, Malawi. · J Affect Disord. · Pubmed #18504058 No free full text.

Abstract: BACKGROUND: Depressive disorder affecting women during the perinatal period is common in low-income countries. The detection and study of maternal depression in a resource-poor setting requires a brief screening tool that is both accurate and practical to administer. METHOD: A Chichewa version of the Self Reporting Questionnaire (SRQ) was developed through a rigorous process of forward and back translation, focus-group discussion and piloting. Criterion validation was conducted as part of a larger study in a sample of women who had brought their infants to a child health clinic in rural Malawi, using DSM-IV major and minor depressive episode as the gold standard diagnoses. RESULTS: The criterion validation was conducted on 114 subjects who did not differ on health and sociodemographic characteristics from the total study sample (n=501). Test characteristics for each possible SRQ cut-off were calculated and Receiver Operator Characteristic (ROC) curves derived. Area under the ROC curve (AUROC) for detection of current major depressive disorder was 0.856 (95% CI 0.813 to 0.900), and for current major or minor depressive disorder was 0.826 (95% CI 0.783 to 0.869). Internal consistency of the SRQ was high (Cronbach's alpha 0.85). LIMITATION: Inter-rater reliability testing was not conducted. CONCLUSION: This Chichewa version of the SRQ shows utility as a brief screening measure for detection of probable maternal depression in rural Malawi.

Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F. · Department of Psychiatry, Rawnsley Building, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL. · Psychosom Med. · Pubmed #18434496 No free full text.

Abstract: OBJECTIVE: Studies investigating the effects of depression on mortality following myocardial infarction (MI) have produced heterogeneous findings. We report on a study investigating whether the timing of the onset of depression, with regard to the MI, affected its impact on subsequent cardiac mortality. METHODS: Five hundred and eighty-eight subjects admitted following MI underwent assessments of cardiac status, cardiac risk factors, and noncardiac illness. We identified separately subjects who were depressed before their MI (pre-MI depression) and those who developed depression in the 12 months after MI (new-onset depression), using a standardized questionnaire and a research interview. Patients dying of cardiac cause were identified during 8-year follow-up using information from death certificates. RESULTS: Multivariate predictors of cardiac death during follow-up included: greater age (hazards ratio (HR) = 1.06, p = .007), previous angina (HR = 4.15, p < .0005), high Killip Class (HR = 2.21, p = .013), prescription of beta-blockers on discharge (HR = 0.37, p = .02), and new-onset depression (HR = 2.33, p = .038). Pre-MI depression did not convey any additional risk of cardiac mortality. CONCLUSION: We have shown increased cardiac mortality in patients who develop depression after suffering MI. Further observational studies need to separate pre- and post-MI depression if we are to determine underlying mechanisms by which depression is associated with mortality following MI.

Creed F. · Department of Psychological Medicine, University of Manchester, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. · Gut. · Pubmed #17625139 No free full text.

This publication has no abstract.

Keeley P, Creed F, Tomenson B, Todd C, Borglin G, Dickens C. · Department of Nursing, Midwifery & Social Work, Coupland III Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK. · Pain. · Pubmed #17611036 No free full text.

Abstract: Psychological and social factors have been shown, separately, to predict outcome in individuals with chronic low back pain. Few previous studies, however, have integrated both psychological and social factors, using prospective study of clinic populations of low back pain patients, to identify which are the most important targets for treatment. One hundred and eight patients with chronic low back pain, newly referred to an orthopaedic outpatient clinic, completed assessments of demographic characteristics, details of back pain, measures of anxiety and depression (Hospital Anxiety and Depression Scale, HADS), fearful beliefs about pain (Fear Avoidance Beliefs Questionnaire), social stresses (Life Events and Difficulties Schedule) and physical aspects of health-related quality of life [SF-36 Physical Component summary Score scale (PCS)]. Six months later subjects completed the SF-36 PCS and the number of healthcare contacts during follow-up was recorded. Independent predictors of SF-36 PCS at 6-month follow-up were duration of pain [(standardised regression coefficient (beta)=-0.18, p=0.04), HADS score (beta)=-0.27, p=0.003] and back pain related social difficulties (beta=-0.42, p<0.0005). Number of healthcare contacts over the 6 months ranged from 1 to 29, and was independently predicted by perceived cause of pain [Incident Rate Ratio (IRR)=1.46, p=0.03], Fear Avoidance Beliefs about work (IRR=1.02, p=0.009) and back pain related social difficulties (IRR=1.16, p=0.03). To conclude, anxiety, depression, fear avoidance beliefs relating to work and back pain related stresses predict impairment in subsequent physical health-related quality of life and number of healthcare contacts. Interventions targeting these psychosocial variables in clinic patients may lead to improved quality of life and healthcare costs.

Rahman A, Bunn J, Lovel H, Creed F. · Department of Psychological Medicine, University of Manchester, Manchester, UK. · Acta Psychiatr Scand. · Pubmed #17498160 links to  free full text

Abstract: OBJECTIVE: There is a high prevalence of depression in south Asian women. We aimed to examine the association between antenatal depression and low birthweight (LBW) in infants in a rural community in Rawalpindi, Pakistan. METHOD: A total of 143 physically healthy mothers with ICD-10 depression in the third trimester of pregnancy and 147 non-depressed mothers of similar gestation were followed from birth. Infant weight was measured and information collected on socioeconomic status, maternal body-mass index and sociodemographic factors. RESULTS: Infants of depressed mothers had lower birthweight (mean 2910 g) than infants of non-depressed mothers (mean 3022 g). The relative risk for LBW (< or =2500 g) in infants of depressed mothers was 1.9 (95% CI 1.3-2.9). The association remained significant after adjustment for confounders by multivariate analyses. CONCLUSION: Low birthweight is a major public health problem in developing countries. Maternal depression during pregnancy predicts LBW. Interventions aimed at maternal depression may help improve infant outcomes.

Dickens C, McGowan L, Percival C, Tomenson B, Cotter L, Heagerty A, Creed F. · Psychological Medicine Research Group, Department of Psychiatry, Manchester University, Manchester, England. · J Am Coll Cardiol. · Pubmed #17481442 No free full text.

Abstract: OBJECTIVES: This study sought to investigate the long-term impact of depression on cardiac mortality after myocardial infarction (MI) and to assess whether the timing of depression influences the findings. BACKGROUND: Previous studies have shown that depression increases the risk of cardiac death after MI, although some studies with robust methodology have failed to show this effect. Clinical trials of depression treatments have failed to improve mortality. Until the relationship between depression and post-MI mortality is understood fully, clinical trials aimed at reducing mortality by treating depression remain premature. METHODS: We recruited 588 subjects after MI and followed up their cases for up to 8 years. Patients underwent detailed assessments of cardiac status, conventional cardiac risk factors, and noncardiac illness at baseline. Depression was assessed for the period immediately preceding MI and at 12 months after MI, using a standardized questionnaire and a research interview. At follow-up, the mortality status, cause, and date of death were recorded for 587 subjects using population records. RESULTS: Multivariate predictors of cardiac death included older age (hazard ratio [HR] = 1.04, p = 0.007), previous angina (HR = 1.8, p = 0.03), previous MIs (HR = 1.6, p = 0.004), Killip class (HR = 1.8, p = 0.005), beta-blockers (HR = 0.5, p = 0.023), and angiotensin-converting enzyme inhibitors (HR = 0.6, p = 0.047) prescribed on discharge. Depression was not associated with cardiac mortality, whether detected immediately before MI (p = 0.48), 12 months after MI (p = 0.27), or at both time points (p = 0.97). CONCLUSIONS: The association between depression and post-MI mortality is complex, possibly being limited to depression immediately after MI. Defining the window when intervention for depression might benefit survival is crucial for the design of future trials.

Husain N, Chaudhry IB, Afridi MA, Tomenson B, Creed F. · University of Manchester and Lancashire Care National Health Service Trust, Manchester M13 9WL, UK. · Br J Psychiatry. · Pubmed #17197654 links to  free full text

Abstract: BACKGROUND: Depression is common in Pakistan but no research on this subject has been reported from the North West Frontier Province (NWFP), host to numerous Afghan refugees. AIMS: To measure depressive symptoms and associated features in a population-based sample. METHOD: A Pushto translation of the Self Reporting Questionnaire (SRQ) was administered to 471 adults living in a village in one of the federally administered tribal areas. Respondents were also assessed with a life events checklist for social problems, a social support questionnaire and the Brief Disability Questionnaire. RESULTS: Sixty per cent (95/158) of women and 45% (140/313) of men scored 9 or more on the SRQ. High SRQ score was associated with few years of education, higher social problem score, less social support and greater disability. High social problem score was the strongest correlate. CONCLUSIONS: This population reports more depressive symptoms than other communities in Pakistan and this probably reflects the very high degree of social stress experienced in the NWFP, which has been affected by years of turmoilin neighbouring Afghanistan.

Creed F. · Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK. · World Psychiatry. · Pubmed #17139341 links to  free full text

Abstract: This paper examines the tendency for general psychiatry to ignore somatization and hypochondriasis. These disorders are rarely included in national surveys of mental health and are not usually regarded as a concern of general psychiatrists; yet primary care doctors and other physicians often feel let down by psychiatry's failure to offer help in this area of medical practice. Many psychiatrists are unaware of the suffering, impaired function and high costs that can result from these disorders, because these occur mainly within primary care and secondary medical services. Difficulties in diagnosis and a tendency to regard them as purely secondary phenomena of depression, anxiety and related disorders mean that general psychiatry may continue to ignore somatization and hypochondriasis. If general psychiatry embraced these disorders more fully, however, it might lead to better prevention and treatment of depression as well as helping to prevent the severe disability that may arise in association with these disorders.