Trends in suicidal ideation in England: the national psychiatric morbidity surveys of 2000 and 2007.

BACKGROUND: Recent falls in suicide rates should be accompanied by a decline in the prevalence of suicidal ideation. METHOD: We used a pseudo-cohort analytic strategy to examine trends in suicidal ideation measured identically in 2000 and 2007, in nationally representative English probability samples of adults aged ≥ 16 years. Suicidal ideation included tiredness of life, death wishes and thoughts of suicide. Logistic regression models were fitted to estimate trends in age-specific prevalence of suicidal ideation in the past year and past week between 2000 and 2007. RESULTS: There were 6799 participants aged 16-71 years in 2000, and 6815 participants aged 16-78 years in 2007. There was little evidence of trends in prevalence of suicidal ideation, with the exception of women aged 44-50 years in 2007, whose prevalence was unusually high. Prevalence of suicidal ideation in the past year followed a W-shaped profile with age, with peaks at the transition to adulthood, in the forties, and in the oldest participants. CONCLUSIONS: Despite falling suicide rates, suicidal ideation did not decline overall between 2000 and 2007. This may indicate the success of the National Suicide Prevention Strategy. Women aged 44-50 years in 2007 were, however, particularly prone to suicidal ideation. As they also have the highest age-adjusted prevalence of common mental disorders and the highest female suicide rate, there are clear implications for treatment access, availability and delivery in primary care.

The population impact of common mental disorders and long-term physical conditions on disability and hospital admission.

BACKGROUND: Long-term physical conditions (LTCs) consume the largest share of healthcare budgets. Although common mental disorders (CMDs) and LTCs often co-occur, the potential impact of improved mental health treatment on severe disability and hospital admissions for physical health problems remains unknown. Method A cross-sectional study of 7403 adults aged 16-95 years living in private households in England was performed. LTCs were ascertained by prompted self-report. CMDs were ascertained by structured clinical interview. Disability was assessed using questions about problems with activities of daily living. Population impact and potential preventive gain were estimated using population-attributable fraction (PAF), and conservative estimates were obtained using 'treated non-cases' as the reference group. RESULTS: Of the respondents, 20.7% reported at least one LTC. The prevalence of CMDs increased with the number of LTCs, but over two-thirds (71.2%) of CMD cases in people with LTCs were untreated. Statistically significant PAFs were found for CMDs and recent hospital admission [13.5%, 95% confidence intervals (CI) 6.6-20.0] and severe disability (31.3%, 95% CI 27.1-35.2) after adjusting for LTCs and other confounders. Only the latter remained significant when using the most conservative estimate of PAF (21.8%, 95% CI 14.0-28.9), and this was reduced only slightly when considering only participants with LTCs (18.5%, 95% CI 7.9-27.9). CONCLUSIONS: Better treatments for CMDs in people with LTCs could achieve almost the same population health gain in terms of reducing severe disability as those targeted at the entire population. Interventions to reduce the prevalence of CMDs among people with LTCs should be part of routine medical care.

Age and birth cohort differences in depression in repeated cross-sectional surveys in England: the National Psychiatric Morbidity Surveys, 1993 to 2007.

BACKGROUND: The National Psychiatric Morbidity Survey (NPMS) programme was partly designed to monitor trends in mental disorders, including depression, with comparable data spanning 1993 to 2007. Findings already published from this programme suggest that concerns about increasing prevalence of common mental disorders (CMDs) may be unfounded. This article focuses on depression and tests the hypothesis that successive birth cohorts experience the same prevalence of depression as they age. METHOD: We carried out a pseudo-cohort analysis of a sequence of three cross-sectional surveys of the English household population using identical diagnostic instruments. The main outcome was ICD-10 depressive episode or disorder. Secondary outcomes were the depression subscales of the Clinical Interview Schedule - Revised (CIS-R). RESULTS: There were 8670, 6977 and 6815 participants in 1993, 2000 and 2007 respectively. In men, the prevalence of depression increased between cohorts born in 1943-1949 and 1950-1956 [odds ratio (OR) 2.5, 95% confidence interval (CI) 1.4-4.2], then remained relatively stable across subsequent cohorts. In women, there was limited evidence of change in prevalence of depression. Women born in 1957-1963, surveyed aged 44-50 years in 2007, had exceptionally high prevalence. It is not clear whether this represents a trend or a quirk of sampling. CONCLUSIONS: There is no evidence of an increase in the prevalence of depression in male cohorts born since 1950. In women, there is limited evidence of increased prevalence. Demand for mental health services may stabilize or even fall for men.

Validity and reliability of a questionnaire to measure the impact of lower urinary tract symptoms on quality of life: the Leicester Impact Scale.

AIMS: To develop a condition specific quality of life measure for males and females with urinary storage symptoms of urgency, frequency, nocturia and incontinence. MATERIALS AND METHODS: A sample of community dwelling males and females aged 40 years or more who were taking part in an epidemiological study provided data for development and validation of the scale. Questions were developed from literature review and discussions with clinicians and patients. Inclusion of items was dependent on levels of missing data and principal components analysis. Validity was assessed by comparison with the Hospital Anxiety and Depression Scale, the Bradburn Negative Affect Scale and single questions concerning the problematic nature of symptoms. Construct validity was assessed by comparing cases and non-cases, and patients with different symptom patterns. Test-retest and inter-rater reliability statistics were calculated for individual items. Responsiveness to change was measured in subjects taking part in a randomised controlled trial of a nursing intervention. RESULTS: The scale showed high levels of internal consistency and measures of construct validity were as hypothesised. Test-retest and inter-rater reliability was moderate to excellent. The distribution of scores was skewed with low levels of impact but the questionnaire was responsive to conservative treatments in patients receiving a nursing intervention. CONCLUSIONS: The questionnaire proved to be a valid and reliable interviewer administered instrument for measuring impact of urinary symptoms.

Does Helicobacter pylori eradication reduce the long-term requirements for acid suppressants in patients with a history of peptic ulcer disease in general practice? Results from a four-year longitudinal study.

BACKGROUND: Acid suppressants, especially proton-pump inhibitors, are major contributors to the drug costs in primary care. Although Helicobacter pylori eradication reduces peptic ulcer relapse, some studies suggest that patients may remain symptomatic and continue to require acid-suppressant therapy. METHODS: We identified all patients taking long-term acid suppressants in a large primary health care clinic to determine the proportion who had peptic ulcer disease and to examine the effect of H. pylori eradication on their long-term requirement for acid suppressants. RESULTS: 126/394 patients taking long-term acid suppressants had a definite diagnosis of peptic ulcer. Of these 126 patients, 60 were considered appropriate for the study. At Stage 1 (May 1994), all patients were tested for H. pylori infection and positive patients (60/66) received eradication therapy with omeprazole 20 mg bd and amoxycillin (1 gm bd) or clarithromycin (500 mg tds) for 2 weeks. Six weeks later (Stage 2) patients, requirements for continued acid-suppressant treatment were determined and previously positive subjects retested using the 13C urea breath rest. This showed that 70% (42/60) had been successfully eradicated. One year later (Stage 3), 44% (18/41) of the patients successfully eradicated still required acid suppressants. The majority of these patients (11/18; 61%) continued to remain on acid-suppressant treatment at 4 years (Stage 4) (95% CI 38%, 83%). CONCLUSIONS: We found that about 1/3 of all patients on long-term acid-suppressant therapy in General Practice had a confirmed diagnosis of peptic ulcer disease. Despite successful eradication treatment for H. pylori at the start of the study, about half of these patients still used acid suppressants after 1 year and 1/4 patients (11/41) in this group continued to remain on acid-suppressant treatment for another 3 years.

Patterns of onset of disability in activities of daily living with age.

OBJECTIVES: To investigate the order in which activities of daily living (ADLs) are lost and whether the order is invariant between the sexes and age groups. DESIGN: Longitudinal data from the first five rounds of a routine health assessment by a nurse in participant's own home. SETTING: One large UK general practice with a list size of 32,500. PARTICIPANTS: Patients registered with the practice and age 75 and older. MEASUREMENTS: Disability was measured by self-report of performance in seven ADLs: mobility around the home, getting to and from the toilet, transfer from chair, transfer from bed, feeding, dressing, and bathing. Disability in each ADL was classified as being independent but having difficulty, using aids or help, or being unable to perform. Age at onset of disability in each ADL was calculated and analyzed using Kaplan-Meier plots and Cox regression models. Subjects who had died or remained independent by their last assessment were not included. RESULTS: The mean times between health assessments was approximately 20 months but with substantial variability both within and between individuals. A total of 1,344 people reported no difficulty in any ADL initially and 47.6% (640) subsequently reported disability. The order of activity restriction was bathing, mobility, toileting, dressing, transfers from bed and chair, and feeding. Women had a higher risk of disability in bathing (relative risk (RR) = 1.6, 95% confidence interval (CI) 1.3-1.9, P < .001) and toileting (RR = 1.7, 95% CI 1.2-2.5, P = .003), while for all ADLs there was a significant increase in the risk of disability with increasing age. The order of onset of disability for ADLs was invariant across sex and age groups. CONCLUSION: Lower-extremity strength (bathing, mobility, toileting) appears to be lost in older people before upper-extremity strength (dressing, feeding). Further work is now needed to develop prevention strategies to delay the onset of these disabilities.

Retrospective case series analysis of patients with inflammatory bowel disease on azathioprine. A district general hospital experience.

OBJECTIVES: The aim of this study was to look at our practice of using azathioprine and to compare our results with those in published trials both from the point of view of response and also the side-effect profile. DESIGN: A retrospective case series analysis was done on patients with inflammatory bowel disease (IBD) who were on azathioprine at Leicester General Hospital. METHODS: 111 patients (47 males, 64 females, mean age 35.3 years) were included from gastroenterology outpatients records between November 1997 and August 1998. Clinical and demographic details were collected. Response in Crohn's disease was determined using the Harvey-Bradshaw index. In case of ulcerative colitis the following parameters were used: stool frequency; rectal bleeding, weight gain, and general well-being. Logistic regression was performed to look at the influence of age, sex and diagnosis in relation to the response/relapse rate. RESULTS: The average duration of treatment with azathioprine was 28.6 months. The starting dose of 1.53 mg/kg was similar to the maintenance dose (1.51 mg/kg). 58 patients had Crohn's disease and 53 patients were diagnosed with ulcerative colitis. 85 patients were steroid-dependent, 9 steroid-resistant, and 17 patients were started on azathioprine on the basis of extensive disease either seen at the time of endoscopy or radiologically. Improvement in clinical features at 3, 6 and 12 months was 69.5, 77 and 84.1%, respectively. 74% patients showed an improvement in relapse rates during the first year on azathioprine compared to 1 year prior to treatment. 68% patients who had shown improvement at 1 year were no longer taking steroids (p = 0.002). Logistic regression did not show any statistically significant influence of age, sex or diagnosis on response. 4.5% patients had leukopenia requiring dose reductions. Severe leukopenia (leukocyte count <2.5 x 10(9)/l) occurred in 3.6% patients. CONCLUSIONS: Response rates in our IBD patients on azathioprine are comparable with those of the published data despite using a relatively smaller dose.

Social support, personality and depressive symptoms over 7 years: the Health and Lifestyle cohort.

BACKGROUND: We tested the hypothesis that a negative relationship between social support and depression is stronger in extroverts. METHODS: Data on social support and personality were obtained from an existing cohort of 9003 adults (the Health and Lifestyle Survey, UK), of whom 3594 respondents who were followed-up 7 years later contributed to the present analysis. Six depression items from the 30-item General Health Questionnaire, summed, were divided into five levels and a proportional odds analysis was performed. Information on social support was also obtained at follow-up. RESULTS: For females, there was a highly significant interaction between Time of Residence in Area and extroversion (P<0.001). For males, interactions involving Adults in Household and Living as Married reached borderline significance (0.050.10). CONCLUSION: It is unlikely that a lack of social support is more or less harmful for introverts, although the hypothesis should be re-tested in a study with a much shorter period of follow-up and higher response rate.

Randomised controlled trial of effectiveness of Leicester hospital at home scheme compared with hospital care.

OBJECTIVE: To compare effectiveness of patient care in hospital at home scheme with hospital care. DESIGN: Pragmatic randomised controlled trial. SETTING: Leicester hospital at home scheme and the city's three acute hospitals. PARTICIPANTS: 199 consecutive patients referred to hospital at home by their general practitioner and assessed as being suitable for admission. Six of 102 patients randomised to hospital at home refused admission, as did 23 of 97 allocated to hospital. INTERVENTION: Hospital at home or hospital inpatient care. MAIN OUTCOME MEASURES: Mortality and change in health status (Barthel index, sickness impact profile 68, EuroQol, Philadelphia geriatric morale scale) assessed at 2 weeks and 3 months after randomisation. The main process measures were service inputs, discharge destination, readmission rates, length of initial stay, and total days of care. RESULTS: Hospital at home group and hospital group showed no significant differences in health status (median scores on sickness impact profile 68 were 29 and 30 respectively at 2 weeks, and 24 and 26 at 3 months) or in dependency (Barthel scores 15 and 14 at 2 weeks and 16 for both groups at 3 months). At 3 months' follow up, 26 (25%) of hospital at home group had died compared with 30 (31%) of hospital group (relative risk 0. 82 (95% confidence interval 0.52 to 1.28)). Hospital at home group required fewer days of treatment than hospital group, both in terms of initial stay (median 8 days v 14.5 days, P=0.026) and total days of care at 3 months (median 9 days v 16 days, P=0.031). CONCLUSIONS: Hospital at home scheme delivered care as effectively as hospital, with no clinically important differences in health status. Hospital at home resulted in significantly shorter lengths of stay, which did not lead to a higher rate of subsequent admission.

Economic evaluation of hospital at home versus hospital care: cost minimisation analysis of data from randomised controlled trial.

OBJECTIVES: To compare the costs of admission to a hospital at home scheme with those of acute hospital admission. DESIGN: Cost minimisation analysis within a pragmatic randomised controlled trial. SETTING: Hospital at home scheme in Leicester and the city's three acute hospitals. PARTICIPANTS: 199 consecutive patients assessed as being suitable for admission to hospital at home for acute care during the 18 month trial period (median age 84 years). INTERVENTION: Hospital at home or hospital inpatient care. MAIN OUTCOME MEASURES: Costs to NHS, social services, patients, and families during the initial episode of treatment and the three months after admission. RESULTS: Mean (median) costs per episode (including any transfer from hospital at home to hospital) were similar when analysed by intention to treat-hospital at home 2569 pounds sterling (1655 pounds sterling), hospital ward 2881 pounds sterling (2031 pounds sterling), bootstrap mean difference -305 (95% confidence interval -1112 to 448). When analysis was restricted to those who accepted their allocated place of care, hospital at home was significantly cheaper-hospital at home 2557 pounds sterling(1710 pounds sterling), hospital ward 3660 pounds sterling (2903 pounds sterling), bootstrap mean difference -1071 (-1843 to -246). At three months the cost differences were sustained. Costs with all cases included were hospital at home 3671 pounds sterling (2491 pounds sterling), hospital ward 3877 pounds sterling (3405 pounds sterling), bootstrap mean difference -210 (-1025 to 635). When only those accepting allocated care were included the costs were hospital at home 3698 pounds sterling (2493 pounds sterling), hospital ward 4761 pounds sterling (3940 pounds sterling), bootstrap mean difference -1063 (-2044 to -163); P=0.009. About 25% of the costs for episodes of hospital at home were incurred through transfer to hospital. Costs per day of care were higher in the hospital at home arm (mean 207 pounds sterling v 134 pounds sterling in the hospital arm, excluding refusers, P<0.001). CONCLUSIONS: Hospital at home can deliver care at similar or lower cost than an equivalent admission to an acute hospital.

Do diabetes clinic attendees stay out of hospital? A matched case-control study.

AIMS: To examine whether routine care for diabetes mellitus influences the risk of hospital admission. METHODS: All people with diabetes in five randomly selected general practices in the city of Leicester were identified from medical records and prescribing information. Cases with a hospital admission between 1992 and 1995 but no admission in the preceding 2 years were compared with age-matched controls in a nested study. RESULTS: The variables significantly associated with an increased risk of admission were duration of diabetes in years (OR 1.07, 95% confidence interval (CI) 1.03-1.11) and number of non-diabetic drugs prescribed (OR 1.51, 95% CI 1.27-1.79). Having attended a hospital clinic in the previous 2 years was associated with reduced risk of admission (OR 0.30, 95% CI 0.14-0.65), whilst having been seen for a diabetes review in general practice was not (OR 0.91, 95% CI 0.41-1.99). Similar results were found for both diabetes-related and unrelated admissions. CONCLUSIONS: Although general practice-based review was not associated with a change in the risk of admission, attendance at a hospital clinic was associated with a decreased risk of admission. These results may be explained by the characteristics of those who attend hospital clinics, as well as by the possible effectiveness of access to specialist services in reducing admissions.

Physical function and perceived health: cohort differences and interrelationships in older people.

Differences between seven-year birth cohorts in physical functioning (as measured by independence in activities of daily living) are compared with corresponding inter-cohort differences in perceived health, in people aged 75 years and over. Age-period-cohort models were fitted to two linked cross-sectional surveys undertaken in 1981 (N = 1,203) and 1988 (N = 1,579). The proportion of older people who were dependent in ADLs was lower in succeeding cohorts but, by contrast, the proportion with less than good self-perceived health was higher. These inter-cohort differences in perceived health were particularly marked for the comparison between 1981 and 1988 of men aged 75-81 years in the dependent subpopulation. Furthermore, self-perceived health remained as strong a predictor of mortality in 1988 as in 1981. Self-perceived health may be indexing a higher prevalence of mild chronic conditions in newer cohorts of older people, with implications for primary health care providers.

Factors associated with decline in function, institutionalization and mortality of elderly people.

Movements between dependency states, institutionalization and death are investigated in a general practice cohort of people aged 75 years and over with follow-up at 5 and 7 years from initial interview. Initially, 1203 people were interviewed, 1124 living in the community and 79 in institutions. By 5 years, 42% (510) had died and by 7 years 58% (700) had died. Dependency was defined as requiring help or aids with at least one activity of daily living (ADL). Of those initially independent, 34% were still independent 7 years later. Women at each age were more likely to become dependent whilst men had higher mortality. Those rating their health as fair or poor were more likely to lose independence at both 5 and 7 years than those rating their health as good. These differences remained, even after adjustment for age, sex and baseline ADL status. With the assumption that once institutionalized a person did not return to live in the community (an assumption upheld by the present data), 7% (79/1124) of those initially resident in the community were institutionalized during the 7 years; the rates for men (6%) being slightly lower than for women (7.5%).