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Objective: To test the feasibility of a telephone delivered intervention, informed by cognitive behavioural principles, for post-stroke fatigue, and estimated its effect on fatigue and other outcomes. Design: Randomised controlled parallel group trial. Setting: Three Scottish stroke services. Subjects: Stroke survivors with fatigue three months to two years post-stroke onset. Interventions: Seven telephone calls (fortnightly then a 'booster session' at 16 weeks) of a manualised intervention, plus information about fatigue, versus information only. Main measures: Feasibility of trial methods, and collected outcome measures (fatigue, mood, anxiety, social participation, quality of life, return to work) just before randomisation, at the end of treatment (four months after randomisation) and at six months after randomisation. Results: Between October 2018 and January 2020, we invited 886 stroke survivors to participate in postal screening: 188/886 (21%) returned questionnaires and consented, of whom 76/188 (40%) were eligible and returned baseline forms; 64/76 (84%) returned six month follow-up questionnaires. Of the 39 allocated the intervention, 23 (59%) attended at least four sessions. At six months, there were no significant differences between the groups (adjusted mean differences in Fatigue Assessment Scale −0.619 (95% CI −4.9631, 3.694; p = 0.768), the Generalised Anxiety Disorder 7 −0.178 (95% CI −3.823, 3.467, p = 0.92), and the Patient Health Questionnaire −0.247 (95% CI −2.935, 2.442, p = 0.851). There were no between-group differences in quality of life, social participation or return to work. Conclusion: Patients can be recruited to a trial of this design. These data will inform the design of further trials in post-stroke fatigue. [ABSTRACT FROM AUTHOR]

There are many challenges in the development, implementation and evaluation of healthcare policy. One challenge is understanding how different stakeholders view a particular policy and what impact these views may have during implementation. Q-methodology is one approach that can be used to help policy makers and researchers actively engage with those who are important in policy implementation, and anticipate their responses. Q-methodology combines qualitative and quantitative research methods to systematically explore and describe the range of viewpoints about a topic. Participants are required to rank a set of predefined statements relating to the topic, according to their own viewpoint. Factor analytic techniques then identify people who are like-minded in the way they view the topic and enable areas of consensus and divergence in viewpoint to be clearly defined. This mapping of viewpoints allows those working in policy implementation to anticipate likely barriers and levers in implementing new policies. [ABSTRACT FROM AUTHOR]

Background: Bipolar disorder is not uncommon, is associated with high disability and risk of suicide, often presents with depression, and can go unrecognised.Aim: To determine the prevalence of unrecognised bipolar disorder among those prescribed antidepressants for depressive or anxiety disorder in UK primary care; whether those with unrecognised bipolar disorder have more severe depression than those who do not; and the accuracy of a screening questionnaire for bipolar disorder, the Mood Disorder Questionnaire (MDQ), in this setting.Design and Setting: Observational primary care study of patients on the lists of 21 general practices in West Yorkshire aged 16-40 years and prescribed antidepressant medication.Method: Participants were recruited using primary care databases, interviewed using a diagnostic interview, and completed the screening questionnaire and rating scales of symptoms and quality of life.Results: The prevalence of unrecognised bipolar disorder was 7.3%. Adjusting for differences between the sample and a national database gives a prevalence of 10.0%. Those with unrecognised bipolar disorder were younger and had greater lifetime depression. The predictive value of the MDQ was poor.Conclusion: Among people aged 16-40 years prescribed antidepressants in primary care for depression or anxiety, there is a substantial proportion with unrecognised bipolar disorder. When seeing patients with depression or anxiety disorder, particularly when they are young or not doing well, clinicians should review the life history for evidence of unrecognised bipolar disorder. Some clinicians might find the MDQ to be a useful supplement to non-standardised questioning. [ABSTRACT FROM AUTHOR]

Background: The place of opioids in the management of chronic, non-cancer pain is limited. Even so their use is escalating, leading to concerns that patients are prescribed strong opioids inappropriately and alternatives to medication are under-used. We aimed to understand the processes which bring about and perpetuate long-term prescribing of opioids for chronic, non-cancer pain. Methods: We held semi-structured interviews with patients and focus groups with general practitioners (GPs). Participants included 23 patients currently prescribed long-term opioids and 15 GPs from Leeds and Bradford, United Kingdom (UK). We used a grounded approach to the analysis of transcripts. Results: Patients are driven by the needs for pain relief, explanation, and improvement or maintenance of quality of life. GPs' responses are shaped by how UK general practice is organised, available therapeutic choices and their expertise in managing chronic pain, especially when facing diagnostic uncertainty or when their own approach is at odds with the patient's wishes. Four features of the resulting transaction between patients and doctors influence prescribing: lack of clarity of strategy, including the risk of any plans being subverted by urgent demands; lack of certainty about locus of control in decision-making, especially in relation to prescribing; continuity in the doctor-patient relationship; and mutuality and trust. Conclusions: Problematic prescribing occurs when patients experience repeated consultations that do not meet their needs and GPs feel unable to negotiate alternative approaches to treatment. Therapeutic short-termism is perpetuated by inconsistent clinical encounters and the absence of mutually-agreed formulations of underlying problems and plans of action. Apart from commissioning improved access to appropriate specialist services, general practices should also consider how they manage problematic opioid prescribing and be prepared to set boundaries with patients. [ABSTRACT FROM AUTHOR]

Background Around 150,000 people each year attend hospitals in England due to self-harm, many of them more than once. Over 5,000 people die by suicide each year in the UK, a quarter of them having attended hospital in the previous year because of self-harm. Self-harm is a major identifiable risk factor for suicide. People receive variable care at hospital; many are not assessed for their psychological needs and little psychological therapy is offered. Despite its frequent occurrence, we have no clear research evidence about how to reduce the repetition of self-harm. Some people who have self-harmed show less active ways of solving problems, and brief problem-solving therapies are considered the most promising psychological treatments. Methods/Design This is a pragmatic, individually randomised, controlled, feasibility study comparing interpersonal problem-solving therapy plus treatment-as-usual with treatment-as-usual alone, for adults attending a general hospital following self-harm. A total of 60 participants will be randomised equally between the treatment arms, which will be balanced with respect to the type of most recent self-harm event, number of previous self-harm events, gender and age. Feasibility objectives are as follows: a) To establish and field test procedures for implementing the problem-solving intervention; b) To determine the feasibility and best method of participant recruitment and follow up; c) To assess therapeutic delivery; d) To assess the feasibility of obtaining the definitive trial's primary and secondary outcomes; e) To assess the perceived burden and acceptability of obtaining the trial's self-reported outcome data; f) To inform the sample size calculation for the definitive trial. Discussion The results of this feasibility study will be used to determine the appropriateness of proceeding to a definitive trial and will allow us to design an achievable trial of interpersonal problem-solving therapy for adults who self-harm. Trial registration Current Controlled Trials (ISRCTN54036115) [ABSTRACT FROM AUTHOR]

Background: Detection of depression can be difficult in primary care, particularly when associated with chronic illness. Patient beliefs may affect detection and subsequent engagement with management. We explored patient beliefs about the nature of depression associated with physical illness. Methods: A qualitative interview study of patients registered with general practices in Leeds, UK. We invited patients with coronary heart disease or diabetes from primary care to participate in semi-structured interviews exploring their beliefs and experiences. We analysed transcripts using a thematic approach, extended to consider narratives as important contextual elements. Results: We interviewed 26 patients, including 17 with personal experience of depression. We developed six themes: recognising a problem, complex causality, the role of the primary care, responsibility, resilience, and the role of their life story. Participants did not consistently talk about depression as an illness-like disorder. They described a change in their sense of self against the background of their life stories. Participants were unsure about seeking help from general practitioners (GPs) and felt a personal responsibility to overcome depression themselves. Chronic illness, as opposed to other life pressures, was seen as a justifiable cause of depression. Conclusions: People with chronic illness do not necessarily regard depression as an easily defined illness, especially outside of the context of their life stories. Efforts to engage patients with chronic illness in the detection and management of depression may need further tailoring to accommodate beliefs about how people view themselves, responsibility and negative views of treatment. [ABSTRACT FROM AUTHOR]

Self-harm remains a serious public health concern, not least because of its strong link with suicide. Twenty-five years ago we lamented the deficits in UK services, research and policy. Since then, there has not been nearly enough effective action in any of these three domains. It is time for action. [ABSTRACT FROM AUTHOR]

Purpose: Symptoms of distress during pregnancy are common and often go unnoticed. There is a well-established relation between life events and depression. The current study aims to explore the association between life events and difficulties, and symptoms of emotional and somatic distress during pregnancy in White and South Asian women in the UK. Methods: 100 pregnant women attending routine antenatal appointments were interviewed using the Life Events and Difficulties Schedule (LEDS). We investigated the frequency and type of events experienced in the year prior to conception and during pregnancy, as predictors for somatic and emotional distress, measured using the GHQ-28. Results: Non-severe stressors accounted for over 90 % of those reported, half of which (43-53 %) were health and reproduction-related. Somatic symptoms were associated with the number of non-severe events, and number of children and emotional symptoms were associated with non-marked difficulties. There was little evidence of an association between severe events and distress. Ethnicity had little effect on any associations although South Asian women were at slightly higher odds of experiencing emotional symptoms, which appear to be buffered by social support. Conclusions: In routine antenatal care it is important to assess both emotional and somatic symptoms. Health professionals need to be sensitive to the health, social, cultural and environmental circumstances of women during pregnancy and ensure appropriate support is in place, particularly for multi-parous women. Regression models explained a small but significant amount of the variance in distress symptoms. Further work is necessary to explore other contributory factors and also the mechanisms through which stressors have their effect. [ABSTRACT FROM AUTHOR]

Background: The UK Department of Health introduced the National Health Service (NHS) Health Check Programme in April 2009 in an attempt to improve primary and secondary prevention of cardiovascular disease in the UK population and to reduce health inequalities. Healthcare professionals' attitudes towards giving lifestyle advice will influence how they interact with patients during consultations. We therefore sought to identify the attitudes of primary care healthcare professionals towards the delivery of lifestyle advice in the context of the NHS Health Check Programme. Methods: Fifty-two primary care healthcare professionals undertook a Q sort with 36 statements that represented a range of viewpoints about the importance of lifestyle change, medication, giving lifestyle advice in the primary care setting, and the individual, social and material factors that might impact on lifestyle related behaviour change. Sorts were analysed by-person using principal components analysis and varimax rotation. Results: Five statistically independent factors (accounts) reflected distinct views on the topic. Account 1 was supportive of initiatives like the NHS Health Check, and emphasised the importance of professionals working collaboratively with patients to facilitate lifestyle change. Account 2 expressed views on the potential overuse of statin medication and placed responsibility for lifestyle change with the patient. Account 3 viewed the healthcare professional role to be one of educator, emphasising the provision of information. Account 4 perceived lifestyle change to be difficult for patients and emphasised the need for healthcare professionals to be role models. Account 5 was inconsistent about the value of lifestyle change, or the role of healthcare professionals in promoting it, a finding that may be due to ambivalence about the health check or to lack of engagement with the Q sort task. We found no strong associations between any of the factors and, gender, role, age or ethnicity. Conclusions: Our findings suggest that healthcare professionals hold viewpoints that may influence how they interact with patients during health checks. When implementing programmes like the NHS Health Check, it would be useful to take healthcare professionals' views into account. Attitudes and beliefs could be explored during training sessions, for example. [ABSTRACT FROM AUTHOR]

Background: delirium is likely to be particularly common in care homes, given the clustering of known risk factors in these settings. Preventing delirium should result in significant benefits, including better quality of care and improved outcomes for residents.Objective: to test the feasibility of ‘Stop Delirium!’, an intervention to prevent delirium in care homes for older people, and to optimise parameters to inform the design of a future trial evaluation.Method: we delivered Stop Delirium! to six care homes over 10 months, in a mixed methods before and after study.Results: Stop Delirium! was successfully implemented in the study homes. We found evidence supporting positive changes in staff attitudes and practice after the intervention. Although qualitative data suggested it was too early to expect changes in resident outcomes, we also found preliminary evidence suggesting potential improvements in a range of outcomes, including a reduction in the number of falls and prescribed medications.Conclusion: a complex intervention for delirium prevention in care homes is feasible and has the potential to improve staff practice and outcomes for residents. This work provides the basis for the next phase of the evaluation to establish its effectiveness and cost-effectiveness. [ABSTRACT FROM AUTHOR]

Objectives. Students are reported to have more symptoms of mental health problems than other young people. Disordered eating and self-harm are common but evidence on comorbidity, especially in community samples, is limited. This study aimed to examine their co-occurrence, onset timing, and the help-seeking of UK university students. Methods. Two surveys were administered to undergraduate students at a single UK university. One was administered electronically (UNIversity Quality of Life and Learning survey) and completed by 5,045 students. The second, questionnaire-based, was completed by 805 students (Student Well-Being study). Both surveys included questions about disordered eating, self-harm thoughts and behaviours, and psychological well-being. Results. A strong relationship was found between reports of disordered eating and self-harm, with co-occurrence observed in 4.5 and 4.9% of students in the two surveys. Disordered eating and self-harm often pre-dated university entrance and there was no evidence of increasing levels of pathology by university year group. A younger age of onset of disordered eating behaviours was reported in those with co-occurring disordered eating and self-harm. Help-seeking rates were low. Conclusions. The risk of co-occurrence and earlier onset-timing of disordered eating are consistent with a limited clinical literature. Information on co-occurrence of mental health problems, their history, and low rates of help-seeking identifies some of the challenge to universities and practitioners. These results suggest the value of access to screening resources and the involvement of service-users in shaping the support provided. [ABSTRACT FROM AUTHOR]

The article highlights a study regarding frequency of antidepressant prescribing in a typical Primary Care Trust in Great Britain. Details of the methodology used in the study are offered. The rates of antidepressant prescribing in 2002 and 2004 are summarized. The mean duration of antidepressant prescribing is mentioned.

Background: The aim of the study was to compare the hospital management and direct costs of self-poisoning in six United Kingdom hospitals and to investigate whether hospital management influences outcome. Method: This was a prospective descriptive study carried out at three teaching hospitals and three district general hospitals in North West England on adults (aged 16 or over) presenting to the study centres with deliberate self-poisoning over a 5-month period. Data were based on demographic and clinical characteristics, management of the current episode, direct costs and repetition of self-poisoning within 12 weeks of index episode. Results: There were 1778 episodes of selfpoisoning during the study period. There were marked differences in management between centres. There was a fivefold difference in the rate of admission to a medical bed (16.5%–81.3%), and a twofold difference in the rate of psychosocial assessment (28.5%–57.7%). These differences remained after adjustment for demographic and clinical factors. Hospital costs per episode varied from £228 to £422 and repetition rate ranged from 10% to 16%. Psychosocial assessment was associated with a twofold reduction in the risk of repetition. Conclusions: The marked variability of services for self-poisoning continue. It seems likely that this is having a detrimental effect on patient outcomes. Large scale intervention studies are required to inform both clinical practice and service provision. [ABSTRACT FROM AUTHOR]

This study aimed to determine whether the style of service provision and the substance ingested in overdose influenced the hospital management and direct costs of self-poisoning at six UK hospitals. Of 1778 self-poisoning episodes presenting over a 5-month period, fewer than half resulted in a specialist assessment. Episodes were more likely to lead to admission or psychosocial assessment if the hospital had a self-harm team, or if the act involved subtances of high lethality. The mean costs of overdose were greater in hospitals with a self-harm team (#378 (SD:1242) v. #289 (SD:751), and greater for drugs of higher lethality such as tricyclics (#634 (SD:911) and poly drug overdoses (#449 (SD:1955)), than for all drug classes (#333 (SD:1027). This study confirms the generally poor level of UK self-harm service provision and suggests the style of services and the drugs ingested both have a significant impact on the hospital management and costs of self-poisoning. [ABSTRACT FROM AUTHOR]

The article comments on the proposal to eliminate variation in psychiatric practice in Great Britain. Variation in practice refers to variation in the rates at which a specific intervention is used and variation in how an individual condition or clinical problem is managed. Very little is little known about the extent to which psychiatric practice is subject to variation because the topic is under-researched.

The `new deal' on junior doctors' hours of work has led to the widespread introduction of working patterns such as full shifts and partial shifts in the United Kingdom. The impact of these changes on the training of medical staff is unclear. The subjects of the current study were 36 pre-registration medical house officers working shift rotas and on-call rotas at a teaching hospital in the north of England. They were studied over a 12-month period using a self-report questionnaire seeking their views on the quality of their training experience and their satisfaction with the in-service training they received. Nursing staff, consultant and medical student opinion was also sought. Partial-shift and full-shift systems led to reduced hours of work when compared to on-call rotas (mean hours: partial shift 65·0; full shift 59·8; on-call 72·7), but they were associated with significantly lower training experience and training satisfaction scores for the house officers than were on-call systems (P < 0·01). Shift systems were unpopular among consultants and medical students but not nursing staff. Despite reducing excessive hours of work, shifts may be detrimental to the training of medical house officers. The further imposition of shift working should be suspended until such time as the impact of new working patterns on the training of medical staff has been determined. [ABSTRACT FROM AUTHOR]

Comments on various topics related to medicine in Great Britain. Algorithm for managing injury from smoke inhalation; Aspects of surgical footwear for orthopedic patients; Details on fetal injection after maternal reinfection with rubella.

Presents correspondence related to medicine in Great Britain. Management of mild hypertension; Recommendation for target systolic blood pressure in elderly patients; Screening for trisomy 18.

Background: Non-fatal self-harm is one of the commonest reasons for adults' emergency hospital attendance. Although strongly associated with fatal and non-fatal repetition, there is weak evidence about effective interventions—and no clear NICE guidance or clinical consensus concerning aftercare. We examined the practicability of a definitive trial to evaluate problem-solving therapy (PST) to reduce repetition of self-harm; MIDSHIPS is a single-centre, parallel-group, individually randomised controlled feasibility trial comparing treatment-as-usual (TAU) alone to TAU plus up to six sessions of brief problem-solving therapy (PST) with adults who had recently attended hospital because of self-harm. Objectives were to adapt the intervention for a UK setting, train therapists, recruit and randomise patients, deliver PST under supervision, and establish comparative outcomes, assessed blindly. Methods: We adapted the problem-solving intervention from an earlier trial and trained a mental-health nurse to deliver it. Adult patients attending the general hospital for self-harm were recruited while undergoing psychosocial assessment by the mental health team, and 62 were randomly allocated (32 TAU, 30 PST). The primary outcome assessed repeat hospital attendance due to further self-harm 6 months post-randomisation. Secondary outcomes included participant-reported outcomes and service use at 3 and 6 months post-randomisation. Results: The recruitment period had to be extended and 710 patients screened in order to establish a trial sample of the planned size (N = 62). A quarter of participants allocated to PST did not undertake the therapy offered; those who received PST attended a median of three sessions. Secondary outcomes were established for 49 (79%) participants at 6 months; all participants' hospital records were retrieved. Repetition of self-harm leading to hospital presentation occurred in 19 of the 62 participants (30.6%, 95% CI 19.2%, 42.1%) within 6 months of randomisation. Promising differential rates of self-harm were observed with an event rate of 23.3% (95% CI 8.2%, 38.5%) in the PST arm; and 37.5% (95% CI 20.7%, 54.3%) in TAU. Economic findings were also encouraging, with a small QALY gain (0.0203) in the PST arm together with less reported use of the NHS in the PST arm (average £2120) than with TAU-only (£2878). Conclusions: The feasibility trial achieved its objectives despite considerable difficulties with recruitment—adapting the PST, training a therapist, recruiting patients who had recently self-harmed, delivering the therapy, and establishing primary and secondary outcomes. These data provide a robust platform for a definitive multicentre randomised controlled trial of brief problem-solving therapy after hospital attendance due to self-harm. Trial registration: Identification number and URL: ISRCTN54036115 http://www.isrctn.com/search?q=midships. Registered: 13 January 2012 [ABSTRACT FROM AUTHOR]

The author reflects on the survey regarding the current use of outcomes measures in psychiatric practice in Great Britain. He discusses the methods that he and his colleagues used in conducting the national survey and the data they have gathered. He stresses that the refusal of psychiatrists to use outcome measures in their day-to-day practice could prevent them to see the importance of the method to themselves and to their patients' care.

Background: Mechanisms by which liaison mental health services (LMHS) may bring about improved patient and organisational outcomes are poorly understood. A small number of logic models have been developed, but they fail to capture the complexity of clinical practice.Method: We synthesised data from a variety of sources including a large national survey, 73 in-depth interviews with acute and liaison staff working in hospitals with different types of liaison mental health services, and relevant local, national and international literature. We generated logic models for two common performance indicators used to assess organisational outcomes for LMHS: response times in the emergency department and hospital length of stay for people with mental health problems.Results: We identified 8 areas of complexity that influence performance, and 6 trade-offs which drove the models in different directions depending upon the balance of the trade-off. The logic models we developed could only be captured by consideration of more than one pass through the system, the complexity in which they operated, and the trade-offs that occurred.Conclusions: Our findings are important for commissioners of liaison services. Reliance on simple target setting may result in services that are unbalanced and not patient-centred. Targets need to be reviewed on a regular basis, together with other data that reflect the wider impact of the service, and any external changes in the system that affect the performance of LMHS, which are beyond their control. [ABSTRACT FROM AUTHOR]

The authors reflect on the need for preventive cardiovascular care among older people, particularly in Great Britain. The authors say that although age is considered as cardiovascular disease (CVD's) non-modifiable risk factor, its effects can be reduced through delaying or preventing the onset of CVD. The authors suggest that the British National Health Service (NHS) should quickly adapt to the ageing population's needs and provide more resources to prevent and treat long-term diseases.

A letter to the editor is presented in response to the article "Screen All for Depression," by M. Sinyor et al. in a previous issue.

Assesses the services for management of self poisoning cases in four teaching hospitals in Great Britain. Average rate of self poisoning patients; Implications of the findings.

Calls for a more rigorous investigative methods in the confidential inquiry into suicides and homicides by mentally ill people in Great Britain. Analysis of the inquiry's report; Failure to achieve complete or unbiased case ascertainment; Problems in clinical practice and key recommendations; Major tasks of the relaunched inquiry.

In this article, the author focuses on a study based on the Avon Longitudinal Study of Parents and Children (ALSPAC) which found many episodes of self harm among young adults in the Great Britain. Topics discussed includes distinction between non-suicidal acts and suicidal acts, self harm act and association between self harm and acts of aggression in adolescents.

Background: There is a paucity of research on the nature of life adversity in depressed and non-depressed older adults. Early life events work used in-depth interviews; however, larger epidemiological trials investigate life adversity using brief questionnaires. This study investigates the type of life adversity experienced in later life and its association with depression and compares adversity captured using a brief (LTE-Q) and in-depth (LEDS) measure.Methods: 960 participants over 65 years were recruited in UK primary care to complete the PHQ-9 and LTE-Q. A sub-sample (n=19) completed the LEDS and a question exploring the subjective experience of the LTE-Q and LEDS.Results: Important life adversity was reported on the LTE-Q in 48% of the sample. In the LTE-Q sample the prevalence of depression (PHQ-9≥10) was 12%. Exposure to recent adversity was associated with doubling of the odds of depression. The LTE-Q only captured a proportion of adversity measured by the LEDS (42% vs 84%). Both measures showed health, bereavement and relationship events were most common.Limitations: The cross-sectional design limits the extent to which inferences can be drawn around the direction of causality between adversity and depression. Recall in older adults is questionable.Conclusions: UK older adults face adversity in areas of health, bereavement and relationships which are associated with depression. This has clinical relevance for psychological interventions for older adults to consider social context and social support. It helps identify the strengths and weaknesses of a brief adversity measure in large scale research. Further research is needed to explore the mechanisms of onset and direction of causality. [ABSTRACT FROM AUTHOR]

Background: Our Cochrane review of selective serotonin inhibitors for stroke recovery indicated that fluoxetine may improve functional recovery, but the trials were small and most were at high risk of bias., Objectives: The Fluoxetine Or Control Under Supervision (FOCUS) trial tested the hypothesis that fluoxetine improves recovery after stroke., Design: The FOCUS trial was a pragmatic, multicentre, parallel-group, individually randomised, placebo-controlled trial., Setting: This trial took place in 103 UK hospitals., Participants: Patients were eligible if they were aged ≥ 18 years, had a clinical stroke diagnosis, with focal neurological deficits, between 2 and 15 days after onset., Interventions: Patients were randomly allocated 20 mg of fluoxetine once per day or the matching placebo for 6 months via a web-based system using a minimisation algorithm., Main Outcome Measures: The primary outcome was the modified Rankin Scale at 6 months. Patients, carers, health-care staff and the trial team were masked to treatment allocation. Outcome was assessed at 6 and 12 months after randomisation. Patients were analysed by their treatment allocation as specified in a published statistical analysis plan., Results: Between 10 September 2012 and 31 March 2017, we recruited 3127 patients, 1564 of whom were allocated fluoxetine and 1563 of whom were allocated placebo. The modified Rankin Scale score at 6 months was available for 1553 out of 1564 (99.3%) of those allocated fluoxetine and 1553 out of 1563 (99.4%) of those allocated placebo. The distribution across modified Rankin Scale categories at 6 months was similar in the two groups (common odds ratio adjusted for minimisation variables 0.951, 95% confidence interval 0.839 to 1.079; p  = 0.439). Compared with placebo, patients who were allocated fluoxetine were less likely to develop a new episode of depression by 6 months [210 (13.0%) vs. 269 (16.9%), difference -3.78%, 95% confidence interval -1.26% to -6.30%; p  = 0.003], but had more bone fractures [45 (2.9%) vs. 23 (1.5%), difference 1.41%, 95% confidence interval 0.38% to 2.43%; p  = 0.007]. There were no statistically significant differences in any other recorded events at 6 or 12 months. Health economic analyses showed no differences between groups in health-related quality of life, hospital bed usage or health-care costs., Limitations: Some non-adherence to trial medication, lack of face-to-face assessment of neurological status at follow-up and lack of formal psychiatric diagnosis during follow-up., Conclusions: 20 mg of fluoxetine daily for 6 months after acute stroke did not improve patients' functional outcome but decreased the occurrence of depression and increased the risk of fractures. These data inform decisions about using fluoxetine after stroke to improve functional outcome or to prevent or treat mood disorders. The Assessment oF FluoxetINe In sTroke recoverY (AFFINITY) (Australasia/Vietnam) and Efficacy oF Fluoxetine - a randomisEd Controlled Trial in Stroke (EFFECTS) (Sweden) trials recruited an additional 2780 patients and will report their results in 2020. These three trials have an almost identical protocol, which was collaboratively developed. Our planned individual patient data meta-analysis will provide more precise estimates of the effects of fluoxetine after stroke and indicate whether or not effects vary depending on patients' characteristics and health-care setting., Trial Registration: Current Controlled Trials ISRCTN83290762., Funding: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment ; Vol. 24, No. 22. See the NIHR Journals Library website for further project information. The Stroke Association (reference TSA 2011101) funded the start-up phase., Competing Interests: Martin Dennis, Maree Hackett, Graeme J Hankey, Gillian Mead and Erik Lundström report grants from the National Health and Medical Research Council (Australia) and funding from the Swedish Research Council Framework grant in clinical therapy research during the conduct of the study. Maree Hackett also reports grants from The Stroke Association (London, UK), grants from the National Institute for Health Research (NIHR) Stroke Research Network and a grant in clinical therapy research during the conduct of the study, and grants from the National Heart Foundation of Australia outside the submitted work. She also held a National Health and Medical Research Council (Australia) Career Development Fellowship, level 2 (reference APP1141328) (2018–21). Stephanie Lewis reports being a member of the NIHR Health Technology Assessment General Committee (2016 to present). Peter Sandercock reports lecture fees from Bayer AG (Leverkusen, Germany) paid to his department, outside the submitted work.

Background and Purpose- The FOCUS trial (Fluoxetine or Control Under Supervision) showed that fluoxetine did not improve modified Rankin Scale scores (mRS) but increased the risk of fractures. We aimed to describe the fractures, their impact on mRS and factors associated with fracture risk. Methods- A United Kingdom, multicenter, parallel-group, randomized, placebo-controlled trial. Patients ≥18 years with a clinical stroke and persisting deficit assessed 2 to 15 days after onset were eligible. Consenting patients were allocated fluoxetine 20 mg or matching placebo for 6 months. The primary outcome was the mRS at 6 months and secondary outcomes included fractures. Results- Sixty-five of 3127 (2.1%) patients had 67 fractures within 6 months of randomization; 43 assigned fluoxetine and 22 placebo. Fifty-nine (90.8%) had fallen and 26 (40%) had fractured their neck of femur. The effect of fluoxetine on mRS (common odds ratio =0.951) was not significantly altered by excluding fracture patients (common odds ratio =0.961). Cox proportional hazards modeling showed that only age >70 year (hazard ratio =1.97; 95% CI, 1.13-3.45; P =0.017), female sex (hazard ratio =2.13; 95% CI, 1.29-3.51; P =0.003), and fluoxetine (hazard ratio =2.00; 95% CI, 1.20-3.34; P =0.008) were independently associated with fractures. Conclusions- Most fractures resulted from falls. Although many fractures were serious, and likely to impair patients' function, the increased fracture risk did not explain the lack of observed effect of fluoxetine on mRS. Only increasing age, female sex, and fluoxetine were independent predictors of fractures. Clinical Trial Registration- URL: http://www.controlled-trials.com. Unique identifier: ISRCTN83290762.

Objectives: To describe the current provision of hospital-based liaison psychiatry services in England, and to determine different models of liaison service that are currently operating in England., Design: Cross-sectional observational study comprising an electronic survey followed by targeted telephone interviews., Setting: All 179 acute hospitals with an emergency department in England., Participants: 168 hospitals that had a liaison psychiatry service completed an electronic survey. Telephone interviews were conducted for 57 hospitals that reported specialist liaison services additional to provision for acute care., Measures: Data included the location, service structures and staffing, working practices, relations with other mental health service providers, policies such as response times and funding. Model 2-based clustering was used to characterise the services. Telephone interviews identified the range of additional liaison psychiatry services provided., Results: Most hospitals (141, 79%) reported a 7-day service responding to acute referrals from the emergency department and wards. However, under half of hospitals had 24 hours access to the service (78, 44%). One-third of hospitals (57, 32%) provided non-acute liaison work including outpatient clinics and links to specialist hospital services. 156 hospitals (87%) had a multidisciplinary service including a psychiatrist and mental health nurses. We derived a four-cluster model of liaison psychiatry using variables resulting from the electronic survey; the salient features of clusters were staffing numbers, especially nursing; provision of rapid response 24 hours 7-day acute services; offering outpatient and other non-acute work, and containing age-specific teams for older adults., Conclusions: This is the most comprehensive study to date of liaison psychiatry in England and demonstrates the wide availability of such services nationally. Although all services provide an acute assessment function, there is no uniformity about hours of coverage or expectation of response times. Most services were better characterised by the model we developed than by current classification systems for liaison psychiatry., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2018. Re-use permitted under CC BY. Published by BMJ.)

Background: Despite the evidence that many stroke survivors report longer term unmet needs, the provision of longer term care is limited. To address this, we are conducting a programme of research to develop an evidence-based and replicable longer term care strategy. The developed complex intervention (named New Start), which includes needs identification, exploration of social networks and components of problem solving and self-management, was designed to improve quality of life by addressing unmet needs and increasing participation., Methods/design: A multicentre, cluster randomised controlled feasibility trial designed to inform the design of a possible future definitive cluster randomised controlled trial (cRCT) and explore the potential clinical and cost-effectiveness of New Start. Ten stroke services across the UK will be randomised on a 1:1 basis either to implement New Start or continue with usual care only. New Start will be delivered by trained facilitators and will be offered to all stroke survivors within the services allocated to the intervention arm. Stroke survivors will be eligible for the trial if they are 4-6 months post-stroke and residing in the community. Carers (if available) will also be invited to take part. Invitation to participate will be initiated by post and outcome measures will be collected via postal questionnaires at 3, 6 and 9 months after recruitment. Outcome data relating to perceived health and disability, wellbeing and quality of life as well as unmet needs will be collected. A 'study within a trial' (SWAT) is planned to determine the most acceptable format in which to provide the postal questionnaires. Details of health and social care service usage will also be collected to inform the economic evaluation. The feasibility of recruiting services and stroke survivors to the trial and of collecting postal outcomes will be assessed and the potential for effectiveness will be investigated. An embedded process evaluation (reported separately) will assess implementation fidelity and explore and clarify causal assumptions regarding implementation., Discussion: This feasibility trial with embedded process evaluation will allow us to gather important and detailed data regarding methodological and implementation issues to inform the design of a possible future definitive cRCT of this complex intervention., Trial Registration: ISRCTN38920246 . Registered 22 June 2016.

Objective: To evaluate the effects of Quality and Outcomes Framework (QOF) incentivised case finding for depression on diagnosis and treatment in targeted and non-targeted long-term conditions., Design: Interrupted time series analysis., Setting: General practices in Leeds, UK., Participants: 65 (58%) of 112 general practices shared data on 37,229 patients with diabetes and coronary heart disease targeted by case finding incentives, and 101,008 patients with four other long-term conditions not targeted (hypertension, epilepsy, chronic obstructive pulmonary disease and asthma)., Intervention: Incentivised case finding for depression using two standard screening questions., Main Outcome Measures: Clinical codes indicating new depression-related diagnoses and new prescriptions of antidepressants. We extracted routinely recorded data from February 2002 through April 2012. The number of new diagnoses and prescriptions for those on registers was modelled with a binomial regression, which provided the strength of associations between time periods and their rates., Results: New diagnoses of depression increased from 21 to 94/100,000 per month in targeted patients between the periods 2002-2004 and 2007-2011 (OR 2.09; 1.92 to 2.27). The rate increased from 27 to 77/100,000 per month in non-targeted patients (OR 1.53; 1.46 to 1.62). The slopes in prescribing for both groups flattened to zero immediately after QOF was introduced but before incentivised case finding (p<0.01 for both). Antidepressant prescribing in targeted patients returned to the pre-QOF secular upward trend (Wald test for equivalence of slope, z=0.73, p=0.47); the slope was less steep for non-targeted patients (z=-4.14, p<0.01)., Conclusions: Incentivised case finding increased new depression-related diagnoses. The establishment of QOF disrupted rising trends in new prescriptions of antidepressants, which resumed following the introduction of incentivised case finding. Prescribing trends are of concern given that they may include people with mild-to-moderate depression unlikely to respond to such treatment., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To identify factors associated with infant growth up to 6 months, with a particular focus on maternal distress, and to explore the effect of ethnicity on any relation between maternal distress and infant growth., Methods: Cohort study recruiting White and Pakistani women in the United Kingdom (UK). Infant growth was measured at birth and 6 months. Standard assessment of mental health (GHQ-28) was undertaken in pregnancy (26-28 weeks gestation) and 6 months postpartum. Modelling included social deprivation, ethnicity, and other known influences on infant growth such as maternal smoking and alcohol consumption., Results: Maternal distress improved markedly from pregnancy to 6 months postpartum. At both times Pakistani women had more somatic and depression symptoms than White women. Depression in pregnancy (GHQ subscale D) was associated with lower infant growth at 6 months. Self-reported social dysfunction in pregnancy (GHQ subscale C) was associated with lower gestational age.. Pakistani women reported higher GHQ scores during pregnancy associated with smaller infants at birth. They lived in areas of higher social deprivation, reported less alcohol consumption and smoking postnatally, all independent influences on growth at 6 months., Conclusions: Maternal mental health in pregnancy is an independent influence on infant growth up to 6 months and is associated with ethnicity which was itself associated with deprivation in our sample. There is a complex relationship between symptoms of maternal distress, ethnicity, deprivation, health behaviours, and early infant growth. Measures should include both emotional and somatic symptoms and interventions to reduce risks of poor early growth need to include psychological and social components.