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BACKGROUND: Biologic therapies have revolutionized the treatment of moderate-to-severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs. OBJECTIVES: To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis. METHODS: Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic-naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions. RESULTS: Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66-0·93); social (unemployment, 0·67, 0·45-0·99); unemployment due to ill health (0·62, 0·48-0·82); ex- and current smoking (0·81, 0·66-0·99 and 0·79, 0·63-0·99, respectively); clinical factors (high weight, 0·99, 0·99-0·99); psoriasis of the palms and/or soles (0·75, 0·61-0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62-0·96). White ethnicity (1·48, 1·12-1·97) and higher baseline PASI (1·04, 1·03-1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response. CONCLUSIONS: Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection.

A Blakemore,1 C Dickens,2 CA Chew-Graham,3 CW Afzal,4 B Tomenson,5 PA Coventry,6 E Guthrie71Division of Nursing, Social Work and Midwifery, School of Health Sciences, University of Manchester, Manchester Academic Health Science Centre, Manchester, UK; 2University of Exeter Medical School, Exeter, St Luke’s Campus, Exeter, UK; 3Research Institute, Primary Care and Health Sciences, West Midlands CLAHRC, Keele, University, Newcastle, UK; 4Health Innovation Manchester, Greater Manchester’s Academic Health Science Network, Manchester Academic Health Science Centre, Manchester, UK; 5Centre for Biostatistics, Institute of Population Health, University of Manchester, Manchester, UK; 6Department of Health Sciences, University of York, York, UK; 7Leeds Institute of Health Sciences, Faculty of Medicine and Health, University of Leeds, Leeds, UKBackground: Depression is common in people with chronic obstructive pulmonary disease (COPD) and has been associated with a variety of poor outcomes. A large proportion of health care costs in the UK are spent on emergency care. This study examined the prospective relationship between depression and use of emergency care in patients with COPD managed in primary care.Methods: This was a twelve-month, prospective longitudinal study of 355 patients with COPD in six primary care practices in the UK. Baseline measures included demographic characteristics, depression and anxiety, severity of COPD, presence or absence of other chronic diseases, and prior use of emergency care. Outcome measures were (a) number of emergency department (ED) visits; or (b) an emergency hospital admission in the follow-up year.Results: Older age, number of comorbid physical health conditions, severity of COPD, prior use of emergency care, and depression were all independently associated with both ED attendance and an emergency hospital admission in the follow-up year. Subthreshold depression (HADS depression score 4–7) was associated with a 2.8 times increased odds of emergency hospital admission, and HADS depression >8 was associated with 4.8 times increased odds.Conclusion: Depression is a predictor of emergency care in COPD, independent of severity of disease or physical comorbidity. Even mild (subthreshold) symptoms of depression more than double the risk of using emergency care, suggesting there is a strong case to develop and deploy integrated preventive strategies in primary care that can promote mental health in people with COPD.Keywords: COPD, depression, anxiety, emergency care, United Kingdom, hospital admission, primary care

BACKGROUND: Biologic therapies have revolutionized the treatment of moderate-to-severe psoriasis. However, for reasons largely unknown, many patients do not respond or lose response to these drugs. OBJECTIVES: To evaluate demographic, social and clinical factors that could be used to predict effectiveness and stratify response to biologic therapies in psoriasis. METHODS: Using a multicentre, observational, prospective pharmacovigilance study (BADBIR), we identified biologic-naive patients starting biologics with outcome data at 6 (n = 3079) and 12 (n = 3110) months. Associations between 31 putative predictors and outcomes were investigated in univariate and multivariable regression analyses. Potential stratifiers of treatment response were investigated with statistical interactions. RESULTS: Eight factors associated with reduced odds of achieving ≥ 90% improvement in Psoriasis Area and Severity Index (PASI 90) at 6 months were identified (described as odds ratio and 95% confidence interval): demographic (female sex, 0·78, 0·66-0·93); social (unemployment, 0·67, 0·45-0·99); unemployment due to ill health (0·62, 0·48-0·82); ex- and current smoking (0·81, 0·66-0·99 and 0·79, 0·63-0·99, respectively); clinical factors (high weight, 0·99, 0·99-0·99); psoriasis of the palms and/or soles (0·75, 0·61-0·91); and presence of small plaques only compared with small and large plaques (0·78, 0·62-0·96). White ethnicity (1·48, 1·12-1·97) and higher baseline PASI (1·04, 1·03-1·04) were associated with increased odds of achieving PASI 90. The findings were largely consistent at 12 months. There was little evidence for predictors of differential treatment response. CONCLUSIONS: Psoriasis phenotype and potentially modifiable factors are associated with poor outcomes with biologics, underscoring the need for lifestyle management. Effect sizes suggest that these factors alone cannot inform treatment selection.

Background Over 70% of the health-care budget in England is spent on the care of people with long-term conditions (LTCs), and a major cost component is unscheduled health care. Psychological morbidity is high in people with LTCs and is associated with a range of adverse outcomes, including increased mortality, poorer physical health outcomes, increased health costs and service utilisation. Objectives The aim of this programme of research was to examine the relationship between psychological morbidity and use of unscheduled care in people with LTCs, and to develop a psychosocial intervention that would have the potential to reduce unscheduled care use. We focused largely on emergency hospital admissions (EHAs) and attendances at emergency departments (EDs). Design A three-phase mixed-methods study. Research methods included systematic reviews; a longitudinal prospective cohort study in primary care to identify people with LTCs at risk of EHA or ED admission; a replication study in primary care using routinely collected data; an exploratory and feasibility cluster randomised controlled trial in primary care; and qualitative studies to identify personal reasons for the use of unscheduled care and factors in routine consultations in primary care that may influence health-care use. People with lived experience of LTCs worked closely with the research team. Setting Primary care. Manchester and London. Participants People aged ≥ 18 years with at least one of four common LTCs: asthma, coronary heart disease, chronic obstructive pulmonary disease (COPD) and diabetes. Participants also included health-care staff. Results Evidence synthesis suggested that depression, but not anxiety, is a predictor of use of unscheduled care in patients with LTCs, and low-intensity complex interventions reduce unscheduled care use in people with asthma and COPD. The results of the prospective study were that depression, not having a partner and life stressors, in addition to prior use of unscheduled care, severity of illness and multimorbidity, were independent predictors of EHA and ED admission. Approximately half of the cost of health care for people with LTCs was accounted for by use of unscheduled care. The results of the replication study, carried out in London, broadly supported our findings for risk of ED attendances, but not EHAs. This was most likely due to low rates of detection of depression in general practitioner (GP) data sets. Qualitative work showed that patients were reluctant to use unscheduled care, deciding to do so when they perceived a serious and urgent need for care, and following previous experience that unscheduled care had successfully and unquestioningly met similar needs in the past. In general, emergency and primary care doctors did not regard unscheduled care as problematic. We found there are missed opportunities to identify and discuss psychosocial issues during routine consultations in primary care due to the ‘overmechanisation’ of routine health-care reviews. The feasibility trial examined two levels of an intervention for people with COPD: we tried to improve the way in which practices manage patients with COPD and developed a targeted psychosocial treatment for patients at risk of using unscheduled care. The former had low acceptability, whereas the latter had high acceptability. Exploratory health economic analyses suggested that the practice-level intervention would be unlikely to be cost-effective, limiting the value of detailed health economic modelling. Limitations The findings of this programme may not apply to all people with LTCs. It was conducted in an area of high social deprivation, which may limit the generalisability to more affluent areas. The response rate to the prospective longitudinal study was low. The feasibility trial focused solely on people with COPD. Conclusions Prior use of unscheduled care is the most powerful predictor of unscheduled care use in people with LTCs. However, psychosocial factors, particularly depression, are important additional predictors of use of unscheduled care in patients with LTCs, independent of severity and multimorbidity. Patients and health-care practitioners are unaware that psychosocial factors influence health-care use, and such factors are rarely acknowledged or addressed in consultations or discussions about use of unscheduled care. A targeted patient intervention for people with LTCs and comorbid depression has shown high levels of acceptability when delivered in a primary care context. An intervention at the level of the GP practice showed little evidence of acceptability or cost-effectiveness. Future work The potential benefits of case-finding for depression in patients with LTCs in primary care need to be evaluated, in addition to further evaluation of the targeted patient intervention.

BackgroundThe diagnosis of somatisation disorder in DSM-IV was based on 'medically unexplained' symptoms, which is unsatisfactory.AimsTo determine the value of a total somatic symptom score as a predictor of health status and healthcare use after adjustment for anxiety, depression and general medical illness.MethodData from nine population-based studies (total n=28377) were analysed.ResultsIn all cross-sectional analyses total somatic symptom score was associated with health status and healthcare use after adjustment for confounders. In two prospective studies total somatic symptom score predicted subsequent health status. This association appeared stronger than that for medically unexplained symptoms.ConclusionsTotal somatic symptom score provides a predictor of health status and healthcare use over and above the effects of anxiety, depression and general medical illnesses. Declaration of interest F.C. has been a member of the American Psychiatric Association DSM-5 work group on somatic distress disorders and he and A.S. are members of the World Health Organization ICD-11 working group on the classification of somatic distress and dissociative disorders.

BACKGROUND: Crohn's disease (CD) is associated with smoking, while ulcerative colitis (UC) is largely a disease of nonsmokers. We aimed to test whether the smoking-linked personality characteristic "impulsive sensation seeking" (ImpSS) is correlated to the differences in smoking in inflammatory bowel disease (IBD). METHODS: In 185 IBD patients, the General Health Questionnaire and the Zuckerman-Kuhlman Personality Questionnaire (ZKPQ) were administered. The Fagerstrom Test for Nicotine Dependence was used to assess smokers' nicotine dependence. RESULTS: CD patients were twice as likely to be active smokers than UC patients. CD patients presented higher ImpSS scores than UC patients, but the differences became nonsignificant after adjustment for age, gender, education and psychological distress. Multivariate analyses, however, showed that the relationship of ImpSS with current smoking was stronger in CD patients. Moderator analysis showed that the relationship of ImpSS with nicotine dependence was also greater in smokers with CD than in those with UC. No other ZKPQ subscale was correlated to disease type, current smoking or nicotine dependence. CONCLUSION: ImpSS is associated with current smoking and nicotine dependence in IBD, and these associations are stronger in CD. These findings might be relevant to more effective interventions aiming at smoking cessation in CD patients. Gen Hosp Psychiatry

OBJECTIVE: The aim of the present study was to test whether psychological distress and personality variables are independently associated with health-related quality of life (HRQOL) in colorectal cancer patients, after adjusting for age, gender, education and disease severity. METHODS: In a cross-sectional study of 162 colorectal cancer patients (response rate 65.6%), the following self-report instruments were administered: the Symptom Distress Checklist-90-R, the Sense of Coherence scale, the Life Style Index and the Hostility and Direction of Hostility Questionnaire. The outcome measures were the four components of the WHO Quality of Life Instrument, Short Form. We used hierarchical regressions to determine whether psychological distress mediates the relationship of personality and disease parameters with HRQOL. RESULTS: The overall proportion of the variance in the four components of HRQOL explained by our regression models ranged from 28.1 to 44.4%. Psychological distress was an independent correlate of HRQOL, associated with physical (p

Background: Early Intervention in Psychosis (EI) was introduced into the British NHS as a result of the NHS Plan, about eleven years ago. The intention was to provide thebest possible care or patients with a first episode of psychosis.Recently however, long term studies over five years have suggested that early gains may be lost. Methods and Aims: We wished to establish whether our own group of patients who had received Early Intervention continued over six years to have better outcomes than patients treated in Community Mental Health Teams. To do this we analysed statistically the data on the readmissions and bed days used by our patients over the first six years of illness. Results: We found that patients, both in the whole two groups and in different sub-groups appeared to demonstrate a number of advantages,not always statistically significant, in favour of the EI treated team. Discussion: In many cases, the small size of the samples may have impeded us observing statistically significant differences, however, in general, it appeared that there were a number of advantages in favour of the EI treated team. Conclusion: Our study, though small, does appear to support the view that Early Intervention Services do improve outcomes and that some of the improvement may endure after the patient leaves EI services. Much larger studies ae however required.

PURPOSE: To test the relative importance of anxiety, depression and somatization as correlates of physical health-related quality of life (HRQOL) in several chronic physical disorders. METHODS: In a cross-sectional study of patients with colorectal cancer (N = 162), glaucoma (N = 100), rheumatoid arthritis (N = 168), systemic sclerosis (N = 56) and systemic lupus erythematosus (N = 56), we assessed specific disease severity and used the Symptom Distress Checklist (SCL-90) for psychologic dimensions. Outcome was assessed with the WHO Quality of Life Instrument, Short Form using hierarchical regression to determine independent correlates of HRQOL. RESULTS: After adjustment for demographic features, stage of cancer and pain (final models), the SCL-90 somatization score was the only psychologic distress covariate significantly correlated to physical HRQOL in all diseases (Betas between -0.33 and -0.49) except in systemic sclerosis and scleroderma, where depression was also a correlate. In glaucoma patients, the SCL-90 somatization score was the only significant covariate for physical HRQOL in the final model. CONCLUSIONS: Since reported number of bodily symptoms is both associated with physical HRQOL and treatable in its own right, our findings suggest a possible new avenue to improve the HRQOL in patients with chronic physical disease. Whether this offers greater benefit than treatments for anxiety and depression needs further research. Qual Life Res