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Biomedical subjects

D Gunnell

Publications and source records attributed to D Gunnell.

At least 37 records · Page 2Linked to original sources
PubMed2001

The influence of the economic and social environment on deliberate self-harm and suicide: an ecological and person-based study.

BACKGROUND: Geographic variations in the incidence of deliberate self-harm (DSH) and suicide have been shown to be associated with area-based measures of socio-economic deprivation and social fragmentation. Previous studies have been subject to methodological limitations. None has investigated whether ecological associations are reflected in characteristics of individuals involved in suicidal behaviour. METHODS: DSH patients presenting to a general hospital between 1985 and 1995 and suicides (including open verdicts) from the same catchment area were studied. Mean annual rates of DSH and suicide by gender were calculated for electoral wards. The wards were amalgamated into 20 groups according to their ranking for socio-economic deprivation (Townsend) and social fragmentation scores. Associations of these variables with DSH and suicide rates were investigated. Characteristics of DSH patients living in ward groups with the highest and lowest socio-economic deprivation and social fragmentation scores were compared. RESULTS: Socio-economic deprivation was associated with DSH rates among males (r = 0.89) and females (r = 0.87). After controlling for social fragmentation the associations remained relatively strong, particularly in young males. Associations with social fragmentation in both genders (males, r = 0.83; females, r = 0.86) were attenuated after controlling for socio-economic deprivation. For suicide, the only significant association was with socio-economic deprivation in males (r = 0.79), but this was attenuated after controlling for social fragmentation. The characteristics of individual DSH patients reflected those of the areas where they lived. CONCLUSIONS: Reducing socio-economic deprivation and its associated problems may be an important strategy in the prevention of suicidal behaviour, especially in young men.

Adolescent↗
PubMed2001

The efficacy of problem-solving treatments after deliberate self-harm: meta-analysis of randomized controlled trials with respect to depression, hopelessness and improvement in problems.

BACKGROUND: Brief problem-solving therapy is regarded as a pragmatic treatment for deliberate self-harm (DSH) patients. A recent meta-analysis of randomized controlled trials (RCTs) evaluating this approach indicated a trend towards reduced repetition of DSH but the pooled odds ratio was not statistically significant. We have now examined other important outcomes using this procedure, namely depression, hopelessness and improvement in problems. METHOD: Six trials in which problem-solving therapy was compared with control treatment were identified from an extensive literature review of RCTs of treatments for DSH patients. Data concerning depression, hopelessness and improvement in problems were extracted. Where relevant statistical data (e.g. standard deviations) were missing these were imputed using various statistical methods. Results were pooled using meta-analytical procedures. RESULTS: At follow-up, patients who were offered problem-solving therapy had significantly greater improvement in scores for depression (standardized mean difference = -0.36; 95% CI -0.61 to -0.11) and hopelessness (weighted mean difference =-3.2; 95% CI -4.0 to -2.41), and significantly more reported improvement in their problems (odds ratio = 2.31; 95% CI 1.29 to 4.13), than patients who were in the control treatment groups. CONCLUSIONS: Problem-solving therapy for DSH patients appears to produce better results than control treatment with regard to improvement in depression, hopelessness and problems. It is desirable that this finding is confirmed in a large trial, which will also allow adequate testing of the impact of this treatment on repetition of DSH.

Cognitive Behavioral Therapy↗
PubMed2001

Secular trends in antidepressant prescribing in the UK, 1975-1998.

BACKGROUND: We have examined secular trends in age- and sex-specific prescribing of antidepressants to determine whether these mirror changes in other population measures of mental health. METHOD: An analysis was carried out of age- and sex-specific rates of antidepressant prescribing by a representative sample or panel of UK general practitioners (GPs) in the period 1975-1998. RESULTS: The number of antidepressant prescriptions issued increased more than twofold in the period 1975-1998 and, in 1998, a total of 23.4 million antidepressant prescriptions were issued by GPs in the United Kingdom. Rates of antidepressant prescribing increased markedly in all age and sex groups with as much as a threefold increase in the older age groups. With the exception of 12-19-year-olds, these increases have been more marked in males, although absolute levels of prescribing are still at least two times higher in females. CONCLUSIONS: Antidepressant prescribing has increased in all age and sex groups. This indicates either that there have been changes in the presentation, recognition and management of depression in general practice or that the prevalence of depression has increased, or a combination of these two phenomena. The higher prescribing rate in females is in keeping with evidence from psychiatric morbidity surveys suggesting that women experience higher levels of psychiatric morbidity than men. Decreases in the ratio of female to male prescribing, however, support other data indicating that, relative to females, the mental health of young males has declined in recent years. Changes in patterns of help-seeking may also contribute to the observed trends.

Adolescent↗
PubMed2001

Childhood housing conditions and later mortality in the Boyd Orr cohort.

STUDY OBJECTIVES: To examine associations between five measures of housing conditions during childhood and subsequent mortality from all causes, coronary heart disease, stroke, and cancer. DESIGN: Historical cohort study. SETTING: Data on housing conditions were collected from survey centres in 16 areas of England and Scotland. PARTICIPANTS: Children of families participating in the Carnegie Survey of Family Diet and Health in pre-war Britain (1937-1939). Analyses are based on a subset of 4168 people who were traced and alive on 1 January 1948. MAIN RESULTS: Poorer housing conditions were generally associated with increased adult mortality. After adjustment for childhood and adult socioeconomic factors, statistically significant associations were only found between lack of private indoor tapped water supply and increased mortality from coronary heart disease (hazard ratio 1.73, (95% CI 1.13, 2.64); and between poor ventilation and overall mortality (hazard ratio for people from households with poorest ventilation relative to best ventilation 1.30, 95% CI 0.97, 1.74). CONCLUSIONS: This study provides evidence that associations between housing conditions in childhood and mortality from common diseases in adulthood are not strong, but are in some respects distinguishable from those of social deprivation.

Adult↗
PubMed2001

Leg length, insulin resistance, and coronary heart disease risk: the Caerphilly Study.

BACKGROUND: Adult height has been inversely associated with coronary heart disease risk in several studies. The mechanism for this association is not well understood, however, and this was investigated by examining components of stature, cardiovascular disease risk factors and subsequent coronary heart disease in a prospective study. METHODS: All men aged 45-59 years living in the town of Caerphilly, South Wales were approached, and 2512 (89%) responded and underwent a detailed examination, which included measurement of height and sitting height (from which an estimate of leg length was derived). Participants were followed up through repeat examinations and the cumulative incidence of coronary heart disease-both fatal and non-fatal-over a 15 year follow up period is the end point in this report. RESULTS: Cross sectional associations between cardiovascular risk factors and components of stature (total height, leg length and trunk length) demonstrated that factors related to the insulin resistance syndrome-the homeostasis model assessment of insulin resistance, fasting triglyceride levels and total to HDL cholesterol ratio-were less favourable in men with shorter legs, while showing reverse or no associations with trunk length. Fibrinogen levels were inversely associated with leg length and showed a weaker association with trunk length. Forced expiratory volume in one second was unrelated to leg length but strongly positively associated to trunk length. Other risk factors showed little association with components of stature. The risk of coronary heart disease was inversely related to leg length but showed little association with trunk length. CONCLUSION: Leg length is the component of stature related to insulin resistance and coronary heart disease risk. As leg length is unrelated to lung function measures it is unlikely that these can explain the association in this cohort. Factors that influence leg length in adulthood-including nutrition, other influences on growth in early life, genetic and epigenetic influences-merit further investigation in this regard. The reported associations suggest that pre-adult influences are important in the aetiology of coronary heart disease and insulin resistance.

Anthropometry↗
PubMed2001

Patterns and predictors of hospitalisation in first-episode psychosis. Prospective cohort study.

BACKGROUND: Little is known about predictors of hospitalisation in patients with first-episode psychosis. AIMS: To identify the pattern and predictors of hospitalisation of patients with a first psychotic episode making their first contact with specialist services. METHOD: Three-year follow-up of a cohort of 166 patients with a first episode of psychosis making contact with psychiatric services in Nottingham between June 1992 and May 1994. RESULTS: Eighty-eight (53.0%) patients were admitted within 1 week of presentation; 32 (19.3%) were never admitted during the 3 years of follow-up. Manic symptoms at presentation were associated with an increased risk of rapid admission and an increased overall risk of admission; negative symptoms and a longer duration of untreated illness had an increased risk of late admission. CONCLUSIONS: Community-oriented psychiatric services might only delay, rather than prevent, admission of patients with predominantly negative symptoms and a longer duration of untreated illness. First-episode studies based upon first admissions are likely to be subject to selection biases, which may limit their representativeness.

Adolescent↗
PubMed2001

Association between schizophrenia and social inequality at birth: case-control study.

BACKGROUND: The association between social inequality at birth and subsequent risk of schizophrenia is uncertain. AIMS: To investigate the relationship between adult-onset schizophrenia and two indicators of social inequality at birth: social class and area of residence. METHOD: A matched case-control design was used with data from birth certificates of first-episode cases and age- and gender-matched controls. RESULTS: Risk increased with increasing levels of deprivation at birth. Subjects whose fathers were social class IV-V or who were born in deprived areas were at increased risk of schizophrenia (odds ratio=2.1; 95% Cl=0.8-5.5). Risk was greater in those with both of these indicators (odds ratio=8.1; 95% Cl=2.7-23.9). There was some evidence that associations were stronger in older subjects. Exclusion of African-Caribbeans or cases with positive family history somewhat attenuated the association. CONCLUSIONS: Indicators of social inequality at birth are associated with increased risk of adult-onset schizophrenia, suggesting that environmental factors are important determinants of schizophrenic disorders.

Age Factors↗
PubMed2001

Guidelines and educational outreach visits from community pharmacists to improve prescribing in general practice: a randomised controlled trial.

OBJECTIVES: To evaluate the effectiveness of guidelines with or without one-to-one educational outreach visits by community pharmacists in improving general practice prescribing for non-steroidal anti-inflammatory drugs (NSAIDs). METHODS: Cluster randomised trial of 20 general practices within Avon, England. Practices were randomised to three groups: control; mailed guidelines; mailed guidelines plus educational outreach visits. General practitioners (GPs) in the latter group received two one-to-one outreach visits from community pharmacists. Changes in prescribing were measured using outcomes derived from prescribing analysis and cost (PACT) data. The primary outcome measure was change in the volume of prescribing for ibuprofen, diclofenac and naproxen as a percentage of total NSAID prescribing. Six secondary outcomes included other measures of prescribing quality and volume. A cost-benefit analysis was performed. RESULTS: No significant differences were observed for the primary outcome measure: practices receiving outreach visits prescribed only 2.1% [95% confidence interval (CI): -0.8 to 5.0] more of the three recommended NSAIDs than the control practices did and 1.6% (95% CI: -1.4 to 4.7) more than practices that received guidelines only. Following adjustment for multiple comparisons, only one secondary outcome showed a statistically significant difference between the groups: the proportion of prescribing of the five most frequently used drugs was 2.2% (95% CI: 0.9 to 3.6) higher in the educational outreach group compared with the control group. A net increase in costs was shown with both interventions. CONCLUSIONS: Although good prescribing at baseline in the participating practices limited the capacity for improvement, this trial provides no evidence that guidelines with or without educational outreach visits from community pharmacists lead to substantial improvements in prescribing behaviour.

Anti-Inflammatory Agents, Non-Steroidal↗
PubMed2001

Psychosocial and pharmacological treatment of patients following deliberate self-harm: the methodological issues involved in evaluating effectiveness.

Development of effective treatments for patients following deliberate self-harm (self-poisoning or self-injury) is a very important element in suicide prevention. The randomized controlled trial (RCT) is the mainstay of evaluation of treatments. In a systematic review of the literature, the effectiveness of treatments based on RCTs was examined and the quality of the RCTs was assessed. Twenty trials were identified, and where possible, these were grouped on the basis of similarities among the types of treatment. In this paper, we examine the methodological aspects of the trials and consider what may be learned that will assist in the design of future studies in this field. The methodological quality of the trials was reasonable, but most trials included too few participants to detect clinically important differences in rates of repeated self-harm. In planning future trials, the following major issues should be addressed: investigators should perform power calculations to determine the number of subjects necessary to detect clinically important effects, provide information on method of randomization and interventions, use standard measures of outcome, and focus on homogeneous subgroups of patients. Improving the methodology of future studies in this field will be essential if sound evidence is to be obtained which can inform effective service provision for deliberate self-harm patients.

Humans↗
PubMed2000

Psychosocial versus pharmacological treatments for deliberate self harm.

OBJECTIVES: To identify and synthesise the findings from all randomised controlled trials that have examined the effectiveness of treatments of patients who have deliberately harmed themselves. SEARCH STRATEGY: Electronic databases screened: MEDLINE (from 1966-February 1999); PsycLit (from 1974-March 1999); Embase (from 1980-January 1999); The Cochrane Controlled Trials Register (CCTR) No.1 1999. Ten journals in the field of psychiatry and psychology were hand searched for the first version of this review. We have updated the hand search of three specialist journals in the field of suicidal research until the end of 1998. Reference lists of papers were checked and trialists contacted. SELECTION CRITERIA: All RCTs of psychosocial and/or psychopharmacological treatment versus standard or less intensive types of aftercare for patients who shortly before entering a study engaged in any type of deliberately initiated self-poisoning or self-injury, both of which are generally subsumed under the term deliberate self-harm. DATA COLLECTION AND ANALYSIS: Data were extracted from the original reports independently by two reviewers. Studies were categorized according to type of treatment. The outcome measure used to assess the efficacy of treatment interventions for deliberate self-harm was the rate of repeated suicidal behaviour. We have been unable to examine other outcome measures as originally planned (e.g. compliance with treatment, depression, hopelessness, suicidal ideation/thoughts, change in problems/problem resolution). MAIN RESULTS: A total of 23 trials were identified in which repetition of deliberate self-harm was reported as an outcome variable. The trials were classified into 11 categories. The summary odds ratio indicated a trend towards reduced repetition of deliberate self-harm for problem-solving therapy compared with standard aftercare (0.70; 0.45 to 1.11) and for provision of an emergency contact card in addition to standard care compared with standard aftercare alone (0.45; 0.19 to 1.07). The summary odds ratio for trials of intensive aftercare plus outreach compared with standard aftercare was 0.83 (0.61 to 1.14), and for antidepressant treatment compared with placebo was 0.83 (0. 47 to 1.48). The remainder of the comparisons were in single small trials. Significantly reduced rates of further self-harm were observed for depot flupenthixol vs. placebo in multiple repeaters (0. 09; 0.02 to 0.50), and for dialectical behaviour therapy vs. standard aftercare (0.24; 0.06 to 0.93). REVIEWER'S CONCLUSIONS: There still remains considerable uncertainty about which forms of psychosocial and physical treatments of self-harm patients are most effective, inclusion of insufficient numbers of patients in trials being the main limiting factor. There is a need for larger trials of treatments associated with trends towards reduced rates of repetition of deliberate self-harm. The results of small single trials which have been associated with statistically significant reductions in repetition must be interpreted with caution and it is desirable that such trials are also replicated.

Cognitive Behavioral Therapy↗
PubMed2000

Method availability and the prevention of suicide--a re-analysis of secular trends in England and Wales 1950-1975.

BACKGROUND: In England and Wales in the 1960s there were marked declines in suicide rates. These reductions were partly attributable to the detoxification of the domestic gas supplies; however, their extent varied by age and gender, with the most striking effects seen in older men. The objective of this study was to investigate method-specific trends in suicide between 1950 and 1975 to elucidate possible explanations for the patterns seen in different demographic groups. METHODS: An analysis of age-standardised method-specific suicide rates for England and Wales between 1950 and 1975 was carried out using routinely available mortality and population statistics. RESULTS: As has previously been shown, there were marked reductions in suicides by gassing in men and women of all ages between 1960 and 1975. In women and younger men, the effects of these reductions on overall suicide rates were partially offset by rises in drug overdose deaths (method substitution), but there were no immediate increases in the use of other suicide methods. In contrast, in older men, reductions in suicide by gassing were accompanied by only a slight increase in overdose suicides as well as reductions in rates of suicide using all other methods. The modest rise in overdose fatalities in older men occurred despite the fact that they were more often prescribed barbiturates and tricyclic antidepressants than younger men. CONCLUSIONS: Accessibility to and the lethality of particular methods of suicide may have profound effects on overall suicide rates. Such effects appear to depend upon the popularity of the method and the extent to which alternative methods that are acceptable to the individual are available. Social and psychological interpretations of fluctuations in suicide rates should only be made after assessing the possible contribution to these of changes in method availability and lethality.

Adolescent↗