Background
While short-term psychodynamic psychotherapies have been shown effective for major dep... more Background While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues. Method This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment ļ³6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of ļ³ 16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score ļ£ 7) and partial remission (defined as HAM-D score ļ£ 12). Results Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohenās d = 0.75) and self-report measures (Cohenās d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%). Limitations It is unclear if the results are generalizable to other providers, geographical locations and cultures. Conclusions Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.
Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergenc... more Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergency and urgent care settings. However, there is little evidence of the effectiveness of ECPs within these different settings. The aim of this study was to evaluate the impact of ECPs on patient pathways and care in different emergency care settings. Methods A pragmatic quasi-experimental multi-site community intervention trial comprising five matched pairs of intervention (ECP) and control services (usual care providers): ambulance, care home, minor injury unit, urgent care centre and GP out-of-hours. The main outcome being assessed was patient disposal pathway following the care episode. Results 5525 patient episodes (nĀ¼2363 intervention and nĀ¼3162 control) were included in the study. A significantly greater percentage of patients were discharged by ECPs working in mobile settings such as the ambulance service (percentage diff. 36.7%, 95% CI 30.8% to 42.7%) and care home service (36.8%, 26.7% to 46.8%). In static services such as out-of-hours (Ć17.9%, Ć30.8% to Ć42.7%) and urgent care centres (Ć11.5%, Ć18.0% to Ć5.1%), a significantly greater percentage of patients were discharged by usual care providers. Conclusions ECPs have a differential impact compared with usual care providers dependent on the operational service settings. Maximal impact occurs when they operate in mobile settings when care is taken to the patient. In these settings ECPs have a broader range of skills than the usual care providers (eg, paramedic), and are targeted to specific clinical groups who can benefit from alternative pathways of care (such as older people who have fallen). Trial Registration No ISRCTN22085282 (Controlled trials.com).
To measure levels of, and change in junior doctor well-being, confidence and self-reported compet... more To measure levels of, and change in junior doctor well-being, confidence and self-reported competence over their second postgraduate training year and the impact of emergency department (ED) placements on these outcomes. A longitudinal study using an online survey administered at four time points (2010-2011). 28 Acute Hospital Trusts, drawn from nine participating Postgraduate Deaneries in England. Junior doctors who had a placement in an ED as part of their second postgraduate training year. Levels of anxiety, depression, motivation, job satisfaction, confidence and self-reported competence, collected at four time points spread over the period of the doctor's second training year (F2). 217 junior doctors were recruited to the study. Over the year there was a significant increase in their overall job satisfaction, confidence and self-reported competence. Junior doctors also reported significantly increased levels of motivation and anxiety, and significantly decreased levels of e...
ABSTRACT A major reform of junior doctor training was undertaken in 2004ā5, with the introduction... more ABSTRACT A major reform of junior doctor training was undertaken in 2004ā5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood. Objectives This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients. Methods Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD). Results Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be āin difficultyā); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD. Conclusions There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme.
Background
While short-term psychodynamic psychotherapies have been shown effective for major dep... more Background While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues. Method This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment ļ³6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of ļ³ 16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score ļ£ 7) and partial remission (defined as HAM-D score ļ£ 12). Results Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohenās d = 0.75) and self-report measures (Cohenās d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%). Limitations It is unclear if the results are generalizable to other providers, geographical locations and cultures. Conclusions Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.
Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergenc... more Background Emergency Care Practitioners (ECPs) are operational in the UK in a variety of emergency and urgent care settings. However, there is little evidence of the effectiveness of ECPs within these different settings. The aim of this study was to evaluate the impact of ECPs on patient pathways and care in different emergency care settings. Methods A pragmatic quasi-experimental multi-site community intervention trial comprising five matched pairs of intervention (ECP) and control services (usual care providers): ambulance, care home, minor injury unit, urgent care centre and GP out-of-hours. The main outcome being assessed was patient disposal pathway following the care episode. Results 5525 patient episodes (nĀ¼2363 intervention and nĀ¼3162 control) were included in the study. A significantly greater percentage of patients were discharged by ECPs working in mobile settings such as the ambulance service (percentage diff. 36.7%, 95% CI 30.8% to 42.7%) and care home service (36.8%, 26.7% to 46.8%). In static services such as out-of-hours (Ć17.9%, Ć30.8% to Ć42.7%) and urgent care centres (Ć11.5%, Ć18.0% to Ć5.1%), a significantly greater percentage of patients were discharged by usual care providers. Conclusions ECPs have a differential impact compared with usual care providers dependent on the operational service settings. Maximal impact occurs when they operate in mobile settings when care is taken to the patient. In these settings ECPs have a broader range of skills than the usual care providers (eg, paramedic), and are targeted to specific clinical groups who can benefit from alternative pathways of care (such as older people who have fallen). Trial Registration No ISRCTN22085282 (Controlled trials.com).
To measure levels of, and change in junior doctor well-being, confidence and self-reported compet... more To measure levels of, and change in junior doctor well-being, confidence and self-reported competence over their second postgraduate training year and the impact of emergency department (ED) placements on these outcomes. A longitudinal study using an online survey administered at four time points (2010-2011). 28 Acute Hospital Trusts, drawn from nine participating Postgraduate Deaneries in England. Junior doctors who had a placement in an ED as part of their second postgraduate training year. Levels of anxiety, depression, motivation, job satisfaction, confidence and self-reported competence, collected at four time points spread over the period of the doctor's second training year (F2). 217 junior doctors were recruited to the study. Over the year there was a significant increase in their overall job satisfaction, confidence and self-reported competence. Junior doctors also reported significantly increased levels of motivation and anxiety, and significantly decreased levels of e...
ABSTRACT A major reform of junior doctor training was undertaken in 2004ā5, with the introduction... more ABSTRACT A major reform of junior doctor training was undertaken in 2004ā5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood. Objectives This study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients. Methods Phase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD). Results Phase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be āin difficultyā); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD. Conclusions There are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme.
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Papers by Chris Stride
While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues.
Method
This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment ļ³6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of ļ³ 16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score ļ£ 7) and partial remission (defined as HAM-D score ļ£ 12).
Results
Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohenās d = 0.75) and self-report measures (Cohenās d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%).
Limitations
It is unclear if the results are generalizable to other providers, geographical locations and cultures.
Conclusions
Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.
While short-term psychodynamic psychotherapies have been shown effective for major depression, it is unclear if this could be a treatment of choice for depressed patients who have not sufficiently responded to existing treatments and commonly have chronic and complex health issues.
Method
This superiority trial used a single blind randomised parallel group design to test the effectiveness of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) for treatment resistant depression (TRD). Patients referred to secondary care community mental health teams (CMHT) who met DSM-IV criteria for major depressive episode, had received antidepressant treatment ļ³6 weeks, and had Hamilton Depression Rating Scale (HAM-D) scores of ļ³ 16 were recruited. The effects of 20 sessions of ISTDP were judged through comparison against secondary care CMHT treatment as usual (TAU). The primary outcome was HAM-D scores at 6 months. Secondary outcomes included dichotomous measures of both remission (defined as HAM-D score ļ£ 7) and partial remission (defined as HAM-D score ļ£ 12).
Results
Sixty patients were randomised to 2 groups (ISTDP=30 and TAU=30), with data collected at baseline, 3, and 6 months. Multi-level linear regression modelling showed that change over time on both depression scales was significantly greater in the ISTDP group in comparison to TAU. Statistically significant between-group treatment differences, in the moderate to large range, favouring ISTDP, were observed on both the observer rated (Cohenās d = 0.75) and self-report measures (Cohenās d = 0.85) of depression. Relative to TAU, patients in the ISTDP group were significantly more likely after 6 months to achieve complete remission (36.0% vs. 3.7%) and partial remission (48.0% vs. 18.5%).
Limitations
It is unclear if the results are generalizable to other providers, geographical locations and cultures.
Conclusions
Time-limited ISTDP appears an effective treatment option for TRD, showing large advantages over routine treatment delivered by secondary care services.