Dean McMillan

... First, risk mitigation strategies designed to reduce the risk of violence are put in place after a clinical risk assessment. This might have reduced the observed predictive accuracy of theclinical method, but would not have affected the actuarial technique. ...

Research on developmental risk factors for sexual offending against children is inherently difficult. Although there are numerous studies in the area, methodological problems are often not given sufficient attention in the design and interpretation of research. Despite the large number of variables retrospectively associated with sexual offending, the status of these as developmental risk factors remains unclear. If sexual offending research is to make progress, five methodological challenges must be met. These include: (1) establishing the temporal relationship between a putative risk factor and sexual perpetration; (2) ruling out third variable effects; (3) avoiding retrospective reporting bias; (4) generating informative tests of risk mechanisms; and (5) modeling complex developmental phenomena. In this review, we outline these methodological problems and suggest that the study of sexualized behavior in childhood and adolescence may provide some leverage on each of these difficulties.

Depressed mood often co-exists with frequent drug and alcohol use. This trial examined the feasibility of screening, recruitment, randomization and engagement of drug and alcohol users in psychological interventions for depression symptoms. A total of 50 patients involved in community drugs and alcohol treatment (CDAT) were randomly allocated to behavioral activation delivered by psychological therapists (n=23) or to cognitive behavioral therapy based self-help introduced by CDAT workers (n=27). We examined recruitment and engagement rates, as well as changes in depression (PHQ-9) symptoms and changes in percent days abstinent (PDA within last month) at 24weeks follow-up. The ratio of screened to recruited participants was 4 to 1, and the randomization schedule successfully generated 2 groups with comparable characteristics. Follow-up was possible with 78% of participants post-treatment. Overall engagement in psychological interventions was low; only 42% of randomized participants a...

To validate the Whooley questions as a screening tool for depression amongst a population of older adults in UK primary care. To assess the diagnostic performance of the Whooley questions as a screening tool for depression amongst older adults in UK primary care. A cross-sectional validation study was conducted with 766 patients aged ≥75 from UK primary care, recruited via 17 general practices based in the North of England during the pilot phase of a randomized controlled trial. Sensitivity, specificity and likelihood ratios comparing the index test (two Whooley questions) with a diagnosis of major depressive disorder (MDD) ascertained by the reference standard Mini International Neuropsychiatric Interview (MINI). The two screening questions had a sensitivity of 94.3% (95% confidence interval, 80.8-99.3%) and specificity of 62.7% (95% confidence interval, 59.0-66.2%). The likelihood ratio for a positive test was 2.5 (95% confidence interval, 2.2-2.9) and the likelihood ratio for a negative test was 0.09 (95% confidence interval, 0.02-0.35). The two Whooley questions missed few cases of depression. However, they were responsible for a high rate of false positives. This creates additional burden on general practitioners, to conduct more detailed investigation on patients who screen positive, but many of whom turn out not to have MDD.

AbstractObjective: To identify factors that may increase the risk of a sexually victimised adolescent boy developing sexually abusive behaviour.Design: Sexually victimised boys who had sexually abused other children were compared with sexually victimised boys who had not done so.Setting: Social services departments in south east England were invited to refer sexually abused and sexually abusing boys to a London postgraduate

ABSTRACT There is growing evidence that Behavioural Activation is an effective treatment for older adults with depression. However, there is a lack of detail given in studies about any adaptations made to interventions or efforts made to remove treatment barriers. Factors such as co-morbid physical health problems, cognitive impairment and problems with social support suggest there may be specific treatment considerations when developing interventions for this group. This article aims to describe adaptations made to a general adult Behavioural Activation manual using literature on treatment factors for older adults as an organizational framework. This information may be of use to mental health workers delivering behavioural interventions to older adults with depression and documents the initial phase of developing a complex intervention.

Major depressive disorder (MDD) may be present in 10%-20% of patients in medical settings. Routine depression screening is sometimes recommended to improve depression management. However, studies of the diagnostic accuracy of depression screening tools have typically used data-driven, exploratory methods to select optimal cutoffs. Often, these studies report results from a small range of cutoff points around whatever cutoff score is most accurate in that given study. When published data are combined in meta-analyses, estimates of accuracy for different cutoff points may be based on data from different studies, rather than data from all studies for each possible cutoff point. As a result, traditional meta-analyses may generate exaggerated estimates of accuracy. Individual patient data (IPD) meta-analyses can address this problem by synthesizing data from all studies for each cutoff score to obtain diagnostic accuracy estimates. The nine-item Patient Health Questionnaire-9 (PHQ-9) and...

There is policy interest in the screening and treatment of mental health problems in young people who offend, but the value of such screening is not yet known. To assess the diagnostic test accuracy of screening measures for mental health problems in young people who offend; to evaluate the clinical effectiveness and cost-effectiveness of screening and treatment; to model estimates of cost; to assess the evidence base for screening against UK National Screening Committee criteria; and to identify future research priorities. In total, 25 electronic databases including MEDLINE, PsycINFO, EMBASE and The Cochrane Library were searched from inception until April 2011. Reverse citation searches of included studies were undertaken and reference list of included studies were examined. Two reviewers independently examined titles and abstracts and extracted data from included studies using a standardised form. The inclusion criteria for the review were (1) population - young offenders (aged 10-21 years); (2) intervention/instrument - screening instruments for mental health problems, implementation of a screening programme or a psychological or pharmacological intervention as part of a clinical trial; (3) comparator - for diagnostic test accuracy studies, any standardised diagnostic interview; for trials, any comparator; (4) outcomes - details of diagnostic test accuracy, mental health outcomes over the short or longer term or measurement of cost data; and (5) study design - for diagnostic test accuracy studies, any design; for screening programmes, randomised controlled trials or controlled trials; for clinical effectiveness studies, randomised controlled trials; for economic studies, economic evaluations of screening strategies or interventions. Of 13,580 studies identified, nine, including eight independent samples, met the inclusion criteria for the diagnostic test accuracy and validity of screening measures review. Screening accuracy was typically modest. No studies examined the clinical effectiveness of screening, although 10 studies were identified that examined the clinical effectiveness of interventions for mental health problems. There were too few studies to make firm conclusions about the clinical effectiveness of treatments in this population. No studies met the inclusion criteria for the assessment of the cost-effectiveness of screening or treatment. An exemplar decision model was developed for depression, which identified a number of the likely key drivers of uncertainty, including the prevalence of unidentified mental health problems, the severity of mental health problems and their relationship to generic measures of outcome and the impact of treatment on recidivism. The information evaluated as part of the review was relevant to five of the UK National Screening Committee criteria. On the basis of the above results, none of the five criteria was met. The conclusions of the review are based on limited evidence. Conclusions are tentative and the decision model should be treated as an exemplar. Evidence on the clinical effectiveness and cost-effectiveness of screening for mental health problems in young people who offend is currently lacking. Future research should consider feasibility trials of clinical interventions to establish important parameters ahead of conducting definitive trials. Future diagnostic studies should compare the diagnostic test accuracy of a range of screening instruments, including those recommended for use in the UK in this population. These studies should be designed to reduce the decision uncertainty identified by the exemplar decision model. This study is registered as PROSPERO CRD42011001466. The National Institute for Health Research Health Technology Assessment programme.

Current evidence suggests that Social Stories can be effective in tackling problem behaviours exhibited by children with autism spectrum disorder. Exploring the meaning of behaviour from a child's perspective allows stories to provide social information that is tailored to their needs. Case reports in children with autism have suggested that these stories can lead to a number of benefits including improvements in social interactions and choice making in educational settings. The feasibility of clinical and cost-effectiveness of a Social Stories toolkit will be assessed using a randomised control framework. Participants (n=50) will be randomised to either the Social Stories intervention or a comparator group where they will be read standard stories for an equivalent amount of time. Statistics will be calculated for recruitment rates, follow-up rates and attrition. Economic analysis will determine appropriate measures of generic health and resource use categories for cost-effectiv...

Sudden gains have been linked to improved outcomes in cognitive behaviour therapy for depression. The relationship between sudden gains and outcome is less clear in other treatment modalities, including interpersonal psychotherapy and supportive expressive therapy, which may indicate different mechanisms of change between treatment modalities. The current study examined sudden gains in adults meeting diagnostic criteria for depression (N = 40) offered up to 12 sessions of behavioural activation treatment. Sudden gains were found in 42.5% of the sample. Sudden gains occurred early (median pre-gain session 2) and were related to outcome: those who experienced a sudden gain had significantly lower post-treatment scores on the PHQ-9. Furthermore, the proportion meeting the reliable and clinically significant change criteria at end of treatment was higher in the sudden gain group. These findings highlight the importance of understanding the mechanisms by which sudden gains relate to ther...

The depression module of the Patient Health Questionnaire-9 (PHQ-9) is a widely used depression screening instrument in nonpsychiatric settings. The PHQ-9 can be scored using different methods, including an algorithm based on Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria and a cut-off based on summed-item scores. The algorithm was the originally proposed scoring method to screen for depression. We summarized the diagnostic test accuracy of the PHQ-9 using the algorithm scoring method across a range of validation studies and compared the diagnostic properties of the PHQ-9 using the algorithm and summed scoring method at the proposed cut-off point of 10. We performed a systematic review of diagnostic accuracy studies of the PHQ-9 using the algorithm scoring method to detect major depressive disorder (MDD). We used meta-analytic methods to calculate summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios for diagnosing MDD of the ...

Hopelessness is considered a pre-eminent risk factor for suicide and non-fatal self-harm. We aimed to quantify the ability of the Beck Hopelessness Scale (BHS) to predict these two outcomes. Medline, Embase, PsycINFO and Cinahl were searched to January 2006. We included cohort studies in which the BHS was applied and patients were followed-up to establish subsequent suicide or non-fatal self-harm. Four studies provided usable data on suicide, and six studies provided data on non-fatal self-harm. Summary sensitivity, specificity, likelihood ratios and diagnostic odds ratios (DORs) were calculated for each study. Random effects meta-analytic pooling across studies at the standard cut-off point (> or =9) was undertaken and summary receiver operating characteristic (ROC) curves constructed. For suicide, pooled sensitivity was 0.80 [95% confidence interval (CI) 0.68-0.90], pooled specificity was 0.42 (95% CI 0.41-0.44), and the pooled DOR was 3.39 (95% CI 1.29-8.88). For non-fatal self-harm, pooled sensitivity was 0.78 (95% CI 0.74-0.82), pooled specificity was 0.42 (95% CI 0.38-0.45), and the pooled DOR was 2.27 (95% CI 1.53-3.37). The standard cut-off point on the BHS identifies a high-risk group for potential suicide, but the magnitude of the risk is lower than previously reported estimates. The standard cut-off point is also capable of identifying those who are at risk of future self-harm, but the low specificity rate means it is unlikely to be of use in targeting treatment designed to lower the rate of repetition.

To investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome. Retrospective cohort data analysis. Clinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change. The AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1-3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose-response effect appears to decline in treatments longer than six sessions. Patients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.