Dr Lydia Poole

Senior Lecturer in Clinical Health Psychology
MSc, PhD, CPsychol, FHEA



Mel Ramasawmy, Lydia Poole, Zareen Thorlu-Bangura, Aneesha Chauhan, Mayur Murali, Parbir Jagpal, Mehar Bijral, Jai Prashar, Abigail G-Medhin, Elizabeth Murray, Fiona Stevenson, Ann Blandford, Henry W W Potts, Kamlesh Khunti, Wasim Hanif, Paramjit Gill, Madiha Sajid, Kiran Patel, Harpreet Sood, Neeraj Bhala, Shivali Modha, Manoj Mistry, Vinod Patel, Sarah N Ali, Aftab Ala, Amitava Banerjee (2022)Frameworks for Implementation, Uptake, and Use of Cardiometabolic Disease–Related Digital Health Interventions in Ethnic Minority Populations: Scoping Review, In: JMIR cardio6(2)e37360 JMIR Publications
A. Steptoe, L. Poole (2016)Chapter 8 - Control and Stress, In: Stress: Concepts, Cognition, Emotion, and Behaviorpp. 73-80 Elsevier Inc

Control over aversive experiences is a central construct in stress research, and can come in many guises, from behavioral control over the source of stimulation, through perceptions of control, to cognitive control as a form of coping response. Control modulates the neurobiological and health consequences of stress exposure, and can also be harnessed in clinical and other situations to ameliorate stress responses.

Mark Hamer, Romano Endrighi, Lydia Poole (2012)Physical Activity, Stress Reduction, and Mood: Insight into Immunological Mechanisms, In: Psychoneuroimmunologypp. 89-102 Humana Press

Psychosocial factors, such as chronic mental stress and mood, are recognized as an important predictor of longevity and wellbeing. In particular, depression is independently associated with cardiovascular disease and all-cause mortality, and is often comorbid with chronic diseases that can worsen their associated health outcomes. Regular exercise is thought to be associated with stress reduction and better mood, which may partly mediate associations between depression, stress, and health outcomes. The underlying mechanisms for the positive effects of exercise on wellbeing remain poorly understood. In this overview we examine epidemiological evidence for an association between physical activity and mental health. We then describe the exercise withdrawal paradigm as an experimental protocol to study mechanisms linking exercise, mood, and stress. In particular we will discuss the potential role of the inflammatory response as a central mechanism.

Laura Panagi, Lydia Poole, Andrew Steptoe, Ruth A Hackett (2022)Inflammatory stress responses and future mental health outcomes in people with type 2 diabetes, In: Brain, behavior, & immunity - health23100472 Elsevier BV

Background: Inflammatory dysregulation may be linked with mental health disturbances in people with Type 2 Diabetes (T2D), however no previous studies have examined longitudinal associations between inflammatory stress responses and mental health outcomes in T2D. Purpose: To better understand the biological mechanisms that might predispose people with T2D to poor mental health in the future. Methods: At baseline, 140 participants with T2D participated in a laboratory stress testing study (mean age = 64 years). Participants underwent two mental stress tasks and blood was sampled before and up to 45 min post-stress to detect plasma interleukin (IL)-6. The Center for Epidemiological Studies-Depression scale and the Short Form-36 Health Survey were completed at baseline and 7.5 years later. We tested associations between IL-6 stress responses and a) depression symptoms and b) mental health-related quality of life (QoL) at baseline and at follow-up using linear regression analyses adjusting for age, sex, and body mass index (BMI). Results: Up to 66 participants provided follow-up data. In cross-sectional analyses, increased IL-6 stress responses immediately post-task were associated with lower mental health-related quality of life (B = -21.73, p = 0.005, 95% CI [-36.82, -6.63]) adjusting for age, sex, and BMI. In longitudinal analyses, increased IL-6 stress responses at 45 min post-task were associated with increased depressive symptoms (B = 10.31 p = 0.048, 95% CI [0.10, 20.51]) and decreased mental health-related QoL (B = -21.18 p = 0.031, 95% CI [-40.34, -2.02]) adjusting for age, sex, and BMI. The association between the 45-min IL-6 response and depressive symptoms at follow-up was diminished after further adjustment for physical health-related QoL and baseline depressive symptoms (B = 10.14, p = 0.055, 95% CI [-0.21,20.48]). Conclusions: This study supports the link between inflammatory stress responsivity and future mental health outcomes in people with T2D. Further research involving a larger sample size is required.

Andrew Steptoe, Lydia Poole (2015)Infectious Diseases: Psychosocial Aspects, In: International Encyclopedia of the Social & Behavioral Sciencespp. 32-36 Elsevier Ltd

Infectious diseases, also known as communicable diseases, are illnesses caused by invasive pathogens such as viruses and bacteria. Psychosocial factors (including life stress, mood, social support, and coping responses) have been shown to influence the acquisition of infections such as the common cold, and the activation of latent infections such as genital herpes. Coping styles have also been shown to affect the course of infectious illness and the duration of symptoms. Several mechanisms are involved in mediating these effects, including the suppression of the individual's immune defenses, changes in the reporting of symptoms, and health-related behaviors such as smoking and physical activity.

L Panagi, R A Hackett, A Steptoe, L Poole (2021)Enjoyment of life predicts reduced type 2 diabetes incidence over 12 years of follow-up: findings from the English Longitudinal Study of Ageing, In: Journal of epidemiology and community health75pp. 297-304 BMJ PUBLISHING GROUP

BACKGROUND: Subjective well-being appears to be associated with reduced risk of type 2 diabetes (T2D). However, it is unknown whether this association is similar across different types of well-being. We examined the relationship between hedonic and eudaimonic well-being and incident T2D, and explored the role of sociodemographic, behavioural and clinical factors in these associations. METHODS: We used data from 4134 diabetes-free participants from the English Longitudinal Study of Ageing (mean age =64.97). Enjoyment of life and purpose in life were assessed using items from the CASP-19 to reflect hedonic and eudaimonic well-being, respectively. Participants reported T2D diagnosis over 12 years. We used Cox proportional hazards regression analyses and also explored the percentage of association explained by different covariates. RESULTS: Results revealed a protective role for enjoyment of life in T2D rate adjusting for sociodemographic (age, sex, wealth, ethnicity, marital status), behavioural (physical activity, smoking, alcohol consumption, body mass index) and clinical (hypertension, coronary heart disease and glycated haemoglobin) characteristics (HR =0.93, p=0.021, 95% CI (0.87, 0.99)). Sociodemographic, behavioural and clinical factors accounted for 27%, 27% and 18% of the association, respectively. The relationship between purpose in life and T2D was non-significant (adjusted HR =0.92, p=0.288, 95% CI (0.78, 1.08)). CONCLUSION: This study illustrates how the link between subjective well-being and T2D varies between well-being components. It also demonstrates that sociodemographic, behavioural and clinical factors partially explain this association. Intervention studies examining whether changes in enjoyment of life can help delay T2D onset are warranted.

Mark Hamer, Lydia Poole, Nadine Messerli-Burgy (2013)Television viewing, C-reactive protein, and depressive symptoms in older adults, In: Brain, behavior, and immunity33pp. 29-32 Elsevier

There is emerging evidence for a link between sedentary behavior and mental health, although the mechanisms remain unknown. We tested if an underlying inflammatory process explains the association between sedentary behavior and depressive symptoms. We conducted a two year follow-up of 4964 (aged 64.5 ± 8.9 years) men and women from the English Longitudinal Study of Ageing, a cohort of community dwelling older adults. Self-reported TV viewing time was assessed at baseline as a marker of leisure time sedentary behavior. The eight-item Centre of Epidemiological Studies Depression (CES-D) scale was administered to measure depressive symptoms at follow-up. At baseline, TV time was associated with C-reactive protein (CRP), adjusted geometric mean CRP values were 2.94 mg/L (6 h/d TV). We observed both a direct association of TV time on CES-D score at follow-up (B = 0.08, 95% CI, 0.05, 0.10) and indirect effects (B = 0.07, 95% CI, 0.05, 0.08). The indirect effects were largely explained through lack of physical activity, smoking, and alcohol, but not by CRP or body mass index.

BACKGROUND: The independent effects of depressive symptoms and sleep problems for future physical illness risk have yet to be studied systematically across a variety of disease endpoints. METHODS: We analysed data from 7395 participants (65.81 ± 9.39 years; 54.8% female) from the English Longitudinal Study of Ageing (ELSA). Baseline was wave 4 and participants were followed up for 6 years until wave 7. Sleep was measured using an adapted version of the Jenkins Sleep Problems questionnaire and depressive symptoms using the Centre for Epidemiological Studies Depression scale. Participants with the illness of interest at baseline [coronary heart disease (CHD), cancer, diabetes/high blood glucose, arthritis] were excluded from models predicting the onset of that illness at follow-up. Logistic regression was used, entering depressive symptoms and sleep problems simultaneously into models controlling for a wide range of covariates. RESULTS: In fully adjusted models depressive symptoms predicted incident CHD (OR 1.11, 95% CI 1.04-1.20, p = 0.004) and diabetes/high blood glucose (OR 1.13, 95% CI 1.04-1.22, p = 0.002) independent of sleep problems; both depressive symptoms (OR 1.10, 95% CI 1.04-1.16, p = 0.002) and sleep problems (OR 1.14, 95% CI 1.02-1.26, p = 0.019) predicted incident arthritis. CONCLUSIONS: Sleep problems and depressive symptoms, and a combination of both, were differentially associated with physical illness onset 6 years later. Our findings highlight the importance of taking into account somatic and affective experiences when looking across a variety of different physical illnesses.

Lydia Poole, Tara Kidd, Amy Ronaldson, Marjan Jahangiri, Andrew Steptoe (2016)Cortisol slope predicts depression symptoms 12 months after coronary artery bypass graft surgery, In: Psychoneuroendocrinology71pp. 22-22 Elsevier Ltd
L Poole, M Jackowska (2017)The Epidemiology of Depressive Symptoms and Poor Sleep: Findings from the English Longitudinal Study of Ageing (ELSA), In: International journal of behavioral medicine25pp. 151-161

PURPOSE: The reasons for the comorbidity between depressed mood and poor sleep are not well understood. METHOD: Participants were 5172 adults aged 50 years and older from the English Longitudinal Study of Ageing. Sleep was measured via self-report and depressive symptoms using the Centre for Epidemiological Studies Depression scale. RESULTS: Greater depressive symptoms and sleep complaints were associated with female sex, non-cohabitation, relative poverty, smoking, infrequent physical activity, infrequent alcohol consumption, higher body mass index (BMI), diagnosis of hypertension, coronary heart disease, diabetes/high blood glucose, pulmonary disease, arthritis, and higher levels of fibrinogen and C-reactive protein (all p 

C Singh Solorzano, A Steptoe, E Leigh, T Kidd, M Jahangiri, L Poole (2019)Pre-surgical Caregiver Burden and Anxiety Are Associated with Post-Surgery Cortisol over the Day in Caregivers of Coronary Artery Bypass Graft Surgery Patients, In: International journal of behavioral medicine26pp. 316-322 Springer

BACKGROUND: The relationship between pre-surgical distress and diurnal cortisol following surgery has not been investigated prospectively in caregivers of coronary artery bypass graft (CABG) patients before. We aimed to examine the relationship between pre-surgical anxiety and caregiver burden and diurnal cortisol measured 2 months after the surgery in the caregivers of CABG patients. METHOD: We used a sample of 103 caregivers of elective CABG patients that were assessed 28.86 days before and 60.94 days after patients' surgery. Anxiety and caregiver burden were assessed using the anxiety subscale of the Hospital Anxiety and Depression Scale and the Oberst Burden Scale respectively. Saliva samples were collected to measure cortisol area under the curve with respect to ground (AUCg) and diurnal cortisol slope. Anxiety and caregiver burden were entered into linear regression models simultaneously. RESULTS: While high levels of pre-surgical anxiety were positively associated with increased follow-up levels of AUCg (β = 0.30, p = 0.001), greater pre-surgery perceived burden score was associated with steeper cortisol slope (β = 0.27, p = 0.017) after controlling for a wide range of covariates. CONCLUSION: These outcomes support the utility of psychological interventions aimed to increase the awareness of caregiving tasks and demands in informal caregivers.

L Poole, A Ronaldson, T Kidd, E Leigh, M Jahangiri, A Steptoe (2017)Pre-surgical depression and anxiety and recovery following coronary artery bypass graft surgery, In: Journal of behavioral medicine40pp. 249-258 Springer

We aimed to explore the combined contribution of pre-surgical depression and anxiety symptoms for recovery following coronary artery bypass graft (CABG) using data from 251 participants. Participants were assessed prior to surgery for depression and anxiety symptoms and followed up at 12 months to assess pain and physical symptoms, while hospital emergency admissions and death/major adverse cardiac events (MACE) were monitored on average 2.68 years after CABG. After controlling for covariates, baseline anxiety symptoms, but not depression, were associated with greater pain (β = 0.231, p = 0.014) and greater physical symptoms (β = 0.194, p = 0.034) 12 months after surgery. On the other hand, after controlling for covariates, baseline depression symptoms, but not anxiety, were associated with greater odds of having an emergency admission (OR 1.088, CI 1.010-1.171, p = 0.027) and greater hazard of death/MACE (HR 1.137, CI 1.042-1.240, p = 0.004). These findings point to different pathways linking mood symptoms with recovery after CABG surgery.

H Bawa, L Poole, D Cooke, L Panagi, A Steptoe, R A Hackett (2020)Diabetes-related distress and daily cortisol output in people with Type 2 diabetes, In: Diabetes research and clinical practice169108472 Elsevier

AIMS: Diabetes-related distress is common in Type 2 Diabetes and is linked with poor diabetes control. However, mechanisms underlying this association are unclear. One pathway that could be involved is neuroendocrine dysfunction, as Type 2 Diabetes is associated with altered diurnal cortisol output. This study investigated the link between diabetes-related distress and diurnal cortisol output. METHODS: 134 people with Type 2 Diabetes provided 5 cortisol samples over the course of a day. Multivariate linear regression models were used to assess whether overall and sub-domains of diabetes-related distress measured by the Diabetes Distress Scale, predicted cortisol parameters (waking cortisol, cortisol awakening response, cortisol slope and evening cortisol). RESULTS: Physician-related distress was associated with greater waking (B = 2.747, p = .015) and evening cortisol (B = 1.375, p = .014), and a blunted cortisol awakening response (B = -3.472, p = .038) adjusting for age, sex, income, body mass index, smoking and time of awakening. No associations were detected for overall distress, emotional, interpersonal or regimen distress. CONCLUSION: Physician-related distress was associated with alterations in daily cortisol output. Longitudinal research is required to understand how physician-related distress is associated with diurnal cortisol patterning over time.

Lydia Poole, Rachael Frost, Hannah Rowlands, Georgia Black (2022)Experience of depression in older adults with and without a physical long-term condition: findings from a qualitative interview study, In: BMJ open12e056566 BMJ

OBJECTIVE: To understand how the lived experience of depression differs among patients with a long-term condition (LTC) compared with those without an LTC, and how the experience differs across different types of LTC. DESIGN: Face-to-face, semistructured interviews. SETTING: Primary care; General Practitioner (GP) surgeries in and around North London. PARTICIPANTS: 41 primary care patients with depression were recruited. Our sample comprised participants aged 55–75 years with depression only (n=12), depression and coronary heart disease (n=5), depression and type 2 diabetes (n=10) and depression and arthritis (n=14). RESULTS: Interviews were conducted, audio recorded, transcribed and analysed using thematic analysis. The results revealed that the cardinal diagnostic symptoms of depression (anhedonia, sadness) were experienced by all our participants regardless of LTC. However, the LTC did interact with depression by compounding somatic, cognitive and emotional symptoms, increasing disability and reducing independence, and hindering attempts at coping with mental illness. Our findings demonstrate common experiences across patients as well as key differences based on LTC. CONCLUSIONS: We suggest four key implications for future care practices of these patients: (1) not all participants with depression and LTC view their mental and physical health as interconnected; there should be allowances in care plans for separate treatment pathways; (2) key features of depression that affect LTC management are social withdrawal and lack of motivation to self-manage or access healthcare; (3) key features of LTCs that worsen depression are pain, the unpredictability of future health and progressive disability; (4) positive self-management of LTC could improve self-efficacy and therefore mood, and should be encouraged.

P Frank, A Kaushal, L Poole, S Lawes, T Chalder, D Cadar (2019)Systemic low-grade inflammation and subsequent depressive symptoms: Is there a mediating role of physical activity?, In: Brain, behavior, and immunity80pp. 688-696 Elsevier

OBJECTIVE: Systemic low-grade inflammation has been associated with the onset of depression, but the exact mechanisms underlying this relationship remain elusive. This study examined whether physical activity (PA) explained the association between elevated plasma levels of inflammatory markers and subsequent depressive symptoms. DESIGN: Prospective cohort design. METHOD: The sample consisted of 3,809 non-depressed men and women (aged 50+) recruited from the English Longitudinal Study of Ageing (ELSA). Serum levels of inflammatory markers (C-reactive protein (CRP), fibrinogen) and covariates (age, sex, education, wealth, body mass index, smoking, cholesterol, triglycerides) were measured at baseline (wave 4, 2008/09). Self-reported weekly moderate/vigorous (high) PA versus no weekly moderate/vigorous (low) PA was examined at a four-year follow-up (wave 6, 2012/13), using a single-item question. Depressive symptoms were assessed at baseline, four years (wave 6, 2012/13) and six years post baseline (wave 7, 2014/15), using the 8-item version of the Centre for Epidemiological Studies Depression Scale (CES-D). RESULTS: Participants with higher baseline concentrations of inflammatory markers were significantly more likely to report low PA levels four years later (CRP: OR: 1.25; 95% CI, 1.05-1.48; fibrinogen: OR: 1.18; 95% CI, 1.05-1.39). Moreover, low PA was associated with higher odds of elevated depressive symptoms at follow-up (OR: 1.59; 95% CI, 1.15-2.19). Mediation analyses revealed that low PA explained a total of 36.71% of the relationship between high CRP and elevated depressive symptoms, and 33.26% between higher levels of fibrinogen and elevated depressive symptoms six years later. No direct association was found between systemic low-grade inflammation and subsequently elevated depressive symptoms. CONCLUSION: These results suggest that low PA is a significant partial mediator of the relationship between systemic low-grade inflammation and subsequent elevated depressive symptoms in a nationally representative cohort of older adults.

A Ronaldson, G J Molloy, A Wikman, L Poole, J C Kaski, A Steptoe (2015)Optimism and recovery after acute coronary syndrome: a clinical cohort study, In: Psychosomatic medicine77(3)pp. 311-318

Optimism is associated with reduced cardiovascular mortality, but its impact on recovery after acute coronary syndrome (ACS) is poorly understood. We hypothesized that greater optimism would lead to more effective physical and emotional adaptation after ACS and would buffer the impact of persistent depressive symptoms on clinical outcomes.

L Poole, R A Hackett, L Panagi, A Steptoe (2019)Subjective wellbeing as a determinant of glycated hemoglobin in older adults: longitudinal findings from the English Longitudinal Study of Ageing, In: Psychological medicine50(11)pp. 1820-1828 Cambridge University Press

BACKGROUND: Previous research has shown an association between subjective wellbeing and incident diabetes. Less is known about the role of wellbeing for subclinical disease trajectories as captured via glycated hemoglobin (HbA1c). We aimed to explore the association between subjective wellbeing and future HbA1c levels, and the role of sociodemographic, behavioral and clinical factors in this association. METHODS: We used data from the English Longitudinal Study of Ageing for this study (N = 2161). Subjective wellbeing (CASP-19) was measured at wave 2 and HbA1c was measured 8 years later at wave 6. Participants were free from diabetes at baseline. We conducted a series of analyses to examine the extent to which the association was accounted for by a range of sociodemographic, behavioral and clinical factors in linear regression models. RESULTS: Models showed that subjective wellbeing (CASP-19 total score) was inversely associated with HbA1c 8 years later after controlling for depressive symptoms, age, sex, and baseline HbA1c (B = -0.035, 95% CI -0.060 to -0.011, p = 0.005). Inclusion of sociodemographic variables and behavioral factors in models accounted for a large proportion (17.0% and 24.5%, respectively) of the relationship between wellbeing and later HbA1c; clinical risk factors explained a smaller proportion of the relationship (3.4%). CONCLUSIONS: Poorer subjective wellbeing is associated with greater HbA1c over 8 years of follow-up and this relationship can in part be explained by sociodemographic, behavioral and clinical factors among older adults.

A Ronaldson, L Poole, T Kidd, E Leigh, M Jahangiri, A Steptoe (2014)Optimism measured pre-operatively is associated with reduced pain intensity and physical symptom reporting after coronary artery bypass graft surgery, In: Journal of psychosomatic research77(4)pp. 278-282

Optimism is thought to be associated with long-term favourable outcomes for patients undergoing coronary artery bypass graft (CABG) surgery. Our objective was to examine the association between optimism and post-operative pain and physical symptoms in CABG patients.

L Poole, E Leigh, T Kidd, A Ronaldson, M Jahangiri, A Steptoe (2014)The combined association of depression and socioeconomic status with length of post-operative hospital stay following coronary artery bypass graft surgery: data from a prospective cohort study, In: Journal of psychosomatic research76(1)pp. 34-40 Elsevier

To understand the association between pre-operative depression symptoms, including cognitive and somatic symptom subtypes, and length of post-operative stay in patients undergoing coronary artery bypass graft (CABG) surgery, and the role of socioeconomic status (SES).

T Kidd, L Poole, A Ronaldson, E Leigh, M Jahangiri, A Steptoe (2016)Attachment anxiety predicts depression and anxiety symptoms following coronary artery bypass graft surgery, In: British Journal of Health Psychology 21(4)pp. 796-811 Wiley

Abstract Objective Depression and anxiety are associated with poor recovery in coronary artery bypass graft (CABG) patients, but little is known about predictors of depression and anxiety symptoms. Design We tested the prospective association between attachment orientation, and symptoms of depression and anxiety in CABG patients, 6–8 weeks, and 12 months following surgery. Method One hundred and fifty-five patients who were undergoing planned CABG surgery were recruited. Patients completed questionnaires measuring attachment, depression, and anxiety prior to surgery, then 6–8 weeks, and 12 months after surgery. Results Attachment anxiety predicted symptoms of depression and anxiety at both follow-up time points, whereas attachment avoidance was not associated with depression or anxiety symptoms. The findings remained significant when controlling for baseline mood scores, social support, demographic, and clinical risk factors. Conclusion These results suggest that attachment anxiety is associated with short-term and long-term depression and anxiety symptoms following CABG surgery. These results may offer important insight into understanding the recovery process in CABG surgery.

Objective: To assess the association between depressive symptoms and incident chronic illness burden in prospective longitudinal analyses. // Methods: We analysed data from 2472 participants (62.88 ± 8.49 years old; 50.8% female) from the English Longitudinal Study of Ageing (ELSA). Depressive symptoms were measured using the Centre for Epidemiological Studies Depression (CES-D) scale at baseline in 2004, and participants were followed up for 10 years. Participants with prevalent illness at baseline (coronary heart disease [CHD], other cardiac illness, stroke, cancer, diabetes/high blood glucose, arthritis, lung disease, osteoporosis and Parkinson's disease) were excluded from models predicting illness burden (the sum of illnesses reported) over follow-up. Linear regression was used controlling for a wide range of covariates. // Results: The mean chronic illness burden was 0.57, with 43.1% experiencing at least one incident physical illness. Baseline continuous CES-D score was a significant predictor of incident chronic illness burden up to 10 years later (incident rate ratio = 1.05, 95% confidence intervals = 0.05–0.21, p = .003), independent of sociodemographic, behavioural, cognitive and clinical covariates. Sensitivity analyses excluding participants who developed a chronic illness within the 2 years following baseline corroborated the main results. // Conclusion: Depressive symptoms were associated with greater incident chronic illness burden 10 years later. These findings have clinical implications for the treatment of depression in physically healthy older adults.

C S Solorzano, E Leigh, A Steptoe, A Ronaldson, T Kidd, M Jahangiri, L Poole (2021)The impact of caregiving burden on mental well-being in coronary artery bypass graft surgery caregivers: The mediatory role of perceived social support, In: International journal of environmental research and public health18(10)5447

An increase in caregiver burden and a decrease in social support have both been identified as predictors of poor caregiver psychological distress. However, little is known about the role of these factors in coronary artery bypass graft (CABG) caregivers. The purpose of this study was to investigate whether change in perceived social support from pre to post surgery mediated the relationship between change in caregiver burden and caregiver depressive symptoms and subjective well-being post surgery. A sample of 101 caregivers of elective CABG patients were assessed 28 days before and 62 days after patients’ surgery. Caregivers completed the Oberst Burden Scale, the Enhancing Recovery in Coronary Heart Disease (ENRICHD) Social Support Instrument, the Beck Depression Inventory, and the Control, Autonomy, Self-Realisation, and Pleasure (CASP-19) scale. Simple mediation analyses showed that change in social support significantly mediated both the relationship between change in caregiver burden and post-surgery depressive symptoms (unstandardised β = 0.041, 95% CI (0.005, 0.112)) and the relationship between change in caregiver burden and post-surgery subjective well-being (unstandardised β = 0.071, 95% CI (0.001, 0.200)). Psychological interventions aimed at the CABG caregiver population should promote social support to deal with the increase of caregivers’ tasks and demands after the patients’ surgery.

M Ramasawmy, L Poole, A Banerjee (2021)Learning our lesson: using past policies to improve digital and ethnic inequalities beyond the pandemic, In: Archives of public health79218 BioMedCentral

COVID-19 has had a disproportionate impact on ethnic minorities in the UK, raising questions about whether learning from the past few decades about the interplay between ethnicity and health inequalities has been effectively incorporated in current health policy. As digital health approaches, such as remote consultations and apps, become more widespread during and after the pandemic, it is important to ensure that these do not contribute to 'widening the gap'. We highlight three areas in which existing knowledge and evidence can be translated into cross-sectoral action to avoid further ethnic and digital health inequalities: data and measurement, improved communication, and embedded equality impact.

A Ronaldson, T Kidd, L Poole, E Leigh, M Jahangiri, A Steptoe (2015)Diurnal Cortisol Rhythm Is Associated With Adverse Cardiac Events and Mortality in Coronary Artery Bypass Patients, In: The journal of clinical endocrinology & metabolism100(10)pp. 3676-3682 Oxford University Press

PURPOSE: There is growing evidence that the hypothalamic-pituitary-adrenal axis plays a role in the progression of cardiovascular disease. We examined the relationship between diurnal cortisol rhythm and adverse events in patients undergoing coronary artery bypass graft (CABG) surgery. We hypothesized that a flatter presurgical diurnal cortisol slope would be associated with higher rates of adverse cardiac events and death in the years following the CABG procedure. METHODS: Repeated measures of saliva were taken over the day from 250 CABG patients 1 month before surgery to assess diurnal cortisol slope and overall output (area under the curve). Long-term clinical outcomes were occurrence of a major adverse cardiac event (MACE) and death, and were collected up to 2.68 (SD = 0.40) years after surgery. Cox proportional hazard models were used to determine relationships between presurgical cortisol and clinical outcomes. EuroSCORE, chronic illness burden, and whether or not the patient had undergone cardiopulmonary bypass were included as covariates in the models. RESULTS: Diurnal cortisol slope predicted the occurrence of MACE or death after surgery (hazard ratio = 0.73; 95% confidence interval = 0.56-0.96; P = .023). Patients with a steeper slope were at reduced risk of adverse outcomes. This association was driven by changes in both waking and evening cortisol levels. CONCLUSION: These results provide evidence for a link between diurnal cortisol rhythm and recovery after CABG. Measuring diurnal cortisol slope before surgery may help to identify those patients at risk of adverse outcomes in the years after the procedure.

L Panagi, L Poole, R A Hackett, A Steptoe (2019)Happiness and Inflammatory Responses to Acute Stress in People With Type 2 Diabetes, In: Annals of behavioral medicine53(4)pp. 309-320 Oxford University Press

Background: Positive psychological characteristics in people with type 2 diabetes (T2D) are associated with better health and longevity, and one plausible physiological mechanism involves lower markers of inflammation. Positive affect is related to lower basal inflammatory markers and smaller inflammatory responses to acute stress, but this association in people with T2D remains to be examined. Purpose: To examine the relationship between happiness and inflammatory markers at baseline and in response to acute stress in people with T2D. Methods One hundred forty people with T2D took part in laboratory-based stress testing. We aggregated daily happiness ratings over 7 days before stress testing. During the laboratory session, participants underwent two mental stress tasks—the mirror tracing and the Stroop task. Blood was sampled at baseline and post-stress (up to 75 min post-stress) to detect plasma interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1Ra), and monocyte chemoattractant protein-1 (MCP-1). Associations between happiness and inflammatory markers and responses were analyzed using multivariable linear regressions. Results: Greater daily happiness significantly predicted lower baseline and post-stress IL-6 concentrations, and lower baseline MCP-1, after adjusting for covariates. The association between happiness and reduced basal IL-6 maintained after further controlling for daily sadness. We did not find significant associations between daily happiness and inflammatory responses to acute stress. No associations were detected for IL-1Ra. Conclusions: Happier individuals with T2D have lower inflammatory markers before and after acute stress, albeit independent of stress responsivity. Findings could provide a protective physiological pathway linking daily happiness with better health in people with T2D.

T Kidd, L Poole, E Leigh, A Ronaldson, M Jahangiri, A Steptoe (2015)Health-related personal control predicts depression symptoms and quality of life but not health behaviour following coronary artery bypass graft surgery, In: Journal of behavioral medicine39pp. 120-127 Springer

To determine the prospective association between health-related control beliefs, quality of life (QOL), depression symptoms, and health behaviours in coronary artery bypass graft (CABG) patients 6-8 weeks following surgery. 149 patients who were undergoing planned CABG surgery were recruited. Patients completed questionnaires measuring health related personal control, treatment control, depression symptoms, QOL, and health behaviours prior to and 6-8 weeks after surgery. Higher levels of health-related personal control predicted better QOL, and lower levels of depression symptoms, but not adherence to medication, cardiac rehabilitation attendance, or physical activity. These results were independent of demographic, behavioural, and clinical covariates. Treatment control was not associated with any outcome. These results suggest that perceived health-related personal control is associated with key aspects of short-term recovery from CABG surgery. Targeted interventions aimed at improving perceptions of health-related personal control may improve health outcomes in this cardiac population.

L Poole, M Ramasawmy, A Banerjee (2021)Digital first during the COVID-19 pandemic: does ethnicity matter?, In: The Lancet public health6(9)pp. E628-E630 ELSEVIER SCI LTD

STUDY OBJECTIVES: This study investigated whether sleep problems, sleep duration and a combination of short or long sleep with sleep problems were predictive of depressive symptoms six years later. METHODS: Participants were 4545 men and women aged 50 years or older from the English Longitudinal Study of Ageing. Sleep problems were indexed through self-report enquiring about the most frequent insomnia symptoms including difficulties falling asleep, waking up several times a night and waking up in the morning feeling tired. Sleep duration was ascertained by asking about average sleep in the weeknight. Depressive symptoms were measured with the Center for Epidemiologic Studies Depression scale. RESULTS: Sleep problems were predictive of elevated depressive symptoms at follow-up (odds ratio [OR] = 1.36, 95% confidence interval [CI] = 1.19–1.56). When explored separately, waking up in the morning feeling tired (OR = 1.71, 95% CI = 1.24–2.37) followed by difficulties falling asleep (OR = 1.49, 95% CI = 1.06–2.11) were also predictors of future depressive symptoms. Compared to optimal duration, short (OR = 1.90, 95% CI = 1.34–2.71) but not long sleep hours were also linked to elevated depressive symptoms. Participants reporting short sleep hours combined with high sleep problems also had an elevated risk of depressive symptoms six years later (OR = 1.85, 95% CI = 1.15–3.00). Long sleep combined with high sleep problems was not predictive of depressive symptoms. CONCLUSIONS: Short and disturbed sleep and their combination increase the risk of future depressive symptoms in older adults.

L Poole, A Ronaldson, T Kidd, E Leigh, M Jahangiri, A Steptoe (2016)Pre-Operative Cognitive Functioning and Inflammatory and Neuroendocrine Responses to Cardiac Surgery, In: Annals of behavioral medicine50(4)pp. 545-553 Oxford University Press

BACKGROUND: Cognitive functioning is linked to cardiac mortality and morbidity, but the mechanisms underlying this relationship are unclear. PURPOSE: To examine the relationship between pre-operative cognitive functioning and post-operative inflammatory and neuroendocrine responses in patients undergoing coronary artery bypass graft (CABG) surgery. METHODS: One-hundred ninety-three outpatients were screened to assess their cognitive function using the Montreal Cognitive Assessment (MoCA) on average 30 days prior to CABG surgery and provided blood samples for the measurement of interleukin (IL)-6 and C-reactive protein (CRP) and saliva samples for the measurement of diurnal cortisol. Participants were followed-up 4-8 days following surgery for the repeat measurement of IL-6 and CRP and 60 days after surgery for the measurement of diurnal salivary cortisol. RESULTS: Patients with low cognitive function (MoCA 

Lydia Poole, Chris Dickens, Andrew Steptoe (2011)The puzzle of depression and acute coronary syndrome: Reviewing the role of acute inflammation, In: Journal of psychosomatic research71(2)pp. 61-68 Elsevier

The relationship between depression and coronary heart disease is well-established, but causal mechanisms are poorly understood. The aim of this review is to stimulate different ways of viewing the relationship between depression and adverse outcomes following acute coronary syndrome (ACS) and coronary artery bypass graft (CABG) surgery patients. We present an argument for depression in ACS and CABG patients being a qualitatively distinct form from that observed in psychiatric populations. This is based on three features: (1) depression developing after cardiac events has been linked in many studies to poorer outcomes than recurrent depression; (2) somatic symptoms of depression following cardiac events are particularly cardiotoxic; (3) depression following an ACS does not respond well to antidepressant treatments. We propose that inflammation is a common causal process responsible in part both for the development of depressive symptoms and for adverse cardiac outcomes, and we draw parallels with inflammation-induced sickness behaviour. Clinical implications of our observations are discussed along with suggestions for further work to advance the field. (C) 2010 Elsevier Inc. All rights reserved.

Laura Panagi, Lydia Poole, Ruth A Hackett, Andrew Steptoe (2019)Sex differences in interleukin-6 stress responses in people with Type 2 diabetes, In: Psychophysiology56(6)e13334

People with Type 2 diabetes (T2D) show dysregulated inflammatory responses to acute stress, but the effect of sex on inflammatory responses in T2D remains unclear. The purpose of this study was to investigate differences in interleukin (IL)-6 stress responses between older men and women with T2D. One hundred and twenty-one people (76 men; mean age = 64.09, SD = 7.35, 45 women; mean age = 63.20, SD = 6.70) with doctor-verified T2D took part in this laboratory-based stress testing study. Participants carried out acute mental stress tasks, and blood was sampled at baseline, immediately poststress, 45 min poststress, and 75 min poststress to detect plasma IL-6 concentrations. IL-6 change scores were computed as the difference between the baseline measurement and the three time points poststress. Main effects and interactions were tested using mixed model analysis of covariance. We found a significant main effect of time on IL-6 levels, and a significant Sex × Time interaction. In adjusted analyses including the three change scores and all the covariates, the significant Sex × Time interaction was maintained; IL-6 responses were greater in women at 45 and 75 min poststress compared with men, adjusting for age, body mass index, smoking, household income, glycated hemoglobin, oral antidiabetic medication, insulin/other injectable antidiabetic medication, depressive symptoms, and time of day of testing. Different inflammatory stress response pathways are present in men and women with T2D, with women producing larger IL-6 increases. The long-term implications of these differences need to be elucidated in future studies.

Reka Agnes Haraszti, Gyorgy Purebl, Gyongyver Salavecz, Lydia Poole, Samantha Dockray, Andrew Steptoe (2014)Morningness-eveningness interferes with perceived health, physical activity, diet and stress levels in working women: A cross-sectional study, In: Chronobiology international31(7)pp. 829-837 Taylor & Francis

Sleep and health are closely interrelated and sleep quality is a well-known contributor to perceived health. However, effects of sleep-timing preference i.e. morningness-eveningness on health has yet to be revealed. In this study, we explored the relationship between morningness-eveningness and perceived health in a sample of female working professionals (N = 202). Sleep-timing preference was measured using the Composite Scale of Morningness. Perceived health was characterized by Center for Epidemiologic Studies Depression Scale, WHO Well-Being Scale-5 and Patient Health Questionnaire-15 scores. We also investigated possible mechanisms, including stress and health-impairing behaviours. In accordance with previous data, we found more depressive mood, lower well-being and poorer perceived health among evening types. To assess health-impairing behaviours we collected data on smoking habits, alcohol consumption, physical activity and diet. Among the possible mechanism variables, greater stress, less frequent physical activity and less healthy diet were associated with eveningness. Furthermore, stress diminished the strength of the association between morningness-eveningness and depressed mood. Physical activity attenuated the strength of the association between morningness-eveningness and well-being. No effects of alcohol consumption could be identified. Our data show that evening preference behaves as a health risk in terms of associating with poor perceived health. Our findings also suggest that this effect might be mediated by health behaviours and stress.

Lydia Poole, Mark Hamer, Andrew J. Wawrzyniak, Andrew Steptoe (2011)The effects of exercise withdrawal on mood and inflammatory cytokine responses in humans, In: Stress (Amsterdam, Netherlands)14(4)pp. 439-447 Taylor & Francis

Mechanisms underlying the relationship between exercise and mood are not well understood. This study sought to investigate the role of pro- and anti-inflammatory cytokines and autonomic balance in determining the impact of exercise withdrawal on negative mood. Healthy men and women who regularly exercised (N == 26, mean age == 25.5 years, SD == 4.5 years) were randomised to exercise withdrawal or exercise maintenance for 2 weeks. Protocol adherence was monitored using accelerometers. Inflammatory markers from plasma (interleukin-6, IL-6; tumour necrosis factor-alpha; interleukin-10; and interleukin-1 receptor antagonist), heart-rate variability (HRV) and measures of mood (General Health Questionnaire-28 (GHQ) and the Profile of Mood States (POMS)) were assessed at study entry and at 2-week follow-up. Exercise withdrawal resulted in significant increases in negative mood over time on both the GHQ (p == 0.028) and the POMS (p == 0.005). Following the intervention, IL-6 concentration was lower in the exercise withdrawal than exercise maintenance condition (p == 0.05). No intervention effects were observed for other cytokines or HRV. The mood changes were significantly related to changes in IL-6 concentration (beta beta == -- 0.50, p == 0.011), indicating that reduction in IL-6 was related to increased negative mood. Our results are consistent with positive effects of exercise on mental health, but further research on inflammatory pathways is warranted.

Andrew Steptoe, Lydia Poole (2011)Use of Biological Measures in Behavioral Medicine, In: A Steptoe (eds.), Handbook of Behavioral Medicinepp. 619-632 Springer Nature
Angelo Compare, Enzo Grossi, Riccardo Bigi, Riccardo Proietti, Edo Shonin, Pedro Silva Orrego, Lydia Poole (2014)Stress-Induced Cardiomyopathy and Psychological Wellbeing 1 Year After an Acute Event, In: Journal of clinical psychology in medical settings21(1)pp. 81-91 Springer Nature

Stress cardiomyopathy (SCM) typically presents similar symptoms to acute myocardial infarction (AMI). However, these symptoms differ when it comes to a transient and completely reversible myocardial dysfunction, which is frequently precipitated by acute stressful events, occurring in the absence of plaque rupture and coronary thrombosis. The purpose of this study was to investigate health-related quality of life (HRQL) and emotional burden subsequent to cardiac events in SCM patients. Thirty-seven SCM patients were compared with 37 matched AMI patients. All selected patients were assessed for HRQL and psychological distress at baseline and 1-year after the acute event. After controlling for covariates, scores on the Psychological General Well Being Index indicated that depressed mood had increased in both groups, but the increase for SCM patients was greater than for AMI patients. The AMI group displayed greater decreases than the SCM in physical quality of life and in total cardiac-related health quality of life. The percentage of patients with psychological distress increased significantly more in the SCM group than in the AMI group, and it made no difference whether the triggering event was emotional or physical. Our results suggest that, despite the more favorable medical prognosis of SCM patients, their cardiac condition being transient and resolving completely in few weeks, the psychological impact associated with their condition is more negative 1 year later than in the case of AMI patients whose medical prognosis is less favorable, and this difference is independent of type of trigger event.

Lydia Poole, Andrew Steptoe, Andrew J. Wawrzyniak, Sophie Bostock, Ellen S. Mitchell, Mark Hamer (2011)Associations of objectively measured physical activity with daily mood ratings and psychophysiological stress responses in women, In: Psychophysiology48(8)pp. 1165-1172 Wiley

The aim of this study was to examine associations of objectively measured physical activity with daily mood ratings and psychophysiological stress responses. We recruited 40 healthy females (aged 28.7 +/- 6.1 yrs) who completed a once-a-day mood rating scale for 7 days, along with a 7-day assessment of physical activity using accelerometers and psychophysiological stress testing. The findings suggest that levels of physical activity as measured using an accelerometer are associated with both depressive symptoms over the past 2 weeks (CES-D) (r=-.33, p=.038) and with daily positive emotional style (r=.49, p=.001). The relationship between physical activity and positive emotional style remained after controlling for age, body mass index, and negative emotional style (t=3.31, p=.002). Physical activity was not related to any psychophysiological stress responses.

Background: Depression and inflammation are interrelated, and both are associated with the development of long-term conditions (LTCs). We investigated whether the combination of elevated depressive symptoms and elevated C-reactive protein (CRP) was associated with the rate of onset of a range of LTCs. Methods: We analysed data from 5360 participants (65.77 +/- 9.46 years; 54.1% female) from the English Longitudinal Study of Ageing (ELSA). Depressive symptoms were indicated using the Centre for Epidemiological Studies Depression (CES-D) scale and scores were combined with high sensitivity (hs)-CRP values to reflect the additive interaction between low/high depressive symptoms (CES-D >= 4) and low/high CRP (> 3mg/L). Participants were followed-up for up to 12 years to predict incident illness. Cox proportional hazard regression was used controlling for covariates. Results: In fully adjusted models, the combination of elevated depressive symptoms and elevated CRP was an independent predictor of coronary heart disease (CHD) (HR = 1.68, 95% C.I. = 1.01-2.78), stroke (HR = 2.02; 95% C.I. = 1.48-2.76), diabetes/high blood glucose (HR = 1.69; 95% C.I. = 1.11-2.57), and pulmonary disease (HR = 1.79; 95% C.I. = 1.02-3.15) relative to low depressive symptoms/low CRP, independently of age, sex, wealth, cohabitation, smoking status, body mass index and hypertension. Elevated depressive symptoms and low CRP was associated with arthritis incidence (HR = 1.49; 95% C.I. = 1.15-1.92). No association was found for cancer incidence. Conclusion: A combination of depressive symptoms and CRP was implicated in the onset of CHD, stroke, diabetes/high blood glucose, and pulmonary disease up to 12 years later, reflecting the role of psychobiological processes across multiple disease states.

Lydia Poole, Tara Kidd, Elizabeth Leigh, Amy Ronaldson, Marjan Jahangiri, Andrew Steptoe (2014)Preoperative Sleep Complaints Are Associated with Poor Physical Recovery in the Months Following Cardiac Surgery, In: Annals of behavioral medicine47(3)pp. 347-357 Oxford Univ Press

Sleep disturbance is associated with poorer outcomes in cardiac patients, but little is known about the independent role of sleep quality in coronary artery bypass graft (CABG) patients. This study aims to examine the relationship between preoperative sleep complaints and post-operative emotional and physical recovery in CABG surgery patients, independently of demographic, clinical and mood factors. Two hundred thirty CABG patients (aged 67.81 +/- 9.07 years) completed measures of self-reported sleep complaints before surgery and health-related quality of life (HRQoL), physical symptoms and pain 2 months after surgery. Greater sleep complaints prior to surgery were associated with greater physical symptoms, poorer physical HRQoL and greater sensory pain after surgery (p < 0.05), but not with affective pain or mental HRQoL. Preoperative mood was not able to explain these associations. Sleep complaints may be implicated in physical recovery from CABG surgery but further work is needed to understand the role of causal pathways.

Lydia Poole, Tara Kidd, Elizabeth Leigh, Amy Ronaldson, Marjan Jahangiri, Andrew Steptoe (2015)Psychological Distress and Intensive Care Unit Stay After Cardiac Surgery: The Role of Illness Concern, In: Health psychology34(3)pp. 283-287 Amer Psychological Assoc

Objective: To examine the association between psychological factors and length of intensive care unit (ICU) stay in patients undergoing elective coronary artery bypass graft (CABG) surgery. Method: We studied 212 adults undergoing CABG surgery preoperatively to assess depression symptoms, anxiety symptoms, and illness perceptions and then followed them up during the in-hospital stay to measure length of ICU stay. Results: Greater preoperative concern about the illness (B = .200, 95% CI [.094,.305], p = < .001), but not depression or anxiety symptoms, was significantly related to longer ICU stays after controlling for demographic, clinical, and behavioral covariates. Conclusions: Illness concern may be particularly relevant for CABG recovery, though more work is needed to delineate the exact mechanisms of this effect.

Andrew Steptoe, Lydia Poole, Amy Ronaldson, Tara Kidd, Elizabeth Leigh, Marjan Jahangiri (2015)Depression 1 Year After CABG Is Predicted by Acute Inflammatory Responses, In: Journal of the American College of Cardiology65(16)pp. 1710-1711 Elsevier
Ruth A Hackett, Lydia Poole, Elizabeth Hunt, Laura Panagi, Andrew Steptoe (2019)Loneliness and biological responses to acute stress in people with Type 2 diabetes, In: Psychophysiology56(6)e13341

Loneliness is linked with all-cause mortality and coronary heart disease. Altered neuroendocrine and inflammatory responses to stress constitute potential pathways linking loneliness and ill-health. Stress responsivity is modified in people with Type 2 diabetes, but it is unclear whether loneliness influences biological stress responses in this population. We assessed interleukin-6 (IL-6), interleukin-1 receptor antagonist (IL-1RA), monocyte chemoattractant protein-1 (MCP-1), and cortisol responses to acute stress in 135 people with Type 2 diabetes. Loneliness was measured used the Revised UCLA Loneliness Scale. Loneliness was inversely associated with cortisol output poststress (B = -4.429, p = 0.019) independent of age, sex, education, marital status, body mass index, and smoking. Lonelier individuals had raised MCP-1 concentrations 75 min poststress independent of covariates (B = 0.713, p = 0.022). No associations between loneliness and IL-6 or IL-1RA concentrations were detected. These results suggest that loneliness is associated with disturbances in stress responsivity in people with diabetes, and the impact of loneliness on health in people with diabetes may be mediated in part through dysregulation of inflammatory and neuroendocrine systems. Future research is required to understand if such changes increase the risk of poorer outcomes in this population.

Tara Kidd, Lydia Poole, Elizabeth Leigh, Amy Ronaldson, Marjan Jahangiri, Andrew Steptoe (2014)Attachment anxiety predicts IL-6 and length of hospital stay in coronary artery bypass graft surgery (CABG) patients, In: Journal of psychosomatic research77(2)pp. 155-157 Elsevier

Objective: The mechanisms underlying the association between adult attachment and health are not well understood. In the current study, we investigated the relationship between attachment anxiety, attachment avoidance; inflammation, and length of hospital stay in coronary artery bypass graft (CABG) surgery patients. Method: 167 CABG patients completed an attachment questionnaire prior to surgery, and blood samples were taken before and after surgery to assess inflammatory activity. Results: We found that attachment anxiety predicted higher plasma interleukin 6 (IL-6) concentration, and this association was mediated by self-reported sleep quality. Anxious attachment also predicted longer hospital stays following CABG surgery, even after controlling for demographic and clinical factors. Conclusion: These data suggest that increased levels of IL-6 may be a process linking adult attachment anxiety with health outcomes. (C) 2014 The Authors. Published by Elsevier Inc.