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The COVID-19 pandemic has disproportionally affected the mental health of health and social care workers (HSCWs), with many experiencing symptoms of depression, anxiety and post-traumatic stress disorder. Psychological interventions have been offered via mental health services and in-house psychology teams, but their effectiveness in this context is not well documented.
To evaluate a stepped-care psychological support pathway for HSCWs from Homerton Healthcare Foundation Trust in London, which offered psychological first aid, evidence-based psychological therapies and group-based well-being workshops.
The service evaluation used a pre–post approach to assess depression, anxiety, functional impairment and post-traumatic stress disorder symptom change for those who attended sessions of psychological first aid, low- or high-intensity cognitive–behavioural therapy or a combination of these. In addition, the acceptability of the psychological first aid sessions and well-being workshops was explored via feedback data.
Across all interventions, statistically significant reductions of depression (d = 1.33), anxiety (d = 1.37) and functional impairment (d = 0.93) were observed, and these reductions were equivalent between the interventions, as well as the demographic and occupational differences between the HSCWs (ethnicity, staff group and redeployment status). HSCWs were highly satisfied with the psychological first aid and well-being workshops.
The evaluation supports the utility of evidence-based interventions delivered as part of a stepped-care pathway for HSCWs with common mental health problems in the context of the COVID-19 pandemic. Given the novel integration of psychological first aid within the stepped-care model as a step one intervention, replication and further testing in larger-scale studies is warranted.
The transition to university and resultant social support network disruption can be detrimental to the mental health of university students. As the need for mental health support is becoming increasingly prevalent in students, identification of factors associated with poorer outcomes is a priority. Changes in social functioning have a bi-directional relationship with mental health, however it is not clear how such measures may be related to effectiveness of psychological treatments.
Growth mixture models were estimated on a sample of 5221 students treated in routine mental health services to identify different trajectories of change in self-rated impairment in social leisure activities and close relationships during the course of treatment. Multinomial regression explored associations between trajectory classes and treatment outcomes.
Five trajectory classes were identified for social leisure activity impairment while three classes were identified for close relationship impairment. In both measures most students remained mildly impaired. Other trajectories included severe impairment with limited improvement, severe impairment with delayed improvement, and, in social leisure activities only, rapid improvement, and deterioration. Trajectories of improvement were associated with positive treatment outcomes while trajectories of worsening or stable severe impairment were associated with negative treatment outcomes.
Changes in social functioning impairment are associated with psychological treatment outcomes in students, suggesting that these changes may be associated with treatment effectiveness as well as recovery experiences. Future research should seek to establish whether a causal link exists to understand whether integrating social support within psychological treatment may bring additional benefit for students.
Depression is an important, potentially modifiable dementia risk factor. However, it is not known whether effective treatment of depression through psychological therapies is associated with reduced dementia incidence. The aim of this study was to investigate associations between reduction in depressive symptoms following psychological therapy and the subsequent incidence of dementia.
National psychological therapy data were linked with hospital records of dementia diagnosis for 119808 people aged 65+. Participants received a course of psychological therapy treatment in Improving Access to Psychological Therapies (IAPT) services between 2012 and 2019. Cox proportional hazards models were run to test associations between improvement in depression following psychological therapy and incidence of dementia diagnosis up to eight years later.
Improvements in depression following treatment were associated with reduced rates of dementia diagnosis up to 8 years later (HR = 0.88, 95% CI 0.83–0.94), after adjustment for key covariates. Strongest effects were observed for vascular dementia (HR = 0.86, 95% CI 0.77–0.97) compared with Alzheimer's disease (HR = 0.91, 95% CI 0.83–1.00).
Reliable improvement in depression across psychological therapy was associated with reduced incidence of future dementia. Results are consistent with at least two possibilities. Firstly, psychological interventions to improve symptoms of depression may have the potential to contribute to dementia risk reduction efforts. Secondly, psychological therapies may be less effective in people with underlying dementia pathology or they may be more likely to drop out of therapy (reverse causality). Tackling the under-representation of older people in psychological therapies and optimizing therapy outcomes is an important goal for future research.
Experience of crisis care may vary across different care models.
To explore the experience of care in standard care and ‘open dialogue’ (a peer-supported community service focused on open dialogue and involving social networks for adults with a recent mental health crisis) 3 months after a crisis.
We conducted semi-structured interviews with 11 participants (6 received open dialogue; 5 received treatment as usual (TAU)) in a feasibility study of open dialogue and analysed the data using a three-step inductive thematic analysis to identify themes that (a) were frequently endorsed and (b) represented the experiences of all participants.
Four themes emerged: (a) feeling able to rely on and access mental health services; (b) supportive and understanding family and friends; (c) having a choice and a voice; and (d) confusion and making sense of experiences. Generally, there was a divergence in experience across the two care models. Open dialogue participants often felt able to rely on and access services and involve their family and friends in their care. TAU participants described a need to rely on services and difficulty when it was not met, needing family and friends for support and wanting them to be more involved in their care. Some participants across both care models experienced confusion after a crisis and described benefits of sense-making.
Understanding crisis care experiences across different care models can inform service development in crisis and continuing mental healthcare services.
To determine: whether young adults (aged 18–24) not in education, employment or training (NEET) have different psychological treatment outcomes to other young adults; any socio-demographic or treatment-related moderators of differential outcomes; and whether service-level changes are associated with better outcomes for those who are NEET.
A cohort was formed of 20 293 young adults treated with psychological therapies in eight Improving Access to Psychological Therapies services. Pre-treatment characteristics, outcomes, and moderators of differential outcomes were compared for those who were and were not NEET. Associations between outcomes and the following were assessed for those that were NEET: missing fewer sessions, attending more sessions, having a recorded diagnosis, and waiting fewer days between referral and starting treatment.
Those who were NEET had worse outcomes: odds ratio (OR) [95% confidence interval (CI)] for reliable recovery = 0.68 (0.63–0.74), for deterioration = 1.41 (1.25–1.60), and for attrition = 1.31 (1.19–1.43). Ethnic minority participants that were NEET had better outcomes than those that were White and NEET. Living in deprived areas was associated with worse outcomes. The intensity of treatment (high or low) did not moderate outcomes, but having more sessions was associated with improved outcomes for those that were NEET: odds (per one-session increase) of reliable recovery = 1.10 (1.08–1.12), deterioration = 0.94 (0.91–0.98), and attrition = 0.68 (0.66–0.71).
Earlier treatment, supporting those that are NEET to attend sessions, and in particular, offering them more sessions before ending treatment might be effective in improving clinical outcomes. Additional support when working with White young adults that are NEET and those in more deprived areas may also be important.
Previous qualitative research suggests that university students feel that current service provision does not meet their needs. Exploring the reasons for this may help to promote service change, encourage the uptake of care, improve outcomes and increase satisfaction within university services.
This study aimed to improve the understanding of how students experience the process of accessing and using mental health support, barriers and facilitators to treatment, and how students would adapt provision to improve experiences.
Semi-structured interviews were conducted with 16 full-time students who had used mental health services at university. Data were analysed using thematic analysis.
Five higher-order themes were identified: personalisation and informed choice, simplifying the process, feeling abandoned ignored or invisible, stigma, and superiority of private and external services. Sixteen subthemes were identified within these themes.
Findings indicate that access to mental health support should be simplified, with collaboration across university and external health and care services, to prevent students feeling lost or abandoned when seeking care. An inclusive approach to support access and provision of services for all presentations of mental health problems should be developed.
This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care.
We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted.
Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3–4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3–4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions.
When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.
Real-life decisions are often complex because they involve making sequential choices that constrain future options. We have previously shown that to render such multi-step decisions manageable, people ‘prune’ (i.e. selectively disregard) branches of decision trees that contain negative outcomes. We have theorized that sub-optimal pruning contributes to depression by promoting an oversampling of branches that result in unsavoury outcomes, which results in a negatively-biased valuation of the world. However, no study has tested this theory in depressed individuals.
Thirty unmedicated depressed and 31 healthy participants were administered a sequential reinforcement-based decision-making task to determine pruning behaviours, and completed measures of depression and anxiety. Computational, Bayesian and frequentist analyses examined group differences in task performance and relationships between pruning and depressive symptoms.
Consistent with prior findings, participants robustly pruned branches of decision trees that began with large losses, regardless of the potential utility of those branches. However, there was no group difference in pruning behaviours. Further, there was no relationship between pruning and levels of depression/anxiety.
We found no evidence that sub-optimal pruning is evident in depression. Future research could determine whether maladaptive pruning behaviours are observable in specific sub-groups of depressed patients (e.g. in treatment-resistant individuals), or whether misuse of other heuristics may contribute to depression.
Treatment outcomes across Improving Access to Psychological Therapies (IAPT) services in England have improved year-on-year, with the national average proportion of patients in recovery at the end of treatment now exceeding the 50% target. This is despite the number of referrals and numbers of treated patients also increasing year-on-year, suggesting that services have evolved local practices and treatment delivery to meet needs whilst improving performance. This study explores whether there have been changes in clinical practice with regard to: (1) the number of sessions and length of treatments; (2) the number of cancellations and non-attendance; and (3) the recording of problem descriptor information, and the association with treatment outcomes in IAPT. Routinely collected data from seven IAPT services involved in the North and Central East London (NCEL) IAPT Service Improvement and Research Network (SIRN) were brought together to form a dataset of nearly 88,000 patients who completed a course of IAPT treatment. Results showed that there was a slight increase in the average number of sessions, and decreases in the length of time in treatment, as well as decreases in both the number of non-attended appointments and the use of inappropriate problem descriptors. These findings highlight a number of areas where potentially small changes to clinical practice may have had positive effects on patient outcomes. The value of using IAPT data to inform service improvement evaluations is discussed.
Key learning aims
(1) How changes to treatment-delivery factors are associated with IAPT patient outcomes.
(2) The link between clinical practice and potential service performance.
(3) How analysing routinely collected data can be used to inform service improvement.
Post-traumatic stress disorder (PTSD) is a potentially chronic and disabling disorder affecting a significant minority of people exposed to trauma. Various psychological treatments have been shown to be effective, but their relative effects are not well established.
We undertook a systematic review and network meta-analyses of psychological interventions for adults with PTSD. Outcomes included PTSD symptom change scores post-treatment and at 1–4-month follow-up, and remission post-treatment.
We included 90 trials, 6560 individuals and 22 interventions. Evidence was of moderate-to-low quality. Eye movement desensitisation and reprocessing (EMDR) [standardised mean difference (SMD) −2.07; 95% credible interval (CrI) −2.70 to −1.44], combined somatic/cognitive therapies (SMD −1.69; 95% CrI −2.66 to −0.73), trauma-focused cognitive behavioural therapy (TF-CBT) (SMD −1.46; 95% CrI −1.87 to −1.05) and self-help with support (SMD −1.46; 95% CrI −2.33 to −0.59) appeared to be most effective at reducing PTSD symptoms post-treatment v. waitlist, followed by non-TF-CBT, TF-CBT combined with a selective serotonin reuptake inhibitor (SSRI), SSRIs, self-help without support and counselling. EMDR and TF-CBT showed sustained effects at 1–4-month follow-up. EMDR, TF-CBT, self-help with support and counselling improved remission rates post-treatment. Results for other interventions were either inconclusive or based on limited evidence.
EMDR and TF-CBT appear to be most effective at reducing symptoms and improving remission rates in adults with PTSD. They are also effective at sustaining symptom improvements beyond treatment endpoint. Further research needs to explore the long-term comparative effectiveness of psychological therapies for adults with PTSD and also the impact of severity and complexity of PTSD on treatment outcomes.
Open dialogue is an integrative approach to the organisation of specialist mental health services and therapeutic meetings.
This qualitative study sought to explore service users' and clinicians’ experiences of network meetings during the implementation of open dialogue in a modified version, for a UK-based mental health service.
In total 19 participants were interviewed (8 service users and 11 clinicians) and an inductive thematic analysis of the data was conducted.
Four dominant themes were identified: (1) open dialogue delivery, (2) the impact of open dialogue principles; (3) intense interactions and enhanced communication, and (4) organisational challenges. Clinicians considered open dialogue as a preferred, but challenging way of working, while being therapeutic. The data indicated that service users' experiences of network meetings were mixed. There was a wide variety of service user views as to what the purpose of a network meeting was and for some witnessing reflective conversations felt strange. However, the majority described feeling listened to and understood, excluding one service user who described their experience as distressing. Clinicians expressed an authentic self in their interactions with service users and both service users and clinicians described network meetings as emotionally expressive, although this was described as overwhelming at times.
The results of this thematic analysis indicate that service users' and clinicians’ experiences of open dialogue warrant further investigation. The intensity of interactions in network meetings should be carefully considered with service users before gaining consent to commence treatment. Implementation of open dialogue should be monitored to assess clinician- and service-level adherence to the principles of the approach.
Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated.
147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion.
The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.
DIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs.
This paper describes the development of the clinical practice guideline on schizophrenia from the National Institute for Clinical Excellence (NICE) and outlines its main recommendations. It reviews the evidence on effective implementation of guidelines generally and examines issues specific to the schizophrenia guideline. It describes NICE'S approach to supporting implementation alongside that developed by the National Collaborating Centre for Mental Health (NCCMH) and looks at local implementation examples for schizophrenia.
The paper highlights key considerations for the forthcoming revision of the NICE schizophrenia guideline. It makes recommendations concerning the scope of the guideline and the quality and type of data available to the guideline developers: the lack of data on outcomes such as quality of life and social functioning, the challenges presented by unpublished papers and areas where evidence is limited. Since publication of the schizophrenia guideline, the NICE development process has undergone significant methodological improvements. The grading of evidence has been refined and more recently NICE proposed that grading of recommendations be dropped. Consensus methods are increasingly and more effectively used to deal with areas where the evidence-base is limited. NICE and the NCCMH have developed a more implementation-ready range of guideline products.
The initial NICE guideline on schizophrenia was positively received nationally and internationally. This paper highlights challenges that will be involved in updating the guideline and ways to refine the methodology of development. Ultimately the impact of the guideline will be measured not in its methodological rigor but in how its successful implementation improves patient care.
Declaration of Interest: Stephen Pilling in receipt of funding from NICE for the production of clinical guidelines.
Aims – The use of specialised services to avoid admission to hospital for people experiencing mental health crises is seen as an integral part of psychiatric services in some countries. The aim of this paper is to assess the impact on costs and costeffectiveness of a crisis resolution team (CRT). Methods – Patients who were experiencing mental health crises sufficient for admission to be considered were randomised to either care provided by a CRT or standard services. The primary outcome measure was inpatient days over a six-month follow-up period. Service use was measured, costs calculated and cost-effectiveness assessed. Results – Patients receiving care from the CRT had non-inpatient costs £768 higher than patients receiving standard care (90% CI, £153 to £1375). With the inclusion of inpatient costs the costs for the CRT group were £2438 lower for the CRT group (90% CI, £937 to £3922). If one less day spent as an inpatient was valued at £100, there would be a 99.5% likelihood of the CRT being costeffective. Conclusion – This CRT was shown to be cost-effective for modest values placed on reductions in inpatient stays.
Long duration of untreated psychosis (DUP) is common and associated with poor outcomes. Strategies to enhance early detection of first-episode psychosis have been advocated.
To evaluate initiatives for early detection of psychosis.
Systematic review of available evidence on the effectiveness of early detection initiatives to reduce the DUP.
The review included 11 studies which evaluated 8 early detection initiatives. Evidence suggests that general practitioner education campaigns and dedicated early intervention services do not by themselves reduce DUP or generate more treated cases. Evidence for multifocus initiatives is mixed: intensive campaigns targeting the general public as well as relevant professionals may be needed. No studies evaluated initiatives targeting young people or professionals from non-health organisations.
How early detection can be achieved is not clear. Evidence is most promising for intensive public awareness campaigns: these require organisation and resourcing at a regional or national level. More good-quality studies are needed to address gaps in knowledge.
Background: Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented. Aims: To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts. Method: Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials. Results: The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported. Conclusions: The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.
The only randomised controlled trial to test high-fidelity assertive
community treatment (ACT) in the UK (the Randomised Evaluation of Assertive
Community Treatment (REACT) study) found no advantage over usual care from
community mental health teams in reducing the need for inpatient care and in
other clinical outcomes, but participants found ACT more acceptable and
engaged better with it. One possible reason for the lack of efficacy of ACT
might be the short period of follow-up (18 months in the REACT study). This
paper reports on participants' service contact, in-patient service use and
adverse events 36 months after randomisation.
This paper assesses the economic impact of a crisis resolution team (CRT) in South London, using data from a prospective controlled trial. Two cohorts of patients were compared. After referral with a psychiatric crisis, the first cohort received existing services and the second cohort had access to input from a CRT. Baseline and follow-up 6-month costs were measured for 181 cases.
At follow-up, mean costs were £1681 less for the post-CRT patients, which was not statistically significant. However, a significant difference of £2189 was observed when patients with any CRT contact were compared with those with none.
The crisis resolution team resulted in lower costs. Such services can thus help to release funds for other forms of care.
A number of developments make the formal specification of competences in CBT both timely and relevant, in particular the Improving Access to Psychological Therapies (IAPT) programme, the increasing focus on process and therapist variables in determining outcome, and the increasing diversity of CBT. This paper outlines the development of an evidence-based methodology for determining both a model and a framework for CBT competences, and considers issues related to the implementation of the framework.