The manner in which heuristics and biases influence clinical decision-making has not been fully investigated and the methods previously used have been rudimentary.

Two studies were conducted to design and test a trial-based methodology to assess the influence of heuristics and biases; specifically, with a focus on how practitioners make decisions about suitability for therapy, treatment fidelity and treatment continuation in psychological services.

Study 1 (N=12) used a qualitative design to develop two clinical vignette-based tasks that had the aim of triggering heuristics and biases during clinical decision making. Study 2 (N=133) then used a randomized crossover experimental design and involved psychological wellbeing practitioners (PWPs) working in the Improving Access to Psychological Therapies (IAPT) programme in England. Vignettes evoked heuristics (anchoring and halo effects) and biased responses away from normative decisions. Participants completed validated measures of decision-making style. The two decision-making tasks from the vignettes yielded a clinical decision score (CDS; higher scores being more consistent with normative/unbiased decisions).

Experimental manipulations used to evoke heuristics did not significantly bias CDS. Decision-making style was not consistently associated with CDS. Clinical decisions were generally normative, although with some variability.

Clinical decision-making can be ‘noisy’ (i.e. variable across practitioners and occasions), but there was little evidence that this variability was systematically influenced by anchoring and halo effects in a stepped-care context.

Cognitive therapy and behavioural activation are both widely applied and effective psychotherapies for depression, but it is unclear which works best for whom. Individual participant data (IPD) meta-analysis allows for examining moderators at the participant level and can provide more precise effect estimates than conventional meta-analysis, which is based on study-level data.

This article describes the protocol for a systematic review and IPD meta-analysis that aims to compare the efficacy of cognitive therapy and behavioural activation for adults with depression, and to explore moderators of treatment effect. (PROSPERO: CRD42022341602)

Systematic literature searches will be conducted in PubMed, PsycINFO, EMBASE and the Cochrane Library, to identify randomised clinical trials comparing cognitive therapy and behavioural activation for adult acute-phase depression. Investigators of these trials will be invited to share their participant-level data. One-stage IPD meta-analyses will be conducted with mixed-effects models to assess treatment effects and to examine various available demographic, clinical and psychological participant characteristics as potential moderators. The primary outcome measure will be depressive symptom level at treatment completion. Secondary outcomes will include post-treatment anxiety, interpersonal functioning and quality of life, as well as follow-up outcomes.

To the best of our knowledge, this will be the first IPD meta-analysis concerning cognitive therapy versus behavioural activation for adult depression. This study has the potential to enhance our knowledge of depression treatment by using state-of-the-art statistical techniques to compare the efficacy of two widely used psychotherapies, and by shedding more light on which of these treatments might work best for whom.

Anxiety and depressive disorders can be chronic and disabling. Although there are effective treatments, only a fraction of those impaired receive treatment. Predictors of treatment-seeking and treatment receipt could be informative for initiatives aiming to tackle the burden of untreated anxiety and depression.

To investigate sociodemographic characteristics associated with treatment-seeking and treatment receipt.

Two binary retrospective reports of lifetime treatment-seeking (n = 44 810) and treatment receipt (n = 37 346) were regressed on sociodemographic factors (age, gender, UK ethnic minority background, educational attainment, household income, neighbourhood deprivation and social isolation) and alternative coping strategies (self-medication with alcohol/drugs and self-help) in UK Biobank participants with lifetime generalised anxiety or major depressive disorder. Analyses were also stratified by gender.

Treatment access was more likely in those who reported use of self-help strategies, with university-level education and those from less economically advantaged circumstances (household income <£30 000 and greater neighbourhood deprivation). Treatment access was less likely in those who were male, from a UK ethnic minority background and with high household incomes (>£100 000). Men who self-medicated and/or had a vocational qualification were also less likely to seek treatment.

This work on retrospective reports of treatment-seeking and treatment receipt at any time of life replicates known associations with treatment-seeking and treatment receipt during time of treatment need. More work is required to understand whether improving rates of treatment-seeking improves prognostic outcomes for individuals with anxiety or depression.

This was a multi-site evaluation of psycho-educational transdiagnostic seminars (TDS) as a pre-treatment intervention to enhance the effectiveness and utilisation of high-intensity cognitive behavioural therapy (CBT).

To evaluate the effectiveness of TDS combined with high-intensity CBT (TDS+CBT) versus a matched sample receiving CBT only. Second, to determine the consistency of results across participating services which employed CBT+TDS. Finally, to determine the acceptability of TDS across patients with different psychological disorders.

106 patients across three services voluntarily attended TDS while on a waiting list for CBT (TDS+CBT). Individual and pooled service pre–post treatment effect sizes were calculated using measures of depression, anxiety and functional impairment. Effectiveness and completion rates for TDS+CBT were compared with a propensity score matched sample from an archival dataset of cases who received high-intensity CBT only.

Pre–post treatment effect sizes for TDS+CBT were comparable to the matched sample. Recovery rates were greater for the group receiving TDS; however, this was not statistically significant. Greater improvements were observed during the waiting-list period for patients who had received TDS for depression (d = 0.49 compared with d = 0.07) and anxiety (d = 0.36 compared with d = 0.04).

Overall, this new evidence found a trend for TDS improving symptoms while awaiting CBT across three separate IAPT services. The effectiveness of TDS now warrants further exploration through an appropriately sized randomised control trial.

Whilst the delivery of low-intensity group psychoeducation is a key feature of the early steps of the Improving Access to Psychological Therapies (IAPT) programme, there is little consensus regarding the skills and competencies demanded.

To identify the competencies involved in facilitating CBT-based group psychoeducation in order to inform future measure development.

A Delphi study in which participants (n = 36) were relevant IAPT stakeholders and then an expert panel (n = 8) review of the competencies identified within the Delphi study to create a shortened, more practical list of competencies.

After three consultation rounds, consensus was reached on 36 competencies. These competencies were assigned to four main categories: group set-up, content, process and closure. A further expert review produced a shortened 16-item set of psychoeducation group facilitation competencies.

The current study has produced a promising framework for assessing facilitator competency in delivering CBT-based group psychoeducational interventions. Weaknesses in the Delphi approach are noted and directions for future measure development research are identified.

To outline the methods of a pragmatic patient preference trial in the Improving Access to Psychological Therapies (IAPT) programme comparing cognitive behavioural therapy guided self-help (CBT-GSH) with cognitive analytic therapy guided self-help (CAT-GSH).

A partially randomised patient preference trial (PRPPT) methodology. Participants will be assessed with the MINI to ascertain a diagnosis of an anxiety disorder. Treatment will be six to eight 35-minute sessions in each arm. The primary outcome measure is the Beck Anxiety Inventory (BAI), with secondary outcome measures of the IAPT minimum dataset and indices of service utilisation. Participants will be followed up at 8 and 24 weeks.

Choice, treatment completion, drop-out and step-up rates will be summarised via a CONSORT diagram. If there are no differences between randomised and preference participants within each form of GSH, then these groups will be collapsed to form a two-arm trial. The primary analysis will compare between-arm standardised effect sizes on the BAI measure, using Cohen’s d+ at 8- and 24-week follow-up. The proportions in each arm achieving reliable and clinical change on the BAI will be established, with interviews exploring the change process with participants achieving a reliable pre–post change on the GAD-7.

The utility of patient preference trials in mental health services are discussed and the necessary further development of robust evidence concerning low-intensity interventions is highlighted.

Cognitive behavioural therapy (CBT) is an effective psychological treatment for major depressive disorder, although some patients experience a return of symptoms after finishing therapy. The ability to predict which individuals are more vulnerable to deterioration would allow for targeted interventions to prevent short-term relapse and longer-term recurrence.

This systematic review and meta-analysis aimed to identify factors associated with an increased risk of relapse and/or recurrence (RR) after CBT for depression.

We reviewed 13 relevant papers, of which a small set of unique samples were eligible for meta-analysis (k = 5, N = 369). Twenty-six predictor variables were identified and grouped into seven categories: residual depressive symptoms; prior episodes of depression; cognitive reactivity; stressful life events; personality factors; clinical and diagnostic factors; demographics.

Meta-analyses indicated that residual depressive symptoms (r = 0.34 [0.10, 0.54], p = .01) and prior episodes (r = 0.19 [0.07, 0.30], p = .002) were statistically significant predictors of RR, but cognitive reactivity was not (r = 0.18 [−0.02, 0.36], p = .08). Other variables lacked replicated findings. On average, 33.4% of patients experienced RR after CBT.

Patients with the above risk factors could be offered evidence-based continuation-phase interventions to enhance the longer-term effectiveness of CBT.

Different diagnostic interviews are used as reference standards for major depression classification in research. Semi-structured interviews involve clinical judgement, whereas fully structured interviews are completely scripted. The Mini International Neuropsychiatric Interview (MINI), a brief fully structured interview, is also sometimes used. It is not known whether interview method is associated with probability of major depression classification.

To evaluate the association between interview method and odds of major depression classification, controlling for depressive symptom scores and participant characteristics.

Data collected for an individual participant data meta-analysis of Patient Health Questionnaire-9 (PHQ-9) diagnostic accuracy were analysed and binomial generalised linear mixed models were fit.

A total of 17 158 participants (2287 with major depression) from 57 primary studies were analysed. Among fully structured interviews, odds of major depression were higher for the MINI compared with the Composite International Diagnostic Interview (CIDI) (odds ratio (OR) = 2.10; 95% CI = 1.15–3.87). Compared with semi-structured interviews, fully structured interviews (MINI excluded) were non-significantly more likely to classify participants with low-level depressive symptoms (PHQ-9 scores ≤6) as having major depression (OR = 3.13; 95% CI = 0.98–10.00), similarly likely for moderate-level symptoms (PHQ-9 scores 7–15) (OR = 0.96; 95% CI = 0.56–1.66) and significantly less likely for high-level symptoms (PHQ-9 scores ≥16) (OR = 0.50; 95% CI = 0.26–0.97).

The MINI may identify more people as depressed than the CIDI, and semi-structured and fully structured interviews may not be interchangeable methods, but these results should be replicated.

Drs Jetté and Patten declare that they received a grant, outside the submitted work, from the Hotchkiss Brain Institute, which was jointly funded by the Institute and Pfizer. Pfizer was the original sponsor of the development of the PHQ-9, which is now in the public domain. Dr Chan is a steering committee member or consultant of Astra Zeneca, Bayer, Lilly, MSD and Pfizer. She has received sponsorships and honorarium for giving lectures and providing consultancy and her affiliated institution has received research grants from these companies. Dr Hegerl declares that within the past 3 years, he was an advisory board member for Lundbeck, Servier and Otsuka Pharma; a consultant for Bayer Pharma; and a speaker for Medice Arzneimittel, Novartis, and Roche Pharma, all outside the submitted work. Dr Inagaki declares that he has received grants from Novartis Pharma, lecture fees from Pfizer, Mochida, Shionogi, Sumitomo Dainippon Pharma, Daiichi-Sankyo, Meiji Seika and Takeda, and royalties from Nippon Hyoron Sha, Nanzando, Seiwa Shoten, Igaku-shoin and Technomics, all outside of the submitted work. Dr Yamada reports personal fees from Meiji Seika Pharma Co., Ltd., MSD K.K., Asahi Kasei Pharma Corporation, Seishin Shobo, Seiwa Shoten Co., Ltd., Igaku-shoin Ltd., Chugai Igakusha and Sentan Igakusha, all outside the submitted work. All other authors declare no competing interests. No funder had any role in the design and conduct of the study; collection, management, analysis and interpretation of the data; preparation, review or approval of the manuscript; and decision to submit the manuscript for publication.

None.

Long-term conditions often coexist with depression and anxiety.

To assess the effectiveness of stepped-care psychological therapies for patients with long-term conditions.

Data from 28 498 patients were analysed using regression to model depression (Patient Health Questionnaire (PHQ-9)) and anxiety (Generalised Anxiety Disorder scale (GAD-7)) outcomes. Post-treatment symptoms and effect sizes (d) were estimated for individuals with and without long-term conditions, controlling for covariates. The likelihood of access and response to intensive psychological interventions was also examined.

Higher post-treatment symptoms were predicted for patients with musculoskeletal problems (d = 0.22–0.27), chronic obstructive pulmonary disease (d = 0.26–0.33), diabetes (d = 0.05–0.13) and psychotic disorders (d = 0.50–0.58). Most long-term conditions were associated with greater odds of accessing high-intensity therapies, yet individuals who accessed these continued to have higher average post-treatment symptoms.

Some long-term conditions are associated with greater intensity of care and poorer outcomes after therapy.

To evaluate a comprehensive risk management programme. A Risk Assessment and Management Self-Efficacy Scale (RAMSES) was used to evaluate the impact of a clinical guideline and training course. Fifty-three psychological therapists were randomly allocated to training v. waiting list in a controlled, delayed-intervention design. Differences in mean self-efficacy scores between groups were examined using analysis of covariance (ANCOVA).

The RAMSES measure had adequate factor structure, internal consistency and construct validity. When adjusting for baseline scores and cluster design, the group exposed to training had a higher mean self-efficacy score than controls. Mean differences between groups were not significant after the control group received training, nor at 6 months' follow-up.

Exposure to training and clinical guidelines can improve self-efficacy in risk assessment and management. An important advance put forward by this study is the specification of areas of competence in risk assessment and management, which can be measured using a psychometrically sound tool.