A core approach to practice-based evidence: A brief history of the origins and applications of the CORE-OM and CORE System

Patient characteristics in a return to work programme for common mental disorders: a cross-sectional study

Background

Mental health problems are a growing cause of sickness absence. There are programmes in many countries to facilitate return to work (RTW) after sickness absence. In Norway, there has been some controversy about patients on sick-leave being prioritized over other patient groups, such as those with more severe diagnoses. However, it is not clear whether patients in RTW programmes actually do differ from patients in regular services.

Methods

This study compared 270 patients treated in an RTW outpatient clinic and 86 patients treated in a regular outpatient clinic, both in specialized mental health care, on patient characteristics, history of treatment and mental health status. Analyses of differences between groups were done by ANOVA tests, chi-square test and logistic regression.

Results

Patients in the RTW clinic had lower scores on the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM). There was no difference in health-related quality of life. RTW patients were somewhat older and more likely to live in relationships and have children, and they had higher incomes. Work participation, previous psychiatric hospitalization and present diagnosis contributed uniquely to an explanation of which patients were included in the respective clinics. The RTW clinic seems to reach its intended target group. Almost all of the patients in this group participated in the work arena, and their psychopathologies were clearly dominated by common mental disorders. Most RTW patients’ general practitioners had followed them fairly closely in the year before referral, suggesting previous attempts at treatment in primary care settings.

Conclusions

Relative to outpatients in a specialized mental health care setting, RTW patients had lower symptoms, but still in the same moderate range of severity. They suffered the same reduction in quality of life. Almost all of the RTW patients were diagnosed with illnesses that can be treated effectively, about half of them had recurring mental health problems and many of them had been treated in primary care settings before referral. These findings indicate that this group has significant health problems that can benefit from treatment in specialized health care settings.

Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults

BACKGROUND

Routine outcome monitoring of common mental health disorders (CMHDs), using patient reported outcome measures (PROMs), has been promoted across primary care, psychological therapy and multidisciplinary mental health care settings, but is likely to be costly, given the high prevalence of CMHDs. There has been no systematic review of the use of PROMs in routine outcome monitoring of CMHDs across these three settings.

OBJECTIVES

To assess the effects of routine measurement and feedback of the results of PROMs during the management of CMHDs in 1) improving the outcome of CMHDs; and 2) in changing the management of CMHDs.

SEARCH METHODS

We searched the Cochrane Depression Anxiety and Neurosis group specialised controlled trials register (CCDANCTR-Studies and CCDANCTR-References), the Oxford University PROMS Bibliography (2002-5), Ovid PsycINFO, Web of Science, The Cochrane Library, and International trial registries, initially to 30 May 2014, and updated to 18 May 2015.

SELECTION CRITERIA

We selected cluster and individually randomised controlled trials (RCTs) including participants with CMHDs aged 18 years and over, in which the results of PROMs were fed back to treating clinicians, or both clinicians and patients. We excluded RCTs in child and adolescent treatment settings, and those in which more than 10% of participants had diagnoses of eating disorders, psychoses, substance use disorders, learning disorders or dementia.

DATA COLLECTION AND ANALYSIS

At least two authors independently identified eligible trials, assessed trial quality, and extracted data. We conducted meta-analysis across studies, pooling outcome measures which were sufficiently similar to each other to justify pooling.

MAIN RESULTS

We included 17 studies involving 8787 participants: nine in multidisciplinary mental health care, six in psychological therapy settings, and two in primary care. Pooling of outcome data to provide a summary estimate of effect across studies was possible only for those studies using the compound Outcome Questionnaire (OQ-45) or Outcome Rating System (ORS) PROMs, which were all conducted in multidisciplinary mental health care or psychological therapy settings, because both primary care studies identified used single symptom outcome measures, which were not directly comparable to the OQ-45 or ORS.Meta-analysis of 12 studies including 3696 participants using these PROMs found no evidence of a difference in outcome in terms of symptoms, between feedback and no-feedback groups (standardised mean difference (SMD) -0.07, 95% confidence interval (CI) -0.16 to 0.01; P value = 0.10). The evidence for this comparison was graded as low quality however, as all included studies were considered at high risk of bias, in most cases due to inadequate blinding of assessors and significant attrition at follow-up.Quality of life was reported in only two studies, social functioning in one, and costs in none. Information on adverse events (thoughts of self-harm or suicide) was collected in one study, but differences between arms were not reported.It was not possible to pool data on changes in drug treatment or referrals as only two studies reported these. Meta-analysis of seven studies including 2608 participants found no evidence of a difference in management of CMHDs between feedback and no-feedback groups, in terms of the number of treatment sessions received (mean difference (MD) -0.02 sessions, 95% CI -0.42 to 0.39; P value = 0.93). However, the evidence for this comparison was also graded as low quality.

AUTHORS' CONCLUSIONS

We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of CMHDs, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies, and should follow them up for longer than six months.

Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services

Background

Domestic violence and abuse (DVA) are associated with increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services.

Objective

Our goal was to characterise the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators.

Design

Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors were analysed. We report the prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. The following mental health measures were used: Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalised Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale to measure posttraumatic stress disorder (PTSD). The Composite Abuse Scale (CAS) measured abuse.

Results

Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and more than three-quarters of respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA.

Conclusions

Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.

Predictors of patient non-attendance at Improving Access to Psychological Therapy services demonstration sites

BACKGROUND

Improving Access to Psychological Therapy (IAPT) services have increased the number of people with common mental health disorders receiving psychological therapy in England, but concerns remain about how equitably these services are accessed.

METHOD

Using cohort patient data (N=363) collected as part of the independent evaluation of the two demonstration sites, logistic regression was utilised to identify socio-demographic, clinical and service factors predictive of IAPT non-attendance.

RESULTS

Significant predictors of IAPT first session non-attendance by patients were: lower non-risk score on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); more frequent thoughts of "being better off dead" (derived from the CORE-OM); either a very recent onset of common mental health disorder (1 month or less) or a long term condition (more than 2 years); and site.

LIMITATIONS

The small sample and low response rate are limitations, as the sample may not be representative of all those referred to IAPT services. The predictive power of the logistic regression model is limited and suggests other variables not available in the dataset may also be important predictors.

CONCLUSIONS

The clinical characteristics of risk to self, severity of emotional distress, and illness duration, along with site, were more predictive of IAPT non-attendance than socio-demographic characteristics. Further testing of the relationship between these variables and IAPT non-attendance is recommended. Clinicians should monitor IAPT uptake in those they refer and implement strategies to increase their engagement with services, particularly when referring people presenting with suicidal ideation or more chronic illness.

Tracking Responses to Items in Measures as a Means of Increasing Therapeutic Engagement in Clients: A Complementary Clinical Approach to Tracking Outcomes

This article presents a novel clinical application of questionnaire feedback, which focuses on change at the individual question level rather than the total mean or clinical score level. We term the approach 'Tracking Responses to Items in Measures' (TRIM) and promote the key aims to be (1) providing both client and practitioner with feedback on areas of positive change that may be masked by numerical feedback, (2) reinforcing client strengths and self-efficacy, (3) exploring potential extra-therapeutic factors that may contribute to the lack of change or deterioration on individual questions and (4) establishing a collaborative dialogue relating clients' problems to their goals and the consequent aims of treatment. This paper profiles the clinical origins and technical development of TRIM as a clear, user-friendly display of item change across sessions using colour codes and illustrates the clinical utility through two clinical vignettes. Although the profile of the TRIM method herein uses the Clinical Outcomes in Routine Evaluation Outcome Measure, we believe the method could easily be used with other measures. These could include Generalized Anxiety Disorder 7 and Patient Health Questionnaire 9 used in English National Health Service primary care Improving Access to Psychological Therapies services, or disorder specific measures for particular problems commonly used in National Health Service specialist services. We suggest TRIM is a practical complement to existing feedback systems, especially in work with clients who may be less likely to show empirically meaningful change on mean item or clinical score levels.

KEY PRACTITIONER MESSAGE

Using outcome questionnaires as conversational tools helps practitioners focus on change at the individual item level rather than the numeric level. Tracking Responses to Items in Measures helps provide clients and practitioners with feedback on areas of positive change that may be masked by summary score analysis. Exploring the lack of change or deterioration on particular questions helps practitioners to assess extra-therapeutic factors that may be compromising change. Using individual item change profiles as feedback for clients helps validate their progress and reinforce their strengths and self-efficacy.

Domestic violence and mental health: a cross-sectional survey of women seeking help from domestic violence support services

Background

Domestic violence and abuse (DVA) are associated with an increased risk of mental illness, but we know little about the mental health of female DVA survivors seeking support from domestic violence services.

Objective

To characterize the demography and mental health of women who access specialist DVA services in the United Kingdom and to investigate associations between severity of abuse and measures of mental health and health state utility, accounting for important confounders and moderators.

Design

Baseline data on 260 women enrolled in a randomized controlled trial of a psychological intervention for DVA survivors was analyzed. We report prevalence of and associations between mental health status and severity of abuse at the time of recruitment. We used logistic and normal regression models for binary and continuous outcomes, respectively. Mental health measures used were: Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM), Patient Health Questionnaire, Generalized Anxiety Disorder Assessment, and the Posttraumatic Diagnostic Scale (PDS) to measure posttraumatic stress disorder. The Composite Abuse Scale (CAS) measured abuse.

Results

Exposure to DVA was high, with a mean CAS score of 56 (SD 34). The mean CORE-OM score was 18 (SD 8) with 76% above the clinical threshold (95% confidence interval: 70–81%). Depression and anxiety levels were high, with means close to clinical thresholds, and all respondents recorded PTSD scores above the clinical threshold. Symptoms of mental illness increased stepwise with increasing severity of DVA.

Conclusions

Women DVA survivors who seek support from DVA services have recently experienced high levels of abuse, depression, anxiety, and especially PTSD. Clinicians need to be aware that patients presenting with mental health conditions or symptoms of depression or anxiety may be experiencing or may have experienced DVA. The high psychological morbidity in this population means that trauma-informed psychological support is needed for survivors who seek support from DVA services.

Experiences of young people in a 16-18 Mental Health Service

BACKGROUND

16-18-year-old young people experience a relatively high incidence of mental health problems but there is a paucity of research on their experience of mental health services (MHS).

METHOD

To gain understanding of young people's experiences of 16-18 MHS, we used qualitative Interpretative Phenomenological Analysis. Ten young people in two 16-18 MHS were interviewed about experiences of using MHS.

RESULTS

Five superordinate themes emerged from the data analysis, 'Power Differentials', 'Parental Involvement', 'Developmentally Attuned Services', 'Developing Self-Expression', 'Continuity and Loss of Relationships'.

CONCLUSIONS

Respondents valued developmentally appropriate MHS and emphasised the value of continuity in therapeutic relationships.

Effect size calculations for the clinician: methods and comparability

OBJECTIVE

The measurement of clinical change via single-group pre-post effect size has become increasingly common in psychotherapy settings that collect practice-based evidence and engage in feedback-informed treatment. Different methods of calculating effect size for the same sample of clients and the same measure can lead to wide-ranging results, reducing interpretability.

METHOD

Effect sizes from therapists-including those drawn from a large web-based database of practicing clinicians-were calculated using nine different methods.

RESULTS

The resulting effect sizes varied significantly depending on the method employed. Differences between measurement methods routinely exceeded 0.40 for individual therapists.

CONCLUSIONS

Three methods for calculating effect sizes are recommended for moderating these differences, including two equations that show promise as valid and practical methods for use by clinicians in professional practice.

Psychological advocacy toward healing (PATH): study protocol for a randomized controlled trial

Background

Domestic violence and abuse (DVA), defined as threatening behavior or abuse by adults who are intimate partners or family members, is a key public health and clinical priority. The prevalence of DVA in the United Kingdom and worldwide is high, and its impact on physical and mental health is detrimental and persistent. There is currently little support within healthcare settings for women experiencing DVA. Psychological problems in particular may be difficult to manage outside specialist services, as conventional forms of therapy such as counseling that do not address the violence may be ineffective or even harmful. The aim of this study is to assess the overall effectiveness and cost-effectiveness of a novel psychological intervention tailored specifically for survivors of DVA and delivered by domestic violence advocates based in third-sector organizations.

Methods and study design

This study is an open, pragmatic, parallel group, individually randomized controlled trial. Women ages 16 years and older experiencing domestic violence are being enrolled and randomly allocated to receive usual DVA agency advocacy support (control) or usual DVA agency support plus psychological intervention (intervention). Those in the intervention group will receive eight specialist psychological advocacy (SPA) sessions weekly or fortnightly, with two follow-up sessions, 1 month and then 3 months later. This will be in addition to any advocacy support sessions each woman receives. Women in the control group will receive usual DVA agency support but no additional SPA sessions. The aim is to recruit 250 women to reach the target sample size. The primary outcomes are psychological well-being and depression severity at 1 yr from baseline, as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures include anxiety, posttraumatic stress, severity and frequency of abuse, quality of life and cost-effectiveness of the intervention. Data from a subsample of women in both groups will contribute to a nested qualitative study with repeat interviews during the year of follow-up.

Discussion

This study will contribute to the evidence base for management of the psychological needs of women experiencing DVA. The findings will have important implications for healthcare commissioners and providers, as well as third sector specialist DVA agencies providing services to this client group.

Trial registration

ISRCTN58561170

The factor structure and psychometric properties of the Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) in Norwegian clinical and non-clinical samples

BACKGROUND

The Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) is a 34-item instrument developed to monitor clinically significant change in out-patients. The CORE-OM covers four domains: well-being, problems/symptoms, functioning and risk, and sums up in two total scores: the mean of All items, and the mean of All non-risk items. The aim of this study was to examine the psychometric properties of the Norwegian translation of the CORE-OM.

METHODS

A clinical sample of 527 out-patients from North Norwegian specialist psychiatric services, and a non-clinical sample of 464 persons were obtained. The non-clinical sample was a convenience sample consisting of friends and family of health personnel, and of students of medicine and clinical psychology. Students also reported psychological stress. Exploratory factor analysis (EFA) was employed in half the clinical sample. Confirmatory (CFA) factor analyses modelling the theoretical sub-domains were performed in the remaining half of the clinical sample. Internal consistency, means, and gender and age differences were studied by comparing the clinical and non-clinical samples. Stability, effect of language (Norwegian versus English), and of psychological stress was studied in the sub-sample of students. Finally, cut-off scores were calculated, and distributions of scores were compared between clinical and non-clinical samples, and between students reporting stress or no stress.

RESULTS

The results indicate that the CORE-OM both measures general (g) psychological distress and sub-domains, of which risk of harm separates most clearly from the g factor. Internal consistency, stability and cut-off scores compared well with the original English version. No, or only negligible, language effects were found. Gender differences were only found for the well-being domain in the non-clinical sample and for the risk domain in the clinical sample. Current patient status explained differences between clinical and non-clinical samples, also when gender and age were controlled for. Students reporting psychological distress during last week scored significantly higher than students reporting no stress. These results further validate the recommended cut-off point of 1 between clinical and non-clinical populations.

CONCLUSIONS

The CORE-OM in Norwegian has psychometric properties at the same level as the English original, and could be recommended for general clinical use. A cut-off point of 1 is recommended for both genders.

Suicide behavior in parents with alcohol abuse problems and suicide behavior in their offspring-adult offspring and counselor perspectives

BACKGROUND

Suicide behavior is relatively common in families with alcohol problems.

AIMS

This study explores associations between suicide behavior in parents with alcohol abuse problems and suicide behavior in their offspring. It aims to expand our understanding of the varied experiences of treatment-seeking young adults who grew up in families with alcohol problems.

METHODS

344 young adult children of alcoholics (ACAs) entering a Danish center for ACA counseling were surveyed about their childhood experiences regarding their own and their parents' attempted, threatened and completed suicide behavior.

RESULTS

Parental suicide behavior was strongly associated with parental drinking; 46% of ACAs reported parental threatened, attempted or completed suicide behavior during their childhood, 13% of ACAs reported threatening suicide themselves, 15% of ACAs reported attempting suicide themselves. At least 54% of ACAs who had attempted suicide had done so without previously threatening suicide. There was a significant association between ACAs whose parents had committed suicide and ACAs who had attempted suicide during their childhood. There was also a significant association between ACAs where both parents had suicide behavior and ACA childhood suicide behavior.

CONCLUSION

The study stresses the importance of addressing and assessing the family history of suicidal behavior in ACAs seeking counseling.

An evaluation of time-limited psychodynamic psychotherapy for couples: a pilot study

OBJECTIVES

Psychodynamic Couple Psychotherapy has developed as a modality in only a few organizations in the public and voluntary sectors in this country. Varieties of couple therapy have evolved due to economic or other constraints, some more open-ended, others involving differing time limits or behavioural techniques. In this study, a time limit of 40 sessions was imposed on the Psychodynamic therapy to improve comparability with other therapeutic approaches. We examined work with 18 couples, employing various measures which, while not in the context of a full controlled trial, produced some interesting and indicative results. We aimed to investigate (1) the effects of time-limited psychodynamic couple psychotherapy, and (2) whether the measures used produce interesting results after 40 weeks.

DESIGN

Within a normal clinical setting, measurements of individual and couple functioning would be taken at fixed points in the course of 40-week couple therapies, and analysed for evidence of significant change. Due to funding and clinical limitations within the setting, a baseline period before therapy started was used instead of a control group.

METHOD

Couples were invited to opt in to the study when applying to the agency for therapy. They were provided with 40 weekly sessions of couple therapy. Videotapes of sessions at beginning, middle, and end of the therapies were rated by independent observer, using the Personal Relatedness Profile (PRP) (Hobson, Patrick, & Valentine, 1998) adapted for couples (Lanman, Grier, & Evans, 2003), alongside two individual self-report measures, Clinical Outcomes in Routine Evaluation (CORE) (Evans et al., 2000), and the Golombok Rust Inventory of Marital Satisfaction (GRIMS) (Rust, Bennun, Crow, & Golumbok, 1990).

RESULTS

The couples showed improvement as rated both by therapists and observers (rating the videotaped sessions) on the PRP after 40 sessions. On the CORE measure, participants showed improvement at both 20 and 40 sessions. On the GRIMS measure of marital satisfaction, results were non-significant.

CONCLUSIONS

The results provide indicative evidence for the effectiveness of 40-session couple psychotherapy and provide some convergent validation for the utility of the PRP (as adapted for couples) as a measure of change.

Introducing the CORE-OM in a South African Context: Validation of the CORE-OM using a South African Student Population Sample

The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) was originally introduced as a standardised, practice-based evidence tool for generating effectiveness data by practitioners within the context of routine clinical practice in the United Kingdom's National Health Service (NHS) settings. Following wide application across UK NHS sites the CORE-OM has proven to be a pragmatic measure of both a) gross psychological distress and b) the effectiveness of psychotherapy interventions across client populations, presenting problems, clinical settings and therapy models. However in order for South Africa to benefit from this tool, the CORE-OM must be applicable within a South African context. This requires its validation within South African populations. The aim of this article is to demonstrate the cross-cultural validity of the CORE-OM, using a South African student population sample and in so doing to provide preliminary referential data for use in interpreting CORE-OM scores within English-medium, South African University student counselling centre contexts.

Outcome measurement in chronic mental illness

This review begins with an outline of outcome measurement in the country where it has been most thoroughly implemented, namely Australia. There follows a consideration of what constitutes an outcome in mental illness generally, and chronic mental illness in particular. Some instruments, such as the Health of the Nation Outcome Scales (HoNOS), focus primarily on illness severity, and examples of their use in the area of chronic mental illness are presented. Other instruments, such as the Life Skills Profile (LSP), assess personal functioning or disability, and that literature is reviewed. One major area of attention in the chronically mentally ill is quality of life. Another fruitful approach to assessing outcome is to look at needs, especially unmet needs, for which the leading instrument is the Camberwell Assessment of Need; relevant findings are reviewed. The most recent area of interest is recovery. While several scales have been developed, there are as yet relatively few reports of their application with patients with chronic mental illness. The concluding section considers the benefits and weaknesses of using the same standard instruments with all consumers within a service, and shows the utility of outcome results in groups and individuals with generally small overall changes.

Emotional well-being in people with sight loss

Literature that is not peer-reviewed and distributed through a publisher is known as ‘grey’. As it is used to inform policy and practice we reviewed the grey literature concerning emotional well-being in people with sight loss. We consulted and searched the websites of UK voluntary organizations, and scanned reference lists of previous reviews for reports available from 2001 to 2008. We summarized 24 studies in two sections: observations that assessed psychosocial well-being or demand for support services ( n = 15); and evaluations of interventions that aimed to improve emotional well-being ( n = 9). Observations showed that people with sight loss can report low emotional well-being, but their statistical and clinical significance requires testing. Interventions showed promise for counselling but also require further evaluation. We encourage service providers and researchers to collaborate and produce high quality research to more persuasively inform policy and practice.

Acupuncture, or non-directive counselling versus usual care for the treatment of depression: a pilot study

BACKGROUND

Depression is one of the most common reasons for consulting in primary care. Acupuncture is a popular complementary therapy choice for depression but its evidence base is poor with more robust high quality trials being required. More than half of depressed patients experience painful symptoms, with severe pain being associated with poor response to antidepressants. Acupuncture may have much to offer as an intervention for depression that also helps alleviate pain. Non-directive counselling is the most widely used psychological approach for depression in NHS settings, and provides a useful pragmatic comparison for acupuncture that would, according to our pre-trial qualitative research, be of high interest to doctors and patients.

METHODS AND DESIGN

The pilot study uses five arms and involves a pragmatic design. All patients will continue to receive usual care. Four groups of patients will be allocated to acupuncture, or non-directive counselling, in addition to usual GP care. The acupuncture and counselling arms will be further split into two groups to explore different treatment regimens. The primary outcome measure is the BDI II. Potentially eligible patients will be screened for depression using the PHQ-9, which is also a secondary outcome measure. Other secondary measures include the SF 36 bodily pain subscale, the CORE OM, the WBQ-12 and the EQ5D. Health economic data will be collected and measures of therapeutic engagement will be used to compare patient's views of therapists and GPs. The study will employ a fully randomised preference design with collection of data on patient preferences and prior expectations.

DISCUSSION

This study has been implemented, and data are currently being analysed to inform the design of a full scale trial. Two practical operational issues that impacted on study implementation are discussed. Firstly, the challenge of recruiting depressed patients via GP consultation. Secondly, the problem of poor uptake and high attrition for counselling and acupuncture, which appeared to be associated with poor questionnaire return, and resulted in missing data. These problems may be relevant to other researchers working in the area of depression, or similar illnesses, where patients may lack motivation and energy to engage in research, or attend for treatment.

TRIAL REGISTRATION

Current Controlled Trials (ISRCTN 59267538).

Evidence-based practice in psychiatric care: defining levels of evidence

Identification and application of the current research evidence to a clinical problem is a goal reflected in professional codes and institutional mission statements. The use of expert opinions and traditions is no longer clinically or legally defensible in an era of using emerging evidence. Application of current research evidence is the emerging standard of care for all health care personnel, including psychiatric mental health care. The emergence of evidence-based practice as the new standard of care obliges all health care providers to use the latest research evidence. The need to make an intervention based on the highest level of evidence mandates that clinicians understand levels of research evidence and how the different classification systems of evidence compare. In this article, the levels of research evidence are reviewed to provide a framework for determining the best evidence to use as a basis for clinical interventions. J Am Psychiatr Nurses Assoc, 2008; 14(3), 181-187. DOI: 10.1177/1078390308321220.

The effectiveness of psychodynamic-interpersonal therapy (PIT) in routine clinical practice: a benchmarking comparison

AIMS

To investigate the effectiveness of psychodynamic-interpersonal therapy (PIT) in a routine clinical practice setting.

METHODS

Full pre-post data were available on 62 out of a total of 67 patients aged between 19 and 60 years. Patients were seen over a 52-month period (2001-2005) receiving a course of PIT therapy (mean number of sessions = 16.9, median number of sessions = 16). The outcomes were assessed using a range of outcome measures: the 32-item version of the Inventory of Interpersonal Problems (IIP-32), the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and the Beck Depression Inventory - Second Edition (BDI-II). Study data were benchmarked against comparative national and local data.

RESULTS

There were significant pre-post reductions on all measures: IIP-32 effect size (ES) = 0.56; CORE-OM ES = 0.76; BDI-II ES = 0.76. Reliable and clinically significant change was achieved by 34% of clients on the BDI-II and by 40% of clients on the CORE-OM. Clients with high pre-therapy levels of interpersonal problems had poorer outcomes.

CONCLUSION

Benchmarking our results against both national and local comparative data showed that our results were less favourable than those obtained where PIT had been used in efficacy trials, but were comparable with reports of other therapies (including cognitive behavioural therapy (CBT)) in routine practice settings. The results show that PIT can yield acceptable clinical outcomes, comparable to CBT in a routine care setting, within the context of current limitations of the practice-based evidence paradigm.