A systematic review and economic evaluation of computerised cognitive behaviour therapy for depression and anxiety

Valuing health States for use in cost-effectiveness analysis

This article reviews the general issues in valuing health states for use in cost-effectiveness analysis and the specific issues considered by the National Institute for Health and Clinical Excellence (NICE) in its recent review of the methods of technology appraisal. The general issues are how to describe health, how to value health and who should provide the values for health. The specific issues considered by NICE included whether and what should be the reference-case instrument, what to do when there are no data using the reference-case measure, what to do when the reference-case measure is not suitable and how to judge when it is not suitable, how to review and synthesize data, and how to incorporate health-state utility values into cost-effectiveness models.

An evaluation of large group CBT psycho-education for anxiety disorders delivered in routine practice

OBJECTIVE

To determine the clinical utility and acceptability of a brief CBT psycho-educational course delivered in an NHS psychotherapy service.

METHODS

All patients referred, found suitable for CBT, and who had an anxiety disorder, were invited to enrol in a psycho-education course, delivered in an outpatient mental health clinic by two mental health nurses with post-registration training in CBT. There were up to 24 patients in each course. Outcome measures used were CORE-OM and Fear Questionnaire administered pre-course and at 12-week follow-up and Client Satisfaction Questionnaire administered post-course.

RESULTS

One-hundred and ninety one patients were referred. Of these 120 remained in contact with the service to the follow-up meeting. Ninety-seven patients were discharged at the follow-up point and 92 requested further individual psychotherapy. A number of patients made a clinical and reliable change as measured by CORE-OM and Fear Questionnaire. One-hundred and two patients completed the CSQ-8 reporting high satisfaction with the intervention.

CONCLUSIONS

The intervention appears to be helpful for a number of patients and largely acceptable for most patients that attend.

PRACTICE IMPLICATIONS

Large group psycho-educational interventions for anxiety disorders could be increasingly used as a method of delivering low intensity treatments within a stepped care model of the treatment of anxiety disorders. The intervention is relatively simple to deliver and potentially could be delivered by primary care clinicians.

Patients with head and neck cancer prefer individualized cognitive behavioural therapy

Cognitive behaviour therapy (CBT) is a widely practiced and approved form of psychotherapy for many psychosocial difficulties. As the efficacy of CBT is recognized, its demand has increased and today exceeds the availability of qualified practitioners. Therefore, the effectiveness of delivering CBT using less labour-intensive modes than individualised therapy has been explored. These include group therapy, bibliotherapy and computer assisted therapy. Given the UK Government's impetus towards patient choice and involvement in the planning of healthcare, it was thought essential to ascertain the preferred delivery mode of patients with head and neck cancer for a CBT based intervention. Therefore, a small retrospective cohort (n= 28) of patients following treatment for head and neck cancer were sent postal questionnaires to ascertain their preferences on mode of CBT delivery. Simultaneously, the views of accredited cognitive behaviour therapists (n= 14) were determined on the optimal mode of CBT delivery to these patients. Findings indicated that patients preferred the more individualized mode of CBT delivery, namely one-to-one therapy, followed closely by bibliotherapy, with group format being the least preferred option. Professionals concurred with patients, in that one-to-one interaction was considered an optimal mode of CBT delivery, but professionals considered it equal to group therapy.

Exploratory economic analyses of two primary care mental health projects: implications for sustainability

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions. Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists. Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio. The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

Stepped care in psychological therapies: access, effectiveness and efficiency. Narrative literature review

BACKGROUND

There is a significant gap between the demand for psychological therapy services and the available supply. One proposal to overcome this problem is to increase efficiency of provision through the adoption of briefer 'minimal interventions' within stepped care models.

AIMS

To examine the theoretical underpinnings of stepped care, together with the practicalities of the adoption of this system of care.

METHOD

Narrative literature review.

RESULTS

The potential clinical and economic benefits of stepped care are dependent upon underlying assumptions of equivalence in terms of clinical outcomes, efficiency in terms of resource use and costs, and acceptability of 'minimal interventions' to patients and therapists. Illustrative studies of these issues are considered.

CONCLUSIONS

Although psychological services might benefit from the adoption of the stepped care model, a substantial research agenda needs to be fulfilled before a judgement can be made as to whether stepped care might be an efficient method of delivering psychological services.

Primary care mental health workers: role expectations, conflict and ambiguity

A number of professionals are involved in mental health in primary care. The NHS Plan proposed the introduction of a new professional, the primary care mental health worker (PCMHW), to improve care in this setting. The present study was conducted to examine pilot PCMHW-type roles currently in existence, to explore staff expectations concerning the new PCMHW role and to consider the issues relating to roles in primary care mental health that are raised by this new worker. The study used a case study design, and involved qualitative interviews with 46 managers and clinicians from primary care and specialist mental health services, including pilot PCMHW-type roles. The key findings were as follows: The pilot PCMHW-type roles were almost exclusively related to client work, whereas respondents had far wider role expectations of the new PCMHWs, relating to perceived gaps in current service provision. This highlights the potential for role conflict. Secondly, there was disagreement and ambiguity among some respondents as to the nature of the new PCMHW's role in client work, and its relationship with the work undertaken by other mental health professionals such as counsellors, psychologists and nurses. Given that multiple professionals are involved in mental health care in primary care, issues relating to roles are likely to be crucial in the effective implementation of the new PCMHWs.

Delivering interventions for depression by using the internet: randomised controlled trial

OBJECTIVE

To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression--a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy.

DESIGN

Randomised controlled trial.

SETTING

Internet users in the community, in Canberra, Australia.

PARTICIPANTS

525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178).

MAIN OUTCOME MEASURES

Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy.

RESULTS

Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the "depression literacy" site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants' understanding of effective evidence based treatments for depression (P < 0.05).

CONCLUSIONS

Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.

Meta-analysis of data on costs from trials of counselling in primary care: using individual patient data to overcome sample size limitations in economic analyses

OBJECTIVE

To assess the feasibility of overcoming sample size limitations in economic analyses of clinical trials through meta-analysis of data on individual patients from multiple trials.

DESIGN

Meta-analysis of individual patient data from trials of counselling in primary care compared with usual care by a general practitioner.

SETTING

Primary care.

PATIENTS

People with mental health problems.

MAIN OUTCOME MEASURES

Direct treatment costs, depressive symptoms, and cost effectiveness.

RESULTS

Meta-analysis of individual patient data proved feasible. The results showed that the previous analyses of individual trials were underpowered to provide useful conclusions about the cost comparisons. The results are sensitive to assumptions made about the costs of sessions with a counsellor and the management of patients by a general practitioner.

CONCLUSIONS

Meta-analysis of individual patient data may assist in overcoming sample size limitations in economic analyses. Although feasible, such analysis has shortcomings that may limit the validity of the results. The relative costs and benefits of this method, as opposed to further collection of primary data, are as yet unclear.