What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression

Can mindfulness and acceptance be learnt by self-help?: a systematic review and meta-analysis of mindfulness and acceptance-based self-help interventions

There is growing evidence that mindfulness and acceptance-based interventions have positive consequences for psychological and physical health. The most well-established of these interventions typically involve relatively large resource commitments, in terms of both the provider and participant. A number of recent studies have begun to explore whether the benefits of such interventions can be generalised to less intensive methods. Methods include pure and guided self-help utilising resources such as books and workbooks, computer programmes and applications and audio-visual materials. This paper presents a systematic review and meta-analysis of studies that have evaluated the effectiveness and acceptability of low-intensity interventions including mindfulness and acceptance-based components. Fifteen RCTs (7 ACT-based, 4 mindfulness-based and 4 multi-component interventions including elements of mindfulness and/or acceptance) were identified and reviewed. Interventions that included mindfulness and/or acceptance-based components produced significant benefits in comparison to control conditions on measures of mindfulness/acceptance, depression and anxiety with small to medium effect sizes. Engagement with the self-help interventions varied but on average two-thirds of participants completed post-intervention measures. Emerging research into low-intensity mindfulness and acceptance-based interventions is hopeful. Recommendations for research and practice are presented.

An evaluation of a collaborative bibliotherapy scheme delivered via a library service

This paper reports on the evaluation of a bibliotherapy scheme delivered via a local library service, in conjunction with General Practice (GP) practices, local social welfare agencies and through self-referral. The Read Yourself Well (RYW) scheme was based on principles established from other similar schemes and as a way of delivering support for adults experiencing mild to moderate mental health problems for whom clinical treatments are not appropriate. The intervention consisted of initial referral and evaluation by the scheme bibliotherapist, a one-hour session at the beginning and end of the intervention where a purpose-designed questionnaire and two mental health assessments were carried out (the General Health Questionnaire and the Clinical Outcomes in Routine Evaluation questionnaire). Contact and support from the bibliotherapist was provided during the intervention period. One hundred and fifty-seven participants were recruited to the evaluation of whom 114 provided full data. Statistical analyses of the mental health scores showed significant improvements post treatment, for, both male and female participants, for all three referral routes, and for participants who were previously library users, and those who joined the library service to participate in the RYW scheme. The results of this large sample evaluation support the proposal that library-based bibliotherapy can be effective in the treatment of mental health problems.

Treatment of child anxiety disorders via guided parent-delivered cognitive-behavioural therapy: randomised controlled trial

BACKGROUND

Promising evidence has emerged of clinical gains using guided self-help cognitive-behavioural therapy (CBT) for child anxiety and by involving parents in treatment; however, the efficacy of guided parent-delivered CBT has not been systematically evaluated in UK primary and secondary settings.

AIMS

To evaluate the efficacy of low-intensity guided parent-delivered CBT treatments for children with anxiety disorders.

METHOD

A total of 194 children presenting with a current anxiety disorder, whose primary carer did not meet criteria for a current anxiety disorder, were randomly allocated to full guided parent-delivered CBT (four face-to-face and four telephone sessions) or brief guided parent-delivered CBT (two face-to-face and two telephone sessions), or a wait-list control group (trial registration: ISRCTN92977593). Presence and severity of child primary anxiety disorder (Anxiety Disorders Interview Schedule for DSM-IV, child/parent versions), improvement in child presentation of anxiety (Clinical Global Impression - Improvement scale), and change in child anxiety symptoms (Spence Children's Anxiety Scale, child/parent version and Child Anxiety Impact scale, parent version) were assessed at post-treatment and for those in the two active treatment groups, 6 months post-treatment.

RESULTS

Full guided parent-delivered CBT produced superior diagnostic outcomes compared with wait-list at post-treatment, whereas brief guided parent-delivered CBT did not: at post-treatment, 25 (50%) of those in the full guided CBT group had recovered from their primary diagnosis, compared with 16 (25%) of those on the wait-list (relative risk (RR) 1.85, 95% CI 1.14-2.99); and in the brief guided CBT group, 18 participants (39%) had recovered from their primary diagnosis post-treatment (RR = 1.56, 95% CI 0.89-2.74). Level of therapist training and experience was unrelated to child outcome.

CONCLUSIONS

Full guided parent-delivered CBT is an effective and inexpensive first-line treatment for child anxiety.

A community-based group-guided self-help intervention for low mood and stress: study protocol for a randomized controlled trial

Background

Depression is a mental health condition which affects millions of people each year, with worldwide rates increasing. Cognitive behavioral therapy (CBT) is recommended in the National Institute for Health and Clinical Excellence (NICE) guidelines for the treatment of depression. However, waiting lists can cause delays for face-to-face therapy. Also a proportion of people decline to present for help through the health service – the so-called treatment gap. Self-referral to CBT using community-based group interventions delivered by a voluntary sector organization may serve to resolve this problem. The aim of this randomized controlled trial (RCT) is to determine the efficacy of such a guided CBT self-help course, the ‘Living Life to the Full’ (LLTTF) classes delivered by the charity Action on Depression (AOD). The primary outcome is level of depression at 6 months assessed using the patient health questionnaire-9 (PHQ9) depression scale. Secondary measures include levels of anxiety and social functioning.

Methods/design

Participants with symptoms of low mood will be recruited from the community through newspaper adverts and also via the AOD website. Participants will receive either immediate or delayed access to guided CBT self-help classes - the eight session LLTTF course. The primary endpoint will be at 6 months at which point the delayed group will be offered the intervention. Levels of depression, anxiety and social functioning will be assessed and an economic analysis will be carried out.

Discussion

This RCT will test whether the LLTTF intervention is effective and/or cost-effective. If the LLTTF community-based classes are found to be cost effective, they may be helpful as both an intervention for those already seeking care in the health service, as well as those seeking help outside that setting, widening access to psychological therapy.

Trial registration

Current Controlled Trials ISRCTN86292664

Understanding adolescent response to a technology-based depression prevention program

Guided by the Behavioral Vaccine Theory of prevention, this study uses a no-control group design to examine intervention variables that predict favorable changes in depressive symptoms at 6- to 8-week follow-up in at-risk adolescents who participated in a primary care, Internet-based prevention program. Participants included 83 adolescents from primary care settings ages 14 to 21 (M = 17.5, SD = 2.04), 56.2% female, with 41% non-White. Participants completed self-report measures, met with a physician, and then completed a 14-module Internet intervention targeting the prevention of depression. Linear regression models indicated that several intervention factors (duration on website in days, the strength of the relationship with the physician, perceptions of ease of use, and the perceived relevance of the material presented) were significantly associated with greater reductions in depressive symptoms from baseline to follow-up. Automatic negative thoughts significantly mediated the relation between change in depressive symptoms scores and both duration of use and physician relationship. Several intervention variables predicted favorable changes in depressive symptom scores among adolescents who participated in an Internet-based prevention program, and the strength of two of these variables was mediated by automatic negative thoughts. These findings support the importance of cognitive factors in preventing adolescent depression and suggest that modifiable aspects of technology-based intervention experience and relationships should be considered in optimizing intervention design.

Effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified: study protocol of a randomized controlled trial

BACKGROUND

Disordered eating behavior and body dissatisfaction affect a large proportion of the Dutch population and account for severe psychological, physical and social morbidity. Yet, the threshold for seeking professional care is still high. In the Netherlands, only 7.5% of patients with bulimia nervosa and 33% of patients with anorexia nervosa are treated within the mental health care system. Easily accessible and low-threshold interventions, therefore, are needed urgently. The internet has great potential to offer such interventions. The aim of this study is to determine whether a web-based treatment program for patients with eating disorders can improve eating disorder psychopathology among female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified.

METHODS/DESIGN

This randomized controlled trial will compare the outcomes of an experimental treatment group to a waiting list control group. In the web-based treatment program, participants will communicate personally and asynchronously with their therapists exclusively via the internet. The first part of the program will focus on analyzing eating attitudes and behaviors. In the second part of the program participants will learn how to change their attitudes and behaviors. Participants assigned to the waiting list control group will receive no-reply email messages once every two weeks during the waiting period of 15 weeks, after which they can start the program. The primary outcome measure is an improvement in eating disorder psychopathology as determined by the Eating Disorder Examination Questionnaire. Secondary outcomes include improvements in body image, physical and mental health, body weight, self-esteem, quality of life, and social contacts. In addition, the participants' motivation for treatment and their acceptability of the program and the therapeutic alliance will be measured. The study will follow the recommendations in the CONSORT statement relating to designing and reporting on RCTs.

DISCUSSION

This study protocol presents the design of a RCT for evaluating the effectiveness of a web-based treatment program using intensive therapeutic support for female patients with bulimia nervosa, binge eating disorder and eating disorders not otherwise specified.

TRIAL REGISTRATION

The protocol for this study is registered with the Netherlands Trial Registry NTR2415.

Development of a guided self-help (GSH) program for the treatment of mild-to-moderate posttraumatic stress disorder (PTSD)

BACKGROUND

There is a shortage of suitably qualified therapists able to deliver evidence-based treatment for posttraumatic stress disorder (PTSD), precluding timely access to intervention. This work aimed to develop an optimally effective, feasible, and acceptable guided self-help (GSH) program for treatment of the disorder.

METHODS

The study followed Medical Research Council (MRC) guidance for the development of a complex intervention. A prototype GSH program was developed through an initial modeling phase. Systematic reviews of the literature informed a portfolio of up-to-date information for key stakeholders to consider and discuss in a series of focus groups and semistructured interviews, which included 10 mental health professionals with expertise in the fields of GSH and/or PTSD, and seven former PTSD sufferers. Data were analyzed through a process of Inductive Thematic Analysis and used to inform the content, delivery, and guidance of a GSH program for PTSD. The prototype was piloted with 19 PTSD sufferers in two pilot studies, and refined on the basis of their quantitative results and qualitative feedback.

RESULTS

The final version was available online and in hardcopy. It included 11 modules, some being mandatory and others optional, allowing tailoring of the intervention to meet an individual's specific needs. Qualitative and quantitative results of the pilot studies supported its efficacy in terms of reducing traumatic stress symptoms and its acceptability to PTSD sufferers.

CONCLUSIONS

Delivering psychological treatment in a GSH format shows promise as an effective and acceptable way of treating mild-to-moderate PTSD.

Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Internet-based behavioral activation--treatment for postnatal depression (Netmums): a randomized controlled trial

BACKGROUND

Despite the high prevalence of postnatal depression (PND), few women seek help. The internet may increase timely access to treatment. We report a randomized controlled trial of a minimal intervention internet Behavioral Activation (iBA) treatment modified to address postnatal specific concerns (Postnatal-iBA).

METHODS

Women (n=910) recruited via a popular UK parenting site, Netmums.com, scoring above 12 on the Edinburgh Postnatal Depression Scale (EPDS) were randomly assigned to receive either Postnatal-iBA delivered or treatment-as-usual (TAU). We investigated the feasibility (recruitment, trial and treatment adherence) and effectiveness (depression status EPDS >12) of the intervention.

RESULTS

Recruitment was excellent; 1261 women, 961 of whom met inclusion criteria, signed up to the trial within two 2-week recruitment periods. Thirty-eight percent (343/910) of women completed the 15-week outcome assessment. Of those who completed 15-week assessment, fewer exceeded the depression cutoff in the Postnatal-iBA group (n=66/181) compared to TAU (n=91/162). Assuming all non-respondents remained depressed, the Postnatal-iBA effect was reduced.

LIMITATIONS

The study suffered from high attrition and future trials need to consider strategies for improving outcome completion. Some women reported struggles "keeping up" with the treatment.

CONCLUSIONS

A minimal support, widely accessible internet Behavioral Activation program for PND is feasible to deliver to community populations when embedded within popular parenting sites. For women who provide outcome data, postnatal-iBA offers promise as an effective treatment for PND. The addition of support may reduce women's struggles to keep pace with the treatment.

No evidence for intervention-dependent influence of methodological features on treatment effect

OBJECTIVES

The goal of this systematic review was to evaluate if the influence of methodological features on treatment effect differs between types of intervention.

STUDY DESIGN AND SETTING

MEDLINE, Embase, Web of Science, Cochrane methodology register, and reference lists were searched for meta-epidemiologic studies on the influence of methodological features on treatment effect. Studies analyzing influence of methodological features related to internal validity were included. We made a distinction among surgical, pharmaceutical, and therapeutical as separate types of intervention. Heterogeneity was calculated to identify differences among these types.

RESULTS

Fourteen meta-epidemiologic studies were found with 51 estimates of influence of methodological features on treatment effect. Heterogeneity was observed among the intervention types for randomization. Surgical intervention studies showed a larger treatment effect when randomized; this was in contrast to pharmaceutical studies that found the opposite. For allocation concealment and double blinding, the influence of methodological features on the treatment effect was comparable across different types of intervention. For the remaining methodological features, there were insufficient observations.

CONCLUSION

The influence of allocation concealment and double blinding on the treatment effect is consistent across studies of different interventional types. The influence of randomization although, may be different between surgical and nonsurgical studies.

Effect of a cognitive behavioral self-help intervention on depression, anxiety, and coping self-efficacy in people with rheumatic disease

OBJECTIVE

The aim of this study was to investigate whether a new cognitive-behavioral self-help program with minimal coaching could improve psychological well-being (depression, anxiety, and coping self-efficacy) in people with rheumatic disease and depressive symptoms.

METHODS

In total, 82 persons with a rheumatic disease enrolled in a randomized controlled trial were allocated to either a group receiving the self-help program or a waiting list control condition group. For both groups, measurements were done at baseline, posttest, and followup. The outcome measures were the depression and anxiety scales of the Hospital Anxiety and Depression Scale and an adaptation of the Generalized Self-Efficacy Scale. Repeated-measures analyses of covariance were performed to evaluate changes in outcome measures from pretest to posttest and from posttest to followup.

RESULTS

The results showed that the self-help program was effective in reducing symptoms of depression and anxiety and in strengthening coping self-efficacy. The positive effects remained after a followup period of 2 months.

CONCLUSION

This cost-effective program could very well be used as a first step in a stepped care approach or as one of the treatment possibilities in a matched care approach.

Improving adherence and clinical outcomes in self-guided internet treatment for anxiety and depression: randomised controlled trial

BACKGROUND

Depression and anxiety are common, disabling and chronic. Self-guided internet-delivered treatments are popular, but few people complete them. New strategies are required to realise their potential.

AIMS

To evaluate the effect of automated emails on the effectiveness, safety, and acceptability of a new automated transdiagnostic self-guided internet-delivered treatment, the Wellbeing Course, for people with depression and anxiety.

METHOD

A randomised controlled trial was conducted through the website: www.ecentreclinic.org. Two hundred and fifty seven people with elevated symptoms were randomly allocated to the 8 week course either with or without automated emails, or to a waitlist control group. Primary outcome measures were the Patient Health Questionnaire 9-Item (PHQ-9) and the Generalized Anxiety Disorder 7-Item (GAD-7).

RESULTS

Participants in the treatment groups had lower PHQ-9 and GAD-7 scores at post-treatment than controls. Automated emails increased rates of course completion (58% vs. 35%), and improved outcomes in a subsample with elevated symptoms.

CONCLUSIONS

The new self-guided course was beneficial, and automated emails facilitated outcomes. Further attention to strategies that facilitate adherence, learning, and safety will help realise the potential of self-guided interventions.

TRIAL REGISTRATION

Australian and New Zealand Clinical Trials Registry ACTRN12610001058066.

A randomised controlled trial of a brief online mindfulness-based intervention

OBJECTIVES

There is growing evidence that mindfulness has positive consequences for both psychological and physical health in both clinical and non-clinical populations. The potential benefits of mindfulness underpin a range of therapeutic intervention approaches designed to increase mindfulness in both clinical and community contexts. Self-guided mindfulness-based interventions may be a way to increase access to the benefits of mindfulness. This study explored whether a brief, online, mindfulness-based intervention can increase mindfulness and reduce perceived stress and anxiety/depression symptoms within a student population.

METHOD

One hundred and four students were randomly allocated to either immediately start a two-week, self-guided, online, mindfulness-based intervention or a wait-list control. Measures of mindfulness, perceived stress and anxiety/depression were administered before and after the intervention period.

RESULTS

Intention to treat analysis identified significant group by time interactions for mindfulness skills, perceived stress and anxiety/depression symptoms. Participation in the intervention was associated with significant improvements in all measured domains, where no significant changes on these measures were found for the control group.

CONCLUSIONS

This provides evidence in support of the feasibility and effectiveness of shorter self-guided mindfulness-based interventions. The limitations and implications of this study for clinical practice are discussed.

Depression self-management support: a systematic review

OBJECTIVE

To systematically review empirical evidence regarding the efficacy of depression self-management support (SMS) interventions for improving depression symptomatology and preventing relapse.

METHODS

Pubmed and PsycINFO databases were searched for relevant articles on depression SMS interventions. Scanning of references in the articles and relevant reviews and communications with field experts yielded additional articles. Two independent reviewers analyzed the articles for inclusion and data was extracted from the selected articles.

RESULTS

13 papers met the inclusion criteria and reported the results of six separate studies, including three pilot studies. The results were mostly positive. A majority of the trials assessing depression severity changes found SMS to be superior to care as usual. SMS interventions were found to improve self-management behaviors and self-efficacy. Mixed results were found concerning relapse rates. Promising results were found on assessments of functional status. Based on the findings, cost-effectiveness remains unclear.

CONCLUSION

SMS has been mostly examined through pilot studies with insufficient power. The results are promising, but larger randomized controlled trials are needed.

PRACTICE IMPLICATIONS

SMS interventions can be administered by non-physician professionals and are well accepted by patients, but more research is needed before we can recommend implementing specific depression SMS approaches in primary care.

The evidence-based practice of psychotherapy: facing the challenges that lie ahead

What does the future hold for psychotherapy research and practice? We review some key influences, including declining psychotherapy utilization, increasing impact of evidence-based medical practices, over-medicalizing of mental health problems, and changing priorities from grant funding agencies. These factors hold potential opportunities but also major pitfalls that will need to be carefully navigated related to implementation/dissemination issues, interdisciplinary collaborations, and psychosocial versus biomedical perspectives related to the nature and treatment of psychopathology. In addition, we review and comment on the other articles contained in this special issue pertaining to the future of evidence-based psychotherapy.

Is computerised CBT really helpful for adult depression?-A meta-analytic re-evaluation of CCBT for adult depression in terms of clinical implementation and methodological validity

BACKGROUND

Depression is a major cause of disability worldwide, and computerised cognitive behavioural therapy (CCBT) is expected to be a more augmentative and efficient treatment. According to previous meta-analyses of CCBT, there is a need for a meta-analytic revaluation of the short-term effectiveness of this therapy and for an evaluation of its long-term effects, functional improvement and dropout.

METHODS

Five databases were used (MEDLINE, PsycINFO, EMBASE, CENTRAL and CiNii). We included all RCTs with proper concealment and blinding of outcome assessment for the clinical effectiveness of CCBT in adults (aged 18 and over) with depression. Using Cohen's method, the standard mean difference (SMD) for the overall pooled effects across the included studies was estimated with a random effect model. The main outcome measure and the relative risk of dropout were included in the meta-analysis.

RESULTS

Fourteen trials met the inclusion criteria, and sixteen comparisons from these were used for the largest meta-analysis ever. All research used appropriate random sequence generation and Intention-to-Treat analyses (ITT), and employed self-reported measures as the primary outcome. For the sixteen comparisons (2807 participants) comparing CCBT and control conditions, the pooled SMD was -0.48 [95% IC -0.63 to -0.33], suggesting similar effect to the past reviews. Also, there was no significant clinical effect at long follow-up and no improvement of function found. Furthermore, a significantly higher drop-out rate was found for CCBT than for controls. When including studies without BDI as a rating scale and with only modern imputation as sensitivity analysis, the pooled SMD remained significant despite the reduction from a moderate to a small effect. Significant publication bias was found in a funnel plot and on two tests (Begg's p = 0.09; Egger's p = 0.01). Using a trim and fill analysis, the SMD was -0.32 [95% CI -0.49 to -0.16].

CONCLUSION

Despite a short-term reduction in depression at post-treatment, the effect at long follow-up and the function improvement were not significant, with significantly high drop-out. Considering the risk of bias, our meta-analysis implied that the clinical usefulness of current CCBT for adult depression may need to be re-considered downwards in terms of practical implementation and methodological validity.

A Pilot Web Based Positive Parenting Intervention to Help Bipolar Parents to Improve Perceived Parenting Skills and Child Outcomes

Background: Children of bipolar parents are at elevated risk for psychiatric disorders including bipolar disorder. Helping bipolar parents to optimize parenting skills may improve their children's mental health outcomes. Clear evidence exists for benefits of behavioural parenting programmes, including those for depressed mothers. However, no studies have explored web-based self-directed parenting interventions for bipolar parents. Aims: The aim of this research was to conduct a pilot study of a web-based parenting intervention based on the Triple P-Positive Parenting Programme. Method: Thirty-nine self-diagnosed bipolar parents were randomly allocated to the web-based intervention or a waiting list control condition. Parents reported on their index child (entry criterion age 4–10 years old). Perceived parenting behaviour and child behaviour problems (internalizing and externalizing) were assessed at inception and 10 weeks later (at course completion). Fifteen participants (4 control group and 11 intervention group) did not provide follow-up data. Results: Levels of child behaviour problems (parent rated; Strengths and Difficulties Questionnaire) were above clinical thresholds at baseline, and problematic perceived parenting (self-rated; Parenting Scale) was at similar levels to those in previous studies of children with clinically significant emotional and behavioural problems. Parents in the intervention group reported improvements in child behaviour problems and problematic perceived parenting compared to controls. Conclusions: A web-based positive parenting intervention may have benefits for bipolar parents and their children. Initial results support improvement in child behaviour and perceived parenting. A more definitive study addressing the limitations of the current work is now called for.

Behavioural activation for depression: efficacy, effectiveness and dissemination

BACKGROUND

Depression being a prevalent psychobiological disorder across the world, there is a need to identify effective, evidence-based treatments that are time and cost-effective in an effort to increase the population's accessibility to treatments. Low-intensity interventions, such as guided self-help treatments, hold promise for the dissemination of evidence-based treatments. Behavioural activation, a component of cognitive-behavioural therapy, is receiving increasing attention and empirical support as a stand-alone psychological treatment for depression. This article reviews behavioural activation's theoretical foundations and efficacy in light of determining its potential as a low-intensity intervention.

METHOD

A systematic review of articles on low-intensity behavioural activation interventions for depression was conducted using the PsychInfo, Medline and Embase databases. Behavioural activation's potential for dissemination as a guided self-help treatment is discussed and future avenues of research are stressed.

LIMITATIONS

Studies on the efficacy of behavioural activation as a guided self-help treatment are very limited to date and there are significant variations among existing studies.

CONCLUSIONS

Based on the research literature, it can be concluded that behavioural activation could be a viable option as a low-intensity guided self-help psychological treatment for mild to moderate depression. Further research is required to better understand the optimal parameters and client-therapist characteristics of this form of low-intensity intervention.

Influence of initial severity of depression on effectiveness of low intensity interventions: meta-analysis of individual patient data

OBJECTIVE

To assess how initial severity of depression affects the benefit derived from low intensity interventions for depression.

DESIGN

Meta-analysis of individual patient data from 16 datasets comparing low intensity interventions with usual care.

SETTING

Primary care and community settings.

PARTICIPANTS

2470 patients with depression.

INTERVENTIONS

Low intensity interventions for depression (such as guided self help by means of written materials and limited professional support, and internet delivered interventions).

MAIN OUTCOME MEASURES

Depression outcomes (measured with the Beck Depression Inventory or Center for Epidemiologic Studies Depression Scale), and the effect of initial depression severity on the effects of low intensity interventions.

RESULTS

Although patients were referred for low intensity interventions, many had moderate to severe depression at baseline. We found a significant interaction between baseline severity and treatment effect (coefficient -0.1 (95% CI -0.19 to -0.002)), suggesting that patients who are more severely depressed at baseline demonstrate larger treatment effects than those who are less severely depressed. However, the magnitude of the interaction (equivalent to an additional drop of around one point on the Beck Depression Inventory for a one standard deviation increase in initial severity) was small and may not be clinically significant.

CONCLUSIONS

The data suggest that patients with more severe depression at baseline show at least as much clinical benefit from low intensity interventions as less severely depressed patients and could usefully be offered these interventions as part of a stepped care model.

Web-based treatment program using intensive therapeutic contact for patients with eating disorders: before-after study

Background

Although eating disorders are common in the Netherlands, only a few patients are treated by mental health care professionals. To reach and treat more patients with eating disorders, Tactus Addiction Treatment developed a web-based treatment program with asynchronous and intensive personalized communication between the patient and the therapist.

Objective

This pilot study evaluated the web-based treatment program using intensive therapeutic contact in a population of 165 patients with an eating disorder.

Methods

In a pre-post design with 6-week and 6-month follow-ups, eating disorder psychopathology, body dissatisfaction, Body Mass Index, physical and mental health, and quality of life were measured. The participant’s satisfaction with the web-based treatment program was also studied. Attrition data were collected, and participants were classified as noncompleters if they did not complete all 10 assignments of the web-based treatment program. Differences in baseline characteristics between completers and noncompleters were studied, as well as reasons for noncompletion. Furthermore, differences in treatment effectiveness, treatment adherence, and baseline characteristics between participants of the three major eating disorder diagnostic groups EDNOS (n=115), BN purging (n=24), and BN nonpurging (n=24) were measured.

Results

Of the 165 participants who started the web-based treatment program, 89 participants (54%) completed all of the program assignments (completers) and 76 participants (46%) ended the program prematurely (noncompleters). Severe body dissatisfaction and physical and mental health problems seemed to have a negative impact on the completion of the web-based treatment program. Among the participants who completed the treatment program, significant improvements were found in eating disorder psychopathology (F=54.6, df = 68, P<.001, d=1.14). Body dissatisfaction, quality of life, and physical and mental health also significantly improved, and almost all of these positive effects were sustained up to 6 months after the participants had completed the web-based treatment program. Body Mass Index improved only within the group of participants suffering from obesity. The improvement in eating disorder psychopathology occurred in all three eating disorder diagnostic groups, and the percentage of completers did not differ significantly between these groups. Participants’ satisfaction with the treatment program, as well as with their therapist, was high, and participants indicated that they would recommend the program to other patients with eating disorders.

Conclusions

The results of this study suggest that the web-based treatment program has the potential to improve eating disorder psychopathology in patients with different types of eating disorders.

Guided self-help cognitive behavioural therapy for depression in primary care: a randomised controlled trial

Background

Access to Cognitive behavioural therapy (CBT) for depression is limited. One solution is CBT self-help books.

Trial Objectives: To assess the impact of a guided self-help CBT book (GSH-CBT) on mood, compared to treatment as usual (TAU).

Hypotheses:

GSH-CBT will have improved mood and knowledge of the causes and treatment of depression compared to the control receiving TAU

Guided self-help will be acceptable to patients and staff.

Methods and Findings

Participants: Adults attending seven general practices in Glasgow, UK with a BDI-II score of ≥14. 141 randomised to GSH-CBT and 140 to TAU.

Interventions: RCT comparing ‘Overcoming Depression: A Five Areas Approach’ book plus 3–4 short face to face support appointments totalling up to 2 hours of guided support, compared with general practitioner TAU.

Primary outcome: The BDI (II) score at 4 months.

Numbers analysed: 281 at baseline, 203 at 4 months (primary outcome), 117 at 12 months.

Outcome: Mean BDI-II scores were lower in the GSH-CBT group at 4 months by 5.3 points (2.6 to 7.9, p<0.001). At 4 and 12 months there were also significantly higher proportions of participants achieving a 50% reduction in BDI-II in the GSH-CBT arm. The mean support was 2 sessions with 42.7 minutes for session 1, 41.4 minutes for session 2 and 40.2 minutes of support for session 3.

Adverse effects/Harms: Significantly less deterioration in mood in GSH-CBT (2.0% compared to 9.8% in the TAU group for BDI—II category change).

Limitations

Weaknesses: Our follow-up rate of 72.2% at 4 months is better than predicted but is poorer at 12 months (41.6%). In the GSH-CBT arm, around 50% of people attended 2 or fewer sessions. 22% failed to take up treatment.

Conclusions

GSH-CBT is substantially more effective than TAU.

Trial Registration

Controlled-Trials.com ISRCTN13475030

Low intensity vs. self-guided internet-delivered psychotherapy for major depression: a multicenter, controlled, randomized study

BACKGROUND

Major depression will become the second most important cause of disability in 2020. Computerized cognitive-behaviour therapy could be an efficacious and cost-effective option for its treatment. No studies on cost-effectiveness of low intensity vs self-guided psychotherapy has been carried out. The aim of this study is to assess the efficacy of low intensity vs self-guided psychotherapy for major depression in the Spanish health system.

METHODS

The study is made up of 3 phases: 1.- Development of a computerized cognitive-behaviour therapy for depression tailored to Spanish health system. 2.- Multicenter controlled, randomized study: A sample (N=450 patients) with mild/moderate depression recruited in primary care. They should have internet availability at home, not receive any previous psychological treatment, and not suffer from any other severe somatic or psychological disorder. They will be allocated to one of 3 treatments: a) Low intensity Internet-delivered psychotherapy + improved treatment as usual (ITAU) by GP, b) Self-guided Internet-delivered psychotherapy + ITAU or c) ITAU. Patients will be diagnosed with MINI psychiatric interview. Main outcome variable will be Beck Depression Inventory. It will be also administered EuroQol 5D (quality of life) and Client Service Receipt Inventory (consume of health and social services). Patients will be assessed at baseline, 3 and 12 months. An intention to treat and a per protocol analysis will be performed.

DISCUSSION

The comparisons between low intensity and self-guided are infrequent, and also a comparative economic evaluation between them and compared with usual treatment in primary. The strength of the study is that it is a multicenter, randomized, controlled trial of low intensity and self-guided Internet-delivered psychotherapy for depression in primary care, being the treatment completely integrated in primary care setting.

TRIAL REGISTRATION

Clinical Trials NCT01611818.

Feasibility study of a self-guided cognitive behaviour therapy Internet intervention for cancer carers

Despite the evidence base for Internet-delivered self-help programmes, their application to cancer carers has not been reported. This feasibility study evaluated a 6-week internet cognitive behaviour therapy (CBT) programme for early stage cancer carers. The study participants comprised 13 carers who were recruited over a 17-month period. Measures included distress, quality of life and programme engagement. Changes over time were measured using effect sizes (Cohen’s d), whereas acceptibility was assessed using qualitative feedback. Low enrolment and high attrition rates resulted in a failure to demonstrate feasibility. Large improvements in negative affect (d = 0.88) and emotional functioning (d = 0.62) were found. For treatment completers, the intervention holds promise in reducing distress. However, in light of the serious challenges with recruitment and retention, further research is needed to resolve participation barriers.

A national survey of the infrastructure and IT policies required to deliver computerised cognitive behavioural therapy in the English NHS

OBJECTIVE

This study aimed to identify if patients have adequate access to Computerised Cognitive Behavioural Therapy (cCBT) programmes in all mental health trusts across England.

DESIGN

The primary researcher contacted a targeted sample of information technology (IT) leads in each mental health trust in England to complete the survey.

SETTING

Telephone, email and postal mail were used to contact an IT lead or nominated expert from each mental health trust.

PARTICIPANTS

48 of the 56 IT experts from each mental health trust in England responded. The experts who were chosen had sufficient knowledge of the infrastructure, technology, policies and regulations to answer all survey questions.

RESULTS

77% of trusts provided computers for direct patient use, with computers in all except one trust meeting the specifications to access cCBT. However, 24% of trusts acknowledged that the number of computers provided was insufficient to provide a trust-wide service. 71% stated that the bandwidth available was adequate to provide access to cCBT sites, yet for many trusts, internet speed was identified as unpredictable and variable between locations. IT policies in only 56% of the trusts allowed National Health Service (NHS) staff to directly support patients as they complete cCBT courses via emails to the patients' personal email account. Only 37% allowed support via internet video calls, and only 9% allowed support via instant messaging services.

CONCLUSIONS

Patient access to cCBT in English NHS mental health trusts is limited by the inadequate number of computers provided to patients, unpredictable bandwidth speed and inconsistent IT policies, which restrict patients from receiving the support needed to maximise the success of this therapy. English NHS mental health trusts need to alter IT policy and improve resources to reduce the waiting time for psychological resources required for patients seeking this evidence-based therapy.

An overview of the effectiveness of psychological therapy for depression and stepped care service delivery models

Depression is one of the most prevalent health disorders globally and causes significant distress and cost to the sufferer and society. Psychological therapy for depression has been recommended over a number of decades; however, access to these treatments remains limited. Cognitive behaviour therapy, behavioural activation, self-help approaches, interpersonal therapy and non-directive therapy all demonstrate moderate to large effect sizes when compared to treatment as usual. Differences between psychological interventions however are small and unstable when reviewed in meta-analyses suggesting that for most people adding complexity to treatment does not result in improved outcomes. Stepped care is one system used to organise delivery of psychological therapy that stratifies interventions across several levels of symptom severity. There is debate regarding the ideal design and operation of this complex system resulting in considerable variability in its use in clinical settings. Further research is needed to identify the most cost effective approach to the delivery of psychological therapies for depression as we need to continue to reduce the gap between demand and access to therapy.

Understanding children's dental anxiety and psychological approaches to its reduction

BACKGROUND

Dental anxiety is a common problem, which can affect people of all ages, but appears to develop mostly in childhood and adolescence. Childhood dental anxiety is not only distressing for the child and their family but is also associated with poor oral health outcomes and an increased reliance on costly specialist dental services.

AIM

This article will consider the prevalence, development, and implications of children's dental anxiety. It will also discuss the opportunities for and challenges of psychological approaches such as cognitive behavioural therapy aimed at the reduction of dental anxiety in children.

One-on-one Mindfulness Meditation Trainings in a Research Setting

We created a standardized one-on-one mindfulness meditation intervention with six weekly 90-minute training sessions and home practice. The trainings included didactic instruction, discussion and guided meditations, and home-practice guided meditations and mindfulness exercises. Twenty-eight participants completed mindful awareness, nonjudgment, perceived stress, positive and negative affect, and credibility/expectancy scales before and after the intervention. There were no adverse events or unanticipated side effects. Participants' mindful awareness and nonjudgment scores and perceived credibility of the intervention increased after the intervention, while negative affect and perceived stress decreased. There was no change in positive affect. Future research is needed comparing group versus one-on-one formats incorporating participant preference in the randomization, personality, and other predictors as measures.

Depression and diabetes: the role and impact of models of health care systems

OBJECTIVES

Depression and diabetes often occur together and their comorbidity has a significant and detrimental impact on health outcomes. The aims of this paper are to review the existing international literature on approaches to health care for comorbid depression and diabetes and draw out the key conclusions for both research and future development in health care delivery.

METHODS

Narrative review of the literature with synthesis by an international team of authors.

RESULTS

The synthesized findings are discussed under four main headings: specialty and generalist care; models for co-ordinating and integrating care; community approaches to service delivery; and the role of health policy.

LIMITATIONS

The review only included literature published in English.

CONCLUSIONS

Translating basic and clinical research findings into improved treatment and outcomes of those with depression and diabetes remains a substantial challenge. There is little research on the difficulties of identifying and implementing best practice into routine health care. Systems need to be designed so that evidence-based interventions are provided in a timely way, with appropriate professional expertise where required.

A pilot randomized controlled trial of the feasibility of a self-directed coping skills intervention for couples facing prostate cancer: rationale and design

BACKGROUND

Although it is known both patients' and partners' reactions to a prostate cancer diagnosis include fear, uncertainty, anxiety and depression with patients' partners' reactions mutually determining how they cope with and adjust to the illness, few psychosocial interventions target couples. Those that are available tend to be led by highly trained professionals, limiting their accessibility and long-term sustainability. In addition, it is recognised that patients who might benefit from conventional face-to-face psychosocial interventions do not access these, either by preference or because of geographical or mobility barriers. Self-directed interventions can overcome some of these limitations and have been shown to contribute to patient well-being. This study will examine the feasibility of a self-directed, coping skills intervention for couples affected by cancer, called Coping-Together, and begin to explore its potential impact on couples' illness adjustment. The pilot version of Coping-Together includes a series of four booklets, a DVD, and a relaxation audio CD.

METHODS/DESIGN

In this double-blind, two-group, parallel, randomized controlled trial, 70 couples will be recruited within 4 months of a prostate cancer diagnosis through urology private practices and randomized to: 1) Coping-Together or 2) a minimal ethical care condition. Minimal ethical care condition couples will be mailed information booklets available at the Cancer Council New South Wales and a brochure for the Cancer Council Helpline. The primary outcome (anxiety) and additional secondary outcomes (distress, depression, dyadic adjustment, quality of life, illness or caregiving appraisal, self-efficacy, and dyadic and individual coping) will be assessed at baseline (before receiving study material) and 2 months post-baseline. Intention-to-treat and per protocol analysis will be conducted.

DISCUSSION

As partners' distress rates exceed not only population norms, but also those reported by patients themselves, it is imperative that coping skills interventions target the couple as a unit and enhance both partners' ability to overcome cancer challenges. This pilot study will examine the feasibility and potential efficacy of Coping-Together in optimising couples' illness adjustment. This is one of the first feasibility studies to test this innovative coping intervention, which in turn will contribute to the larger literature advocating for psychosocial care of couples affected by prostate cancer.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12611000438954.

A national survey of health service infrastructure and policy impacts on access to computerised CBT in Scotland

Background

NICE recommends computerised cognitive behavioural therapy (cCBT) for the treatment of several mental health problems such as anxiety and depression. cCBT may be one way that services can reduce waiting lists and improve capacity and efficiency. However, there is some doubt about the extent to which the National Health Service (NHS) in the UK is embracing this new health technology in practice. This study aimed to investigate Scottish health service infrastructure and policies that promote or impede the implementation of cCBT in the NHS.

Methods

A telephone survey of lead IT staff at all health board areas across Scotland to systematically enquire about the ability of local IT infrastructure and IT policies to support delivery of cCBT.

Results

Overall, most of the health boards possess the required software to use cCBT programmes. However, the majority of NHS health boards reported that they lack dedicated computers for patient use, hence access to cCBT at NHS sites is limited. Additionally, local policy in the majority of boards prevent staff from routinely contacting patients via email, skype or instant messenger, making the delivery of short, efficient support sessions difficult.

Conclusions

Conclusions: Overall most of the infrastructure is in place but is not utilised in ways that allow effective delivery. For cCBT to be successfully delivered within a guided support model, as recommended by national guidelines, dedicated patient computers should be provided to allow access to online interventions. Additionally, policy should allow staff to support patients in convenient ways such as via email or live chat. These measures would increase the likelihood of achieving Scottish health service targets to reduce waiting time for psychological therapies to 18 weeks.

Evaluation of a cognitive behavioural self-help manual for reducing depression: a randomized controlled trial

The prevalence of depression is increasing in Thailand. We used a randomized controlled trial to examine the effectiveness of a self-help programme in reducing depression in people with depression in Chiang Mai Province in Thailand. Fifty-six individuals diagnosed with moderate depression participated. They were assigned randomly to an intervention (n= 27) or control (n= 29) group. The intervention group were given a self-help manual along with standard care and treatment, while the control group continued to receive standard care and treatment. Both groups were also given a short weekly telephone call. The findings showed statistically significant differences between the groups, and within the intervention group, in their depression levels. Between baseline and post-test, a sharp decrease in depression was evident in the intervention group, whereas the level of depression increased in the control group. Between post-test and follow-up, a decrease was apparent in depression in both groups. However, the intervention group showed a much lower level of depression than the control group. The results support the use of bibliotherapy as an adjunct to mental health nurses' and other professionals' work in caring for people with moderate depression in the community.

TRIAL REGISTRATION

http://www.ANZCTR.org.au/ACTRN12611000905965.aspx.

Effects of yoga on psychologic function and quality of life in women with breast cancer: a meta-analysis of randomized controlled trials

OBJECTIVE

The aim of this meta-analysis was to evaluate the effects of yoga on psychologic function and quality of life (QoL) in women with breast cancer.

DESIGN

A systematic search of PubMed, EMBASE, the Cochrane Library, the Chinese Biomedical Literature Database, and the Chinese Digital Journals Full-text Database was carried out. Randomized control trials (RCTs) examining the effects of yoga, versus a control group receiving no intervention, on psychologic functioning and QoL in women with breast cancer were included. Methodological quality of included RCTs was assessed according to the Cochrane Handbook for Systematic Reviews of Interventions 5.0.1, and data were analyzed using the Cochrane Collaboration's Review Manager 5.1.

RESULTS

Six (6) studies involving 382 patients were included. The meta-analysis showed that yoga can improve QoL for women with breast cancer. A statistically significant effect favoring yoga for the outcome of QoL was found (standard mean difference=0.27, 95% confidence interval [0.02, 0.52], p=0.03). Although the effects of yoga on psychologic function outcomes--such as anxiety, depression, distress and sleep--were in the expected direction, these effects were not statistically significant (p>0.05). Fatigue showed no significant difference (p>0.05).

CONCLUSIONS

The present data provided little indication of how effective yoga might be when they were applied by women with breast cancer except for mildly effective in QOL improvement. The findings were based on a small body of evidence in which methodological quality was not high. Further well-designed RCTs with large sample size are needed to clarify the utility of yoga practice for this population.

Preventing major depression in older medical inpatients: innovation or flight of fancy?

Major depression in older medical inpatients is frequent, persistent, and disabling (Cole and Bellavance, 1997). The incidence is 20.5%–30.2% during the 12 months following admission to hospital (Fenton et al., 1997; Cole et al., 2008). Up to 73% of patients have a protracted course (Koenig et al., 1992; Cole et al., 2006; Koenig, 2006). Moreover, major depression in older medical inpatients appears to be associated with decreased function (Covinsky et al., 1997), increased use of health care services (Koenig et al., 1989; Büla et al., 2001), increased caregiver burden (McCusker et al., 2007), and possibly increased mortality (Cole, 2007).

The experience of recovery from the perspective of people with common mental health problems: findings from a telephone survey

BACKGROUND

For people with common mental health problems such as depression and anxiety related disorders the understanding of what recovery means and what it may entail is less fully developed than for people with less common mental health problems such as schizophrenia.

AIM

The aim of this telephone survey was to obtain a clearer conception and better understanding of the value of recovery from the perspective of service users who have experienced common mental health problems.

METHODS

Data was collected from telephone interviews with 98 service users using a mixture of quantitative and qualitative methods.

RESULTS

The service users' quantitative ratings of their subjective improvement indicated that recovery was a state of being that was manifestly different from the experience of being unwell. The data from the qualitative interviews corroborated these findings. A central theme that also emerged from the analysis of the data was that recovery was associated with having a greater sense of balance and control. Service users indicated that this sense of balance and control operated on many levels, however it was most significant in the context of dealing with their most salient concerns and pursuing their personal goals.

CONCLUSION

More emphasis may need to be placed on enabling service users to identify their salient concerns and pursue their personal goals in order to give them the sense of balance and control they are looking for.

Informing the development of services supporting self-care for severe, long term mental health conditions: a mixed method study of community based mental health initiatives in England

BACKGROUND

Supporting self-care is being explored across health care systems internationally as an approach to improving care for long term conditions in the context of ageing populations and economic constraint. UK health policy advocates a range of approaches to supporting self-care, including the application of generic self-management type programmes across conditions. Within mental health, the scope of self-care remains poorly conceptualised and the existing evidence base for supporting self-care is correspondingly disparate. This paper aims to inform the development of support for self-care in mental health by considering how generic self-care policy guidance is implemented in the context of services supporting people with severe, long term mental health problems.

METHODS

A mixed method study was undertaken comprising standardised psychosocial measures, questionnaires about health service use and qualitative interviews with 120 new referrals to three contrasting community based initiatives supporting self-care for severe, long term mental health problems, repeated nine months later. A framework approach was taken to qualitative analysis, an exploratory statistical analysis sought to identify possible associations between a range of independent variables and self-care outcomes, and a narrative synthesis brought these analyses together.

RESULTS

Participants reported improvement in self-care outcomes (e.g. greater empowerment; less use of Accident and Emergency services). These changes were not associated with level of engagement with self-care support. Level of engagement was associated with positive collaboration with support staff. Qualitative data described the value of different models of supporting self-care and considered challenges. Synthesis of analyses suggested that timing support for self-care, giving service users control over when and how they accessed support, quality of service user-staff relationships and decision making around medication are important issues in supporting self-care in mental health.

CONCLUSIONS

Service delivery components - e.g. peer support groups, personal planning - advocated in generic self-care policy have value when implemented in a mental health context. Support for self-care in mental health should focus on core, mental health specific qualities; issues of control, enabling staff-service user relationships and shared decision making. The broad empirical basis of our research indicates the wider relevance of our findings across mental health settings.

Client Contact in Self-Help Therapy for Anxiety and Depression: Necessary But Can Take a Variety of Forms Beside Therapist Contact

Self-administered therapies (SATs) have been promoted as a way to increase access to evidence-based mental health services. Recent meta-analyses and literature reviews suggest that SATs with clinical guidance are more effective than SATs with no contact for the treatment of anxiety and depression. However, little attention has been paid to the role of nonguidance contact, contact that does not involve the provision of assistance in the application of specific therapy techniques such as emails to encourage treatment adherence. The present article examines the impact of nonguidance contact on the outcomes of SATs for anxiety and depression. Electronic databases were searched to identify studies conducted over the past two decades by independent research teams that have tested cognitive-behavioural SATs over multiple trials. Findings suggest that the involvement or guidance of a therapist is not essential for SATs to produce significant benefits as long as nonguidance contact is provided. It is suggested that even very minimal levels of nonguidance contact increase SAT's outcomes by motivating treatment engagement and improving adherence. The benefit of SATs that can be accessed directly by large numbers of individuals and that do not require therapist involvement to ensure efficacy can potentially significantly increase the cost effectiveness and quality of mental health service delivery.

Guided self-help concreteness training as an intervention for major depression in primary care: a Phase II randomized controlled trial

BACKGROUND

The development of widely accessible, effective psychological interventions for depression is a priority. This randomized trial provides the first controlled data on an innovative cognitive bias modification (CBM) training guided self-help intervention for depression.

METHOD

One hundred and twenty-one consecutively recruited participants meeting criteria for current major depression were randomly allocated to treatment as usual (TAU) or to TAU plus concreteness training (CNT) guided self-help or to TAU plus relaxation training (RT) guided self-help. CNT involved repeated practice at mental exercises designed to switch patients from an unhelpful abstract thinking habit to a helpful concrete thinking habit, thereby targeting depressogenic cognitive processes (rumination, overgeneralization).

RESULTS

The addition of CNT to TAU significantly improved depressive symptoms at post-treatment [mean difference on the Hamilton Rating Scale for Depression (HAMD) 4.28, 95% confidence interval (CI) 1.29-7.26], 3- and 6-month follow-ups, and for rumination and overgeneralization post-treatment. There was no difference in the reduction of symptoms between CNT and RT (mean difference on the HAMD 1.98, 95% CI -1.14 to 5.11), although CNT significantly reduced rumination and overgeneralization relative to RT post-treatment, suggesting a specific benefit on these cognitive processes.

CONCLUSIONS

This study provides preliminary evidence that CNT guided self-help may be a useful addition to TAU in treating major depression in primary care, although the effect was not significantly different from an existing active treatment (RT) matched for structural and common factors. Because of its relative brevity and distinct format, it may have value as an additional innovative approach to increase the accessibility of treatment choices for depression.

A randomized, placebo-controlled trial of online cognitive behavioral therapy for chronic insomnia disorder delivered via an automated media-rich web application

STUDY OBJECTIVES

The internet provides a pervasive milieu for healthcare delivery. The purpose of this study was to determine the effectiveness of a novel web-based cognitive behavioral therapy (CBT) course delivered by an automated virtual therapist, when compared with a credible placebo; an approach required because web products may be intrinsically engaging, and vulnerable to placebo response.

DESIGN

Randomized, placebo-controlled trial comprising 3 arms: CBT, imagery relief therapy (IRT: placebo), treatment as usual (TAU).

SETTING

Online community of participants in the UK.

PARTICIPANTS

One hundred sixty-four adults (120 F: [mean age 49y (18-78y)] meeting proposed DSM-5 criteria for Insomnia Disorder, randomly assigned to CBT (n = 55; 40 F), IRT placebo (n = 55; 42 F) or TAU (n = 54; 38 F).

INTERVENTIONS

CBT and IRT each comprised 6 online sessions delivered by an animated personal therapist, with automated web and email support. Participants also had access to a video library/back catalogue of session content and Wikipedia style articles. Online CBT users had access to a moderated social network/community of users. TAU comprised no restrictions on usual care and access to an online sleep diary.

MEASUREMENTS AND RESULTS

Major assessments at baseline, post-treatment, and at follow-up 8-weeks post-treatment; outcomes appraised by online sleep diaries and clinical status. On the primary endpoint of sleep efficiency (SE; total time asleep expressed as a percentage of the total time spent in bed), online CBT was associated with sustained improvement at post-treatment (+20%) relative to both TAU (+6%; d = 0.95) and IRT (+6%: d = 1.06), and at 8 weeks (+20%) relative to IRT (+7%: d = 1.00) and TAU (+9%: d = 0.69) These findings were mirrored across a range of sleep diary measures. Clinical benefits of CBT were evidenced by modest superiority over placebo on daytime outcomes (d = 0.23-0.37) and by substantial improved sleep-wake functioning on the Sleep Condition Indicator (range of d = 0.77-1.20). Three-quarters of CBT participants (76% [CBT] vs. 29% [IRT] and 18% [TAU]) completed treatment with SE > 80%, more than half (55% [CBT] vs. 17% [IRT] and 8% [TAU]) with SE > 85%, and over one-third (38% [CBT] vs. 6% [IRT] and 0% [TAU]) with SE > 90%; these improvements were largely maintained during follow-up.

CONCLUSION

CBT delivered using a media-rich web application with automated support and a community forum is effective in improving the sleep and associated daytime functioning of adults with insomnia disorder.

CLINICAL TRIAL REGISTRATION

ISRCTN - 44615689.

The views of relatives of young people with psychosis on how to design a Relatives Education And Coping Toolkit (REACT)

BACKGROUND

Relatives of people with psychosis experience high levels of distress. Interventions are needed which can reduce distress and are widely available.

AIMS

This study presents the views of relatives on how to design a supported self-management intervention for relatives.

METHOD

Four focus groups were carried out and relatives were asked for their views on the content, format, support required, likely barriers and potential impact on the outcome of a self-management toolkit.

RESULTS

Relatives were generally very positive about the development of a toolkit. Relatives had clear ideas about the design, emphasising particularly that it needs to be comprehensive, modular, supported and able to translate general information into the specific detail they require for their family member. Many of the ideas informed the development of Relatives Education And Coping Toolkit. Some suggestions, such as multiple modes of delivery, earlier access to the toolkit in primary care and peer support from other relatives, were not possible in this study but should be considered for future development.

CONCLUSIONS

Relatives supported the development of a supported self-management toolkit intervention. They also emphasised the importance of offering such interventions alongside other valued aspects of services including face-to-face contact with clinicians, peer support from other relatives and crisis support.

Cognitive behavioural therapy self-help for depression: an overview

BACKGROUND

The World Health Organisation suggests that 60-80% of those affected by depression can be effectively treated using medication or psychotherapy within primary care. However, less than 50% of those affected actually receive such treatments. In practice, it remains a challenge to provide access to psychotherapy due to limited numbers of therapists combined with a growing number of treatment guidelines recommending the delivery of evidence-based psychological therapies such as cognitive behavioural therapy (CBT). One way to overcome this problem is to offer therapy in different ways - with so-called low-intensity (LI) working. One example of LI working is CBT self-help (CBT-SH).

AIMS

To provide an overview of the current literature surrounding the effectiveness of CBT-SH with a particular focus on depression and discuss the future directions for both research and policy implementation.

CONCLUSIONS

It is clear that self-help has a place within a healthcare framework but more work is needed to clarify where and how it should be delivered. The paper concludes that there appears to be enough benefits and sufficient evidence to argue for the introduction of LI working as an appropriate first step for most people facing depression and anxiety.

Stepped care: a method to deliver increased access to psychological therapies

OBJECTIVE

To introduce stepped care as a method of organizing the delivery of treatments, and to consider the factors necessary for implementation.

METHOD

Stepped care is described within the context of strategies such as collaborative care that aim to increase access to mental health care through the improved coordination of care between primary and specialist mental health services. Results from the implementation of stepped care in the United Kingdom and elsewhere are used to highlight the factors required for introducing stepped care into routine services. Issues to address when implementing high-volume services for common mental health problems are derived from this experience.

RESULTS

Stepped care sits within the continuum of organizational systems, from situations where responsibility rests almost entirely with primary care clinicians to systems where all patients are managed by specialists for the entire duration of their treatment. Its core principles of delivering low-burden treatments first, followed by careful patient progress monitoring to step patients up to more intensive treatment, are easy to articulate but lead to considerable implementation diversity when services attempt to work in this manner. Services need to ensure they have specific staff competency training, including skills in delivering evidence-based treatments, access to telephony, and smart patient management informatics systems.

CONCLUSIONS

Stepped care can provide the delivery system for supported self-management. To be successful, health systems need high levels of clinical outcome data and appropriately trained workers. Further attention is required to ensure equity of access and to reduce patient attrition in these systems.