Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures

Predictors of functional disability in disability welfare claimants

BACKGROUND

People unemployed and claiming welfare due to poor health are by definition functionally disabled. Understanding the factors associated with such disability is crucial in the development of biopsychosocial formulations and associated occupational rehabilitation.

METHOD

A cross-sectional design in a sample of claimants (n = 4,119) of health-related welfare, unemployed due to mental or physical health problems. Participants provided socio-demographic information and completed validated measures of psychological distress, self-efficacy and disability. Hierarchical multiple regression analyses then tested which psychological and socio-demographic factors were associated with disability.

RESULTS

Despite equal rates of functional disability across health condition groups, differing variables were associated with disability for mental and physical health conditions. Psychological distress was the strongest predictor of disability across all health conditions. For physical conditions, lack of previous employment was the only additional variable associated with current disability and for mental health conditions age and self-efficacy were additional factors.

CONCLUSION

Results are discussed in terms of biopsychosocial formulations of health-related unemployment, the potential mechanisms by which psychological distress can influence disability, the methodological limitations of cross sectional regression analyses and the implications for condition-specific occupational rehabilitation.

Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM): valuation of CORE-6D

Background. The Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) is used to evaluate the effectiveness of psychological therapies in people with common mental disorders. The objective of this study was to estimate a preference-based index for this population using CORE-6D, a health state classification system derived from the CORE-OM consisting of a 5-item emotional component and a physical item, and to demonstrate a novel method for generating states that are not orthogonal. Methods. Rasch analysis was used to identify 11 emotional health states from CORE-6D that were frequently observed in the study population and are, thus, plausible (in contrast, conventional statistical design might generate implausible states). Combined with the 3 response levels of the physical item of CORE-6D, they generate 33 plausible health states, 18 of which were selected for valuation. A valuation survey of 220 members of the public in South Yorkshire, United Kingdom, was undertaken using the time tradeoff (TTO) method. Regression analysis was subsequently used to predict values for all possible states described by CORE-6D. Results. A number of multivariate regression models were built to predict values for the 33 health states of CORE-6D, using the Rasch logit value of the emotional state and the response level of the physical item as independent variables. A cubic model with high predictive value (adjusted R² = 0.990) was selected to predict TTO values for all 729 CORE-6D health states. Conclusion. The CORE-6D preference-based index will enable the assessment of cost-effectiveness of interventions for people with common mental disorders using existing and prospective CORE-OM data sets. The new method for generating states may be useful for other instruments with highly correlated dimensions.

Iatrogenic effects of psychosocial interventions: treatment, life context, and personal risk factors

Between 7% and 15% of individuals who participate in psychosocial interventions for substance use disorders may be worse off after treatment than before. Intervention-related predictors of iatrogenic effects include lack of bonding; lack of goal direction and monitoring; confrontation, criticism, and high emotional arousal; models and norms for substance use; and stigma and inaccurate expectations. Life context and personal predictors include lack of support, criticism, and more severe substance use and psychological problems. Ongoing monitoring and safety standards are needed to identify and counteract adverse consequences of intervention programs.

Individually tailored internet-based treatment for young adults and adults with panic attacks: randomized controlled trial

Background

Previous studies on Internet-based treatment with minimal therapist guidance have shown promising results for several specific diagnoses.

Objective

To (1) investigate the effects of a tailored, therapist-guided, Internet-based treatment for individuals with reoccurring panic attacks, and (2) to examine whether people in different age groups (18–30 years and 31–45 years) would respond differently to the treatment.

Methods

We recruited 149 participants from an online list of individuals having expressed an interest in Internet treatment. Screening consisted of online questionnaires followed by a telephone interview. A total of 57 participants were included after a semistructured diagnostic interview, and they were randomly assigned to an 8-week treatment program (n = 29) or to a control condition (n = 28). Treatment consisted of individually prescribed cognitive behavior therapy text modules in conjunction with online therapist guidance. The control group consisted of people on a waitlist who later received treatment.

Results

All dependent measures improved significantly immediately following treatment and at the 12-month follow-up. The between-group effect size on the primary outcome measure, the Panic Disorder Severity Scale, was d = 1.41 (95% confidence interval 0.81–1.95) at posttreatment. The within-group effect size from pretreatment to 12-month follow-up was d = 1.66 (95% confidence interval 1.14–2.35). Age group had no effect, suggesting that age did not influence the outcome.

Conclusions

Tailoring an Internet-based treatment can be a feasible approach in the treatment of panic symptoms and comorbid anxiety and depressive symptoms. Younger adults benefit as much as adults over 30 years and up to 45 years of age.

Trial Registration

Clinicaltrials.gov NCT01296321; http://www.clinicaltrials.gov/ct2/show/NCT01296321 (Archived by WebCite at http://www.webcitation.org/65wddsqlL)

Technology-enhanced monitoring in psychotherapy and e-mental health

Advances in technology increasingly facilitate data collection in the context of psychosocial and psychotherapeutic care. Such technology-enhanced assessments (e.g. via Internet-based systems and mobile devices) open new perspectives for research into processes related to mental health and well-being. The use of this knowledge for the development and refinement of (online and face-to-face) therapeutic interventions promises to contribute to an optimization of care. The aim of this paper is to provide an overview on how information and communication technologies may be used (a) to improve our understanding of illness development and recovery through longitudinal technology-enhanced assessment of symptoms and behaviors (e.g. outcome monitoring and ecological momentary assessment) and (b) to optimize care for mental disorders by integrating such monitoring assessments in specific interventions (e.g. ecological momentary interventions and supportive monitoring) in face-to-face or e-mental health settings.

Faktoren psychosozialer Beeinträchtigung

Zusammenfassung. Routinemäßige Qualitätssicherung und Erfolgsforschung in der Psychotherapie sollte nach Expertenmeinung mehrdimensional erfolgen. Dazu können einerseits eigens entworfene klinische Instrumente („core batteries”) oder Batterien etablierter Einzelinstrumente eingesetzt werden. Empirisch zeigt sich jedoch, dass „core batteries” meist durch einen Generalfaktor dominiert werden, ähnlich wie die weit verbreitete und ebenso mehrdimensional konzipierte SCL-90-R. Anhand einer Stichprobe psychosomatischer Patienten mit heterogenen Diagnosen (N = 1285) wird demonstriert, dass dies ebenso für eine Batterie anderer klinischer Skalen (BDI, IIP-D, SF-36, SOC-29, STAI, STAXI, TAS-26) zutrifft. Der Raum, der zudem durch diese Skalen mit der SCL-90-R gebildet wird, ist vierdimensional und wird durch „psychische Belastung” sowie drei Faktoren zum interpersonellen Verhalten und Problemen aufgespannt. Die Bedeutung dieser Ergebnisse für die klinische Forschung und Theoriebildung, wie für die mehrdimensionale Evaluation wird diskutiert.

Psychological treatment outcomes in routine NHS services: what do we mean by treatment effectiveness?

OBJECTIVES

The question of how effective therapies are in routine practice is crucial. The answer depends on how we define effectiveness. Both the definition of who was treated and the index chosen to represent outcome can affect estimates dramatically.

DESIGN

We used data from the Clinical Outcomes in Routine Evaluation (CORE) Primary Care National Practice-Based Evidence database-2005 on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) from 33,587 patients and examined rates of improvement in psychological therapies in UK National Health Service (NHS) primary care services using various definitions of effectiveness.

METHODS

We constructed successively more restrictive sub-samples of patients, including practice-based analogues of several types of intent-to-treat (ITT) groups and completer groups. We focussed on patients scoring above clinical cut-off at intake, but we also considered samples that included sub-clinical patients. We assessed two types of recovery rates, improvement rates, mean pre-post change, and pre-post effect sizes for each sub-sample.

RESULTS

There was wide variation in the overall effectiveness of treatments as a function of which subset of data was considered and which specific criterion of recovery rate was adopted. Recovery rates and pre-post effect sizes ranged from 19% to 65% and 0.60 to 1.95, respectively.

CONCLUSIONS

Because estimates of effectiveness could have significant policy implications, clarity on the meanings of the differing constructions is essential.

Tailored internet-administered treatment of anxiety disorders for primary care patients: study protocol for a randomised controlled trial

Background

Internet-administered cognitive behavioural therapy (ICBT) has been found to be effective for a range of anxiety disorders. However, most studies have focused on one specific primary diagnosis and co-morbidity has not been considered. In primary care settings, patients with anxiety often suffer from more than one psychiatric condition, making it difficult to disseminate ICBT for specific conditions. The aim of this study will be to investigate if ICBT tailored according to symptom profile can be a feasible treatment for primary care patients with anxiety disorders. It is a randomised controlled trial aimed to evaluate the treatment against an active control group.

Methods

Participants with anxiety disorders and co-morbid conditions (N = 128), will be recruited from a primary care population. The Clinical Outcome in Routine Evaluation (CORE-OM) will serve as the primary outcome measure. Secondary measures include self-reported depression, anxiety, quality of life and loss of production and the use of health care. All assessments will be collected via the Internet and measure points will be baseline, post treatment and 12 months post treatment.

Discussion

This trial will add to the body of knowledge on the effectiveness of ICBT for anxiety disorders in primary care. The trial will also add knowledge on the long term effects of ICBT when delivered for regular clinic patients

Trial Registration

ClinicalTrials.gov: NCT01390168

What do parents and carers think about routine outcome measures and their use? A focus group study of CAMHS attenders

Currently service user involvement in routine outcomes monitoring has been minimal, particularly in Children's services. There needs to be a more sustained effort to involve service users because of the valuable information that they could provide for service development and improvement. Focus groups were conducted with service users, including parents, carers and young people from a London CAMHS. Their views were elicited on routine outcomes monitoring in general, three specific approaches and suggestions about what else might be important to capture when measuring outcomes. The focus groups raised a number of issues pertinent to routine outcomes monitoring in general, including the reliability of answers, the need for the measures to reflect more than just a tick-box approach and that different people will have different perspectives. Analysis also focused on feedback about the three specific measures discussed. It is important that service users are involved in the process of outcome measurement, from the development of measures, to their application in therapeutic encounters and in service development. Outcome monitoring needs to become a more collaborative process in order that services are measuring what service users think is important, as most would agree that a service should deliver the outcomes that its users want to see.

Two short forms of the Agnew Relationship Measure: the ARM-5 and ARM-12

This article reports the development and psychometric properties of two short forms of the 28-item Agnew Relationship Measure, the ARM-12 and ARM-5. For the ARM-12, results of previous research were used together with conceptual considerations to select three items to represent each of four ARM subscales: Bond, Partnership, Confidence, and Openness. For the ARM-5, item-analytic principles were used to select five items to represent overall alliance. In all three ARMs, client and therapist versions were constructed to contain parallel items. We drew data to assess reliability and validity from three UK trials of brief therapy for depression. Results indicated that the two short ARMs have acceptable psychometric properties and that they converged with each other and with the full ARM.

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.

Piloting a practice research network: a 12-month evaluation of the Human Givens approach in primary care at a general medical practice

OBJECTIVE

To investigate the effectiveness of the Human Givens (HG) approach to the management of emotional distress in a primary care setting. To investigate whether or not the use of a shorter version (i.e., CORE-10) of a well-established psychometric instrument (i.e., Clinical Outcome in Routine Evaluation (CORE) CORE-outcome measure, CORE-OM) for sessional data collection is feasible for large-scale implementation of a practice research network (PRN).

DESIGN

All clients who chose to opt into assessment for treatment with three accredited HG therapists following referral for management of psychological distress, primarily anxiety and depression, by General Medical Practitioners (GPs) or GP practice nurses working in a primary care general medical practice over a 12-month period were included.

METHODS

The primary outcome measures were the CORE-OM and CORE-10. Pre-post effect sizes (Cohen's d) were calculated using pre, post, and pooled standard deviations to facilitate comparison with previously published studies. Mixed-design analysis of variance (ANOVA) was used to look at differences in pre- and post-treatment symptoms and potential treatment effects based on type of termination and gender. Observed intent-to-treat pre-post effect size using the CORE-OM was also benchmarked against data from Clark et al. (2009) improving access to psychological therapies (IAPT) pilot site data. Results obtained using CORE-OM were compared with those obtained using CORE-10 to evaluate the feasibility of using the CORE-10 for routine use in real-world clinical settings.

RESULTS

Pre- to post-treatment changes measured with the CORE-OM and CORE-10 suggested that the therapy was highly effective, with clients remaining in treatment to completion demonstrating the greatest benefit. Reliable change and recovery rates comparisons between the CORE-OM and CORE-10 indicated that the CORE-10 is a viable alternative to the CORE-OM. Result of the benchmarking indicated that the observed pre-post effect size was clinically equivalent to IAPT data published by Clark et al. (2009).

CONCLUSIONS

Although replications are warranted as the current investigation is a pilot study, the HG approach appears to be an effective treatment. CORE-10 is a satisfactory generic sessional assessment to use in place of the 34-item CORE-OM. Use of a shorter yet reliable outcome measure is likely to increase assessment completion rates. PRNs appear to be a suitable mechanism to establish treatment effectiveness across a wide range of treatments in different settings.

Impact of length or relevance of questionnaires on attrition in online trials: randomized controlled trial

BACKGROUND

There has been limited study of factors influencing response rates and attrition in online research. Online experiments were nested within the pilot (study 1, n = 3780) and main trial (study 2, n = 2667) phases of an evaluation of a Web-based intervention for hazardous drinkers: the Down Your Drink randomized controlled trial (DYD-RCT).

OBJECTIVES

The objective was to determine whether differences in the length and relevance of questionnaires can impact upon loss to follow-up in online trials.

METHODS

A randomized controlled trial design was used. All participants who consented to enter DYD-RCT and completed the primary outcome questionnaires were randomized to complete one of four secondary outcome questionnaires at baseline and at follow-up. These questionnaires varied in length (additional 23 or 34 versus 10 items) and relevance (alcohol problems versus mental health). The outcome measure was the proportion of participants who completed follow-up at each of two follow-up intervals: study 1 after 1 and 3 months and study 2 after 3 and 12 months.

RESULTS

At all four follow-up intervals there were no significant effects of additional questionnaire length on follow-up. Randomization to the less relevant questionnaire resulted in significantly lower rates of follow-up in two of the four assessments made (absolute difference of 4%, 95% confidence interval [CI] 0%-8%, in both study 1 after 1 month and in study 2 after 12 months). A post hoc pooled analysis across all four follow-up intervals found this effect of marginal statistical significance (unadjusted difference, 3%, range 1%-5%, P = .01; difference adjusted for prespecified covariates, 3%, range 0%-5%, P = .05).

CONCLUSIONS

Apparently minor differences in study design decisions may have a measurable impact on attrition in trials. Further investigation is warranted of the impact of the relevance of outcome measures on follow-up rates and, more broadly, of the consequences of what we ask participants to do when we invite them to take part in research studies.

TRIAL REGISTRATION

ISRCTN Register 31070347; http://www.controlled-trials.com/ISRCTN31070347/31070347 Archived by WebCite at (http://www.webcitation.org/62cpeyYaY).

Implementing NICE guidelines for the psychological treatment of depression and anxiety disorders: the IAPT experience

The Improving Access to Psychological Therapies (IAPT) programme is a large-scale initiative that aims to greatly increase the availability of NICE recommended psychological treatment for depression and anxiety disorders within the National Health Service in England. This article describes the background to the programme, the arguments on which it is based, the therapist training scheme, the clinical service model, and a summary of progress to date. At mid-point in a national roll-out of the programme progress is generally in line with expectation, and a large number of people who would not otherwise have had the opportunity to receive evidence-based psychological treatment have accessed, and benefited from, the new IAPT services. Planned future developments and challenges for the programme are briefly described.

Can the patient decide which modules to endorse? An open trial of tailored internet treatment of anxiety disorders

Internet-delivered cognitive behaviour therapy commonly consists of disorder-specific modules that are based on face-to-face manuals. A recent development in the field is to tailor the treatment according to patient profile, which has the potential to cover comorbid conditions in association with anxiety and mood disorders. However, it could be that the patients themselves are able to decide what modules to use. The authors tested this in an open pilot trial with 27 patients with mixed anxiety disorders. Modules were introduced with a brief description, and patients could choose which modules to use. The exception was the two first modules and the last, which involved psychoeducation and relapse prevention. The treatment period lasted for 10 weeks. Results showed large within-group effect sizes, with an average Cohen's d of 0.88. In a structured clinical interview, a majority (54%) had significantly improved 10 weeks after commencing treatment. Only one person dropped out. On the basis of results of this preliminary study, the authors suggest that the role of choice and tailoring should be further explored in controlled trials and that patient choice could be incorporated into Internet-delivered treatment packages.

Lending an ear to feedback systems: evaluation of recovery and non-response in psychotherapy in a German outpatient setting

Systems providing feedback on treatment progress have been implemented in outpatient psychotherapy. They are recognized as a helpful tool to identify possible treatment failures. This report presents the ideas underlying the planning of feedback interventions and the implementation of such programs into practice settings. Strategies to identify patients at risk for treatment failure (rationally- and empirically-derived decision rules) are presented. Additionally, evidence for the usefulness of feedback systems is discussed. The report ends with the description of an ongoing feedback intervention study in private practices in Germany (aimed at gathering information on 400 therapists with 2,000 patients).

Universal prevention of depression in women postnatally: cluster randomized trial evidence in primary care

BACKGROUND

To test whether receiving care from a health visitor (HV) trained in identification and psychological intervention methods prevents depression 6-18 months postnatally in women who are not depressed 6 weeks postnatally.

METHOD

The study was a prospective cluster trial, randomized by GP practice, with follow-up for 18 months in 101 primary care teams in the Trent area of England. The participants were women scoring <12 on the postal Edinburgh Postnatal Depression Scale (EPDS) at 6 weeks postnatally (1474 intervention and 767 control women). Intervention HVs (n=89, 63 clusters) were trained in identifying depressive symptoms using the EPDS and face-to-face clinical assessment and in providing psychologically orientated sessions based on cognitive behavioral or person-centered principles. The control group comprised HVs (n=49, 37 clusters) providing care as usual (CAU). The primary outcome measure was the proportion of women scoring ≥ 12 on the EPDS at 6 months postnatally. Secondary outcomes were mean EPDS score, Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) score, State-Trait Anxiety Inventory (STAI), 12-item Short Form Health Survey (SF-12) and Parenting Stress Index Short Form (PSI-SF) scores at 6, 12 and 18 months.

RESULTS

After adjusting for individual-level covariates, living alone, previous postnatal depression (PND), the presence of one or more adverse life events and the 6-week EPDS score, the odds ratio (OR) for EPDS ≥ 12 at 6 months was 0.71 [95% confidence interval (CI) 0.53-0.97, p=0.031] for the intervention group (IG) women compared with the control (CAU) group women. Two subgroups were formed by baseline severity: a 'subthreshold' subgroup with a 6-week EPDS score of 6-11 (n=999) and a 'lowest severity' subgroup with a 6-week EPDS score of 0-5 (n=1242). There was no difference in psychological effectiveness by subgroup (interaction term: z=-0.28, p=0.782).

CONCLUSIONS

This study provides new evidence of a universal, enduring preventive effect for depression in women who screen negative for depression postnatally.

Dimensions of variation on the CORE-OM

BACKGROUND

The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is a self-report measure comprising 28 items tapping three domains; subjective well-being, psychological problems and functioning. In addition to the potential theoretical value of the domains for operationalizing the phase model of psychotherapy, when consulted, managers and clinicians considered the distinction between problems and functioning important for assessing case-mix and clinical outcomes. A further domain comprising six items was included to indicate possible risk. Subsequent analysis has suggested an alternative structure for CORE-OM with factors for risk and positively and negatively worded items (Evans et al., 2002).

METHODS

This study compares models for the interpersonal factor structure in data from the CORE-OM in 2,140 patients receiving psychological therapy in the UK.

RESULTS

A multi-method, multi-trait, nested factors solution accounted optimally for the CORE-OM item covariance, with a first-order general factor latent and residualized first-order factors of subjective well-being, psychological problems, functioning and risk and with positively and negatively worded methods factors. The general factor was labelled psychological distress. Scale quality for CORE-OM, using a scoring method in which non-risk items are treated as a single scale and risk items as a second scale is satisfactory.

IMPLICATIONS

The CORE-OM has a complex factor structure and may be best scored as 2 scales for risk and psychological distress. The distinct measurement of psychological problems and functioning is problematic, partly because many patients receiving out-patient psychological therapies and counselling services function relatively well in comparison with patients receiving general psychiatric services. In addition, a clear distinction between self-report scales for these variables is overshadowed by their common variance with a general factor for psychological distress. An alternative strategy for operationalizing this distinction is proposed.

Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from a measure of common mental health problems (CORE-OM)

PURPOSE

To describe a new approach for deriving a preference-based index from a condition specific measure that uses Rasch analysis to develop health states.

METHODS

The CORE-OM is a 34-item instrument monitoring clinical outcomes of people with common mental health problems. The CORE-OM is characterised by high correlation across its domains. Rasch analysis was used to reduce the number of items and response levels in order to produce a unidimensional measure and to generate a credible set of health states corresponding to different levels of symptom severity using the Rasch item threshold map.

RESULTS

The proposed methodology resulted in the development of CORE-6D, a 2-dimensional health state descriptive system consisting of a unidimensional 5-item emotional component (derived from Rasch analysis) and a physical symptom item. Inspection of the Rasch item threshold map of the emotional component helped identify a set of 11 plausible health states, which, combined with 3 physical symptom item levels, form 33 plausible health states that can be used for the valuation of the instrument, resulting in the development of a preference-based index.

CONCLUSIONS

This is a useful new approach to develop preference-based measures from existing instruments with high correlations across domains. The CORE-6D preference-based index will enable calculation of Quality-Adjusted Life Years in people with common mental health problems.

A randomized trial of face-to-face counselling versus telephone counselling versus bibliotherapy for occupational stress

OBJECTIVE

The aim of the present study was to compare the effectiveness and acceptability of three interventions for occupational stress.

METHODS/DESIGN

A total of 90 National Health Service employees were randomized to face-to-face counselling or telephone counselling or bibliotherapy. Outcomes were assessed at post-intervention and 4-month follow-up. Clinical Outcomes in Routine Evaluation (CORE), General Health Questionnaire (GHQ-12), and Perceived Stress Scale (PSS-10) were used to evaluate intervention outcomes. An intention-to-treat analyses was performed.

RESULTS

Repeated measures analysis revealed significant time effects on all measures with the exception of CORE Risk. No significant group effects were detected on all outcome measures. No time by group significant interaction effects were detected on any of the outcome measures with the exception of CORE Functioning and GHQ total. With regard to acceptability of interventions, participants expressed a preference for face-to-face counselling over the other two modalities.

CONCLUSIONS

Overall, it was concluded that the three intervention groups are equally effective. Given that bibliotherapy is the least costly of the three, results from the present study might be considered in relation to a stepped care approach to occupational stress management with bibliotherapy as the first line of intervention, followed by telephone and face-to-face counselling as required.

The acceptability of computer-aided cognitive behavioural therapy: a pragmatic study

The clinical and cost-effectiveness of a computer-aided cognitive behavioural therapy (CCBT) programme, Beating the Blues, is indicated by a number of studies, but relatively little is known about its acceptability for patients with depression, anxiety, or both. This study investigated the acceptability of Beating the Blues offered on eight scheduled clinic visits with brief face-to-face support. Pre and posttreatment measures explored the relationship among programme acceptability, treatment continuation, and outcomes for people accessing the programme in routine care. Two hundred and nineteen patients with depression, anxiety, or both were offered Beating the Blues in 11 primary and secondary care practices. One hundred and ninety-one (87%) completed the pretreatment measures and 84 (38%) completed a treatment feedback questionnaire. Analysis of treatment acceptability for CCBT indicated a positive patient experience with the programme. Pretreatment expectancies predicted CCBT treatment completion but not outcomes. No differences were found between men and women on pretreatment measures. Posttreatment, women reported more favourable responses to the therapy, finding the programme more helpful and more satisfactory, than did men. No relationship between treatment acceptability and age was found. Study limitations, including research methods and attrition rates, and implications for future research are discussed. It is concluded that the Beating the Blues CCBT programme is an acceptable treatment for common mental health problems in routine care.

Validation of the Italian version of the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM)

The Clinical Outcomes in Routine Evaluation--Outcome Measure (CORE-OM) was translated into Italian and tested in non-clinical (n = 263) and clinical (n = 647) samples. The translation showed good acceptability, internal consistency and convergent validity in both samples. There were large and statistically significant differences between clinical and non-clinical datasets on all scores. The reliable change criteria were similar to those for the UK referential data. Some of the clinically significant change criteria, particularly for the men, were moderately different from the UK cutting points. The Italian version of the CORE-OM showed respectable psychometric parameters. However, it seemed plausible that non-clinical and clinical distributions of self-report scores on psychopathology and functioning measures may differ by language and culture.

KEY PRACTITIONER MESSAGE

*A good quality Italian translation of the CORE-OM, and hence the GP-CORE, CORE-10 and CORE-5 measures also, is now available for use by practitioners and anyone surveying or exploring general psychological state. The measures can be obtained from CORE-IMS or yourself and practitioners are encouraged to share anonymised data so that good clinical and non-clinical referential databases can be established for Italy.

Systematic review of practice-based research on psychological therapies in routine clinic settings

PURPOSE

To review the published material on practice-based research and to compare results with benchmarks derived from efficacy studies.

METHODS

Electronic and manual searches were carried out up to and including 2008. Studies were screened for content relevance and selected according to specified inclusion criteria. Data were extracted from all studies that met criteria and were quality assessed using an adapted version of a checklist designed for the appraisal of both randomized and non-randomized studies of health care interventions. Studies were synthesized according to (1) the type of problem being treated and (2) study design using descriptive and meta-analytic methods where appropriate.

RESULTS

Psychological treatment conducted in routine clinic settings is effective for a range of client problems, particularly common mental health problems (uncontrolled effect size = 1.29; 95% CI = 1.26-1.33, N = 10,842). When benchmarked against data from efficacy studies, practice-based studies yielded effect sizes that fell short of the selected benchmark. In contrast, the practice-based studies achieved the benchmark for percentage of clients meeting a stringent criterion for recovery.

CONCLUSIONS

Clients receiving treatment as normally delivered within routine practice report significant relief of symptoms. However, the result of comparisons with efficacy benchmarks is dependent on the outcome index used. Notwithstanding this, substantive factors are also likely to contribute. Therefore, in addition to attending to methodological issues, further work is required to understand the relative contribution of these factors.

Revisiting practice-based research networks as a platform for mental health services research

Practice-based research networks (PBRNs)-collaborations of practice settings that work together to generate research knowledge-are underused in mental health services research. This article proposes an agenda for mental health services research that uses a variety of PBRN structures and that focuses on what really happens in practice, the effectiveness of practice innovations in real world care, the challenges of implementing evidence supported interventions, modification of clinician behavior, and assessment of the effect of mental health policy changes on practice. The challenges of conducting research within PBRNs are substantial, including difficulties in maintaining positive member relations, securing ongoing funding, sustaining productivity, overcoming IRB entanglements and achieving both scientific excellence in recruitment and measurement validity and utility for practitioner members. However, the awareness of these challenges allows researchers and practitioners to build networks that creatively overcome them and that infuse mental health services research with heavy doses of the realities of everyday clinical practice.

An open trial in the NHS of Blues Begone: a new home based computerized CBT program

BACKGROUND

Computer based treatment for depression and anxiety has been available for several years and has demonstrated useful clinical effects. Most existing computerized CBT products in the UK that are designed to treat depression and co-morbid anxiety require patients to visit a clinic and require staff input to manage the process. Such intervention adds to the costs and bottlenecks in delivering a clinically effective treatment with mass availability. Internet treatment options are becoming more readily available, although data to support use are not yet strong, and most still require human assessment and telephone support. Blues Begone is a new computerized CBT program that has been designed to be used at home with minimal human support.

METHOD

This pilot project provides data from an open trial of Blues Begone with both primary and secondary care patients.

RESULTS

One hundred patients started Blues Begone, 58 completed the program, 72% (n = 42) of completers achieved reliable change and (n = 36) 62% achieved both reliable and clinically significant change, and may be considered to have recovered by the end of the program.

CONCLUSION

These data provide the first demonstration of the potential viability of Blues Begone as a home based computerized treatment for depression and anxiety.

Improving access to psychological therapy: Initial evaluation of two UK demonstration sites

Recently the UK Government announced an unprecedented, large-scale initiative for Improving Access to Psychological Therapies (IAPT) for depression and anxiety disorders. Prior to this development, the Department of Health established two pilot projects that aimed to collect valuable information to inform the national roll-out. Doncaster and Newham received additional funds to rapidly increase the availability of CBT-related interventions and to deploy them in new clinical services, operating on stepped-care principles, when appropriate. This article reports an evaluation of the new services (termed ‘demonstration sites’) during their first thirteen months of operation. A session-by-session outcome monitoring system achieved unusually high levels of pre to post-treatment data completeness. Large numbers of patients were treated, with low-intensity interventions (such as guided self-help) being particularly helpful for achieving high throughput. Clinical outcomes were broadly in line with expectation. 55–56% of patients who had attended at least twice (including the assessment interview) were classified as recovered when they left the services and 5% had improved their employment status. Treatment gains were largely maintained at 10 month follow-up. Opening the services to self-referral appeared to facilitate access for some groups that tend to be underrepresented in general practice referrals. Outcomes were comparable for the different ethnic groups who access the services. Issues for the further development of IAPT are discussed.

Entwicklung und psychometrische Kennwerte des Fragebogens zur Evaluation von Psychotherapieverläufen (FEP)

Zusammenfassung. Die kontinuierliche Messung des therapeutischen Fortschritts ist im Rahmen der Qualitätssicherung in Psychotherapie und Psychiatrie ein zentrales Element. In dieser Arbeit wird ein deutschsprachiges Messinstrument vorgestellt, welches sich zur Erhebung des Therapieverlaufs eignet. Das Instrument ist multidimensional, veränderungssensitiv und zusätzlich „public domain” verfügbar. Theoretisch wurden drei klinisch-therapeutische Konzeptualisierungen zentraler Veränderungsprozesse integriert: das Phasenmodell therapeutischer Veränderung, das Kreismodell interpersonaler Beziehungen sowie das Kongruenzkonzept. Anhand von lediglich 40 Items werden die Dimensionen Wohlbefinden, Beschwerden, interpersonale Beziehung und Kongruenz erhoben. Zur Validierung wurden eine ambulante Psychotherapiestichprobe (N = 184), eine nicht-klinische (N = 274) sowie eine studentische Stichprobe (N = 96) herangezogen. Die vier Dimensionen sowie ein daraus resultierender Gesamtwert psychischer Beeinträchtigung weisen gute Werte der Reliabilität auf. Das Instrument kann sowohl zur Verlaufs-, als auch zur Ergebnismessung eingesetzt werden.

Psychiatric morbidity and treatment pathway outcomes of patients presenting to specialist NHS psychodynamic psychotherapy services: results from a multi-centre study

OBJECTIVE

Little is known about socio-demographic, diagnostic, and clinical characteristics of patients referred for assessment to psychodynamic psychotherapy services. The aim of this study was to remedy this by prospectively collecting comprehensive and systematic demographic and clinical information on a large number of patients referred to NHS psychodynamic psychotherapy services.

DESIGN

Fourteen psychotherapy services operating within a National Health Service joined the study and contributed data for 1,136 patients referred from primary and secondary care clinics.

METHOD

Patients were assessed using questionnaires and self-rated measures, which included the clinician-based version of the diagnostic form of the Millon clinical multi-axial inventory-III-revised edition (MCMI-III-R), the brief symptom inventory (BSI), the inventory of interpersonal problems (IIP), and the clinical outcome in routine evaluation (CORE). The pathway from assessment through to treatment and variables associated with treatment uptake and exclusion are described and examined.

RESULTS

Most patients were in the moderate to severe range of psychiatric severity at the time of presentation. Ninety-five percent met clinically based criteria for a psychiatric disorder (mostly anxiety and mood disorders) and/or personality disorder. Although the majority of patients were found suitable for treatment (N=935, 82%), analysis of uptake showed relatively high rates of treatment rejection by patients and treatment drop-out. Partial outcome data at 6-month follow-up after intake into treatment revealed significant change but modest effect size (d=0.35).

CONCLUSION

Systematic collection of baseline and outcome data would provide a national database of the performance of psychotherapy services that would be invaluable in facilitating comparative studies.

Clinical effectiveness of health visitor training in psychologically informed approaches for depression in postnatal women: pragmatic cluster randomised trial in primary care

OBJECTIVE

To evaluate benefits for postnatal women of two psychologically informed interventions by health visitors.

DESIGN

Prospective cluster trial randomised by general practice, with 18 month follow-up.

SETTING

101 general practices in Trent, England.

PARTICIPANTS

2749 women allocated to intervention, 1335 to control.

INTERVENTION

Health visitors (n=89 63 clusters) were trained to identify depressive symptoms at six to eight weeks postnatally using the Edinburgh postnatal depression scale (EPDS) and clinical assessment and also trained in providing psychologically informed sessions based on cognitive behavioural or person centred principles for an hour a week for eight weeks. Health visitors in the control group (n=49 38 clusters) provided usual care.

MAIN OUTCOME MEASURES

Score >or=12 on the Edinburgh postnatal depression scale at six months. Secondary outcomes were mean Edinburgh postnatal depression scale, clinical outcomes in routine evaluation-outcome measure (CORE-OM), state-trait anxiety inventory (STAI), SF-12, and parenting stress index short form (PSI-SF) scores at six, 12, 18 months.

RESULTS

4084 eligible women consented and 595 women had a six week EPDS score >or=12. Of these, 418 had EPDS scores available at six weeks and six months. At six months, 34% women (93/271) in the intervention group and 46% (67/147) in the control group had an EPDS score >or=12. The odds ratio for score >or=12 at six months was 0.62 (95% confidence interval 0.40 to 0.97, P=0.036) for women in the intervention group compared with women in the control group. After adjustment for covariates, the odds ratio was 0.60 (0.38 to 0.95, P=0.028). At six months, 12.4% (234/1880) of all women in the intervention group and 16.7% (166/995) of all women in the control group had scores >or=12 (0.67, 0.51 to 0.87, P=0.003). Benefit for women in the intervention group with a six week EPDS score >or=12 and for all women was maintained at 12 months postnatally. There was no differential benefit for either psychological approach over the other.

CONCLUSION

Training health visitors to assess women, identify symptoms of postnatal depression, and deliver psychologically informed sessions was clinically effective at six and 12 months postnatally compared with usual care.

TRIAL REGISTRATION

ISRCTN92195776.

Identifikation und Aufklärung von Veränderungssprüngen im individuellen Psychotherapieverlauf

Zusammenfassung. Theoretischer Hintergrund: Die Identifikation diskontinuierlicher Veränderungen im Psychotherapieverlauf sowie deren Erklärung sind Gegenstand der modernen Psychotherapieforschung, welche die patientenorientierte Forschung sowie die Evaluation von Behandlungsfortschritt vorsieht. Fragestellungen: Ziel der vorliegenden Studie ist die Aufklärung möglicher Ursachen für Veränderungssprünge in positive und negative Richtung im Therapieprozess, welche als Sudden Gains und Sudden Losses definiert sind, sowie deren Zusammenhang zum Therapieerfolg. Methode: Mikroprozessanalytisch werden 128 kritische Sudden Gain- und Loss-Sitzungen hinsichtlich Prozessparametern wie therapeutischen Techniken, allgemeinen Wirkfaktoren, u.a. das interpersonale Verhalten der Therapeuten, aber auch außertherapeutische Elemente untersucht. Resultate: Die Analyse der kritischen Therapiesitzungen vor einem Sudden Gain oder Loss ergab, dass sich diese Sitzungstypen qualitativ voneinander unterscheiden und, wie in der bisherigen Forschung bestätigt, kognitive Veränderungen, interpersonale Aspekte der Therapeuten, die therapeutische Beziehung, der emotionale Status der Patienten und außertherapeutische Faktoren Einfluss nehmen. Schlussfolgerung: Die Bedeutung von diskontinuierlichen, insbesondere negativen, Therapieverläufen kann erfolgreich anhand mikroprozessanalytischer Methodik aufgezeigt werden.

Balancing rigour and relevance in guideline development for depression: the case for comprehensive cohort studies

PURPOSE

Clinical guidelines for the treatment of depression have not yet realized their potential for improving the delivery of the psychological therapies within national healthcare systems. Current guidelines emphasize treatment efficacy and issues in service delivery are relatively neglected. Hence, there is a hierarchy of evidence in which randomized efficacy trials are given primacy over naturalistic (i.e. practice-based) data. Such a strategy is inadequate to address important questions about best delivery of safe and acceptable psychological therapies and exacerbates divisions between research and practice communities.

METHODS

Selected narrative review.

RESULTS

Both randomized controlled trials and practice-based studies have shortcomings that can be ameliorated by the adoption of practical clinical trials embedded within large cohort studies - that is, comprehensive cohort studies.

CONCLUSIONS

Comprehensive cohort studies have the potential to deliver an evidence base which is both rigorous and relevant. This could satisfy the scientific community as well as allowing practitioners and service users to be fully involved and committed to the process of collecting evidence and implementing guidance. We argue this would be a sound foundation upon which to build an evidence base upon which to develop future clinical guidelines for depression.

Developing guided self-help for depression using the Medical Research Council complex interventions framework: a description of the modelling phase and results of an exploratory randomised controlled trial

BACKGROUND

Current guidelines for the management of depression suggest the use of guided self-help for patients with mild to moderate disorders. However, there is little consensus concerning the optimal form and delivery of this intervention. To develop acceptable and effective interventions, a phased process has been proposed, using a modelling phase to examine and develop an intervention prior to preliminary testing in an exploratory trial. This paper (a) describes the modelling phase used to develop a guided self-help intervention for depression in primary care and (b) reports data from an exploratory randomised trial of the intervention.

METHODS

A guided self-help intervention was developed following a modelling phase which involved a systematic review, meta synthesis and a consensus process. The intervention was then tested in an exploratory randomised controlled trial by examining (a) fidelity using analysis of taped guided self-help sessions (b) acceptability to patients and professionals through qualitative interviews (c) effectiveness through estimation of the intervention effect size.

RESULTS

Fifty eight patients were recruited to the exploratory trial. Seven professionals and nine patients were interviewed, and 22 tapes of sessions analysed for fidelity. Generally, fidelity to the intervention protocol was high, and the professionals delivered the majority of the specific components (with the exception of the use of feedback). Acceptability to both professionals and patients was also high. The effect size of the intervention on outcomes was small, and in line with previous analyses showing the modest effect of guided self-help in primary care. However, the sample size was small and confidence intervals around the effectiveness estimate were wide.

CONCLUSION

The general principles of the modelling phase adopted in this study are designed to draw on a range of evidence, potentially providing an intervention that is evidence-based, patient-centred and acceptable to professionals. However, the pilot outcome data did not suggest that the intervention developed was particularly effective. The advantages and disadvantages of the general methods used in the modelling phase are discussed, and possible reasons for the failure to demonstrate a larger effect in this particular case are outlined.