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McLoughlin C, McWhirter L, Pisegna K, Tijssen MAJ, Tak LM, Carson A, Stone J. Stigma in functional neurological disorder (FND) - A systematic review. Clin Psychol Rev 2024; 112:102460. [PMID: 38905960 DOI: 10.1016/j.cpr.2024.102460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Revised: 05/10/2024] [Accepted: 06/10/2024] [Indexed: 06/23/2024]
Abstract
OBJECTIVE The purpose of this systematic review was to evaluate stigma and Functional Neurological Disorder (FND) regarding: 1) prevalence and associated factors, 2) the nature and context of stigma in FND, and 3) stigma-reduction interventions. METHODS We searched four relevant databases from inception to December 2023, using search terms relevant to FND and stigma themes. We employed the method of synthesis by "aggregation and configuration" to synthesise and analyse the data into emergent themes. RESULTS We found 127 studies, spanning 148 countries, involving 18,886 participants. Of these, 4889 were patients, 13,123 were healthcare professionals, and 526 were caregivers. Quantitatively, stigma has been mainly studied in patients with functional seizures, and was higher than patients with epilepsy in three studies. Stigma experienced by patients is associated with poorer quality of life and caregiver burden. We found 10 themes and 29 subthemes revealing stigma as a systemic process, with intrapersonal, interpersonal and structural aspects. Few studies examined the perspective of caregivers, the public or online community. We identified six anti-stigma interventions. CONCLUSION Stigma in FND is a layered process, and affects patient quality of life and provision of care. Stigma needs to be addressed from the top structures, at governmental level, so that appropriate care pathways can be created, giving patients with FND parity of esteem with other medical conditions.
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Affiliation(s)
- Caoimhe McLoughlin
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom.
| | - Laura McWhirter
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Marina A J Tijssen
- UMCG Expertise Centre Movement Disorders Groningen, University of Groningen, Groningen, the Netherlands
| | - Lineke M Tak
- Dimence Alkura, Specialist center Persistent Somatic Symptoms, Nico Bolkensteinlaan 65, 7416 SE Deventer, the Netherlands
| | - Alan Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
| | - Jon Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
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Goldstein LH, Stone J, Reuber M, Landau S, Robinson EJ, Carson A, Medford N, Chalder T. Reflections on the CODES trial for adults with dissociative seizures: what we found and considerations for future studies. BMJ Neurol Open 2024; 6:e000659. [PMID: 38860230 PMCID: PMC11163627 DOI: 10.1136/bmjno-2024-000659] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 04/21/2024] [Indexed: 06/12/2024] Open
Abstract
The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures multicentre randomised controlled trial is the largest, fully-powered study to test the clinical and cost-effectiveness of a psychotherapeutic intervention in this population. We also explored predictors or moderators of outcomes and investigated mechanisms of change in therapy. In this current review of findings, we discuss issues related to the design of the trial and consider the study's nested qualitative studies which were undertaken not only to shed light on the original research questions but to provide insights and recommendations for other researchers in the field of functional neurological disorder. Finally, we consider issues relating to the possible clinical application of our study findings.
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Affiliation(s)
- Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Jon Stone
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, The University of Sheffield, Sheffield, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emily J Robinson
- School of Population Health and Environmental Sciences, King's College London, London, UK
- Research Data and Statistics Unit, Royal Marsden Clinical Trials Unit, The Royal Marsden NHS Foundation Trust, Surrey, UK
| | - Alan Carson
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, The University of Edinburgh, Edinburgh, UK
| | - Nick Medford
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Sørensen CW, Sonne C, Sacha M, Kristiansen M, Hannemose SZ, Stein DJ, Carlsson J. Potential advantages of combining randomized controlled trials with qualitative research in mood and anxiety disorders - A systematic review. J Affect Disord 2023; 325:701-712. [PMID: 36642313 DOI: 10.1016/j.jad.2023.01.038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/05/2023] [Accepted: 01/08/2023] [Indexed: 01/14/2023]
Abstract
INTRODUCTION Most randomized controlled trials (RCTs) of mood and anxiety disorders employ solely quantitative methods. Supplementing quantitative data with qualitative methods, a so-called mixed-method approach, would seem useful, however this area has not been rigorously reviewed. We undertook a systematic review of RCTs of mood and anxiety disorders that employed concurrent quantitative data collection and qualitative methods exploring the participants' perspective, with the aim of 1. determining the number of such studies, 2. describing study characteristics, and 3. identifying potential advantages of a mixed-method approach. METHODS Following PRISMA guidelines, a systematic literature search for RCTs of mood and anxiety disorders, concurrently applying quantitative and qualitative methods, was conducted using EMBASE, PsycINFO and Pubmed, from their inception to February 2021. Categories of potential advantages of this mixed method approach were developed. RESULTS A total of 45 RCTs were included. The qualitative components typically included 10-40 participants, mostly consisting of interviews after the intervention. The majority of papers did not state a specific rationale for using a mixed method approach. Four categories of advantages emerged: 1. determine acceptability/feasibility, 2. investigate efficacy, 3. inform implementation in clinical practice and 4. generate new hypotheses based on the combination of quantitative and qualitative data. LIMITATIONS Lack of cross-referencing and consistent terminology challenged identification of relevant publications. CONCLUSION There are a number of potential advantages of applying mixed method approaches in RCTs within psychiatric research. Intentional consideration of such advantages early in trial design may increase the likelihood of gaining added value.
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Affiliation(s)
- Carina Winkler Sørensen
- The Mental Health Services of the Capital Region of Denmark, Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark; Mental Health Centre Copenhagen, Denmark.
| | - Charlotte Sonne
- The Mental Health Services of the Capital Region of Denmark, Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark
| | - Maria Sacha
- The Mental Health Services of the Capital Region of Denmark, Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark
| | - Maria Kristiansen
- Department of Public Health & Center for Healthy Aging, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Sigrid Zeuthen Hannemose
- The Mental Health Services of the Capital Region of Denmark, Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark
| | - Dan J Stein
- SA MRC Unit on Risk & Resilience in Mental Disorders, Dept of Psychiatry, South Africa; Neuroscience Institute, University of Cape Town, South Africa
| | - Jessica Carlsson
- The Mental Health Services of the Capital Region of Denmark, Competence Centre for Transcultural Psychiatry, Mental Health Centre Ballerup, Copenhagen, Denmark; Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Varley D, Sweetman J, Brabyn S, Lagos D, van der Feltz-Cornelis C. The clinical management of functional neurological disorder: A scoping review of the literature. J Psychosom Res 2023; 165:111121. [PMID: 36549074 DOI: 10.1016/j.jpsychores.2022.111121] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 12/13/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To date, there have been no reviews bringing together evidence on the clinical management of functional neurological disorder (FND) and patients', caregivers', and healthcare workers' experiences. This review provides an overview of the literature focused on the clinical management of FND. METHODS Four databases were searched, and a consultation exercise was conducted to retrieve relevant records dated from September 2010 to September 2020. Articles documenting diagnostic methods, treatments or interventions, or the experiences and perspectives of patients and healthcare workers in the clinical management of FND were included. RESULTS In total, 2756 records were retrieved, with 162 included in this review. The diagnostic methods reported predominantly included positive clinical signs, v-EEG and EEG. Psychological treatments and medication were the most reported treatments. Mixed findings of the effectiveness of CBT were found. Haloperidol, physiotherapy and scripted diagnosis were found to be effective in reducing FND symptoms. Several facilitators and barriers for patients accessing treatment for FND were reported. CONCLUSION The literature describing the clinical management for FND has increased considerably in recent times. A wide variety of diagnostic tools and treatments and interventions were found, with more focus being placed on tests that confirm a diagnosis than 'rule-out' tests. The main treatment type found in this review was medication. This review revealed that there is a lack of high-quality evidence and reflects the need for official clinical guidelines for FND, providing healthcare workers and patients the support needed to navigate the process to diagnose and manage FND.
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Affiliation(s)
- Danielle Varley
- Department of Health Sciences, University of York, York YO10 5DD, UK.
| | - Jennifer Sweetman
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Dimitris Lagos
- Hull York Medical School, University of York, York YO10 5DD, UK
| | - Christina van der Feltz-Cornelis
- Department of Health Sciences, University of York, York YO10 5DD, UK; Hull York Medical School, University of York, York YO10 5DD, UK; York Biomedical Research Institute, University of York, York YO10 5DD, UK; Institute of Health Informatics, University College London, London NW1 2DA, UK
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Goldstein LH, Robinson EJ, Chalder T, Stone J, Reuber M, Medford N, Carson A, Moore M, Landau S. Moderators of cognitive behavioural therapy treatment effects and predictors of outcome in the CODES randomised controlled trial for adults with dissociative seizures. J Psychosom Res 2022; 158:110921. [PMID: 35617911 DOI: 10.1016/j.jpsychores.2022.110921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Revised: 04/08/2022] [Accepted: 04/12/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE We explored moderators of cognitive behavioural therapy (CBT) treatment effects and predictors of outcome at 12-month follow-up in the CODES Trial (N = 368) comparing CBT plus standardised medical care (SMC) vs SMC-alone for dissociative seizures (DS). METHODS We undertook moderator analyses of baseline characteristics to determine who had benefited from being offered CBT 12 months post-randomisation. Outcomes included: monthly DS frequency, psychosocial functioning (Work and Social Adjustment Scale - WSAS), and health-related quality of life (Mental Component Summary (MCS) and Physical Component Summary (PCS) SF-12v2 scores). When moderating effects were absent, we tested whether baseline variables predicted change irrespective of treatment allocation. RESULTS Moderator analyses revealed greater benefits (p < 0.05) of CBT on DS frequency for participants with more (≥22) symptoms (Modified PHQ-15) or ≥ 1 current (M.I.N.I.-confirmed) comorbid psychiatric diagnosis at baseline. The effect of CBT on PCS scores was moderated by gender; women did better than men in the CBT + SMC group. Predictors of improved outcome included: not receiving disability benefits, lower anxiety and/or depression scores (PCS, MCS, WSAS); shorter duration, younger age at DS onset, employment, fewer symptoms and higher educational qualification (PCS, WSAS); stronger belief in the diagnosis and in CBT as a "logical" treatment (MCS). Some variables that clinically might be expected to moderate/predict outcome (e.g., maladaptive personality traits, confidence in treatment) were not shown to be relevant. CONCLUSION Patient complexity interacted with treatment. CBT was more likely to reduce DS frequency in those with greater comorbidity. Other patient characteristics predicted outcome regardless of the received intervention.
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Affiliation(s)
- L H Goldstein
- King's College London, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, UK.
| | - E J Robinson
- King's College London, School of Population Health and Environmental Sciences, UK; Research Data and Statistics Unit, Royal Marsden Clinical Trials Unit, The Royal Marsden NHS Foundation Trust, Surrey, UK.
| | - T Chalder
- King's College London, Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, UK.
| | - J Stone
- Centre for Clinical Brain Sciences, University of Edinburgh, UK.
| | - M Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK.
| | - N Medford
- South London and Maudsley NHS Foundation Trust, London, UK.
| | - A Carson
- Centre for Clinical Brain Sciences, University of Edinburgh, UK.
| | - M Moore
- Centre for Social Justice and Global Responsibility, School of Law and Social Sciences, London South Bank University, London, UK.
| | - S Landau
- King's College London, Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, UK.
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Stigma in Functional Seizures: A Scoping Review. Seizure 2022; 99:131-152. [DOI: 10.1016/j.seizure.2022.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 05/12/2022] [Accepted: 05/18/2022] [Indexed: 11/18/2022] Open
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Goldstein LH, Robinson EJ, Chalder T, Reuber M, Medford N, Stone J, Carson A, Moore M, Landau S. Six-month outcomes of the CODES randomised controlled trial of cognitive behavioural therapy for dissociative seizures: a secondary analysis. Seizure 2022; 96:128-136. [PMID: 35228117 PMCID: PMC8970049 DOI: 10.1016/j.seizure.2022.01.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 10/25/2022] Open
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Functional seizures: The patient’s perspective of a diagnostic and treatment odyssey. Epilepsy Behav Rep 2022; 17:100509. [PMID: 35112075 PMCID: PMC8790607 DOI: 10.1016/j.ebr.2021.100509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Revised: 11/16/2021] [Accepted: 11/21/2021] [Indexed: 11/22/2022] Open
Abstract
Functional seizures remains a complex neuropsychiatric condition to identify and treat. Practitioners must address management of physical symptoms and underlying causes. Management strategies can fail if their reasoning is not properly communicated. Better outcomes may result where treatment rationale is emphasized from outset.
Functional seizures can be challenging to properly diagnose, often leading to delays in treatment. The etiology of functional seizures is multifactorial, with psychological factors identified in many, but not all cases. Misdiagnosis may occur due to clinical features mimicking other medical conditions. Once a correct diagnosis is reached, delivery of definitive, evidence-based treatment may be challenging due to limited availability of specialized resources. Research shows psychological education and cognitive behavioral therapy (CBT) have the greatest efficacy. However, individual differences, including acceptance of the diagnosis, therapeutic alliance, duration of symptoms, comorbidities, and access to care may influence outcomes. There is a critical need for reports that can help identify barriers to effective diagnosis and treatment. We present the diagnosis and treatment of a woman who visited the emergency room after an attack of predominant left-sided paralysis, speech dysfunction and altered awareness. Following multiple daily episodes and visits to multiple medical practitioners, testing led to a diagnosis of functional seizures. While the patient was recommended to undergo a variety of therapeutic interventions, including CBT, she ultimately terminated treatment. In a subsequent interview, the patient revealed her personal experience with perceived limitations of acute management strategies. We explore the complexities of diagnosing and treating individuals with functional seizures.
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Goldstein LH, Robinson EJ, Pilecka I, Perdue I, Mosweu I, Read J, Jordan H, Wilkinson M, Rawlings G, Feehan SJ, Callaghan H, Day E, Purnell J, Baldellou Lopez M, Brockington A, Burness C, Poole NA, Eastwood C, Moore M, Mellers JD, Stone J, Carson A, Medford N, Reuber M, McCrone P, Murray J, Richardson MP, Landau S, Chalder T. Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT. Health Technol Assess 2021; 25:1-144. [PMID: 34196269 DOI: 10.3310/hta25430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures. DESIGN This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. SETTING This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services. PARTICIPANTS Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. INTERVENTIONS Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. MAIN OUTCOME MEASURES The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. RESULTS In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway. LIMITATIONS Unlike outcome assessors, participants and clinicians were not blinded to the interventions. CONCLUSIONS There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy. FUTURE WORK Examination of moderators and mediators of outcome. TRIAL REGISTRATION Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emily J Robinson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Izabela Pilecka
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain Perdue
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iris Mosweu
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Julie Read
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Harriet Jordan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Wilkinson
- Canterbury Christ Church University, Salamons Institute for Applied Psychology, Tunbridge Wells, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Gregg Rawlings
- School of Clinical Psychology, University of Sheffield, Sheffield, UK
| | - Sarah J Feehan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hannah Callaghan
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Elana Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Purnell
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maria Baldellou Lopez
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alice Brockington
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Norman A Poole
- Department of Neuropsychiatry, St George's Hospital, South West London and St George's NHS Mental Health NHS Trust, London, UK
| | - Carole Eastwood
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michele Moore
- Centre for Social Justice and Global Responsibility, School of Law and Social Sciences, London South Bank University, London, UK
| | | | - Jon Stone
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nick Medford
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Paul McCrone
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Joanna Murray
- Department of Health Services & Population Research, Institute of Psychiatry,Psychology and Neuroscience, King's College London, London, UK
| | - Mark P Richardson
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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