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Richards DA, Bower P, Chew-Graham C, Gask L, Lovell K, Cape J, Pilling S, Araya R, Kessler D, Barkham M, Bland JM, Gilbody S, Green C, Lewis G, Manning C, Kontopantelis E, Hill JJ, Hughes-Morley A, Russell A. Clinical effectiveness and cost-effectiveness of collaborative care for depression in UK primary care (CADET): a cluster randomised controlled trial. Health Technol Assess 2016; 20:1-192. [PMID: 26910256 DOI: 10.3310/hta20140] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Collaborative care is effective for depression management in the USA. There is little UK evidence on its clinical effectiveness and cost-effectiveness. OBJECTIVE To determine the clinical effectiveness and cost-effectiveness of collaborative care compared with usual care in the management of patients with moderate to severe depression. DESIGN Cluster randomised controlled trial. SETTING UK primary care practices (n = 51) in three UK primary care districts. PARTICIPANTS A total of 581 adults aged ≥ 18 years in general practice with a current International Classification of Diseases, Tenth Edition depressive episode, excluding acutely suicidal people, those with psychosis, bipolar disorder or low mood associated with bereavement, those whose primary presentation was substance abuse and those receiving psychological treatment. INTERVENTIONS Collaborative care: 14 weeks of 6-12 telephone contacts by care managers; mental health specialist supervision, including depression education, medication management, behavioural activation, relapse prevention and primary care liaison. Usual care was general practitioner standard practice. MAIN OUTCOME MEASURES Blinded researchers collected depression [Patient Health Questionnaire-9 (PHQ-9)], anxiety (General Anxiety Disorder-7) and quality of life (European Quality of Life-5 Dimensions three-level version), Short Form questionnaire-36 items) outcomes at 4, 12 and 36 months, satisfaction (Client Satisfaction Questionnaire-8) outcomes at 4 months and treatment and service use costs at 12 months. RESULTS In total, 276 and 305 participants were randomised to collaborative care and usual care respectively. Collaborative care participants had a mean depression score that was 1.33 PHQ-9 points lower [n = 230; 95% confidence interval (CI) 0.35 to 2.31; p = 0.009] than that of participants in usual care at 4 months and 1.36 PHQ-9 points lower (n = 275; 95% CI 0.07 to 2.64; p = 0.04) at 12 months after adjustment for baseline depression (effect size 0.28, 95% CI 0.01 to 0.52; odds ratio for recovery 1.88, 95% CI 1.28 to 2.75; number needed to treat 6.5). Quality of mental health but not physical health was significantly better for collaborative care at 4 months but not at 12 months. There was no difference for anxiety. Participants receiving collaborative care were significantly more satisfied with treatment. Differences between groups had disappeared at 36 months. Collaborative care had a mean cost of £272.50 per participant with similar health and social care service use between collaborative care and usual care. Collaborative care offered a mean incremental gain of 0.02 (95% CI -0.02 to 0.06) quality-adjusted life-years (QALYs) over 12 months at a mean incremental cost of £270.72 (95% CI -£202.98 to £886.04) and had an estimated mean cost per QALY of £14,248, which is below current UK willingness-to-pay thresholds. Sensitivity analyses including informal care costs indicated that collaborative care is expected to be less costly and more effective. The amount of participant behavioural activation was the only effect mediator. CONCLUSIONS Collaborative care improves depression up to 12 months after initiation of the intervention, is preferred by patients over usual care, offers health gains at a relatively low cost, is cost-effective compared with usual care and is mediated by patient activation. Supervision was by expert clinicians and of short duration and more intensive therapy may have improved outcomes. In addition, one participant requiring inpatient treatment incurred very significant costs and substantially inflated our cost per QALY estimate. Future work should test enhanced intervention content not collaborative care per se. TRIAL REGISTRATION Current Controlled Trials ISRCTN32829227. FUNDING This project was funded by the Medical Research Council (MRC) (G0701013) and managed by the National Institute for Health Research (NIHR) on behalf of the MRC-NIHR partnership.
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Affiliation(s)
| | - Peter Bower
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Linda Gask
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - John Cape
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Stephen Pilling
- Division of Psychology and Language Sciences, University College London, London, UK
| | - Ricardo Araya
- London School of Hygiene and Tropical Medicine, London, UK
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Michael Barkham
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield, UK
| | - J Martin Bland
- Department of Health Sciences, University of York, York, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Colin Green
- University of Exeter Medical School, Exeter, UK
| | - Glyn Lewis
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Chris Manning
- Public and Patient Advocate, Upstream Healthcare, Teddington, UK
| | - Evangelos Kontopantelis
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | | | - Adwoa Hughes-Morley
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
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Predictors of IAPT psychological well-being practitioners’ intention to use CBT self-help materials routinely in their clinical practice. COGNITIVE BEHAVIOUR THERAPIST 2016. [DOI: 10.1017/s1754470x16000076] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
AbstractDespite efficacy and effectiveness evidence, and recommendations from the National Institute for Health and Care Excellence (NICE), use of CBT self-help materials remains inconsistent in UK mental health services. Since 2006, the Improving Access to Psychological Therapies (IAPT) programme has provided standardized training and mandates routine use of CBT self-help materials by their trainee psychological well-being practitioners (PWPs). This study tested whether the main constructs of the theory of planned behaviour (TPB; attitudes, subjective norms, and perceived behavioural control), past use, prior training and demographic characteristics, would predict PWPs’ intention to use self-help materials routinely in their clinical practice. Stage 1 utilized a standardized procedure to create measures for the constructs of TPB, before the design and testing of a web-based, cross-sectional questionnaire. In stage 2, the questionnaire was administered to a convenience sample of trainee PWPs (n = 94). Data was analysed using multiple linear regression, mediation analyses, and content analysis. TPB constructs predicted intention to use self-help materials, with only direct attitude contributing significantly to 70% of the variance in intention. Past use of materials predicted intention, via direct and indirect mediation. Qualitative data from 43 trainees highlighted clients’ experience of self-help materials as positive, albeit with some practical constraints. The results suggest that the main constructs of TPB have some utility in predicting trainee PWPs’ intention to use self-help materials routinely. Future prospective, longitudinal research could investigate actual use of self-help materials to elucidate cognitive factors involved in trainees’ clinical decision-making post-qualification.
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Castelnuovo G, Pietrabissa G, Cattivelli R, Manzoni GM, Molinari E. Not Only Clinical Efficacy in Psychological Treatments: Clinical Psychology Must Promote Cost-Benefit, Cost-Effectiveness, and Cost-Utility Analysis. Front Psychol 2016; 7:563. [PMID: 27242562 PMCID: PMC4860399 DOI: 10.3389/fpsyg.2016.00563] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2016] [Accepted: 04/05/2016] [Indexed: 01/17/2023] Open
Affiliation(s)
- Gianluca Castelnuovo
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCSVerbania, Italy; Department of Psychology, Catholic University of MilanMilano, Italy
| | - Giada Pietrabissa
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCSVerbania, Italy; Department of Psychology, Catholic University of MilanMilano, Italy
| | - Roberto Cattivelli
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCSVerbania, Italy; Department of Psychology, Catholic University of MilanMilano, Italy
| | - Gian Mauro Manzoni
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCSVerbania, Italy; Faculty of Psychology, eCampus UniversityNovedrate, Italy
| | - Enrico Molinari
- Psychology Research Laboratory, Istituto Auxologico Italiano IRCCSVerbania, Italy; Department of Psychology, Catholic University of MilanMilano, Italy
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Effectiveness of Cognitive Behavioural Self-Help for the Treatment of Depression and Anxiety in People with Long-Term Physical Health Conditions: a Systematic Review and Meta-Analysis of Randomised Controlled Trials. Ann Behav Med 2016; 49:579-93. [PMID: 25690370 DOI: 10.1007/s12160-015-9689-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
BACKGROUND Depression and anxiety are prevalent comorbidities in people with long-term physical health conditions; however, there is limited access to evidence-based treatments for comorbid mental health difficulties. PURPOSE This study is a meta-analysis examining the effectiveness of cognitive behavioural self-help for physical symptoms, depression and anxiety in people with long-term conditions. METHODS This study involves a systematic search of electronic databases supplemented by expert contact, reference and citation checking and grey literature. RESULTS The meta-analysis yielded a small effect size for 11 studies reporting primary outcomes of depression (g = -0.20) and 8 studies anxiety (g = -0.21) with a large effect size (g = -1.14) for 1 study examining physical health symptoms. There were no significant moderators of the main effect. CONCLUSIONS Limited evidence supports cognitive behavioural self-help for depression, anxiety and physical symptoms in people with long-term conditions. Small effect sizes for depression and anxiety may result from failure to recruit participants with clinical levels of these difficulties at baseline.
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Elliott KP, Westmacott R, Hunsley J, Rumstein-McKean O, Best M. The Process of Seeking Psychotherapy and Its Impact on Therapy Expectations and Experiences. Clin Psychol Psychother 2014; 22:399-408. [DOI: 10.1002/cpp.1900] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2013] [Revised: 03/19/2014] [Accepted: 03/22/2014] [Indexed: 11/10/2022]
Affiliation(s)
| | | | - John Hunsley
- School of Psychology; University of Ottawa; Ottawa Canada
| | | | - Marlene Best
- School of Psychology; University of Ottawa; Ottawa Canada
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Steve G, Katie A, Christine E, Mike L, Stephen M, Lucy S, Kati T, Rachel W, Sarah W. 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. BMC Health Serv Res 2012; 12:189. [PMID: 22769593 PMCID: PMC3468356 DOI: 10.1186/1472-6963-12-189] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Accepted: 06/21/2012] [Indexed: 11/30/2022] Open
Abstract
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.
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Affiliation(s)
- Gillard Steve
- Section of Mental Health, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - Adams Katie
- NHS Evidence, National Institute for Health and Clinical Excellence, Manchester, UK
| | | | - Lucock Mike
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Miller Stephen
- South West London & St George’s Mental Health NHS Trust, London, UK
| | - Simons Lucy
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Turner Kati
- Section of Mental Health, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
| | - White Rachel
- Department of Psychology, Institute of Psychiatry, Kings College London, London, UK
| | - White Sarah
- Section of Mental Health, St George’s, University of London, Cranmer Terrace, London, SW17 0RE, UK
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7
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Barazzone N, Cavanagh K, Richards DA. Computerized cognitive behavioural therapy and the therapeutic alliance: A qualitative enquiry. BRITISH JOURNAL OF CLINICAL PSYCHOLOGY 2012; 51:396-417. [DOI: 10.1111/j.2044-8260.2012.02035.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Lucock M, Gillard S, Adams K, Simons L, White R, Edwards C. Self-care in mental health services: a narrative review. HEALTH & SOCIAL CARE IN THE COMMUNITY 2011; 19:602-616. [PMID: 21749527 DOI: 10.1111/j.1365-2524.2011.01014.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
Self-care is an important approach to the management of long-term health conditions and in preventing ill-health by living a healthy lifestyle. The concept has been used to a limited extent in relation to mental health, but it overlaps with the related concepts of recovery, self-management and self-help. These related concepts all entail individuals having more choice and control over treatment and a greater role in recovery and maintaining their health and well-being. This paper reviews qualitative empirical research that provides information on the nature of self-care in mental health from the perspective of people experiencing mental health problems. Twenty qualitative studies were identified from a systematic search of the literature. The methods used in these studies were critically appraised and key themes across studies identified self-care behaviours and processes supporting self-care. The paper also highlights challenges to this approach in mental health and provides a conceptual framework of the relationships between self-care support, self-care behaviours and strategies, and well-being for the individual. It also highlights limitations in the current evidence base and identifies areas for future research.
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Affiliation(s)
- Mike Lucock
- Centre for Health and Social Care Research, University of Huddersfield, UK.
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Müller BH, Kull S, Wilhelm FH, Michael T. One-session computer-based exposure treatment for spider-fearful individuals--efficacy of a minimal self-help intervention in a randomised controlled trial. J Behav Ther Exp Psychiatry 2011; 42:179-84. [PMID: 21315879 DOI: 10.1016/j.jbtep.2010.12.001] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2010] [Revised: 11/30/2010] [Accepted: 12/06/2010] [Indexed: 11/19/2022]
Abstract
Computer-based self-help treatments have been proposed to provide greater access to treatment while requiring minimum input from a therapist. The authors employed a randomised controlled trial to investigate the efficacy of one-session computer-based exposure (CBE) as a self-help treatment for spider-fearful individuals. Spider-fearful participants in a CBE group underwent one 27-min session of standardised exposure to nine fear-eliciting spider pictures. Treatment outcome was compared to spider-fearful control participants exposed to nine neutral pictures. Fear reduction was quantified on a subjective level by the Fear of Spiders Questionnaire (FSQ) and complemented with a behavioural approach test (BAT). Results demonstrate that compared to control participants, CBE participants showed greater fear reduction from pre- to posttreatment on both the subjective level (FSQ) and the behavioural level (BAT). Moreover, in contrast to the control group, the obtained subjective fear reduction effect remained stable in the CBE group at 1-month follow-up. These findings highlight the role of computer-based self-help as a minimal but effective intervention to reduce fear of spiders.
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Affiliation(s)
- Birgit H Müller
- Department of Clinical Psychology and Psychotherapy, University of Basel, Missionsstrasse 60/62, CH-4055 Basel, Switzerland.
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Morgan AJ, Jorm AF. Outcomes of self-help efforts in anxiety disorders. Expert Rev Pharmacoecon Outcomes Res 2010; 9:445-59. [PMID: 19817528 DOI: 10.1586/erp.09.47] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Anxiety disorders are prevalent mental disorders that are a significant burden on the community. There are effective treatments available, but many people do not seek treatment and there is a lack of professionals available to provide evidence-based treatment to all those with anxiety disorders. Recently, there has been increased attention on ways to cost effectively meet the demand for treatment with minimal cost to health services. Self-help efforts have been proposed to play a role, either as an initial minimal treatment in stepped-care models of treatment, or as strategies undertaken by an individual to prevent a full disorder developing. This review examines what is known from randomized controlled trials about the efficacy of self-help interventions for anxiety disorders.
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Affiliation(s)
- Amy J Morgan
- Orygen Youth Health Research Centre, Centre for Youth Mental Health, University of Melbourne, Parkville, Victoria 3052, Australia.
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11
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Jackson T. Accessibility, efficiency and effectiveness in psychological services for adults with learning disabilities. ACTA ACUST UNITED AC 2009. [DOI: 10.1108/17530180200900034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Richards DA, Hughes-Morley A, Hayes RA, Araya R, Barkham M, Bland JM, Bower P, Cape J, Chew-Graham CA, Gask L, Gilbody S, Green C, Kessler D, Lewis G, Lovell K, Manning C, Pilling S. Collaborative Depression Trial (CADET): multi-centre randomised controlled trial of collaborative care for depression--study protocol. BMC Health Serv Res 2009; 9:188. [PMID: 19832996 PMCID: PMC2770465 DOI: 10.1186/1472-6963-9-188] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 10/16/2009] [Indexed: 01/17/2023] Open
Abstract
Background Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework. Methods/Design A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9. Discussion If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients. Trial Registration Number ISRCTN32829227
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Affiliation(s)
- David A Richards
- Mood Disorders Centre, School of Psychology, University of Exeter, EX4 4QG, UK.
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Empirically grounded clinical interventions clients' and referrers' perceptions of computer-guided CBT (FearFighter). Behav Cogn Psychother 2009; 37:1-9. [PMID: 19364403 DOI: 10.1017/s135246580800492x] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND Computer-guided CBT has been shown to be a potentially useful way of closing the gap between the demand and supply for CBT. Moreover, this approach has additional benefits in terms of less travel times for treatment, accessibility in remote and unusual locations, increased confidentiality, easier disclosure of sensitive information, and more egalitarian therapist-client interactions. Research on computerized CBT has concentrated on clinical outcomes, but the views of clients on this treatment approach have been relatively neglected. AIMS The aims were to assess client satisfaction, professionals' views, and ease of programme use after completion of treatment via an internet-based CBT programme for panic and phobic anxiety (FearFighter). METHOD A feasibility and effectiveness study of FearFighter was conducted in remote and rural areas of Scotland. Treatment data are available for 35 clients at post-treatment, of whom 29 completed an 18-item set of rating scales designed to assess satisfaction, including ease of use, accessibility, how far needs were met, whether changes to the programme were required, the benefits and drawbacks of not having a therapist, and quality of support. Open-ended questions were included. Referring agencies were also asked to rate their views on FearFighter. RESULTS Clients reported moderate to high levels of improvement and of overall satisfaction; very few difficulties in logging on to and using the programme were encountered. Similar levels of satisfaction with the programme were reported by referrers. CONCLUSIONS It is concluded that computer-guided CBT is acceptable to clients and to professionals, and that it could play a valuable part in a "stepped care" system of delivering CBT.
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Farrand P, Confue P, Byng R, Shaw S. Guided self-help supported by paraprofessional mental health workers: an uncontrolled before--after cohort study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2009; 17:9-17. [PMID: 18564197 DOI: 10.1111/j.1365-2524.2008.00792.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
There has been considerable development of guided self-help clinics within primary care. This uncontrolled before-after cohort study examines efficiency and effectiveness of these clinics when supported by paraprofessional mental health workers having little mental health training and experience. Data were collected by seven Graduate Mental Health Workers (GMHW) located in South-west England. Alongside an analysis of clinic attendance and dropout, efficiency was measured with respect to the number and length of sessions to support patients with the effectiveness of the interventions examined with respect to problem severity. Over a 15-month period, 1162 patients were referred to the GMHW clinics with 658 adopting guided self-help. Patients using guided self-help received an average input per patient, excluding assessment, of four sessions of 40 minutes. Dropout rate was comparable to other primary-care-based mental health clinics supported by experienced mental health professionals with 458 patients completing all support sessions. However, only 233 patients went on to attend the 3 months of follow-up session. Effectiveness of guided self-help clinics supported by paraprofessional mental health workers was comparable to that supported by an experienced mental health nurse. Improvements in problem severity were statistically significant, with 55% and 58% (final support session) and 63% and 62% (3 months of follow-up) of patients experiencing clinically significant and reliable change for anxiety and depression, respectively. However, concerns exist over the efficiency of the GMHW clinic especially with respect to the use of longer support sessions and high dropout rate at the 3 months of follow-up session. The paper concludes by highlighting the effectiveness of guided self-help when supported by paraprofessional mental health workers, but questions the utility of the two-plus-one model of service delivery proposing a collaborative care approach as an alternative.
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Affiliation(s)
- Paul Farrand
- School of Applied Psychosocial Studies, University of Plymouth, UK.
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Kaltenthaler E, Parry G, Beverley C, Ferriter M. Computerised cognitive-behavioural therapy for depression: systematic review. Br J Psychiatry 2008; 193:181-4. [PMID: 18757972 DOI: 10.1192/bjp.bp.106.025981] [Citation(s) in RCA: 162] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Computerised cognitive-behavioural therapy (CCBT) is used for treating depression and provides a potentially useful alternative to therapist cognitive-behavioural therapy (CBT). AIMS To systematically review the evidence for the effectiveness of CCBT for the treatment of mild to moderate depression. METHOD Electronic databases were searched to identify randomised controlled trials. Selected studies were quality assessed and data extracted by two reviewers. RESULTS Four studies of three computer software packages met the inclusion criteria. Comparators were treatment as usual, using a depression education website and an attention placebo. CONCLUSIONS There is some evidence to support the effectiveness of CCBT for the treatment of depression. However, all studies were associated with considerable drop-out rates and little evidence was presented regarding participants' preferences and the acceptability of the therapy. More research is needed to determine the place of CCBT in the potential range of treatment options offered to individuals with depression.
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Affiliation(s)
- Eva Kaltenthaler
- ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield S1 4DA, UK.
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Farrand P, Duncan F, Byng R. Impact of graduate mental health workers upon primary care mental health: a qualitative study. HEALTH & SOCIAL CARE IN THE COMMUNITY 2007; 15:486-93. [PMID: 17685994 DOI: 10.1111/j.1365-2524.2007.00707.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
The role of the primary care graduate mental health worker (GMHW) was developed to improve the availability of mental health services within primary care. However, little is known concerning the impact of the role upon primary care mental health. Semistructured interviews were undertaken with 27 key stakeholders (12 clients, 10 managers/supervisors, 5 general practitioners) who had experience of the GMHW role and activities provided. Thematic analysis of interview transcripts highlighted four main themes: Access to primary care mental health, Inappropriate referrals, GMHW characteristics, and Role developments. All participant groups highlighted a range of ways in which the GMHW role was making significant contributions to primary care mental health. Many of these were associated with increasing access to mental health services afforded by the range of interventions provided. Benefits, however, may exclude working clients who expressed concerns about a lack of flexibility in the appointment times offered. Concerns arise as a consequence of inappropriate referrals made by some general practitioners. Such referrals were, in part, motivated by a belief that developments in primary care mental health should have been directed towards clients with more severe difficulties. In conclusion, this study suggests that the GMHW role is having a significant impact upon primary care mental health. Attempts to improve primary care mental health through the incorporation of the GMHW role within stepped care models of mental health service delivery should be encouraged.
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Affiliation(s)
- Paul Farrand
- School of Applied Psychosocial Studies, Faculty of Health and Social Work, University of Plymouth, Exeter, UK.
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Khan N, Bower P, Rogers A. Guided self-help in primary care mental health: meta-synthesis of qualitative studies of patient experience. Br J Psychiatry 2007; 191:206-11. [PMID: 17766759 DOI: 10.1192/bjp.bp.106.032011] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND There is a gap between the supply of trained cognitive-behavioural therapists to treat depression and demand for care in the community. There is interest in the potential of self-help interventions, which require less input from a therapist. However, the design of effective self-help interventions is complex. Qualitative research can help to explore some of this complexity. AIMS The study aimed to identify qualitative studies of patient experience of depression management in primary care, synthesise these studies to develop an explanatory framework, and then apply this framework to the development of a guided self-help intervention for depression. METHOD A meta-synthesis was conducted of published qualitative research. RESULTS The synthesis revealed a number of themes, including the nature of personal experience in depression; help-seeking in primary care; control and helplessness in engagement with treatment; stigma associated with treatment; and patients' understandings of self-help interventions. CONCLUSIONS This meta-synthesis of qualitative studies provided a useful explanatory framework for the development of effective and acceptable guided self-help interventions for depression.
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Affiliation(s)
- Nagina Khan
- National Primary Care Research and Development Centre, 5th Floor Williamson Building, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Macdonald W, Mead N, Bower P, Richards D, Lovell K. A qualitative study of patients' perceptions of a 'minimal' psychological therapy. Int J Soc Psychiatry 2007; 53:23-35. [PMID: 17333949 DOI: 10.1177/0020764006066841] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Access to psychological therapy is often difficult. Problems with access may be overcome through 'minimal interventions' (such as books and computer programs), which encourage self-help for mental health problems and are less dependent on the availability of specialist therapists. However, to be effective, such interventions must be acceptable to patients. AIMS To use qualitative methods to explore patient attitudes, by examining patient expectancies of psychological therapy and their experiences with a 'minimal intervention' (guided self-help). METHODS Qualitative interviews (N = 24) were conducted with patients after they had received guided self-help for depression as part of a randomised controlled trial. RESULTS There were important gaps between patients' expectancies of psychological therapy and their experience of the guided self-help. These gaps related to the process of therapy (e.g. time, professional expertise) and outcomes. Particularly salient was a theme relating to explanatory models. Patients were often seeking insight into the 'cause' of their current difficulties, whereas the minimal intervention was largely focused on symptom resolution. CONCLUSIONS The effective implementation of 'minimal interventions' requires an understanding of the expectancies of patients concerning psychological therapy, in order to provide a basis for effective communication and negotiation between professionals and patients.
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Affiliation(s)
- Wendy Macdonald
- National Primary Care Research and Development Centre, University of Manchester, UK.
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McFarland R, Wylie K, Ridley J. Self-help therapies within the NHS: providing a service for patients experiencing relationship difficulties. SEXOLOGIES 2007. [DOI: 10.1016/j.sexol.2006.07.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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McEvoy P, Richards D. Gatekeeping access to community mental health teams: a qualitative study. Int J Nurs Stud 2006; 44:387-95. [PMID: 16843468 DOI: 10.1016/j.ijnurstu.2006.05.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2006] [Revised: 05/13/2006] [Accepted: 05/21/2006] [Indexed: 11/28/2022]
Abstract
BACKGROUND Gatekeeping access to services at the interface with primary care has been identified as one of the key issues that community mental health teams (CMHTs) have to confront. OBJECTIVES The aim of this study was to develop a better understanding of the contextual influences that impact upon the outcome of gatekeeping decisions. DESIGN An interview-based qualitative study, informed by the philosophy of critical realism. SETTING An urban catchment area in Northern England. PARTICIPANTS Twenty-nine interviews were conducted with gatekeeping clinicians and service managers. METHOD A convenience sample of clinicians was initially approached to take part in a series of semi-structured interviews. This was followed up by a purposive sample of clinicians and service managers, as specific contextual influences were identified and explored in detail. The emerging analysis was then subjected to critical scrutiny by a further sample of gatekeeping clinicians. FINDINGS A clear hierarchy of appropriateness was identified with four dimensions: severity, risk, beneficence and a moral dimension. It was suggested that the salient contextual influences that shaped the hierarchy were: (a) the need to fit in with strategic planning directives, (b) the burden of responsibility that clinicians carried, (c) the high number of referrals and the relatively slow turnover of patients on clinical caseloads, (d) the position of CMHTs in the economy of care and (e) the character of the relationship between clinicians and service managers. CONCLUSION The findings from the study support a multi-level view of the gatekeeping process within CMHTs, which takes account of the role that key contextual influences play in shaping the range of options that are available to gatekeeping clinicians.
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Affiliation(s)
- Phil McEvoy
- Salford PCT/University of Manchester, Manchester, UK.
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Richards DA, Lankshear AJ, Fletcher J, Rogers A, Barkham M, Bower P, Gask L, Gilbody S, Lovell K. Developing a U.K. protocol for collaborative care: a qualitative study. Gen Hosp Psychiatry 2006; 28:296-305. [PMID: 16814628 DOI: 10.1016/j.genhosppsych.2006.03.005] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2006] [Revised: 03/11/2006] [Accepted: 03/13/2006] [Indexed: 01/18/2023]
Abstract
OBJECTIVE This study aimed to explore the views of stakeholders including patients, general practitioners (GPs) and mental health workers on the feasibility, acceptability and barriers to a collaborative care model for treatment of depression within the context of U.K. primary health care. METHOD We used semistructured interviews and focus groups with a purposive sample of 11 patients and 38 professionals from a wide selection of primary and secondary care mental health services, as well as framework analysis using a "constant comparative" approach to identify key concepts and themes. RESULTS Regular contact for patients with depression is acceptable and valued by both patients and professionals. However, patients value support, whereas professionals focus on information. To be acceptable to patients, contacts about medication or psychosocial support must minimize the potential for patient disempowerment. The use of the telephone is convenient and lends anonymity, but established mental health workers think it will impair their judgments. While patients merely identified the need for skilled case managers, GPs preferred established professionals; however, these workers did not see themselves in this role. All involved were cautious about deploying new workers. Additional barriers included practical and organizational issues. CONCLUSIONS Although a telephone-delivered mix of medication support and low-intensity psychological intervention is generally acceptable, significant issues to be addressed include the values of the current mental health workforce, fears about new workers' experience and competence, the balance of face-to-face and telephone contacts and case manager education in nonspecific skills necessary to develop a therapeutic alliance, as well as the knowledge and skills required for education, medication support and behavioral activation. Qualitative research can add value to careful modeling of collaborative care prior to international implementation.
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Affiliation(s)
- David A Richards
- Department of Health Sciences, University of York, YO10 5DD, UK.
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Trusler K, Doherty C, Mullin T, Grant S, McBride J. Waiting times for primary care psychological therapy and counselling services. COUNSELLING & PSYCHOTHERAPY RESEARCH 2006. [DOI: 10.1080/14733140600581358] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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Bower P, Jerrim S, Gask L. Primary care mental health workers: role expectations, conflict and ambiguity. HEALTH & SOCIAL CARE IN THE COMMUNITY 2004; 12:336-345. [PMID: 15272889 DOI: 10.1111/j.1365-2524.2004.00503.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Abstract
A number of professionals are involved in mental health in primary care. The NHS Plan proposed the introduction of a new professional, the primary care mental health worker (PCMHW), to improve care in this setting. The present study was conducted to examine pilot PCMHW-type roles currently in existence, to explore staff expectations concerning the new PCMHW role and to consider the issues relating to roles in primary care mental health that are raised by this new worker. The study used a case study design, and involved qualitative interviews with 46 managers and clinicians from primary care and specialist mental health services, including pilot PCMHW-type roles. The key findings were as follows: The pilot PCMHW-type roles were almost exclusively related to client work, whereas respondents had far wider role expectations of the new PCMHWs, relating to perceived gaps in current service provision. This highlights the potential for role conflict. Secondly, there was disagreement and ambiguity among some respondents as to the nature of the new PCMHW's role in client work, and its relationship with the work undertaken by other mental health professionals such as counsellors, psychologists and nurses. Given that multiple professionals are involved in mental health care in primary care, issues relating to roles are likely to be crucial in the effective implementation of the new PCMHWs.
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Affiliation(s)
- Peter Bower
- National Primary Care Research and Development Centre, University of Manchester, Manchester, UK.
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