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Camacho EM, Shields GE, Chew-Graham CA, Eisner E, Gilbody S, Littlewood E, McMillan D, Watson K, Fearon P, Sharp DJ. Generating EQ-5D-3L health utility scores from the Edinburgh Postnatal Depression Scale: a perinatal mapping study. Eur J Health Econ 2024; 25:319-332. [PMID: 37093502 PMCID: PMC10858827 DOI: 10.1007/s10198-023-01589-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 04/11/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Perinatal depression (PND) describes depression experienced by parents during pregnancy or in the first year after a baby is born. The EQ-5D instrument (a generic measure of health status) is not often collected in perinatal research, however disease-specific measures, such as the Edinburgh Postnatal Depression Scale (EPDS) are widely used. Mapping can be used to estimate generic health utility index values from disease-specific measures like the EPDS. OBJECTIVE To develop a mapping algorithm to estimate EQ-5D utility index values from the EPDS. METHODS Patient-level data from the BaBY PaNDA study (English observational cohort study) provided 1068 observations with paired EPDS and EQ-5D (3-level version; EQ-5D-3L) responses. We compared the performance of six alternative regression model types, each with four specifications of covariates (EPDS score and age: base, squared, and cubed). Model performance (ability to predict utility values) was assessed by ranking mean error, mean absolute error, and root mean square error. Algorithm performance in 3 external datasets was also evaluated. RESULTS There was moderate correlation between EPDS score and utility values (coefficient: - 0.42). The best performing model type was a two-part model, followed by ordinary least squared. Inclusion of squared and cubed covariates improved model performance. Based on graphs of observed and predicted utility values, the algorithm performed better when utility was above 0.6. CONCLUSIONS This direct mapping algorithm allows the estimation of health utility values from EPDS scores. The algorithm has good external validity but is likely to perform better in samples with higher health status.
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Affiliation(s)
- Elizabeth M Camacho
- School of Health Sciences, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PT, UK.
| | - Gemma E Shields
- School of Health Sciences, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PT, UK
| | | | - Emily Eisner
- School of Health Sciences, University of Manchester, Jean McFarlane Building, Oxford Road, Manchester, M13 9PT, UK
- Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Simon Gilbody
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | | | - Dean McMillan
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Kylie Watson
- Manchester University NHS Foundation Trust, Manchester, UK
| | - Pasco Fearon
- Research Department of Clinical, Educational and Health Psychology, University College London, London, UK
| | - Deborah J Sharp
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
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Gilbody S, Littlewood E, McMillan D, Atha L, Bailey D, Baird K, Brady S, Burke L, Chew-Graham CA, Coventry P, Crosland S, Fairhurst C, Henry A, Hollingsworth K, Newbronner E, Ryde E, Shearsmith L, Wang HI, Webster J, Woodhouse R, Clegg A, Dexter-Smith S, Gentry T, Hewitt C, Hill A, Lovell K, Sloan C, Traviss-Turner G, Pratt S, Ekers D. Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trial. Lancet Healthy Longev 2024; 5:e97-e107. [PMID: 38310902 PMCID: PMC10834375 DOI: 10.1016/s2666-7568(23)00238-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Older adults were more likely to be socially isolated during the COVID-19 pandemic, with increased risk of depression and loneliness. We aimed to investigate whether a behavioural activation intervention delivered via telephone could mitigate depression and loneliness in at-risk older people during the COVID-19 pandemic. METHODS BASIL+ (Behavioural Activation in Social Isolation) was a pragmatic randomised controlled trial conducted among patients recruited from general practices in England and Wales, and was designed to assess the effectiveness of behavioural activation in mitigating depression and loneliness among older people during the COVID-19 pandemic. Eligible participants were aged 65 years and older, socially isolated, with a score of 5 or higher on the Patient Health Questionnaire-9 (PHQ-9), and had multiple long-term conditions. Participants were allocated in a 1:1 ratio to the intervention (behavioural activation) or control groups by use of simple randomisation without stratification. Behavioural activation was delivered by telephone; participants were offered up to eight weekly sessions with trained BASIL+ Support Workers. Behavioural activation was adapted to maintain social connections and encourage socially reinforcing activities. Participants in the control group received usual care with existing COVID-19 wellbeing resources. The primary clinical outcome was self-reported depression severity, assessed by the PHQ-9, at 3 months. Outcomes were assessed masked to allocation and analysis was by treatment allocation. This trial is registered with the ISRCTN registry (ISRCTN63034289). FINDINGS Between Feb 8, 2021, and Feb 28, 2022, 449 eligible participants were identified and 435 from 26 general practices were recruited and randomly assigned (1:1) to the behavioural activation intervention (n=218) or to the control group (usual care with signposting; n=217). The mean age of participants was 75·7 years (SD 6·7); 270 (62·1%) of 435 participants were female, and 418 (96·1%) were White. Participants in the intervention group attended an average of 5·2 (SD 2·9) of eight remote behavioural activation sessions. The adjusted mean difference in PHQ-9 scores between the control and intervention groups at 3 months was -1·65 (95% CI -2·54 to -0·75, p=0·0003). No adverse events were reported that were attributable to the behavioural activation intervention. INTERPRETATION Behavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York, UK; Hull York Medical School, University of York, York, UK.
| | - Elizabeth Littlewood
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK; Hull York Medical School, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Lucy Atha
- Department of Health Sciences, University of York, York, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | - Kalpita Baird
- Department of Health Sciences, University of York, York, UK
| | - Samantha Brady
- Department of Health Sciences, University of York, York, UK
| | - Lauren Burke
- Department of Health Sciences, University of York, York, UK
| | | | - Peter Coventry
- Department of Health Sciences, University of York, York, UK; York Environmental Sustainability Institute, University of York, York, UK
| | | | | | - Andrew Henry
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Kelly Hollingsworth
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | | | | | - Andrew Clegg
- School of Medicine, University of Leeds, Leeds, UK
| | - Sarah Dexter-Smith
- Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | | | - Andrew Hill
- School of Medicine, University of Leeds, Leeds, UK
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | | | | | - David Ekers
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
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Camacho EM, Shields GE, Eisner E, Littlewood E, Watson K, Chew-Graham CA, McMillan D, Ali S, Gilbody S. An economic evaluation of universal and targeted case-finding strategies for identifying antenatal depression: a model-based analysis comparing common case-finding instruments. Arch Womens Ment Health 2023:10.1007/s00737-023-01377-2. [PMID: 37851079 DOI: 10.1007/s00737-023-01377-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 09/30/2023] [Indexed: 10/19/2023]
Abstract
Half of women with depression in the perinatal period are not identified in routine care, and missed cases reflect inequalities in other areas of maternity care. Case finding (screening) for depression in pregnant women may be a cost-effective strategy to improve identification, and targeted case finding directs finite resources towards the greatest need. We compared the cost-effectiveness of three case-finding strategies: no case finding, universal (all pregnant women), and targeted (only pregnant women with risk factors for antenatal depression, i.e. history of anxiety/depression, age < 20 years, and adverse life events). A decision tree model was developed to represent case finding (at around 20 weeks gestation) and subsequent treatment for antenatal depression (up to 40 weeks gestation). Costs include case finding and treatment. Health benefits are measured as quality-adjusted life years (QALYs). The sensitivity and specificity of case-finding instruments and prevalence and severity of antenatal depression were estimated from a cohort study of pregnant women. Other model parameters were derived from published literature and expert consultation. The most cost-effective case-finding strategy was a two-stage strategy comprising the Whooley questions followed by the PHQ-9. The mean costs were £52 (universal), £61 (no case finding), and £62 (targeted case finding). Both case-finding strategies improve health compared with no case finding. Universal case finding is cost-saving. Costs associated with targeted case finding are similar to no case finding, with greater health gains, although targeted case finding is not cost-effective compared with universal case finding. Universal case finding for antenatal depression is cost-saving compared to no case finding and more cost-effective than targeted case finding.
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Affiliation(s)
- Elizabeth M Camacho
- School of Health Sciences, University of Manchester, Manchester, UK.
- Institute of Population Health, University of Liverpool, Liverpool, UK.
| | - Gemma E Shields
- School of Health Sciences, University of Manchester, Manchester, UK
| | - Emily Eisner
- School of Health Sciences, University of Manchester, Manchester, UK
- Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | | | - Kylie Watson
- Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Dean McMillan
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
- Schulich School of Medicine & Dentistry, Western University, London, Canada
| | - Simon Gilbody
- Hull York Medical School and Department of Health Sciences, University of York, York, UK
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Camacho E, Shields G, Eisner E, Chew-Graham C, Gilbody S, Littlewood E, McMillan D, Watson K. Exploring the cost-effectiveness of case-finding for antenatal depression: an economic modelling study. Br J Gen Pract 2023; 73:bjgp23X733977. [PMID: 37479293 DOI: 10.3399/bjgp23x733977] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023] Open
Abstract
BACKGROUND The NHS has limited human and financial resources, with particular pressures in primary care. The National Institute for Health and Care Excellence (NICE) makes decisions on which services can be commissioned within the NHS. Many women experiencing antenatal depression are not identified as such in routine care and so may not access support. Current NICE guidance does not recommend universal case-finding for antenatal depression; however, a programme targeted towards pregnant women with risk factors (for example, previous mental illness, traumatic life events) has not been considered. AIM To explore the cost-effectiveness of case-finding for antenatal depression: targeted vs. universal vs. no case-finding. METHOD The following case-finding tools were evaluated: Edinburgh Postnatal Depression Scale, Whooley questions, PHQ-9. One- and two-stage strategies were considered (second tool administered following positive response to Whooley questions). A decision tree model of costs and health outcomes from 20-40 weeks' gestation was developed. Health was measured as quality-adjusted-life-years (QALYs). Costs included case-finding and treatment for depression. RESULTS The two-stage Whooley/PHQ-9 option was the most cost-effective case-finding strategy. Implementing a universal case-finding strategy was associated with lower costs than no case-finding (£52 vs £61) and more QALYs (0.3458 vs 0.3455). Targeted case-finding has similar costs to no case-finding and more QALYs (0.3459), requiring a spend of £1775 to improve health by 1 QALY. CONCLUSION Universal case-finding for antenatal depression is cost-saving and improves health compared with no case-finding. It should be considered by policymakers to improve the identification and support of women experiencing antenatal depression in primary and maternity care.
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Camacho EM, Shields GE, Eisner E, Littlewood E, Watson K, Chew-Graham CA, McMillan D, Ali S, Gilbody S. An economic evaluation of targeted case-finding strategies for identifying postnatal depression: A model-based analysis comparing common case-finding instruments. J Affect Disord 2023; 334:26-34. [PMID: 37142002 DOI: 10.1016/j.jad.2023.04.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Revised: 04/20/2023] [Accepted: 04/28/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Half of women with postnatal depression (PND) are not identified in routine care. We aimed to estimate the cost-effectiveness of PND case-finding in women with risk factors for PND. METHODS A decision tree was developed to represent the one-year costs and health outcomes associated with case-finding and treatment for PND. The sensitivity and specificity of case-finding instruments, and prevalence and severity of PND, for women with ≥1 PND risk factor were estimated from a cohort of postnatal women. Risk factors were history of anxiety/depression, age < 20 years, and adverse life events. Other model parameters were derived from published literature and expert consultation. Case-finding for high-risk women only was compared with no case-finding and universal case-finding. RESULTS More than half of the cohort had one or more PND risk factor (57.8 %; 95 % CI 52.7 %-62.7 %). The most cost-effective case-finding strategy was the Edinburgh Postnatal Depression Scale with a cut-off of ≥10 (EPDS-10). Among high-risk women, there is a high probability that EPDS-10 case-finding for PND is cost-effective compared to no case-finding (78.5 % at a threshold of £20,000/QALY), with an ICER of £8146/QALY gained. Universal case-finding is even more cost-effective at £2945/QALY gained (versus no case-finding). There is a greater health improvement with universal rather than targeted case-finding. LIMITATIONS The model includes costs and health benefits for mothers in the first year postpartum, the broader (e.g. families, societal) and long-term impacts are also important. CONCLUSIONS Universal PND case-finding is more cost-effective than targeted case-finding which itself is more cost-effective than not case-finding.
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Affiliation(s)
| | - Gemma E Shields
- School of Health Sciences, University of Manchester, United Kingdom
| | - Emily Eisner
- School of Health Sciences, University of Manchester, United Kingdom; Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
| | | | - Kylie Watson
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | | | - Dean McMillan
- Hull York Medical School and Department of Health Sciences, University of York, United Kingdom
| | - Shehzad Ali
- Hull York Medical School and Department of Health Sciences, University of York, United Kingdom; Schulich School of Medicine & Dentistry, Western University, Canada
| | - Simon Gilbody
- Hull York Medical School and Department of Health Sciences, University of York, United Kingdom
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Shearsmith L, Coventry PA, Sloan C, Henry A, Newbronner L, Littlewood E, Bailey D, Gascoyne S, Burke L, Ryde E, Woodhouse R, McMillan D, Ekers D, Gilbody S, Chew-Graham C. Acceptability of a behavioural intervention to mitigate the psychological impacts of COVID-19 restrictions in older people with long-term conditions: a qualitative study. BMJ Open 2023; 13:e064694. [PMID: 36914198 PMCID: PMC10015671 DOI: 10.1136/bmjopen-2022-064694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic heightened the need to address loneliness, social isolation and associated incidence of depression among older adults. Between June and October 2020, the Behavioural Activation in Social IsoLation (BASIL) pilot study investigated the acceptability and feasibility of a remotely delivered brief psychological intervention (behavioural cctivation) to prevent and reduce loneliness and depression in older people with long-term conditions during the COVID-19 pandemic. DESIGN An embedded qualitative study was conducted. Semi-structured interviews generated data that was analysed inductively using thematic analysis and then deductively using the theoretical framework of acceptability (TFA). SETTING NHS and third sector organisations in England. PARTICIPANTS Sixteen older adults and nine support workers participating in the BASIL pilot study. RESULTS Acceptability of the intervention was high across all constructs of the TFA: Older adults and BASIL Support Workers described a positive Affective Attitude towards the intervention linked to altruism, however the activity planning aspect of the intervention was limited due to COVID-19 restrictions. A manageable Burden was involved with delivering and participating in the intervention. For Ethicality, older adults valued social contact and making changes, support workers valued being able to observe those changes. The intervention was understood by older adults and support workers, although less understanding in older adults without low mood (Intervention Coherence). Opportunity Cost was low for support workers and older adults. Behavioural Activation was perceived to be useful in the pandemic and likely to achieve its aims (Perceived Effectiveness), especially if tailored to people with both low mood and long-term conditions. Self-efficacy developed over time and with experience for both support workers and older adults. CONCLUSIONS Overall, BASIL pilot study processes and the intervention were acceptable. Use of the TFA provided valuable insights into how the intervention was experienced and how the acceptability of study processes and the intervention could be enhanced ahead of the larger definitive trial (BASIL+).
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Affiliation(s)
| | - Peter A Coventry
- Department of Health Sciences, University of York, York, UK
- York Environmental Sustainability Institute, University of York, York, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Andrew Henry
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | - Liz Newbronner
- Department of Health Sciences, University of York, York, UK
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | - Lauren Burke
- Department of Health Sciences, University of York, York, UK
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
- Mental Health and Addiction Research Group, Hull York Medical School, Hull, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Littlewood E, McMillan D, Chew Graham C, Bailey D, Gascoyne S, Sloane C, Burke L, Coventry P, Crosland S, Fairhurst C, Henry A, Hewitt C, Baird K, Ryde E, Shearsmith L, Traviss-Turner G, Woodhouse R, Webster J, Meader N, Churchill R, Eddy E, Heron P, Hicklin N, Shafran R, Almeida O, Clegg A, Gentry T, Hill A, Lovell K, Dexter-Smith S, Ekers D, Gilbody S. Can we mitigate the psychological impacts of social isolation using behavioural activation? Long-term results of the UK BASIL urgent public health COVID-19 pilot randomised controlled trial and living systematic review. Evid Based Ment Health 2022; 25:e49-e57. [PMID: 36223980 PMCID: PMC9811092 DOI: 10.1136/ebmental-2022-300530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Behavioural and cognitive interventions remain credible approaches in addressing loneliness and depression. There was a need to rapidly generate and assimilate trial-based data during COVID-19. OBJECTIVES We undertook a parallel pilot RCT of behavioural activation (a brief behavioural intervention) for depression and loneliness (Behavioural Activation in Social Isolation, the BASIL-C19 trial ISRCTN94091479). We also assimilate these data in a living systematic review (PROSPERO CRD42021298788) of cognitive and/or behavioural interventions. METHODS Participants (≥65 years) with long-term conditions were computer randomised to behavioural activation (n=47) versus care as usual (n=49). Primary outcome was PHQ-9. Secondary outcomes included loneliness (De Jong Scale). Data from the BASIL-C19 trial were included in a metanalysis of depression and loneliness. FINDINGS The 12 months adjusted mean difference for PHQ-9 was -0.70 (95% CI -2.61 to 1.20) and for loneliness was -0.39 (95% CI -1.43 to 0.65).The BASIL-C19 living systematic review (12 trials) found short-term reductions in depression (standardised mean difference (SMD)=-0.31, 95% CI -0.51 to -0.11) and loneliness (SMD=-0.48, 95% CI -0.70 to -0.27). There were few long-term trials, but there was evidence of some benefit (loneliness SMD=-0.20, 95% CI -0.40 to -0.01; depression SMD=-0.20, 95% CI -0.47 to 0.07). DISCUSSION We delivered a pilot trial of a behavioural intervention targeting loneliness and depression; achieving long-term follow-up. Living meta-analysis provides strong evidence of short-term benefit for loneliness and depression for cognitive and/or behavioural approaches. A fully powered BASIL trial is underway. CLINICAL IMPLICATIONS Scalable behavioural and cognitive approaches should be considered as population-level strategies for depression and loneliness on the basis of a living systematic review.
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Affiliation(s)
| | - Dean McMillan
- Health Sciences, University of York, York, UK
- Centre for Health and Population Science, Hull York Medical School, Hull, UK
| | | | | | | | | | | | - Peter Coventry
- Health Sciences, University of York, York, UK
- York Environmental Sustainability Institute, University of York, York, UK
| | | | | | | | | | | | - Eloise Ryde
- Health Sciences, University of York, York, UK
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | | | | | | | - Judith Webster
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Nick Meader
- Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders Group, University of York, York, UK
| | - Elizabeth Eddy
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Paul Heron
- Health Sciences, University of York, York, UK
| | - Nisha Hicklin
- Department of Psychology, Royal Holloway University of London, Egham, UK
| | - Roz Shafran
- PPP, University College London Institute of Child Health, London, UK
- Paediatric Psychology Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Osvaldo Almeida
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Clegg
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Tom Gentry
- Health and Care Policy, Age UK, London, UK
| | - Andrew Hill
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
| | - Sarah Dexter-Smith
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - David Ekers
- Health Sciences, University of York, York, UK
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Simon Gilbody
- Health Sciences, University of York, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
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Buckman JEJ, Saunders R, Stott J, Cohen ZD, Arundell LL, Eley TC, Hollon SD, Kendrick T, Ambler G, Watkins E, Gilbody S, Kessler D, Wiles N, Richards D, Brabyn S, Littlewood E, DeRubeis RJ, Lewis G, Pilling S. Socioeconomic Indicators of Treatment Prognosis for Adults With Depression: A Systematic Review and Individual Patient Data Meta-analysis. JAMA Psychiatry 2022; 79:406-416. [PMID: 35262620 PMCID: PMC8908224 DOI: 10.1001/jamapsychiatry.2022.0100] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Importance Socioeconomic factors are associated with the prevalence of depression, but their associations with prognosis are unknown. Understanding this association would aid in the clinical management of depression. Objective To determine whether employment status, financial strain, housing status, and educational attainment inform prognosis for adults treated for depression in primary care, independent of treatment and after accounting for clinical prognostic factors. Data Sources The Embase, International Pharmaceutical Abstracts, MEDLINE, PsycINFO, and Cochrane (CENTRAL) databases were searched from database inception to October 8, 2021. Study Selection Inclusion criteria were as follows: randomized clinical trials that used the Revised Clinical Interview Schedule (CIS-R; the most common comprehensive screening and diagnostic measure of depressive and anxiety symptoms in primary care randomized clinical trials), measured socioeconomic factors at baseline, and sampled patients with unipolar depression who sought treatment for depression from general physicians/practitioners or who scored 12 or more points on the CIS-R. Exclusion criteria included patients with depression secondary to a personality or psychotic disorder or neurologic condition, studies of bipolar or psychotic depression, studies that included children or adolescents, and feasibility studies. Studies were independently assessed against inclusion and exclusion criteria by 2 reviewers. Data Extraction and Synthesis Data were extracted and cleaned by data managers for each included study, further cleaned by multiple reviewers, and cross-checked by study chief investigators. Risk of bias and quality were assessed using the Quality in Prognosis Studies (QUIPS) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) tools, respectively. This study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses-Individual Participant Data (PRISMA-IPD) reporting guidelines. Main Outcomes and Measures Depressive symptoms at 3 to 4 months after baseline. Results This systematic review and individual patient data meta-analysis identified 9 eligible studies that provided individual patient data for 4864 patients (mean [SD] age, 42.5 (14.0) years; 3279 women [67.4%]). The 2-stage random-effects meta-analysis end point depressive symptom scale scores were 28% (95% CI, 20%-36%) higher for unemployed patients than for employed patients and 18% (95% CI, 6%-30%) lower for patients who were homeowners than for patients living with family or friends, in hostels, or homeless, which were equivalent to 4.2 points (95% CI, 3.6-6.2 points) and 2.9 points (95% CI, 1.1-4.9 points) on the Beck Depression Inventory II, respectively. Financial strain and educational attainment were associated with prognosis independent of treatment, but unlike employment and housing status, there was little evidence of associations after adjusting for clinical prognostic factors. Conclusions and Relevance Results of this systematic review and meta-analysis revealed that unemployment was associated with a poor prognosis whereas home ownership was associated with improved prognosis. These differences were clinically important and independent of the type of treatment received. Interventions that address employment or housing difficulties could improve outcomes for patients with depression.
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Affiliation(s)
- Joshua E. J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
- iCope Camden & Islington NHS Foundation Trust, St Pancras Hospital, London, United Kingdom
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Joshua Stott
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | | | - Laura-Louise Arundell
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
| | - Thalia C. Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, United Kingdom
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, Tennessee
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Gareth Ambler
- Statistical Science, University College London, London, United Kingdom
| | - Edward Watkins
- Department of Psychology, University of Exeter, Exeter, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
| | - David Kessler
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Nicola Wiles
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - David Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, Exeter, United Kingdom
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Bergen, Norway
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Robert J. DeRubeis
- University of Pennsylvania College of Arts and Sciences, Department of Psychology, Philadelphia
| | - Glyn Lewis
- Division of Psychiatry, University College London, London, United Kingdom
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, London, United Kingdom
- Camden & Islington NHS Foundation Trust, London, United Kingdom
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9
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Burke L, Littlewood E, Gascoyne S, McMillan D, Chew-Graham CA, Bailey D, Sloan C, Fairhurst C, Baird K, Hewitt C, Henry A, Ryde E, Shearsmith L, Coventry P, Crosland S, Newbronner E, Traviss-Turner G, Woodhouse R, Clegg A, Gentry T, Hill A, Lovell K, Dexter Smith S, Webster J, Ekers D, Gilbody S. Behavioural Activation for Social IsoLation (BASIL+) trial (Behavioural activation to mitigate depression and loneliness among older people with long-term conditions): Protocol for a fully-powered pragmatic randomised controlled trial. PLoS One 2022; 17:e0263856. [PMID: 35324908 PMCID: PMC8947398 DOI: 10.1371/journal.pone.0263856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Depression is a leading mental health problem worldwide. People with long-term conditions are at increased risk of experiencing depression. The COVID-19 pandemic led to strict social restrictions being imposed across the UK population. Social isolation can have negative consequences on the physical and mental wellbeing of older adults. In the Behavioural Activation in Social IsoLation (BASIL+) trial we will test whether a brief psychological intervention (based on Behavioural Activation), delivered remotely, can mitigate depression and loneliness in older adults with long-term conditions during isolation. Methods We will conduct a two-arm, parallel-group, randomised controlled trial across several research sites, to evaluate the clinical and cost-effectiveness of the BASIL+ intervention. Participants will be recruited via participating general practices across England and Wales. Participants must be aged ≥65 with two or more long-term conditions, or a condition that may indicate they are within a ‘clinically extremely vulnerable’ group in relation to COVID-19, and have scored ≥5 on the Patient Health Questionnaire (PHQ9), to be eligible for inclusion. Randomisation will be 1:1, stratified by research site. Intervention participants will receive up to eight intervention sessions delivered remotely by trained BASIL+ Support Workers and supported by a self-help booklet. Control participants will receive usual care, with additional signposting to reputable sources of self-help and information, including advice on keeping mentally and physically well. A qualitative process evaluation will also be undertaken to explore the acceptability of the BASIL+ intervention, as well as barriers and enablers to integrating the intervention into participants’ existing health and care support, and the impact of the intervention on participants’ mood and general wellbeing in the context of the COVID-19 restrictions. Semi-structured interviews will be conducted with intervention participants, participant’s caregivers/supportive others and BASIL+ Support Workers. Outcome data will be collected at one, three, and 12 months post-randomisation. Clinical and cost-effectiveness will be evaluated. The primary outcome is depressive symptoms at the three-month follow up, measured by the PHQ9. Secondary outcomes include loneliness, social isolation, anxiety, quality of life, and a bespoke health services use questionnaire. Discussion This study is the first large-scale trial evaluating a brief Behavioural Activation intervention in this population, and builds upon the results of a successful external pilot trial. Trial registration ClinicalTrials.Gov identifier ISRCTN63034289, registered on 5th February 2021.
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Affiliation(s)
- Lauren Burke
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, United Kingdom
| | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, United Kingdom
| | - Claire Sloan
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Kalpita Baird
- Department of Health Sciences, University of York, York, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Henry
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Leanne Shearsmith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter Coventry
- Department of Health Sciences, University of York, York, United Kingdom
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, United Kingdom
| | | | | | - Rebecca Woodhouse
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Clegg
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Tom Gentry
- Age UK, Tavis House, 1–6 Tavistock Square, London United Kingdom
| | - Andrew Hill
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Sarah Dexter Smith
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | | | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
- * E-mail:
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10
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Littlewood E, Chew-Graham CA, Coleman E, Gascoyne S, Sloan C, Ali S, Badenhorst J, Bailey D, Crosland S, Kitchen CEW, McMillan D, Pearson C, Todd A, Whittlesea C, Bambra C, Hewitt C, Jones C, Keding A, Newbronner E, Paterson A, Rhodes S, Ryde E, Toner P, Watson M, Gilbody S, Ekers D. A psychological intervention by community pharmacies to prevent depression in adults with subthreshold depression and long-term conditions: the CHEMIST pilot RCT. Public Health Res 2022. [DOI: 10.3310/ekze0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Depression is common in people with long-term health conditions, and this combination can lead to worsened health outcomes and increased health-care costs. Subthreshold depression, a risk factor for major depression, is prevalent in this population, but many people remain untreated due to the demand on services. The community pharmacy may be an alternative setting to offer mental health support; however, insufficient evidence exists to support implementation.
Objectives
To conduct a feasibility study and pilot randomised controlled trial of a community pharmacy-delivered psychological intervention aimed at preventing depression in adults with long-term health conditions.
Design
A feasibility study with nested qualitative evaluation and an external pilot, two-arm, 1 : 1 individually randomised controlled trial with nested process and economic evaluations.
Setting
Community pharmacies in the north of England.
Participants
Adults aged ≥ 18 years with subthreshold depression and at least one long-term health condition.
Intervention
A bespoke enhanced support intervention (behavioural activation within a collaborative care framework) involving up to six sessions delivered by trained community pharmacy staff (intervention facilitators) compared with usual care.
Main outcome measures
Recruitment and retention rates, completeness of outcome measures and intervention engagement. The intended primary outcome was depression severity at 4 months, assessed by the Patient Health Questionnaire-9.
Results
In the feasibility study, 24 participants were recruited. Outcome measure completeness was 95–100%. Retention at 4 months was 83%. Seventeen participants (71%) commenced intervention sessions and all completed two or more sessions. Depression symptoms reduced slightly at 4 months. The process evaluation suggested that the intervention was acceptable to participants and intervention facilitators. In the pilot randomised controlled trial, 44 participants (target of 100 participants) were randomised (intervention, n = 24; usual care, n = 20). Outcome measure completeness was 100%. Retention at 4 months was 93%. Eighteen participants (75%) commenced intervention sessions and 16 completed two or more sessions. Depression symptoms reduced slightly at 4 months, with a slightly larger reduction in the usual-care arm, although the small sample size limits any conclusions. The process evaluation reported good acceptability of the intervention and identified barriers associated with study implementation and its impact on core pharmacy functions. The economic analysis revealed some indication of reduced resource use/costs associated with the intervention, but this is limited by the small sample size. Intervention costs were low.
Limitations
The main limitation is the small sample size due to difficulties with recruitment and barriers to implementing the study within existing pharmacy practices.
Conclusions
The community pharmacy represents a new setting to deliver a depression prevention intervention. Recruitment was a challenge and pharmacy staff encountered barriers to effective implementation of the study within busy pharmacy practice. Despite these challenges, good retention rates and intervention engagement were demonstrated, and process evaluation suggested that the intervention was acceptable in this setting. To the best of our knowledge, this is the first study to demonstrate that community pharmacy staff can be trained to deliver a depression prevention intervention.
Future work
Further work is needed to address barriers to recruitment, intervention delivery and implementation of psychological interventions in the community pharmacy setting.
Trial registration
This trial is registered as ISRCTN11290592.
Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | | | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Jay Badenhorst
- Whitworth Chemists Ltd, Foxhills Industrial Estate, Scunthorpe, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | | | - Adam Todd
- Institute of Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- School of Pharmacy, Newcastle upon Tyne, UK
| | - Cate Whittlesea
- University College London School of Pharmacy, University College London, London, UK
| | - Clare Bambra
- Institute of Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Claire Jones
- Public Health Team, Adult & Health Services, Durham County Council, Durham, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | | | - Alastair Paterson
- Pharmacy Department, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Shelley Rhodes
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Paul Toner
- Department of Health Sciences, University of York, York, UK
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen’s University Belfast, Belfast, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
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11
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Chew-Graham CA, Kitchen CEW, Gascoyne S, Littlewood E, Coleman E, Bailey D, Crosland S, Pearson C, Ali S, Badenhorst J, Bambra C, Hewitt C, Jones C, Keding A, McMillan D, Sloan C, Todd A, Toner P, Whittlesea C, Watson M, Gilbody S, Ekers D. The feasibility and acceptability of a brief psychological intervention for adults with long-term health conditions and subthreshold depression delivered via community pharmacies: a mixed methods evaluation-the Community Pharmacies Mood Intervention Study (CHEMIST). Pilot Feasibility Stud 2022; 8:27. [PMID: 35115052 PMCID: PMC8812235 DOI: 10.1186/s40814-022-00992-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adults with long-term health conditions (LTCs) are more likely to experience depressive symptoms which can worsen health outcomes and quality of life, and increase healthcare costs. Subthreshold depression may go undetected and/or untreated. The Community Pharmacies Mood Intervention Study (CHEMIST) explored whether community pharmacies represent a suitable setting to offer brief psychological support to people with LTCs and comorbid subthreshold depression. METHODS A feasibility intervention study with a nested mixed methods evaluation was employed. Adults with subthreshold depression and a minimum of one LTC were recruited from community pharmacies/local general practices and offered a brief psychological support intervention ('Enhanced Support Intervention' (ESI)), based on behavioural activation within a Collaborative Care framework. The intervention included up to six sessions supported by pharmacy staff ('ESI facilitators') trained to deliver the ESI within the community pharmacy setting. Recruitment, retention rates and engagement with the ESI were assessed. Semi-structured, one-to-one interviews with pharmacy staff and study participants, and a focus group with pharmacy staff, explored experiences and acceptability of the study and the ESI. Themes were mapped onto constructs of the Theoretical Framework of Acceptability. RESULTS Recruitment of ESI participants was challenging and slower than anticipated despite the varied methods of recruitment employed; although, this was useful in identifying barriers and enabling factors for participation. Engagament with the ESI was good with n=17 (71%) recruited participants commencing the ESI. The ESI was found to be acceptable to participants and ESI facilitators. Retention rate at 4 months was good n=20 (87.0%). The main barriers to identifying potential participants for pharmacy staff were lack of time, resources and limited experience in research. The ESI training and support manual were acceptable to ESI facilitators. The ESI and supporting patient workbook were acceptable to people with LTCs and subthreshold depression. CONCLUSIONS Community pharmacies were viewed as an acceptable setting in which to deliver preventative brief psychological support to people with LTCs at risk of depression. This feasibility study provided important data to inform the design of a pilot randomised controlled trial in this setting and highlighted important considerations for future pharmacy-based research. TRIAL REGISTRATION ISRCTN11290592.
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Affiliation(s)
| | | | | | | | | | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK.,Department of Epidemiology and Biostatistics, Western University, Ontario, Canada
| | - Jay Badenhorst
- Whitworth Chemists Ltd, Foxhills Industrial Estate, Scunthorpe, UK
| | - Clare Bambra
- Institute of Population Health Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | | | - Claire Jones
- Public Health Team, Adult & Health Services, Durham County Council, Durham, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Adam Todd
- Institute of Population Health Sciences, Newcastle University, Newcastle-upon-Tyne, UK.,School of Pharmacy, Newcastle upon Tyne, UK
| | - Paul Toner
- Department of Health Sciences, University of York, York, UK.,Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK
| | - Cate Whittlesea
- UCL School of Pharmacy, University College London, London, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK.,Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
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12
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Gilbody S, Littlewood E, McMillan D, Chew-Graham CA, Bailey D, Gascoyne S, Sloan C, Burke L, Coventry P, Crosland S, Fairhurst C, Henry A, Hewitt C, Joshi K, Ryde E, Shearsmith L, Traviss-Turner G, Woodhouse R, Clegg A, Gentry T, Hill AJ, Lovell K, Dexter Smith S, Webster J, Ekers D. Behavioural activation to prevent depression and loneliness among socially isolated older people with long-term conditions: The BASIL COVID-19 pilot randomised controlled trial. PLoS Med 2021; 18:e1003779. [PMID: 34637450 PMCID: PMC8509874 DOI: 10.1371/journal.pmed.1003779] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/20/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Older adults, including those with long-term conditions (LTCs), are vulnerable to social isolation. They are likely to have become more socially isolated during the Coronavirus Disease 2019 (COVID-19) pandemic, often due to advice to "shield" to protect them from infection. This places them at particular risk of depression and loneliness. There is a need for brief scalable psychosocial interventions to mitigate the psychological impacts of social isolation. Behavioural activation (BA) is a credible candidate intervention, but a trial is needed. METHODS AND FINDINGS We undertook an external pilot parallel randomised trial (ISRCTN94091479) designed to test recruitment, retention and engagement with, and the acceptability and preliminary effects of the intervention. Participants aged ≥65 years with 2 or more LTCs were recruited in primary care and randomised by computer and with concealed allocation between June and October 2020. BA was offered to intervention participants (n = 47), and control participants received usual primary care (n = 49). Assessment of outcome was made blind to treatment allocation. The primary outcome was depression severity (measured using the Patient Health Questionnaire 9 (PHQ-9)). We also measured health-related quality of life (measured by the Short Form (SF)-12v2 mental component scale (MCS) and physical component scale (PCS)), anxiety (measured by the Generalised Anxiety Disorder 7 (GAD-7)), perceived social and emotional loneliness (measured by the De Jong Gierveld Scale: 11-item loneliness scale). Outcome was measured at 1 and 3 months. The mean age of participants was aged 74 years (standard deviation (SD) 5.5) and they were mostly White (n = 92, 95.8%), and approximately two-thirds of the sample were female (n = 59, 61.5%). Remote recruitment was possible, and 45/47 (95.7%) randomised to the intervention completed 1 or more sessions (median 6 sessions) out of 8. A total of 90 (93.8%) completed the 1-month follow-up, and 86 (89.6%) completed the 3-month follow-up, with similar rates for control (1 month: 45/49 and 3 months 44/49) and intervention (1 month: 45/47and 3 months: 42/47) follow-up. Between-group comparisons were made using a confidence interval (CI) approach, and by adjusting for the covariate of interest at baseline. At 1 month (the primary clinical outcome point), the median number of completed sessions for people receiving the BA intervention was 3, and almost all participants were still receiving the BA intervention. The between-group comparison for the primary clinical outcome at 1 month was an adjusted between-group mean difference of -0.50 PHQ-9 points (95% CI -2.01 to 1.01), but only a small number of participants had completed the intervention at this point. At 3 months, the PHQ-9 adjusted mean difference (AMD) was 0.19 (95% CI -1.36 to 1.75). When we examined loneliness, the adjusted between-group difference in the De Jong Gierveld Loneliness Scale at 1 month was 0.28 (95% CI -0.51 to 1.06) and at 3 months -0.87 (95% CI -1.56 to -0.18), suggesting evidence of benefit of the intervention at this time point. For anxiety, the GAD adjusted between-group difference at 1 month was 0.20 (-1.33, 1.73) and at 3 months 0.31 (-1.08, 1.70). For the SF-12 (physical component score), the adjusted between-group difference at 1 month was 0.34 (-4.17, 4.85) and at 3 months 0.11 (-4.46, 4.67). For the SF-12 (mental component score), the adjusted between-group difference at 1 month was 1.91 (-2.64, 5.15) and at 3 months 1.26 (-2.64, 5.15). Participants who withdrew had minimal depressive symptoms at entry. There were no adverse events. The Behavioural Activation in Social Isolation (BASIL) study had 2 main limitations. First, we found that the intervention was still being delivered at the prespecified primary outcome point, and this fed into the design of the main trial where a primary outcome of 3 months is now collected. Second, this was a pilot trial and was not designed to test between-group differences with high levels of statistical power. Type 2 errors are likely to have occurred, and a larger trial is now underway to test for robust effects and replicate signals of effectiveness in important secondary outcomes such as loneliness. CONCLUSIONS In this study, we observed that BA is a credible intervention to mitigate the psychological impacts of COVID-19 isolation for older adults. We demonstrated that it is feasible to undertake a trial of BA. The intervention can be delivered remotely and at scale, but should be reserved for older adults with evidence of depressive symptoms. The significant reduction in loneliness is unlikely to be a chance finding, and replication will be explored in a fully powered randomised controlled trial (RCT). TRIAL REGISTRATION ISRCTN94091479.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, United Kingdom
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, United Kingdom
| | - Claire Sloan
- Department of Health Sciences, University of York, York, United Kingdom
| | - Lauren Burke
- Department of Health Sciences, University of York, York, United Kingdom
| | - Peter Coventry
- Department of Health Sciences, University of York, York, United Kingdom
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Andrew Henry
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, United Kingdom
| | - Kalpita Joshi
- Department of Health Sciences, University of York, York, United Kingdom
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Leanne Shearsmith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Rebecca Woodhouse
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Clegg
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Andrew J. Hill
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Sarah Dexter Smith
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | | | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
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13
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Gilbody S, Littlewood E, Gascoyne S, McMillan D, Ekers D, Chew-Graham CA, Creswell C, Wright J. Mitigating the impacts of COVID-19: where are the mental health trials? Lancet Psychiatry 2021; 8:647-650. [PMID: 34087112 PMCID: PMC8169044 DOI: 10.1016/s2215-0366(21)00204-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | - Dean McMillan
- University of York, York YO10 5DD, UK; Hull York Medical School, York, UK
| | - David Ekers
- University of York, York YO10 5DD, UK; Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | | | | | - John Wright
- Yorkshire and Humberside Applied Research Collaboration, Bradford Institute for Health Research, Bradford, UK
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Buckman JEJ, Saunders R, Stott J, Arundell LL, O'Driscoll C, Davies MR, Eley TC, Hollon SD, Kendrick T, Ambler G, Cohen ZD, Watkins E, Gilbody S, Wiles N, Kessler D, Richards D, Brabyn S, Littlewood E, DeRubeis RJ, Lewis G, Pilling S. Role of age, gender and marital status in prognosis for adults with depression: An individual patient data meta-analysis. Epidemiol Psychiatr Sci 2021; 30:e42. [PMID: 34085616 PMCID: PMC7610920 DOI: 10.1017/s2045796021000342] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/04/2021] [Accepted: 05/09/2021] [Indexed: 11/21/2022] Open
Abstract
AIMS To determine whether age, gender and marital status are associated with prognosis for adults with depression who sought treatment in primary care. METHODS Medline, Embase, PsycINFO and Cochrane Central were searched from inception to 1st December 2020 for randomised controlled trials (RCTs) of adults seeking treatment for depression from their general practitioners, that used the Revised Clinical Interview Schedule so that there was uniformity in the measurement of clinical prognostic factors, and that reported on age, gender and marital status. Individual participant data were gathered from all nine eligible RCTs (N = 4864). Two-stage random-effects meta-analyses were conducted to ascertain the independent association between: (i) age, (ii) gender and (iii) marital status, and depressive symptoms at 3-4, 6-8, and 9-12 months post-baseline and remission at 3-4 months. Risk of bias was evaluated using QUIPS and quality was assessed using GRADE. PROSPERO registration: CRD42019129512. Pre-registered protocol https://osf.io/e5zup/. RESULTS There was no evidence of an association between age and prognosis before or after adjusting for depressive 'disorder characteristics' that are associated with prognosis (symptom severity, durations of depression and anxiety, comorbid panic disorderand a history of antidepressant treatment). Difference in mean depressive symptom score at 3-4 months post-baseline per-5-year increase in age = 0(95% CI: -0.02 to 0.02). There was no evidence for a difference in prognoses for men and women at 3-4 months or 9-12 months post-baseline, but men had worse prognoses at 6-8 months (percentage difference in depressive symptoms for men compared to women: 15.08% (95% CI: 4.82 to 26.35)). However, this was largely driven by a single study that contributed data at 6-8 months and not the other time points. Further, there was little evidence for an association after adjusting for depressive 'disorder characteristics' and employment status (12.23% (-1.69 to 28.12)). Participants that were either single (percentage difference in depressive symptoms for single participants: 9.25% (95% CI: 2.78 to 16.13) or no longer married (8.02% (95% CI: 1.31 to 15.18)) had worse prognoses than those that were married, even after adjusting for depressive 'disorder characteristics' and all available confounders. CONCLUSION Clinicians and researchers will continue to routinely record age and gender, but despite their importance for incidence and prevalence of depression, they appear to offer little information regarding prognosis. Patients that are single or no longer married may be expected to have slightly worse prognoses than those that are married. Ensuring this is recorded routinely alongside depressive 'disorder characteristics' in clinic may be important.
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Affiliation(s)
- J. E. J. Buckman
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
- iCope – Camden & Islington NHS Foundation Trust, St Pancras Hospital, LondonNW1 0PE, UK
| | - R. Saunders
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - J. Stott
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - L.-L. Arundell
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - C. O'Driscoll
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
| | - M. R. Davies
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, LondonSE5 8AF, UK
| | - T. C. Eley
- Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, Psychology & Neuroscience, King's College London, LondonSE5 8AF, UK
| | - S. D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN37240, USA
| | - T. Kendrick
- Faculty of Medicine, Primary Care, Population Sciences and Medical Education, University of Southampton, SouthamptonSO16 5ST, UK
| | - G. Ambler
- Statistical Science, University College London, LondonWC1E 7HB, UK
| | - Z. D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA, 90095, USA
| | - E. Watkins
- Department of Psychology, University of Exeter, ExeterEX4 4QG, UK
| | - S. Gilbody
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - N. Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, BristolBS8 2BN, UK
| | - D. Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - D. Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, ExeterEX1 2LU, UK
- Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Inndalsveien 28, 5063Bergen, Norway
| | - S. Brabyn
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - E. Littlewood
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - R. J. DeRubeis
- Department of Psychology, School of Arts and Sciences, 425 S. University Avenue, PhiladelphiaPA, 19104-60185, USA
| | - G. Lewis
- Division of Psychiatry, University College London, LondonW1T 7NF, UK
| | - S. Pilling
- Research Department of Clinical, Educational & Health Psychology, Centre for Outcomes Research and Effectiveness (CORE), University College London, 1-19 Torrington Place, LondonWC1E 7HB, UK
- Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
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15
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Furukawa TA, Suganuma A, Ostinelli EG, Andersson G, Beevers CG, Shumake J, Berger T, Boele FW, Buntrock C, Carlbring P, Choi I, Christensen H, Mackinnon A, Dahne J, Huibers MJH, Ebert DD, Farrer L, Forand NR, Strunk DR, Ezawa ID, Forsell E, Kaldo V, Geraedts A, Gilbody S, Littlewood E, Brabyn S, Hadjistavropoulos HD, Schneider LH, Johansson R, Kenter R, Kivi M, Björkelund C, Kleiboer A, Riper H, Klein JP, Schröder J, Meyer B, Moritz S, Bücker L, Lintvedt O, Johansson P, Lundgren J, Milgrom J, Gemmill AW, Mohr DC, Montero-Marin J, Garcia-Campayo J, Nobis S, Zarski AC, O'Moore K, Williams AD, Newby JM, Perini S, Phillips R, Schneider J, Pots W, Pugh NE, Richards D, Rosso IM, Rauch SL, Sheeber LB, Smith J, Spek V, Pop VJ, Ünlü B, van Bastelaar KMP, van Luenen S, Garnefski N, Kraaij V, Vernmark K, Warmerdam L, van Straten A, Zagorscak P, Knaevelsrud C, Heinrich M, Miguel C, Cipriani A, Efthimiou O, Karyotaki E, Cuijpers P. Dismantling, optimising, and personalising internet cognitive behavioural therapy for depression: a systematic review and component network meta-analysis using individual participant data. Lancet Psychiatry 2021; 8:500-511. [PMID: 33957075 PMCID: PMC8838916 DOI: 10.1016/s2215-0366(21)00077-8] [Citation(s) in RCA: 76] [Impact Index Per Article: 25.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 02/12/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Internet cognitive behavioural therapy (iCBT) is a viable delivery format of CBT for depression. However, iCBT programmes include training in a wide array of cognitive and behavioural skills via different delivery methods, and it remains unclear which of these components are more efficacious and for whom. METHODS We did a systematic review and individual participant data component network meta-analysis (cNMA) of iCBT trials for depression. We searched PubMed, PsycINFO, Embase, and the Cochrane Library for randomised controlled trials (RCTs) published from database inception to Jan 1, 2019, that compared any form of iCBT against another or a control condition in the acute treatment of adults (aged ≥18 years) with depression. Studies with inpatients or patients with bipolar depression were excluded. We sought individual participant data from the original authors. When these data were unavailable, we used aggregate data. Two independent researchers identified the included components. The primary outcome was depression severity, expressed as incremental mean difference (iMD) in the Patient Health Questionnaire-9 (PHQ-9) scores when a component is added to a treatment. We developed a web app that estimates relative efficacies between any two combinations of components, given baseline patient characteristics. This study is registered in PROSPERO, CRD42018104683. FINDINGS We identified 76 RCTs, including 48 trials contributing individual participant data (11 704 participants) and 28 trials with aggregate data (6474 participants). The participants' weighted mean age was 42·0 years and 12 406 (71%) of 17 521 reported were women. There was suggestive evidence that behavioural activation might be beneficial (iMD -1·83 [95% credible interval (CrI) -2·90 to -0·80]) and that relaxation might be harmful (1·20 [95% CrI 0·17 to 2·27]). Baseline severity emerged as the strongest prognostic factor for endpoint depression. Combining human and automated encouragement reduced dropouts from treatment (incremental odds ratio, 0·32 [95% CrI 0·13 to 0·93]). The risk of bias was low for the randomisation process, missing outcome data, or selection of reported results in most of the included studies, uncertain for deviation from intended interventions, and high for measurement of outcomes. There was moderate to high heterogeneity among the studies and their components. INTERPRETATION The individual patient data cNMA revealed potentially helpful, less helpful, or harmful components and delivery formats for iCBT packages. iCBT packages aiming to be effective and efficient might choose to include beneficial components and exclude ones that are potentially detrimental. Our web app can facilitate shared decision making by therapist and patient in choosing their preferred iCBT package. FUNDING Japan Society for the Promotion of Science.
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Affiliation(s)
- Toshi A Furukawa
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan.
| | - Aya Suganuma
- Department of Health Promotion and Human Behavior, Kyoto University Graduate School of Medicine/School of Public Health, Kyoto, Japan
| | - Edoardo G Ostinelli
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Gerhard Andersson
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | - Christopher G Beevers
- Department of Psychology and Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Jason Shumake
- Department of Psychology and Institute for Mental Health Research, University of Texas at Austin, Austin, TX, USA
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Florien Willemijn Boele
- Patient Centred Outcomes Research Group, Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - Claudia Buntrock
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Per Carlbring
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Isabella Choi
- Central Clinical School, Brain and Mind Centre, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Helen Christensen
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Andrew Mackinnon
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Jennifer Dahne
- Department of Psychiatry and Behavioral Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Marcus J H Huibers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - David D Ebert
- Department for Sport and Health Sciences, Chair for Psychology & Digital Mental Health Care, Technical University Munich, Germany
| | - Louise Farrer
- Centre for Mental Health Research, The Australian National University, Canberra, Australia
| | - Nicholas R Forand
- Department of Psychiatry, The Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Daniel R Strunk
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Iony D Ezawa
- Department of Psychology, The Ohio State University, Columbus, OH, USA
| | - Erik Forsell
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden
| | - Viktor Kaldo
- Department of Clinical Neuroscience, Centre for Psychiatry Research, Karolinska Institutet and Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; Department of Psychology, Faculty of Health and Life Sciences, Linnaeus University, Växjö, Sweden
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | | | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | | | - Luke H Schneider
- Anxiety Treatment and Research Clinic, St Joseph's Healthcare Hamilton, Hamilton, ON, Canada
| | - Robert Johansson
- Department of Psychology, Stockholm University, Stockholm, Sweden
| | - Robin Kenter
- Department of Clinical Psychology, Faculty of Psychology, University of Bergen, Bergen, Norway
| | - Marie Kivi
- Department of Psychology, University of Gothenburg, Gothenburg, Sweden
| | - Cecilia Björkelund
- Primary Health Care, School of Public Health and Community Medicine, Institute of Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Annet Kleiboer
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Heleen Riper
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Jan Philipp Klein
- Department of Psychiatry and Psychotherapy, Luebeck University, Luebeck, Germany
| | - Johanna Schröder
- Institute for Sex Research, Sexual Medicine and Forensic Psychiatry, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Björn Meyer
- Research Department, GAIA AG, Hamburg, Germany
| | - Steffen Moritz
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lara Bücker
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ove Lintvedt
- Norwegian Center for E-health research, Tromsø, Norway
| | - Peter Johansson
- Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Johan Lundgren
- Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Jeannette Milgrom
- Parent-Infant Research Institute and Austin Health, Melbourne School of Psychological Sciences, University of Melbourne, VIC, Australia
| | - Alan W Gemmill
- Parent-Infant Research Institute and Austin Health, Melbourne School of Psychological Sciences, University of Melbourne, VIC, Australia
| | - David C Mohr
- Center for Behavioral Intervention Technologies, Department of Preventive Medicine, Northwestern University, Chicago, IL, USA
| | - Jesus Montero-Marin
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK
| | - Javier Garcia-Campayo
- Aragon Institute for Health Research, Miguel Servet University Hospital, Zaragoza, Spain; Primary Care Prevention and Health Promotion Research Network, RedIAPP, Madrid, Spain
| | | | - Anna-Carlotta Zarski
- Department of Clinical Psychology and Psychotherapy, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Kathleen O'Moore
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, NSW, Australia
| | - Alishia D Williams
- Department of Psychology, Faculty of Science, The University of New South Wales, Sydney, NSW, Australia
| | - Jill M Newby
- School of Psychology, University of New South Wales at the Black Dog Institute, Sydney, NSW, Australia
| | - Sarah Perini
- Clinical Research Unit for Anxiety and Depression, St Vincent's Hospital, Sydney, NSW, Australia
| | - Rachel Phillips
- Faculty of Medicine, School of Public Health, Imperial College London, London, UK
| | - Justine Schneider
- School of Sociology & Social Policy and Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Wendy Pots
- Department of Psychology, Health & Technology, University of Twente, Enschede, Netherlands
| | | | - Derek Richards
- University of Dublin, Trinity College, School of Psychology, E-mental Health Research Group, Dublin, Ireland; SilverCloud Health, Clinical Research & Innovation, Dublin, Ireland
| | | | | | | | - Jessica Smith
- Imperial Clinical Trials Unit, Imperial College London, London, UK
| | - Viola Spek
- School of Applied Psychology, Fontys University of Applied Science, Eindhoven, Netherlands
| | - Victor J Pop
- Department of Medical & Clinical Psychology, Tilburg University, Tilburg, Netherlands
| | | | | | - Sanne van Luenen
- Department of Clinical Psychology, Leiden University, Leiden, Netherlands
| | - Nadia Garnefski
- Department of Clinical Psychology, Leiden University, Leiden, Netherlands
| | - Vivian Kraaij
- Department of Clinical Psychology, Leiden University, Leiden, Netherlands
| | - Kristofer Vernmark
- Department of Behavioral Sciences and Learning, Linköping University, Linköping, Sweden
| | | | - Annemieke van Straten
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Pavle Zagorscak
- Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany
| | | | - Manuel Heinrich
- Department of Education and Psychology, Freie Universität Berlin, Berlin, Germany
| | - Clara Miguel
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
| | - Andrea Cipriani
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Oxford Health NHS Foundation Trust, Warneford Hospital, Oxford, UK
| | - Orestis Efthimiou
- Department of Psychiatry, Warneford Hospital, University of Oxford, Oxford, UK; Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Eirini Karyotaki
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - Pim Cuijpers
- Department of Clinical, Neuro and Developmental Psychology, Vrije Universiteit Amsterdam, Amsterdam, Netherlands
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Buckman JEJ, Saunders R, Cohen ZD, Barnett P, Clarke K, Ambler G, DeRubeis RJ, Gilbody S, Hollon SD, Kendrick T, Watkins E, Wiles N, Kessler D, Richards D, Sharp D, Brabyn S, Littlewood E, Salisbury C, White IR, Lewis G, Pilling S. The contribution of depressive 'disorder characteristics' to determinations of prognosis for adults with depression: an individual patient data meta-analysis. Psychol Med 2021; 51:1068-1081. [PMID: 33849685 PMCID: PMC8188529 DOI: 10.1017/s0033291721001367] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 03/08/2021] [Accepted: 03/26/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND This study aimed to investigate general factors associated with prognosis regardless of the type of treatment received, for adults with depression in primary care. METHODS We searched Medline, Embase, PsycINFO and Cochrane Central (inception to 12/01/2020) for RCTs that included the most commonly used comprehensive measure of depressive and anxiety disorder symptoms and diagnoses, in primary care depression RCTs (the Revised Clinical Interview Schedule: CIS-R). Two-stage random-effects meta-analyses were conducted. RESULTS Twelve (n = 6024) of thirteen eligible studies (n = 6175) provided individual patient data. There was a 31% (95%CI: 25 to 37) difference in depressive symptoms at 3-4 months per standard deviation increase in baseline depressive symptoms. Four additional factors: the duration of anxiety; duration of depression; comorbid panic disorder; and a history of antidepressant treatment were also independently associated with poorer prognosis. There was evidence that the difference in prognosis when these factors were combined could be of clinical importance. Adding these variables improved the amount of variance explained in 3-4 month depressive symptoms from 16% using depressive symptom severity alone to 27%. Risk of bias (assessed with QUIPS) was low in all studies and quality (assessed with GRADE) was high. Sensitivity analyses did not alter our conclusions. CONCLUSIONS When adults seek treatment for depression clinicians should routinely assess for the duration of anxiety, duration of depression, comorbid panic disorder, and a history of antidepressant treatment alongside depressive symptom severity. This could provide clinicians and patients with useful and desired information to elucidate prognosis and aid the clinical management of depression.
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Affiliation(s)
- Joshua E. J. Buckman
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
- iCope – Camden and Islington Psychological Therapies Services, Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
| | - Rob Saunders
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Zachary D. Cohen
- Department of Psychiatry, University of California, Los Angeles, Los Angeles, CA90095, USA
| | - Phoebe Barnett
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Katherine Clarke
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
| | - Gareth Ambler
- Statistical Science, University College London, LondonWC1E 7HB, UK
| | - Robert J. DeRubeis
- Department of Psychology, School of Arts and Sciences, University of Pennsylvania, Philadelphia, PA19104-60185, USA
| | - Simon Gilbody
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | - Steven D. Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN37240, USA
| | - Tony Kendrick
- Primary Care, Population Sciences and Medical Education, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, SouthamptonSO16 5ST, UK
| | - Edward Watkins
- Department of Psychology, University of Exeter, ExeterEX4 4QG, UK
| | - Nicola Wiles
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, BristolBS8 2BN, UK
| | - David Kessler
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - David Richards
- Institute of Health Research, University of Exeter College of Medicine and Health, ExeterEX1 2LU, UK
| | - Deborah Sharp
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, YorkYO10 5DD, UK
| | | | - Chris Salisbury
- Centre for Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, Bristol, UK
| | - Ian R. White
- MRC Clinical Trials Unit, Institute of Clinical Trials and Methodology, University College London, LondonWC1V 6LJ, UK
| | - Glyn Lewis
- Division of Psychiatry, University College London, LondonW1T 7NF, UK
| | - Stephen Pilling
- Centre for Outcomes Research and Effectiveness (CORE), Research Department of Clinical, Educational & Health Psychology, University College London, LondonWC1E 7HB, UK
- Camden & Islington NHS Foundation Trust, 4 St Pancras Way, LondonNW1 0PE, UK
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Eddy E, Heron P, McMillan D, Dawson S, Ekers D, Hickin N, Littlewood E, Shafran R, Meader N, Gilbody S. Cognitive or behavioural interventions (or both) to prevent or mitigate loneliness in adolescents, adults, and older adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Elizabeth Eddy
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Paul Heron
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Dean McMillan
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School; University of Bristol; Bristol UK
- Cochrane Common Mental Disorders; University of York; York UK
| | - David Ekers
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
- Lanchester Road Hospital; Tees, Esk and Wear Valleys NHS Foundation Trust; Durham UK
| | - Nisha Hickin
- South West London and St George's Mental Health NHS Trust; London UK
- Great Ormond Street Institute of Child Health; University College London; London UK
| | - Elizabeth Littlewood
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | | | - Nicholas Meader
- Centre for Reviews and Dissemination; University of York; York UK
- Cochrane Common Mental Disorders; University of York; York UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
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18
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Littlewood E, Ali S, Badenhorst J, Bailey D, Bambra C, Chew-Graham C, Coleman E, Crosland S, Gascoyne S, Gilbody S, Hewitt C, Jones C, Keding A, Kitchen C, McMillan D, Pearson C, Rhodes S, Sloan C, Todd A, Watson M, Whittlesea C, Ekers D. Community Pharmacies Mood Intervention Study (CHEMIST): feasibility and external pilot randomised controlled trial protocol. Pilot Feasibility Stud 2019; 5:71. [PMID: 31161045 PMCID: PMC6540405 DOI: 10.1186/s40814-019-0457-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
FEASIBILITY STUDY Objectives:Refine a bespoke enhanced support intervention (ESI) (including self-help materials, intervention manual and training) for implementation by community pharmacy (CP) staff to people with sub-threshold depression and long-term conditions (LTCs) based upon evidence-supported interventions in primary careDevelop and refine study procedures (recruitment strategies and set up, screening, participant recruitment, assessment, suitability of outcome measures and data collection procedures) for testing in the pilot study phaseDesign: A case series/qualitative studySetting: UK community pharmacyPopulation: Adults with long-term health conditions who screen-positive for depression but who do not reach the threshold for DSM IV Moderate Depressive disorderIntervention: Enhanced support intervention (ESI) delivered by an appropriately trained community pharmacy team member involving four to six sessions over four months. ESI is a modified form of an intervention within the collaborative care framework for sub-threshold depression validated in previous studies in UK primary care which appears suitable for implementation in community settings.Sample size: 20-30 participantsOutcomes: Study implementation (recruitment and attrition rates), quality of data collection at baseline and 4 months and ESI adherence (number of contacts, DNA and drop out) as per objectives 1a/bQualitative evaluation: Semi-structured interviews with up to 10 participants and ESI facilitators and focus group(s) (range of pharmacy staff n = 8-10) will be conducted to explore the acceptability of the intervention and feasibility of the study, training and study procedures. EXTERNAL PILOT STUDY Objectives:Quantify the flow of participants (eligibility, recruitment and follow-up rate)Evaluate proposed recruitment, assessment and outcome measure collection methodsExamine the delivery of the enhanced support intervention in a community pharmacy setting (intervention uptake, retention and dose) to inform process evaluationProcess evaluation, using semi-structured interviews with participants across a range of socio-economic settings, and pharmacy staff to explore the acceptability of the ESI within community pharmacy, elements of the intervention that were considered useful (or not) and appropriateness of study proceduresDesign: Pilot randomised controlled trial, including a prospective economic and qualitative evaluationSetting: As abovePopulation: As aboveIntervention: As above with adaptations post feasibility studyComparator: Usual careSample size: 100 participantsOutcomes: Data will be used to estimate recruitment, intervention delivery and study completion rates as per objectives 2a-d. Definitive estimates of the effectiveness of ESI will not be made.Primary outcome: Depression severity (Patient Health Questionnaire 9) at four months.Secondary outcomes: Patient acceptance, uptake and attrition. ICD10 depression status, anxiety (GAD 7), health-related quality of life (SF-12v2) and health-state utility (EQ5D 3L) will be measured at four months.Economic evaluation: The incremental cost per QALY will be calculated from both the NHS and societal perspective.Process evaluation: Using mixed methods, potential mediators/moderators of the intervention, the acceptability (to participants and pharmacy staff), barriers and facilitators to the use of ESI in community pharmacy, and impact on usual practice will be examined. Semi-structured interviews with approximately 30 study participants, 20 pharmacy staff and eight GPs near participating pharmacies will be conducted. TRIAL REGISTRATION ISRCTN: ISRCTN11290592Protocol version number: Version 4.1 (dated 16th January 2018)Study Sponsor Tees Esk and Wear Valleys NHS Foundation Trust.
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Affiliation(s)
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Jay Badenhorst
- Whitworth Chemists Ltd, 2C Atkinson Way, Foxhill Industrial Estate, Scunthorpe, DN15 8QJ UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Clare Bambra
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG UK
| | - Elizabeth Coleman
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Claire Jones
- Public Health Team, Children & Adult Services, Durham County Council, County Hall, DH1 5UJ UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Charlotte Kitchen
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Caroline Pearson
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Shelley Rhodes
- University of Exeter Medical School, University of Exeter, Exeter, EX1 2LU UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Adam Todd
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
- School of Pharmacy, King George VI Building, Queen Victoria Road, Newcastle Upon Tyne, NE1 7RU UK
| | - Michelle Watson
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Cate Whittlesea
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX UK
| | - David Ekers
- Department of Health Sciences, University of York, York, YO10 5DD UK
- Tees Esk and Wear Valleys NHS FT/University of York, Tarncroft House, Lanchester Road Hospital, Durham, DH1 5RD UK
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19
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Karyotaki E, Kemmeren L, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, Mackinnon A, Meyer B, Botella C, Littlewood E, Andersson G, Christensen H, Klein JP, Schröder J, Bretón-López J, Scheider J, Griffiths K, Farrer L, Huibers MJH, Phillips R, Gilbody S, Moritz S, Berger T, Pop V, Spek V, Cuijpers P. Is self-guided internet-based cognitive behavioural therapy (iCBT) harmful? An individual participant data meta-analysis. Psychol Med 2018; 48:2456-2466. [PMID: 29540243 PMCID: PMC6190066 DOI: 10.1017/s0033291718000648] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2017] [Revised: 01/02/2018] [Accepted: 02/16/2018] [Indexed: 11/07/2022]
Abstract
BACKGROUND Little is known about potential harmful effects as a consequence of self-guided internet-based cognitive behaviour therapy (iCBT), such as symptom deterioration rates. Thus, safety concerns remain and hamper the implementation of self-guided iCBT into clinical practice. We aimed to conduct an individual participant data (IPD) meta-analysis to determine the prevalence of clinically significant deterioration (symptom worsening) in adults with depressive symptoms who received self-guided iCBT compared with control conditions. Several socio-demographic, clinical and study-level variables were tested as potential moderators of deterioration. METHODS Randomised controlled trials that reported results of self-guided iCBT compared with control conditions in adults with symptoms of depression were selected. Mixed effects models with participants nested within studies were used to examine possible clinically significant deterioration rates. RESULTS Thirteen out of 16 eligible trials were included in the present IPD meta-analysis. Of the 3805 participants analysed, 7.2% showed clinically significant deterioration (5.8% and 9.1% of participants in the intervention and control groups, respectively). Participants in self-guided iCBT were less likely to deteriorate (OR 0.62, p < 0.001) compared with control conditions. None of the examined participant- and study-level moderators were significantly associated with deterioration rates. CONCLUSIONS Self-guided iCBT has a lower rate of negative outcomes on symptoms than control conditions and could be a first step treatment approach for adult depression as well as an alternative to watchful waiting in general practice.
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Affiliation(s)
- Eirini Karyotaki
- Department of Clinical Psychology, VU Amsterdam and Institute for Public Health Research, Amsterdam, the Netherlands
| | - Lise Kemmeren
- Department of Psychiatry, GGZ inGeest and VU University Medical Centre, Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Heleen Riper
- Department of Clinical Psychology, VU Amsterdam and Institute for Public Health Research, Amsterdam, the Netherlands
| | - Jos Twisk
- Department of Epidemiology and Biostatistics and Amsterdam Institute for Public Health Research, VU University Amsterdam, Amsterdam, the Netherlands
| | - Adriaan Hoogendoorn
- Department of Psychiatry, GGZ inGeest and VU University Medical Centre, Amsterdam Public Health research institute, Amsterdam, the Netherlands
| | - Annet Kleiboer
- Department of Clinical Psychology, VU Amsterdam and Institute for Public Health Research, Amsterdam, the Netherlands
| | - Adriana Mira
- Department of Psychology and Technology, Jaume University, Castellon, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto Salud Carlos III, Spain
| | - Andrew Mackinnon
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, Australia
- Center for Mental Health, University of Melbourne, Melbourne, Australia
| | - Björn Meyer
- Research Department, Germany and Department of Psychology, City University, Gaia AG, Hamburg, London, UK
| | - Cristina Botella
- Department of Psychology and Technology, Jaume University, Castellon, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto Salud Carlos III, Spain
| | | | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Sweden Institute for Disability Research, Linköping University, Linköping, Sweden
- Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute for Disability Research, Stockholm, Sweden
| | - Helen Christensen
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, Australia
| | - Jan P. Klein
- Department of Psychiatry and Psychotherapy, Lübeck University, Lübeck, Germany
| | - Johanna Schröder
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Juana Bretón-López
- Department of Psychology and Technology, Jaume University, Castellon, Spain
- CIBER Fisiopatología Obesidad y Nutrición (CIBERobn), Instituto Salud Carlos III, Spain
| | - Justine Scheider
- Institute of Mental Health, University of Nottingham, Nottingham, UK
| | - Kathy Griffiths
- Research School of Psychology, College of Biology, Medicine & Environment, Australian National University, Canberra, Australia
| | - Louise Farrer
- Centre for Mental Health Research, The Australian National University, Canberra, Australia
| | - Marcus J. H. Huibers
- Department of Clinical Psychology, VU Amsterdam and Institute for Public Health Research, Amsterdam, the Netherlands
| | - Rachel Phillips
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Steffen Moritz
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Victor Pop
- CoRPS – Center of Research on Psychology in Somatic diseases, Tilburg University, Tilburg, the Netherlands
| | - Viola Spek
- CoRPS – Center of Research on Psychology in Somatic diseases, Tilburg University, Tilburg, the Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, VU Amsterdam and Institute for Public Health Research, Amsterdam, the Netherlands
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20
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Brabyn S, Araya R, Barkham M, Bower P, Cooper C, Duarte A, Kessler D, Knowles S, Lovell K, Littlewood E, Mattock R, Palmer S, Pervin J, Richards D, Tallon D, White D, Walker S, Worthy G, Gilbody S. The second Randomised Evaluation of the Effectiveness, cost-effectiveness and Acceptability of Computerised Therapy (REEACT-2) trial: does the provision of telephone support enhance the effectiveness of computer-delivered cognitive behaviour therapy? A randomised controlled trial. Health Technol Assess 2018; 20:1-64. [PMID: 27922448 DOI: 10.3310/hta20890] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Computerised cognitive behaviour therapy (cCBT) is an efficient form of therapy potentially improving access to psychological care. Indirect evidence suggests that the uptake and effectiveness of cCBT can be increased if facilitated by telephone, but this is not routinely offered in the NHS. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of telephone-facilitated free-to-use cCBT [e.g. MoodGYM (National Institute for Mental Health Research, Australian National University, Canberra, ACT, Australia)] with minimally supported cCBT. DESIGN This study was a multisite, pragmatic, open, two-arm, parallel-group randomised controlled trial with a concurrent economic evaluation. SETTING Participants were recruited from GP practices in Bristol, Manchester, Sheffield, Hull and the north-east of England. PARTICIPANTS Potential participants were eligible to participate in the trial if they were adults with depression scoring ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9). INTERVENTIONS Participants were randomised using a computer-generated random number sequence to receive minimally supported cCBT or telephone-facilitated cCBT. Participants continued with usual general practitioner care. MAIN OUTCOME MEASURES The primary outcome was self-reported symptoms of depression, as assessed by the PHQ-9 at 4 months post randomisation. SECONDARY OUTCOMES Secondary outcomes were depression at 12 months and anxiety, somatoform complaints, health utility (as assessed by the European Quality of Life-5 Dimensions questionnaire) and resource use at 4 and 12 months. RESULTS Clinical effectiveness: 182 participants were randomised to minimally supported cCBT and 187 participants to telephone-facilitated cCBT. There was a difference in the severity of depression at 4 and 12 months, with lower levels in the telephone-facilitated group. The odds of no longer being depressed (defined as a PHQ-9 score of < 10) at 4 months were twice as high in the telephone-facilitated cCBT group [odds ratio (OR) 2.05, 95% confidence interval (CI) 1.23 to 3.42]. The benefit of telephone-facilitated cCBT was no longer significant at 12 months (OR 1.63, 95% CI 0.98 to 2.71). At 4 months the between-group difference in PHQ-9 scores was 1.9 (95% CI 0.5 to 3.3). At 12 months the results still favoured telephone-facilitated cCBT but were no longer statistically significant, with a difference in PHQ-9 score of 0.9 (95% CI -0.5 to 2.3). When considering the whole follow-up period, telephone-facilitated cCBT was asssociated with significantly lower PHQ-9 scores than minimally supported cCBT (mean difference -1.41, 95% CI -2.63 to -0.17; p = 0.025). There was a significant improvement in anxiety scores over the trial period (between-group difference 1.1, 95% CI 0.1 to 2.3; p = 0.037). In the case of somatic complaints (assessed using the Patient Health Questionnaire-15), there was a borderline statistically significant difference over the trial period (between-group difference 1.1, 95% CI 0.0 to 1.8; p = 0.051). There were gains in quality-adjusted life-years at reduced cost when telephone facilitation was added to MoodGYM. However, the results were subject to uncertainty. CONCLUSIONS The results showed short-term benefits from the addition of telephone facilitation to cCBT. The effect was small to moderate and comparable with that of other primary care psychological interventions. Telephone facilitation should be considered when offering cCBT for depression. LIMITATIONS Participants' depression was assessed with the PHQ-9, cCBT use was quite low and there was a slightly greater than anticipated loss to follow-up. FUTURE RESEARCH RECOMMENDATIONS Improve the acceptability of cCBT and its capacity to address coexisting disorders. Large-scale pragmatic trials of cCBT with bibliotherapy and telephone-based interventions are required. TRIAL REGISTRATION Current Controlled Trials ISRCTN55310481. 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. 20, No. 89. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | - Ricardo Araya
- Department of Population Health, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Barkham
- Centre for Psychological Services Research, University of Sheffield, Sheffield, UK
| | - Peter Bower
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Cindy Cooper
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | - David Kessler
- Academic Unit of Primary Health Care, University of Bristol, Bristol, UK
| | - Sarah Knowles
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | | | - Richard Mattock
- Department of Health Sciences, University of York, York, UK.,Centre for Health Economics, University of York, York, UK
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - David Richards
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Debbie Tallon
- School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - David White
- Clinical Trials Research Unit, University of Sheffield, Sheffield, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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21
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Littlewood E, Ali S, Dyson L, Keding A, Ansell P, Bailey D, Bates D, Baxter C, Beresford-Dent J, Clarke A, Gascoyne S, Gray C, Hackney L, Hewitt C, Hutchinson D, Jefferson L, Mann R, Marshall D, McMillan D, North A, Nutbrown S, Peckham E, Pervin J, Richardson Z, Swan K, Taylor H, Waterhouse B, Wills L, Woodhouse R, Gilbody S. Identifying perinatal depression with case-finding instruments: a mixed-methods study (BaBY PaNDA – Born and Bred in Yorkshire PeriNatal Depression Diagnostic Accuracy). Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background
Perinatal depression is well recognised as a mental health condition but < 50% of cases are identified in routine practice. A case-finding strategy using the Whooley questions is currently recommended by the National Institute for Health and Care Excellence.
Objectives
To determine the diagnostic accuracy, acceptability and cost-effectiveness of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to identify perinatal depression.
Design
A prospective diagnostic accuracy cohort study, with concurrent qualitative and economic evaluations.
Setting
Maternity services in England.
Participants
A total of 391 pregnant women.
Main outcome measures
Women completed the Whooley questions, EPDS and a diagnostic reference standard (Clinical Interview Schedule – Revised) during pregnancy (20 weeks) and postnatally (3–4 months). Qualitative interviews were conducted with health professionals (HPs) and a subsample of women.
Results
Diagnostic accuracy results: depression prevalence rates were 10.3% during pregnancy and 10.5% postnatally. The Whooley questions and EPDS (cut-off point of ≥ 10) performed reasonably well, with comparable sensitivity [pregnancy: Whooley questions 85.0%, 95% confidence interval (CI) 70.2% to 94.3%; EPDS 82.5%, 95% CI 67.2% to 92.7%; postnatally: Whooley questions 85.7%, 95% CI 69.7% to 95.2%; EPDS 82.9%, 95% CI 66.4% to 93.4%] and specificity (pregnancy: Whooley questions 83.7%, 95% CI 79.4% to 87.4%; EPDS 86.6%, 95% CI 82.5% to 90.0%; postnatally: Whooley questions 80.6%, 95% CI 75.7% to 84.9%; EPDS 87.6%, 95% CI 83.3% to 91.1%). Diagnostic accuracy of the EPDS (cut-off point of ≥ 13) was poor at both time points (pregnancy: sensitivity 45%, 95% CI 29.3% to 61.5%, and specificity 95.7%, 95% CI 93.0% to 97.6%; postnatally: sensitivity 62.9%, 95% CI 44.9% to 78.5%, and specificity 95.7%, 95% CI 92.7% to 97.7%). Qualitative evaluation: women and HPs were supportive of screening/case-finding for perinatal depression. The EPDS was preferred to the Whooley questions by women and HPs, mainly because of its ‘softer’ wording. Whooley question 1 was thought to be less acceptable, largely because of the terms ‘depressed’ and ‘hopeless’, leading to women not revealing their depressive symptoms. HPs identified a ‘patient-centred’ environment that focused on the mother and baby to promote discussion about mental health. Cost-effectiveness results: screening/case-finding using the Whooley questions or the EPDS alone was not the most cost-effective strategy. A two-stage strategy, ‘Whooley questions followed by the Patient Health Questionnaire’ (a measure assessing depression symptomatology), was the most cost-effective strategy in the range between £20,000 and £30,000 per quality-adjusted life-year in both the prenatal and postnatal decision models.
Limitations
Perinatal depression diagnosis was not cross-referenced with women’s medical records so the proportion of new cases identified is unknown. The clinical effectiveness and cost-effectiveness of screening/case-finding strategies was not assessed as part of a randomised controlled trial.
Conclusions
The Whooley questions and EPDS had acceptable sensitivity and specificity, but their use in practice might be limited by low predictive value and variation in their acceptability. A two-stage strategy was more cost-effective than single-stage strategies. Neither case-finding instrument met National Screening Committee criteria.
Future work
The yield of screening/case-finding should be established with reference to health-care records. The clinical effectiveness and cost-effectiveness of screening/case-finding for perinatal depression needs to be tested in a randomised controlled trial.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Elizabeth Littlewood
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Lisa Dyson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Pat Ansell
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Della Bailey
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Debrah Bates
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Catherine Baxter
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Jules Beresford-Dent
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Arabella Clarke
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Samantha Gascoyne
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Carol Gray
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Lisa Hackney
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Dorothy Hutchinson
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Rachel Mann
- Department of Health Sciences, University of York, York, UK
| | - David Marshall
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Dean McMillan
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Hull York Medical School, York, UK
| | - Alice North
- Patient and public involvement representative, York, UK
| | - Sarah Nutbrown
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Emily Peckham
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Jodi Pervin
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Zoe Richardson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Kelly Swan
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Holly Taylor
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Bev Waterhouse
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Louise Wills
- Harrogate and District NHS Foundation Trust, Harrogate District Hospital, Harrogate, UK
| | - Rebecca Woodhouse
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Hull York Medical School, York, UK
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22
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Duarte A, Walker S, Littlewood E, Brabyn S, Hewitt C, Gilbody S, Palmer S. Cost-effectiveness of computerized cognitive-behavioural therapy for the treatment of depression in primary care: findings from the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Psychol Med 2017; 47:1825-1835. [PMID: 28228182 DOI: 10.1017/s0033291717000289] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Computerized cognitive-behavioural therapy (cCBT) forms a core component of stepped psychological care for depression. Existing evidence for cCBT has been informed by developer-led trials. This is the first study based on a large independent pragmatic trial to assess the cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care compared with usual GP care alone and to establish the differential cost-effectiveness of a free-to-use cCBT programme (MoodGYM) in comparison with a commercial programme (Beating the Blues) in primary care. METHOD Costs were estimated from a healthcare perspective and outcomes measured using quality-adjusted life years (QALYs) over 2 years. The incremental cost-effectiveness of each cCBT programme was compared with usual GP care. Uncertainty was estimated using probabilistic sensitivity analysis and scenario analyses were performed to assess the robustness of results. RESULTS Neither cCBT programme was found to be cost-effective compared with usual GP care alone. At a £20 000 per QALY threshold, usual GP care alone had the highest probability of being cost-effective (0.55) followed by MoodGYM (0.42) and Beating the Blues (0.04). Usual GP care alone was also the cost-effective intervention in the majority of scenario analyses. However, the magnitude of the differences in costs and QALYs between all groups appeared minor (and non-significant). CONCLUSIONS Technically supported cCBT programmes do not appear any more cost-effective than usual GP care alone. No cost-effective advantage of the commercially developed cCBT programme was evident compared with the free-to-use cCBT programme. Current UK practice recommendations for cCBT may need to be reconsidered in the light of the results.
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Affiliation(s)
- A Duarte
- Centre for Health Economics, University of York,Heslington,York YO10 5DD,UK
| | - S Walker
- Centre for Health Economics, University of York,Heslington,York YO10 5DD,UK
| | - E Littlewood
- Department of Health Sciences,University of York,Heslington,York YO10 5DD,UK
| | - S Brabyn
- Department of Health Sciences,University of York,Heslington,York YO10 5DD,UK
| | - C Hewitt
- Department of Health Sciences,University of York,Heslington,York YO10 5DD,UK
| | - S Gilbody
- Department of Health Sciences,University of York,Heslington,York YO10 5DD,UK
| | - S Palmer
- Centre for Health Economics, University of York,Heslington,York YO10 5DD,UK
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Gilbody S, Brabyn S, Lovell K, Kessler D, Devlin T, Smith L, Araya R, Barkham M, Bower P, Cooper C, Knowles S, Littlewood E, Richards DA, Tallon D, White D, Worthy G. Telephone-supported computerised cognitive-behavioural therapy: REEACT-2 large-scale pragmatic randomised controlled trial. Br J Psychiatry 2017; 210:362-367. [PMID: 28254959 DOI: 10.1192/bjp.bp.116.192435] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 10/29/2016] [Accepted: 11/03/2016] [Indexed: 01/23/2023]
Abstract
BackgroundComputerised cognitive-behavioural therapy (cCBT) for depression has the potential to be efficient therapy but engagement is poor in primary care trials.AimsWe tested the benefits of adding telephone support to cCBT.MethodWe compared telephone-facilitated cCBT (MoodGYM) (n = 187) to minimally supported cCBT (MoodGYM) (n = 182) in a pragmatic randomised trial (trial registration: ISRCTN55310481). Outcomes were depression severity (Patient Health Questionnaire (PHQ)-9), anxiety (Generalized Anxiety Disorder Questionnaire (GAD)-7) and somatoform complaints (PHQ-15) at 4 and 12 months.ResultsUse of cCBT increased by a factor of between 1.5 and 2 with telephone facilitation. At 4 months PHQ-9 scores were 1.9 points lower (95% CI 0.5-3.3) for telephone-supported cCBT. At 12 months, the results were no longer statistically significant (0.9 PHQ-9 points, 95% CI -0.5 to 2.3). There was improvement in anxiety scores and for somatic complaints.ConclusionsTelephone facilitation of cCBT improves engagement and expedites depression improvement. The effect was small to moderate and comparable with other low-intensity psychological interventions.
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Affiliation(s)
- Simon Gilbody
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Sally Brabyn
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Karina Lovell
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - David Kessler
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Thomas Devlin
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Lucy Smith
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Ricardo Araya
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Michael Barkham
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Peter Bower
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Cindy Cooper
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Sarah Knowles
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Elizabeth Littlewood
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - David A Richards
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Debbie Tallon
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - David White
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
| | - Gillian Worthy
- Simon Gilbody, DPhil, FRCPsych, Sally Brabyn, MA, MSc, Department of Health Sciences, University of York, York; Karina Lovell, RN, MSc, PhD, School of Nursing, Midwifery and Social Work, University of Manchester, Manchester; David Kessler, MBBS, MRCPsych, MD, MRCGP, Academic Unit of Primary Health Care, University of Bristol, Bristol; Thomas Devlin, PhD, Lucy Smith, BA, PGDip, Department of Health Sciences, University of York, York; Ricardo Araya, PhD, MRCPsych, Centre of Global Mental Health, London School of Hygiene and Tropical Medicine, London; Michael Barkham, PhD, Centre for Psychological Services Research, University of Sheffield, Sheffield; Peter Bower, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Cindy Cooper, PhD, School of Health and Related Research, University of Sheffield and Clinical Trials Research Unit, University of Sheffield, UK; Sarah Knowles, PhD, NIHR School for Primary Care Research, University of Manchester, Manchester; Elizabeth Littlewood, PhD, Department of Health Sciences, University of York, York; David A. Richards, RN, PhDhc, PhD, University of Exeter Medical School, University of Exeter, Exeter; Debbie Tallon, MSc, School of Social and Community Medicine, University of Bristol, Bristol; David White, MPH, Clinical Trials Research Unit, University of Sheffield, Sheffield; Gillian Worthy, MSc, York Trials Unit, University of York, York, UK
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Karyotaki E, Riper H, Twisk J, Hoogendoorn A, Kleiboer A, Mira A, Mackinnon A, Meyer B, Botella C, Littlewood E, Andersson G, Christensen H, Klein JP, Schröder J, Bretón-López J, Scheider J, Griffiths K, Farrer L, Huibers MJH, Phillips R, Gilbody S, Moritz S, Berger T, Pop V, Spek V, Cuijpers P. Efficacy of Self-guided Internet-Based Cognitive Behavioral Therapy in the Treatment of Depressive Symptoms: A Meta-analysis of Individual Participant Data. JAMA Psychiatry 2017; 74:351-359. [PMID: 28241179 DOI: 10.1001/jamapsychiatry.2017.0044] [Citation(s) in RCA: 404] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Self-guided internet-based cognitive behavioral therapy (iCBT) has the potential to increase access and availability of evidence-based therapy and reduce the cost of depression treatment. OBJECTIVES To estimate the effect of self-guided iCBT in treating adults with depressive symptoms compared with controls and evaluate the moderating effects of treatment outcome and response. DATA SOURCES A total of 13 384 abstracts were retrieved through a systematic literature search in PubMed, Embase, PsycINFO, and Cochrane Library from database inception to January 1, 2016. STUDY SELECTION Randomized clinical trials in which self-guided iCBT was compared with a control (usual care, waiting list, or attention control) in individuals with symptoms of depression. DATA EXTRACTION AND SYNTHESIS Primary authors provided individual participant data from 3876 participants from 13 of 16 eligible studies. Missing data were handled using multiple imputations. Mixed-effects models with participants nested within studies were used to examine treatment outcomes and moderators. MAIN OUTCOMES AND MEASURES Outcomes included the Beck Depression Inventory, Center for Epidemiological Studies-Depression Scale, and 9-item Patient Health Questionnaire scores. Scales were standardized across the pool of the included studies. RESULTS Of the 3876 study participants, the mean (SD) age was 42.0 (11.7) years, 2531 (66.0%) of 3832 were female, 1368 (53.1%) of 2574 completed secondary education, and 2262 (71.9%) of 3146 were employed. Self-guided iCBT was significantly more effective than controls on depressive symptoms severity (β = -0.21; Hedges g = 0.27) and treatment response (β = 0.53; odds ratio, 1.95; 95% CI, 1.52-2.50; number needed to treat, 8). Adherence to treatment was associated with lower depressive symptoms (β = -0.19; P = .001) and greater response to treatment (β = 0.90; P < .001). None of the examined participant and study-level variables moderated treatment outcomes. CONCLUSIONS AND RELEVANCE Self-guided iCBT is effective in treating depressive symptoms. The use of meta-analyses of individual participant data provides substantial evidence for clinical and policy decision making because self-guided iCBT can be considered as an evidence-based first-step approach in treating symptoms of depression. Several limitations of the iCBT should be addressed before it can be disseminated into routine care.
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Affiliation(s)
- Eirini Karyotaki
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Heleen Riper
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Jos Twisk
- Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, Vrije Universiteit University Amsterdam, Amsterdam, the Netherlands
| | - Adriaan Hoogendoorn
- Department of Psychiatry, Geestelijke Gezondheidszorg inGeest inGeest and Vrije Universiteit University Medical Centre, Amsterdam, the Netherlands4EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Annet Kleiboer
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Adriana Mira
- Department of Psychology and Technology, Jaume University, Castellon, Spain
| | - Andrew Mackinnon
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, Australia7Center for Mental Health, University of Melbourne, Melbourne, Australia
| | - Björn Meyer
- Research Department, Gaia AG, Hamburg, Germany9Department of Psychology, City University, London, England
| | - Cristina Botella
- Department of Psychology and Technology, Jaume University, Castellon, Spain10IBER of Physiopathology of Obesity and Nutrition, Santiago de Compostela, Spain
| | | | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Sweden Institute for Disability Research, Linköping University, Linköping, Sweden13Department of Clinical Neuroscience, Psychiatry Section, Karolinska Institute for Disability Research, Stockholm, Sweden
| | - Helen Christensen
- Black Dog Institute and University of New South Wales, Prince of Wales Hospital, Sydney, Australia
| | - Jan P Klein
- Department of Psychiatry and Psychotherapy, Luebeck University, Luebeck, Germany
| | - Johanna Schröder
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Juana Bretón-López
- Department of Psychology and Technology, Jaume University, Castellon, Spain10IBER of Physiopathology of Obesity and Nutrition, Santiago de Compostela, Spain
| | - Justine Scheider
- Institute of Mental Health, University of Nottingham, Nottingham, England
| | - Kathy Griffiths
- Research School of Psychology, College of Biology, Medicine & Environment, Australian National University, Canberra, Australia
| | - Louise Farrer
- Centre for Mental Health Research, The Australian National University, Canberra, Australia
| | - Marcus J H Huibers
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands
| | - Rachel Phillips
- Department of Primary Care and Public Health Sciences, King's College London, London, England
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, England
| | - Steffen Moritz
- Department of Psychiatry and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thomas Berger
- Department of Clinical Psychology and Psychotherapy, University of Bern, Bern, Switzerland
| | - Victor Pop
- Department of Psychology and Health, Tilburg University and Diagnostic Centre Eindhoven, Eindhoven, the Netherlands
| | - Viola Spek
- Department of Psychology and Health, Tilburg University and Diagnostic Centre Eindhoven, Eindhoven, the Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology and EMGO Institute for Health and Care Research, Vrije Universiteit Amsterdam, Amsterdam, the Netherlands2Department of Epidemiology and Biostatistics and EMGO Institute for Health and Care Research, Vrije Universiteit University Amsterdam, Amsterdam, the Netherlands
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Wright B, Tindall L, Littlewood E, Allgar V, Abeles P, Trépel D, Ali S. Computerised cognitive-behavioural therapy for depression in adolescents: feasibility results and 4-month outcomes of a UK randomised controlled trial. BMJ Open 2017; 7:e012834. [PMID: 28132000 PMCID: PMC5278287 DOI: 10.1136/bmjopen-2016-012834] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/16/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES Computer-administered cognitive-behavioural therapy (CCBT) may be a promising treatment for adolescents with depression, particularly due to its increased availability and accessibility. The feasibility of delivering a randomised controlled trial (RCT) comparing a CCBT program (Stressbusters) with an attention control (self-help websites) for adolescent depression was evaluated. DESIGN Single centre RCT feasibility study. SETTING The trial was run within community and clinical settings in York, UK. PARTICIPANTS Adolescents (aged 12-18) with low mood/depression were assessed for eligibility, 91 of whom met the inclusion criteria and were consented and randomised to Stressbusters (n=45) or websites (n=46) using remote computerised single allocation. Those with comorbid physical illness were included but those with psychosis, active suicidality or postnatal depression were not. INTERVENTIONS An eight-session CCBT program (Stressbusters) designed for use with adolescents with low mood/depression was compared with an attention control (accessing low mood self-help websites). PRIMARY AND SECONDARY OUTCOME MEASURES Participants completed mood and quality of life measures and a service Use Questionnaire throughout completion of the trial and 4 months post intervention. Measures included the Beck Depression Inventory (BDI) (primary outcome measure), Mood and Feelings Questionnaire (MFQ), Spence Children's Anxiety Scale (SCAS), the EuroQol five dimensions questionnaire (youth) (EQ-5D-Y) and Health Utility Index Mark 2 (HUI-2). Changes in self-reported measures and completion rates were assessed by treatment group. RESULTS From baseline to 4 months post intervention, BDI scores and MFQ scores decreased for the Stressbusters group but increased in the website group. Quality of life, as measured by the EQ-5D-Y, increased for both groups while costs at 4 months were similar to baseline. Good feasibility outcomes were found, suggesting the trial process to be feasible and acceptable for adolescents with depression. CONCLUSIONS With modifications, a fully powered RCT is achievable to investigate a promising treatment for adolescent depression in a climate where child mental health service resources are limited. TRIAL REGISTRATION NUMBER ISRCTN31219579.
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Affiliation(s)
- Barry Wright
- University of York (Child Oriented Mental health Intervention Centre – COMIC), Adolescent and Family Unit, York, UK
| | - Lucy Tindall
- Leeds and York Partnership NHS Foundation Trust (Child Oriented Mental health Intervention Centre – COMIC), York, UK
| | | | | | - Paul Abeles
- Central Manchester University Hospitals NHS Foundation Trust, Manchester, UK
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Darwin Z, Galdas P, Hinchliff S, Littlewood E, McMillan D, McGowan L, Gilbody S. Fathers' views and experiences of their own mental health during pregnancy and the first postnatal year: a qualitative interview study of men participating in the UK Born and Bred in Yorkshire (BaBY) cohort. BMC Pregnancy Childbirth 2017; 17:45. [PMID: 28125983 PMCID: PMC5270346 DOI: 10.1186/s12884-017-1229-4] [Citation(s) in RCA: 104] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Accepted: 01/19/2017] [Indexed: 11/10/2022] Open
Abstract
Background The prevalence of fathers’ depression and anxiety in the perinatal period (i.e. from conception to 1 year after birth) is approximately 5–10%, and 5–15%, respectively; their children face increased risk of adverse emotional and behavioural outcomes, independent of maternal mental health. Critically, fathers can be protective against the development of maternal perinatal mental health problems and their effects on child outcomes. Preventing and treating paternal mental health problems and promoting paternal psychological wellbeing may therefore benefit the family as a whole. This study examined fathers’ views and direct experiences of paternal perinatal mental health. Methods Men in the Born and Bred in Yorkshire (BaBY) epidemiological prospective cohort who met eligibility criteria (baby born <12 months; completed Mental Health and Wellbeing [MHWB] questionnaires) were invited to participate. Those expressing interest (n = 42) were purposively sampled to ensure diversity of MHWB scores. In-depth interviews were conducted at 5–10 months postpartum with 19 men aged 25–44 years. The majority were first-time fathers and UK born; all lived with their partner. Data were analysed using thematic analysis. Results Four themes were identified: ‘legitimacy of paternal stress and entitlement to health professionals’ support’, ‘protecting the partnership’, ‘navigating fatherhood’, and, ‘diversity of men’s support networks’. Men largely described their ‘stress’ with reference to exhaustion, poor concentration and irritability. Despite feeling excluded by maternity services, fathers questioned their entitlement to support, noting that services are pressured and ‘should’ be focused on mothers. Men emphasised the need to support their partner and protect their partnership as central to the successfully navigation of fatherhood; they used existing support networks where available but noted the paucity of tailored support for fathers. Conclusions Fathers experience psychological distress in the perinatal period but question the legitimacy of their experiences. Men may thus be reluctant to express their support needs or seek help amid concerns that to do so would detract from their partner’s needs. Resources are needed that are tailored to men, framed around fatherhood, rather than mental health or mental illness, and align men’s self-care with their role as supporter and protector. Further research is needed to inform how best to identify and manage both parents’ mental health needs and promote their psychological wellbeing, in the context of achievable models of service delivery. Electronic supplementary material The online version of this article (doi:10.1186/s12884-017-1229-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Z Darwin
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK.
| | - P Galdas
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - S Hinchliff
- School of Nursing and Midwifery, University of Sheffield, Sheffield, S10 2LA, UK
| | - E Littlewood
- Hull York Medical School, University of York, York, YO10 5DD, UK
| | - D McMillan
- Department of Health Sciences, University of York, York, YO10 5DD, UK.,Hull York Medical School, University of York, York, YO10 5DD, UK
| | - L McGowan
- School of Healthcare, University of Leeds, Leeds, LS2 9JT, UK
| | - S Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD, UK.,Hull York Medical School, University of York, York, YO10 5DD, UK
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Marshall D, Wright B, Allgar V, Adamson J, Williams C, Ainsworth H, Cook L, Varley D, Hackney L, Dempster P, Ali S, Trepel D, Collingridge Moore D, Littlewood E, McMillan D. Social Stories in mainstream schools for children with autism spectrum disorder: a feasibility randomised controlled trial. BMJ Open 2016; 6:e011748. [PMID: 27515756 PMCID: PMC4985921 DOI: 10.1136/bmjopen-2016-011748] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To assess the feasibility of recruitment, retention, outcome measures and intervention training/delivery among teachers, parents and children. To calculate a sample size estimation for full trial. DESIGN A single-centre, unblinded, cluster feasibility randomised controlled trial examining Social Stories delivered within a school environment compared with an attentional control. SETTING 37 primary schools in York, UK. PARTICIPANTS 50 participants were recruited and a cluster randomisation approach by school was examined. Participants were randomised into the treatment group (n=23) or a waiting list control group (n=27). OUTCOME MEASURES Acceptability and feasibility of the trial, intervention and of measurements required to assess outcomes in a definitive trial. RESULTS An assessment of the questionnaire completion rates indicated teachers would be most appropriate to complete the primary outcome measure. 2 outcome measures: the Social Responsiveness Scale (SRS)-2 and a goal-based measure showed both the highest levels of completion rates (above 80%) at the primary follow-up point (6 weeks postintervention) and captured relevant social and behaviour outcomes. Power calculations were based on these 2 outcome measures leading to a total proposed sample size of 180 participant groups. CONCLUSIONS Results suggest that a future trial would be feasible to conduct and could inform the policy and practice of using Social Stories in mainstream schools. TRIAL REGISTRATION NUMBER ISRCTN96286707; Results.
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Affiliation(s)
| | | | | | - Joy Adamson
- Department of Health Sciences, University of York, York, UK
| | | | | | - Liz Cook
- Department of Health Sciences, University of York, York, UK
| | | | | | - Paul Dempster
- Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK
| | - Dominic Trepel
- Department of Health Sciences, University of York, York, UK
| | | | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
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Littlewood E, Duarte A, Hewitt C, Knowles S, Palmer S, Walker S, Andersen P, Araya R, Barkham M, Bower P, Brabyn S, Brierley G, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Muhammad U, Parry G, Richards DA, Richardson R, Tallon D, Tharmanathan P, White D, Gilbody S. A randomised controlled trial of computerised cognitive behaviour therapy for the treatment of depression in primary care: the Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy (REEACT) trial. Health Technol Assess 2016; 19:viii, xxi-171. [PMID: 26685904 DOI: 10.3310/hta191010] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Computerised cognitive behaviour therapy (cCBT) has been developed as an efficient form of therapy delivery with the potential to enhance access to psychological care. Independent research is needed which examines both the clinical effectiveness and cost-effectiveness of cCBT over the short and longer term. OBJECTIVES To compare the clinical effectiveness and cost-effectiveness of cCBT as an adjunct to usual general practitioner (GP) care against usual GP care alone, for a free-to-use cCBT program (MoodGYM; National Institute for Mental Health Research, Australian National University, Canberra, Australia) and a commercial pay-to-use cCBT program (Beating the Blues(®); Ultrasis, London, UK) for adults with depression, and to determine the acceptability of cCBT and the experiences of users. DESIGN A pragmatic, multicentre, three-armed, parallel, randomised controlled trial (RCT) with concurrent economic and qualitative evaluations. Simple randomisation was used. Participants and researchers were not blind to treatment allocation. SETTING Primary care in England. PARTICIPANTS Adults with depression who scored ≥ 10 on the Patient Health Questionnaire-9 (PHQ-9). INTERVENTIONS Participants who were randomised to either of the two intervention groups received cCBT (Beating the Blues or MoodGYM) in addition to usual GP care. Participants who were randomised to the control group were offered usual GP care. MAIN OUTCOME MEASURES The primary outcome was depression at 4 months (PHQ-9). Secondary outcomes were depression at 12 and 24 months; measures of mental health and health-related quality of life at 4, 12 and 24 months; treatment preference; and the acceptability of cCBT and experiences of users. RESULTS Clinical effectiveness: 210 patients were randomised to Beating the Blues, 242 patients were randomised to MoodGYM and 239 patients were randomised to usual GP care (total 691). There was no difference in the primary outcome (depression measured at 4 months) either between Beating the Blues and usual GP care [odds ratio (OR) 1.19, 95% confidence interval (CI) 0.75 to 1.88] or between MoodGYM and usual GP care (OR 0.98, 95% CI 0.62 to 1.56). There was no overall difference across all time points for either intervention compared with usual GP care in a mixed model (Beating the Blues versus usual GP care, p = 0.96; and MoodGYM versus usual GP care, p = 0.11). However, a small but statistically significant difference between MoodGYM and usual GP care at 12 months was found (OR 0.56, 95% CI 0.34 to 0.93). Free-to-use cCBT (MoodGYM) was not inferior to pay-to-use cCBT (Beating the Blues) (OR 0.91, 90% CI 0.62 to 1.34; p = 0.69). There were no consistent benefits of either intervention when secondary outcomes were examined. There were no serious adverse events thought likely to be related to the trial intervention. Despite the provision of regular technical telephone support, there was low uptake of the cCBT programs. Cost-effectiveness: cost-effectiveness analyses suggest that neither Beating the Blues nor MoodGYM appeared cost-effective compared with usual GP care alone. Qualitative evaluation: participants were often demotivated to access the computer programs, by reason of depression. Some expressed the view that a greater level of therapeutic input would be needed to promote engagement. CONCLUSIONS The benefits that have previously been observed in developer-led trials were not found in this large pragmatic RCT. The benefits of cCBT when added to routine primary care were minimal, and uptake of this mode of therapy was relatively low. There remains a clinical and economic need for effective low-intensity psychological treatments for depression with improved patient engagement. TRIAL REGISTRATION This trial is registered as ISRCTN91947481. FUNDING This project was funded by the National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
| | - Ana Duarte
- Centre for Health Economics, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Sarah Knowles
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.,National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - Stephen Palmer
- Centre for Health Economics, University of York, York, UK
| | - Simon Walker
- Centre for Health Economics, University of York, York, UK
| | - Phil Andersen
- Department of Health Sciences, University of York, York, UK
| | - Ricardo Araya
- Academic Unit of Psychiatry, University of Bristol, Bristol, UK.,Department of Population Health, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Barkham
- Centre for Psychological Services Research, University of Sheffield, Sheffield, UK
| | - Peter Bower
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - Sally Brabyn
- Department of Health Sciences, University of York, York, UK
| | - Gwen Brierley
- Department of Health Sciences, University of York, York, UK.,Medical Research Council (MRC) Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Linda Gask
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK)
| | - David Kessler
- Academic Unit of Primary Health Care, University of Bristol, Bristol, UK
| | - Helen Lester
- National Institute for Health Research (NIHR) School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester, UK (previously National Primary Care Research and Development Centre, University of Manchester, Manchester, UK).,Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, UK
| | - Usman Muhammad
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Glenys Parry
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David A Richards
- Department of Health Sciences, University of York, York, UK.,University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | - Debbie Tallon
- School of Social & Community Medicine, University of Bristol, Bristol, UK
| | - Puvan Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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Littlewood E, Ali S, Ansell P, Dyson L, Gascoyne S, Hewitt C, Keding A, Mann R, McMillan D, Morgan D, Swan K, Waterhouse B, Gilbody S. Identification of depression in women during pregnancy and the early postnatal period using the Whooley questions and the Edinburgh Postnatal Depression Scale: protocol for the Born and Bred in Yorkshire: PeriNatal Depression Diagnostic Accuracy (BaBY PaNDA) study. BMJ Open 2016; 6:e011223. [PMID: 27297012 PMCID: PMC4916566 DOI: 10.1136/bmjopen-2016-011223] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
INTRODUCTION Perinatal depression is well recognised as a mental health condition but <50% of cases are identified by healthcare professionals in routine clinical practice. The Edinburgh Postnatal Depression Scale (EPDS) is often used to detect symptoms of postnatal depression in maternity and child services. The National Institute for Health and Care Excellence (NICE) recommends 2 'ultra-brief' case-finding questions (the Whooley questions) to aid identification of depression during the perinatal period, but this recommendation was made in the absence of any validation studies in a perinatal population. Limited research exists on the acceptability of these depression case-finding instruments and the cost-effectiveness of routine screening for perinatal depression. METHODS AND ANALYSIS The diagnostic accuracy of the Whooley questions and the EPDS will be determined against a reference standard (the Client Interview Schedule-Revised) during pregnancy (around 20 weeks) and the early postnatal period (around 3-4 months post partum) in a sample of 379 women. Further outcome measures will assess a range of psychological comorbidities, health-related quality of life and resource utilisation. Women will be followed up 12 months postnatally. The sensitivity, specificity and predictive values of the Whooley questions and the EPDS will be calculated against the reference standard at 20 weeks pregnancy and 3-4 months post partum. Acceptability of the depression case-finding instruments to women and healthcare professionals will involve in-depth qualitative interviews. An existing decision analytic model will be adapted to determine the cost-effectiveness of routine screening for perinatal depression. ETHICS AND DISSEMINATION This study is considered low risk for participants. Robust protocols will deal with cases where risk of depression, self-harm or suicide is identified. The protocol received favourable ethical opinion from the North East-York Research Ethics Committee (reference: 11/NE/0022). The study findings will be published in peer-reviewed journals and presented at relevant conferences.
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Affiliation(s)
- Elizabeth Littlewood
- Department of Health Sciences, Mental Health and Addiction Research Group, University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, Mental Health and Addiction Research Group, University of York, York, UK
| | - Pat Ansell
- Department of Health Sciences, Epidemiology and Cancer Statistics Research Group, University of York, York, UK
| | - Lisa Dyson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Samantha Gascoyne
- Department of Health Sciences, Mental Health and Addiction Research Group, University of York, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Rachel Mann
- Social Policy Research Unit, University of York, York, UK
| | - Dean McMillan
- Department of Health Sciences, Mental Health and Addiction Research Group, University of York, York, UK Hull York Medical School, University of York, York, UK
| | | | - Kelly Swan
- Department of Health Sciences, Epidemiology and Cancer Statistics Research Group, University of York, York, UK
| | - Bev Waterhouse
- Children, Women & Families Division, Calderdale and Huddersfield NHS Foundation Trust, Calderdale Royal Hospital, Halifax, UK
| | - Simon Gilbody
- Department of Health Sciences, Mental Health and Addiction Research Group, University of York, York, UK Hull York Medical School, University of York, York, UK
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Abstract
OBJECTIVE To explore patient experience of computerised cognitive behaviour therapy (cCBT) for depression in a pragmatic randomised controlled trial (Randomised Evaluation of the Effectiveness and Acceptability of Computerised Therapy, REEACT). DESIGN Qualitative semistructured interviews with 36 participants. PARTICIPANTS Depressed patients with a Patient Health Questionnaire 9 of 10 or above recruited into the REEACT randomised controlled trial. SETTING Primary care settings in England. RESULTS Participant experience was on a continuum, with some patients unable or unwilling to accept psychological therapy without interpersonal contact while others appreciated the enhanced anonymity and flexibility of cCBT. The majority of patients were ambivalent, recognising the potential benefits offered by cCBT but struggling with challenges posed by the severity of their illness, lack of support and limited personalisation of programme content. Low completion rates were commonly reported, although more positive patients reported greater engagement. Both positive and ambivalent patients perceived a need for monitoring or follow-up to support completion, while negative patients reported deliberate non-adherence due to dissatisfaction with the programme. Patients also reported that severity of depression impacted on engagement, and viewed cCBT as unsuitable for patients undergoing more severe depressive episodes. CONCLUSIONS The study demonstrates both the unique demands and benefits of computerised therapy. cCBT was preferred by some patients and rejected by others, but the majority of patients were ambivalent about the therapy. cCBT could be offered within a menu of options in stepped care if matched appropriately to individual patients or could be offered with enhanced support to appeal to a greater number of patients. TRIAL REGISTRATION NUMBER ISRCTN91947481.
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Affiliation(s)
- Sarah E Knowles
- Centre for Primary Care, NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Karina Lovell
- School of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Peter Bower
- Centre for Primary Care, NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Simon Gilbody
- Mental Health & Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Elizabeth Littlewood
- Mental Health & Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Helen Lester
- School of Health and Population Sciences, University of Birmingham, Birmingham, UK
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Gilbody S, Littlewood E, Hewitt C, Brierley G, Tharmanathan P, Araya R, Barkham M, Bower P, Cooper C, Gask L, Kessler D, Lester H, Lovell K, Parry G, Richards DA, Andersen P, Brabyn S, Knowles S, Shepherd C, Tallon D, White D. Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial. BMJ 2015; 351:h5627. [PMID: 26559241 PMCID: PMC4641883 DOI: 10.1136/bmj.h5627] [Citation(s) in RCA: 249] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 12/04/2022]
Abstract
STUDY QUESTION How effective is supported computerised cognitive behaviour therapy (cCBT) as an adjunct to usual primary care for adults with depression? METHODS This was a pragmatic, multicentre, three arm, parallel randomised controlled trial with simple randomisation. Treatment allocation was not blinded. Participants were adults with symptoms of depression (score ≥ 10 on nine item patient health questionnaire, PHQ-9) who were randomised to receive a commercially produced cCBT programme ("Beating the Blues") or a free to use cCBT programme (MoodGYM) in addition to usual GP care. Participants were supported and encouraged to complete the programme via weekly telephone calls. Control participants were offered usual GP care, with no constraints on the range of treatments that could be accessed. The primary outcome was severity of depression assessed with the PHQ-9 at four months. Secondary outcomes included health related quality of life (measured by SF-36) and psychological wellbeing (measured by CORE-OM) at four, 12, and 24 months and depression at 12 and 24 months. STUDY ANSWER AND LIMITATIONS Participants offered commercial or free to use cCBT experienced no additional improvement in depression compared with usual GP care at four months (odds ratio 1.19 (95% confidence interval 0.75 to 1.88) for Beating the Blues v usual GP care; 0.98 (0.62 to 1.56) for MoodGYM v usual GP care). There was no evidence of an overall difference between either programme compared with usual GP care (0.99 (0.57 to 1.70) and 0.68 (0.42 to 1.10), respectively) at any time point. Commercially provided cCBT conferred no additional benefit over free to use cCBT or usual GP care at any follow-up point. Uptake and use of cCBT was low, despite regular telephone support. Nearly a quarter of participants (24%) had dropped out by four months. The study did not have enough power to detect small differences so these cannot be ruled out. Findings cannot be generalised to cCBT offered with a much higher level of guidance and support. WHAT THIS STUDY ADDS Supported cCBT does not substantially improve depression outcomes compared with usual GP care alone. In this study, neither a commercially available nor free to use computerised CBT intervention was superior to usual GP care. FUNDING, COMPETING INTERESTS, DATA SHARING Commissioned and funded by the UK National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme (project No 06/43/05). The authors have no competing interests. Requests for patient level data will be considered by the REEACT trial management groupTrial registration Current Controlled Trials ISRCTN91947481.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Gwen Brierley
- MRC Epidemiology Unit, University of Cambridge School of Clinical Medicine, Cambridge CB2 0QQ, UK
| | - Puvan Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Ricardo Araya
- Department of Population Health, London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK
| | - Michael Barkham
- Centre for Psychological Services Research, Department of Psychology, University of Sheffield, Sheffield S10 2TP, UK
| | - Peter Bower
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - Linda Gask
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - David Kessler
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol BS8 2BN, UK
| | - Helen Lester
- Primary Care Clinical Sciences Building, University of Birmingham, Edgbaston, Birmingham B15 2TT, UK
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester M13 9PL, UK
| | - Glenys Parry
- School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
| | - David A Richards
- University of Exeter Medical School, University of Exeter, Exeter EX1 2LU, UK
| | - Phil Andersen
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sally Brabyn
- Department of Health Sciences, University of York, York YO10 5DD, UK
| | - Sarah Knowles
- NIHR School for Primary Care Research, Manchester Academic Health Science Centre, University of Manchester, Manchester M13 9NT, UK
| | - Charles Shepherd
- Faculty of Health and Social Care, University of Hull, Hull HU6 7RX, UK
| | - Debbie Tallon
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol BS8 2BN, UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield S1 4DA, UK
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Wright B, Tindall L, Littlewood E, Adamson J, Allgar V, Bennett S, Gilbody S, Verduyn C, Alderson-Day B, Dyson L, Trépel D, Ali S. Computerised cognitive behaviour therapy for depression in adolescents: study protocol for a feasibility randomised controlled trial. BMJ Open 2014; 4:e006488. [PMID: 25361841 PMCID: PMC4216856 DOI: 10.1136/bmjopen-2014-006488] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION The 1 year prevalence of depression in adolescents is about 2%. Treatment with antidepressant medication is not recommended for initial treatment in young people due to concerns over high side effects, poor efficacy and addictive potential. Evidence suggests that cognitive behaviour therapy (CBT) is an effective treatment for depression and is currently one of the main treatment options recommended in adolescents. Given the affinity young people have with information technology they may be treated effectively, more widely and earlier in their illness evolution using computer-administered CBT (CCBT). Currently little is known about the clinical and resource implications of implementing CCBT within the National Health Service for adolescents with low mood/depression. We aim to establish the feasibility of running a fully powered randomised controlled trial (RCT). METHODS AND ANALYSIS Adolescents aged 12-18 with low mood/depression, (scoring ≥20 on the Mood and Feelings Questionnaire (MFQ)), will be approached to participate. Consenting participants will be randomised to either a CCBT programme (Stressbusters) or accessing selected websites providing information about low mood/depression. The primary outcome measure will be the Beck Depression Inventory (BDI). Participants will also complete generic health measures (EQ5D-Y, HUI2) and resource use questionnaires to examine the feasibility of cost-effectiveness analysis. Questionnaires will be completed at baseline, 4 and 12-month follow-ups. Progress and risk will be monitored via the MFQ administered at each treatment session. The acceptability of a CCBT programme to adolescents; and the willingness of clinicians to recruit participants and of participants to be randomised, recruitment rates, attrition rates and questionnaire completion rates will be collected for feasibility analysis. We will estimate 'numbers needed' to plan a fully powered RCT of clinical and cost-effectiveness. ETHICS AND DISSEMINATION The current trial protocol received a favourable ethical opinion from Leeds (West) Research and Ethics Committee. (Reference: 10/H1307/137). TRIAL REGISTRATION NUMBER ISRCTN31219579.
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Affiliation(s)
- Barry Wright
- Limetrees Child Adolescent and Family Unit, York, UK
| | - Lucy Tindall
- Limetrees Child Adolescent and Family Unit, York, UK
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Ali S, Littlewood E, McMillan D, Delgadillo J, Miranda A, Croudace T, Gilbody S. Heterogeneity in patient-reported outcomes following low-intensity mental health interventions: a multilevel analysis. PLoS One 2014; 9:e99658. [PMID: 25207881 PMCID: PMC4160171 DOI: 10.1371/journal.pone.0099658] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 05/18/2014] [Indexed: 11/18/2022] Open
Abstract
Background Variability in patient-reported outcomes of psychological treatments has been partly attributed to therapists – a phenomenon commonly known as therapist effects. Meta-analytic reviews reveal wide variation in therapist-attributable variability in psychotherapy outcomes, with most studies reporting therapist effects in the region of 5% to 10% and some finding minimal to no therapist effects. However, all except one study to date have been conducted in high-intensity or mixed intervention groups; therefore, there is scarcity of evidence on therapist effects in brief low-intensity psychological interventions. Objective To examine therapist effects in low-intensity interventions for depression and anxiety in a naturalistic setting. Data and Analysis Session-by-session data on patient-reported outcome measures were available for a cohort of 1,376 primary care psychotherapy patients treated by 38 therapists. Outcome measures included PHQ-9 (sensitive to depression) and GAD-7 (sensitive to general anxiety disorder) measures. Three-level hierarchical linear modelling was employed to estimate therapist-attributable proportion of variance in clinical outcomes. Therapist effects were evaluated using the intra-cluster correlation coefficient (ICC) and Bayesian empirical predictions of therapist random effects. Three sensitivity analyses were conducted: 1) using both treatment completers and non-completers; 2) a sub-sample of cases with baseline scores above the conventional clinical thresholds for PHQ-9 and GAD-7; and 3) a two-level model (using patient-level pre- and post-treatment scores nested within therapists). Results The ICC estimates for all outcome measures were very small, ranging between 0% and 1.3%, although most were statistically significant. The Bayesian empirical predictions showed that therapist random effects were not statistically significantly different from each other. Between patient variability explained most of the variance in outcomes. Conclusion Consistent with the only other study to date in low intensity interventions, evidence was found to suggest minimal to no therapist effects in patient-reported outcomes. This draws attention to the more prominent source of variability which is found at the between-patient level.
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Affiliation(s)
- Shehzad Ali
- Department of Health Sciences, University of York, York, United Kingdom
- Centre for Health Economics, University of York, York, United Kingdom
- * E-mail:
| | | | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
| | - Jaime Delgadillo
- Primary Care Mental Health Service, Leeds Community Healthcare NHS Trust, Leeds, United Kingdom
| | - Alfonso Miranda
- Centro de Investigación y Docencia Económicas, Mexico City, Mexico
| | - Tim Croudace
- Department of Health Sciences, University of York, York, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
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Clark L, Fairhurst C, Hewitt CE, Birks Y, Brabyn S, Cockayne S, Rodgers S, Hicks K, Hodgson R, Littlewood E, Torgerson DJ. A methodological review of recent meta-analyses has found significant heterogeneity in age between randomized groups. J Clin Epidemiol 2014; 67:1016-24. [DOI: 10.1016/j.jclinepi.2014.04.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 04/10/2014] [Accepted: 04/23/2014] [Indexed: 12/20/2022]
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Wright B, Marshall D, Collingridge Moore D, Ainsworth H, Hackney L, Adamson J, Ali S, Allgar V, Cook L, Dyson L, Littlewood E, Hargate R, McLaren A, McMillan D, Trépel D, Whitehead J, Williams C. Autism Spectrum Social Stories In Schools Trial (ASSSIST): study protocol for a feasibility randomised controlled trial analysing clinical and cost-effectiveness of Social Stories in mainstream schools. BMJ Open 2014; 4:e005952. [PMID: 25009139 PMCID: PMC4091400 DOI: 10.1136/bmjopen-2014-005952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Current evidence suggests that Social Stories can be effective in tackling problem behaviours exhibited by children with autism spectrum disorder. Exploring the meaning of behaviour from a child's perspective allows stories to provide social information that is tailored to their needs. Case reports in children with autism have suggested that these stories can lead to a number of benefits including improvements in social interactions and choice making in educational settings. METHODS AND ANALYSIS The feasibility of clinical and cost-effectiveness of a Social Stories toolkit will be assessed using a randomised control framework. Participants (n=50) will be randomised to either the Social Stories intervention or a comparator group where they will be read standard stories for an equivalent amount of time. Statistics will be calculated for recruitment rates, follow-up rates and attrition. Economic analysis will determine appropriate measures of generic health and resource use categories for cost-effectiveness analysis. Qualitative analysis will ascertain information on perceptions about the feasibility and acceptability of the intervention. ETHICS AND DISSEMINATION National Health Service Ethics Approval (NHS; ref 11/YH/0340) for the trial protocol has been obtained along with NHS Research and Development permission from Leeds and York Partnership NHS Foundation Trust. All adverse events will be closely monitored, documented and reported to the study Data Monitoring Ethics Committee. At least one article in a peer reviewed journal will be published and research findings presented at relevant conferences. TRIAL REGISTRATION NUMBER ISRCTN96286707.
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Affiliation(s)
| | | | | | | | | | - Joy Adamson
- York Trials Unit, Department of Health Sciences, York, UK
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK
| | | | - Liz Cook
- York Trials Unit, Department of Health Sciences, York, UK
| | - Lisa Dyson
- York Trials Unit, Department of Health Sciences, York, UK
| | | | | | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
| | - Dominic Trépel
- Department of Health Sciences, University of York, York, UK
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Knowles SE, Toms G, Sanders C, Bee P, Lovell K, Rennick-Egglestone S, Coyle D, Kennedy CM, Littlewood E, Kessler D, Gilbody S, Bower P. Qualitative meta-synthesis of user experience of computerised therapy for depression and anxiety. PLoS One 2014; 9:e84323. [PMID: 24465404 PMCID: PMC3894944 DOI: 10.1371/journal.pone.0084323] [Citation(s) in RCA: 130] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Accepted: 11/14/2013] [Indexed: 11/19/2022] Open
Abstract
Objective Computerised therapies play an integral role in efforts to improve access to psychological treatment for patients with depression and anxiety. However, despite recognised problems with uptake, there has been a lack of investigation into the barriers and facilitators of engagement. We aimed to systematically review and synthesise findings from qualitative studies of computerised therapies, in order to identify factors impacting on engagement. Method Systematic review and meta-synthesis of qualitative studies of user experiences of computer delivered therapy for depression and/or anxiety. Results 8 studies were included in the review. All except one were of desktop based cognitive behavioural treatments. Black and minority ethnic and older participants were underrepresented, and only one study addressed users with a co-morbid physical health problem. Through synthesis, we identified two key overarching concepts, regarding the need for treatments to be sensitive to the individual, and the dialectal nature of user experience, with different degrees of support and anonymity experienced as both positive and negative. We propose that these factors can be conceptually understood as the ‘non-specific’ or ‘common’ factors of computerised therapy, analogous to but distinct from the common factors of traditional face-to-face therapies. Conclusion Experience of computerised therapy could be improved through personalisation and sensitisation of content to individual users, recognising the need for users to experience a sense of ‘self’ in the treatment which is currently absent. Exploiting the common factors of computerised therapy, through enhancing perceived connection and collaboration, could offer a way of reconciling tensions due to the dialectal nature of user experience. Future research should explore whether the findings are generalisable to other patient groups, to other delivery formats (such as mobile technology) and other treatment modalities beyond cognitive behaviour therapy. The proposed model could aid the development of enhancements to current packages to improve uptake and support engagement.
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Affiliation(s)
- Sarah E Knowles
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester, United Kingdom
| | - Gill Toms
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester, United Kingdom
| | - Caroline Sanders
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester, United Kingdom
| | - Penny Bee
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, United Kingdom
| | - Karina Lovell
- School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, United Kingdom
| | | | - David Coyle
- Department of Computer Science, University of Bristol, Bristol, United Kingdom
| | - Catriona M Kennedy
- School of Computer Science, University of Birmingham, Birmingham, United Kingdom
| | - Elizabeth Littlewood
- Mental Health & Addictions Research Group, University of York, York, United Kingdom
| | - David Kessler
- School of Social and Community Medicine, University of Bristol, Bristol, United Kingdom
| | - Simon Gilbody
- Mental Health & Addictions Research Group, University of York, York, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester, United Kingdom
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Clark L, Fairhurst C, Hewitt C, Birks Y, Brabyn S, Cockayne S, Rodgers S, Hicks K, Hodgson R, Littlewood E, Torgerson D. Assessing the presence of selection bias in meta-analyses of randomised trials using baseline heterogeneity. Trials 2013. [PMCID: PMC3981136 DOI: 10.1186/1745-6215-14-s1-o96] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Mosimann UP, Rowan EN, Partington CE, Collerton D, Littlewood E, O'Brien JT, Burn DJ, McKeith IG. Characteristics of visual hallucinations in Parkinson disease dementia and dementia with lewy bodies. Am J Geriatr Psychiatry 2006; 14:153-60. [PMID: 16473980 DOI: 10.1097/01.jgp.0000192480.89813.80] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVE Parkinson disease dementia (PDD) and dementia with Lewy bodies (DLB) have overlapping clinical and pathologic features. Recurrent visual hallucinations (RVH) are common in both disorders. The authors have compared details of hallucination characteristics and associated neuropsychiatric features in DLB and PDD. METHODS This is a descriptive, cross-sectional study using the Institute of Psychiatry Visual Hallucinations Interview (IP-VHI) to explore self-reported frequency, duration, and phenomenology of RVH in PDD and DLB. The caregivers' ratings of hallucinations and other neuropsychiatric features were elicited with the Neuropsychiatric Inventory (NPI). RESULTS Fifty-six patients (35 PDD; 21 DLB) with RVH were assessed. Hallucination characteristics were similar in both disorders. Simple hallucinations were rare. Most patients experienced complex hallucinations daily, normally lasting minutes. They commonly saw people or animals and the experiences were usually perceived as unpleasant. NPI anxiety scores were higher in PDD. Neuropsychiatric symptoms coexisting with hallucinations were apathy, sleep disturbance, and anxiety. CONCLUSIONS Patients with mild to moderate dementia can provide detailed information about their hallucinations. Characteristics of RVH were similar in PDD and DLB, and phenomenology suggests the involvement of dorsal and ventral visual pathways in their generation. The coexistence of RVH with anxiety, apathy, and sleep disturbance is likely to impair patients' quality of life and may have treatment implications.
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Affiliation(s)
- Urs P Mosimann
- Institute for Ageing and Health, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, United Kingdom.
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Thomas AJ, Burn DJ, Rowan EN, Littlewood E, Newby J, Cousins D, Pakrasi S, Richardson J, Sanders J, McKeith IG. A comparison of the efficacy of donepezil in Parkinson's disease with dementia and dementia with Lewy bodies. Int J Geriatr Psychiatry 2005; 20:938-44. [PMID: 16163744 DOI: 10.1002/gps.1381] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Parkinson's disease with dementia (PDD) and dementia with Lewy bodies (DLB) overlap in phenomenology and neurochemical deficits. We hypothesised they would not differ in their response to the cholinesterase inhibitor donepezil. METHODS We recruited 70 subjects, 30 DLB and 40 PDD, in an open label study to compare the efficacy of donepezil in these two patient groups. They were assessed at baseline, 4, 12 and 20 weeks. The main outcome measures were the Mini-Mental State Examination (MMSE), Neuropsychiatric Inventory (NPI) and motor sub-section of the Unified Parkinson's Disease Rating Scale (UPDRS III). RESULTS PDD patients were younger than DLB and had more severe parkinsonism at baseline. The groups were similar on all other variables of interest. By 20 weeks the mean MMSE score increased by 3.9 points in the DLB group and by 3.2 points in PDD. The mean NPI score reduced by 14.6 points for DLB and 12.0 points for PDD. These treatment effects were all significant compared to baseline (p < 0.001) but there were no significant between-group treatment differences (MMSE p = 0.56, NPI p = 0.39). UPDRS III motor scores did not change significantly from baseline values in either group. Although adverse effects were common (69%) they were usually mild and 64 patients (91%) completed the study. The four patients who did withdraw with adverse effects all had a PDD diagnosis. CONCLUSIONS Donepezil produced similar improvements in cognition and behaviour in DLB and PDD. This supports the hypothesis that the two disorders are closely related clinically and neurobiologically. Larger scale, placebo controlled clinical trials are needed to provide an evidence base to guide the clinical use of cholinesterase inhibitors in Lewy body disease.
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Affiliation(s)
- Alan J Thomas
- Institute for Ageing and Health, University of Newcastle upon Tyne, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK
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Minett TSC, Thomas A, Wilkinson LM, Daniel SL, Sanders J, Richardson J, Littlewood E, Myint P, Newby J, McKeith IG. What happens when donepezil is suddenly withdrawn? An open label trial in dementia with Lewy bodies and Parkinson's disease with dementia. Int J Geriatr Psychiatry 2003; 18:988-93. [PMID: 14618549 DOI: 10.1002/gps.995] [Citation(s) in RCA: 95] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND This open label study was designed to assess the effects of donepezil treatment, its withdrawal and subsequent recommencement on cognitive functioning, behaviour and parkinsonian symptoms in patients with probable dementia with Lewy bodies (DLB) and with Parkinson's disease who subsequently developed dementia (PDD). METHODS Eight patients with DLB and 11 with PDD were treated with up to 10 mg of donepezil daily for 20 weeks followed by a 6-week withdrawal period. The primary outcome measures were the Mini-Mental State Examination (MMSE), the total Neuropsychiatric Inventory (NPI) and the Unified Parkinson's Disease Rating Scale III. Testing was conducted before dosing, at week 20, at a withdrawal visit and 3 months after recommencement on donepezil. RESULTS Patients with DLB and PDD showed a significant improvement in cognition with treatment, loss of this improvement on withdrawal and restoration of treatment gains on recommencement. Both groups also demonstrated favourable, behavioural changes with treatment, PDD patients in particular deteriorating significantly after withdrawal. The only NPI symptom domain that showed a consistent significant response to both treatment (positive) and withdrawal (negative) was hallucinations. The medication was well tolerated and parkinsonian features did not alter significantly over the testing sessions. CONCLUSIONS Our results suggest that treatment with donepezil improves cognition and hallucinations without increasing parkinsonian symptoms, and its sudden withdrawal is usually detrimental, producing acute cognitive and behavioural decline. Although recommencement on donepezil appears to reverse this deterioration we do not advise its abrupt discontinuation in this population.
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Affiliation(s)
- Thaís S C Minett
- Institute for Ageing and Health, Wolfson Research Centre, Newcastle General Hospital, Newcastle upon Tyne, UK
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