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Keetharuth AD, Gould RL, McDermott CJ, Thompson BJ, Rawlinson C, Bradburn M, Bursnall M, Kumar P, Turton EJ, Tappenden P, White D, Howard RJ, Serfaty MA, McCracken LM, Graham CD, Al-Chalabi A, Goldstein LH, Lawrence V, Cooper C, Young T. Cost-effectiveness of acceptance and commitment therapy for people living with motor neuron disease, and their health-related quality of life. Eur J Neurol 2024:e16317. [PMID: 38660985 DOI: 10.1111/ene.16317] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 03/27/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Given the degenerative nature of the condition, people living with motor neuron disease (MND) experience high levels of psychological distress. The purpose of this research was to investigate the cost-effectiveness of acceptance and commitment therapy (ACT), adapted for the specific needs of this population, for improving quality of life. METHODS A trial-based cost-utility analysis over a 9-month period was conducted comparing ACT plus usual care (n = 97) versus usual care alone (n = 94) from the perspective of the National Health Service. In the primary analysis, quality-adjusted life years (QALYs) were computed using health utilities generated from the EQ-5D-5L questionnaire. Sensitivity analyses and subgroup analyses were also carried out. RESULTS Difference in costs was statistically significant between the two arms, driven mainly by the intervention costs. Effects measured by EQ-5D-5L were not statistically significantly different between the two arms. The incremental cost-effectiveness was above the £20,000 to £30,000 per QALY gained threshold used in the UK. However, the difference in effects was statistically significant when measured by the McGill Quality of Life-Revised (MQOL-R) questionnaire. The intervention was cost-effective in a subgroup experiencing medium deterioration in motor neuron symptoms. CONCLUSIONS Despite the intervention being cost-ineffective in the primary analysis, the significant difference in the effects measured by MQOL-R, the low costs of the intervention, the results in the subgroup analysis, and the fact that ACT was shown to improve the quality of life for people living with MND, suggest that ACT could be incorporated into MND clinical services.
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Affiliation(s)
- Anju D Keetharuth
- School of Medicine and Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Rebecca L Gould
- Division of Psychiatry, University College London, London, UK
| | | | - Benjamin J Thompson
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | | | - Mike Bradburn
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Matt Bursnall
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pavithra Kumar
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Emily J Turton
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Paul Tappenden
- School of Medicine and Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - David White
- School of Medicine and Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert J Howard
- Division of Psychiatry, University College London, London, UK
| | - Marc A Serfaty
- Division of Psychiatry, University College London, London, UK
- Priory Hospital North London, London, UK
| | | | - Christopher D Graham
- Department of Psychological Sciences & Health, University of Strathclyde, Glasgow, UK
| | - Ammar Al-Chalabi
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Vanessa Lawrence
- Health Service & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
| | - Tracey Young
- School of Medicine and Population Health, Sheffield Centre for Health and Related Research, University of Sheffield, Sheffield, UK
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Gould RL, Rawlinson C, Thompson B, Weeks K, Gossage-Worrall R, Cantrill H, Serfaty MA, Graham CD, McCracken LM, White D, Howard RJ, Bursnall M, Bradburn M, Al-Chalabi A, Orrell R, Chhetri SK, Noad R, Radunovic A, Williams T, Young CA, Dick D, Lawrence V, Goldstein LH, Young T, Ealing J, McLeod H, Williams N, Weatherly H, Cave R, Chiwera T, Pagnini F, Cooper C, Shaw PJ, McDermott CJ. Acceptance and Commitment Therapy for people living with motor neuron disease: an uncontrolled feasibility study. Pilot Feasibility Stud 2023; 9:116. [PMID: 37420261 DOI: 10.1186/s40814-023-01354-7] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/27/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Motor neuron disease (MND) is a fatal, progressive neurodegenerative disease that causes progressive weakening and wasting of limb, bulbar, thoracic and abdominal muscles. Clear evidence-based guidance on how psychological distress should be managed in people living with MND (plwMND) is lacking. Acceptance and Commitment Therapy (ACT) is a form of psychological therapy that may be particularly suitable for this population. However, to the authors' knowledge, no study to date has evaluated ACT for plwMND. Consequently, the primary aim of this uncontrolled feasibility study was to examine the feasibility and acceptability of ACT for improving the psychological health of plwMND. METHODS PlwMND aged ≥ 18 years were recruited from 10 UK MND Care Centres/Clinics. Participants received up to 8 one-to-one ACT sessions, developed specifically for plwMND, plus usual care. Co-primary feasibility and acceptability outcomes were uptake (≥ 80% of the target sample [N = 28] recruited) and initial engagement with the intervention (≥ 70% completing ≥ 2 sessions). Secondary outcomes included measures of quality of life, anxiety, depression, disease-related functioning, health status and psychological flexibility in plwMND and quality of life and burden in caregivers. Outcomes were assessed at baseline and 6 months. RESULTS Both a priori indicators of success were met: 29 plwMND (104%) were recruited and 76% (22/29) attended ≥ 2 sessions. Attrition at 6-months was higher than anticipated (8/29, 28%), but only two dropouts were due to lack of acceptability of the intervention. Acceptability was further supported by good satisfaction with therapy and session attendance. Data were possibly suggestive of small improvements in anxiety and psychological quality of life from baseline to 6 months in plwMND, despite a small but expected deterioration in disease-related functioning and health status. CONCLUSIONS There was good evidence of acceptability and feasibility. Limitations included the lack of a control group and small sample size, which complicate interpretation of findings. A fully powered RCT to evaluate the clinical and cost-effectiveness of ACT for plwMND is underway. TRIAL REGISTRATION The study was pre-registered with the ISRCTN Registry (ISRCTN12655391).
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Affiliation(s)
- Rebecca L Gould
- Division of Psychiatry, University College London, Wing B, 6th Floor Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK.
| | - Charlotte Rawlinson
- Division of Psychiatry, University College London, Wing B, 6th Floor Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Ben Thompson
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Kirsty Weeks
- Division of Psychiatry, University College London, Wing B, 6th Floor Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Rebecca Gossage-Worrall
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hannah Cantrill
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marc A Serfaty
- Division of Psychiatry, University College London, Wing B, 6th Floor Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
- Priory Hospital North London, London, UK
| | - Christopher D Graham
- Strathclyde Psychology, Department of Psychological Sciences & Health, University of Strathclyde, Glasgow, UK
| | | | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert J Howard
- Division of Psychiatry, University College London, Wing B, 6th Floor Maple House, 149 Tottenham Court Rd, London, W1T 7NF, UK
| | - Matt Bursnall
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Ammar Al-Chalabi
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Richard Orrell
- Department of Clinical and Movement Neurosciences, Institute of Neurology, University College London, London, UK
| | - Suresh K Chhetri
- Lancashire Teaching Hospitals NHS Foundation Trust, Lancashire, UK
| | - Rupert Noad
- Department of Neuropsychology, Derriford Hospital, Plymouth, UK
| | | | - Tim Williams
- The Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | | | - David Dick
- Norfolk and Norwich University Hospital, Norwich, UK
| | - Vanessa Lawrence
- Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - John Ealing
- Manchester Centre for Clinical Neurosciences, Salford Royal NHS Foundation Trust, Salford, UK
| | - Hamish McLeod
- Mental Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Nicola Williams
- Primary Care Clinical Trials Unit, Oxford University, Oxford, UK
| | | | - Richard Cave
- Language and Cognition, University College London, London, UK
| | - Theresa Chiwera
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Francesco Pagnini
- Department of Psychology, Università Cattolica del Sacro Cuore, Milan, Italy
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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Gould RL, Thompson BJ, Rawlinson C, Kumar P, White D, Serfaty MA, Graham CD, McCracken LM, Bursnall M, Bradburn M, Young T, Howard RJ, Al-Chalabi A, Goldstein LH, Lawrence V, Cooper C, Shaw PJ, McDermott CJ. A randomised controlled trial of acceptance and commitment therapy plus usual care compared to usual care alone for improving psychological health in people with motor neuron disease (COMMEND): study protocol. BMC Neurol 2022; 22:431. [PMID: 36380299 PMCID: PMC9664029 DOI: 10.1186/s12883-022-02950-5] [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] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/28/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Motor neuron disease (MND) is a rapidly progressive, fatal neurodegenerative disease that predominantly affects motor neurons from the motor cortex to the spinal cord and causes progressive wasting and weakening of bulbar, limb, abdominal and thoracic muscles. Prognosis is poor and median survival is 2-3 years following symptom onset. Psychological distress is relatively common in people living with MND. However, formal psychotherapy is not routinely part of standard care within MND Care Centres/clinics in the UK, and clear evidence-based guidance on improving the psychological health of people living with MND is lacking. Previous research suggests that Acceptance and Commitment Therapy (ACT) may be particularly suitable for people living with MND and may help improve their psychological health. AIMS To assess the clinical and cost-effectiveness of ACT modified for MND plus usual multidisciplinary care (UC) in comparison to UC alone for improving psychological health in people living with MND. METHODS The COMMEND trial is a multi-centre, assessor-blind, parallel, two-arm RCT with a 10-month internal pilot phase. 188 individuals aged ≥ 18 years with a diagnosis of definite, laboratory-supported probable, clinically probable, or possible familial or sporadic amyotrophic lateral sclerosis, and additionally the progressive muscular atrophy and primary lateral sclerosis variants, will be recruited from approximately 14 UK-based MND Care Centres/clinics and via self-referral. Participants will be randomly allocated to receive up to eight 1:1 sessions of ACT plus UC or UC alone by an online randomisation system. Participants will complete outcome measures at baseline and at 6- and 9-months post-randomisation. The primary outcome will be quality of life at six months. Secondary outcomes will include depression, anxiety, psychological flexibility, health-related quality of life, adverse events, ALS functioning, survival at nine months, satisfaction with therapy, resource use and quality-adjusted life years. Primary analyses will be by intention to treat and data will be analysed using multi-level modelling. DISCUSSION This trial will provide definitive evidence on the clinical and cost-effectiveness of ACT plus UC in comparison to UC alone for improving psychological health in people living with MND. TRIAL REGISTRATION ISRCTN Registry, ISRCTN12655391. Registered 17 July 2017, https://www.isrctn.com/ISRCTN12655391 . PROTOCOL VERSION 3.1 (10/06/2020).
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Affiliation(s)
- Rebecca L Gould
- Division of Psychiatry, University College London, Wing B, 6th floor Maple House, 149 Tottenham Court Rd, W1T 7NF, London, UK.
| | - Benjamin J Thompson
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Charlotte Rawlinson
- Division of Psychiatry, University College London, Wing B, 6th floor Maple House, 149 Tottenham Court Rd, W1T 7NF, London, UK
| | - Pavithra Kumar
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - David White
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Marc A Serfaty
- Division of Psychiatry, University College London, Wing B, 6th floor Maple House, 149 Tottenham Court Rd, W1T 7NF, London, UK
- Priory Hospital North London, London, UK
| | | | | | - Matt Bursnall
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Tracey Young
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Robert J Howard
- Division of Psychiatry, University College London, Wing B, 6th floor Maple House, 149 Tottenham Court Rd, W1T 7NF, London, UK
| | - Ammar Al-Chalabi
- Maurice Wohl Clinical Neuroscience Institute, King's College London, London, UK
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Vanessa Lawrence
- Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Cindy Cooper
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Pamela J Shaw
- Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
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Gould RL, Wetherell JL, Serfaty MA, Kimona K, Lawrence V, Jones R, Livingston G, Wilkinson P, Walters K, Novere ML, Howard RJ. Acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder: the FACTOID feasibility study. Health Technol Assess 2021; 25:1-150. [PMID: 34542399 DOI: 10.3310/hta25540] [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] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Generalised anxiety disorder, characterised by excessive anxiety and worry, is the most common anxiety disorder among older people. It is a condition that may persist for decades and is associated with numerous negative outcomes. Front-line treatments include pharmacological and psychological therapy, but many older people do not find these treatments effective. Guidance on managing treatment-resistant generalised anxiety disorder in older people is lacking. OBJECTIVES To assess whether or not a study to examine the clinical effectiveness and cost-effectiveness of acceptance and commitment therapy for older people with treatment-resistant generalised anxiety disorder is feasible, we developed an intervention based on acceptance and commitment therapy for this population, assessed its acceptability and feasibility in an uncontrolled feasibility study and clarified key study design parameters. DESIGN Phase 1 involved qualitative interviews to develop and optimise an intervention as well as a survey of service users and clinicians to clarify usual care. Phase 2 involved an uncontrolled feasibility study and qualitative interviews to refine the intervention. SETTING Participants were recruited from general practices, Improving Access to Psychological Therapies services, Community Mental Health Teams and the community. PARTICIPANTS Participants were people aged ≥ 65 years with treatment-resistant generalised anxiety disorder. INTERVENTION Participants received up to 16 one-to-one sessions of acceptance and commitment therapy, adapted for older people with treatment-resistant generalised anxiety disorder, in addition to usual care. Sessions were delivered by therapists based in primary and secondary care services, either in the clinic or at participants' homes. Sessions were weekly for the first 14 sessions and fortnightly thereafter. MAIN OUTCOME MEASURES The co-primary outcome measures for phase 2 were acceptability (session attendance and satisfaction with therapy) and feasibility (recruitment and retention). Secondary outcome measures included additional measures of acceptability and feasibility and self-reported measures of anxiety, worry, depression and psychological flexibility. Self-reported outcomes were assessed at 0 weeks (baseline) and 20 weeks (follow-up). Health economic outcomes included intervention and resource use costs and health-related quality of life. RESULTS Fifteen older people with treatment-resistant generalised anxiety disorder participated in phase 1 and 37 participated in phase 2. A high level of feasibility was demonstrated by a recruitment rate of 93% and a retention rate of 81%. A high level of acceptability was found with respect to session attendance (70% of participants attended ≥ 10 sessions) and satisfaction with therapy was adequate (60% of participants scored ≥ 21 out of 30 points on the Satisfaction with Therapy subscale of the Satisfaction with Therapy and Therapist Scale-Revised, although 80% of participants had not finished receiving therapy at the time of rating). Secondary outcome measures and qualitative data further supported the feasibility and acceptability of the intervention. Health economic data supported the feasibility of examining cost-effectiveness in a future randomised controlled trial. Although the study was not powered to examine clinical effectiveness, there was indicative evidence of improvements in scores for anxiety, depression and psychological flexibility. LIMITATIONS Non-specific therapeutic factors were not controlled for, and recruitment in phase 2 was limited to London. CONCLUSIONS There was evidence of high levels of feasibility and acceptability and indicative evidence of improvements in symptoms of anxiety, depression and psychological flexibility. The results of this study suggest that a larger-scale randomised controlled trial would be feasible to conduct and is warranted. TRIAL REGISTRATION Current Controlled Trials ISRCTN12268776. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 54. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Rebecca L Gould
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Julie Loebach Wetherell
- Department of Psychiatry, VA San Diego Healthcare System, University of California San Diego, La Jolla, CA, USA
| | - Marc A Serfaty
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Kate Kimona
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Vanessa Lawrence
- Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rebecca Jones
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Gill Livingston
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | | | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Marie Le Novere
- Department of Primary Care and Population Health, University College London, London, UK
| | - Robert J Howard
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
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Gould RL, Wetherell JL, Kimona K, Serfaty MA, Jones R, Graham CD, Lawrence V, Livingston G, Wilkinson P, Walters K, Le Novere M, Leroi I, Barber R, Lee E, Cook J, Wuthrich VM, Howard RJ. Acceptance and commitment therapy for late-life treatment-resistant generalised anxiety disorder: a feasibility study. Age Ageing 2021; 50:1751-1761. [PMID: 33852722 PMCID: PMC8437065 DOI: 10.1093/ageing/afab059] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/08/2020] [Revised: 01/31/2021] [Accepted: 02/04/2021] [Indexed: 11/18/2022] Open
Abstract
Background Generalised anxiety disorder (GAD) is the most common anxiety disorder in older people. First-line management includes pharmacological and psychological therapies, but many do not find these effective or acceptable. Little is known about how to manage treatment-resistant generalised anxiety disorder (TR-GAD) in older people. Objectives To examine the acceptability, feasibility and preliminary estimates of the effectiveness of acceptance and commitment therapy (ACT) for older people with TR-GAD. Participants People aged ≥65 years with TR-GAD (defined as not responding to GAD treatment, tolerate it or refused treatment) recruited from primary and secondary care services and the community. Intervention Participants received up to 16 one-to-one sessions of ACT, developed specifically for older people with TR-GAD, in addition to usual care. Measurements Co-primary outcomes were feasibility (defined as recruitment of ≥32 participants and retention of ≥60% at follow-up) and acceptability (defined as participants attending ≥10 sessions and scoring ≥21/30 on the satisfaction with therapy subscale). Secondary outcomes included measures of anxiety, worry, depression and psychological flexibility (assessed at 0 and 20 weeks). Results Thirty-seven participants were recruited, 30 (81%) were retained and 26 (70%) attended ≥10 sessions. A total of 18/30 (60%) participants scored ≥21/30 on the satisfaction with therapy subscale. There was preliminary evidence suggesting that ACT may improve anxiety, depression and psychological flexibility. Conclusions There was evidence of good feasibility and acceptability, although satisfaction with therapy scores suggested that further refinement of the intervention may be necessary. Results indicate that a larger-scale randomised controlled trial of ACT for TR-GAD is feasible and warranted.
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Affiliation(s)
- Rebecca L Gould
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Julie Loebach Wetherell
- Mental Health Service, VA San Diego Healthcare System, San Diego, CA, USA
- Department of Psychiatry, University of California, San Diego, CA, USA
| | - Kate Kimona
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | - Marc A Serfaty
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
- Priory Hospital North London, London, UK
| | - Rebecca Jones
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | | | - Vanessa Lawrence
- Health Services and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Gill Livingston
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
| | | | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Marie Le Novere
- Department of Primary Care and Population Health, University College London, London, UK
| | - Iracema Leroi
- Global Brain Health Institute, School of Medicine, Trinity College Dublin, Dublin, Ireland
| | - Robert Barber
- Centre for Health of the Elderly, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, UK
| | - Ellen Lee
- Clinical Trials Research Unit, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Jo Cook
- The Bexleyheath Centre, Oxleas NHS Foundation Trust, Bexleyheath, UK
| | - Viviana M Wuthrich
- Department of Psychology, Centre for Emotional Health, Macquarie University, Sydney, Australia
- Department of Psychology, Centre for Ageing, Cognition and Wellbeing, Macquarie University, Sydney, Australia
| | - Robert J Howard
- Division of Psychiatry, Faculty of Brain Sciences, University College London, London, UK
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Lawrence V, Kimona K, Howard RJ, Serfaty MA, Wetherell JL, Livingston G, Wilkinson P, Walters K, Jones R, Wuthrich VM, Gould RL. Optimising the acceptability and feasibility of acceptance and commitment therapy for treatment-resistant generalised anxiety disorder in older adults. Age Ageing 2019; 48:741-750. [PMID: 31297539 DOI: 10.1093/ageing/afz082] [Citation(s) in RCA: 5] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 03/19/2019] [Accepted: 06/10/2019] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND generalised anxiety disorder (GAD) is common in later life with a prevalence of 3-12%. Many only partially respond to cognitive behavioural therapy or pharmacotherapy and can be classified as treatment resistant. These patients experience poor quality of life, and are at increased risk of comorbid depression, falls and loneliness. Acceptance and commitment therapy (ACT) is an emerging therapy, which may be particularly suited to this population, but has not been tailored to their needs. OBJECTIVES to optimise the acceptability and feasibility of ACT for older adults with treatment-resistant GAD. DESIGN a person-based approach to ground the adapted ACT intervention in the perspectives and lives of those who will use it. METHODS first, we conducted qualitative interviews with 15 older adults with GAD and 36 healthcare professionals to develop guiding principles to inform the intervention. Second, we consulted service users and clinical experts and interviewed the same 15 older adults using 'think aloud' techniques to enhance its acceptability and feasibility. RESULTS in Stage 1, older adults' concerns and needs were categorised in four themes: 'Expert in one's own condition', 'Deep seated coping strategies', 'Expert in therapy' and 'Support with implementation'. In Stage 2, implications for therapy were identified that included an early focus on values and ACT as a collaborative partnership, examining beliefs around 'self as worrier' and the role of avoidance, validating and accommodating individuals' knowledge and experience and compensating for age-related cognitive changes. DISCUSSION Our systematic approach combined rigour and transparency to develop a therapeutic intervention tailored to the specific needs of older adults with treatment-resistant GAD.
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Affiliation(s)
- Vanessa Lawrence
- Health Services & Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King’s College London, London, UK
| | - Kate Kimona
- Division of Psychiatry, University College London, London, UK
| | - Robert J Howard
- Division of Psychiatry, University College London, London, UK
| | - Marc A Serfaty
- Division of Psychiatry, University College London, London, UK
| | | | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
| | | | - Kate Walters
- Department of Primary Care and Population Health, University College London, London, UK
| | - Rebecca Jones
- Division of Psychiatry, University College London, London, UK
| | - Viviana M Wuthrich
- Department of Psychology, Centre for Emotional Health, Macquarie University
| | - Rebecca L Gould
- Division of Psychiatry, University College London, London, UK
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Holman AJ, Serfaty MA, Leurent BE, King MB. Cost-effectiveness of cognitive behaviour therapy versus talking and usual care for depressed older people in primary care. BMC Health Serv Res 2011; 11:33. [PMID: 21314920 PMCID: PMC3046916 DOI: 10.1186/1472-6963-11-33] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2010] [Accepted: 02/11/2011] [Indexed: 11/10/2022] Open
Abstract
Background Whilst evidence suggests cognitive behaviour therapy (CBT) may be effective for depressed older people in a primary care setting, few studies have examined its cost-effectiveness. The aim of this study was to compare the cost-effectiveness of cognitive behaviour therapy (CBT), a talking control (TC) and treatment as usual (TAU), delivered in a primary care setting, for older people with depression. Methods Cost data generated from a single blind randomised controlled trial of 204 people aged 65 years or more were offered only Treatment as Usual, or TAU plus up to twelve sessions of CBT or a talking control is presented. The Beck Depression Inventory II (BDI-II) was the main outcome measure for depression. Direct treatment costs were compared with reductions in depression scores. Cost-effectiveness analysis was conducted using non-parametric bootstrapping. The primary analysis focussed on the cost-effectiveness of CBT compared with TAU at 10 months follow up. Results Complete cost data were available for 198 patients at 4 and 10 month follow up. There were no significant differences between groups in baseline costs. The majority of health service contacts at follow up were made with general practitioners. Fewer contacts with mental health services were recorded in patients allocated to CBT, though these differences were not significant. Overall total per patient costs (including intervention costs) were significantly higher in the CBT group compared with the TAU group at 10 month follow up (difference £427, 95% CI: £56 - £787, p < 0.001). Reductions in BDI-II scores were significantly greater in the CBT group (difference 3.6 points, 95% CI: 0.7-6.5 points, p = 0.018). CBT is associated with an incremental cost of £120 per additional point reduction in BDI score and a 90% probability of being considered cost-effective if purchasers are willing to pay up to £270 per point reduction in the BDI-II score. Conclusions CBT is significantly more costly than TAU alone or TAU plus TC, but more clinically effective. Based on current estimates, CBT is likely to be recommended as a cost-effective treatment option for this patient group if the value placed on a unit reduction in BDI-II is greater than £115. Trial Registration isrctn.org Identifier: ISRCTN18271323
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Affiliation(s)
- Amanda J Holman
- Research Department of Mental Health Sciences, University College Medical School, London, UK.
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Serfaty MA, Lawrie A, Smith B, Brind AM, Watson JP, Gilvarry E, Bassendine MF. Risk factors and medical follow-up of drug users tested for hepatitis C--can the risk of transmission be reduced? Drug Alcohol Rev 2005; 16:339-47. [PMID: 16203447 DOI: 10.1080/09595239700186721] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Of 1728 patients attending a regional drug and alcohol clinic, 202 were considered at risk of hepatitis C virus (HCV). Forty-nine per cent (99/202) agreed to testing-67% (67) were HCV antibody positive. Age and a history of needle sharing was the significant factor associated with positive HCV status. Patients on methadone maintenance medication were more-likely to have been HCV positive, but significantly (p = 0.005) less likely to have shared needles in the previous year. Seventy-three per cent (49/67) attended for follow-up at a "liver clinic". Fifty per cent were infected with genotype 1a. Eighteen patients were biopsied and all were abnormal, ranging from mild hepatitis to severe fibrotic hepatitis. Attendance for medical follow-up was poor, which emphasizes the importance of preventative measures such as methadone maintenance programmes for reducing the spread of HCV.
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Affiliation(s)
- M A Serfaty
- Drug and Alcohol Unit, Plummer Court, Newcastle upon Tyne, NE1 6UR, UK
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Serfaty MA, Martin LM, Lingham R, Ferrier IN. The effect of psychotropic medication on seizure duration during bilateral electroconvulsive therapy: a retrospective study. J Psychopharmacol 1996; 10:303-8. [PMID: 22302978 DOI: 10.1177/026988119601000408] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [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: 11/16/2022]
Abstract
A five-year retrospective study investigating the effects of psychotropic medication on first seizure length was undertaken on 109 patients who received 131 courses of electroconvulsive therapy (ECT). Bilateral ECT was administered under methohexitone anaesthesia. Induction of a seizure was successful in 105 patients. Stepwise linear regression analysis showed that except for selective serotonin reuptake inhibitors (SSRIs) seizure length was not affected by psychotropic medication, SSRIs were associated with prolonged seizure length (p=0.0012). Less than one-third of the subjects had drugs with anticonvulsant properties omitted before treatment. Drugs with anticonvulsant properties did not shorten seizure length. Though this study suggests that SSRIs may prolong fit length, further clarification of the predictors for seizure duration is required.
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Affiliation(s)
- M A Serfaty
- University Department of Psychiatry, The Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NEI 4LP, UK
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