Anne Garland

THE REVISED COGNITIVE THERAPY SCALE (CTS-R): PSYCHOMETRIC PROPERTIES

The existing scale for assessing competence in cognitive therapy (CTS) dates from 1988 and only the previous version of 1980 has been validated to any extent. A revised version, the CTS-R, was devised to improve on the CTS by: eliminating overlap between items, improving on the scaling system, and defining items more clearly. Kolbs well-known educational model was used as a guideline. In the new 14-item scale, three new items measure general therapeutic flair, the facilitation of emotional expression, and therapists non-verbal behaviours (optional). We hypothesized that the CTS-R would prove more user friendly and demonstrate satisfactory reliability and validity. Twenty-one mental health professionals undergoing training in cognitive therapy provided 102 video-tapes of therapy with 34 patients, reflecting three stages of therapy. The tapes were rated by four expert raters, in a balanced design. The CTS-R showed high internal consistency and adequate average inter-rater reliability. Reliability for individual items varied widely among pairs of raters. Validity was demonstrated by improved ratings of competence for trainees who saw patients early and later during the course of training. Although raters found the CTS-R a more useful tool than the CTS and satisfactory reliability and validity were demonstrated, more refinement is needed in item definition. The study has led to modifications in the CTS-R, which are in the process of evaluation.

Cognitive behavioural therapy as an adjunct to pharmacotherapy for primary care based patients with treatment resistant depression: results of the CoBalT randomised controlled trial

BACKGROUND Only a third of patients with depression respond fully to antidepressant medication but little evidence exists regarding the best next-step treatment for those whose symptoms are treatment resistant. The CoBalT trial aimed to examine the effectiveness of cognitive behavioural therapy (CBT) as an adjunct to usual care (including pharmacotherapy) for primary care patients with treatment resistant depression compared with usual care alone. METHODS This two parallel-group multicentre randomised controlled trial recruited 469 patients aged 18-75 years with treatment resistant depression (on antidepressants for ≥6 weeks, Beck depression inventory [BDI] score ≥14 and international classification of diseases [ICD]-10 criteria for depression) from 73 UK general practices. Participants were randomised, with a computer generated code (stratified by centre and minimised according to baseline BDI score, whether the general practice had a counsellor, previous treatment with antidepressants, and duration of present episode of depression) to one of two groups: usual care or CBT in addition to usual care, and were followed up for 12 months. Because of the nature of the intervention it was not possible to mask participants, general practitioners, CBT therapists, or researchers to the treatment allocation. Analyses were by intention to treat. The primary outcome was response, defined as at least 50% reduction in depressive symptoms (BDI score) at 6 months compared with baseline. This trial is registered, ISRCTN38231611. FINDINGS Between Nov 4, 2008, and Sept 30, 2010, we assigned 235 patients to usual care, and 234 to CBT plus usual care. 422 participants (90%) were followed up at 6 months and 396 (84%) at 12 months, finishing on Oct 31, 2011. 95 participants (46%) in the intervention group met criteria for response at 6 months compared with 46 (22%) in the usual care group (odds ratio 3·26, 95% CI 2·10-5·06, p<0·001). INTERPRETATION Before this study, no evidence from large-scale randomised controlled trials was available for the effectiveness of augmentation of antidepressant medication with CBT as a next-step for patients whose depression has not responded to pharmacotherapy. Our study has provided robust evidence that CBT as an adjunct to usual care that includes antidepressants is an effective treatment, reducing depressive symptoms in this population. FUNDING National Institute for Health Research Health Technology Assessment.

Cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial

BACKGROUND Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication. AIMS To assess the cost-effectiveness of cognitive-behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone. METHOD Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs). RESULTS The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups. CONCLUSIONS The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.

Cost-effectiveness of CBT as an adjunct to pharmacotherapy for treatment resistant depression in primary care: economic evaluation of the CoBaIT Trial

BACKGROUND Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication. AIMS To assess the cost-effectiveness of cognitive-behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone. METHOD Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs). RESULTS The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups. CONCLUSIONS The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT.

Randomised controlled trial of the clinical and cost effectiveness of a specialist team for managing refractory unipolar depressive disorder

BackgroundAround 40 per cent of patients with unipolar depressive disorder who are treated in secondary care mental health services do not respond to first or second line treatments for depression. Such patients have 20 times the suicide rate of the general population and treatment response becomes harder to achieve and sustain the longer they remain depressed. Despite this there are no randomised controlled trials of community based service delivery interventions delivering both algorithm based pharmacotherapy and psychotherapy for patients with chronic depressive disorder in secondary care mental health services who remain moderately or severely depressed after six months treatment. Without such trials evidence based guidelines on services for such patients cannot be derived.Methods/designSingle blind individually randomised controlled trial of a specialist depression disorder team (psychiatrist and psychotherapist jointly assessing and providing algorithm based drug and psychological treatment) versus usual secondary care treatment. We will recruit 174 patients with unipolar depressive disorder in secondary mental health services with a Hamilton Depression Rating Scale (HDRS) score ≥ 16 and global assessment of function (GAF) ≤ 60 after ≥ 6 months treatment. The primary outcome measures will be the HDRS and GAF supplemented by economic analysis incuding the EQ5 D and analysis of barriers to care, implementation and the process of care. Audits to benchmark both treatment arms against national standards of care will aid the interpretation of the results of the study.DiscussionThis trial will be the first to assess the effectiveness and implementation of a community based specialist depression disorder team. The study has been specially designed as part of the CLAHRC Nottinghamshire, Derbyshire and Lincolnshire joint collaboration between university, health and social care organisations to provide information of direct relevance to decisions on commissioning, service provision and implementation.Trial registrationClinical trials.gov identifier NCT01047124

Training the wider workforce in cognitive behavioural self-help: the SPIRIT (Structured Psychosocial InteRventions in Teams) training course.

BACKGROUND The use of Cognitive Behavioural Therapy (CBT) self-help materials for depression is increasingly recommended as part of stepped care service models. Such resources can be delivered by both new specialist workers (such as the IAPT services in England), or by introducing this style of working into an existing workforce as described in the current paper. The Structured Psychosocial InteRventions in Teams (SPIRIT) course consists of 38.5 hours of workshops, and 5 hours of clinical supervision in the use of CBT self-help (CBSH). METHOD This study describes an evaluation of the effectiveness of the course when offered to community and inpatient mental health staff from a wide range of adult and older adult mental health teams in NHS Greater Glasgow Mental Health Division. RESULTS Training resulted in both subjective and objective knowledge and skills gains at the end of training that were largely sustained 3 months later. At that time point, 40% of staff still reported use of CBSH in the last week. Satisfaction with the training is high, using validated rating scales. CONCLUSIONS The SPIRIT training has gone some way to increasing access to CBSH for use in everyday clinical practice.

Beliefs about Depression in Patients and Their Partners

We examined beliefs about depression in patients and their partners and explored the impact of beliefs on perceptions of marital functioning, level of distress and caregiving in partners, and clinical outcome of major depression. Fifteen patients meeting criteria for major depressive disorder and their co-habiting spouses were interviewed at baseline using the Reasons for Depression Questionnaire (Addis, Truax and Jacobson, 1995) and measures of symptom severity, distress, caregiver consequences and marital satisfaction. Outcome was assessed at 6 months. Identifying biological reasons for depression was significantly associated with patient severity of depression and with caregiver burden. Caregiver distress was significantly associated with endorsement of interpersonal reasons for depression. Concordance in reason giving between patients and partners was significantly associated with a good outcome. This is the first study to show that beliefs about depression held by patients and their partners may have an impact on the clinical outcome of major depression.

Factor structure and longitudinal measurement invariance of PHQ-9 for specialist mental health care patients with persistent major depressive disorder: Exploratory Structural Equation Modelling

BACKGROUND The Patient Health Questionnaire-9 (PHQ-9) is a widely used instrument for measuring levels of depression in patients in clinical practice and academic research; its factor structure has been investigated in various samples, with limited evidence of measurement equivalence/invariance (ME/I) but not in patients with more severe depression of long duration. This study aims to explore the factor structure of the PHQ-9 and the ME/I between treatment groups over time for these patients. METHODS 187 secondary care patients with persistent major depressive disorder (PMDD) were recruited to a randomised controlled trial (RCT) with allocation to either a specialist depression team arm or a general mental health arm; their PHQ-9 score was measured at baseline, 3, 6, 9 and 12 months. Exploratory Structural Equational Modelling (ESEM) was performed to examine the factor structure for this specific patient group. ME/I between treatment arm at and across follow-up time were further explored by means of multiple-group ESEM approach using the best-fitted factor structure. RESULTS A two-factor structure was evidenced (somatic and affective factor). This two-factor structure had strong factorial invariance between the treatment groups at and across follow up times. LIMITATIONS Participants were largely white British in a RCT with 40% attrition potentially limiting the studys generalisability. Not all two-factor modelling criteria were met at every time-point. CONCLUSION PHQ-9 has a two-factor structure for PMDD patients, with strong measurement invariance between treatment groups at and across follow-up time, demonstrating its validity for RCTs and prospective longitudinal studies in chronic moderate to severe depression.