Glenys Parry

The acceptability to patients of computerized cognitive behaviour therapy for depression: a systematic review.

BACKGROUND Cognitive behaviour therapy (CBT) is widely used to treat depression. However, CBT is not always available to patients because of a shortage of therapists and long waiting times. Computerized CBT (CCBT) is one of several alternatives currently available to treat patients with depression. Evidence of its clinical effectiveness has led to programs being used increasingly within the UK and elsewhere. However, little information is available regarding the acceptability of CCBT to patients. METHOD A systematic review of sources of information on acceptability to patients of CCBT for depression. RESULTS Sources of information on acceptability included: recruitment rates, patient drop-outs and patient-completed questionnaires. We identified 16 studies of CCBT for the treatment of depression that provided at least some information on these sources. Limited information was provided on patient take-up rates and recruitment methods. Drop-out rates were comparable to other forms of treatment. Take-up rates, when reported, were much lower. Six of the 16 studies included specific questions on patient acceptability or satisfaction although information was only provided for those who had completed treatment. Several studies have reported positive expectancies and high satisfaction in routine care CCBT services for those completing treatment. CONCLUSIONS Trials of CCBT should include more detailed information on patient recruitment methods, drop-out rates and reasons for dropping out. It is important that well-designed surveys and qualitative studies are included alongside trials to determine levels and determinants of patient acceptability.

Health status of Gypsies and Travellers in England

Objective: To provide the first valid and reliable estimate of the health status of Gypsies and Travellers in England by using standardised instruments to compare their health with that of a UK resident non-Traveller sample, drawn from different socioeconomic and ethnic groups, matched for age and sex. Design: Epidemiological survey, by structured interview, of quota sample and concurrent age–sex-matched comparators. Setting: The homes or alternative community settings of the participants at five study locations in England. Participants: Gypsies and Travellers of UK or Irish origin (n = 293) and an age–sex-matched comparison sample (n = 260); non-Gypsies or Travellers from rural communities, deprived inner-city White residents and ethnic minority populations. Results: Gypsies and Travellers reported poorer health status for the last year, were significantly more likely to have a long-term illness, health problem or disability, which limits daily activities or work, had more problems with mobility, self-care, usual activities, pain or discomfort and anxiety or depression as assessed using the EuroQol-5D health utility measure, and a higher overall prevalence of reported chest pain, respiratory problems, arthritis, miscarriage and premature death of offspring. No inequality was reported in diabetes, stroke and cancer. Conclusions: Significant health inequalities exist between the Gypsy and Traveller population in England and their non-Gypsy counterparts, even when compared with other socially deprived or excluded groups, and with other ethnic minorities.

Health-related beliefs and experiences of Gypsies and Travellers: a qualitative study

Objective: To illuminate findings of the survey of the health status of Gypsies and Travellers by exploring their health-related beliefs and experiences. Design: Qualitative study of a purposive subsample from in-depth interviews using framework analysis. Setting: The homes or alternative community settings of the participants in five geographically dispersed study locations in England. Participants: 27 Gypsies and Travellers with an experience of ill health, purposively sampled from a larger population participating in an epidemiological survey of health status. Results: The experience of poor health and daily encounters of ill health among extended family members were normalised and accepted. Four major themes emerged relating to health beliefs and the effect of lifestyle on health for these respondents: the travelling way; low expectations of health; self-reliance and staying in control; fatalism and fear of death. These themes dominated accounts of health experience and were relevant to the experience. These themes add richness to the health status data and inform our understanding. Conclusions: Among Gypsies and Travellers, coherent cultural beliefs and attitudes underpin health-related behaviour, and health experiences must be understood in this context. In this group, ill health is seen as normal, an inevitable consequence of adverse social experiences, and is stoically and fatalistically accepted. The provision of effective healthcare and improvement of poor health in Gypsies and Travellers will require multi-agency awareness of these issues.

Computerised cognitive behaviour therapy (cCBT) as treatment for depression in primary care (REEACT trial): large scale pragmatic randomised controlled trial.

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 group Trial registration Current Controlled Trials ISRCTN91947481.

How valid and responsive are generic health status measures, such as EQ-5D and SF-36, in schizophrenia? A systematic review.

Objectives Generic health status measures such as the short form health survey (SF-36) and EuroQol-5D (EQ-5D) are increasingly being used to inform health policy. They are claimed to be applicable across disease areas and have started to be used within mental health research. This review aims to assess the construct validity and responsiveness of four generic health status measures in schizophrenia, including the preference-based SF-6D and EQ-5D. Method A systematic review of the literature was undertaken. Ten databases were searched from inception to August 2009 and reference lists scrutinized to identify relevant studies. Studies were appraised and data extracted. A narrative synthesis was performed of the evidence on construct validity including known groups validity (detecting a difference in health-related quality of life (HRQL) scores between two different groups such as samples from the general population and people with schizophrenia), convergent validity (strength of association between generic HRQL and other measures (e.g., symptom or functional), and responsiveness. Responsiveness was considered by: 1) differences in generic HRQL measure scores in responders/non-responders and 2) correlation between changes on generic HRQL measures and changes in specific measures obtained from patients and clinicians. Results Thirty-three studies were identified that provided data on the validity and/or responsiveness of the instruments. Most of the evidence concerns the SF-36 and EQ-5D, and for these instruments there was evidence for known group validity. The evidence for convergent validity and responsiveness was mixed, with studies presenting contradictory results. Conclusion Although the evidence base is limited in a number of important respects, including problems with the measures used to develop constructs in the validation studies, it is sufficient to raise doubts about the use of generic measures of health like the EQ-5D and SF-36 in patients with schizophrenia.

COMPUTERIZED COGNITIVE BEHAVIOUR THERAPY: A SYSTEMATIC REVIEW

Depression, anxiety disorders and phobias are common mental health problems associated with considerable occupational and interpersonal impairment. Although there is substantial evidence to support the use of cognitive behaviour therapy (CBT) in the treatment of these disorders, access is limited. Computerized cognitive behaviour therapy (CCBT) is one of a variety of aids to self-management that offer patients the potential benefits of CBT with less therapist involvement than therapist led CBT (TCBT). In this systematic review of the efficacy of CCBT, 16 studies were identified. Of these 11 were RCTS and the remaining 5 were pilot or cohort studies. The quality of studies ranged from poor to moderate (although the criteria used precluded the highest rating). In the studies comparing CCBT with TCBT, five studies showed CCBT have equivalent outcomes to TCBT. One study of depressed inpatients found TCBT to be significantly more effective than CCBT. Four studies found CCBT to be more effective than treatment as usual (TAU). Two studies found CCBT to be no more effective than TAU. Two studies compared CCBT with bibliotherapy. Of these, one study found CCBT to be as effective as bibliotherapy and one found bibliotherapy to be significantly more effective than CCBT on some outcome measures. Although the results of this review are not conclusive, CCBT is potentially useful in the treatment of anxiety disorders, depression and phobias. From the results of this review, we make three recommendations to improve the quality of research in this field, and suggest four areas requiring further research.

A systematic review, psychometric analysis and qualitative assessment of generic preference-based measures of health in mental health populations and the estimation of mapping functions from widely used specific measures

BACKGROUND Generic preference-based measures of health like the EQ-5D and SF-6D(®) are increasingly being used in economic evaluation and outcome assessment. However, there are concerns as to whether or not these generic measures are appropriate for use in people with mental health problems. OBJECTIVES The EQ-5D and SF-36(®) (including its derivatives the SF-12(®) and SF-6D) were assessed using the psychometric criteria of validity and responsiveness using quantitative and qualitative methods. Another aim was to estimate mapping functions between the EQ-5D and SF-6D and condition-specific measures, where appropriate. DESIGN Four studies were undertaken to examine the appropriateness of the measures: (1) a systematic review of quantitative evidence on validity and responsiveness; (2) a further quantitative assessment of these criteria using existing data sets; (3) a review of qualitative research on the quality of life of people with mental health problems; and (4) qualitative semistructured interviews of people with a full range of problems. A fifth study estimated mapping functions between mental health-specific measures and the EQ-5D and SF-6D. SETTING A choice of venue was offered for the interviews including the participants own home, a room at the university or a centre frequently used by mental health services. PARTICIPANTS The interviews were undertaken with 19 people with a broad range of mental health problems at varying levels of severity. MAIN OUTCOME MEASURES The reviews included the EQ-5D and SF-36 (and the SF-12 and SF-6D). The psychometric analysis included the Hospital Anxiety and Depression Scale (HADS), Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), Generalised Anxiety Disorder Assessment (GAD-7), General Health Questionnaire (GHQ-12) and Patient Health Questionnaire (PHQ-9). RESULTS (1) and (2) The EQ-5D and SF-36 achieved an adequate level of performance in depression, and to some extent in anxiety and personality disorder. Results from the psychometric analyses in schizophrenia and bipolar disorder have been more mixed. (3) A framework analysis of 13 studies identified six major themes. (4) The interview data fitted the themes from the review well and resulted in minor modifications to the themes. The final set of themes comprised: well-being and ill-being; control, autonomy and choice; self-perception; belonging; activity; hope and hopelessness; and physical health. CONCLUSIONS The EQ-5D and SF-36 achieved mixed results in the quantitative testing against psychometric criteria. The qualitative analysis suggests this is because they provide a very limited coverage of themes identified by people with mental health problems. Recommendations for future work include the development of new preference-based measures in mental health that are based on, or substantially revise, an existing measure. FUNDING The Medical Research Council.

The acceptability of computerised cognitive behavioural therapy for the treatment of depression in people with chronic physical disease: a qualitative study of people with multiple sclerosis.

Background: People with chronic physical conditions are at elevated risk of depression. Due to a shortage of Cognitive Behavioural Therapy (CBT) practitioners, computerised CBT (CCBT) is recommended for people with mild to moderate depression. We assessed the applicability of CCBT for the treatment of depression in people with multiple sclerosis (MS). Methods: Depth interviews with 17 people with MS and mild to moderate depression who used one of the two CCBT packages for either eight (Beating the Blues; n = 8) or five (MoodGym; n = 9) weekly sessions were analysed using ‘Framework’. Results: Participants found CCBT-use burdensome due to their physical symptoms. In addition to perpetuating social isolation, the lack of human input meant some participants were unable to define problems, set goals or distinguish between events, thoughts and beliefs as required. CCBT did not legitimise their grief over losses concomitant with their MS. They characterised depression symptom inventories as contaminated by somatic symptoms of their MS. One CCBT package (MoodGym) was perceived as using inappropriate case material for people with the symptoms of MS. Conclusions: It is likely that generic CCBT packages for the treatment of depression will need to be adapted for people with chronic physical conditions to maximise their potential for health benefit.

Can the impact of public involvement on research be evaluated? A mixed methods study

Background  Public involvement is central to health and social research policies, yet few systematic evaluations of its impact have been carried out, raising questions about the feasibility of evaluating the impact of public involvement.

The implications of psychotherapy research for clinical practice and service development: Lessons and limitations

Evidence-based practice is increasingly discussed and practised within the NHS. Psychotherapy research clearly has a part to play in informing such practice, but the differing agendas of researchers, clinicians and purchasers need to be recognised if research is to make a constructive contribution. A good starting point is to acknowledge that research and clinical practice are not isomorphous, because the methodologies underpinning research inevitably distort outcomes. This makes it risky to generalise uncritically from research to practice, although it is equally true that good practice should take note of accumulating evidence about evidence of efficacy. Drawing on recent academic and NHS policy reviews, this article notes that overall there is good evidence for the efficacy of the psychological therapies, although evidence for the efficacy of specific therapies in relation to specific conditions is not strong, and some therapies are better researched than others. There is also evidence that it may be u...