John Cape

Brief psychological therapies for anxiety and depression in primary care: meta-analysis and meta-regression

BackgroundPsychological therapies provided in primary care are usually briefer than in secondary care. There has been no recent comprehensive review comparing their effectiveness for common mental health problems. We aimed to compare the effectiveness of different types of brief psychological therapy administered within primary care across and between anxiety, depressive and mixed disorders.MethodsMeta-analysis and meta-regression of randomized controlled trials of brief psychological therapies of adult patients with anxiety, depression or mixed common mental health problems treated in primary care compared to primary care treatment as usual.ResultsThirty-four studies, involving 3962 patients, were included. Most were of brief cognitive behaviour therapy (CBT; n = 13), counselling (n = 8) or problem solving therapy (PST; n = 12). There was differential effectiveness between studies of CBT, with studies of CBT for anxiety disorders having a pooled effect size [d -1.06, 95% confidence interval (CI) -1.31 to -0.80] greater than that of studies of CBT for depression (d -0.33, 95% CI -0.60 to -0.06) or studies of CBT for mixed anxiety and depression (d -0.26, 95% CI -0.44 to -0.08). Counselling for depression and mixed anxiety and depression (d -0.32, 95% CI -0.52 to -0.11) and problem solving therapy (PST) for depression and mixed anxiety and depression (d -0.21, 95% CI -0.37 to -0.05) were also effective. Controlling for diagnosis, meta-regression found no difference between CBT, counselling and PST.ConclusionsBrief CBT, counselling and PST are all effective treatments in primary care, but effect sizes are low compared to longer length treatments. The exception is brief CBT for anxiety, which has comparable effect sizes.

Clinical effectiveness of collaborative care for depression in UK primary care (CADET): cluster randomised controlled trial

Objective To compare the clinical effectiveness of collaborative care with usual care in the management of patients with moderate to severe depression. Design Cluster randomised controlled trial. Setting 51 primary care practices in three primary care districts in the United Kingdom. Participants 581 adults aged 18 years and older who met ICD-10 (international classification of diseases, 10th revision) criteria for a depressive episode on the revised Clinical Interview Schedule. We excluded acutely suicidal patients and those with psychosis, or with type I or type II bipolar disorder; patients whose low mood was associated with bereavement or whose primary presenting problem was alcohol or drug abuse; and patients receiving psychological treatment for their depression by specialist mental health services. We identified potentially eligible participants by searching computerised case records in general practices for patients with depression. Interventions Collaborative care, including depression education, drug management, behavioural activation, relapse prevention, and primary care liaison, was delivered by care managers. Collaborative care involved six to 12 contacts with participants over 14 weeks, supervised by mental health specialists. Usual care was family doctors’ standard clinical practice. Main outcome measures Depression symptoms (patient health questionnaire 9; PHQ-9), anxiety (generalised anxiety disorder 7; GAD-7), and quality of life (short form 36 questionnaire; SF-36) at four and 12 months; satisfaction with service quality (client satisfaction questionnaire; CSQ-8) at four months. Results 276 participants were allocated to collaborative care and 305 allocated to usual care. At four months, mean depression score was 11.1 (standard deviation 7.3) for the collaborative care group and 12.7 (6.8) for the usual care group. After adjustment for baseline depression, mean depression score was 1.33 PHQ-9 points lower (95% confidence interval 0.35 to 2.31, P=0.009) in participants receiving collaborative care than in those receiving usual care at four months, and 1.36 points lower (0.07 to 2.64, P=0.04) at 12 months. Quality of mental health but not physical health was significantly better for collaborative care than for usual care at four months, but not 12 months. Anxiety did not differ between groups. Participants receiving collaborative care were significantly more satisfied with treatment than those receiving usual care. The number needed to treat for one patient to drop below the accepted diagnostic threshold for depression on the PHQ-9 was 8.4 immediately after treatment, and 6.5 at 12 months. Conclusions Collaborative care has persistent positive effects up to 12 months after initiation of the intervention and is preferred by patients over usual care. Trial registration number ISRCTN32829227.

The Sleep Condition Indicator: a clinical screening tool to evaluate insomnia disorder

Objective Describe the development and psychometric validation of a brief scale (the Sleep Condition Indicator (SCI)) to evaluate insomnia disorder in everyday clinical practice. Design The SCI was evaluated across five study samples. Content validity, internal consistency and concurrent validity were investigated. Participants 30 941 individuals (71% female) completed the SCI along with other descriptive demographic and clinical information. Setting Data acquired on dedicated websites. Results The eight-item SCI (concerns about getting to sleep, remaining asleep, sleep quality, daytime personal functioning, daytime performance, duration of sleep problem, nights per week having a sleep problem and extent troubled by poor sleep) had robust internal consistency (α≥0.86) and showed convergent validity with the Pittsburgh Sleep Quality Index and Insomnia Severity Index. A two-item short-form (SCI-02: nights per week having a sleep problem, extent troubled by poor sleep), derived using linear regression modelling, correlated strongly with the SCI total score (r=0.90). Conclusions The SCI has potential as a clinical screening tool for appraising insomnia symptoms against Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria.

Patient‐rated therapeutic relationship and outcome in general practitioner treatment of psychological problems

OBJECTIVE To explore the association between therapeutic relationship and clinical outcome in general medical practitioner (GP) treatment of emotional problems. DESIGN Correlational analyses of patient and observer measures of GP consultations with 3-month clinical outcomes. METHOD Patients of nine GPs, presenting with emotional problems as assessed by the 30-item General Health Questionnaire (GHQ-30), were interviewed and completed a questionnaire about their experience of their consultation with the GP. The audiotaped consultations were coded by external observers for patient involvement, doctor empathy and amount of the consultation that involved listening interactions (patient talking and doctor listening). After 3 months the patients completed a postal follow-up questionnaire including the GHQ-30 and a single item measure of patient perceived change. RESULTS Fifty-seven patients provided follow-up data. Interview and questionnaire measures of patient perceptions of their relationship with the GP in the consultation predicted both GHQ-30 outcome at 3 months (partial correlations controlling for initial GHQ-30, r = .30 and r = .36) and patient perceived change on the single item measure. Observer ratings of patient involvement and doctor empathy predicted patient rated change on the single item measure, but not follow-up GHQ-30. Observer coded listening interactions were unrelated to both outcome measures. CONCLUSION The results indicate an association between patient perceptions of how GP and patient related in the consultation and reduction in symptom severity 3 months later.

The effects of improving sleep on mental health (OASIS): a randomised controlled trial with mediation analysis

Summary Background Sleep difficulties might be a contributory causal factor in the occurrence of mental health problems. If this is true, improving sleep should benefit psychological health. We aimed to determine whether treating insomnia leads to a reduction in paranoia and hallucinations. Methods We did this single-blind, randomised controlled trial (OASIS) at 26 UK universities. University students with insomnia were randomly assigned (1:1) with simple randomisation to receive digital cognitive behavioural therapy (CBT) for insomnia or usual care, and the research team were masked to the treatment. Online assessments took place at weeks 0, 3, 10 (end of therapy), and 22. The primary outcome measures were for insomnia, paranoia, and hallucinatory experiences. We did intention-to-treat analyses. The trial is registered with the ISRCTN registry, number ISRCTN61272251. Findings Between March 5, 2015, and Feb 17, 2016, we randomly assigned 3755 participants to receive digital CBT for insomnia (n=1891) or usual practice (n=1864). Compared with usual practice, the sleep intervention at 10 weeks reduced insomnia (adjusted difference 4·78, 95% CI 4·29 to 5·26, Cohens d=1·11; p<0·0001), paranoia (−2·22, −2·98 to −1·45, Cohens d=0·19; p<0·0001), and hallucinations (−1·58, −1·98 to −1·18, Cohens d=0·24; p<0·0001). Insomnia was a mediator of change in paranoia and hallucinations. No adverse events were reported. Interpretation To our knowledge, this is the largest randomised controlled trial of a psychological intervention for a mental health problem. It provides strong evidence that insomnia is a causal factor in the occurrence of psychotic experiences and other mental health problems. Whether the results generalise beyond a student population requires testing. The treatment of disrupted sleep might require a higher priority in mental health provision. Funding Wellcome Trust.

What is the role of consultation–liaison psychiatry in the management of depression in primary care? A systematic review and meta-analysis ☆ ☆☆ ★

OBJECTIVE To assess the effectiveness of consultation-liaison services, involving mental health professionals working to advise and support primary care professionals in the management of depression. METHODS Studies of consultation-liaison for depression in primary care were identified from a systematic search of electronic databases, augmented by identification of papers from reference lists, published reviews and from hand searching. Data on study quality, intervention characteristics and outcomes were extracted by two reviewers, and outcome data were meta-analyzed. RESULTS Five studies met the criteria. There was no significant effect of consultation-liaison on antidepressant use (risk ratio 1.23, 95% CI 0.91 to 1.66) or depression outcomes in the short- (standardized mean difference -0.04, 95% CI -0.21 to 0.14) or long-term (standardized mean difference 0.06, 95% CI -0.13 to 0.26). CONCLUSIONS Evidence concerning consultation-liaison for depression in primary care remains limited, but the existing studies do not suggest it is more effective than usual care. Further research is required to explore the mechanisms by which consultation-liaison might be made more effective, including the potential role of consultation-liaison in combination with other models of care, and in other patient populations.

Practice improvement methods: conceptual base, evidence-based research, and practice-based recommendations.

OBJECTIVES To provide (1) an overview of the purpose of practice improvement methods and a conceptual base for the relationship between the various practice improvement methods; (2) an evidence-based review of the range of practice improvement methods; and (3) practice-based recommendations. DESIGN AND METHOD Secondary research design using electronic literature search of PsycINFO database was carried out on eight practice improvement methods (PIMs) and the evidence for effectiveness presented. RESULTS There is evidence of effectiveness in changing practice for each of the PIMs reviewed, and for some, there is also evidence of effects on patient outcomes. Each has strengths and weaknesses. However, the stronger conclusion from reviews is that use of multiple PIMs is more likely to impact clinical practice and patient outcomes than use of a single PIM. CONCLUSION The development of PIMs should concentrate on combination and integration between methods to maximize their effectiveness.

Cost-Effectiveness of Collaborative Care for Depression in UK Primary Care: Economic Evaluation of a Randomised Controlled Trial (CADET)

Background Collaborative care is an effective treatment for the management of depression but evidence on its cost-effectiveness in the UK is lacking. Aims To assess the cost-effectiveness of collaborative care in a UK primary care setting. Methods An economic evaluation alongside a multi-centre cluster randomised controlled trial comparing collaborative care with usual primary care for adults with depression (n = 581). Costs, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICER) were calculated over a 12-month follow-up, from the perspective of the UK National Health Service and Personal Social Services (i.e. Third Party Payer). Sensitivity analyses are reported, and uncertainty is presented using the cost-effectiveness acceptability curve (CEAC) and the cost-effectiveness plane. Results The collaborative care intervention had a mean cost of £272.50 per participant. Health and social care service use, excluding collaborative care, indicated a similar profile of resource use between collaborative care and usual care participants. Collaborative care offered a mean incremental gain of 0.02 (95% CI: –0.02, 0.06) quality-adjusted life-years over 12 months, at a mean incremental cost of £270.72 (95% CI: –202.98, 886.04), and resulted in an estimated mean cost per QALY of £14,248. Where costs associated with informal care are considered in sensitivity analyses collaborative care is expected to be less costly and more effective, thereby dominating treatment as usual. Conclusion Collaborative care offers health gains at a relatively low cost, and is cost-effective compared with usual care against a decision-maker willingness to pay threshold of £20,000 per QALY gained. Results here support the commissioning of collaborative care in a UK primary care setting.

Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation

BackgroundPatients with psychosocial problems may benefit from a variety of community, educational, recreational and voluntary sector resources, but GPs often under-refer to these through lack of knowledge and time. This study evaluated the acceptability and effectiveness of graduate primary care mental health workers (GPCMHWs) facilitating access to voluntary and community sector services for patients with psychosocial problems.MethodsPatients with psychosocial problems from 13 general practices in London were referred to a GPCMHW Community Link scheme providing information and support to access voluntary and community resources. Patient satisfaction, mental health and social outcomes, and use of primary care resources, were evaluated.Results108 patients consented to take part in the study. At three-month follow-up, 63 (58%) had made contact with a community service identified as suitable for their needs. Most were satisfied with the help provided by the GPCMHW in identifying and supporting access to a suitable service. There was a reduction in the number of patients with a probable mental health problem on the GHQ-12 from 83% to 52% (difference 31% (95% CI, 17% – 44%). Social adjustment improved and frequencies of primary care consultations and of prescription of psychotropic medications were reduced.ConclusionGraduates with limited training in mental health and no prior knowledge of local community resources can help patients with psychosocial problems access voluntary and community services, and patients value such a scheme. There was some evidence of effectiveness in reducing psychosocial and mental health problems.

Rated casemix of general practitioner referrals to practice counsellors and clinical psychologists: A retrospective survey of a year's caseload.

Although evidence-based guidelines are beginning to be produced as to which psychological therapies might be appropriate for which patients, little is known about how general medical practitioners (GPs) in practice distribute referrals between different psychological therapy services. In a retrospective survey, 19 practice counsellors and 10 clinical psychologists from the same geographical area rated a years caseload of GP referrals using identical data collection methods. Rated casemix was found to be broadly similar, although practice counsellors rated relationship and bereavement problems as more common in their caseloads (totalling 986 patients), and clinical psychologists rated panic disorder, phobias, and obsessive-compulsive problems as more common in their caseloads (totalling 320 patients). Depression and anxiety reactions were the most common problems rated in both groups, but the clinical psychologist cases of depression were rated as more severe and complex. Where differences were found, they may have reflected the different ways that counsellors and clinical psychologists conceptualize cases rather than actual differences in casemix. The results are discussed in relation to evidence-based guideline recommendations about cases appropriate to be seen by practice counsellors and by clinical psychologists in primary and secondary care, and the need to adapt such guidance to local services and skills of practitioners.