Mike Lucock

Service profiling and outcomes benchmarking using the CORE-OM: Toward practice-based evidence in the psychological therapies.

To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.

Cognitive factors in social anxiety and its treatment

The evidence for the skills deficit and response inhibition models of social anxiety is reviewed. Evidence inconsistent with both hypotheses suggests that social anxiety may be better considered from a cognitive-behavioural perspective. There is already evidence that socially anxious patients underestimate their ability to deal with socially threatening situations. In this study it was demonstrated that, compared with matched control subjects, such patients overestimate the probability that unpleasant social events will occur in the first place, and that cognitively oriented treatment produced specific changes in this appraisal.

Early sudden gains in psychotherapy under Routine clinic conditions: Practice-based evidence

Sudden gains--large, enduring reductions in symptom intensity from one session to the next--were identified by T. Z. Tang and R. J. DeRubeis (1999b) on the basis of data from 2 manualized clinical trials of cognitive therapy for depression. The authors found similar sudden gains among clients with a variety of disorders treated with a variety of approaches in routine clinic settings. Clients (N = 135 who met inclusion criteria) completed short forms of the Clinical Outcomes in Routine Evaluation (CORE-SF) preceding 7 to 74 individual sessions. Those who experienced sudden gains within their first 16 sessions (n = 23) had significantly lower CORE-SF scores in their final 3 sessions than did the other clients.

Patient and Public Involvement in the Coproduction of Knowledge: Reflection on the Analysis of Qualitative Data in a Mental Health Study

Patient and public involvement in health research is increasingly well established internationally, but the impacts of involvement on the research process are hard to evaluate. We describe a process of qualitative data analysis in a mental health research project with a high level of mental health service user and carer involvement, and reflect critically on how we produced our findings. Team members not from research backgrounds sometimes challenged academic conventions, leading to complex findings that would otherwise have been missing. An essential component of how we coproduced knowledge involved retaining methodological flexibility so that nonconventional research voices in the team could situate and critique what was conventionally known. Deliberate and transparent reflection on how “who we are” informed the knowledge we produced was integral to our inquiry. We conclude that reflecting on knowledge (co)production is a useful tool for evaluating the impact of patient and public involvement on health research.

Predicting Change for Individual Psychotherapy Clients on the Basis of their Nearest Neighbors.

This study extended client-focused research by using the nearest neighbor (NN) approach, a client-specific sampling and prediction strategy derived from research on alpine avalanches. Psychotherapy clients (N=203) seen in routine practice settings in the United Kingdom completed a battery of intake measures and then completed symptom intensity ratings before each session. Forecasts of each clients rate of change and session-by-session variability were computed on the basis of that clients NNs (n=10-50 in different comparisons). Alternative forecasts used linear or log-linear slopes and were compared with an alternative prediction strategy. Results showed that the NN approach was superior to the alternative model in predicting rate of change, though the advantage was less clear for predicting variability.

Transforming between Beck Depression Inventory and CORE-OM scores in routine clinical practice.

OBJECTIVES The Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) and the Beck Depression Inventory (BDI) are routinely used to assess emotional problems. It would be helpful to be able to compare scores when only one of the measures is available. We investigated the relationship between the measures and produced translation tables. METHODS Level of agreement between CORE-OM and BDI-I was assessed for 2,234 clients who had completed both measures at referral for routine secondary care. Tables for predicting between the measures were constructed using several methods, including non-linear regression and non-parametric smoothing. Results were cross-validated on a separate sample of 326 clients. RESULTS High correlations between the measures were obtained (r=.862 for female clients; r=.855 for male clients). Accuracy in predicting caseness is higher than predicting depression levels. CONCLUSIONS CORE-OM and BDI can be compared in routine clinical settings with acceptable accuracy.

Early changes, attrition, and dose-response in low intensity psychological interventions.

OBJECTIVES To investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome. DESIGN Retrospective cohort data analysis. METHOD Clinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change. RESULTS The AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1-3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose-response effect appears to decline in treatments longer than six sessions. CONCLUSIONS Patients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.

Stability of the CORE-OM and the BDI-I prior to therapy: Evidence from routine practice

BACKGROUND It is important to know the stability of standard outcome measures prior to therapy over differing periods of time that map onto the realities of waiting times in routine service settings. METHOD We studied 1,684 clients who completed one or both the targeted measures Clinical Outcomes in Routine Evaluation-Outcome Measures (CORE-OM) and Beck Depression Inventory-I (BDI-I) two times, at intervals of up to 12 months, prior to beginning psychotherapy. We also selected an additional 1,623 clients who completed the CORE-OM (N=1,623), BDI-I (N=980) or both at referral, but had no records of further contact with the service. RESULTS There was little change in the mean CORE-OM or BDI-I scores between referral and clinical assessment. The test-retest correlations showed substantial stability on both measures, declining only moderately at the longer intervals studied. CONCLUSION The high test-retest correlations for periods of up to 6 months suggest that psychological disturbance was both reliably measured by the CORE-OM and the BDI-I, and reasonably stable among clients waiting to be assessed. Implications for routine practice are discussed.

Self‐care in mental health services: a narrative review

Self-care is an important approach to the management of long-term health conditions and in preventing ill-health by living a healthy lifestyle. The concept has been used to a limited extent in relation to mental health, but it overlaps with the related concepts of recovery, self-management and self-help. These related concepts all entail individuals having more choice and control over treatment and a greater role in recovery and maintaining their health and well-being. This paper reviews qualitative empirical research that provides information on the nature of self-care in mental health from the perspective of people experiencing mental health problems. Twenty qualitative studies were identified from a systematic search of the literature. The methods used in these studies were critically appraised and key themes across studies identified self-care behaviours and processes supporting self-care. The paper also highlights challenges to this approach in mental health and provides a conceptual framework of the relationships between self-care support, self-care behaviours and strategies, and well-being for the individual. It also highlights limitations in the current evidence base and identifies areas for future research.

The process of long-term art therapy: a case study combining artwork and clinical outcome

Abstract The authors present process and outcome data collected during the treatment of a client seen for weekly art therapy sessions over 6 years in the UK National Health Service. Routine outcome measures completed before and after therapy with a 3-year follow-up confirmed positive therapy results. The client was part of a research study that required completing an evaluation instrument (Clinical Outcomes in Routine Evaluation Outcome Measure: CORE-OM) before each session. Retrospectively, the significance of the volume of data this produced over 6 years was recognized, and researchers collated numerical data for a single case study. At the same time, the art therapist reviewed her notes from therapy and the artwork produced by the client. Artwork was categorized by the therapist as representing different phases of therapy. After therapy ended, data from the researchers and the therapist were then systematically examined together. This study explores links between progress indicated by the CORE-OM and type of art produced, highlighting issues relating to the process, appropriateness, and cost-effectiveness of long-term therapy.