Penny Bee

Psychotherapy mediated by remote communication technologies: a meta-analytic review

BackgroundAccess to psychotherapy is limited by psychopathology (e.g. agoraphobia), physical disability, occupational or social constraints and/or residency in under-served areas. For these populations, interventions delivered via remote communication technologies (e.g. telephone, internet) may be more appropriate. However, there are concerns that such delivery may influence the therapeutic relationship and thus reduce therapy effectiveness. This review aimed to determine the clinical effectiveness of remotely communicated, therapist-delivered psychotherapy.MethodsSystematic review (including electronic database searching and correspondence with authors) of randomised trials of individual remote psychotherapy. Electronic databases searched included MEDLINE (1966–2006), PsycInfo (1967–2006), EMBASE (1980–2006) and CINAHL databases (1982–2006). The Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Collaboration Depression, Anxiety and Neurosis Controlled Trials Register (CCDAN-CTR). All searches were conducted to include studies with a publication date to July 2006.ResultsThirteen studies were identified, ten assessing psychotherapy by telephone, two by internet and one by videoconference. Pooled effect sizes for remote therapy versus control conditions were 0.44 for depression (95%CI 0.29 to 0.59, 7 comparisons, n = 726) and 1.15 for anxiety-related disorders (95%CI 0.81 to 1.49, 3 comparisons, n = 168). There were few comparisons of remote versus face-to-face psychotherapy.ConclusionRemote therapy has the potential to overcome some of the barriers to conventional psychological therapy services. Telephone-based interventions are a particularly popular research focus and as a means of therapeutic communication may confer specific advantages in terms of their widespread availability and ease of operation. However, the available evidence is limited in quantity and quality. More rigorous trials are required to confirm these preliminary estimates of effectiveness. Future research priorities should include overcoming the methodological shortcomings of published work by conducting large-scale trials that incorporate both clinical outcome and more process-orientated measures.

Subjective experiences of younger people with dementia and their families: implications for UK research, policy and practice

Young-onset dementia (dementia in people under 65 years of age) remains an under-researched area of dementia care. As populations age in industrialized countries, dementia is set to increase: this includes dementias in younger people. Current estimates suggest there are over 15 000 younger people living with dementia in the UK, whilst dedicated services and research in this area remain limited. Younger people may be affected by rarer forms of dementia that can create various kinds of impairment in the individual. For example, as Boxer and Miller report, although memory can be affected, people with conditions such as frontotemporal dementia can present initially with personality changes as the primary symptom. Younger people may also have more difficulties with visuospatial and semantic tasks when compared with an person, and there are likely to be personal and societal implications for the entire family.

Qualitative meta-synthesis of user experience of computerised therapy for depression and anxiety

Objective Computerised therapies play an integral role in efforts to improve access to psychological treatment for patients with depression and anxiety. However, despite recognised problems with uptake, there has been a lack of investigation into the barriers and facilitators of engagement. We aimed to systematically review and synthesise findings from qualitative studies of computerised therapies, in order to identify factors impacting on engagement. Method Systematic review and meta-synthesis of qualitative studies of user experiences of computer delivered therapy for depression and/or anxiety. Results 8 studies were included in the review. All except one were of desktop based cognitive behavioural treatments. Black and minority ethnic and older participants were underrepresented, and only one study addressed users with a co-morbid physical health problem. Through synthesis, we identified two key overarching concepts, regarding the need for treatments to be sensitive to the individual, and the dialectal nature of user experience, with different degrees of support and anonymity experienced as both positive and negative. We propose that these factors can be conceptually understood as the ‘non-specific’ or ‘common’ factors of computerised therapy, analogous to but distinct from the common factors of traditional face-to-face therapies. Conclusion Experience of computerised therapy could be improved through personalisation and sensitisation of content to individual users, recognising the need for users to experience a sense of ‘self’ in the treatment which is currently absent. Exploiting the common factors of computerised therapy, through enhancing perceived connection and collaboration, could offer a way of reconciling tensions due to the dialectal nature of user experience. Future research should explore whether the findings are generalisable to other patient groups, to other delivery formats (such as mobile technology) and other treatment modalities beyond cognitive behaviour therapy. The proposed model could aid the development of enhancements to current packages to improve uptake and support engagement.

Can we improve the morale of staff working in psychiatric units? A systematic review

Background: Those working in psychiatric units care for some of the most vulnerable and needy patients within health services, and suffer some of the highest levels of job dissatisfaction and burnout within healthcare workforce. Poor staff morale is bad for patient care and is economically wasteful. The same level of evidence of effectiveness and efficiency should be considered in workforce planning as is required in patient care. This has hitherto not occurred. Aim: To examine the impact and cost effectiveness of strategies to improve staff morale and reduce “burnout” amongst staff working in psychiatric units. Methods: We conducted a systematic review of robust evaluations of strategies designed to improve psychological wellbeing or the working experience of staff working in psychiatric units. We searched the following databases: EMBASE; MEDLINE; PsycINFO; CINAHL; Sociological Abstracts; HMIC; Management and Marketing Abstracts; Management Contents and Inside Conferences (all to 2004), and sought the following outcomes: Psychological wellbeing; Job satisfaction; staff burnout and stress; staff sickness and turnover; Direct and indirect costs. The following designs were included: Randomised Controlled Trails (RCTs); Controlled Clinical Trials (CCTs); Controlled Before and after studies (CBAs); and interrupted time series (ITSs). We conducted a narrative overview of key design features, endpoints and results. Results: We identified eight evaluations of strategies to improve staff morale (3 RCTs; 3 CCTs and 2 CBAs). Educational interventions designed to enhance the skill and competency of staff were the most commonly evaluated, and showed positive impact on at least one outcome of interest. Psycho-social interventions that sought out members of staff who were experiencing emotional problems and offered work-based support and enhanced social support networks were positive in US healthcare settings, but had been incompletely implemented and evaluated in UK settings. Organisational interventions, such as a shift to continuous care and primary nursing also showed a potential to be effective in reducing sickness rates and improving job satisfaction. Conclusions: There is substantial opportunity to design and implement interventions to improve the working experience of staff in psychiatric units. There is an onus to evaluate the longer term impact and cost effectiveness of these strategies. Unfortunately strategies are currently being implemented in the absence of any prospective evaluation. Declaration of interest: The authors have no conflict of interest.

Capacity, responsibility, and motivation: a critical qualitative evaluation of patient and practitioner views about barriers to self-management in people with multimorbidity

BackgroundPrimary care is increasingly focussed on the care of people with two or more long-term conditions (multimorbidity). The UK Department of Health strategy for long term conditions is to use self-management support for the majority of patients but there is evidence of limited engagement among primary care professionals and patients with multimorbidity. Furthermore, multimorbidity is more common in areas of socioeconomic deprivation but deprivation may act as a barrier to patient engagement in self-management practices.BackgroundEffective self-management is considered critical to meet the needs of people living with long term conditions but achieving this is a significant challenge in patients with multimorbidity. This study aimed to explore patient and practitioner views on factors influencing engagement in self-management in the context of multimorbidity.MethodsA qualitative study using individual semi-structured interviews with 20 patients and 20 practitioners drawn from four general practices in Greater Manchester situated in areas of high and low social deprivation.Patients were purposively sampled on socioeconomic deprivation (defined by Index of Multiple Deprivation (IMD) score), number and type of long term conditions (2 or more of: coronary heart disease, diabetes mellitus, osteoarthritis, chronic obstructive pulmonary disease and depression), age and gender. Practitioners were sampled by deprivation status of the practice area; role (i.e. salaried GP, GP principal, practice nurse); and number of years’ experience. Interviews were audio-recorded and transcribed verbatim. Analysis used a thematic approach based on Framework.ResultsThree main factors were identified as influencing patient engagement in self-management: capacity (access and availability of socio-economic resources and time; knowledge; and emotional and physical energy), responsibility (the degree to which patients and practitioners agreed about the division of labour about chronic disease management, including self-management) and motivation (willingness to take-up types of self-management practices). Socioeconomic deprivation negatively impacted on all three factors. Motivation was especially reduced in the presence of mental and physical multimorbidity.ConclusionFull engagement in self-management practices in multimorbidity was only present where patients’ articulated a sense of capacity, responsibility, and motivation. Patient `know-how’ or interpretive capacity to self-manage multimorbidity is potentially an important precursor to responsibility and motivation, and might be a critical target for intervention. However, individual and social resources are needed to generate capacity, responsibility, and motivation for self-management, pointing to a balanced role for health services and wider enabling networks.

The prevalence of nursing staff stress on adult acute psychiatric in-patient wards. A systematic review.

Concerns about recent changes in acute in-patient mental healthcare environments have led to fears about staff stress and poor morale in acute in-patient mental healthcare staff. To review the prevalence of low staff morale, stress, burnout, job satisfaction and psychological well-being amongst staff working in in-patient psychiatric wards. Systematic review. Of 34 mental health studies identified, 13 were specific to acute in-patient settings, and 21 were specific to other non-specified ward-based samples. Most studies did not find very high levels of staff burnout and poor morale but were mostly small, of poor quality and provided incomplete or non-standardised prevalence data. The prevalence of indicators of low morale on acute in-patient mental health wards has been poorly researched and remains unclear. Multi-site, prospective epidemiological studies using validated measures of stress together with personal and organizational variables influencing staff stress in acute in-patient wards are required.

Mapping nursing activity in acute inpatient mental healthcare settings

Background: The quality of care on acute inpatient mental health units is a matter of national and international concern. A major determinant of the quality of care experienced by service users is the use of nursing time. Aims: To map, classify and compare the patterns of activities for qualified and unqualified nursing staff in three acute inpatient mental health wards in three UK NHS-provider organizations, and to compare the proportions of time dedicated to user-centred and non user-centred activities. Method: Open interviews with staff undertaken hourly during five, three-day data collection periods per ward. Results: A total of 505 hours of nursing activity were assessed. Half of all activity reported was staff-user contact, however, the majority was during containment activities. Qualified staff were responsible for ward administration, unqualified staff for the majority of staff-user interaction. Unqualified staff reported higher satisfaction with their work, positively correlated with patient contact time. Conclusions: Working practices built on highly prescriptive nursing routines need to be reconfigured in order to allow qualified staff more time to engage with patients and unqualified staff to use their time with service users more constructively. Declaration of interest: This study was funded by three mental health trusts in the North West United Kingdom. We know of no financial relationship that may pose a conflict of interest.

Professional perspectives on service user and carer involvement in mental health care planning: A qualitative study

Background Involving users/carers in mental health care-planning is central to international policy initiatives yet users frequently report feeling excluded from the care planning process. Rigorous explorations of mental health professionals’ experiences of care planning are lacking, limiting our understanding of this important translational gap. Objectives To explore professional perceptions of delivering collaborative mental health care-planning and involving service users and carers in their care. Design Qualitative interviews and focus groups with data combined and subjected to framework analysis. Setting UK secondary care mental health services. Participants 51 multi-disciplinary professionals involved in care planning and recruited via study advertisements. Results Emergent themes identified care-planning as a meaningful platform for user/carer involvement but revealed philosophical tensions between user involvement and professional accountability. Professionals emphasised their individual, relational skills as a core facilitator of involvement, highlighting some important deficiencies in conventional staff training programmes. Conclusions Although internationally accepted on philosophical grounds, user-involved care-planning is poorly defined and lacks effective implementation support. Its full realisation demands greater recognition of both the historical and contemporary contexts in which statutory mental healthcare occurs.

The development and evaluation of a complex health education intervention for adults with a diagnosis of schizophrenia

Life expectancy in adults with schizophrenia is reduced by approximately 15 years compared with others in the population. Two thirds of premature deaths result from natural causes triggered by unhealthy lifestyles and the side-effects of antipsychotic medication. There is a need to develop and evaluate health education interventions for people with this diagnosis. In this paper we describe how with reference to the UK Medical Research Councils complex interventions framework we developed and evaluated a health education intervention designed specifically for adults with schizophrenia. The study was completed in three separate but interrelated phases: (1) theoretical work was undertaken to identify the components of effective health education interventions; (2) this information was synthesized to develop the intervention; and (3) the intervention was tested in an open exploratory trial which used mixed methods to evaluate the feasibility, acceptability and potential effect of the intervention. 45 service users were referred, 39 attended the groups and 65% attended at least half of the sessions. Participants reported significant increases in their consumption of fruit and vegetables and levels of physical activity. Results suggest that this model of health education is feasible and acceptable for this population and that it shows promise in supporting health-related behaviour changes.

Bringing meaning to user involvement in mental health care planning: a qualitative exploration of service user perspectives

BACKGROUND Service users wish to be involved in care planning but typically feel marginalized in this process. Qualitative explorations of the barriers and enablers of user involvement in mental health care planning are limited. QUESTION How is user involvement in care planning conceptualized by service users and how can meaningful involvement be instilled in the care planning process? METHODS In 2013, we conducted five focus groups (n = 27) and 23 individual interviews with current or recent adult users of secondary care mental health services (n = 27) in England. Eight users participated in both. Data were analysed using Framework Analysis. Results Ten themes emerged from the data: these themes encompassed procedural elements (connection; contribution; currency; care consolidation; and consequence), service user characteristics (capacity and confidence) and professional enablers (consultation; choice; and clarity of expression). Procedural elements were discussed most frequently in service user discourse. DISCUSSION The process of care planning, centred on the user-clinician relationship, is key to user involvement. IMPLICATIONS FOR PRACTICE Users describe a common model of meaningful involvement in care planning. Their requests, summarized through a 10C framework of care planning involvement, provide clear direction for improving service users satisfaction with care planning and enhancing the culture of services.