Stephen Pilling

Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation.

BACKGROUND Social skills training and cognitive remediation are psychological techniques with considerable face validity for the treatment of negative symptoms of schizophrenia and their consequences. This paper provides a meta-analytical review of these treatments. It includes an appreciable number of randomized controlled trials, using comparisons against both standard care and other active interventions. However, the assessment of particular outcomes sometimes had to be based on single studies. METHOD A detailed search strategy was used to identify randomized controlled trials of social skills training and cognitive remediation, primarily employing electronic databases. Randomized controlled trials (RCTs) that met predefined criteria were then subjected to meta-analysis on a variety of outcome measures. RESULTS There was no clear evidence for any benefits of social skills training on relapse rate, global adjustment, social functioning, quality of life or treatment compliance. Cognitive remediation had no benefit on attention, verbal memory, visual memory, planning, cognitive flexibility or mental state. CONCLUSIONS Social skills training and cognitive remediation do not appear to confer reliable benefits for patients with schizophrenia and cannot be recommended for clinical practice.

The REACT study: randomised evaluation of assertive community treatment in north London

Abstract Objective To compare outcomes of care from assertive community treatment teams with care by community mental health teams for people with serious mental illnesses. Design Non-blind randomised controlled trial. Setting Two inner London boroughs. Participants 251 men and women under the care of adult secondary mental health services with recent high use of inpatient care and difficulties engaging with community services. Interventions Treatment from assertive community treatment team (127 participants) or continuation of care from community mental health team (124 participants). Main outcome measures Primary outcome was inpatient bed use 18 months after randomisation. Secondary outcomes included symptoms, social function, client satisfaction, and engagement with services. Results No significant differences were found in inpatient bed use (median difference 1, 95% confidence interval −16 to 38) or in clinical or social outcomes for the two treatment groups. Clients who received care from the assertive community treatment team seemed better engaged (adapted homeless engagement acceptance schedule: difference in means 1.1, 1.0 to 1.9), and those who agreed to be interviewed were more satisfied with services (adapted client satisfaction questionnaire: difference in means 7.14, 0.9 to 13.4). Conclusions Community mental health teams are able to support people with serious mental illnesses as effectively as assertive community treatment teams, but assertive community treatment may be better at engaging clients and may lead to greater satisfaction with services.

Psychological and pharmacological interventions for social anxiety disorder in adults: a systematic review and network meta-analysis

Summary Background Social anxiety disorder—a chronic and naturally unremitting disease that causes substantial impairment—can be treated with pharmacological, psychological, and self-help interventions. We aimed to compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults. Methods We did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146. Findings We included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD −1·01, 95% credible interval [CrI] −1·56 to −0·45), benzodiazepines (−0·96, −1·56 to −0·36), selective serotonin-reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRIs and SNRIs; −0·91, −1·23 to −0·60), and anticonvulsants (−0·81, −1·36 to −0·28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive–behavioural therapy (CBT; SMD −1·19, 95% CrI −1·56 to −0·81), group CBT (−0·92, −1·33 to −0·51), exposure and social skills (−0·86, −1·42 to −0·29), self-help with support (−0·86, −1·36 to −0·36), self-help without support (−0·75, −1·25 to −0·26), and psychodynamic psychotherapy (−0·62, −0·93 to −0·31). Individual CBT compared with psychological placebo (SMD −0·56, 95% CrI −1·00 to −0·11), and SSRIs and SNRIs compared with pill placebo (−0·44, −0·67 to −0·22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD −0·56, 95% CrI −1·03 to −0·11) and interpersonal psychotherapy, mindfulness, and supportive therapy (−0·82, −1·41 to −0·24). Interpretation Individual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit. Funding National Institute for Health and Care Excellence.

A systematic review and meta-analysis of randomised controlled trials of peer support for people with severe mental illness

BackgroundLittle is known about whether peer support improves outcomes for people with severe mental illness.MethodA systematic review and meta-analysis was conducted. Cochrane CENTRAL Register, Medline, Embase, PsycINFO, and CINAHL were searched to July 2013 without restriction by publication status. Randomised trials of non-residential peer support interventions were included. Trial interventions were categorised and analysed separately as: mutual peer support, peer support services, or peer delivered mental health services. Meta-analyses were performed where possible, and studies were assessed for bias and the quality of evidence described.ResultsEighteen trials including 5597 participants were included. These comprised four trials of mutual support programmes, eleven trials of peer support services, and three trials of peer-delivered services. There was substantial variation between trials in participants’ characteristics and programme content. Outcomes were incompletely reported; there was high risk of bias. From small numbers of studies in the analyses it was possible to conduct, there was little or no evidence that peer support was associated with positive effects on hospitalisation, overall symptoms or satisfaction with services. There was some evidence that peer support was associated with positive effects on measures of hope, recovery and empowerment at and beyond the end of the intervention, although this was not consistent within or across different types of peer support.ConclusionsDespite the promotion and uptake of peer support internationally, there is little evidence from current trials about the effects of peer support for people with severe mental illness. Although there are few positive findings, this review has important implications for policy and practice: current evidence does not support recommendations or mandatory requirements from policy makers for mental health services to provide peer support programmes. Further peer support programmes should be implemented within the context of high quality research projects wherever possible. Deficiencies in the conduct and reporting of existing trials exemplify difficulties in the evaluation of complex interventions.

The health service use and cost of eating disorders.

BACKGROUND The economic burden and health service use of eating disorders have received little attention, although such data are necessary to estimate the implications of any changes in clinical practice for patient care and health care resource requirements. This systematic review reports the current international evidence on the resource use and cost of eating disorders. METHOD Relevant literature (1980-2002) was identified from searches of electronic databases and expert contacts. RESULTS Two cost-of-illness studies from the UK and Germany, one burden-of-disease study from Australia and 14 other publications with relevant data from the UK, USA, Austria, Denmark and The Netherlands could be identified. In the UK, the health care cost of anorexia nervosa was estimated to be 4.2 million UK pounds in 1990. In Germany, the health care cost was 65 million Euro for anorexia nervosa and 10 million Euro for bulimia nervosa during 1998. The Australian study reported the health care costs of eating disorders to be Aus

Using an Evidence-Based Methodology to Identify the Competences Required to Deliver Effective Cognitive and Behavioural Therapy for Depression and Anxiety Disorders

22 million for year 1993/1994. Other costing studies focused mostly on in-patient care reporting highly variable estimates. There is a dearth of research on non-health care costs. CONCLUSIONS The limited available evidence reflects a general under-detection and under-treatment of eating disorders. Although both cost-of-illness studies may significantly underestimate the costs of eating disorders because of important omitted cost items, other evidence suggests that the economic burden is likely to be substantial. Comprehensive data on the resource use of patients with eating disorders are urgently needed for better estimations, and to be able to determine cost-effective treatment options.

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

A number of developments make the formal specification of competences in CBT both timely and relevant, in particular the Improving Access to Psychological Therapies (IAPT) programme, the increasing focus on process and therapist variables in determining outcome, and the increasing diversity of CBT. This paper outlines the development of an evidence-based methodology for determining both a model and a framework for CBT competences, and considers issues related to the implementation of the framework.

Initiatives to shorten duration of untreated psychosis: systematic review

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.

Antenatal and postnatal mental health: summary of updated NICE guidance

BACKGROUND Long duration of untreated psychosis (DUP) is common and associated with poor outcomes. Strategies to enhance early detection of first-episode psychosis have been advocated. AIMS To evaluate initiatives for early detection of psychosis. METHOD Systematic review of available evidence on the effectiveness of early detection initiatives to reduce the DUP. RESULTS The review included 11 studies which evaluated 8 early detection initiatives. Evidence suggests that general practitioner education campaigns and dedicated early intervention services do not by themselves reduce DUP or generate more treated cases. Evidence for multifocus initiatives is mixed: intensive campaigns targeting the general public as well as relevant professionals may be needed. No studies evaluated initiatives targeting young people or professionals from non-health organisations. CONCLUSIONS How early detection can be achieved is not clear. Evidence is most promising for intensive public awareness campaigns: these require organisation and resourcing at a regional or national level. More good-quality studies are needed to address gaps in knowledge.

Case identification of depression in patients with chronic physical health problems: a diagnostic accuracy meta-analysis of 113 studies

The bottom line This guideline is an update of the 2007 National Institute for Health and Care Excellence (NICE) guideline on antenatal and postnatal mental health.1 It covers a broad range of mental disorders, including depression, anxiety disorders, eating disorders, drug and alcohol use disorders, and severe mental illness (such as psychosis, bipolar disorder, schizophrenia, and severe depression), which can all occur in the antenatal and postnatal periods. The guidance focuses on aspects of the identification and management of these disorders that are specific to this context. For example, women with bipolar disorder are at increased risk of a relapse in the early postpartum period, and postpartum psychoses (whether in women with bipolar disorder or not) are particularly rapid in onset and severe.2 These problems are managed differently during the antenatal and postnatal periods than at other times because of the impact that the mental disorder and its treatment (for example, the use of psychotropic drugs) can have on the fetus or baby.3 4 This article summarises the most recent recommendations from NICE on the clinical management …