Using evidence to improve Psychological Therapies Services

Psychological therapy services offer help to clients with many different sorts of mental health problems using a variety of therapies provided by a range of different professional groups and are supported by a large amount of research evidence. However, applying evidence-based practice in routine clinical settings presents particular challenges. This paper outlines some of the difficulties applying research findings to routine settings and argues for a more inclusive approach to linking evidence with practice. It describes a systematic approach to service evaluation and practice based evidence within a large psychological therapies service. This approach is integrated into the service delivery. It enables clinicians to become engaged in the process of reflecting on evidence in a non-threatening way and allows innovative ways of enhancing reflective practice by linking evidence with practice in routine settings

Leaving No Footprints

In this paper, clients’ experiences of therapy are used to examine two essential paradoxes: neutrality and influence, in the minimalist version of Solution Focused Brief Therapy developed by the author and his colleagues at BRIEF. Both concepts are linked to trust, a radical trust in each client to know what is best for their future, and a trust that decisions about this future are solely the business of the client. Maintaining this trust in the face of our own ideas and good wishes towards our clients requires a discipline which may not suit all Solution Focused practitioners

Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2):a multicentre observational cohort study

Background: Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. Methods: Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. Findings: Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0–20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1–5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27–10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29–0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53–0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60–0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07–0·43, p=0·0065; and 0·33, 0·14–0·51, p=0·00059, respectively). Interpretation: In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. Funding: The Stroke Association and the British Heart Foundation

Cerebral microbleeds and intracranial haemorrhage risk in patients anticoagulated for atrial fibrillation after acute ischaemic stroke or transient ischaemic attack (CROMIS-2): a multicentre observational cohort study

Summary Background: Cerebral microbleeds are a potential neuroimaging biomarker of cerebral small vessel diseases that are prone to intracranial bleeding. We aimed to determine whether presence of cerebral microbleeds can identify patients at high risk of symptomatic intracranial haemorrhage when anticoagulated for atrial fibrillation after recent ischaemic stroke or transient ischaemic attack. Methods: Our observational, multicentre, prospective inception cohort study recruited adults aged 18 years or older from 79 hospitals in the UK and one in the Netherlands with atrial fibrillation and recent acute ischaemic stroke or transient ischaemic attack, treated with a vitamin K antagonist or direct oral anticoagulant, and followed up for 24 months using general practitioner and patient postal questionnaires, telephone interviews, hospital visits, and National Health Service digital data on hospital admissions or death. We excluded patients if they could not undergo MRI, had a definite contraindication to anticoagulation, or had previously received therapeutic anticoagulation. The primary outcome was symptomatic intracranial haemorrhage occurring at any time before the final follow-up at 24 months. The log-rank test was used to compare rates of intracranial haemorrhage between those with and without cerebral microbleeds. We developed two prediction models using Cox regression: first, including all predictors associated with intracranial haemorrhage at the 20% level in univariable analysis; and second, including cerebral microbleed presence and HAS-BLED score. We then compared these with the HAS-BLED score alone. This study is registered with ClinicalTrials.gov, number NCT02513316. Findings: Between Aug 4, 2011, and July 31, 2015, we recruited 1490 participants of whom follow-up data were available for 1447 (97%), over a mean period of 850 days (SD 373; 3366 patient-years). The symptomatic intracranial haemorrhage rate in patients with cerebral microbleeds was 9·8 per 1000 patient-years (95% CI 4·0–20·3) compared with 2·6 per 1000 patient-years (95% CI 1·1–5·4) in those without cerebral microbleeds (adjusted hazard ratio 3·67, 95% CI 1·27–10·60). Compared with the HAS-BLED score alone (C-index 0·41, 95% CI 0·29–0·53), models including cerebral microbleeds and HAS-BLED (0·66, 0·53–0·80) and cerebral microbleeds, diabetes, anticoagulant type, and HAS-BLED (0·74, 0·60–0·88) predicted symptomatic intracranial haemorrhage significantly better (difference in C-index 0·25, 95% CI 0·07–0·43, p=0·0065; and 0·33, 0·14–0·51, p=0·00059, respectively). Interpretation In patients with atrial fibrillation anticoagulated after recent ischaemic stroke or transient ischaemic attack, cerebral microbleed presence is independently associated with symptomatic intracranial haemorrhage risk and could be used to inform anticoagulation decisions. Large-scale collaborative observational cohort analyses are needed to refine and validate intracranial haemorrhage risk scores incorporating cerebral microbleeds to identify patients at risk of net harm from oral anticoagulation. Funding The Stroke Association and the British Heart Foundation

Evaluating psychological therapies services: A review of outcome measures and their utility

We describe the use of a number of outcome measures that have been used over the past eight years to evaluate adult psychological therapies services in the Wakefield & Pontefract locality of the South West Yorkshire Mental Health NHS Trust. The psychological therapies service now has a unique database of outcome measures completed by 5563 clients, which has been used nationally and internationally for service evaluation and research purposes. Internally, the database has informed the clinical service, allowing prioritising of referrals and feedback to clinicians and referral agencies on the quality of the service and appropriateness of referrals. We describe the properties and intended use of the measures, the way results are fed back to the service and evaluate the usefulness of the measures in routine service settings. Implications for psychological therapies and other mental health services are discussed including: • Choice of generic or specific outcome measures • How the measures relate to one another • Clinical usefulness of the measures, including risk assessment • Interpretation of results, including availability of norms and how to assess change • Practical utility, including cos

Childhood cognitive function and later-life economic activity: Linking the Scottish Mental Survey 1947 to administrative data.

A project investigating the association between early-life factors (e.g., cognitive ability, socioeconomic status, and education) and later-life economic activity. This capitalises on data linkage between the Scottish Mental Survey 1947 and the Scottish Longitudinal Survey, and features life course analyses

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 (1999) 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

Assessing risk and emotional disturbance using the CORE-OM and HoNOS outcome measures at the interface between primary and secondary mental healthcare

AIMS AND METHOD There is interest in how outcome measures routinely used in mental health settings compare with each other in assessing risk and emotional disturbance. The relation between the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM), a client-completed measure, and the Health of the Nation Outcome Scale (HoNOS), a clinician-completed measure, was explored using data from 297 clients referred to secondary services by a primary care mental health liaison team. RESULTS The correlation between CORE-OM and HoNOS was 0.50, with cluster and factor analyses revealing overlap between the measures in assessing risk to self and others and general emotional issues. CLINICAL IMPLICATIONS Although the measures are typically used in different settings, the overlap suggests that both might be useful in any setting where assessment for mental health problems and risk is neede