The impact of alcohol use on drop-out and psychological treatment outcomes in Improving Access to Psychological Therapies Services: an Audit

Background: The impact of alcohol use disorders (AUD) on psychological treatments for depression or anxiety in primary care psychological treatment services is unknown. Aims: To establish levels of alcohol misuse in an Improving Access to Psychological Therapies (IAPT) service, examine the impact of higher risk drinking on IAPT treatment outcomes and drop-out, and to inform good practice in working with alcohol misuse in IAPT services. Method: 3643 patients completed a brief questionnaire on alcohol use pre-treatment in addition to measures of depression, anxiety and functioning. Symptom and functioning measures were re-administered at all treatment sessions. Results: Severity of alcohol misuse was not associated with treatment outcomes, although those scoring eight or more on the AUDIT-C were more likely to drop out from treatment. Conclusions: IAPT services may be well placed to offer psychological therapies to patients with common mental disorders and comorbid AUD. Patients with AUD can have equivalent treatment outcomes to those without AUD, but some higher risk drinkers may find accessing IAPT treatment more difficult as they are more likely to drop out. Alcohol misuse on its own should not be used as an exclusion criterion from IAPT services. Recommendations are given as to how clinicians can: adjust their assessments to consider the appropriateness of IAPT treatment for patients that misuse alcohol, consider the potential impact of alcohol misuse on treatment, and improve engagement in treatment for higher risk drinkers

Depression: Can we predict who will relapse?

This thesis addresses risk factors and proposed mechanisms to explain relapse to depression. Volume 1 comprises three parts: Part 1 is a literature review consisting of meta-reviews of systematic and non-systematic reviews of studies reporting on risk factors for relapse to depression, and a systematic-review of neuroimaging and experimental studies investigating risk factors for relapse and potential mechanisms of action of these risk factors. The reviews found that only residual symptoms of depression at the end of treatment and childhood maltreatment were sufficiently evidenced as predictors of relapse and neither have great clinical utility. A number of psychological and neuropsychological factors were suggested to play a role in conferring risk for relapse. Considering the inter-relationships between these factors the reviews were used to propose a conceptual framework which may be used to help guide future research into relapse to depression in adults. Part 2 is an empirical paper in which data were analysed from service users of a primary care mental health service to identify risk factors for relapse and for the presence of residual symptoms, and survival analysis methods were used to determine when relapses occur most often and what factors impact survival. In addition, a prospective cohort study was formed to investigate the relationship between cognitive control and depressive symptoms. The findings confirmed that cognitive control can be used to predict residual symptoms of depression post-treatment and therefore potentially to predict relapse. Part 3 is a critical appraisal focussing on the theoretical reasons as to why studying relapse in a manner as used in the prospective study is so important and discusses the logistical difficulties conducting such research in the current context of NHS services and of the D.Clin.Psy research project. Methodological decisions made that impacted upon the research process are discussed and reflective conclusions are offered

Latent variable mixture modelling and individual treatment prediction

Understanding which groups of patients are more or less likely to benefit from specific treatments has important implications for healthcare. Many personalised medicine approaches in mental health employ variable-centred approaches to predicting treatment response, yet person-centred approaches that identify clinical profiles of patients can provide information on the likelihood of a range of important outcomes. In this paper, we discuss the use of latent variable mixture modelling and demonstrate its use in the application of a patient profiling algorithm using routinely collected patient data to predict outcomes from psychological treatments. This validation study analysed data from two services, which included n = 44,905 patients entering treatment. There were different patterns of reliable recovery, improvement and clinical deterioration from therapy, across the eight profiles which were consistent over time. Outcomes varied between different types of therapy within the profiles: there were significantly higher odds of reliable recovery with High Intensity therapies in two profiles (32.5% of patients) and of reliable improvement in three profiles (32.2% of patients) compared with Low Intensity treatments. In three profiles (37.4% of patients) reliable recovery was significantly more likely if patients had CBT vs Counselling. The developments and potential application of latent variable mixture approaches are further discussed

The barriers, benefits and training needs of clinicians delivering psychological therapy via video

BACKGROUND: Due to the COVID-19 pandemic, mental health services have had to offer psychological therapy via video with little time to prepare or mitigate potential problems. Identifying the barriers, benefits and training needs highlighted by clinicians may support the effective delivery of care. METHOD: Changes in the mode therapy sessions were delivered in during 2020 were assessed in two high-volume psychological therapies services. Sixty-six therapists completed a survey about their experiences of delivering therapy via video. RESULTS: The lockdown in March 2020 precipitated a dramatic shift from face-to-face to telephone and video-delivered sessions. Most clinicians (89%) found video-based sessions acceptable. Barriers to effective delivery included technological issues, problems with online platforms, and feeling more tired after sessions. Benefits included generalised learning from behavioural work, improvements in efficiency and in the therapeutic relationship, particularly in comparison with telephone-based sessions. Tutorials and support guides were recommended to maximise use of sessions via video. CONCLUSIONS: Video-delivered therapy was liked by clinicians and preferred to telephone-based sessions. Issues with platforms, internet connections and access for patients need addressing, local troubleshooting guides, video-based tutorials and greater support for low-intensity therapists to maximise uptake of video sessions where appropriate, may be beneficial

Trends in depression & anxiety symptom severity among mental health service attendees during the COVID-19 pandemic

Background: General population surveys have shown that some groups, particularly young women, experienced increased distress during nationally mandated restrictions to control the spread of COVID-19. However, there has been limited research on such trends among people with pre-existing mental health conditions, leaving mental health services ill equipped to plan for current and future lockdowns. / Methods: Mean weekly scores on the GAD-7 and PHQ-9 between 01/01/2020-22/06/2020 (n=9,538 individuals) for all patients of two psychological treatment services (Improving Access to Psychological Therapies) in London, were compared to mean weekly scores from the same time periods in 2017-2019 (n=37,849). The proportion of scores which were above the clinical thresholds for ‘caseness’ each week were compared, and scores between groups based on gender, age group, and ethnicity, were also compared. / Results: Confirmed community transmission in the UK (26/02/2020-03/03/2020) and the announcement of the national ‘lockdown’ (23/03/2020) were associated with significant increases in anxiety symptom scores. ‘Lockdown’ was associated with a decrease in depression scores. These changes were not maintained during lockdown. Significant increases in depression and anxiety were observed at week 23, as restrictions were eased. / Limitations: This was an exploratory analysis in two services only. Residual confounding and selection biases cannot be ruled out. / Conclusions: Differences in the weekly average symptom scores were short-term; they did not continue throughout ‘lockdown’ as might have been expected, except among older people. Replication of this study in other settings and investigating the potential benefits of more regular reviews or more intensive treatments for at-risk groups, are warranted

The effectiveness of adapted psychological interventions for people from ethnic minority groups: A systematic review and conceptual typology.

This review assessed the efficacy of adapted psychological interventions for Black and minority ethnic (BME) groups. A conceptual typology was developed based on adaptations reported in the literature, drawing on the common factors model, competence frameworks and distinctions between types of cultural adaptations. These distinctions were used to explore the efficacy of different adaptations in improving symptoms of a range of mental health problems for minority groups. Bibliographic searches of MEDLINE, Embase, PsycINFO, HMIC, ASSIA, CENTRAL, CDSR and CINAHL spanned the period from 1965 to December 2020. Adaptations to interventions were categorised: i) treatment specific: therapist-related, ii) treatment-specific: content-related and iii) organisation-specific. Meta-analyses of RCTs found a significant effect on symptom reduction when adapted interventions were compared to non-adapted active treatments (K = 30, Hedge's g = -0.43 [95% CI: -0.61, -0.25], p < .001). Studies often incorporated multiple adaptations, limiting the exploration of the comparative effectiveness of different adaptation types, although inclusion of organisation-specific adaptations may be associated with greater benefits. Future research, practitioner training and treatment and service development pertaining to adapted care for minority groups may benefit from adopting the conceptual typology described

Implementing peer support in higher education: A feasibility study

Background: When experiencing mental distress, many university students seek support from their peers. In schools and mental health services, formalised peer support interventions have demonstrated some success but implementation challenges have been reported. This study aimed to assess the feasibility, acceptability and safety of a novel manualized peer support intervention and associated data collection processes. Methods: A longitudinal mixed methods study was conducted following the pilot of a peer support intervention at a large London university between June 2021 and May 2022. The study utilised data routinely recorded on all students who booked a peer support session, focus groups with nine peer workers and five staff members implementing the intervention, pre-post intervention surveys with 13 students and qualitative interviews with 10 of those students. Results: 169 bookings were made during the pilot, of which 130 (77%) were attended, with November the peak month. Staff and peer workers described strong motivation and commitment to implement the intervention, noting that the peer support model and peer worker role addressed previously unmet needs at the university. However, students described implementation problems relating to the coherence of the intervention and the burden of participation. While students mostly described acceptable experiences, there were examples where acceptability was lower. No adverse events were reported during the pilot. Conclusion: The training and supervision of peer workers, and the provision of one-to-one peer support to students was found to be feasible, mostly acceptable, and safe. However, sustained implementation difficulties were observed. These pose challenges to the scalability of peer support in universities. We make recommendations to improve implementation of peer support including improving reach, greater clarity about the intervention, and fuller involvement of students throughout

Measurement invariance and differential item functioning of the PHQ-9 and GAD-7 between working age and older adults seeking treatment for common mental disorders

Background: The nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalised Anxiety Disorder (GAD-7) scale are widely used clinically and within research, and so it is important to determine how the measures, and individual items within the measures, are answered by adults of differing ages. This study sought to evaluate measurement invariance and differential item functioning (DIF) of the PHQ-9 and GAD-7 between working age and older adults seeking routine psychological treatment. // Methods: Data of working age (18–64 years old) and older (≥65) adults in eight Improving Access to Psychological Therapies (IAPT) services were used. Confirmatory factor analysis (CFA) was used to establish unidimensionality of the PHQ-9 and GAD-7, with multiple-group CFA to test measurement invariance and The Multiple Indicators, Multiple Causes Models approach to assess DIF. The employed methods were applied to a propensity score matched (PSM) sample in sensitivity analyses to control for potential confounding. // Results: Data from 166,816 patients (159,325 working age, 7491 older) were used to show measurement invariance for the PHQ-9 and GAD-7, with limited evidence of DIF and similar results found with a PSM sample (n = 5868). // Limitations: The localised sample creates an inability to detect geographical variance, and the potential effect of unmeasured confounders cannot be ruled out. // Conclusions: The findings support the use of the PHQ-9 and GAD-7 measures for working age and older adults, both clinically and in research settings. This study validates using the measures for these age groups to assess clinically significant symptom thresholds, and monitor treatment outcomes between them