@Home eTherapy service for people with common mental health problems: an evaluation

Background: Ensuring rapid access to psychological interventions is a priority of mental health services. The involvement of peer workers to support the delivery of more accessible treatment options such as computerised cognitive behaviour therapy (CCBT) is recognised. Aims: To evaluate the implementation of a third sector remote CCBT @Home eTherapy service for people experiencing common mental health problems supported by individuals with lived experience. Method Supported CCBT packages with telephone support were delivered over a 30-month period. Self-complete measures identifying levels of depression, anxiety and functioning were administered at each treatment appointment. Results: Over 2000 people were referred to the @Home eTherapy service, two thirds attended an initial assessment and 53.4% of referrals assigned to CCBT completed treatment. Statistically significant improvements in anxiety, depression and functioning were found, with 61.6% of treated clients meeting recovery criteria. Conclusions: The service meets Improving Access to Psychological Therapies (IAPT) key performance targets, and is comparable to other IAPT services using CCBT. Evidence for the successful implementation of such a service by a third sector organisation is provided

What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression.

Reproduced with permission of the publisher. © 2007 Cambridge University Press.Background. Although self-help interventions are effective in treating depression, less is known about the factors that determine effectiveness (i.e. moderators of effect). This study sought to determine whether the content of self-help interventions, the study populations or aspects of study design were the most important moderators. Method. Randomized trials of the effectiveness of self-help interventions versus controls in the treatment of depressive symptoms were identified using previous reviews and electronic database searches. Data on moderators (i.e. patient populations, study design, intervention content) and outcomes were extracted and analysed using meta-regression. Results. Thirty-four studies were identified with 39 comparisons. Study design factors associated with greater effectiveness were unclear allocation concealment, observer-rated outcome measures and waiting-list control groups. Greater effectiveness was also associated with recruitment in non-clinical settings, patients with existing depression (rather than those ‘at risk ’), contact with a therapist (i.e. guided self-help) and the use of cognitive behavioural therapy (CBT) techniques. However, only guided self-help remained significant in the multivariate analysis [regression coefficient 0.36, 95% confidence interval (CI) 0.05–0.68, p=0.03]. In the subset of guided studies, there were no significant associations between outcomes and the session length, content, delivery mode or therapist background. Conclusions. The results provide some insights into moderators of self-help interventions, which might assist in the design of future interventions. However, the present study did not provide a comprehensive description, and other research methods might be required to identify factors associated with the effectiveness of self-help

Decision-making in stepped care for common mental health problems

Stepped care is designed to provide mental health treatment in the most effective and efficient way. It aims to provide patients with low intensity interventions in the first instance and only move onto high intensity treatments if outcome is not 'successful'. However, there is a paucity of research about how health professionals make decisions about treatment and the experiences of patients within this decision-making process. Using a multi-method approach, this study aimed to explore health professional and patient decision-making in stepped care for anxiety and depression. 24 health professional interviews from three stepped care sites were conducted, which included the completion of an active information search (AIS) think-aloud task. In addition, 14 patients were interviewed about their experiences of decision-making whilst being managed within stepped care model. Qualitative interview data was analysed using the principles of Framework analysis, while some of the data collected in the AIS think-aloud task lent itself to quantitative analysis.This study revealed that three core tensions exist when making decisions within the stepped care model. These are 1. The notion of standardisation of outcomes versus the individual needs of patients; 2. The public health orientation of stepped care versus the therapeutic orientation of health professionals and; 3. The rhetoric about patient choices versus the realities of shared decision-making in a resource-limited system.The complexity of decision-making within the stepped care model was highlighted. The success of stepped care relies on ensuring that there is an adequate workforce to deliver the intended interventions, where this is not present health professionals are faced with difficult decisions and it is clear that those most affected are the less-experienced frontline workers. Scarcity of resources impacts heavily upon the decisions that are made. This can have a substantial impact upon variability in treatment decisions and on the ability to allow for patient choice to be incorporated. Decisions that are made for a patient are influenced by the need to provide them with the treatment that they want (which may not be regarded as what they need within the stepped care model nor necessarily by the health professional) and the capacity of the service. The problem that exists with primary care mental health is that the current demands exceed capacity. Optimal patient care is, in part, traded off by the need to meet the demands of the service. Improving the flexibility of the service may be one solution to the problem and adopting a stratified/stepped care approach might help to resolve some of the tensions and help to relieve some of the capacity issues.EThOS - Electronic Theses Online ServiceNational Institute for Health Research (NIHR)GBUnited Kingdo

The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme

From Wiley via Jisc Publications RouterHistory: received 2020-05-22, rev-recd 2021-02-09, accepted 2021-02-17, pub-electronic 2021-03-30, pub-print 2021-06Article version: VoRPublication status: PublishedFunder: Health Services and Delivery Research Programme; Id: http://dx.doi.org/10.13039/501100002001; Grant(s): 16/48/07Abstract: Despite widespread use, evidence is sparse on whether financial incentives in healthcare should be linked to structure, process or outcome. We examine the impact of different incentive types on the quantity and effectiveness of referrals made by general practices to a new national prevention programme in England. We measured effectiveness by the number of referrals resulting in programme attendance. We surveyed local commissioners about their use of financial incentives and linked this information to numbers of programme referrals and attendances from 5170 general practices between April 2016 and March 2018. We used multivariate probit regressions to identify commissioner characteristics associated with the use of different incentive types and negative binomial regressions to estimate their effect on practice rates of referral and attendance. Financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Compared to practices without financial incentives, neither structure nor process incentives were associated with statistically significant increases in referrals or attendances, but outcome incentives were associated with 84% more referrals and 93% more attendances. Outcome incentives were the only form of pay‐for‐performance to stimulate more participation in this national disease prevention programme

Enhancing the Behaviour Change Wheel with synthesis, stakeholder involvement and decision-making: a case example using the 'Enhancing the Quality of Psychological Interventions Delivered by Telephone' (EQUITy) research programme.

From Europe PMC via Jisc Publications RouterHistory: ppub 2021-05-01, epub 2021-05-14Publication status: PublishedFunder: Programme Grants for Applied Research; Grant(s): RP-PG-1016-20010BackgroundUsing frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process.MethodIn phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria.ResultsThe COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels.ConclusionFrameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting

Assessing mental health service user and carer involvement in physical health care planning: The development and validation of a new patient-reported experience measure

BackgroundPeople living with serious mental health conditions experience increased morbidity due to physical health issues driven by medication side-effects and lifestyle factors. Coordinated mental and physical healthcare delivered in accordance with a care plan could help to reduce morbidity and mortality in this population. Efforts to develop new models of care are hampered by a lack of validated instruments to accurately assess the extent to which mental health services users and carers are involved in care planning for physical health.ObjectiveTo develop a brief and accurate patient-reported experience measure (PREM) capable of assessing involvement in physical health care planning for mental health service users and their carers.MethodsWe employed psychometric and statistical techniques to refine a bank of candidate questionnaire items, derived from qualitative interviews, into a valid and reliable measure involvement in physical health care planning. We assessed the psychometric performance of the item bank using modern psychometric analyses. We assessed unidimensionality, scalability, fit to the partial credit Rasch model, category threshold ordering, local dependency, differential item functioning, and test-retest reliability. Once purified of poorly performing and erroneous items, we simulated computerized adaptive testing (CAT) with 15, 10 and 5 items using the calibrated item bank.ResultsIssues with category threshold ordering, local dependency and differential item functioning were evident for a number of items in the nascent item bank and were resolved by removing problematic items. The final 19 item PREM had excellent fit to the Rasch model fit (x2 = 192.94, df = 1515, P = .02, RMSEA = .03 (95% CI = .01-.04). The 19-item bank had excellent reliability (marginal r = 0.87). The correlation between questionnaire scores at baseline and 2-week follow-up was high (r = .70, P DiscussionWe developed a flexible patient reported outcome measure to quantify service user and carer involvement in physical health care planning. We demonstrate the potential to substantially reduce assessment length whilst maintaining reliability by utilizing CAT

Are there interactional differences between telephone and face-to-face psychological therapy? : A systematic review of comparative studies

Background Despite comparable clinical outcomes, therapists and patients express reservations about the delivery of psychological therapy by telephone. These concerns centre around the quality of the therapeutic relationship and the ability to exercise professional skill and judgement in the absence of visual cues. However, the empirical evidence base for such perceptions has not been clearly established. Methods We conducted a systematic review to establish what is known empirically about interactional differences between psychotherapeutic encounters conducted face-to-face vs. by telephone. Results The review identified 15 studies that used situated, comparative approaches to exploring interactional aspects of telephone and face-to-face psychological therapy. These studies revealed evidence of little difference between modes in terms of therapeutic alliance, disclosure, empathy, attentiveness or participation. However, telephone therapy sessions were significantly shorter than those conducted face-to-face. Limitations We identified only a small number of heterogeneous studies, many of which used non-randomised, opportunity samples and did not use validated measures to assess the constructs under investigation. Disparate therapeutic modalities were used across studies and samples included both clinically diagnosed and non-clinical populations. Conclusions Available evidence suggests a lack of support for the viewpoint that the telephone has a detrimental effect on interactional aspects of psychological therapy. The challenge for clinical practice is to translate this evidence into a change in practitioner and patient attitudes and behaviours. In order to do so, it is important to understand and address the breadth of factors that underpin ongoing ambivalence towards the telephone mode, which pose a barrier to wider implementation

Out of Pocket Expenses in Obsessive Compulsive Disorder

Background: Despite anecdotal evidence that the out of pocket costs of OCD can be substantial in some cases, there is no evidence on how many people they affect, or the magnitude of these costs. Aims: This paper explores the type and quantity of out of pocket expenses reported by a large sample of adults with OCD. Methods: Data on out of pocket expenses were collected from participants taking part in the OCTET multi-centre randomised controlled trial. Participants were aged 18+, meeting DSM-IV criteria for OCD, and scoring 16+ on the Yale Brown Obsessive Compulsive Scale. Individual-level resource use data including a description and estimated cost of out of pocket expenses were measured using an adapted version of the Adult Service Use Schedule (AD-SUS): a questionnaire used to collect data on resource use. Results: Forty-five percent (208/465) reported out of pocket expenses due to their OCD. The mean cost of out of pocket expenses was £19.19 per week (SD £27.56 SD), range £0.06–£224.00. Conclusions: Future economic evaluations involving participants with OCD should include out of pocket expenses, but careful consideration of alternative approaches to the collection and costing of this data is needed

Obsessive Compulsive Treatment Efficacy Trial (OCTET) comparing the clinical and cost effectiveness of self-managed therapies: study protocol for a randomised controlled trial

Background: UK National Institute of Health and Clinical Excellence guidelines for obsessive compulsive disorder (OCD) specify recommendations for the treatment and management of OCD using a stepped care approach. Steps three to six of this model recommend treatment options for people with OCD that range from low-intensity guided self-help (GSH) to more intensive psychological and pharmacological interventions. Cognitive behavioural therapy (CBT), including exposure and response prevention, is the recommended psychological treatment. However, whilst there is some preliminary evidence that self-managed therapy packages for OCD can be effective, a more robust evidence base of their clinical and cost effectiveness and acceptability is required. Methods/Design: Our proposed study will test two different self-help treatments for OCD: 1) computerised CBT (cCBT) using OCFighter, an internet-delivered OCD treatment package; and 2) GSH using a book. Both treatments will be accompanied by email or telephone support from a mental health professional. We will evaluate the effectiveness, cost and patient and health professional acceptability of the treatments. Discussion: This study will provide more robust evidence of efficacy, cost effectiveness and acceptability of self-help treatments for OCD. If cCBT and/or GSH prove effective, it will provide additional, more accessible treatment options for people with OCD