Search

The National Institute for Health and Clinical Excellence recently updated its guideline on treating and managing depression in adults. The first part of this two part unit covered the identification, assessment and initial management of persistent subthreshold depressive symptoms and mild to moderate depression. This second part looks at the core treatments for moderate to severe depression, as well as mild to moderate depression and persistent subthreshold symptoms that have not responded to low intensity interventions.

Nurses must ensure their practice remains up to date and that they are aware of changes in the evidence base for managing depression. This two part unit on the updated National Institute for Health and Clinical Excellence guideline on depression outlines some of the main areas that were updated and the implications for nursing practice.

Background: Researchers in clinical trials usually pay close attention to therapist selection, training, supervision and monitoring, but the extent of this input has not been systematically documented., Aims: To describe the extent of training and supervision activity within clinical trials, and to consider any implications for transporting therapies from research to routine clinical contexts., Method: Twenty-seven randomized studies examining the efficacy of CBT interventions for people with depression or anxiety disorders were selected on the basis of their quality and impact on the field. Published and unpublished sources were used to gather information about therapist selection, training and supervision within these trials., Results: The review identified the extent of investment by researchers in assuring therapist expertise, adherence and competence. It also indicated inconsistencies in the clarity with which this input was reported., Conclusions: The ubiquity of intervention-specific training in research contexts risks being overlooked when commissioning evidence-based therapies in routine practice. This has clear implications for the likely effectiveness of interventions. Greater consistency in the reporting of training in clinical trials may help to draw attention to the role of training and supervision in maximizing clinical outcomes.

Background: Drug users (including both injection drug users and crack cocaine users), are at high levels of risk for contracting HIV. Therefore it is important to reduce the injection and/or sexual risk behaviours of these groups both for the benefit of themselves and for society as a whole., Objectives: To assess the efficacy of multi-session psychosocial interventions in comparison with standard education and minimal intervention controls for the reduction of injection and sexual risk behaviour., Search Strategy: Electronic searches were conducted of a number of bibliographic databases (including Cochrane Library, CINAHL, MEDLINE, PsycINFO). In addition, other methods of locating papers were employed including contacting various authors working in the field of HIV risk reduction and examining reference lists of applicable papers identified in the electronic search., Selection Criteria: The inclusion criteria consisted of randomised and quazi-randomised trials assessing the efficacy of psychosocial interventions in the reduction of injection and sexual risk behaviour for people who misused opiates, cocaine, or a combination of these drugs., Data Collection and Analysis: Two authors independently assessed the eligibility of studies identified by the search strategy, quality assessed these studies and extracted the data. A total of 35 trials met the eligibility criteria of the review providing data on 11,867 participants., Main Results: There were minimal differences identified between multi-session psychosocial interventions and standard educational interventions for both injection and sexual risk behaviour. Although it should be noted there were large pre-post changes for both groups suggesting both were effective in reducing risk behaviours. In addition, there was some evidence of benefit for multi-session psychosocial interventions when compared with minimal controls. Subgroup analyses suggest that people in formal treatment are likely to respond to multi-session psychosocial interventions. It also appears single-gender groups may be associated with greater benefit., Authors' Conclusions: There is limited support for the widespread use of formal multi-session psychosocial interventions for reducing injection and sexual risk behaviour. Brief standard education interventions appear to be a more cost-effective option. Further research is required to assess if there are particular groups of drug users more likely to respond to such interventions.

The second in this two part unit on depression in people with long term conditions examines the range of treatment options for moderate to severe depression, and for persistent subthreshold/mild to moderate illness that does not respond to treatment. Part 1 discussed the prevalence and causes of depression in this group, identification and assessment, and also outlined initial treatment for mild illness.

The first in this two part unit on depression in adults with long term conditions examines new NICE guidance on identifying and managing this mental health problem. It discusses the prevalence and causes of depression in this group, how to identify and assess the condition, and initial management options for those with subthreshold/mild to moderate symptoms.

Background: Comprising of both organisational and patient level components, collaborative care is a potentially powerful intervention for improving depression treatment in UK primary Care. However, as previous models have been developed and evaluated in the United States, it is necessary to establish the effect of collaborative care in the UK in order to determine whether this innovative treatment model can replicate benefits for patients outside the US. This Phase III trial was preceded by a Phase II patient level RCT, following the MRC Complex Intervention Framework., Methods/design: A multi-centre controlled trial with cluster-randomised allocation of GP practices. GP practices will be randomised to usual care control or to "collaborative care" - a combination of case manager coordinated support and brief psychological treatment, enhanced specialist and GP communication. The primary outcome will be symptoms of depression as assessed by the PHQ-9., Discussion: If collaborative care is demonstrated to be effective we will have evidence to enable the NHS to substantially improve the organisation of depressed patients in primary care, and to assist primary care providers to deliver a model of enhanced depression care which is both effective and acceptable to patients.

Background: The only randomised trial of assertive community treatment (ACT) carried out in England (the "REACT" study: randomised evaluation of assertive community treatment in North London) found no clinically significant advantage over usual care from community mental health teams (CMHTs). However, ACT clients were more satisfied and better engaged with services. To understand these findings better, we investigated the content of care and interventions offered to study participants., Method: Quantitative data were collected to compare team structures and processes. Qualitative interviews with care co-ordinators of 40 of the 251 REACT study participants (20 ACT, 20 CMHT clients) were carried out and thematic analysis was used to explore differences in the approaches of the two types of team., Results: CMHTs scored low for ACT model fidelity and ACTTs scored high or ACT-like. All staff cited client engagement as their primary aim, but ACT approaches were less formal, more frequent and more successful than CMHTs'. Two aspects of ACT appeared important for engagement: small case loads and the team approach. Successful client engagement appeared to be associated with greater staff satisfaction., Conclusions: The findings from this study assist in understanding why the ACT approach is more acceptable to clients deemed by CMHTs as "hard to engage". The key elements of ACT that facilitate client engagement may not be easily replicated within CMHTs due to their larger, varied caseloads.

The only randomised controlled trial to test high-fidelity assertive community treatment (ACT) in the UK (the Randomised Evaluation of Assertive Community Treatment (REACT) study) found no advantage over usual care from community mental health teams in reducing the need for in-patient care and in other clinical outcomes, but participants found ACT more acceptable and engaged better with it. One possible reason for the lack of efficacy of ACT might be the short period of follow-up (18 months in the REACT study). This paper reports on participants' service contact, in-patient service use and adverse events 36 months after randomisation.

Objective: Assertive community treatment (ACT) is a key component of mental health care, but recent information on its cost-effectiveness is limited. This article provides a cost-effectiveness analysis of assertive community treatment and usual care from community mental health teams (CMHTs) in the United Kingdom., Methods: Participants who had difficulties engaging with community services were randomly assigned to ACT (N=127) or continued usual care from CMHTs (N= 124). Costs were measured at baseline and 18 months later and compared between the two groups. In the analysis, cost data were linked to information on satisfaction, which had been shown to be significantly higher with ACT., Results: Total follow-up costs over 18 months were higher for the ACT group by pounds sterling 4,031 ($6,369), but this was not statistically significant (95% confidence interval of - pounds sterling 2,592 to pounds sterling 10,690 [-$4,095 to $16,890]). A one-unit improvement in satisfaction was associated with extra costs in the ACT group of pounds sterling 473 ($747)., Conclusions: The costs of ACT were not significantly different from usual care. ACT did, however, result in greater levels of client satisfaction and engagement with services and as such may be the preferred community treatment option for patients with long-term serious mental health problems.

Aims: The use of specialised services to avoid admission to hospital for people experiencing mental health crises is seen as an integral part of psychiatric services in some countries. The aim of this paper is to assess the impact on costs and cost-effectiveness of a crisis resolution team (CRT)., Methods: Patients who were experiencing mental health crises sufficient for admission to be considered were randomised to either care provided by a CRT or standard services. The primary outcome measure was inpatient days over a six-month follow-up period. Service use was measured, costs calculated and cost-effectiveness assessed., Results: Patients receiving care from the CRT had non-inpatient costs pounds sterling 768 higher than patients receiving standard care (90% CI, pounds sterling 153 to pounds sterling 1375). With the inclusion of inpatient costs the costs for the CRT group were pounds sterling 2438 lower for the CRT group (90% CI, pounds sterling 937 to pounds sterling 3922). If one less day spent as an inpatient was valued at pounds sterling 100, there would be a 99.5% likelihood of the CRT being cost-effective., Conclusion: This CRT was shown to be cost-effective for modest values placed on reductions in inpatient stays.

This paper sets out the rationale and process for the development of clinical guidelines, particularly as they apply to psychological therapies and mental health more generally. The methods by which they are produced are briefly reviewed and some commonly identified problems associated with guideline development are also discussed. The evidence for their effective implementation is reviewed and likely future development in clinical guidelines in mental health and psychological therapies are discussed.

Background: Crisis resolution teams (CRTs) provide a community alternative to psychiatric hospital admission for patients presenting in crisis. Little is known about the characteristics of patients admitted despite the availability of such teams., Methods: Data were drawn from three investigations of the outcomes of CRTs in inner London. A literature review was used to identify candidate explanatory variables that may be associated with admission despite the availability of intensive home treatment. The main outcome variable was admission to hospital within 8 weeks of the initial crisis. Associations between this outcome and the candidate explanatory variables were tested using first univariate and then multivariate analysis., Results: Patients who were uncooperative with initial assessment (OR 10.25 95% CI-4.20-24.97), at risk of self-neglect (OR 2.93 1.42-6.05), had a history of compulsory admission (OR 2.64 1.07-6.55), assessed outside usual office hours (OR 2.34 1.11-4.94) and/or were assessed in hospital casualty departments (OR 3.12 1.55-6.26), were more likely to be admitted. Other than age, no socio-demographic features or diagnostic variables were significantly associated with risk of admission., Conclusion: With the introduction of CRTs, inpatient wards face a significant challenge, as patients who cooperate little with treatment, neglect themselves, or have previously been compulsorily detained are especially likely to be admitted. The increased risk of admission associated with casualty department assessment may be remediable.

Background: Health care practice based on research evidence requires that evidence is synthesised, and that recommendations based on this evidence are implemented. It also requires an intermediate step: translating synthesised evidence into practice recommendations. There is considerable literature on evidence synthesis and implementation, but little on how guideline development groups (GDGs) produce recommendations. This is a complex process, with many influences on communication and decision-making, e.g., the quality of evidence, methods of presentation, practical/resource constraints, individual values, professional and scientific interests, social and psychological processes. To make this process more transparent and potentially effective, we need to understand these influences. Psychological theories of decision-making and social influence provide a framework for this understanding., Objectives: This study aims to investigate the processes by which GDGs formulate recommendations, drawing on psychological theories of decision-making and social influence. The findings will potentially inform the further evolution of GDG methods, such as choice of members and procedures for presenting evidence, conducting discussion and formulating recommendations., Methods: Longitudinal observation of the meetings of three National Institute of Health and Clinical Excellence (NICE) GDGs, one from each of acute, mental health and public health, will be tape recorded and transcribed. Interviews with a sample of GDG members at the beginning, middle, and end of the GDG's work will be recorded and transcribed. Site documents including relevant e-mail interchanges, GDG meeting minutes, and stakeholders' responses to the drafts of the recommendations will be collected. Data will be selected for analysis if they refer to either evidence or recommendations; the focus is on "hot spots", e.g., dilemmas, conflicts, and uncertainty. Data will be analysed thematically and by content analysis, drawing on psychological theories of decision-making and social influence.

Background: Evaluations of interventions to improve implementation of guidelines have failed to produce a clear pattern of results favouring a particular method. While implementation depends on clinicians and managers changing a variety of behaviours, psychological theories of behaviour and behaviour change are seldom used to try to understand difficulties in implementation or to develop interventions to overcome them., Objectives: This study applied psychological theory to examine explanations for difficulties in implementation. It used a theoretical framework derived from an interdisciplinary consensus exercise to code interviews across 11 theoretical domains. The focus of the study was a National Institute for Health and Clinical Excellence's Schizophrenia guideline recommendation that family intervention should be offered to the families of people with schizophrenia., Methods: Participants were recruited from community mental health teams from three United Kingdom National Health Service (NHS) Trusts; 20 members (social workers, nurses, team managers, psychologists, and psychiatrists) participated. Semi-structured interviews were audio-taped and transcribed. Interview questions were based on the theoretical domains and addressed respondents' knowledge, attitudes and opinions regarding the guideline. Two researchers independently coded the transcript segments from each interview that were related to each theoretical domain. A score of 1 indicated that the transcript segments relating to the domain did not appear to contain description of difficulties in implementation of the family therapy guidelines; similarly a score of 0.5 indicated possible difficulties and a score of 0 indicated definite difficulties., Results: Coding respondents' answers to questions related to the three domains 'beliefs about consequences,' 'social/professional role and identity,' and 'motivation' produced the three highest total scores indicating that factors relating to these domains were unlikely to constitute difficulties in implementation. 'Environmental context and resources' was the lowest scoring domain, with 'Emotion' scoring the second lowest, suggesting that these were likely to be areas for considering intervention. The two main resources identified as problems were time and training. The emotions that appeared to potentially influence the offer of family therapy were self-doubt and fear., Conclusion: This exploratory study demonstrates an approach to developing a theoretical understanding of implementation difficulties.

Background: The relative efficacy of different psychological treatments for chronic post-traumatic stress disorder (PTSD) is unclear., Aims: To determine the efficacy of specific psychological treatments for chronic PTSD., Method: In a systematic review of randomised controlled trials, eligible studies were assessed against methodological quality criteria and data were extracted and analysed., Results: Thirty-eight randomised controlled trials were included in the meta-analysis. Trauma-focused cognitive-behavioural therapy (TFCBT), eye movement desensitisation and reprocessing (EMDR), stress management and group cognitive-behavioural therapy improved PTSD symptoms more than waiting-list or usual care. There was inconclusive evidence regarding other therapies. There was no evidence of a difference in efficacy between TFCBT and EMDR but there was some evidence that TFCBT and EMDR were superior to stress management and other therapies, and that stress management was superior to other therapies., Conclusions: The first-line psychological treatment for PTSD should be trauma-focused (TFCBT or EMDR).

Background: Treatment options for depression include antidepressants, psychological therapy and a combination of the two., Aims: To develop cost-effective clinical guidelines., Method: Systematic literature reviews were used to identify clinical, utility and cost data. A decision analysis was then conducted to compare the benefits and costs of antidepressants with combination therapy for moderate and severe depression in secondary care in the UK., Results: Over the 15-month analysis period, combination therapy resulted in higher costs and an expected 0.16 increase per person in the probability of remission and no relapse compared with antidepressants. The cost per additional successfully treated patient was 4056 UK pounds (95% CI1400-18300); the cost per quality-adjusted life year gained was 5777 UK pounds (95% CI1900-33 800) for severe depression and 14 540 UK pounds (95% CI 4800-79 400) for moderate depression., Conclusions: Combination therapy is likely to be a cost-effective first-line secondary care treatment for severe depression. Its cost-effectiveness for moderate depression is more uncertain from current evidence. Targeted combination therapy could improve resource utilisation.

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.

This paper describes the development of the clinical practice guideline on schizophrenia from the National Institute for Clinical Excellence (NICE) and outlines its main recommendations. It reviews the evidence on effective implementation of guidelines generally and examines issues specific to the schizophrenia guideline. It describes NICE's approach to supporting implementation alongside that developed by the National Collaborating Centre for Mental Health (NCCMH) and looks at local implementation examples for schizophrenia. The paper highlights key considerations for the forthcoming revision of the NICE schizophrenia guideline. It makes recommendations concerning the scope of the guideline and the quality and type of data available to the guideline developers: the lack of data on outcomes such as quality of life and social functioning, the challenges presented by unpublished papers and areas where evidence is limited. Since publication of the schizophrenia guideline, the NICE development process has undergone significant methodological improvements. The grading of evidence has been refined and more recently NICE proposed that grading of recommendations be dropped. Consensus methods are increasingly and more effectively used to deal with areas where the evidence-base is limited. NICE and the NCCMH have developed a more implementation-ready range of guideline products. The initial NICE guideline on schizophrenia was positively received nationally and internationally. This paper highlights challenges that will be involved in updating the guideline and ways to refine the methodology of development. Ultimately the impact of the guideline will be measured not in its methodological rigor but in how its successful implementation improves patient care.

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 $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.

Objective: To evaluate the effectiveness of a crisis resolution team., Design: Randomised controlled trial., Participants: 260 residents of the inner London Borough of Islington who were experiencing crises severe enough for hospital admission to be considered., Interventions: Acute care including a 24 hour crisis resolution team (experimental group), compared with standard care from inpatient services and community mental health teams (control group)., Main Outcome Measures: Hospital admission and patients' satisfaction., Results: Patients in the experimental group were less likely to be admitted to hospital in the eight weeks after the crisis (odds ratio 0.19, 95% confidence interval 0.11 to 0.32), though compulsory admission was not significantly reduced. A difference of 1.6 points in the mean score on the client satisfaction questionnaire (CSQ-8) was not quite significant (P = 0.07), although it became so after adjustment for baseline characteristics (P = 0.002)., Conclusion: Crisis resolution teams can reduce hospital admissions in mental health crises. They may also increase satisfaction in patients, but this was an equivocal finding.

Background: Crisis resolution teams (CRTs) are being introduced throughout England, but their evidence base is limited., Aims: To compare outcomes of crises before and after introduction of a CRT., Method: A new methodology was developed for identification and operational definition of crises. A quasi-experimental design was used to compare cohorts presenting just before and just after a CRT was established., Results: Following introduction of the CRT, the admission rate in the 6 weeks after a crisis fell from 71% to 49% (OR 0.38, 95% CI 0.21-0.70). A difference of 5.6 points (95% CI 2.0-8.3) on mean Client Satisfaction Questionnaire (CSQ-8) score favoured the CRT. These findings remained significant after adjustment for baseline differences. No clear difference emerged in involuntary hospitalisations, symptoms, social functioning or quality of life., Conclusions: CRTs may prevent some admissions and patients prefer them, although other outcomes appear unchanged in the short term.