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AimsThe Enhanced Trauma Pathway (ETP) at Berkshire Healthcare NHS Foundation Trust was established in 2018 to manage high demand on a highly specialist psychology team called the Berkshire Traumatic Stress Service (BTSS). The ETP is used to treat complicated cases of Post-Traumatic Stress Disorder (PTSD) within the IAPT service. However, because of the ETP there is now a cohort of Service Users (SUs) presenting to IAPT with a higher complexity than has been typical, presenting new challenges for the service. We aim to evaluate and redesign the ETP within IAPT to meet the needs of the changing population.MethodsClinically Led workforcE and Activity Redesign (CLEAR) is a workforce transformation methodology with four unique stages: i) Clinical Engagement: in-depth qualitative analysis of interview data from staff ii) Data Interrogation: cohort analysis using clinical and workforce data visualisations and analysis, iii) Innovation: developing novel solutions with insights from triangulated qualitative and quantitative data, iv) Recommendations: formulation of new models of care (NMOC) and smaller quick high impact service innovations. Thematic analysis was used for the qualitative data. Quantitative data analysis was conducted using the IAPT dataset.Results27 semi-structured interviews were conducted with staff. SUs on the ETP had longer waiting times, their treatment took longer (18 sessions for ETP Vs 12 for core step 3) and they had lower recovery rates: 32.9% for ETP, 49.9% for core step 3 in IAPT and 57.3% for the whole IAPT service. SUs on the ETP presented with increased risk concerns, often not mitigated by stabilisation work offered. Thematic analysis also identified challenges with recruitment, a lack of qualified staff and inefficient use of skills across the pathway. Staff well-being was found to be paramount, however supporting staff was found to be challenging due to national constraints placed upon IAPT and the targets the service is asked to achieve. A series of recommendations were made including three options for a NMOC. The options suggested different ways to redesign the pathway including an option where there would be a trauma only team within IAPT working exclusively on the ETP.ConclusionThis evaluation highlights the challenges for the ETP and identifies NMOC to reduce their impact on the service. Further work is required to assess the NMOC once it has been implemented and to further evaluate the needs of the SUs presenting to this service.

An amendment to this paper has been published and can be accessed via a link at the top of the paper.

Utilization of internet-delivered cognitive behavioural therapy (iCBT) for treating depression and anxiety disorders in stepped-care models, such as the UK’s Improving Access to Psychological Therapies (IAPT), is a potential solution for addressing the treatment gap in mental health. We investigated the effectiveness and cost-effectiveness of iCBT when fully integrated within IAPT stepped-care settings. We conducted an 8-week pragmatic randomized controlled trial with a 2:1 (iCBT intervention: waiting-list) allocation, for participants referred to an IAPT Step 2 service with depression and anxiety symptoms (Trial registration: ISRCTN91967124). The primary outcomes measures were PHQ-9 (depressive symptoms) and GAD-7 (anxiety symptoms) and WSAS (functional impairment) as a secondary outcome. The cost-effectiveness analysis was based on EQ-5D-5L (preference-based health status) to elicit the quality-adjust life year (QALY) and a modified-Client Service Receipt Inventory (care resource-use). Diagnostic interviews were administered at baseline and 3 months. Three-hundred and sixty-one participants were randomized (iCBT, 241; waiting-list, 120). Intention-to-treat analyses showed significant interaction effects for the PHQ-9 (b = −2.75, 95% CI −4.00, −1.50) and GAD-7 (b = −2.79, 95% CI −4.00, −1.58) in favour of iCBT at 8-week and further improvements observed up to 12-months. Over 8-weeks the probability of cost-effectiveness was 46.6% if decision makers are willing to pay £30,000 per QALY, increasing to 91.2% when the control-arm’s outcomes and costs were extrapolated over 12-months. Results indicate that iCBT for depression and anxiety is effective and potentially cost-effective in the long-term within IAPT. Upscaling the use of iCBT as part of stepped care could help to enhance IAPT outcomes. The pragmatic trial design supports the ecological validity of the findings.

The way individuals appraise positive emotions may modulate affective experience during positive activity scheduling. Individuals may either engage in dampening appraisals (e.g., think "this is too good to last") or amplifying appraisals (e.g., think "I deserve this"). A cross-over randomized design was used to examine the consequences of these appraisal styles. Participants (N = 43) rated positive affect (PA) and negative affect (NA) during four daily walks in pleasant locations, whilst following dampening, emotion-focus amplifying (focusing on how good one feels), self-focus amplifying (focusing on positive self qualities), or control instructions. There was no difference between the two amplifying and control conditions, which all increased PA and reduced NA during the walks. However, the dampening condition significantly differed from all other conditions, reducing PA and increasing NA during the walk. Individual differences in anhedonia symptoms did not significantly moderate the pattern of findings. This evidence supports the view that dampening appraisals may be one mechanism driving anhedonia and may account for why positive activity scheduling can sometimes backfire when utilized in the clinic.

Two studies examined whether use of dampening appraisals (e.g., thinking “this is too good to last”) or amplifying appraisals (e.g., thinking “I deserve this”) modulated affective experience when remembering (Study One) and anticipating (Study Two) positive events. Both studies used a mixed within-between participants design, with participants completing an uninstructed positive recall/anticipation task before being randomized to either control, dampening, or amplifying instructions during a second positive recall/anticipation task. During memory recall (Study One), instructed dampening increased dampening appraisals and led to a reduction in happiness and pleasantness and an increase in sadness, significantly differing from the control and amplifying conditions. While the amplifying condition significantly increased amplifying appraisals, it did not alter affective experience (relative to the control condition). During anticipation (Study Two), identical findings emerged for the dampening manipulation. The amplifying manipulation did not significantly increase amplifying appraisals, precluding conclusions being drawn about the impact of amplifying in this study. These results suggest that dampening appraisals contribute to altered affective experience when imagining and recalling positive activities and may account for why attempts to do so can have paradoxically negative effects in clinical populations. Moreover, the studies preliminarily validate a novel scale measuring state appraisal of positive experiences.