A method describing care pathways for users of mental health services is reviewed. The integrated care pathways approach provides a focus for determining which psychological interventions are required, together with the different contributions and roles of mental health staff. It could also assist in the costing and resourcing of services.
Aim: This study aims to assess the feasibility and effectiveness of collecting sessional outcome data from clients and providing feedback to therapists about symptoms and alliance. We aim to assess whether the benefits of monitoring and feedback on client outcome observed in the US, translate to routine UK secondary care psychological therapies. Therapists’ use of feedback and issues of acceptability and compliance will be explored. Method: Outcome data was collected from consenting clients across two South West Yorkshire sites. Our feedback system used two brief distress measures, which clients completed before each therapy session, and one post session measure assessing helpfulness, alliance and stage of therapy. This data combined with benchmark data determines clients ‘not on track’. Therapists received feedback after each client’s fourth session. Reflexive dialogue between therapists, service users and researchers was implemented.
Results: To date, we have found that it is feasible to operate a feedback system in standard UK psychological therapies providing that initiatives are introduced to enhance ease and acceptability. This is a work in progress and we anticipate that feedback for clients ‘not on track’ will enhance overall therapeutic outcome whilst rendering no effect on those who are ‘on track’.
Discussion: Monitoring and feedback is a promising development in modern psychotherapy practise. Such systems can provide increased sensitivity to client progress; therapists can use this information to guide their care plan to improve overall outcome. We are uniquely placed to identify barriers to implementation and offer recommendations for future replications.
To complement the evidence-based practice paradigm, the authors argued for a core outcome measure to provide practice-based evidence for the psychological therapies. Utility requires instruments that are acceptable scientifically, as well as to service users, and a coordinated implementation of the measure at a national level. The development of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) is summarized. Data are presented across 39 secondary-care services (n = 2,710) and within an intensively evaluated single service (n = 1,455). Results suggest that the CORE-OM is a valid and reliable measure for multiple settings and is acceptable to users and clinicians as well as policy makers. Baseline data levels of patient presenting problem severity, including risk, are reported in addition to outcome benchmarks that use the concept of reliable and clinically significant change. Basic quality improvement in outcomes for a single service is considered.
To study the time course and prediction of responses to reassurance after gastroscopy showing no serious illness.Selection of consecutive patients were assessed before gastroscopy, immediately after reassurance, and at follow up at 24 hours, 1 week, 1 month, and 1 year. Responses of subgroups of patients identified as high, medium, and low health anxiety by the health anxiety questionnaire were analysed.Endoscopy clinic in a general hospital.Oral reassurance that there was "nothing seriously wrong."One consultant physician and 60 patients aged 18-74 referred for gastroscopy.Physician's and patients' ratings of the extent of the reassurance and patients' ratings of their anxiety about their health and of their illness belief.There was good agreement between the patients and the physician about whether reassurance had been given. Health anxiety and illness belief decreased markedly after reassurance. Patients with high health anxiety showed a significant resurgence in their worry and illness belief at 24 hours and 1 week, and these levels were maintained at 1 months and 1 year later. Patients with medium levels of health anxiety showed a reduction in worry and illness belief after reassurance, and this was generally maintained during follow up. Patients with low health anxiety maintained low levels of health worry and illness belief throughout the study. Partial correlation analyses showed that the levels of worry and illness belief after reassurance were predicted by the health anxiety questionnaire. This measure also had predictive value beyond that of a measure of general anxiety.Medical reassurance results in a reduction of worry about health and of illness belief, but this may be very short term. Measurable individual differences in health anxiety can be used to predict the response to reassurance.
Abstract People who experience sexual violence are highly likely to experience psychological and/or mental health (MH) problems as a result. People who use MH services often have a history of sexual assault and are also likely to be revictimised as an adult. Yet despite there being a very clear association, MH services are not yet performing routine enquiry, and even if they do, are not confident about how to record and manage disclosures. There is some emerging evidence that people with MH problems are exposed to sexual violence in inpatient MH settings, perpetrated by both other patients or members of staff. In this editorial, we explore the evidence to support a wider focus on sexual violence as a part of routine care, as well as some recommendations about how staff can more effectively discuss sexual issues including that of sexual victimisation.
Background Depression is the most common mental disorder in community settings and a major cause of disability across the world. The objective of treatment is to achieve remission or at least adequate control of depressive symptoms; however, even after successful treatment, the risk of relapse after remission is significant. Although the effectiveness of low-intensity interventions has been extensively evaluated to treat primary symptoms of psychological difficulties, there has been substantially less research examining the use of these interventions as a relapse prevention strategy. Objective To systematically review the clinical effectiveness and cost-effectiveness of low-intensity psychological or psychosocial interventions to prevent relapse or recurrence in patients with depression. As the broader definition of 'low-intensity' psychological intervention is somewhat contested, the review was conducted in two parts: A, a systematic review of all evaluations of 'low-intensity' interventions that were delivered by para-professionals, peer supporters or psychological well-being practitioners as defined by the Improving Access to Psychological Therapies programme; and B, a scoping review of relevant evaluations of interventions involving qualified mental health professionals (e.g. psychiatrists, clinical psychologists, cognitive behavioural therapists) involving < 6 hours of contact per patient. Data sources Comprehensive literature searches were developed; electronic databases were searched from inception until September 2010 (including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, EMBASE, The Cochrane Library), internet resources were used to identify guidelines on the treatment of depression, and the bibliographies of relevant reviews, guidelines and included studies were scrutinised. Review methods Two reviewers independently screened titles and abstracts; data were extracted independently by one reviewer using a standardised data extraction form and checked by another. Discrepancies were resolved by consensus, with involvement of a third reviewer when necessary. The inclusion criteria were population – adults or adolescents who had received treatment for depression; intervention – part A, low-intensity interventions, specifically any unsupported psychological/psychosocial interventions or any supported interventions that did not involve highly qualified mental health professionals, and, part B, interventions carried out by qualified mental health professionals that involved < 6 hours of contact per patient; comparator – any, including no treatment, placebo, psychological or pharmacological interventions; outcomes – relapse or recurrence, other outcomes (e.g. social function, quality of life) were recorded where reported; and study design – for clinical effectiveness, randomised, quasi-randomised and non-randomised studies with concurrent control patients. For cost-effectiveness, full economic evaluations that compared two or more treatment options and considered both costs and consequences. No studies met the main part A inclusion criteria. Results For the clinical effectiveness review, 17 studies (14 completed, three ongoing), reported in 27 publications, met the part B inclusion criteria. These studies were clinically and methodologically diverse, and reported differing degrees of efficacy for the evaluated interventions. One randomised controlled trial (RCT), which evaluated a collaborative care-type programme, was potentially relevant to part A; this study reported no difference between patients receiving the intervention and those receiving usual care in terms of relapse of depression over 12 months. For the cost-effectiveness review, two studies met the criteria for part B. One of these was an economic evaluation of the RCT above, which was potentially relevant to part A. This evaluation found that the intervention may be a cost-effective use of resources when compared with usual care; however, it was unclear how valid these estimates were for the NHS. Limitations Although any definition of 'brief' is likely to be somewhat arbitrary, an inclusion threshold of 6 hours contact per patient was used to select brief high-intensity intervention studies. Most excluded studies evaluated clearly resource-intensive interventions, though occasionally, studies were excluded on the basis of having only slightly more than 6 hours contact per patient. Conclusions There is inadequate evidence to determine the clinical effectiveness or cost-effectiveness of low-intensity interventions for the prevention of relapse or recurrence of depression. A scoping review of brief high-intensity therapies indicates that some approaches have shown promise in some studies, but findings have not been consistent. Many uncertainties remain and further primary research is required. Careful consideration should be given to the scope of such research; it is important to evaluate the broader patient pathway accounting for the heterogeneous patient groups of interest. Future RCTs conducted in a UK primary care setting should include adult participants in remission or recovery from depression, and evaluate the quality of the intervention and consistency of delivery across practitioners where appropriate. The occurrence of relapse or recurrence should be measured using established methods, and functional outcomes as well as symptoms should be measured; data on quality of life using a generic instrument, such as the European Quality of Life-5 Dimensions (EQ-5D), should be collected. Funding The National Institute for Health Research Health Technology Assessment programme.
The Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) and the Beck Depression Inventory (BDI) are routinely used to assess emotional problems. It would be helpful to be able to compare scores when only one of the measures is available. We investigated the relationship between the measures and produced translation tables.Level of agreement between CORE-OM and BDI-I was assessed for 2,234 clients who had completed both measures at referral for routine secondary care. Tables for predicting between the measures were constructed using several methods, including non-linear regression and non-parametric smoothing. Results were cross-validated on a separate sample of 326 clients.High correlations between the measures were obtained (r=.862 for female clients; r=.855 for male clients). Accuracy in predicting caseness is higher than predicting depression levels.CORE-OM and BDI can be compared in routine clinical settings with acceptable accuracy.
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Dr Stratin is sitting in a clinic with Mr B, a 45-year-old man who had an anterior ST-elevation myocardial infarction (STEMI) treated with primary percutaneous coronary intervention 6 weeks ago. He felt ‘fixed’ by his treatment and was shocked but relieved to be discharged home after 3 days. He lives alone and has returned to his work as a self-employed builder. Mr B has continued to smoke after his acute myocardial infarction. He is also anxious about his risk of future recurrence and has had to question his assumptions about his physical health and expectations about his health in future years. He is obese and not undertaking any structured exercise. His blood pressure is elevated and he admits that the way in which he takes his cardioprotective medication is a ‘bit hit and miss’.
This clinical scenario illustrates common psychosocial factors that can impact negatively on a patient’s recovery and clinical outcomes following treatment for STEMI. These factors will be described and strategies that can be applied to Mr B’ care summarised.
Behavioural cardiology is defined as ‘the study and application of psychosocial factors in the assessment and reduction of cardiovascular risk’.1 Over the last 15 years, there has been a growing recognition that psychosocial risk factors make a significant contribution to the atherosclerotic process leading to cardiovascular disease (CVD) through biological and behavioural mechanisms.2 It is recognised that psychosocial risk factors, such as depression and social isolation, are as potent as many biological and behavioural coronary risk factors. In this paper, we will …
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