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Janssen NP, Hendriks GJ, Sens R, Lucassen P, Oude Voshaar RC, Ekers D, van Marwijk H, Spijker J, Bosmans JE. Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial. J Affect Disord 2024; 350:665-672. [PMID: 38244792 DOI: 10.1016/j.jad.2024.01.109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 12/23/2023] [Accepted: 01/09/2024] [Indexed: 01/22/2024]
Abstract
INTRODUCTION Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown. METHODS An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios. RESULTS Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs. DISCUSSION Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.
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Affiliation(s)
- Noortje P Janssen
- Behavioural Science Institute, Radboud University, 6525 XZ Nijmegen, the Netherlands; Department of Primary and Community Care, Research Institute of Health Sciences, Radboud University Medical Centre Nijmegen, 6525 EZ Nijmegen, the Netherlands; Institute for Integrated Mental Health Care Pro Persona, 6525 DX Nijmegen, the Netherlands.
| | - Gert-Jan Hendriks
- Behavioural Science Institute, Radboud University, 6525 XZ Nijmegen, the Netherlands; Institute for Integrated Mental Health Care Pro Persona, 6525 DX Nijmegen, the Netherlands
| | - Renate Sens
- Department of Health Sciences, VU University, 1081 HV Amsterdam, the Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Research Institute of Health Sciences, Radboud University Medical Centre Nijmegen, 6525 EZ Nijmegen, the Netherlands
| | - Richard C Oude Voshaar
- University of Groningen, Department of Psychiatry, University Medical Centre Groningen, 9713 GZ Groningen, the Netherlands
| | - David Ekers
- Mental Health and Addictions Research Group, Tees Esk and Wear Valleys NHS FT/University of York, TS60SZ York, UK
| | - Harm van Marwijk
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, BN1 9PH Brighton, United Kingdom
| | - Jan Spijker
- Behavioural Science Institute, Radboud University, 6525 XZ Nijmegen, the Netherlands; Institute for Integrated Mental Health Care Pro Persona, 6525 DX Nijmegen, the Netherlands
| | - Judith E Bosmans
- Department of Health Sciences, VU University, 1081 HV Amsterdam, the Netherlands
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Smith J, Eskandari F, McGeechan GJ, Teasdale SB, Lake AA, Ker S, Williamson K, Augustine A, Sauvage NL, Lynch C, Moore H, Scott S, Ekers D, Whittaker V, Robinson J, Giles EL. Food insecurity in adults with severe mental illness living in Northern England: A co-produced cross-sectional study. Nutr Diet 2024. [PMID: 38472093 DOI: 10.1111/1747-0080.12868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/10/2024] [Accepted: 02/05/2024] [Indexed: 03/14/2024]
Abstract
AIM This study aimed to explore food insecurity prevalence and experiences of adults with severe mental illness living in Northern England. METHODS This mixed-methods cross-sectional study took place between March and October 2022. Participants were adults with self-reported severe mental illness living in Northern England. The survey included demographic, health, and financial questions. Food insecurity was measured using the US Department of Agriculture Adult Food Security measure. Quantitative data were analysed using descriptive statistics and binary logistic regression; and qualitative data using content analysis. RESULTS In total, 135 participants completed the survey, with a mean age of 44.7 years (SD: 14.1, range: 18-75 years). Participants were predominantly male (53.3%), white (88%) and from Yorkshire (50.4%). The food insecurity prevalence was 50.4% (n = 68). There was statistical significance in food insecurity status by region (p = 0.001); impacts of severe mental illness on activities of daily living (p = 0.02); and the Covid pandemic on food access (p < 0.001). The North West had the highest prevalence of food insecurity (73.3%); followed by the Humber and North East regions (66.7%); and Yorkshire (33.8%). In multivariable binary logistic regression, severe mental illness' impact on daily living was the only predictive variable for food insecurity (odds ratio = 4.618, 95% confidence interval: 1.071-19.924, p = 0.04). CONCLUSION The prevalence of food insecurity in this study is higher than is reported in similar studies (41%). Mental health practitioners should routinely assess and monitor food insecurity in people living with severe mental illness. Further research should focus on food insecurity interventions in this population.
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Affiliation(s)
- Jo Smith
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
| | - Fatemeh Eskandari
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
| | - Grant J McGeechan
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
- Centre for Applied Psychological Science, Teesside University, School of Social Sciences, Humanities and Law, Middlesbrough, UK
| | - Scott B Teasdale
- Department of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, New South Wales, Australia
- Mindgardens Neuroscience Network, University of New South Wales, Sydney, New South Wales, Australia
| | - Amelia A Lake
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
| | - Suzy Ker
- Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Kevin Williamson
- Rotherham, Doncaster and South Humber NHS Foundation Trust, Doncaster, UK
| | | | | | - Chris Lynch
- Equally Well UK, Centre for Mental Health, London, UK
| | - Hannah Moore
- Equally Well UK, Centre for Mental Health, London, UK
| | - Steph Scott
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Ridley Building, 5th Floor, Newcastle University, Newcastle upon Tyne, UK
| | - David Ekers
- Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Vicki Whittaker
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Jonathan Robinson
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Emma L Giles
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle University, Newcastle upon Tyne, UK
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Gilbody S, Littlewood E, McMillan D, Atha L, Bailey D, Baird K, Brady S, Burke L, Chew-Graham CA, Coventry P, Crosland S, Fairhurst C, Henry A, Hollingsworth K, Newbronner E, Ryde E, Shearsmith L, Wang HI, Webster J, Woodhouse R, Clegg A, Dexter-Smith S, Gentry T, Hewitt C, Hill A, Lovell K, Sloan C, Traviss-Turner G, Pratt S, Ekers D. Behavioural activation to mitigate the psychological impacts of COVID-19 restrictions on older people in England and Wales (BASIL+): a pragmatic randomised controlled trial. Lancet Healthy Longev 2024; 5:e97-e107. [PMID: 38310902 PMCID: PMC10834375 DOI: 10.1016/s2666-7568(23)00238-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 10/27/2023] [Accepted: 11/09/2023] [Indexed: 02/06/2024] Open
Abstract
BACKGROUND Older adults were more likely to be socially isolated during the COVID-19 pandemic, with increased risk of depression and loneliness. We aimed to investigate whether a behavioural activation intervention delivered via telephone could mitigate depression and loneliness in at-risk older people during the COVID-19 pandemic. METHODS BASIL+ (Behavioural Activation in Social Isolation) was a pragmatic randomised controlled trial conducted among patients recruited from general practices in England and Wales, and was designed to assess the effectiveness of behavioural activation in mitigating depression and loneliness among older people during the COVID-19 pandemic. Eligible participants were aged 65 years and older, socially isolated, with a score of 5 or higher on the Patient Health Questionnaire-9 (PHQ-9), and had multiple long-term conditions. Participants were allocated in a 1:1 ratio to the intervention (behavioural activation) or control groups by use of simple randomisation without stratification. Behavioural activation was delivered by telephone; participants were offered up to eight weekly sessions with trained BASIL+ Support Workers. Behavioural activation was adapted to maintain social connections and encourage socially reinforcing activities. Participants in the control group received usual care with existing COVID-19 wellbeing resources. The primary clinical outcome was self-reported depression severity, assessed by the PHQ-9, at 3 months. Outcomes were assessed masked to allocation and analysis was by treatment allocation. This trial is registered with the ISRCTN registry (ISRCTN63034289). FINDINGS Between Feb 8, 2021, and Feb 28, 2022, 449 eligible participants were identified and 435 from 26 general practices were recruited and randomly assigned (1:1) to the behavioural activation intervention (n=218) or to the control group (usual care with signposting; n=217). The mean age of participants was 75·7 years (SD 6·7); 270 (62·1%) of 435 participants were female, and 418 (96·1%) were White. Participants in the intervention group attended an average of 5·2 (SD 2·9) of eight remote behavioural activation sessions. The adjusted mean difference in PHQ-9 scores between the control and intervention groups at 3 months was -1·65 (95% CI -2·54 to -0·75, p=0·0003). No adverse events were reported that were attributable to the behavioural activation intervention. INTERPRETATION Behavioural activation is an effective and potentially scalable intervention that can reduce symptoms of depression and emotional loneliness in at-risk groups in the short term. The findings of this trial add to the range of strategies to improve the mental health of older adults with multiple long-term conditions. These results can be helpful to policy makers beyond the pandemic in reducing the global burden of depression and addressing the health impacts of loneliness, particularly in at-risk groups. FUNDING UK National Institute for Health and Care Research.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York, UK; Hull York Medical School, University of York, York, UK.
| | - Elizabeth Littlewood
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK; Hull York Medical School, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Lucy Atha
- Department of Health Sciences, University of York, York, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | - Kalpita Baird
- Department of Health Sciences, University of York, York, UK
| | - Samantha Brady
- Department of Health Sciences, University of York, York, UK
| | - Lauren Burke
- Department of Health Sciences, University of York, York, UK
| | | | - Peter Coventry
- Department of Health Sciences, University of York, York, UK; York Environmental Sustainability Institute, University of York, York, UK
| | | | | | - Andrew Henry
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | - Kelly Hollingsworth
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | - Han-I Wang
- Department of Health Sciences, University of York, York, UK
| | | | | | - Andrew Clegg
- School of Medicine, University of Leeds, Leeds, UK
| | - Sarah Dexter-Smith
- Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
| | | | | | - Andrew Hill
- School of Medicine, University of Leeds, Leeds, UK
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | | | | | - David Ekers
- Department of Health Sciences, University of York, York, UK; Tees, Esk and Wear Valleys NHS Foundation Trust, Research & Development, Flatts Lane Centre, Middlesbrough, UK
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Jennings HM, Anas A, Asmat S, Naz A, Afaq S, Ahmed N, Aslam F, Gomez GZ, Siddiqi N, Ekers D. Living with depression and diabetes: A qualitative study in Bangladesh and Pakistan. PLOS Glob Public Health 2024; 4:e0002846. [PMID: 38271347 PMCID: PMC10810509 DOI: 10.1371/journal.pgph.0002846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
Diabetes and depression are both serious health conditions. While their relationship is bidirectional and each condition adversely affects outcomes for the other, they are treated separately. In low and middle income countries, such as Bangladesh and Pakistan, health systems are already stretched and the integration of diabetes and depression care is rarely a priority. Within this context through interviews with patients, healthcare workers and policy makers the study explored: lived experiences of people living with depression and diabetes, current practice in mental health and diabetes care and barriers and perspectives on integrating a brief psychological therapy into diabetes care. The findings of the study included: differing patient and practitioner understandings of distress/depression, high levels of stigma for mental health and a lack of awareness and training on treating depression. While it was apparent there is a need for more holistic care and the concept of a brief psychological intervention appeared acceptable to participants, many logistical barriers to integrating a mental health intervention into diabetes care were identified. The study highlights the importance of context and of recognising drivers and understandings of distress when planning for more integrated mental and physical health services, and specifically when adapting and implementing a new intervention into existing services.
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Affiliation(s)
- Hannah Maria Jennings
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, Heslington, United Kingdom
| | - Ashraful Anas
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Sara Asmat
- Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Anum Naz
- Institute of Psychiatry (IoP), Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Saima Afaq
- Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Faiza Aslam
- Institute of Psychiatry (IoP), Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | | | - Najma Siddiqi
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, Heslington, United Kingdom
| | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees Esk and Wear Valleys NHS FT, Darlington, United Kingdom
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Giles EL, Eskandari F, McGeechan G, Scott S, Lake AA, Teasdale S, Ekers D, Augustine A, Le Savauge N, Lynch C, Moore H, Smith J. Food insecurity in adults with severe mental illness living in Northern England: Peer research interview findings. Int J Ment Health Nurs 2023. [PMID: 38059552 DOI: 10.1111/inm.13270] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 11/02/2023] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
Food insecurity means that a person does not have access to sufficient nutritious food for normal growth and health. Food insecurity can lead to many health problems such as obesity, heart disease, diabetes, and other long term health conditions. People living with a severe mental illness are more likely to experience food insecurity than people without mental illness. Peer-led in-depth interviews were conducted with adults with severe mental illness from Northern England, during which their experiences of food insecurity and strategies to tackle food insecurity were discussed. Interviews took place between March and December 2022, with interviews being transcribed and analysed using deductive and inductive thematic analysis. Thirteen interviews were conducted, finding that food insecurity in adults with severe mental illness was often a long-standing issue. Unemployment, the cost-of-living crisis and fuel poverty impacted on experiences of food insecurity. Difficulties accessing food banks such as transport, stigma, and the limited selection of available food was also discussed. Strategies to tackle food insecurity centred on making food banks more accessible and improving the quality of available food. Future research should aim to eradicate food insecurity for adults with severe mental illness, as limited research and action focuses on this population group over and above 'mental illness' or 'poor mental health'. Removing barriers to accessing food such as lack of transport, and providing food which is of adequate nutritional quality, should be prioritised, as well as tackling the stigma and accessibility issues surrounding food banks use.
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Affiliation(s)
- Emma L Giles
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
| | - Fatemeh Eskandari
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
| | - Grant McGeechan
- Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
- Centre for Applied Psychological Science, School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Steph Scott
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Amelia A Lake
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
| | - Scott Teasdale
- Discipline of Psychiatry & Mental Health, University of New South Wales, Sydney, New South Wales, Australia
| | - David Ekers
- Department of Health Sciences, University of York (Mental Health and Addictions Research Group), York, UK
- Flatts Lane Centre, Tees, Esk and Wear Valleys NHS Foundation Trust Flatts Lane, Normanby, Tees Valley, Middlesbrough, UK
| | | | | | | | | | - Jo Smith
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
- Fuse, The Centre for Translational Research in Public Health, Newcastle upon Tyne, UK
- Flatts Lane Centre, Tees, Esk and Wear Valleys NHS Foundation Trust Flatts Lane, Normanby, Tees Valley, Middlesbrough, UK
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Zainab R, Kandasamy A, Bhat NA, Dsouza CV, Jennings H, Jackson C, Mazumdar P, Hewitt CE, Ekers D, Narayanan G, Rao GN, Coales K, Muliyala KP, Chaturvedi SK, Murthy P, Siddiqi N. Behavioral Activation for Comorbid Depression in People With Noncommunicable Disease in India: Protocol for a Randomized Controlled Feasibility Trial. JMIR Res Protoc 2023; 12:e41127. [PMID: 37971791 PMCID: PMC10690525 DOI: 10.2196/41127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Revised: 03/23/2023] [Accepted: 04/18/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND The increasing burden of depression and noncommunicable disease (NCD) is a global challenge, especially in low- and middle-income countries, considering the resource constraints and lack of trained human resources in these settings. Effective treatment of depression in people with NCDs has the potential to enhance both the mental and physical well-being of this population. It will also result in the effective use of the available health care resources. Brief psychological therapies, such as behavioral activation (BA), are effective for the treatment of depression. BA has not been adapted in the community health care services of India, and the feasibility of using BA as an intervention for depression in NCD and its effectiveness in these settings have not been systematically evaluated. OBJECTIVE Our objective is to adapt BA for the Indian NCD context and test the acceptability, feasibility, and implementation of the adapted BA intervention (BEACON intervention package [BIP]). Additionally, we aim to test the feasibility of a randomized controlled trial evaluation of BIP for the treatment of depression compared with enhanced usual care. METHODS Following well-established frameworks for intervention adaptation, we first adapted BA (to fit the linguistic, cultural, and resource context) for delivery in India. The intervention was also adapted for potential remote delivery by telephone. In a randomized controlled trial, we will be testing the acceptability, feasibility, and implementation of the adapted BA intervention (BIP). We shall also test if a randomized controlled feasibility trial can be delivered effectively and estimate important parameters (eg, recruitment and retention rates and completeness of follow-up) needed to design a future definitive trial. RESULTS Following the receipt of approval from all the relevant agencies, the development of the BIP was started on November 28, 2020, and completed on August 18, 2021, and the quantitative data collection was started on August 23, 2021, and completed on December 10, 2021. Process evaluation (qualitative data) collection is ongoing. Both the qualitative and quantitative data analyses are ongoing. CONCLUSIONS This study may offer insights that could help in closing the gap in the treatment of common mental illness, particularly in nations with limited resources, infrastructure, and systems such as India. To close this gap, BEACON tries to provide BA for depression in NCDs through qualified NCD (BA) counselors integrated within the state-run NCD clinics. The results of this study may aid in understanding whether BA as an intervention is acceptable for the population and how feasible it will be to deliver such interventions for depression in NCD in South Asian countries such as India. The BIP may also be used in the future by Indian community clinics as a brief intervention program. TRIAL REGISTRATION Clinical Trials Registry of India CTRI/2020/05/025048; https://tinyurl.com/mpt33jv5. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID) DERR1-10.2196/41127.
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Affiliation(s)
- Rayeesa Zainab
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Arun Kandasamy
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Naseer Ahmad Bhat
- Jindal School of Psychology and Counselling, O P Jindal Global University, Sonipat, India
| | | | - Hannah Jennings
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
| | - Cath Jackson
- Valid Research LTD, West Yorkshire, United Kingdom
| | - Papiya Mazumdar
- School of Politics and International Studies, Faculty of Social Science, University of Leeds, Leeds, United Kingdom
| | | | - David Ekers
- Tees Esk and Wear Valleys NHS Foundation Trust, North Yorkshire, United Kingdom
- Department of Medicine, Pharmacy, and Health, Durham University, North Yorkshire, United Kingdom
| | | | - Girish N Rao
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Karen Coales
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
| | | | | | - Pratima Murthy
- National Institute of Mental Health and Neuro Sciences, Bangalore, India
| | - Najma Siddiqi
- Department of Health Sciences, University of York & Hull York Medical School, Heslington, United Kingdom
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7
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Janssen NP, Lucassen P, Huibers MJH, Ekers D, Broekman T, Bosmans JE, Van Marwijk H, Spijker J, Oude Voshaar R, Hendriks GJ. Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial. Psychother Psychosom 2023; 92:255-266. [PMID: 37385226 DOI: 10.1159/000531201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 05/19/2023] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Effective non-pharmacological treatment options for depression in older adults are lacking. OBJECTIVE The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated. METHODS In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up. RESULTS Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24). CONCLUSIONS BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.
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Affiliation(s)
- Noortje P Janssen
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Department of Primary and Community Care, Research Institute of Health Sciences, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
- Institute for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
| | - Peter Lucassen
- Department of Primary and Community Care, Research Institute of Health Sciences, Radboud University Medical Centre Nijmegen, Nijmegen, The Netherlands
| | - Marcus J H Huibers
- NPI Centre for Personality Disorders/Arkin Amsterdam, Amsterdam, The Netherlands
| | - David Ekers
- Mental Health and Addictions Research Group, Tees Esk and Wear Valleys NHS FT/University of York, York, UK
| | | | - Judith E Bosmans
- Department of Health Sciences, VU University, Amsterdam, The Netherlands
| | - Harm Van Marwijk
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Brighton, UK
| | - Jan Spijker
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Institute for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
| | - Richard Oude Voshaar
- Department of Psychiatry, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gert-Jan Hendriks
- Behavioural Science Institute, Radboud University, Nijmegen, The Netherlands
- Institute for Integrated Mental Health Care Pro Persona, Nijmegen, The Netherlands
- Department of Psychiatry, Radboud University Medical Centre, Nijmegen, The Netherlands
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Kitchen CEW, Lewis S, Ekers D, Gega L, Tiffin PA. Barriers and enablers for young people, parents and therapists undertaking behavioural activation for depression: A qualitative evaluation within a randomised controlled trial. Psychol Psychother 2023; 96:504-524. [PMID: 36808208 PMCID: PMC10952148 DOI: 10.1111/papt.12452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 02/03/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Adolescent depression is common, long-lasting and debilitating. Behavioural Activation (BA) is a brief, evidence-based therapy for depression in adults with promising outcomes for young people. OBJECTIVES We sought to understand how young people, their parents and therapists experienced manualised BA for depression within Child and Adolescent Mental Health Services. DESIGN Participants in a randomised controlled trial aged 12 to17 with depression, their parents and therapists were invited to a semi-structured interview with a researcher to explore their experiences of receiving, supporting or delivering BA. METHODS Six young people, five parents and five therapists were interviewed. Verbatim interview transcripts were coded using thematic analysis. RESULTS Factors that may optimise delivery of BA were: boosting the young person's motivation, tailoring parental input to the young person's needs/wishes and developing a positive collaboration between the young person and therapist. Engagement with treatment may be hindered by a mismatch between BA delivery and young person's preferences, concurrent mental health comorbidities that are not addressed within a wider care package, lack of parental support and therapist preconceptions against manualised therapy or BA. CONCLUSIONS Manualised BA for young people requires flexibility and adjustment to meet individual and family needs. Therapist preparation could dispel hindering preconceptions about the suitability and potential value of this brief and simple intervention for young people with complex needs and different learning styles.
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Affiliation(s)
| | - Sue Lewis
- School of Health in Social ScienceUniversity of EdinburghEdinburghUK
| | - David Ekers
- Department of Health SciencesUniversity of YorkYorkUK
- Tees, Esk and Wear Valleys NHS Foundation TrustDurhamUK
| | - Lina Gega
- Department of Health SciencesUniversity of YorkYorkUK
- Hull York Medical SchoolUniversity of YorkYorkUK
| | - Paul A. Tiffin
- Department of Health SciencesUniversity of YorkYorkUK
- Tees, Esk and Wear Valleys NHS Foundation TrustDurhamUK
- Hull York Medical SchoolUniversity of YorkYorkUK
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9
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Zavala GA, Jennings HM, Afaq S, Alam A, Ahmed N, Aslam F, Arsh A, Coales K, Ekers D, Nabi M, Naz A, Shakur N, Siddiqi N, Wright JM, Kellar I. Effectiveness and implementation of psychological interventions for depression in people with non-communicable diseases in South Asia: Systematic review and meta-analysis. Int J Ment Health 2023; 52:260-284. [PMID: 38013979 PMCID: PMC10461698 DOI: 10.1080/00207411.2023.2202431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2023]
Abstract
We evaluate the effectiveness of psychological interventions for depression in people with NCDs in South Asia and explore the individual, organizational, and policy-level barriers and facilitators for the implementation and scaling up of these interventions. Eight databases (and local web pages) were searched in May 2022. We conducted random effects models to evaluate the pooled effect of psychological interventions on depression in people with NCDs. We extracted the individual, organizational, and policy level barriers and facilitators. We found five randomized control trials, nine qualitative studies, and 35 policy documents that fitted the inclusion criteria. The pooled standardized mean difference in depression comparing psychological interventions with usual care was -2.31 (95% CI, -4.16 to -0.45; p = .015, I2 = 96.0%). We found barriers and facilitators to intervention delivery, mental health appears in the policy agenda in Bangladesh and Pakistan. However, there is a lack of policies relating to training in mental health for NCD health providers and a lack of integration of mental health care with NCD care. All of the psychological interventions reported to be effective in treating depression in this population. There are important delivery and policy barriers to the implementation and scaling up of psychological interventions for people with NCDs.
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Affiliation(s)
- Gerardo A. Zavala
- Department of Health Sciences, University of York, York, United Kingdom
| | - Hannah Maria Jennings
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, York, United Kingdom
| | - Saima Afaq
- Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Ashraful Alam
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Naveed Ahmed
- Diabetic Association of Bangladesh, Dhaka, Bangladesh
| | - Faiza Aslam
- Institute of Psychiatry (IoP), Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | - Aatik Arsh
- Institute of Public Health and Social Sciences, Khyber Medical University, Peshawar, Pakistan
| | - Karen Coales
- Department of Health Sciences, University of York, York, United Kingdom
| | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees Esk and Wear Valleys NHS FT, York, United Kingdom
| | | | - Anum Naz
- Institute of Psychiatry (IoP), Benazir Bhutto Hospital, Rawalpindi Medical University, Rawalpindi, Pakistan
| | | | - Najma Siddiqi
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, York, United Kingdom
| | - Judy M. Wright
- School of Medicine, University of Leeds, Leeds, United Kingdom
| | - Ian Kellar
- School of Psychology, University of Leeds, Leeds, United Kingdom
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10
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Shearsmith L, Coventry PA, Sloan C, Henry A, Newbronner L, Littlewood E, Bailey D, Gascoyne S, Burke L, Ryde E, Woodhouse R, McMillan D, Ekers D, Gilbody S, Chew-Graham C. Acceptability of a behavioural intervention to mitigate the psychological impacts of COVID-19 restrictions in older people with long-term conditions: a qualitative study. BMJ Open 2023; 13:e064694. [PMID: 36914198 PMCID: PMC10015671 DOI: 10.1136/bmjopen-2022-064694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/14/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic heightened the need to address loneliness, social isolation and associated incidence of depression among older adults. Between June and October 2020, the Behavioural Activation in Social IsoLation (BASIL) pilot study investigated the acceptability and feasibility of a remotely delivered brief psychological intervention (behavioural cctivation) to prevent and reduce loneliness and depression in older people with long-term conditions during the COVID-19 pandemic. DESIGN An embedded qualitative study was conducted. Semi-structured interviews generated data that was analysed inductively using thematic analysis and then deductively using the theoretical framework of acceptability (TFA). SETTING NHS and third sector organisations in England. PARTICIPANTS Sixteen older adults and nine support workers participating in the BASIL pilot study. RESULTS Acceptability of the intervention was high across all constructs of the TFA: Older adults and BASIL Support Workers described a positive Affective Attitude towards the intervention linked to altruism, however the activity planning aspect of the intervention was limited due to COVID-19 restrictions. A manageable Burden was involved with delivering and participating in the intervention. For Ethicality, older adults valued social contact and making changes, support workers valued being able to observe those changes. The intervention was understood by older adults and support workers, although less understanding in older adults without low mood (Intervention Coherence). Opportunity Cost was low for support workers and older adults. Behavioural Activation was perceived to be useful in the pandemic and likely to achieve its aims (Perceived Effectiveness), especially if tailored to people with both low mood and long-term conditions. Self-efficacy developed over time and with experience for both support workers and older adults. CONCLUSIONS Overall, BASIL pilot study processes and the intervention were acceptable. Use of the TFA provided valuable insights into how the intervention was experienced and how the acceptability of study processes and the intervention could be enhanced ahead of the larger definitive trial (BASIL+).
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Affiliation(s)
| | - Peter A Coventry
- Department of Health Sciences, University of York, York, UK
- York Environmental Sustainability Institute, University of York, York, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Andrew Henry
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | - Liz Newbronner
- Department of Health Sciences, University of York, York, UK
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | - Lauren Burke
- Department of Health Sciences, University of York, York, UK
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
- Mental Health and Addiction Research Group, Hull York Medical School, Hull, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees Esk and Wear Valleys NHS Foundation Trust, Flatts Lane Centre, Middlesbrough, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
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11
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Littlewood E, McMillan D, Chew Graham C, Bailey D, Gascoyne S, Sloane C, Burke L, Coventry P, Crosland S, Fairhurst C, Henry A, Hewitt C, Baird K, Ryde E, Shearsmith L, Traviss-Turner G, Woodhouse R, Webster J, Meader N, Churchill R, Eddy E, Heron P, Hicklin N, Shafran R, Almeida O, Clegg A, Gentry T, Hill A, Lovell K, Dexter-Smith S, Ekers D, Gilbody S. Can we mitigate the psychological impacts of social isolation using behavioural activation? Long-term results of the UK BASIL urgent public health COVID-19 pilot randomised controlled trial and living systematic review. Evid Based Ment Health 2022; 25:e49-e57. [PMID: 36223980 PMCID: PMC9811092 DOI: 10.1136/ebmental-2022-300530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Behavioural and cognitive interventions remain credible approaches in addressing loneliness and depression. There was a need to rapidly generate and assimilate trial-based data during COVID-19. OBJECTIVES We undertook a parallel pilot RCT of behavioural activation (a brief behavioural intervention) for depression and loneliness (Behavioural Activation in Social Isolation, the BASIL-C19 trial ISRCTN94091479). We also assimilate these data in a living systematic review (PROSPERO CRD42021298788) of cognitive and/or behavioural interventions. METHODS Participants (≥65 years) with long-term conditions were computer randomised to behavioural activation (n=47) versus care as usual (n=49). Primary outcome was PHQ-9. Secondary outcomes included loneliness (De Jong Scale). Data from the BASIL-C19 trial were included in a metanalysis of depression and loneliness. FINDINGS The 12 months adjusted mean difference for PHQ-9 was -0.70 (95% CI -2.61 to 1.20) and for loneliness was -0.39 (95% CI -1.43 to 0.65).The BASIL-C19 living systematic review (12 trials) found short-term reductions in depression (standardised mean difference (SMD)=-0.31, 95% CI -0.51 to -0.11) and loneliness (SMD=-0.48, 95% CI -0.70 to -0.27). There were few long-term trials, but there was evidence of some benefit (loneliness SMD=-0.20, 95% CI -0.40 to -0.01; depression SMD=-0.20, 95% CI -0.47 to 0.07). DISCUSSION We delivered a pilot trial of a behavioural intervention targeting loneliness and depression; achieving long-term follow-up. Living meta-analysis provides strong evidence of short-term benefit for loneliness and depression for cognitive and/or behavioural approaches. A fully powered BASIL trial is underway. CLINICAL IMPLICATIONS Scalable behavioural and cognitive approaches should be considered as population-level strategies for depression and loneliness on the basis of a living systematic review.
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Affiliation(s)
| | - Dean McMillan
- Health Sciences, University of York, York, UK
- Centre for Health and Population Science, Hull York Medical School, Hull, UK
| | | | | | | | | | | | - Peter Coventry
- Health Sciences, University of York, York, UK
- York Environmental Sustainability Institute, University of York, York, UK
| | | | | | | | | | | | - Eloise Ryde
- Health Sciences, University of York, York, UK
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | | | | | | | - Judith Webster
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Nick Meader
- Faculty of Medical Sciences, University of Newcastle, Newcastle upon Tyne, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders Group, University of York, York, UK
| | - Elizabeth Eddy
- Faculty of Health and Life Sciences, University of Liverpool, Liverpool, UK
| | - Paul Heron
- Health Sciences, University of York, York, UK
| | - Nisha Hicklin
- Department of Psychology, Royal Holloway University of London, Egham, UK
| | - Roz Shafran
- PPP, University College London Institute of Child Health, London, UK
- Paediatric Psychology Services, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Osvaldo Almeida
- UWA Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Andrew Clegg
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
- Bradford Institute for Health Research, Bradford Royal Infirmary, Bradford, UK
| | - Tom Gentry
- Health and Care Policy, Age UK, London, UK
| | - Andrew Hill
- Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Karina Lovell
- Division of Nursing, Midwifery and Social Work, The University of Manchester, Manchester, UK
| | - Sarah Dexter-Smith
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - David Ekers
- Health Sciences, University of York, York, UK
- Research and Development Unit, Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Simon Gilbody
- Health Sciences, University of York, York, UK
- Centre for Health and Population Sciences, Hull York Medical School, York, UK
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12
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Alsayednasser B, Widnall E, O'Mahen H, Wright K, Warren F, Ladwa A, Khazanov GK, Byford S, Kuyken W, Watkins E, Ekers D, Reed N, Fletcher E, McMillan D, Farrand P, Richards D, Dunn BD. How well do Cognitive Behavioural Therapy and Behavioural Activation for depression repair anhedonia? A secondary analysis of the COBRA randomized controlled trial. Behav Res Ther 2022; 159:104185. [PMID: 36371903 DOI: 10.1016/j.brat.2022.104185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 08/19/2022] [Accepted: 08/19/2022] [Indexed: 12/14/2022]
Abstract
A secondary analysis of the COBRA randomized controlled trial was conducted to examine how well Cognitive Behavioural Therapy (CBT) and Behavioural Activation (BA) repair anhedonia. Patients with current major depressive disorder (N = 440) were randomized to receive BA or CBT, and anhedonia and depression outcomes were measured after acute treatment (six months) and at two further follow up intervals (12 and 18 months). Anhedonia was assessed using the Snaith Hamilton Pleasure Scale (SHAPS; a measure of consummatory pleasure). Both CBT and BA led to significant improvements in anhedonia during acute treatment, with no significant difference between treatments. Participants remained above healthy population averages of anhedonia at six months, and there was no further significant improvement in anhedonia at 12-month or 18-month follow up. Greater baseline anhedonia severity predicted reduced repair of depression symptoms and fewer depression-free days across the follow-up period in both the BA and CBT arms. The extent of anhedonia repair was less marked than the extent of depression repair across both treatment arms. These findings demonstrate that CBT and BA are similarly and only partially effective in treating anhedonia. Therefore, both therapies should be further refined or novel treatments should be developed in order better to treat anhedonia.
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Affiliation(s)
| | | | | | - Kim Wright
- Mood Disorders Centre, University of Exeter, UK
| | - Fiona Warren
- College of Medicine and Health, University of Exeter, UK
| | - Asha Ladwa
- Mood Disorders Centre, University of Exeter, UK
| | | | - Sarah Byford
- Health Service & Population Research Department, Kings College London, UK
| | | | - Ed Watkins
- Mood Disorders Centre, University of Exeter, UK
| | - David Ekers
- Department of Health Science, University of York, UK; Tees Esk and Wear Valleys NHS Foundation Trust, UK
| | - Nigel Reed
- Mood Disorders Centre, University of Exeter, UK
| | - Emily Fletcher
- College of Medicine and Health, University of Exeter, UK
| | - Dean McMillan
- Department of Health Sciences and Hull York Medical School, University of York, UK
| | | | - David Richards
- College of Medicine and Health, University of Exeter, UK; Department of Health and Caring Sciences, Western Norway University of Applied Sciences, Norway
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13
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Almeida OP, Patel H, Velasquez D, Kelly R, Lai R, Ford AH, Curran E, Flicker L, Chong TWH, Etherton-Beer C, LoGiudice D, Ellis KA, Martini A, Westphal A, Ekers D, Gilbody S, Lautenschlager NT. Behavioral Activation in Nursing Homes to Treat Depression (BAN-Dep): Results From a Clustered, Randomized, Single-Blinded, Controlled Clinical Trial. Am J Geriatr Psychiatry 2022; 30:1313-1323. [PMID: 35680539 DOI: 10.1016/j.jagp.2022.05.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/11/2022] [Accepted: 05/12/2022] [Indexed: 01/25/2023]
Abstract
OBJECTIVES To determine if behavioral activation (BA) delivered by trained staff decreases prevalence of clinically significant symptoms of depression among older adults living in residential aged care facilities (RACFs). METHODS Clustered, randomized, single-blinded, controlled trial of BA for adults aged over 60 years living permanently in a RACF with symptoms of depression (Patient Health Questionnaire, PHQ-9 ≥ 5). BA was delivered over 8-12 weeks using a structured workbook. The proportion of residents with PHQ-9 ≥ 10 at weeks 12, 26, and 52, as well as anxiety symptoms (GAD-7), physical (PCS), and mental (MCS) quality of life, loneliness, and loss to follow-up were main outcomes of interest RESULTS: We recruited 54 RACFs (26 intervention) and 188 of their residents (89 intervention). Participants were aged 61-100 years and 132 (70.2%) were women. PHQ-9 ≥ 10 interacted with BA at week 12 (OR = 0.34, 95%CI = 0.11-1.07), but differences between the groups were not statistically significant at any time-point. GAD-7 ≥ 10 interacted with BA at week 26 (OR = 0.12, 95%CI = 0.02-0.58), but not at any other time-point. Overall, the intervention had no effect on the scores of the PHQ-9, GAD-7, PCS, MCS, and loneliness scale. Loss to follow-up was similar between groups. Adherence to all stages of the intervention was poor (36.2%). CONCLUSIONS Disruption by the COVID-19 pandemic and staffing issues in RACFs undermined recruitment and adherence. In such a context, a BA program delivered by RACF staff was not associated with better mental health outcomes for residents over 52 weeks.
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Affiliation(s)
- Osvaldo P Almeida
- Medical School (OPA, HP, RK, AHF, LF, CE-B), University of Western Australia, Perth, Australia.
| | - Hema Patel
- Medical School (OPA, HP, RK, AHF, LF, CE-B), University of Western Australia, Perth, Australia
| | - Diana Velasquez
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia
| | - Rachael Kelly
- Medical School (OPA, HP, RK, AHF, LF, CE-B), University of Western Australia, Perth, Australia
| | - Rhoda Lai
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia
| | - Andrew H Ford
- Medical School (OPA, HP, RK, AHF, LF, CE-B), University of Western Australia, Perth, Australia
| | - Eleanor Curran
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia; NorthWestern Mental Health (EC, NTL), Royal Melbourne Hospital, Melbourne, Australia
| | - Leon Flicker
- Medical School (OPA, HP, RK, AHF, LF, CE-B), University of Western Australia, Perth, Australia
| | - Terence W H Chong
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia; St Vincent's Hospital Melbourne (TWHC), Melbourne, Australia
| | | | - Dina LoGiudice
- Department of Medicine (DL), University of Melbourne, Melbourne, Australia
| | - Kathryn A Ellis
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia; Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, Australia
| | | | - Alissa Westphal
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia
| | - David Ekers
- Tees Esk and Wear Valleys NHS FT/MHARG (KAE, DE), University of York, York, UK
| | - Simon Gilbody
- Mental Health and Addictions Research Group (SG), HYMS & University of York, York, UK
| | - Nicola T Lautenschlager
- Department of Psychiatry (DV, RL, EC, TWHC, KAE, AW, NTL), University of Melbourne, Melbourne, Australia; NorthWestern Mental Health (EC, NTL), Royal Melbourne Hospital, Melbourne, Australia
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14
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Burke L, Littlewood E, Gascoyne S, McMillan D, Chew-Graham CA, Bailey D, Sloan C, Fairhurst C, Baird K, Hewitt C, Henry A, Ryde E, Shearsmith L, Coventry P, Crosland S, Newbronner E, Traviss-Turner G, Woodhouse R, Clegg A, Gentry T, Hill A, Lovell K, Dexter Smith S, Webster J, Ekers D, Gilbody S. Behavioural Activation for Social IsoLation (BASIL+) trial (Behavioural activation to mitigate depression and loneliness among older people with long-term conditions): Protocol for a fully-powered pragmatic randomised controlled trial. PLoS One 2022; 17:e0263856. [PMID: 35324908 PMCID: PMC8947398 DOI: 10.1371/journal.pone.0263856] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 02/07/2022] [Indexed: 11/18/2022] Open
Abstract
Introduction Depression is a leading mental health problem worldwide. People with long-term conditions are at increased risk of experiencing depression. The COVID-19 pandemic led to strict social restrictions being imposed across the UK population. Social isolation can have negative consequences on the physical and mental wellbeing of older adults. In the Behavioural Activation in Social IsoLation (BASIL+) trial we will test whether a brief psychological intervention (based on Behavioural Activation), delivered remotely, can mitigate depression and loneliness in older adults with long-term conditions during isolation. Methods We will conduct a two-arm, parallel-group, randomised controlled trial across several research sites, to evaluate the clinical and cost-effectiveness of the BASIL+ intervention. Participants will be recruited via participating general practices across England and Wales. Participants must be aged ≥65 with two or more long-term conditions, or a condition that may indicate they are within a ‘clinically extremely vulnerable’ group in relation to COVID-19, and have scored ≥5 on the Patient Health Questionnaire (PHQ9), to be eligible for inclusion. Randomisation will be 1:1, stratified by research site. Intervention participants will receive up to eight intervention sessions delivered remotely by trained BASIL+ Support Workers and supported by a self-help booklet. Control participants will receive usual care, with additional signposting to reputable sources of self-help and information, including advice on keeping mentally and physically well. A qualitative process evaluation will also be undertaken to explore the acceptability of the BASIL+ intervention, as well as barriers and enablers to integrating the intervention into participants’ existing health and care support, and the impact of the intervention on participants’ mood and general wellbeing in the context of the COVID-19 restrictions. Semi-structured interviews will be conducted with intervention participants, participant’s caregivers/supportive others and BASIL+ Support Workers. Outcome data will be collected at one, three, and 12 months post-randomisation. Clinical and cost-effectiveness will be evaluated. The primary outcome is depressive symptoms at the three-month follow up, measured by the PHQ9. Secondary outcomes include loneliness, social isolation, anxiety, quality of life, and a bespoke health services use questionnaire. Discussion This study is the first large-scale trial evaluating a brief Behavioural Activation intervention in this population, and builds upon the results of a successful external pilot trial. Trial registration ClinicalTrials.Gov identifier ISRCTN63034289, registered on 5th February 2021.
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Affiliation(s)
- Lauren Burke
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, United Kingdom
| | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, United Kingdom
| | - Claire Sloan
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Kalpita Baird
- Department of Health Sciences, University of York, York, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Henry
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Leanne Shearsmith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Peter Coventry
- Department of Health Sciences, University of York, York, United Kingdom
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, United Kingdom
| | | | | | - Rebecca Woodhouse
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Clegg
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Tom Gentry
- Age UK, Tavis House, 1–6 Tavistock Square, London United Kingdom
| | - Andrew Hill
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Sarah Dexter Smith
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | | | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
- * E-mail:
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15
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Littlewood E, Chew-Graham CA, Coleman E, Gascoyne S, Sloan C, Ali S, Badenhorst J, Bailey D, Crosland S, Kitchen CEW, McMillan D, Pearson C, Todd A, Whittlesea C, Bambra C, Hewitt C, Jones C, Keding A, Newbronner E, Paterson A, Rhodes S, Ryde E, Toner P, Watson M, Gilbody S, Ekers D. A psychological intervention by community pharmacies to prevent depression in adults with subthreshold depression and long-term conditions: the CHEMIST pilot RCT. Public Health Res 2022. [DOI: 10.3310/ekze0617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
Depression is common in people with long-term health conditions, and this combination can lead to worsened health outcomes and increased health-care costs. Subthreshold depression, a risk factor for major depression, is prevalent in this population, but many people remain untreated due to the demand on services. The community pharmacy may be an alternative setting to offer mental health support; however, insufficient evidence exists to support implementation.
Objectives
To conduct a feasibility study and pilot randomised controlled trial of a community pharmacy-delivered psychological intervention aimed at preventing depression in adults with long-term health conditions.
Design
A feasibility study with nested qualitative evaluation and an external pilot, two-arm, 1 : 1 individually randomised controlled trial with nested process and economic evaluations.
Setting
Community pharmacies in the north of England.
Participants
Adults aged ≥ 18 years with subthreshold depression and at least one long-term health condition.
Intervention
A bespoke enhanced support intervention (behavioural activation within a collaborative care framework) involving up to six sessions delivered by trained community pharmacy staff (intervention facilitators) compared with usual care.
Main outcome measures
Recruitment and retention rates, completeness of outcome measures and intervention engagement. The intended primary outcome was depression severity at 4 months, assessed by the Patient Health Questionnaire-9.
Results
In the feasibility study, 24 participants were recruited. Outcome measure completeness was 95–100%. Retention at 4 months was 83%. Seventeen participants (71%) commenced intervention sessions and all completed two or more sessions. Depression symptoms reduced slightly at 4 months. The process evaluation suggested that the intervention was acceptable to participants and intervention facilitators. In the pilot randomised controlled trial, 44 participants (target of 100 participants) were randomised (intervention, n = 24; usual care, n = 20). Outcome measure completeness was 100%. Retention at 4 months was 93%. Eighteen participants (75%) commenced intervention sessions and 16 completed two or more sessions. Depression symptoms reduced slightly at 4 months, with a slightly larger reduction in the usual-care arm, although the small sample size limits any conclusions. The process evaluation reported good acceptability of the intervention and identified barriers associated with study implementation and its impact on core pharmacy functions. The economic analysis revealed some indication of reduced resource use/costs associated with the intervention, but this is limited by the small sample size. Intervention costs were low.
Limitations
The main limitation is the small sample size due to difficulties with recruitment and barriers to implementing the study within existing pharmacy practices.
Conclusions
The community pharmacy represents a new setting to deliver a depression prevention intervention. Recruitment was a challenge and pharmacy staff encountered barriers to effective implementation of the study within busy pharmacy practice. Despite these challenges, good retention rates and intervention engagement were demonstrated, and process evaluation suggested that the intervention was acceptable in this setting. To the best of our knowledge, this is the first study to demonstrate that community pharmacy staff can be trained to deliver a depression prevention intervention.
Future work
Further work is needed to address barriers to recruitment, intervention delivery and implementation of psychological interventions in the community pharmacy setting.
Trial registration
This trial is registered as ISRCTN11290592.
Funding
This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 5. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | | | | | | | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK
- Department of Epidemiology and Biostatistics, Western University, London, ON, Canada
| | - Jay Badenhorst
- Whitworth Chemists Ltd, Foxhills Industrial Estate, Scunthorpe, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | | | - Adam Todd
- Institute of Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
- School of Pharmacy, Newcastle upon Tyne, UK
| | - Cate Whittlesea
- University College London School of Pharmacy, University College London, London, UK
| | - Clare Bambra
- Institute of Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Claire Jones
- Public Health Team, Adult & Health Services, Durham County Council, Durham, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | | | - Alastair Paterson
- Pharmacy Department, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Shelley Rhodes
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Paul Toner
- Department of Health Sciences, University of York, York, UK
- Centre for Improving Health-Related Quality of Life, School of Psychology, Queen’s University Belfast, Belfast, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
- Hull York Medical School, University of York, York, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK
- Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
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Chew-Graham CA, Kitchen CEW, Gascoyne S, Littlewood E, Coleman E, Bailey D, Crosland S, Pearson C, Ali S, Badenhorst J, Bambra C, Hewitt C, Jones C, Keding A, McMillan D, Sloan C, Todd A, Toner P, Whittlesea C, Watson M, Gilbody S, Ekers D. The feasibility and acceptability of a brief psychological intervention for adults with long-term health conditions and subthreshold depression delivered via community pharmacies: a mixed methods evaluation-the Community Pharmacies Mood Intervention Study (CHEMIST). Pilot Feasibility Stud 2022; 8:27. [PMID: 35115052 PMCID: PMC8812235 DOI: 10.1186/s40814-022-00992-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/25/2022] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Adults with long-term health conditions (LTCs) are more likely to experience depressive symptoms which can worsen health outcomes and quality of life, and increase healthcare costs. Subthreshold depression may go undetected and/or untreated. The Community Pharmacies Mood Intervention Study (CHEMIST) explored whether community pharmacies represent a suitable setting to offer brief psychological support to people with LTCs and comorbid subthreshold depression. METHODS A feasibility intervention study with a nested mixed methods evaluation was employed. Adults with subthreshold depression and a minimum of one LTC were recruited from community pharmacies/local general practices and offered a brief psychological support intervention ('Enhanced Support Intervention' (ESI)), based on behavioural activation within a Collaborative Care framework. The intervention included up to six sessions supported by pharmacy staff ('ESI facilitators') trained to deliver the ESI within the community pharmacy setting. Recruitment, retention rates and engagement with the ESI were assessed. Semi-structured, one-to-one interviews with pharmacy staff and study participants, and a focus group with pharmacy staff, explored experiences and acceptability of the study and the ESI. Themes were mapped onto constructs of the Theoretical Framework of Acceptability. RESULTS Recruitment of ESI participants was challenging and slower than anticipated despite the varied methods of recruitment employed; although, this was useful in identifying barriers and enabling factors for participation. Engagament with the ESI was good with n=17 (71%) recruited participants commencing the ESI. The ESI was found to be acceptable to participants and ESI facilitators. Retention rate at 4 months was good n=20 (87.0%). The main barriers to identifying potential participants for pharmacy staff were lack of time, resources and limited experience in research. The ESI training and support manual were acceptable to ESI facilitators. The ESI and supporting patient workbook were acceptable to people with LTCs and subthreshold depression. CONCLUSIONS Community pharmacies were viewed as an acceptable setting in which to deliver preventative brief psychological support to people with LTCs at risk of depression. This feasibility study provided important data to inform the design of a pilot randomised controlled trial in this setting and highlighted important considerations for future pharmacy-based research. TRIAL REGISTRATION ISRCTN11290592.
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Affiliation(s)
| | | | | | | | | | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Shehzad Ali
- Department of Health Sciences, University of York, York, UK.,Department of Epidemiology and Biostatistics, Western University, Ontario, Canada
| | - Jay Badenhorst
- Whitworth Chemists Ltd, Foxhills Industrial Estate, Scunthorpe, UK
| | - Clare Bambra
- Institute of Population Health Sciences, Newcastle University, Newcastle-upon-Tyne, UK
| | | | - Claire Jones
- Public Health Team, Adult & Health Services, Durham County Council, Durham, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, UK
| | - Adam Todd
- Institute of Population Health Sciences, Newcastle University, Newcastle-upon-Tyne, UK.,School of Pharmacy, Newcastle upon Tyne, UK
| | - Paul Toner
- Department of Health Sciences, University of York, York, UK.,Centre for Improving Health-Related Quality of Life, School of Psychology, Queen's University Belfast, Belfast, UK
| | - Cate Whittlesea
- UCL School of Pharmacy, University College London, London, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK.,Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
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Gilbody S, Brabyn S, Mitchell A, Ekers D, McMillan D, Bailey D, Hems D, Chew Graham CA, Keding A, Bosanquet K. Can We Prevent Depression in At-Risk Older Adults Using Self-Help? The UK SHARD Trial of Behavioral Activation. Am J Geriatr Psychiatry 2022; 30:197-207. [PMID: 34266750 DOI: 10.1016/j.jagp.2021.06.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/12/2021] [Accepted: 06/14/2021] [Indexed: 11/17/2022]
Abstract
BACKGROUND Treatment of established depression is the dominant approach to care of older adults, but prevention holds much promise. Self-help interventions are a feasible preventive approach, since they are scalable and low cost. There are few trials in this area. Behavioral Activation (BA) is a credible candidate psychological approach, which has been shown to work in therapist led care but not been trialled in a self-help form. AIM To test the effectiveness of an unguided self-help intervention based on BA for older adults. METHODS We compared a self-help intervention based on BA for older people (n = 172) to usual care (n = 160) in a pragmatic randomized controlled trial. Outcomes were depression status and severity (PHQ9) and health related quality of life (SF12). The primary timepoint of the primary outcome was depression at 4 months, with longer term follow up at 12 months to test sustained impact of the primary outcome. RESULTS At 4 months adjusted PHQ-9 scores for BA self-help were 0.79 lower (95% CI: -1.70 to 0.13; p = 0.09) and the proportion of participants with case-level depression was significantly reduced (BA 31/137 (22.6%) versus usual care 41/141 (29.1%); Odds Ratio 0.48; 95% CI: 0.26-0.92; p = 0.03). There was no PHQ-9 difference at 12 months or for health related quality of life at any point (4 or 12 months). DISCUSSION Self-help using BA for older people at risk of depression is a feasible and scalable intervention with potential short-term benefits in preventing depression.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK; Hull York Medical School (SG, DM), UK.
| | - Sally Brabyn
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK
| | - Alex Mitchell
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK; York Trials Unit (AM, AD), University of York, UK
| | - David Ekers
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK; Tees Esk and Wear Valleys NHS Foundation Trust (DE), North Yorkshire, UK
| | - Dean McMillan
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK; Hull York Medical School (SG, DM), UK
| | - Della Bailey
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK
| | - Deborah Hems
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK
| | | | - Ada Keding
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK; York Trials Unit (AM, AD), University of York, UK
| | - Kate Bosanquet
- Department of Health Sciences (SG, SB, AM, DE, DM, DB, DH, AK, KB), University of York, UK
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18
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O'Mahen HA, Hayes A, Harries C, Ladwa A, Mostazir M, Ekers D, McMillan D, Richards D, Wright K. A comparison of the effects of sudden gains and depression spikes on short- and long-term depressive symptoms in a randomized controlled trial of behavioral activation and cognitive behavioural therapy. J Consult Clin Psychol 2022; 89:957-969. [PMID: 35025537 DOI: 10.1037/ccp0000577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE The aim of this study was to examine the effects of sudden gains and depression spikes in a randomized controlled trial of cognitive behavioral therapy (CBT) and behavioral activation (BA) for depression (COBRA trial). METHOD This is a secondary analysis of 300 adults with major depressive disorder (MDD) who received CBT (n = 156) or BA (n = 144) (Richards et al., 2016). The Patient Health Questionnaire (PHQ-9) and Structured Clinical Interview Schedule (SCID) were used to measure depression symptoms at 6-, 12-, and 18-month follow-up. RESULTS One-hundred and ten (37%) individuals experienced sudden gains, and 77 (26%) experienced depression spikes. There were no differences in rates of gains or spikes between treatments. Individuals with sudden gains had lower PHQ-9 scores across follow-up and were less likely to meet SCID criteria than those without a sudden gain. Generalized estimating equation (GEE) models demonstrated that individuals who had a sudden gain and were in CBT had lower PHQ-9 scores at 6 and 18 months than those in BA. Conversely, individuals who had a depression spike and were in CBT had higher PHQ-9 scores across follow-up compared to those without a depression spike and also a greater chance of meeting SCID criteria for MDD at 18 months than those who received BA. CONCLUSIONS The short- and long-term impact of discontinuous change varied by type of treatment package. Identifying strategies within treatment packages and client processes that are associated with gains and spikes may help to inform treatment planning and clinical decision-making. (PsycInfo Database Record (c) 2022 APA, all rights reserved).
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Affiliation(s)
| | - Adele Hayes
- Department of Psychology, University of Delaware
| | | | - Asha Ladwa
- Mood Disorders Centre, University of Exeter
| | | | | | - Dean McMillan
- Centre for Health and Population Sciences, Department of Health Sciences, Hull York Medical School
| | - David Richards
- Complex Interventions Group, University of Exeter Medical School
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19
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Rochat TJ, Dube S, Herbst K, Hoegfeldt CA, Redinger S, Khoza T, Bland RM, Richter L, Linsell L, Desmond C, Yousafzai AK, Craske M, Juszczak E, Abas M, Edwards T, Ekers D, Stein A. An evaluation of a combined psychological and parenting intervention for HIV-positive women depressed in the perinatal period, to enhance child development and reduce maternal depression: study protocol for the Insika Yomama cluster randomised controlled trial. Trials 2021; 22:914. [PMID: 34903257 PMCID: PMC8666837 DOI: 10.1186/s13063-021-05672-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 09/30/2021] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND The combination of poverty, HIV and depression in the perinatal period represents a major public health challenge in many Southern African countries. In some areas, up to a third of HIV-positive women experience perinatal depression. Perinatal depression is associated with negative effects on parenting and key domains of child development including cognitive, behavioural and growth, especially in socio-economically disadvantaged communities. Several studies have documented the benefits of psychological interventions for perinatal depression in low- and middle-income countries, but none have evaluated an integrated psychological and parenting intervention for HIV-positive women using task-sharing. This randomised controlled trial aims to evaluate the effect of a home-based intervention, combining a psychological treatment for depression and a parenting programme for perinatally depressed HIV-positive women. METHODS This study is a cluster randomised controlled trial, consisting of 48-60 geospatial clusters. A total of 528 pregnant HIV-positive women aged ≥ 16 years who meet the criteria for depression on the Edinburgh Postnatal Depression Scale (EPDS, score ≥ 9)) are recruited from antenatal clinics in rural KwaZulu-Natal, South Africa. The geospatial clusters are randomised on an allocation ratio of 1:1 to either the intervention or Enhanced Standard of Care (ESoC). The intervention group receives 10 home-based counselling sessions by a lay counsellor (4 antenatal and 6 postnatal sessions) and a booster session at 16 months. The intervention combines behavioural activation for depression with a parenting programme, adapted from the UNICEF/WHO Care for Child Development programme. The ESoC group receives two antenatal and two postnatal counselling support and advice telephone calls. In addition, measures have been taken to enhance the routine standard of care. The co-primary outcomes are child cognitive development at 24 months assessed on the cognitive subscale of the Bayley Scales of Infant Development-Third Edition and maternal depression at 12 months measured by the EPDS. ANALYSIS The primary analysis will be a modified intention-to-treat analysis. The primary outcomes will be analysed using mixed-effects linear regression. DISCUSSION If this treatment is successful, policymakers could use this model of mental healthcare delivered by lay counsellors within HIV treatment programmes to provide more comprehensive services for families affected by HIV. TRIAL REGISTRATION ISRCTN registry # 11284870 (14/11/2017) and SANCTR DOH-27-102020-9097 (17/11/2017).
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Affiliation(s)
- Tamsen J. Rochat
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Samukelisiwe Dube
- Africa Health Research Institute, Durban, KwaZulu-Natal South Africa
| | - Kobus Herbst
- Africa Health Research Institute, Durban, KwaZulu-Natal South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
| | | | - Stephanie Redinger
- SAMRC/Wits Developmental Pathways for Health Research Unit, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Thandeka Khoza
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Ruth Margret Bland
- Institute of Health and Wellbeing and Royal Hospital for Children, University of Glasgow, Glasgow, UK
| | - Linda Richter
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - Louise Linsell
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Chris Desmond
- Priceless, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | | | | | - Ed Juszczak
- National Perinatal Epidemiology Unit, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Melanie Abas
- Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Taygen Edwards
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
| | - David Ekers
- Tees Esk and Wear Valleys NHS FT, Darlington, UK
| | - Alan Stein
- DSI-NRF Centre of Excellence in Human Development, University of the Witwatersrand, Johannesburg, South Africa
- DSI-MRC South African Population Research Infrastructure Network (SAPRIN), Durban, South Africa
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
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Gilbody S, Littlewood E, McMillan D, Chew-Graham CA, Bailey D, Gascoyne S, Sloan C, Burke L, Coventry P, Crosland S, Fairhurst C, Henry A, Hewitt C, Joshi K, Ryde E, Shearsmith L, Traviss-Turner G, Woodhouse R, Clegg A, Gentry T, Hill AJ, Lovell K, Dexter Smith S, Webster J, Ekers D. Behavioural activation to prevent depression and loneliness among socially isolated older people with long-term conditions: The BASIL COVID-19 pilot randomised controlled trial. PLoS Med 2021; 18:e1003779. [PMID: 34637450 PMCID: PMC8509874 DOI: 10.1371/journal.pmed.1003779] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2021] [Accepted: 08/20/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Older adults, including those with long-term conditions (LTCs), are vulnerable to social isolation. They are likely to have become more socially isolated during the Coronavirus Disease 2019 (COVID-19) pandemic, often due to advice to "shield" to protect them from infection. This places them at particular risk of depression and loneliness. There is a need for brief scalable psychosocial interventions to mitigate the psychological impacts of social isolation. Behavioural activation (BA) is a credible candidate intervention, but a trial is needed. METHODS AND FINDINGS We undertook an external pilot parallel randomised trial (ISRCTN94091479) designed to test recruitment, retention and engagement with, and the acceptability and preliminary effects of the intervention. Participants aged ≥65 years with 2 or more LTCs were recruited in primary care and randomised by computer and with concealed allocation between June and October 2020. BA was offered to intervention participants (n = 47), and control participants received usual primary care (n = 49). Assessment of outcome was made blind to treatment allocation. The primary outcome was depression severity (measured using the Patient Health Questionnaire 9 (PHQ-9)). We also measured health-related quality of life (measured by the Short Form (SF)-12v2 mental component scale (MCS) and physical component scale (PCS)), anxiety (measured by the Generalised Anxiety Disorder 7 (GAD-7)), perceived social and emotional loneliness (measured by the De Jong Gierveld Scale: 11-item loneliness scale). Outcome was measured at 1 and 3 months. The mean age of participants was aged 74 years (standard deviation (SD) 5.5) and they were mostly White (n = 92, 95.8%), and approximately two-thirds of the sample were female (n = 59, 61.5%). Remote recruitment was possible, and 45/47 (95.7%) randomised to the intervention completed 1 or more sessions (median 6 sessions) out of 8. A total of 90 (93.8%) completed the 1-month follow-up, and 86 (89.6%) completed the 3-month follow-up, with similar rates for control (1 month: 45/49 and 3 months 44/49) and intervention (1 month: 45/47and 3 months: 42/47) follow-up. Between-group comparisons were made using a confidence interval (CI) approach, and by adjusting for the covariate of interest at baseline. At 1 month (the primary clinical outcome point), the median number of completed sessions for people receiving the BA intervention was 3, and almost all participants were still receiving the BA intervention. The between-group comparison for the primary clinical outcome at 1 month was an adjusted between-group mean difference of -0.50 PHQ-9 points (95% CI -2.01 to 1.01), but only a small number of participants had completed the intervention at this point. At 3 months, the PHQ-9 adjusted mean difference (AMD) was 0.19 (95% CI -1.36 to 1.75). When we examined loneliness, the adjusted between-group difference in the De Jong Gierveld Loneliness Scale at 1 month was 0.28 (95% CI -0.51 to 1.06) and at 3 months -0.87 (95% CI -1.56 to -0.18), suggesting evidence of benefit of the intervention at this time point. For anxiety, the GAD adjusted between-group difference at 1 month was 0.20 (-1.33, 1.73) and at 3 months 0.31 (-1.08, 1.70). For the SF-12 (physical component score), the adjusted between-group difference at 1 month was 0.34 (-4.17, 4.85) and at 3 months 0.11 (-4.46, 4.67). For the SF-12 (mental component score), the adjusted between-group difference at 1 month was 1.91 (-2.64, 5.15) and at 3 months 1.26 (-2.64, 5.15). Participants who withdrew had minimal depressive symptoms at entry. There were no adverse events. The Behavioural Activation in Social Isolation (BASIL) study had 2 main limitations. First, we found that the intervention was still being delivered at the prespecified primary outcome point, and this fed into the design of the main trial where a primary outcome of 3 months is now collected. Second, this was a pilot trial and was not designed to test between-group differences with high levels of statistical power. Type 2 errors are likely to have occurred, and a larger trial is now underway to test for robust effects and replicate signals of effectiveness in important secondary outcomes such as loneliness. CONCLUSIONS In this study, we observed that BA is a credible intervention to mitigate the psychological impacts of COVID-19 isolation for older adults. We demonstrated that it is feasible to undertake a trial of BA. The intervention can be delivered remotely and at scale, but should be reserved for older adults with evidence of depressive symptoms. The significant reduction in loneliness is unlikely to be a chance finding, and replication will be explored in a fully powered randomised controlled trial (RCT). TRIAL REGISTRATION ISRCTN94091479.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Dean McMillan
- Department of Health Sciences, University of York, York, United Kingdom
- Hull York Medical School, University of York, York, United Kingdom
| | | | - Della Bailey
- Department of Health Sciences, University of York, York, United Kingdom
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, United Kingdom
| | - Claire Sloan
- Department of Health Sciences, University of York, York, United Kingdom
| | - Lauren Burke
- Department of Health Sciences, University of York, York, United Kingdom
| | - Peter Coventry
- Department of Health Sciences, University of York, York, United Kingdom
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, United Kingdom
| | | | - Andrew Henry
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, United Kingdom
| | - Kalpita Joshi
- Department of Health Sciences, University of York, York, United Kingdom
| | - Eloise Ryde
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | - Leanne Shearsmith
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Rebecca Woodhouse
- Department of Health Sciences, University of York, York, United Kingdom
| | - Andrew Clegg
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | | | - Andrew J. Hill
- Leeds Institute of Health Sciences, University of Leeds, Leeds, United Kingdom
| | - Karina Lovell
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | - Sarah Dexter Smith
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
| | | | - David Ekers
- Department of Health Sciences, University of York, York, United Kingdom
- Tees, Esk and Wear Valleys NHS FT, Research & Development, Flatts Lane Centre, Middlesbrough, United Kingdom
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21
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Kitchen CEW, Tiffin PA, Lewis S, Gega L, Ekers D. Innovations in Practice: A randomised controlled feasibility trial of Behavioural Activation as a treatment for young people with depression. Child Adolesc Ment Health 2021; 26:290-295. [PMID: 32725758 DOI: 10.1111/camh.12415] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/03/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND Behavioural Activation (BA) treatment effectively reduces symptoms of depression in adults and is more cost-effective than more complex therapies. Two recent systematic reviews of BA for depression in young people highlighted the need for more studies in this area. METHODS In order to evaluate the acceptability of BA treatment for adolescents with depression and the feasibility of conducting a trial of this intervention in Child and Adolescent Mental Health Services (CAMHS), 22 patients from across three sites were randomised to BA or usual CAMHS care. Existing CAMHS staff were trained to deliver the manualised intervention via a brief course. Following treatment, young people and their parents/carers were asked to complete a feedback survey. Symptoms and functioning were assessed at 3- and 6-month follow-up. The trial was registered with the ISRCTN Registry (ref: ISRCTN52147450; https://www.isrctn.com/). RESULTS Recruitment targets were achieved through screening large numbers of CAMHS service users. Intervention adherence by the participating adolescents was high (median number of completed BA sessions was seven out of a total of eight). There were tentative suggestions of improvements following treatment; a large change in a positive direction for the BA group, but not for usual care, was observed by visual comparisons of mean scores on measures of depression, self-esteem and functioning. No adverse events were reported. CONCLUSIONS The findings suggest that BA in this setting is acceptable and warrants evaluation via a fully powered randomised controlled trial.
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Affiliation(s)
| | - Paul A Tiffin
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK.,Tees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK
| | - Sue Lewis
- School of Social and Political Science, University of Edinburgh, Edinburgh, UK
| | - Lina Gega
- Department of Health Sciences, University of York, York, UK
| | - David Ekers
- Department of Health Sciences, University of York, York, UK.,Tees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK
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Gilbody S, Littlewood E, Gascoyne S, McMillan D, Ekers D, Chew-Graham CA, Creswell C, Wright J. Mitigating the impacts of COVID-19: where are the mental health trials? Lancet Psychiatry 2021; 8:647-650. [PMID: 34087112 PMCID: PMC8169044 DOI: 10.1016/s2215-0366(21)00204-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 05/24/2021] [Indexed: 01/19/2023]
Affiliation(s)
| | | | | | - Dean McMillan
- University of York, York YO10 5DD, UK; Hull York Medical School, York, UK
| | - David Ekers
- University of York, York YO10 5DD, UK; Research and Development, Tees, Esk and Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | | | | | - John Wright
- Yorkshire and Humberside Applied Research Collaboration, Bradford Institute for Health Research, Bradford, UK
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Eddy E, Heron P, McMillan D, Dawson S, Ekers D, Hickin N, Littlewood E, Shafran R, Meader N, Gilbody S. Cognitive or behavioural interventions (or both) to prevent or mitigate loneliness in adolescents, adults, and older adults. Hippokratia 2020. [DOI: 10.1002/14651858.cd013791] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- Elizabeth Eddy
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Paul Heron
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Dean McMillan
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | - Sarah Dawson
- Population Health Sciences, Bristol Medical School; University of Bristol; Bristol UK
- Cochrane Common Mental Disorders; University of York; York UK
| | - David Ekers
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
- Lanchester Road Hospital; Tees, Esk and Wear Valleys NHS Foundation Trust; Durham UK
| | - Nisha Hickin
- South West London and St George's Mental Health NHS Trust; London UK
- Great Ormond Street Institute of Child Health; University College London; London UK
| | - Elizabeth Littlewood
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
| | | | - Nicholas Meader
- Centre for Reviews and Dissemination; University of York; York UK
- Cochrane Common Mental Disorders; University of York; York UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences; University of York; York UK
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24
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Uphoff E, Pires M, Barbui C, Barua D, Churchill R, Cristofalo D, Ekers D, Fottrell E, Mazumdar P, Purgato M, Rana R, Wright J, Siddiqi N. Behavioural activation therapy for depression in adults with non-communicable diseases. Cochrane Database Syst Rev 2020; 8:CD013461. [PMID: 32841367 PMCID: PMC8094508 DOI: 10.1002/14651858.cd013461.pub2] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Depression is common in people with non-communicable diseases (NCDs) such as cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. The co-existence of depression and NCDs may affect health behaviours, compliance with treatment, physiological factors, and quality of life. This in turn is associated with worse outcomes for both conditions. Behavioural activation is not currently indicated for the treatment of depression in this population in the UK, but is increasingly being used to treat depression in adults. OBJECTIVES To examine the effects of behavioural activation compared with any control group for the treatment of depression in adults with NCDs. To examine the effects of behavioural activation compared with each control group separately (no treatment, waiting list, other psychological therapy, pharmacological treatment, or any other type of treatment as usual) for the treatment of depression in adults with NCDs. SEARCH METHODS We searched CCMD-CTR, CENTRAL, Ovid MEDLINE, Embase, four other databases, and two trial registers on 4 October 2019 to identify randomised controlled trials (RCTs) of behavioural activation for depression in participants with NCDs, together with grey literature and reference checking. We applied no restrictions on date, language, or publication status to the searches. SELECTION CRITERIA We included RCTs of behavioural activation for the treatment of depression in adults with one of four NCDs: cardiovascular disease, diabetes, cancer, and chronic respiratory conditions. Only participants with a formal diagnosis of both depression and an NCD were eligible. Studies were included if behavioural activation was the main component of the intervention. We included studies with any comparator that was not behavioural activation, and regardless of reported outcomes. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane, including independent screening of titles/abstracts and full-text manuscripts, data extraction, and risk of bias assessments in duplicate. Where necessary, we contacted study authors for more information. MAIN RESULTS We included two studies, contributing data from 181 participants to the analyses. Both studies recruited participants from US hospital clinics; one included people who were recovering from a stroke and the other women with breast cancer. For both studies, the intervention consisted of eight weeks of face-to-face behavioural therapy, with one study comparing to poststroke treatment as usual and the other comparing to problem-solving therapy. Both studies were at risk of performance bias and potential conflict of interest arising from author involvement in the development of the intervention. For one study, risks of selection bias and reporting bias were unclear and the study was judged at high risk of attrition bias. Treatment efficacy (remission) was greater for behavioural activation than for comparators in the short term (risk ratio (RR) 1.53, 95% confidence interval (CI) 0.98 to 2.38; low-certainty evidence) and medium term (RR 1.76, 95% CI 1.01 to 3.08; moderate-certainty evidence), but these estimates lacked precision and effects were reduced in the long term (RR 1.42, 95% CI 0.91 to 2.23; moderate-certainty evidence). We found no evidence of a difference in treatment acceptability in the short term (RR 1.81, 95% CI 0.68 to 4.82) and medium term (RR 0.88, 95% CI 0.25 to 3.10) (low-certainty evidence). There was no evidence of a difference in depression symptoms between behavioural activation and comparators (short term: MD -1.15, 95% CI -2.71 to 0.41; low-certainty evidence). One study found no difference for quality of life (short term: MD 0.40, 95% CI -0.16 to 0.96; low-certainty evidence), functioning (short term: MD 2.70, 95% CI -6.99 to 12.39; low-certainty evidence), and anxiety symptoms (short term: MD -1.70, 95% CI -4.50 to 1.10; low-certainty evidence). Neither study reported data on adverse effects. AUTHORS' CONCLUSIONS Evidence from this review was not sufficient to draw conclusions on the efficacy and acceptability of behavioural activation for the treatment of depression in adults with NCDs. A future review may wish to include, or focus on, studies of people with subthreshold depression or depression symptoms without a formal diagnosis, as this may inform whether behavioural activation could be used to treat mild or undiagnosed (or both) depressive symptoms in people with NCDs. Evidence from low-resource settings including low- and middle-income countries, for which behavioural activation may offer a feasible alternative to other treatments for depression, would be of interest.
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Affiliation(s)
- Eleonora Uphoff
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Malini Pires
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Corrado Barbui
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | | | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Doriana Cristofalo
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - David Ekers
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Lanchester Road Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK
| | - Edward Fottrell
- Centre for Health Policy, Institute of Global Health Innovation, University College London, London, UK
| | - Papiya Mazumdar
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Marianna Purgato
- Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry, University of Verona, Verona, Italy
| | - Rusham Rana
- Institute of Psychiatry, Benazir Bhutto Hospital, Rawalpindi, Pakistan
| | - Judy Wright
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Najma Siddiqi
- Department of Health Sciences, Hull York Medical School, University of York, York, UK
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Uphoff E, Ekers D, Robertson L, Dawson S, Sanger E, South E, Samaan Z, Richards D, Meader N, Churchill R. Behavioural activation therapy for depression in adults. Cochrane Database Syst Rev 2020; 7:CD013305. [PMID: 32628293 PMCID: PMC7390059 DOI: 10.1002/14651858.cd013305.pub2] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Behavioural activation is a brief psychotherapeutic approach that seeks to change the way a person interacts with their environment. Behavioural activation is increasingly receiving attention as a potentially cost-effective intervention for depression, which may require less resources and may be easier to deliver and implement than other types of psychotherapy. OBJECTIVES To examine the effects of behavioural activation compared with other psychological therapies for depression in adults. To examine the effects of behavioural activation compared with medication for depression in adults. To examine the effects of behavioural activation compared with treatment as usual/waiting list/placebo no treatment for depression in adults. SEARCH METHODS We searched CCMD-CTR (all available years), CENTRAL (current issue), Ovid MEDLINE (1946 onwards), Ovid EMBASE (1980 onwards), and Ovid PsycINFO (1806 onwards) on the 17 January 2020 to identify randomised controlled trials (RCTs) of 'behavioural activation', or the main elements of behavioural activation for depression in participants with clinically diagnosed depression or subthreshold depression. We did not apply any restrictions on date, language or publication status to the searches. We searched international trials registries via the World Health Organization's trials portal (ICTRP) and ClinicalTrials.gov to identify unpublished or ongoing trials. SELECTION CRITERIA We included randomised controlled trials (RCTs) of behavioural activation for the treatment of depression or symptoms of depression in adults aged 18 or over. We excluded RCTs conducted in inpatient settings and with trial participants selected because of a physical comorbidity. Studies were included regardless of reported outcomes. DATA COLLECTION AND ANALYSIS Two review authors independently screened all titles/abstracts and full-text manuscripts for inclusion. Data extraction and 'Risk of bias' assessments were also performed by two review authors in duplicate. Where necessary, we contacted study authors for more information. MAIN RESULTS Fifty-three studies with 5495 participants were included; 51 parallel group RCTs and two cluster-RCTs. We found moderate-certainty evidence that behavioural activation had greater short-term efficacy than treatment as usual (risk ratio (RR) 1.40, 95% confidence interval (CI) 1.10 to 1.78; 7 RCTs, 1533 participants), although this difference was no longer evident in sensitivity analyses using a worst-case or intention-to-treat scenario. Compared with waiting list, behavioural activation may be more effective, but there were fewer data in this comparison and evidence was of low certainty (RR 2.14, 95% CI 0.90 to 5.09; 1 RCT, 26 participants). No evidence on treatment efficacy was available for behavioural activation versus placebo and behavioural activation versus no treatment. We found moderate-certainty evidence suggesting no evidence of a difference in short-term treatment efficacy between behavioural activation and CBT (RR 0.99, 95% CI 0.92 to 1.07; 5 RCTs, 601 participants). Fewer data were available for other comparators. No evidence of a difference in short term-efficacy was found between behavioural activation and third-wave CBT (RR 1.10, 95% CI 0.91 to 1.33; 2 RCTs, 98 participants; low certainty), and psychodynamic therapy (RR 1.21, 95% CI 0.74 to 1.99; 1 RCT,60 participants; very low certainty). Behavioural activation was more effective than humanistic therapy (RR 1.84, 95% CI 1.15 to 2.95; 2 RCTs, 46 participants; low certainty) and medication (RR 1.77, 95% CI 1.14 to 2.76; 1 RCT; 141 participants; moderate certainty), but both of these results were based on a small number of trials and participants. No evidence on treatment efficacy was available for comparisons between behavioural activation versus interpersonal, cognitive analytic, and integrative therapies. There was moderate-certainty evidence that behavioural activation might have lower treatment acceptability (based on dropout rate) than treatment as usual in the short term, although the data did not confirm a difference and results lacked precision (RR 1.64, 95% CI 0.81 to 3.31; 14 RCTs, 2518 participants). Moderate-certainty evidence did not suggest any difference in short-term acceptability between behavioural activation and waiting list (RR 1.17, 95% CI 0.70 to 1.93; 8 RCTs. 359 participants), no treatment (RR 0.97, 95% CI 0.45 to 2.09; 3 RCTs, 187 participants), medication (RR 0.52, 95% CI 0.23 to 1.16; 2 RCTs, 243 participants), or placebo (RR 0.72, 95% CI 0.31 to 1.67; 1 RCT; 96 participants; low-certainty evidence). No evidence on treatment acceptability was available comparing behavioural activation versus psychodynamic therapy. Low-certainty evidence did not show a difference in short-term treatment acceptability (dropout rate) between behavioural activation and CBT (RR 1.03, 95% CI 0.85 to 1.25; 12 RCTs, 1195 participants), third-wave CBT (RR 0.84, 95% CI 0.33 to 2.10; 3 RCTs, 147 participants); humanistic therapy (RR 1.06, 95% CI 0.20 to 5.55; 2 RCTs, 96 participants) (very low certainty), and interpersonal, cognitive analytic, and integrative therapy (RR 0.84, 95% CI 0.32 to 2.20; 4 RCTs, 123 participants). Results from medium- and long-term primary outcomes, secondary outcomes, subgroup analyses, and sensitivity analyses are summarised in the text. AUTHORS' CONCLUSIONS This systematic review suggests that behavioural activation may be more effective than humanistic therapy, medication, and treatment as usual, and that it may be no less effective than CBT, psychodynamic therapy, or being placed on a waiting list. However, our confidence in these findings is limited due to concerns about the certainty of the evidence. We found no evidence of a difference in short-term treatment acceptability (based on dropouts) between behavioural activation and most comparison groups (CBT, humanistic therapy, waiting list, placebo, medication, no treatment or treatment as usual). Again, our confidence in all these findings is limited due to concerns about the certainty of the evidence. No data were available about the efficacy of behaioural activation compared with placebo, or about treatment acceptability comparing behavioural activation and psychodynamic therapy, interpersonal, cognitive analytic and integrative therapies. The evidence could be strengthened by better reporting and better quality RCTs of behavioural activation and by assessing working mechanisms of behavioural activation.
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Affiliation(s)
- Eleonora Uphoff
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - David Ekers
- Lanchester Road Hospital, Tees, Esk and Wear Valleys NHS Foundation Trust, Durham, UK
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Lindsay Robertson
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Sarah Dawson
- Cochrane Common Mental Disorders, University of York, York, UK
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emily Sanger
- Cochrane Common Mental Disorders, University of York, York, UK
| | - Emily South
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Zainab Samaan
- Psychiatry, Faculty of Health Sciences, McMaster University, Hamilton, Canada
| | | | - Nicholas Meader
- Centre for Reviews and Dissemination, University of York, York, UK
| | - Rachel Churchill
- Cochrane Common Mental Disorders, University of York, York, UK
- Centre for Reviews and Dissemination, University of York, York, UK
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Arnott B, Kitchen CEW, Ekers D, Gega L, Tiffin PA. Behavioural activation for overweight and obese adolescents with low mood delivered in a community setting: feasibility study. BMJ Paediatr Open 2020; 4:e000624. [PMID: 32399504 PMCID: PMC7204816 DOI: 10.1136/bmjpo-2019-000624] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2019] [Revised: 04/02/2020] [Accepted: 04/03/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Mood and weight problems are common in young people, yet few treatments address both conditions concurrently. Behavioural activation (BA) has shown promise as a treatment for adults with comorbid obesity and depression. This study aimed to examine the feasibility and acceptability of a manualised BA treatment targeting weight and mood problems in young people. METHODS Young people with low mood and weight difficulties were identified via a school-based screening process. Following a diagnostic interview, young people with clinically significant mood problems and concurrent overweight/obesity were invited to participate. A total of 8-12 sessions of BA were delivered by a graduate therapist to eight adolescents (four male) aged 12-15 years. Weight, mood and functioning were assessed before, during and after treatment, and a semistructured qualitative interview was conducted, along with selected outcome measures at 4 months' follow-up. RESULTS Low attrition and positive qualitative feedback suggested the intervention was acceptable. Trends towards a reduction in reported depression symptoms and improved functioning scores were observed at follow-up, with more mixed results for change in body mass index. Of those attending the 4-month follow-up, 57% (4/7) no longer met the screening threshold for major depressive disorder. However, low screening and baseline recruitment rates would pose challenges to executing a larger trial. CONCLUSIONS BA delivered by a graduate therapist in a British community setting is an acceptable, feasible treatment for comorbid mood and weight problems in adolescence, and its effectiveness should be evaluated in an adequately powered randomised controlled trial.
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Affiliation(s)
- Bronia Arnott
- Population Health Sciences Institute Newcastle University, Newcastle upon Tyne, UK
| | | | - David Ekers
- Department of Health Sciences, University of York, York, North Yorkshire, UK.,Tees Esk and Wear Valleys NHS Foundation Trust, Durham, UK
| | - Lina Gega
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Paul Alexander Tiffin
- Department of Health Sciences & the Hull York Medical School, University of York, York, North Yorkshire, UK.,Tees Esk and Wear Valleys NHS Foundation Trust, Teesside, UK
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Brown JVE, Walton N, Meader N, Todd A, Webster LAD, Steele R, Sampson SJ, Churchill R, McMillan D, Gilbody S, Ekers D. Pharmacy-based management for depression in adults. Cochrane Database Syst Rev 2019; 12:CD013299. [PMID: 31868236 PMCID: PMC6927244 DOI: 10.1002/14651858.cd013299.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is common for peoples not to take antidepressant medication as prescribed, with around 50% of people likely to prematurely discontinue taking their medication after six months. Community pharmacists may be well placed to have a role in antidepressant management because of their unique pharmacotherapeutic knowledge and ease of access for people. Pharmacists are in an ideal position to offer proactive interventions to people with depression or depressive symptoms. However, the effectiveness and acceptability of existing pharmacist-based interventions is not yet well understood. The degree to which a pharmacy-based management approach might be beneficial, acceptable to people, and effective as part of the overall management for those with depression is, to date, unclear. A systematic review of randomised controlled trials (RCTs) will help answer these questions and add important knowledge to the currently sparse evidence base. OBJECTIVES To examine the effects of pharmacy-based management interventions compared with active control (e.g. patient information materials or any other active intervention delivered by someone other than the pharmacist or the pharmacy team), waiting list, or treatment as usual (e.g. standard pharmacist advice or antidepressant education, signposting to support available in primary care services, brief medication counselling, and/or (self-)monitoring of medication adherence offered by a healthcare professional outside the pharmacy team) at improving depression outcomes in adults. SEARCH METHODS We searched the Cochrane Common Mental Disorders Controlled Trials Register (CCMD-CTR) to June 2016; the Cochrane Library (Issue 11, 2018); and Ovid MEDLINE, Embase, and PsycINFO to December 2018. We searched theses and dissertation databases and international trial registers for unpublished/ongoing trials. We applied no restrictions on date, language, or publication status to the searches. SELECTION CRITERIA: We included all RCTs and cluster-RCTs where a pharmacy-based intervention was compared with treatment as usual, waiting list, or an alternative intervention in the management of depression in adults over 16 years of age. Eligible studies had to report at least one of the following outcomes at any time point: depression symptom change, acceptability of the intervention, diagnosis of depression, non-adherence to medication, frequency of primary care appointments, quality of life, social functioning, or adverse events. DATA COLLECTION AND ANALYSIS: Two authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment (including GRADE). We discussed disagreements within the team until we reached consensus. Where data did not allow meta-analyses, we synthesised results narratively. MAIN RESULTS: Twelve studies (2215 participants) met the inclusion criteria and compared pharmacy-based management with treatment as usual. Two studies (291 participants) also included an active control (both used patient information leaflets providing information about the prescribed antidepressant). Neither of these studies reported depression symptom change. A narrative synthesis of results on acceptability of the intervention was inconclusive, with one study reporting better acceptability of pharmacy-based management and the other better acceptability of the active control. One study reported that participants in the pharmacy-based management group had better medication adherence than the control participants. One study reported adverse events with no difference between groups. The studies reported no other outcomes. Meta-analyses comparing pharmacy-based management with treatment as usual showed no evidence of a difference in the effect of the intervention on depression symptom change (dichotomous data; improvement in symptoms yes/no: risk ratio (RR), 0.95, 95% confidence interval (CI) 0.86 to 1.05; 4 RCTs, 475 participants; moderate-quality evidence; continuous data: standard mean difference (SMD) -0.04, 95% CI -0.19 to 0.10; 5 RCTs, 718 participants; high-certainty evidence), or acceptability of the intervention (RR 1.09, 95% CI 0.81 to 1.45; 12 RCTs, 2072 participants; moderate-certainty evidence). The risk of non-adherence was reduced in participants receiving pharmacy-based management (RR 0.73, 95% CI 0.61 to 0.87; 6 RCTs, 911 participants; high-certainty evidence). We were unable to meta-analyse data on diagnosis of depression, frequency of primary care appointments, quality of life, or social functioning. AUTHORS' CONCLUSIONS We found no evidence of a difference between pharmacy-based management for depression in adults compared with treatment as usual in facilitating depression symptom change. Based on numbers of participants leaving the trials early, there may be no difference in acceptability between pharmacy-based management and controls. However, there was uncertainty due to the low-certainty evidence.
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Affiliation(s)
- Jennifer Valeska Elli Brown
- University of YorkCochrane Common Mental DisordersYorkUK
- University of YorkCentre for Reviews and DisseminationYorkUK
| | - Nick Walton
- Newcastle UniversityInstitute of Health and SocietyNewcastle upon TyneUK
| | - Nicholas Meader
- University of YorkCochrane Common Mental DisordersYorkUK
- University of YorkCentre for Reviews and DisseminationYorkUK
| | - Adam Todd
- Newcastle UniversitySchool of PharmacyQueen Victoria RoadNewcastle upon TyneUKNE1 7RU
| | - Lisa AD Webster
- Leeds Trinity UniversitySchool of Social and Health ScienceLeedsUK
| | - Rachel Steele
- Tees, Esk and Wear Valleys NHS Foundation TrustLibrary and Information ServiceDurhamUKDH1 5RD
| | | | - Rachel Churchill
- University of YorkCochrane Common Mental DisordersYorkUK
- University of YorkCentre for Reviews and DisseminationYorkUK
| | - Dean McMillan
- University of YorkMental Health and Addiction Research Group, Department of Health SciencesHeslingtonYork‐ None ‐UKY010 5DD
| | - Simon Gilbody
- University of YorkMental Health and Addiction Research Group, Department of Health SciencesHeslingtonYork‐ None ‐UKY010 5DD
| | - David Ekers
- University of YorkMental Health and Addiction Research Group, Department of Health SciencesHeslingtonYork‐ None ‐UKY010 5DD
- Tees, Esk and Wear Valleys NHS Foundation TrustLanchester Road HospitalDurhamUK
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Velasquez Reyes D, Patel H, Lautenschlager N, Ford AH, Curran E, Kelly R, Lai R, Chong T, Flicker L, Ekers D, Gilbody S, Etherton-Beer C, Lo Giudice D, Ellis KA, Martini A, Almeida OP. Behavioural activation in nursing homes to treat depression (BAN-Dep): study protocol for a pragmatic randomised controlled trial. BMJ Open 2019; 9:e032421. [PMID: 31676658 PMCID: PMC6830697 DOI: 10.1136/bmjopen-2019-032421] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Depression is a common disorder among older people living in residential aged care facilities. Several trials have demonstrated the effectiveness of behavioural therapies in treating depressive symptoms in older adults living in the community and in residential aged care. Behavioural Activation is demonstrably effective even when delivered by non-specialists (staff without formal psychological training), although strategies for adapting its use in residential aged care facilities are yet to be explored. This study will determine whether training residential care staff in the use of a structured Behavioural Activation programme is more effective at decreasing depressive symptoms among older residents than internet-based training about depression recognition and management alone. METHOD AND ANALYSIS The behavioural activation in nursing homes to treat depression (BAN-Dep) trial is a pragmatic two-arm parallel clustered randomised controlled trial. It will recruit 666 residents aged 60 or older from 100 residential aged care facilities, which will be randomly assigned to the Behavioural Activation or control intervention. Staff in both treatment groups will be encouraged to complete the Beyondblue Professional Education to Aged Care e-learning programme to improve their recognition of and ability to respond to depression in older adults. Selected staff from intervention facilities will undergo additional training to deliver an 8-module Behavioural Activation programme to residents with subthreshold symptoms of depression-they will receive ongoing Mental support from trained Behavioural Activation therapists. Outcome measures will be collected by blind research officer at baseline and after 3, 6 and 12 months. The Patient Health Questionnaire-9 is the primary outcome measure of the study. ETHICS AND DISSEMINATION The trial will comply with the principles of the Declaration of Helsinki for Human Rights and is overseen by the University of Western Australia (reference RA/4/20/4234) and Melbourne Health (reference number HREC/18/MH/47) Ethics Committees. The results of this research project will be disseminated through publications and/or presentations in a variety of media to health professionals, academics, clinicians and the public. Only de-identified group data will be presented. TRIAL REGISTRATION ACTRN12618000634279.
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Affiliation(s)
| | - Hema Patel
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| | | | - Andrew H Ford
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| | - Eleanor Curran
- Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Rachael Kelly
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| | - Rhoda Lai
- Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Terence Chong
- Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Leon Flicker
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| | | | | | - Christopher Etherton-Beer
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
| | | | - Kathryn A Ellis
- Psychiatry, The University of Melbourne, Melbourne, Victoria, Australia
| | - Angelita Martini
- Brightwater Care Group, Osborne Park, Western Australia, Australia
| | - Osvaldo P Almeida
- Medical School, University of Western Australia Faculty of Medicine Dentistry and Health Sciences, Perth, Western Australia, Australia
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Uphoff E, Pires M, Barbui C, Barua D, Churchill R, Ekers D, Fottrell E, Mazumdar P, Purgato M, Rana R, Wright J, Siddiqi N. Behavioural activation therapies for depression in adults with non-communicable diseases. Hippokratia 2019. [DOI: 10.1002/14651858.cd013461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Eleonora Uphoff
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
| | - Malini Pires
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
| | - Corrado Barbui
- University of Verona; Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; Verona Italy
| | | | - Rachel Churchill
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
| | - David Ekers
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
- Tees, Esk and Wear Valleys NHS Foundation Trust; Lanchester Road Hospital; Durham UK
| | - Edward Fottrell
- University College London; Centre for Health Policy, Institute of Global Health Innovation; London UK
| | - Papiya Mazumdar
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; York UK
| | - Marianna Purgato
- University of Verona; Department of Neurosciences, Biomedicine and Movement Sciences, Section of Psychiatry; Verona Italy
| | - Rusham Rana
- Benazir Bhutto Hospital; Institute of Psychiatry; Rawalpindi Pakistan
| | - Judy Wright
- University of Leeds; Leeds Institute of Health Sciences; Leeds UK
| | - Najma Siddiqi
- Hull York Medical School, University of York; Department of Health Sciences; Heslington York North Yorkshire UK Y010 5DD
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30
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Littlewood E, Ali S, Badenhorst J, Bailey D, Bambra C, Chew-Graham C, Coleman E, Crosland S, Gascoyne S, Gilbody S, Hewitt C, Jones C, Keding A, Kitchen C, McMillan D, Pearson C, Rhodes S, Sloan C, Todd A, Watson M, Whittlesea C, Ekers D. Community Pharmacies Mood Intervention Study (CHEMIST): feasibility and external pilot randomised controlled trial protocol. Pilot Feasibility Stud 2019; 5:71. [PMID: 31161045 PMCID: PMC6540405 DOI: 10.1186/s40814-019-0457-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 05/09/2019] [Indexed: 11/10/2022] Open
Abstract
FEASIBILITY STUDY Objectives:Refine a bespoke enhanced support intervention (ESI) (including self-help materials, intervention manual and training) for implementation by community pharmacy (CP) staff to people with sub-threshold depression and long-term conditions (LTCs) based upon evidence-supported interventions in primary careDevelop and refine study procedures (recruitment strategies and set up, screening, participant recruitment, assessment, suitability of outcome measures and data collection procedures) for testing in the pilot study phaseDesign: A case series/qualitative studySetting: UK community pharmacyPopulation: Adults with long-term health conditions who screen-positive for depression but who do not reach the threshold for DSM IV Moderate Depressive disorderIntervention: Enhanced support intervention (ESI) delivered by an appropriately trained community pharmacy team member involving four to six sessions over four months. ESI is a modified form of an intervention within the collaborative care framework for sub-threshold depression validated in previous studies in UK primary care which appears suitable for implementation in community settings.Sample size: 20-30 participantsOutcomes: Study implementation (recruitment and attrition rates), quality of data collection at baseline and 4 months and ESI adherence (number of contacts, DNA and drop out) as per objectives 1a/bQualitative evaluation: Semi-structured interviews with up to 10 participants and ESI facilitators and focus group(s) (range of pharmacy staff n = 8-10) will be conducted to explore the acceptability of the intervention and feasibility of the study, training and study procedures. EXTERNAL PILOT STUDY Objectives:Quantify the flow of participants (eligibility, recruitment and follow-up rate)Evaluate proposed recruitment, assessment and outcome measure collection methodsExamine the delivery of the enhanced support intervention in a community pharmacy setting (intervention uptake, retention and dose) to inform process evaluationProcess evaluation, using semi-structured interviews with participants across a range of socio-economic settings, and pharmacy staff to explore the acceptability of the ESI within community pharmacy, elements of the intervention that were considered useful (or not) and appropriateness of study proceduresDesign: Pilot randomised controlled trial, including a prospective economic and qualitative evaluationSetting: As abovePopulation: As aboveIntervention: As above with adaptations post feasibility studyComparator: Usual careSample size: 100 participantsOutcomes: Data will be used to estimate recruitment, intervention delivery and study completion rates as per objectives 2a-d. Definitive estimates of the effectiveness of ESI will not be made.Primary outcome: Depression severity (Patient Health Questionnaire 9) at four months.Secondary outcomes: Patient acceptance, uptake and attrition. ICD10 depression status, anxiety (GAD 7), health-related quality of life (SF-12v2) and health-state utility (EQ5D 3L) will be measured at four months.Economic evaluation: The incremental cost per QALY will be calculated from both the NHS and societal perspective.Process evaluation: Using mixed methods, potential mediators/moderators of the intervention, the acceptability (to participants and pharmacy staff), barriers and facilitators to the use of ESI in community pharmacy, and impact on usual practice will be examined. Semi-structured interviews with approximately 30 study participants, 20 pharmacy staff and eight GPs near participating pharmacies will be conducted. TRIAL REGISTRATION ISRCTN: ISRCTN11290592Protocol version number: Version 4.1 (dated 16th January 2018)Study Sponsor Tees Esk and Wear Valleys NHS Foundation Trust.
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Affiliation(s)
| | - Shehzad Ali
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Jay Badenhorst
- Whitworth Chemists Ltd, 2C Atkinson Way, Foxhill Industrial Estate, Scunthorpe, DN15 8QJ UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Clare Bambra
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Staffordshire, ST5 5BG UK
| | - Elizabeth Coleman
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Suzanne Crosland
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Claire Jones
- Public Health Team, Children & Adult Services, Durham County Council, County Hall, DH1 5UJ UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Charlotte Kitchen
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Caroline Pearson
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Shelley Rhodes
- University of Exeter Medical School, University of Exeter, Exeter, EX1 2LU UK
| | - Claire Sloan
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Adam Todd
- Institute of Health & Society, Newcastle University, Richardson Road, Newcastle Upon Tyne, NE2 4AX UK
- School of Pharmacy, King George VI Building, Queen Victoria Road, Newcastle Upon Tyne, NE1 7RU UK
| | - Michelle Watson
- Department of Health Sciences, University of York, York, YO10 5DD UK
| | - Cate Whittlesea
- UCL School of Pharmacy, University College London, 29-39 Brunswick Square, London, WC1N 1AX UK
| | - David Ekers
- Department of Health Sciences, University of York, York, YO10 5DD UK
- Tees Esk and Wear Valleys NHS FT/University of York, Tarncroft House, Lanchester Road Hospital, Durham, DH1 5RD UK
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Affiliation(s)
- Eleonora Uphoff
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
| | - David Ekers
- Tees, Esk and Wear Valleys NHS Foundation Trust; Lanchester Road Hospital; Durham UK
- University of York; Mental Health and Addiction Research Group, Department of Health Sciences; Heslington York UK YO10 5DD
| | - Sarah Dawson
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of Bristol; Population Health Sciences, Bristol Medical School; Bristol UK
| | - David Richards
- University of Exeter; School of Psychology; Washington Singer Laboratories Perry Road Exeter UK EX4 4QG
| | - Rachel Churchill
- University of York; Cochrane Common Mental Disorders; Heslington York - None - UK YO10 5DD
- University of York; Centre for Reviews and Dissemination; York UK
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Bosanquet K, Adamson J, Atherton K, Bailey D, Baxter C, Beresford-Dent J, Birtwistle J, Chew-Graham C, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hamilton J, Hargate R, Hewitt C, Holmes J, Keding A, Lewis H, McMillan D, Meer S, Mitchell N, Nutbrown S, Overend K, Parrott S, Pervin J, Richards DA, Spilsbury K, Torgerson D, Traviss-Turner G, Trépel D, Woodhouse R, Gilbody S. CollAborative care for Screen-Positive EldeRs with major depression (CASPER plus): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-252. [PMID: 29171379 DOI: 10.3310/hta21670] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression in older adults is common and is associated with poor quality of life, increased morbidity and early mortality, and increased health and social care use. Collaborative care, a low-intensity intervention for depression that is shown to be effective in working-age adults, has not yet been evaluated in older people with depression who are managed in UK primary care. The CollAborative care for Screen-Positive EldeRs (CASPER) plus trial fills the evidence gap identified by the most recent guidelines on depression management. OBJECTIVES To establish the clinical effectiveness and cost-effectiveness of collaborative care for older adults with major depressive disorder in primary care. DESIGN A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with embedded qualitative study. Participants were automatically randomised by computer, by the York Trials Unit Randomisation Service, on a 1 : 1 basis using simple unstratified randomisation after informed consent and baseline measures were collected. Blinding was not possible. SETTING Sixty-nine general practices in the north of England. PARTICIPANTS A total of 485 participants aged ≥ 65 years with major depressive disorder. INTERVENTIONS A low-intensity intervention of collaborative care, including behavioural activation, delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual general practitioner (GP) care. The control arm received only usual GP care. MAIN OUTCOME MEASURES The primary outcome measure was Patient Health Questionnaire-9 items score at 4 months post randomisation. Secondary outcome measures included depression severity and caseness at 12 and 18 months, the EuroQol-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder-7 items, Connor-Davidson Resilience Scale-2 items, a medication questionnaire, objective data and adverse events. Participants were followed up at 12 and 18 months. RESULTS In total, 485 participants were randomised (collaborative care, n = 249; usual care, n = 236), with 390 participants (80%: collaborative care, 75%; usual care, 86%) followed up at 4 months, 358 participants (74%: collaborative care, 70%; usual care, 78%) followed up at 12 months and 344 participants (71%: collaborative care, 67%; usual care, 75%) followed up at 18 months. A total of 415 participants were included in primary analysis (collaborative care, n = 198; usual care, n = 217), which revealed a statistically significant effect in favour of collaborative care at the primary end point at 4 months [8.98 vs. 10.90 score points, mean difference 1.92 score points, 95% confidence interval (CI) 0.85 to 2.99 score points; p < 0.001], equivalent to a standard effect size of 0.34. However, treatment differences were not maintained in the longer term (at 12 months: 0.19 score points, 95% CI -0.92 to 1.29 score points; p = 0.741; at 18 months: < 0.01 score points, 95% CI -1.12 to 1.12 score points; p = 0.997). The study recorded details of all serious adverse events (SAEs), which consisted of 'unscheduled hospitalisation', 'other medically important condition' and 'death'. No SAEs were related to the intervention. Collaborative care showed a small but non-significant increase in quality-adjusted life-years (QALYs) over the 18-month period, with a higher cost. Overall, the mean cost per incremental QALY for collaborative care compared with usual care was £26,016; however, for participants attending six or more sessions, collaborative care appears to represent better value for money (£9876/QALY). LIMITATIONS Study limitations are identified at different stages: design (blinding unfeasible, potential contamination), process (relatively low overall consent rate, differential attrition/retention rates) and analysis (no baseline health-care resource cost or secondary/social care data). CONCLUSION Collaborative care was effective for older people with case-level depression across a range of outcomes in the short term though the reduction in depression severity was not maintained over the longer term of 12 or 18 months. Participants who received six or more sessions of collaborative care did benefit substantially more than those who received fewer treatment sessions but this difference was not statistically significant. FUTURE WORK RECOMMENDATIONS Recommendations for future research include investigating the longer-term effect of the intervention. Depression is a recurrent disorder and it would be useful to assess its impact on relapse and the prevention of future case-level depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN45842879. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 67. See the NIHR Journals Library website for further project information.
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Affiliation(s)
| | - Joy Adamson
- Department of Health Sciences, University of York, York, UK
| | - Katie Atherton
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | | | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Stoke-on-Trent, UK
| | - Emily Clare
- Northumberland, Tyne and Wear NHS Foundation Trust, National Institute for Health Research Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | - Jaime Delgadillo
- Department of Health Sciences, University of York, York, UK.,Primary Care Mental Health Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - David Ekers
- Mental Health Research Group, Durham University, Durham, UK.,Research and Development Department, Tees, Esk & Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Deborah Foster
- Department of Health Sciences, University of York, York, UK
| | - Rhian Gabe
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | | | - Lesley Haley
- Research and Development Department, Tees, Esk & Wear Valleys NHS Foundation Trust, Middlesbrough, UK
| | - Jahnese Hamilton
- Northumberland, Tyne and Wear NHS Foundation Trust, National Institute for Health Research Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | | | | | - John Holmes
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | - Helen Lewis
- Department of Health Sciences, University of York, York, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | | | - Sarah Nutbrown
- Department of Health Sciences, University of York, York, UK
| | - Karen Overend
- Department of Health Sciences, University of York, York, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, York, UK
| | - Jodi Pervin
- Department of Health Sciences, University of York, York, UK
| | - David A Richards
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | | | | | - Dominic Trépel
- Department of Health Sciences, University of York, York, UK
| | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
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Richards DA, Rhodes S, Ekers D, McMillan D, Taylor RS, Byford S, Barrett B, Finning K, Ganguli P, Warren F, Farrand P, Gilbody S, Kuyken W, O'Mahen H, Watkins E, Wright K, Reed N, Fletcher E, Hollon SD, Moore L, Backhouse A, Farrow C, Garry J, Kemp D, Plummer F, Warner F, Woodhouse R. Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive-behavioural therapy for depression. Health Technol Assess 2018; 21:1-366. [PMID: 28857042 DOI: 10.3310/hta21460] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments. DESIGN Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation. SETTING Three community mental health services in England. PARTICIPANTS Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services. INTERVENTIONS BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists. OUTCOMES Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months. RESULTS We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p < 0.001), but no differences in non-intervention (hospital, community health, social care and medication costs) or total (non-intervention plus intervention) costs. Costs were lower and QALY outcomes better in the BA group, generating an incremental cost-effectiveness ratio of -£6865. The probability of BA being cost-effective compared with CBT was almost 80% at the National Institute for Health and Care Excellence's preferred willingness-to-pay threshold of £20,000-30,000 per QALY. There were no trial-related adverse events. LIMITATIONS In this pragmatic trial many depressed participants in both groups were also taking antidepressant medication, although most had been doing so for a considerable time before entering the trial. Around one-third of participants chose not to complete a PP dose of treatment, a finding common in both psychotherapy trials and routine practice. CONCLUSIONS We found that BA is as effective as CBT, more cost-effective and can be delivered by MHWs with no professional training in psychological therapies. FUTURE WORK Settings and countries with a paucity of professionally qualified psychological therapists, might choose to investigate the delivery of effective psychological therapy for depression without the need to develop an extensive and costly professional infrastructure. TRIAL REGISTRATION Current Controlled Trials ISRCTN27473954. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David A Richards
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Shelley Rhodes
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - David Ekers
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
| | - Rod S Taylor
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Sarah Byford
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Barbara Barrett
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Katie Finning
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Poushali Ganguli
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Fiona Warren
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Paul Farrand
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Willem Kuyken
- Oxford Mindfulness Centre, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Heather O'Mahen
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Ed Watkins
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Kim Wright
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Nigel Reed
- Lived Experience Group, care of Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Emily Fletcher
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Lucy Moore
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Amy Backhouse
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Claire Farrow
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Julie Garry
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Deborah Kemp
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Faye Plummer
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary, Bradford, UK
| | - Faith Warner
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
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Lewis H, Adamson J, Atherton K, Bailey D, Birtwistle J, Bosanquet K, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hargate R, Hewitt C, Holmes J, Keding A, Lilley-Kelly A, Maya J, McMillan D, Meer S, Meredith J, Mitchell N, Nutbrown S, Overend K, Pasterfield M, Richards D, Spilsbury K, Torgerson D, Traviss-Turner G, Trépel D, Woodhouse R, Ziegler F, Gilbody S. CollAborative care and active surveillance for Screen-Positive EldeRs with subthreshold depression (CASPER): a multicentred randomised controlled trial of clinical effectiveness and cost-effectiveness. Health Technol Assess 2018; 21:1-196. [PMID: 28248154 DOI: 10.3310/hta21080] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Efforts to reduce the burden of illness and personal suffering associated with depression in older adults have focused on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/subthreshold depression, but these patients also suffer significant impairments in their quality of life and level of functioning. There is currently no clear evidence-based guidance regarding treatment for this patient group. OBJECTIVES To establish the clinical effectiveness and cost-effectiveness of a low-intensity intervention of collaborative care for primary care older adults who screened positive for subthreshold depression. DESIGN A pragmatic, multicentred, two-arm, parallel, individually randomised controlled trial with a qualitative study embedded within the pilot. Randomisation occurred after informed consent and baseline measures were collected. SETTING Thirty-two general practitioner (GP) practices in the north of England. PARTICIPANTS A total of 705 participants aged ≥ 75 years during the pilot phase and ≥ 65 years during the main trial with subthreshold depression. INTERVENTIONS Participants in the intervention group received a low-intensity intervention of collaborative care, which included behavioural activation delivered by a case manager for an average of six sessions over 7-8 weeks, alongside usual GP care. Control-arm participants received only usual GP care. MAIN OUTCOME MEASURES The primary outcome measure was a self-reported measure of depression severity, the Patient Health Questionnaire-9 items PHQ-9 score at 4 months post randomisation. Secondary outcome measures included the European Quality of Life-5 Dimensions, Short Form questionnaire-12 items, Patient Health Questionnaire-15 items, Generalised Anxiety Disorder seven-item scale, Connor-Davidson Resilience Scale two-item version, a medication questionnaire and objective data. Participants were followed up for 12 months. RESULTS In total, 705 participants were randomised (collaborative care n = 344, usual care n = 361), with 586 participants (83%; collaborative care 76%, usual care 90%) followed up at 4 months and 519 participants (74%; collaborative care 68%, usual care 79%) followed up at 12 months. Attrition was markedly greater in the collaborative care arm. Model estimates at the primary end point of 4 months revealed a statistically significant effect in favour of collaborative care compared with usual care [mean difference 1.31 score points, 95% confidence interval (CI) 0.67 to 1.95 score points; p < 0.001]. The difference equates to a standard effect size of 0.30, for which the trial was powered. Treatment differences measured by the PHQ-9 were maintained at 12 months' follow-up (mean difference 1.33 score points, 95% CI 0.55 to 2.10 score points; p = 0.001). Base-case cost-effectiveness analysis found that the incremental cost-effectiveness ratio was £9633 per quality-adjusted life-year (QALY). On average, participants allocated to collaborative care displayed significantly higher QALYs than those allocated to the control group (annual difference in adjusted QALYs of 0.044, 95% bias-corrected CI 0.015 to 0.072; p = 0.003). CONCLUSIONS Collaborative care has been shown to be clinically effective and cost-effective for older adults with subthreshold depression and to reduce the proportion of people who go on to develop case-level depression at 12 months. This intervention could feasibly be delivered in the NHS at an acceptable cost-benefit ratio. Important future work would include investigating the longer-term effect of collaborative care on the CASPER population, which could be conducted by introducing an extension to follow-up, and investigating the impact of collaborative care on managing multimorbidities in people with subthreshold depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN02202951. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Lewis
- Department of Health Sciences, University of York, York, UK
| | - Joy Adamson
- Department of Health Sciences, University of York, York, UK
| | - Katie Atherton
- Leeds and York Partnership NHS Foundation Trust, Leeds, UK
| | - Della Bailey
- Department of Health Sciences, University of York, York, UK
| | | | | | - Emily Clare
- Northumberland, Tyne and Wear NHS Foundation Trust, NIHR Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | - Jaime Delgadillo
- Primary Care Mental Health Service, Leeds Community Healthcare NHS Trust, Leeds, UK
| | - David Ekers
- Mental Health Research Group, University of Durham, Durham, UK
| | - Deborah Foster
- Department of Health Sciences, University of York, York, UK
| | - Rhian Gabe
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | | | - Lesley Haley
- Tees, Esk and Wear Valleys NHS Foundation Trust, NIHR Clinical Research Network North East and North Cumbria, Research and Development Department, Middlesbrough, UK
| | | | | | - John Holmes
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ada Keding
- Department of Health Sciences, University of York, York, UK
| | | | - Jahnese Maya
- Northumberland, Tyne and Wear NHS Foundation Trust, NIHR Clinical Research Network (Mental Health) North East and North Cumbria, Newcastle upon Tyne, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
| | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Jodi Meredith
- Department of Health Sciences, University of York, York, UK
| | | | - Sarah Nutbrown
- Department of Health Sciences, University of York, York, UK
| | - Karen Overend
- Department of Health Sciences, University of York, York, UK
| | | | - David Richards
- Department of Psychology, College of Life and Environmental Sciences, University of Exeter, Exeter, UK
| | | | | | | | - Dominic Trépel
- Department of Health Sciences, University of York, York, UK
| | | | | | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK.,Hull York Medical School, University of York, York, UK
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Kitchen CEW, Lewis S, Tiffin PA, Welsh PR, Howey L, Ekers D. A focused ethnography of a Child and Adolescent Mental Health Service: factors relevant to the implementation of a depression trial. Trials 2017; 18:237. [PMID: 28545545 PMCID: PMC5445271 DOI: 10.1186/s13063-017-1982-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 05/10/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Prior to commencing a randomised controlled trial, we conducted a focused ethnography to ensure that the trial was well suited to the proposed setting. METHODS A six-month observation of a Child and Adolescent Mental Health Service site in the North-East of England was undertaken to observe the site procedures, staff culture and patient care pathways. During this period, documentary data were collected and interviews were conducted with key informants to provide insight into staff perceptions of the proposed trial. The data were coded using thematic analysis and the resulting themes were verified by a second coder. RESULTS Seventeen documents were collected, 158 h of observation and six formal staff interviews were undertaken. Four themes emerged from the data; non-clinically orientated variation in practice, diagnosis, capacity and staff economy. Non-clinically orientated variation in practice occurred when staff decisions were based upon resource availability rather than on clinical judgement. Diagnosis demonstrated differing staff confidence in making diagnoses and in the treatment of patients who had received a diagnosis. Capacity consisted of the time to attend training and the psychological capacity to consider or incorporate learning into practice. Staff economy was characterised by staff changes and shortages. There was significant interaction between the themes, with staff economy emerging as a central barrier to research. The results directly informed adaptations to the trial protocol. CONCLUSIONS An ethnographic approach has provided important insights into the individual, practical and organisational boundaries into which a trial would need to be implemented.
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Affiliation(s)
- C E W Kitchen
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK.
| | - S Lewis
- Department of Geography, Durham University, Durham, UK
| | - P A Tiffin
- Department of Health Sciences, University of York, York, UK
| | - P R Welsh
- School of Psychology, Newcastle University, Newcastle upon Tyne, UK
| | - L Howey
- Tees, Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - D Ekers
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
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Finning K, Richards DA, Moore L, Ekers D, McMillan D, Farrand PA, O'Mahen HA, Watkins ER, Wright KA, Fletcher E, Rhodes S, Woodhouse R, Wray F. Cost and outcome of behavioural activation versus cognitive behavioural therapy for depression (COBRA): a qualitative process evaluation. BMJ Open 2017; 7:e014161. [PMID: 28408544 PMCID: PMC5541446 DOI: 10.1136/bmjopen-2016-014161] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 02/21/2017] [Accepted: 03/08/2017] [Indexed: 12/05/2022] Open
Abstract
OBJECTIVE To explore participant views on acceptability, mechanisms of change and impact of behavioural activation (BA) delivered by junior mental health workers (MHWs) versus cognitive behavioural therapy (CBT) delivered by professional psychotherapists. DESIGN Semistructured qualitative interviews analysed using a framework approach. PARTICIPANTS 36 participants with major depressive disorder purposively sampled from a randomised controlled trial of BA versus CBT (the COBRA trial). SETTING Primary care psychological therapies services in Devon, Durham and Leeds, UK. RESULTS Elements of therapy considered to be beneficial included its length and regularity, the opportunity to learn and not dwelling on the past. Homework was an important, although challenging aspect of treatment. Therapists were perceived as experts who played an important role in treatment. For some participants the most important element of therapy was having someone to talk to, but for others the specific factors associated with BA and CBT were crucial, with behavioural change considered important for participants in both treatments, and cognitive change unsurprisingly discussed more by those receiving CBT. Both therapies were considered to have a positive impact on symptoms of depression and other areas of life including feelings about themselves, self-care, work and relationships. Barriers to therapy included work, family life and emotional challenges. A subset (n=2) of BA participants commented that therapy felt too simple, and MHWs could be perceived as inexperienced. Many participants saw therapy as a learning experience, providing them with tools to take away, with work on relapse prevention essential. CONCLUSIONS Despite barriers for some participants, BA and CBT were perceived to have many benefits, to have brought about cognitive and behavioural change and to produce improvements in many domains of participants' lives. To optimise the delivery of BA, inexperienced junior MHWs should be supported through good quality training and ongoing supervision. TRIAL REGISTRATION NUMBER ISRCTN27473954, 09/12/2011.
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Affiliation(s)
| | | | - Lucy Moore
- University of Exeter Medical School, Exeter, UK
| | - David Ekers
- Tees Esk and Wear Valleys NHS Foundation Trust, Darlington, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
| | - Paul A Farrand
- School of Psychology, University of Exeter, Exeter, UK
- Clinical Education Development and Research (CEDAR), University of Exeter, Exeter, UK
| | | | | | - Kim A Wright
- School of Psychology, University of Exeter, Exeter, UK
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Gilbody S, Lewis H, Adamson J, Atherton K, Bailey D, Birtwistle J, Bosanquet K, Clare E, Delgadillo J, Ekers D, Foster D, Gabe R, Gascoyne S, Haley L, Hamilton J, Hargate R, Hewitt C, Holmes J, Keding A, Lilley-Kelly A, Meer S, Mitchell N, Overend K, Pasterfield M, Pervin J, Richards DA, Spilsbury K, Traviss-Turner G, Trépel D, Woodhouse R, Ziegler F, McMillan D. Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial. JAMA 2017; 317:728-737. [PMID: 28241357 DOI: 10.1001/jama.2017.0130] [Citation(s) in RCA: 75] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE There is little evidence to guide management of depressive symptoms in older people. OBJECTIVE To evaluate whether a collaborative care intervention can reduce depressive symptoms and prevent more severe depression in older people. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial conducted from May 24, 2011, to November 14, 2014, in 32 primary care centers in the United Kingdom among 705 participants aged 65 years or older with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) subthreshold depression; participants were followed up for 12 months. INTERVENTIONS Collaborative care (n=344) was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. The control group received usual primary care (n=361). MAIN OUTCOMES AND MEASURES The primary outcome was self-reported depression severity at 4-month follow-up on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27). Included among 10 prespecified secondary outcomes were the PHQ-9 score at 12-month follow-up and the proportion meeting criteria for depressive disorder (PHQ-9 score ≥10) at 4- and 12-month follow-up. RESULTS The 705 participants were 58% female with a mean age of 77 (SD, 7.1) years. Four-month retention was 83%, with higher loss to follow-up in collaborative care (82/344 [24%]) vs usual care (37/361 [10%]). Collaborative care resulted in lower PHQ-9 scores vs usual care at 4-month follow-up (mean score with collaborative care, 5.36 vs with usual care, 6.67; mean difference, -1.31; 95% CI, -1.95 to -0.67; P < .001). Treatment differences remained at 12 months (mean PHQ-9 score with collaborative care, 5.93 vs with usual care, 7.25; mean difference, -1.33; 95% CI, -2.10 to -0.55). The proportions of participants meeting criteria for depression at 4-month follow-up were 17.2% (45/262) vs 23.5% (76/324), respectively (difference, -6.3% [95% CI, -12.8% to 0.2%]; relative risk, 0.83 [95% CI, 0.61-1.27]; P = .25) and at 12-month follow-up were 15.7% (37/235) vs 27.8% (79/284) (difference, -12.1% [95% CI, -19.1% to -5.1%]; relative risk, 0.65 [95% CI, 0.46-0.91]; P = .01). CONCLUSIONS AND RELEVANCE Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy. TRIAL REGISTRATION isrctn.org Identifier: ISRCTN02202951.
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Affiliation(s)
- Simon Gilbody
- Department of Health Sciences, University of York, Heslington, England2Hull York Medical School, University of York, Heslington, England
| | - Helen Lewis
- Department of Health Sciences, University of York, Heslington, England
| | - Joy Adamson
- Department of Health Sciences, University of York, Heslington, England
| | - Katie Atherton
- Leeds and York Partnership NHS Foundation Trust, Leeds, England
| | - Della Bailey
- Department of Health Sciences, University of York, Heslington, England
| | | | | | - Emily Clare
- Northumberland Tyne and Wear NHS Foundation Trust, NIHR Clinical Research Network (Mental Health) North East and North Cumbria, Academic Psychiatry, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle Upon Tyne, England
| | | | - David Ekers
- Mental Health Research Group, University of Durham, Durham, England8Tees Esk and Wear Valleys NHS Foundation Trust, NIHR Clinical Research Network North East and North Cumbria, Research and Development Department, Middlesbrough, England
| | - Deborah Foster
- Department of Health Sciences, University of York, Heslington, England
| | - Rhian Gabe
- Department of Health Sciences, University of York, Heslington, England
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, Heslington, England
| | - Lesley Haley
- Tees Esk and Wear Valleys NHS Foundation Trust, NIHR Clinical Research Network North East and North Cumbria, Research and Development Department, Middlesbrough, England
| | - Jahnese Hamilton
- Northumberland Tyne and Wear NHS Foundation Trust, NIHR Clinical Research Network (Mental Health) North East and North Cumbria, Academic Psychiatry, Wolfson Research Centre, Campus for Ageing and Vitality, Newcastle Upon Tyne, England
| | - Rebecca Hargate
- Leeds and York Partnership NHS Foundation Trust, Leeds, England
| | - Catherine Hewitt
- Department of Health Sciences, University of York, Heslington, England
| | - John Holmes
- Leeds Institute of Health Sciences, University of Leeds, Leeds, England
| | - Ada Keding
- Department of Health Sciences, University of York, Heslington, England
| | | | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Leeds, England
| | - Natasha Mitchell
- Department of Health Sciences, University of York, Heslington, England
| | - Karen Overend
- Department of Health Sciences, University of York, Heslington, England
| | | | - Jodi Pervin
- Department of Health Sciences, University of York, Heslington, England
| | - David A Richards
- Institute of Health Research, Medical School, University of Exeter, Exeter, England
| | - Karen Spilsbury
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, England
| | | | - Dominic Trépel
- Department of Health Sciences, University of York, Heslington, England
| | - Rebecca Woodhouse
- Department of Health Sciences, University of York, Heslington, England
| | - Friederike Ziegler
- Department of Urban Studies and Planning, University of Sheffield, Sheffield, England
| | - Dean McMillan
- Department of Health Sciences, University of York, Heslington, England2Hull York Medical School, University of York, Heslington, England
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Webster LAD, Ekers D, Chew-Graham CA. Feasibility of training practice nurses to deliver a psychosocial intervention within a collaborative care framework for people with depression and long-term conditions. BMC Nurs 2016; 15:71. [PMID: 27980453 PMCID: PMC5142437 DOI: 10.1186/s12912-016-0190-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Accepted: 11/22/2016] [Indexed: 01/12/2023] Open
Abstract
Background Practice nurses (PNs) deliver much of the chronic disease management in primary care and have been highlighted as appropriately placed within the service to manage patients with long-term physical conditions (LTCs) and co-morbid depression. This nested qualitative evaluation within a service development pilot provided the opportunity to examine the acceptability of a Brief Behavioural Activation (BBA) intervention within a collaborative care framework. Barriers and facilitators to engaging with the intervention from the patient and clinician perspective will be used to guide future service development and research. Methods The study was conducted across 8 practices in one Primary Care Trust 1 in England. Through purposive sampling professionals (n = 10) taking part in the intervention (nurses, GPs and a mental health gateway worker) and patients (n = 4) receiving the intervention participated in semi-structured qualitative interviews. Analysis utilised the four Normalisation Process Theory (NPT) concepts of coherence, cognitive participation, collective action and reflexive monitoring to explore the how this intervention could be implemented in practice. Results Awareness of depression and the stigma associated with the label of depression meant that, from a patient perspective a PN being available to ‘listen’ was perceived as valuable. Competing practice priorities, perceived lack of time and resources, and lack of engagement by the whole practice team were considered the greatest barriers to the implementation of this intervention in routine primary care. Conclusion Lack of understanding of, participation in, and support from the whole practice team in the collaborative care model exacerbated the pressures perceived by PNs. The need for formal supervision of PNs to enable them to undertake the role of case manager for patients with depression and long-term conditions is emphasised. Electronic supplementary material The online version of this article (doi:10.1186/s12912-016-0190-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lisa A D Webster
- School of Social and Health Sciences, Leeds Trinity University, Brownberrie Lane, Horsforth, Leeds, LS18 5HD UK
| | - David Ekers
- Wolfson Research Institute for Health and Wellbeing, Durham University/Tees Esk and Wear Valleys NHS Foundation Trust, Queen's Campus, University Boulevard, Stockton on Tees, TS17 6BH UK
| | - Carolyn A Chew-Graham
- Clinical Academic Training, Research Institute, Primary Care and Health Sciences, Keele University, Keele, Staffordshire ST5 5BG UK
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Richards DA, Ekers D, McMillan D, Taylor RS, Byford S, Warren FC, Barrett B, Farrand PA, Gilbody S, Kuyken W, O'Mahen H, Watkins ER, Wright KA, Hollon SD, Reed N, Rhodes S, Fletcher E, Finning K. Cost and Outcome of Behavioural Activation versus Cognitive Behavioural Therapy for Depression (COBRA): a randomised, controlled, non-inferiority trial. Lancet 2016; 388:871-80. [PMID: 27461440 PMCID: PMC5007415 DOI: 10.1016/s0140-6736(16)31140-0] [Citation(s) in RCA: 301] [Impact Index Per Article: 37.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Depression is a common, debilitating, and costly disorder. Many patients request psychological therapy, but the best-evidenced therapy-cognitive behavioural therapy (CBT)-is complex and costly. A simpler therapy-behavioural activation (BA)-might be as effective and cheaper than is CBT. We aimed to establish the clinical efficacy and cost-effectiveness of BA compared with CBT for adults with depression. METHODS In this randomised, controlled, non-inferiority trial, we recruited adults aged 18 years or older meeting Diagnostic and Statistical Manual of Mental Disorders IV criteria for major depressive disorder from primary care and psychological therapy services in Devon, Durham, and Leeds (UK). We excluded people who were receiving psychological therapy, were alcohol or drug dependent, were acutely suicidal or had attempted suicide in the previous 2 months, or were cognitively impaired, or who had bipolar disorder or psychosis or psychotic symptoms. We randomly assigned participants (1:1) remotely using computer-generated allocation (minimisation used; stratified by depression severity [Patient Health Questionnaire 9 (PHQ-9) score of <19 vs ≥19], antidepressant use, and recruitment site) to BA from junior mental health workers or CBT from psychological therapists. Randomisation done at the Peninsula Clinical Trials Unit was concealed from investigators. Treatment was given open label, but outcome assessors were masked. The primary outcome was depression symptoms according to the PHQ-9 at 12 months. We analysed all those who were randomly allocated and had complete data (modified intention to treat [mITT]) and also all those who were randomly allocated, had complete data, and received at least eight treatment sessions (per protocol [PP]). We analysed safety in the mITT population. The non-inferiority margin was 1·9 PHQ-9 points. This trial is registered with the ISCRTN registry, number ISRCTN27473954. FINDINGS Between Sept 26, 2012, and April 3, 2014, we randomly allocated 221 (50%) participants to BA and 219 (50%) to CBT. 175 (79%) participants were assessable for the primary outcome in the mITT population in the BA group compared with 189 (86%) in the CBT group, whereas 135 (61%) were assessable in the PP population in the BA group compared with 151 (69%) in the CBT group. BA was non-inferior to CBT (mITT: CBT 8·4 PHQ-9 points [SD 7·5], BA 8·4 PHQ-9 points [7·0], mean difference 0·1 PHQ-9 points [95% CI -1·3 to 1·5], p=0·89; PP: CBT 7·9 PHQ-9 points [7·3]; BA 7·8 [6·5], mean difference 0·0 PHQ-9 points [-1·5 to 1·6], p=0·99). Two (1%) non-trial-related deaths (one [1%] multidrug toxicity in the BA group and one [1%] cancer in the CBT group) and 15 depression-related, but not treatment-related, serious adverse events (three in the BA group and 12 in the CBT group) occurred in three [2%] participants in the BA group (two [1%] patients who overdosed and one [1%] who self-harmed) and eight (4%) participants in the CBT group (seven [4%] who overdosed and one [1%] who self-harmed). INTERPRETATION We found that BA, a simpler psychological treatment than CBT, can be delivered by junior mental health workers with less intensive and costly training, with no lesser effect than CBT. Effective psychological therapy for depression can be delivered without the need for costly and highly trained professionals. FUNDING National Institute for Health Research.
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Affiliation(s)
| | - David Ekers
- Psychological Therapy Department, Tees, Esk and Wear Valleys NHS Foundation Trust, Chester-le-Street, County Durham, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, Heslington, York, UK
| | - Rod S Taylor
- Medical School, University of Exeter, Exeter, UK
| | - Sarah Byford
- Institute of Psychiatry, Kings College London, London, UK
| | | | | | | | - Simon Gilbody
- Department of Health Sciences, University of York, Heslington, York, UK
| | - Willem Kuyken
- Department of Psychiatry, University of Oxford, The Prince of Wales International Centre, Warneford Hospital, Oxford, UK
| | | | - Ed R Watkins
- School of Psychology, University of Exeter, Exeter, UK
| | - Kim A Wright
- School of Psychology, University of Exeter, Exeter, UK
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Nigel Reed
- Lived Experience Group, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
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Overend K, Lewis H, Bailey D, Bosanquet K, Chew-Graham C, Ekers D, Gascoyne S, Hems D, Holmes J, Keding A, McMillan D, Meer S, Meredith J, Mitchell N, Nutbrown S, Parrott S, Richards D, Traviss G, Trépel D, Woodhouse R, Gilbody S. Erratum to: CASPER plus (CollAborative care in screen-positive EldeRs with major depressive disorder): study protocol for a randomised controlled trial. Trials 2016; 17:217. [PMID: 27121377 PMCID: PMC4848845 DOI: 10.1186/s13063-016-1361-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/22/2016] [Indexed: 11/10/2022] Open
Affiliation(s)
- Karen Overend
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Helen Lewis
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Della Bailey
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Kate Bosanquet
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Carolyn Chew-Graham
- Research Institute, Primary Care and Health Sciences, Keele University, Keele, ST5 5BG, UK
| | - David Ekers
- Centre for Mental Health Research, University of Durham, Durham, TS17 6BH, UK
| | - Samantha Gascoyne
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Deborah Hems
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - John Holmes
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah, Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Ada Keding
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Shaista Meer
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah, Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Jodi Meredith
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Natasha Mitchell
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Sarah Nutbrown
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Steve Parrott
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - David Richards
- Washington Singer Laboratories, School of Psychology, University of Exeter, Perry Road, Exeter, EX4 4QG, UK
| | - Gemma Traviss
- Leeds Institute of Health Sciences, University of Leeds, Charles Thackrah, Building, 101 Clarendon Road, Leeds, LS2 9LJ, UK
| | - Dominic Trépel
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Rebecca Woodhouse
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree, Building Heslington, York, YO10 5DD, UK.
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Welsh P, Kitchen CEW, Ekers D, Webster L, Tiffin PA. Behavioural activation therapy for adolescents 'at risk' for psychosis? Early Interv Psychiatry 2016; 10:186-8. [PMID: 24958235 DOI: 10.1111/eip.12155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2014] [Accepted: 04/29/2014] [Indexed: 11/30/2022]
Abstract
The following hypothesis explores the possibility of using behavioural activation therapy for adolescents with an at-risk mental state for psychosis. Support is drawn from psychosis-related survey and pilot data as well as a robust evidence base for adult depression. However, we acknowledge that extensive feasibility work is required before exploring this hypothesis further.
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Affiliation(s)
- Patrick Welsh
- School for Medicine, Pharmacy & Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK
| | - Charlotte E W Kitchen
- School for Medicine, Pharmacy & Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK
| | - David Ekers
- School for Medicine, Pharmacy & Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK
| | - Lisa Webster
- School for Medicine, Pharmacy & Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK
| | - Paul A Tiffin
- School for Medicine, Pharmacy & Health, The Wolfson Research Institute, Durham University, Queen's Campus, Stockton-on-Tees, UK
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Bosanquet K, Mitchell N, Gabe R, Lewis H, McMillan D, Ekers D, Bailey D, Gilbody S. Diagnostic accuracy of the Whooley depression tool in older adults in UK primary care. J Affect Disord 2015; 182:39-43. [PMID: 25969415 DOI: 10.1016/j.jad.2015.04.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Accepted: 04/09/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE OF RESEARCH To validate the Whooley questions as a screening tool for depression amongst a population of older adults in UK primary care. OBJECTIVE To assess the diagnostic performance of the Whooley questions as a screening tool for depression amongst older adults in UK primary care. PARTICIPANTS A cross-sectional validation study was conducted with 766 patients aged ≥75 from UK primary care, recruited via 17 general practices based in the North of England during the pilot phase of a randomized controlled trial. MAIN OUTCOME MEASURES Sensitivity, specificity and likelihood ratios comparing the index test (two Whooley questions) with a diagnosis of major depressive disorder (MDD) ascertained by the reference standard Mini International Neuropsychiatric Interview (MINI). RESULTS The two screening questions had a sensitivity of 94.3% (95% confidence interval, 80.8-99.3%) and specificity of 62.7% (95% confidence interval, 59.0-66.2%). The likelihood ratio for a positive test was 2.5 (95% confidence interval, 2.2-2.9) and the likelihood ratio for a negative test was 0.09 (95% confidence interval, 0.02-0.35). CONCLUSION The two Whooley questions missed few cases of depression. However, they were responsible for a high rate of false positives. This creates additional burden on general practitioners, to conduct more detailed investigation on patients who screen positive, but many of whom turn out not to have MDD.
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Affiliation(s)
- Katharine Bosanquet
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK.
| | - Natasha Mitchell
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Rhian Gabe
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Helen Lewis
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Dean McMillan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK; Hull York Medical School, University of York, Heslington, York YO10 5DD, UK
| | - David Ekers
- Mental Health Research Group, University of Durham, Durham TS17 6BH, UK
| | - Della Bailey
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Simon Gilbody
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK; Hull York Medical School, University of York, Heslington, York YO10 5DD, UK
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43
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Overend K, Lewis H, Bailey D, Bosanquet K, Chew-Graham C, Ekers D, Gascoyne S, Hems D, Holmes J, Keding A, McMillan D, Meer S, Meredith J, Mitchell N, Nutbrown S, Parrott S, Richards D, Traviss G, Trépel D, Woodhouse R, Gilbody S. CASPER plus (CollAborative care in Screen-Positive EldeRs with major depressive disorder): study protocol for a randomised controlled trial. Trials 2014; 15:451. [PMID: 25409776 PMCID: PMC4247639 DOI: 10.1186/1745-6215-15-451] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2014] [Accepted: 10/14/2014] [Indexed: 11/25/2022] Open
Abstract
Background Depression accounts for the greatest disease burden of all mental health disorders, contributes heavily to healthcare costs, and by 2020 is set to become the second largest cause of global disability. Although 10% to 16% of people aged 65 years and over are likely to experience depressive symptoms, the condition is under-diagnosed and often inadequately treated in primary care. Later-life depression is associated with chronic illness and disability, cognitive impairment and social isolation. With a progressively ageing population it becomes increasingly important to refine strategies to identity and manage depression in older people. Currently, management may be limited to the prescription of antidepressants where there may be poor concordance; older people may lack awareness of psychosocial interventions and general practitioners may neglect to offer this treatment option. Methods/design CASPER Plus is a multi-centre, randomised controlled trial of a collaborative care intervention for individuals aged 65 years and over experiencing moderate to severe depression. Selected practices in the North of England identify potentially eligible patients and invite them to participate in the study. A diagnostic interview is carried out and participants with major depressive disorder are randomised to either collaborative care or usual care. The recruitment target is 450 participants. The intervention, behavioural activation and medication management in a collaborative care framework, has been adapted to meet the complex needs of older people. It is delivered over eight to 10 weekly sessions by a case manager liaising with general practitioners. The trial aims to evaluate the clinical and cost effectiveness of collaborative care in addition to usual GP care versus usual GP care alone. The primary clinical outcome, depression severity, will be measured with the Patient Health Questionnaire-9 (PHQ-9) at baseline, 4, 12 and 18 months. Cost effectiveness analysis will assess health-related quality of life using the SF-12 and EQ-5D and will examine cost-consequences of collaborative care. A qualitative process evaluation will be undertaken to explore acceptability, gauge the extent to which the intervention is implemented and to explore sustainability beyond the clinical trial. Discussion Results will add to existing evidence and a positive outcome may lead to the commissioning of this model of service in primary care. Trial registration ISRCTN45842879 (24 July 2012).
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Simon Gilbody
- Department of Health Sciences, University of York, Seebohm Rowntree, Building, Heslington, York YO10 5DD, UK.
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Ekers D, Webster L, Van Straten A, Cuijpers P, Richards D, Gilbody S. Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PLoS One 2014; 9:e100100. [PMID: 24936656 PMCID: PMC4061095 DOI: 10.1371/journal.pone.0100100] [Citation(s) in RCA: 303] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2014] [Accepted: 05/22/2014] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Depression is a common, disabling condition for which psychological treatments are recommended. Behavioural activation has attracted increased interest in recent years. It has been over 5 years since our meta-analyses summarised the evidence supporting and this systematic review updates those findings and examines moderators of treatment effect. METHOD Randomised trials of behavioural activation for depression versus controls or anti-depressant medication were identified using electronic database searches, previous reviews and reference lists. Data on symptom level and study level moderators were extracted and analysed using meta-analysis, sub-group analysis and meta-regression respectively. RESULTS Twenty six randomised controlled trials including 1524 subjects were included in this meta-analysis. A random effects meta-analysis of symptom level post treatment showed behavioural activation to be superior to controls (SMD -0.74 CI -0.91 to -0.56, k = 25, N = 1088) and medication (SMD -0.42 CI -0.83 to-0.00, k = 4, N = 283). Study quality was low in the majority of studies and follow- up time periods short. There was no indication of publication bias and subgroup analysis showed limited association between moderators and effect size. CONCLUSIONS The results in this meta-analysis support and strengthen the evidence base indicating Behavioural Activation is an effective treatment for depression. Further high quality research with longer term follow-up is needed to strengthen the evidence base.
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Affiliation(s)
- David Ekers
- Durham University/Tees Esk and Wear Valleys NHS Foundation Trust, Department of Medicine, Pharmacy & Health, Durham University, Stockton on Tees, United Kingdom
| | - Lisa Webster
- Department of Medicine, Pharmacy & Health, Durham University, Stockton on Tees, United Kingdom
| | - Annemieke Van Straten
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Amsterdam, The Netherlands
| | - David Richards
- School of Medicine, University of Exeter, Exeter, United Kingdom
| | - Simon Gilbody
- Hull York Medical School and Department of Health Sciences, University of York, York, United Kingdom
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Rhodes S, Richards DA, Ekers D, McMillan D, Byford S, Farrand PA, Gilbody S, Hollon SD, Kuyken W, Martell C, O’Mahen HA, O’Neill E, Reed N, Taylor RS, Watkins ER, Wright KA. Cost and outcome of behavioural activation versus cognitive behaviour therapy for depression (COBRA): study protocol for a randomised controlled trial. Trials 2014; 15:29. [PMID: 24447460 PMCID: PMC3903024 DOI: 10.1186/1745-6215-15-29] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/08/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. METHODS/DESIGN COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. DISCUSSION The clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN27473954.
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Affiliation(s)
- Shelley Rhodes
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2 LU, UK
| | - David A Richards
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2 LU, UK
| | - David Ekers
- Durham University/Tees Esk and Wear Valleys NHS Foundation Trust, Wolfson Research Institute for Health and Wellbeing, Durham University, Queen’s Campus, University Boulevard, Stockton on Tees, Durham TS17 6BH, UK
| | - Dean McMillan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Sarah Byford
- Institute of Psychiatry, Kings College London, De Crespigny Park, London SE5 8AF, UK
| | - Paul A Farrand
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Simon Gilbody
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Steven D Hollon
- Department of Psychology, 306 Wilson Hall, 21st Avenue South, Vanderbilt University, 2301 Vanderbilt Place, Nashville, TN 37240-7817, USA
| | - Willem Kuyken
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Christopher Martell
- Department of Psychology, University of Wisconsin, Milwaukee, P.O. Box 413, Milwaukee WI 53201, USA
| | - Heather A O’Mahen
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Emer O’Neill
- Depression Alliance, 20 Great Dover Street, London SE1 4LX, UK
| | - Nigel Reed
- Lived Experience Group, c/o School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Rod S Taylor
- University of Exeter Medical School, The Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, UK
| | - Ed R Watkins
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Kim A Wright
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
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Murphy R, Ekers D, Webster L. An update to depression case management by practice nurses in primary care: a service evaluation. J Psychiatr Ment Health Nurs 2014; 21:827-33. [PMID: 24673912 DOI: 10.1111/jpm.12153] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/20/2014] [Indexed: 11/28/2022]
Abstract
There is a recognized need to enhance non-pharmaceutical interventions in a way that is more accessible to the primary care population. Collaborative care has been shown to have a positive impact upon depression symptoms and a core element of the collaborative care approach is the case manager. This paper is a service evaluation of a collaborative care intervention that uses primary care nurses as the depression case manager and is a follow-up to the service audit carried out by Ekers and Wilson. The results support the notion that primary care nurses are ideally placed for delivering care to depressed patients; especially in cases were a patient also has a comorbid long-term medical condition. There is a recognized need to enhance non-pharmaceutical interventions for depression in the primary care. This service evaluation of collaborative care for depression by primary care practice nurses is an update of Ekers and Wilson (2008), reporting outcomes 5 years following initial training. From an initial 13 trained practice nurses, three provided anonymized data. Mean post-treatment Patient Health Questionnaire-9 (PHQ9) score was 8 [standard deviation (SD) 6.53, n = 185], indicating a mean positive change in depression symptom level of 8.9 [SD 7.01, 95% confidence interval (CI) 7.89-9.93, P < 0.001]. Subgroup analysis for patients identified with a comorbid long-term conditions (LTC) mean post-treatment PHQ9 score was 9 (SD 7.72, n = 33), indicating a mean positive change in depression symptom level of 8.1 (SD 5.79, 95% CI 6.04-10.41, P < 0.001). Nurses provided feedback on the intervention showing potential areas that would benefit from further detailed qualitative review. It was concluded that primary care practice nurses would be ideally placed to deliver collaborative care to depression patients with comorbid LTCs.
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Affiliation(s)
- R Murphy
- School of Medicine Pharmacy & Health, University of Durham/Tees Esk and Wear Valleys NHS Foundation Trust, Durham, UK
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47
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Ekers D, Murphy R, Archer J, Ebenezer C, Kemp D, Gilbody S. Nurse-delivered collaborative care for depression and long-term physical conditions: a systematic review and meta-analysis. J Affect Disord 2013; 149:14-22. [PMID: 23545062 DOI: 10.1016/j.jad.2013.02.032] [Citation(s) in RCA: 74] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2012] [Revised: 02/21/2013] [Accepted: 02/23/2013] [Indexed: 01/22/2023]
Abstract
BACKGROUND Depression will be the second largest cause of disease burden by 2020. It is commonly associated with long term physical health conditions resulting in worsened clinical outcome and increased costs. Nurses would appear ideally placed to facilitate depression management in those people with long term health problems within health care clinics. This article reviews the evidence to support such a clinical approach. METHOD A systematic review and meta-analysis of randomised trials of nurse led management of depression in patients with long term health problems. Databases were searched between December 2011 and May 2012, data were extracted and analysed using Comprehensive Meta Analysis software. Subgroup analysis and meta-regression were used to explore the impact of study level moderators of effect. RESULTS Nurse delivered collaborative care was compared to usual care in 14 studies including 4440 participants. The mean effect size at follow-up was d=0.43 95% CI 0.34 to 0.52 p<0.001 NNT 4.23, representing a moderate impact on depression severity. Results were consistent across studies and maintained at longer term follow up. LIMITATIONS Data were only available on depression outcomes and with most studies being USA based generalizability is somewhat limited. To date only one study reported cost effectiveness outcomes. CONCLUSIONS Based upon the research literature nurse led depression management provides effective treatment across a range of long term health conditions. Nurses are ideally placed to deliver such interventions and further research is required to examine the cost utility of the approach and its durability outside of the USA.
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Affiliation(s)
- David Ekers
- Wolfson Research Institute, School of Medicine, Pharmacy and Health, Durham University/Tees Esk and Wear Valleys NHS Foundation Trust, United Kingdom.
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Abstract
Depression is one of the most prevalent health disorders globally and causes significant distress and cost to the sufferer and society. Psychological therapy for depression has been recommended over a number of decades; however, access to these treatments remains limited. Cognitive behaviour therapy, behavioural activation, self-help approaches, interpersonal therapy and non-directive therapy all demonstrate moderate to large effect sizes when compared to treatment as usual. Differences between psychological interventions however are small and unstable when reviewed in meta-analyses suggesting that for most people adding complexity to treatment does not result in improved outcomes. Stepped care is one system used to organise delivery of psychological therapy that stratifies interventions across several levels of symptom severity. There is debate regarding the ideal design and operation of this complex system resulting in considerable variability in its use in clinical settings. Further research is needed to identify the most cost effective approach to the delivery of psychological therapies for depression as we need to continue to reduce the gap between demand and access to therapy.
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Affiliation(s)
- David Ekers
- Senior Clinical Lecturer in Psychological Therapy Research, Wolfson Research Institute, Durham University; and Tees Esk & Wear Valleys NHS Foundation Trust, UK
| | - Lisa Webster
- Post Doctoral Research Associate, Wolfson Research Institute, Durham University, UK
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49
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Abstract
Behavioural activation by non-specialists appears effective in the treatment of depression. We examined incremental cost-effectiveness of behavioural activation (n = 24) v. treatment as usual (n = 23) in a randomised controlled trial. Intention-to-treat analyses indicated a quality-adjusted life-year (QALY) difference in favour of behavioural activation of 0.20 (95% CI 0.01-0.39, P = 0.042), incremental cost-effectiveness ratio of £5756 per QALY and a 97% probability that behavioural activation is more cost-effective at a threshold value of £20,000. Results are promising for dissemination of behavioural activation but require replication in a larger study.
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Affiliation(s)
- David Ekers
- Tees Esk and Wear Valleys NHS Foundation Trust/Mental Health Research Centre, Durham University, Durham, UK.
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50
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Mitchell N, Hewitt C, Adamson J, Parrott S, Torgerson D, Ekers D, Holmes J, Lester H, McMillan D, Richards D, Spilsbury K, Godfrey C, Gilbody S. A randomised evaluation of CollAborative care and active surveillance for Screen-Positive EldeRs with sub-threshold depression (CASPER): study protocol for a randomized controlled trial. Trials 2011; 12:225. [PMID: 21988800 PMCID: PMC3204244 DOI: 10.1186/1745-6215-12-225] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2011] [Accepted: 10/11/2011] [Indexed: 11/16/2022] Open
Abstract
Background Depression accounts for the greatest burden of disease among all mental health problems, and is expected to become the second-highest amongst all general health problems by 2020. By the age of 75, 1 in 7 older people meet formal diagnostic criteria for depression. Efforts to ameliorate the burden of illness and personal suffering associated with depression in older people have focussed on those with more severe depressive syndromes. Less attention has been paid to those with mild disorders/sub-threshold depressive syndromes but these patients also suffer impairments in their quality of life and level of functioning. Methods/Design The CASPER study has been designed to assemble an epidemiological cohort of people over 75 years of age (the CASPER cohort), from which we will identify those eligible to participate in a trial of collaborative care for sub-threshold depression (the CASPER trial). We aim to undertake a pragmatic randomised controlled multi-centre trial evaluating the effectiveness and cost-effectiveness of collaborative care; a low intensity psychological intervention in addition to usual general practitioner care versus usual general practitioner care alone. General practitioners from practices based in the North of England will be asked to identify potentially eligible patients over the age of 75 years. Patients will be sent a letter inviting them to participate in the study. We aim to recruit approximately 540 participants for the CASPER trial. A diagnostic interview will be carried out to ascertain trial eligibility with the major depressive episode module of the Mini International Neuropsychiatric Interview (M.I.N.I.), eligible participants randomised to either the intervention or usual care. The primary outcome will be measured with the Patient Health Questionnaire-9 (PHQ-9) and additional quality of life measures will be collected. Data will be collected at baseline, 4 and 12 months for both trial and cohort participants. Trial Registration ISRCTN: ISRCTN02202951
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Affiliation(s)
- Natasha Mitchell
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York, YO10 5DD, UK
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