Internationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) ...service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites.
We used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014–15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014–15 and 2015–16.
Five service organisation features predicted clinical outcomes in 2014–15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11–42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors.
Traditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes.
Wellcome Trust.
Social anxiety disorder—a chronic and naturally unremitting disease that causes substantial impairment—can be treated with pharmacological, psychological, and self-help interventions. We aimed to ...compare these interventions and to identify which are most effective for the acute treatment of social anxiety disorder in adults.
We did a systematic review and network meta-analysis of interventions for adults with social anxiety disorder, identified from published and unpublished sources between 1988 and Sept 13, 2013. We analysed interventions by class and individually. Outcomes were validated measures of social anxiety, reported as standardised mean differences (SMDs) compared with a waitlist reference. This study is registered with PROSPERO, number CRD42012003146.
We included 101 trials (13 164 participants) of 41 interventions or control conditions (17 classes) in the analyses. Classes of pharmacological interventions that had greater effects on outcomes compared with waitlist were monoamine oxidase inhibitors (SMD −1·01, 95% credible interval CrI −1·56 to −0·45), benzodiazepines (−0·96, −1·56 to −0·36), selective serotonin-reuptake inhibitors and serotonin–norepinephrine reuptake inhibitors (SSRIs and SNRIs; −0·91, −1·23 to −0·60), and anticonvulsants (−0·81, −1·36 to −0·28). Compared with waitlist, efficacious classes of psychological interventions were individual cognitive–behavioural therapy (CBT; SMD −1·19, 95% CrI −1·56 to −0·81), group CBT (−0·92, −1·33 to −0·51), exposure and social skills (−0·86, −1·42 to −0·29), self-help with support (−0·86, −1·36 to −0·36), self-help without support (−0·75, −1·25 to −0·26), and psychodynamic psychotherapy (−0·62, −0·93 to −0·31). Individual CBT compared with psychological placebo (SMD −0·56, 95% CrI −1·00 to −0·11), and SSRIs and SNRIs compared with pill placebo (−0·44, −0·67 to −0·22) were the only classes of interventions that had greater effects on outcomes than appropriate placebo. Individual CBT also had a greater effect than psychodynamic psychotherapy (SMD −0·56, 95% CrI −1·03 to −0·11) and interpersonal psychotherapy, mindfulness, and supportive therapy (−0·82, −1·41 to −0·24).
Individual CBT (which other studies have shown to have a lower risk of side-effects than pharmacotherapy) is associated with large effect sizes. Thus, it should be regarded as the best intervention for the initial treatment of social anxiety disorder. For individuals who decline psychological intervention, SSRIs show the most consistent evidence of benefit.
National Institute for Health and Care Excellence.
Over the last two decades, treatment guidelines have become major aids in the delivery of evidence‐based care and improvement of clinical outcomes. The International Society for Traumatic Stress ...Studies (ISTSS) produced the first guidelines for the prevention and treatment of posttraumatic stress disorder (PTSD) in 2000 and published its latest recommendations, along with position papers on complex PTSD (CPTSD), in November 2018. A rigorous methodology was developed and followed; scoping questions were posed, systematic reviews were undertaken, and 361 randomized controlled trials were included according to the a priori agreed inclusion criteria. In total, 208 meta‐analyses were conducted and used to generate 125 recommendations (101 for adults and 24 for children and adolescents) for specific prevention and treatment interventions, using an agreed definition of clinical importance and recommendation setting algorithm. There were eight strong, eight standard, five low effect, 26 emerging evidence, and 78 insufficient evidence to recommend recommendations. The inclusion of separate scoping questions on treatments for complex presentations of PTSD was considered but decided against due to definitional issues and the virtual absence of studies specifically designed to clearly answer possible scoping questions in this area. Narrative reviews were undertaken and position papers prepared (one for adults and one for children and adolescents) to consider the current issues around CPTSD and make recommendations to facilitate further research. This paper describes the methodology and results of the ISTSS Guideline process and considers the interpretation and implementation of the recommendations.
Resumen
Spanish s by Asociación Chilena de Estrés Traumático (ACET)
Nuevas guías para la prevención y el tratamiento del trastorno de estrés postraumático de la Sociedad Internacional de Estudios de Estrés Traumático: metodología y proceso de desarrollo
GUIAS DE LA ISTSS PARA EL TEPT
En las últimas dos décadas, las guías de tratamiento se han convertido en una ayuda importante para la prestación de atención basada en la evidencia y la mejora de los resultados clínicos. La Sociedad Internacional de Estudios de Estrés Traumático (ISTSS en sus siglas en inglés) produjo las primeras guías para la prevención y tratamiento del trastorno de estrés postraumático (TEPT) en 2000 y publicó sus últimas recomendaciones, junto con los documentos de posición sobre el TEPT complejo (TEPT‐C), en noviembre de 2018. Se desarrolló y siguió una metodología rigurosa; se plantearon preguntas de alcance, se realizaron revisiones sistemáticas y se incluyeron 361 ensayos controlados aleatorizados de acuerdo con los criterios de inclusión acordados a priori. En total, se realizaron 208 metanálisis y fueron utilizados para generar 125 recomendaciones (101 para adultos y 24 para niños y adolescentes) para intervenciones específicas de prevención y tratamiento, utilizando una definición acordada de la importancia clínica y un algoritmo de configuración de recomendaciones. Hubo ocho estudios con pruebas sólidas, ocho como estándar, cinco con bajo efecto, 26 con evidencia emergente y 78 fueron evaluados como con evidencia insuficiente para ser recomendados en las recomendaciones. Se consideró la inclusión de preguntas de alcance separadas sobre tratamientos para presentaciones complejas de TEPT, pero se decidió en contra debido a cuestiones de definición y ausencia virtual de estudios diseñados específicamente para responder con claridad las posibles preguntas de alcance en esta área. Se realizaron revisiones narrativas y se prepararon documentos de posición (uno para adultos y otro para niños y adolescentes) para considerar los problemas actuales en torno al TEPT‐C y hacer recomendaciones para facilitar la investigación adicional. Este documento describe la metodología y los resultados del proceso de la Guía de la ISTSS y considera la interpretación y la implementación de las recomendaciones.
抽象
Traditional and Simplified Chinese s by the Asian Society for Traumatic Stress Studies (AsianSTSS)
簡體及繁體中文撮要由亞洲創傷心理研究學會翻譯
The International Society for Traumatic Stress Studies New Guidelines for the Prevention and Treatment of PTSD: Methodology and Development Process
Traditional Chinese
標題: 國際創傷壓力研究協會就PTSD預防和治療提供的新指引:方法學與發展過程
撮要: 過去二十年來, 治療指引成為了提供實證為本治療和改善臨床療效的主要輔助工具。國際創傷壓力研究協會(ISTSS)於2000年推出了首個創傷後壓力症(PTSD)預防和治療指引, 並於2018年11月發表最新的建議, 及對於複雜性PTSD (CPTSD)的意見書。過程中發展出嚴謹的方法學、基於觀察提出問題, 並作出了系統性審核。我們基於先驗地同意的包含準則, 找出361項隨機對照試驗;共進行了208項元分析, 採用對臨床重要性一致同意的定義, 以及一致同意產生建議的演算法, 從而得出125項特殊的預防建議及干預治療建議(101 項關於成人;24 項關於兒童及青少年)。讓我們作出建議的試驗研究當中, 8個具有力證據、8個為標準、5個低效、26個有新證據、78個證據不足。我們曾考慮包含對PTSD複雜情況的個別治療觀察問題, 但因為在定義方面仍存有問題, 而且欠缺能清楚解答那些潛在觀察問題的實質研究, 所以最後取消該考慮。我們亦進行了敘述評估, 及就當前有關CPTSD的疑問撰寫意見書(一份關於成人, 一份關於兒童及青少年), 並對未來研究作出建議。本文描述ISTSS提供指引過程的方法學和結果, 並探討建議的詮釋和運用。
Simplified Chinese
标题: 国际创伤压力研究协会就PTSD预防和治疗提供的新指引:方法学与发展过程
撮要: 过去二十年来, 治疗指引成为了提供实证为本治疗和改善临床疗效的主要辅助工具。国际创伤压力研究协会(ISTSS)于2000年推出了首个创伤后压力症(PTSD)预防和治疗指引, 并于2018年11月发表最新的建议, 及对于复杂性PTSD (CPTSD)的意见书。过程中发展出严谨的方法学、基于观察提出问题, 并作出了系统性审核。我们基于先验地同意的包含准则, 找出361项随机对照试验;共进行了208项元分析, 采用对临床重要性一致同意的定义, 以及一致同意产生建议的算法, 从而得出125项特殊的预防建议及干预治疗建议(101 项关于成人;24 项关于儿童及青少年)。让我们作出建议的试验研究当中, 8个具有力证据、8个为标准、5个低效、26个有新证据、78个证据不足。我们曾考虑包含对PTSD复杂情况的个别治疗观察问题, 但因为在定义方面仍存有问题, 而且欠缺能清楚解答那些潜在观察问题的实质研究, 所以最后取消该考虑。我们亦进行了叙述评估, 及就当前有关CPTSD的疑问撰写意见书(一份关于成人, 一份关于儿童及青少年), 并对未来研究作出建议。本文描述ISTSS提供指引过程的方法学和结果, 并探讨建议的诠释和运用。
Post-traumatic stress disorder (PTSD) is a severe and disabling condition that may lead to functional impairment and reduced productivity. Psychological interventions have been shown to be effective ...in its management. The objective of this study was to assess the cost-effectiveness of a range of interventions for adults with PTSD.
A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of 10 interventions and no treatment for adults with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion.
Eye movement desensitisation and reprocessing (EMDR) appeared to be the most cost-effective intervention for adults with PTSD (with a probability of 0.34 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, selective serotonin reuptake inhibitors (SSRIs), trauma-focused cognitive behavioural therapy (TF-CBT), self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appeared to be less cost-effective than no treatment. TF-CBT had the largest evidence base.
A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD.
The characteristics of Emergency Department (ED) attendances due to mental or behavioural health disorders need to be described to enable appropriate development of services. We aimed to describe the ...epidemiology of mental health-related ED attendances within health care systems free at the point of access, including clinical reason for presentation, previous service use, and patient sociodemographic characteristics.
Systematic review and meta-analysis of observational studies describing ED attendances by patients with common mental health conditions.
18 studies from seven countries met eligibility criteria. Patients attending due to mental or behavioural health disorders accounted for 4% of ED attendances; a third were due to self-harm or suicidal ideation. 58.1% of attendees had a history of psychiatric illness and up to 58% were admitted. The majority of studies were single site and of low quality so results must be interpreted cautiously.
Prevalence studies of mental health-related ED attendances are required to enable the development of services to meet specific needs.
Purpose
Pregnancy and the first postnatal year can be a difficult and distressing period for women with mental health problems, particularly if they are not able to access appropriate and timely ...assessment and treatment. The aim of this systematic review was to synthesise qualitative evidence on experiences of care for women with (or at risk of developing) antenatal or postnatal mental health problems across a range of disorders (including non-psychotic mental disorders).
Methods
Six electronic databases were searched for papers published from 2000 to April 2014. Thirty-nine studies were identified that met the inclusion criteria. Findings were synthesised using secondary framework and thematic analysis approaches.
Results
Seven key themes were identified across mental disorder groups: an unmet need for collaborative and integrated care; stigma and fears about loss of custody; healthcare professionals unable or unwilling to address psychological needs; focus on babies over mothers; importance of non-judgemental and compassionate support; an unmet need for information; importance of service user involvement in treatment decisions.
Conclusions
Women’s experience of accessing and engaging with care for mental health problems could be improved if given the opportunity to develop trusting relationships with healthcare professionals who acknowledge and reinforce the woman’s role in caring for her baby in a non-judgemental and compassionate manner, and foster hope and optimism about treatment. Information for women, their families and healthcare professionals, and the provision of individualised care and treatment, are also crucial to enable full implementation of a person-centred programme of care.
Standard depression treatments, including antidepressant medication and cognitive behavioural therapy (CBT), are ineffective for many patients. Prefrontal transcranial direct current stimulation ...(tDCS) has been proposed as an alternative treatment, but has shown inconsistent efficacy for depression, and its mechanisms are poorly understood. We recruited unmedicated patients with major depressive disorder (N = 71 approached; N = 39 randomised) for a mechanistic, double-blind, randomized controlled trial consisting of eight weekly sessions of prefrontal tDCS administered to the left prefrontal cortex prior to CBT. We probed (1) whether tDCS improved the efficacy of CBT relative to sham stimulation; and (2) whether neural measures predicted clinical response. We found a modest and non-significant effect of tDCS on clinical outcome over and above CBT (active: 50%; sham: 31.6%; odds ratio: 2.16, 95% CI = 0.59-7.99), but a strong relationship, predicted a priori, between baseline activation during a working memory task in the stimulated prefrontal region and symptom improvement. Repeating our analyses of symptom outcome splitting the sample according to this biomarker revealed that tDCS was significantly superior to sham in individuals with high left prefrontal cortex activation at baseline; we also show 86% accuracy in predicting clinical response using this measure. Exploratory analyses revealed several other regions where activation at baseline was associated with subsequent response to CBT, irrespective of tDCS. This mechanistic trial revealed variable, but predictable, clinical effects of prefrontal tDCS combined with CBT for depression. We have discovered a potential explanation for this variability: individual differences in baseline activation of the region stimulated. Such a biomarker could potentially be used to pre-select patients for trials and, eventually, in the clinic.
Over 600 RCTs have demonstrated the effectiveness of psychosocial interventions for children and young people's mental health, but little is known about the long-term outcomes. This systematic review ...sought to establish whether the effects of selective and indicated interventions were sustained at 12 months.
We conducted a systematic review and meta-analysis focusing on studies reporting medium term outcomes (12 months after end of intervention).
We identified 138 trials with 12-month follow-up data, yielding 165 comparisons, 99 of which also reported outcomes at end of intervention, yielding 117 comparisons. We found evidence of effect relative to control at end of intervention (K = 115, g = 0.39; 95% CI: 0.30-0.47 I2 = 84.19%, N = 13,982) which was maintained at 12 months (K = 165, g = 0.31, CI: 0.25-0.37, I2 = 77.35%, N = 25,652) across a range of diagnostic groups. We explored the impact of potential moderators on outcome, including modality, format and intensity of intervention, selective or indicated intervention, site of delivery, professional/para-professional and fidelity of delivery. We assessed both risk of study bias and publication bias.
Psychosocial interventions provided in a range of settings by professionals and paraprofessionals can deliver lasting benefits. High levels of heterogeneity, moderate to high risk of bias for most studies and evidence of publication bias require caution in interpreting the results. Lack of studies in diagnostic groups such as ADHD and self-harm limit the conclusions that can be drawn. Programmes that increase such interventions' availability are justified by the benefits to children and young people and the decreased likelihood of disorder in adulthood.
Open dialogue (OD) is a multi-component therapeutic and organizational intervention for crisis and continuing community mental health care with a therapeutic focus on clients' social networks. The ...development and implementation of this model of care in the United Kingdom requires considerable contextual adaptations which need to be assessed to support effective implementation. Program fidelity-the extent to which core components of an intervention are delivered as intended by an intervention protocol at all levels-is crucial for these adaptations.
To develop, pilot, and implement a program fidelity measure for community mental health services providing OD and 'treatment as usual' (TAU) or standard NHS crisis and community care.
Measure structure, content, and scoring were developed and refined through an iterative process of discussion between the research team and OD experts. Measure was piloted in the 6 OD and 6 TAU services participating in a large-scale research program.
Initial data suggests that the Community Mental Health Team Fidelity Scale (COM-FIDE) is a potentially reliable and feasible measure of the fidelity of community mental health services and specific OD components of such services.
IntroductionShared decision making (SDM) has been advocated as a key component of person-centred care and recovery from mental illness. Although the principles of SDM have been well documented, there ...is a lack of guidance about how to accomplish SDM in mental healthcare. The objective of the present protocol is to describe the methods for an umbrella review to determine the effectiveness elements of SDM interventions for persons diagnosed with a mental illness. An umbrella review’s key characteristic is that it only considers for inclusion the highest level of evidence, namely other systematic reviews and meta-analyses.Methods and AnalysisElectronic searches will be performed in CINAHL, PubMed, Scopus, Ovid MEDLINE, Ovid EMBASE, Ovid Cochrane Library, Web of Science, Scopus and Ovid PsycINFO. Based on Joanna Briggs Institute recommended guidelines, review articles will be included if they were published between 2010 and 2021. This approach will help identify current and emerging evidence-based treatment options in mental illness. Included articles will be assessed for quality using Assessment of Multiple Systematic Reviews 2 tool and ratings of the quality of evidence in each review. Presentation of results will align with guidelines in the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 statement. Findings will be stratified by mode of intervention and implementation characteristics and will inform development of SDM taxonomy in mental healthcare.Ethics and disseminationThis umbrella review will focus on the analysis of secondary data and does not require ethics approval. Findings will be disseminated widely to clinicians, researchers and services users via journal publication, conference presentations and social media. The results will contribute to the conceptualisation and understanding of effective SDM interventions in mental healthcare and to improving the quality of SDM for individuals with a mental illness.PROSPERO registration numberCRD42020190700.
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