Psychological Therapies Service Research Articles

Therapists' experience of working with refugees and asylum seekers who have been tortured: An interpretative phenomenological analysis.

The novel concept of "the trauma therapists" journey' during their work with formerly tortured refugees and asylum seekers is introduced, mapped, and explicated for a convenience sample of 10 psychological therapists/practitioners who work in the United Kingdom. This study operationalized semistructured interviews that were focused on therapists' experiences of providing trauma psychotherapy to sanctuary seekers who presented to a range of psychological therapy services. The methods of interpretative phenomenological analysis were deemed appropriate for use to explore their experiences, thoughts, and feelings. Four superordinate themes were conceptualized, namely: (a) questioning self-preparedness, (b) the challenge of trauma wrapped in complexity, (c) psychological flexibility that arises from the therapist's role and internal conflict, and (d) personal impact. The empirical findings suggest that therapists who work with sanctuary seekers who have been tortured encounter a complex range of experiences. These include frequently finding themselves engaged in activities that go beyond and are in conflict with their expectations of their professional role, and, in many cases, this engagement results in vicarious trauma and burnout. All practitioners communicated in some detail how their work with sanctuary seekers, who had experienced torture and presented with trauma, affected them to varying degrees. The research has led to recommendations, which include the prioritization of self-care, multicultural competencies, continual development, and ensuring the availability of appropriate professional supervision support as part of ethical trauma practice. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Predicting post-treatment symptom severity for adults receiving psychological therapy in routine care for generalised anxiety disorder: a machine learning approach

Approximately half of generalised anxiety disorder (GAD) patients do not recover from first-line treatments, and no validated prediction models exist to inform individuals or clinicians of potential treatment benefits. This study aimed to develop and validate an accurate and explainable prediction model of post-treatment GAD symptom severity. Data from adults receiving treatment for GAD in eight Improving Access to Psychological Therapies (IAPT) services (n=15,859) were separated into training, validation and holdout datasets. Thirteen machine learning algorithms were compared using 10-fold cross-validation, against two simple clinically relevant comparison models. The best-performing model was tested on the holdout dataset and model-specific explainability measures identified the most important predictors. A Bayesian Additive Regression Trees model out-performed all comparison models (MSE=16.54[95%CI=15.58;17.51]; MAE=3.19; R²=0.33, including single predictor linear regression: MSE=20.70[95%CI=19.58;21.82]; MAE=3.94; R²=0.14). The five most important predictors were: PHQ-9 anhedonia, GAD-7 annoyance/irritability, restlessness and fear items, then the referral-assessment waiting time. The best-performing model accurately predicted post-treatment GAD severity using only pre-treatment data, outperforming comparison models that approximated clinical judgement and remaining within the GAD-7 error of measurement and minimal clinically important differences. This model could inform treatment decision-making and provide desired information to clinicians and patients receiving treatment for GAD.

The perceived helpfulness and acceptability of a bespoke psychological therapy service for registered nurses experiencing psychological distress: A qualitative study.

To understand the perceived helpfulness and acceptability of a bespoke psychological therapy service for registered nurses. The service provided a free and confidential specialist mental health service to all healthcare professionals, including nurses and nursing students. An exploratory study using a descriptive qualitative approach. A purposive sample of 20 registered nurses accessing a bespoke psychological therapy service in Wales participated in audio-recorded semi-structured interviews in January 2022. Transcribed data were analysed using reflexive thematic analysis. Four interrelated themes were identified from the data analysis: COVID [SARS-CoV-2] changed things; You're a nurse, you're human; I've got 'me' back; and pretty close to miracle workers. Participants attempted to live up to an idealized image of a nurse, generating self-stigmatizing beliefs that negatively affected their mental health. The psychological therapy service enabled participants to put their roles into perspective, that is, separate themselves from their role, be vulnerable, and develop confidence and adaptive coping strategies. Participants valued the minimal barriers and ease of access to support. The complex relationship between nurse identity and the challenges of the workplace needs to be central to nurse education. Nurses can benefit from rapid access to a timely, confidential, and independent self-referring psychological therapy service. This qualitative study explored the helpfulness and accessibility of psychological support for nurses. The main themes were that COVID changed things; You're a nurse, you're human; I've got 'me' back; and pretty close to miracle workers. The findings will impact how nurses are supported in the United Kingdom and worldwide. This report adheres to the standards for reporting qualitative research (SRQR). No patient or public contribution.

Predictors of primary care psychological therapy outcomes for depression and anxiety in people living with dementia: evidence from national healthcare records in England.

Psychological therapies can be effective in reducing symptoms of depression and anxiety in people living with dementia (PLWD). However, factors associated with better therapy outcomes in PLWD are currently unknown. To investigate whether dementia-specific and non-dementia-specific factors are associated with therapy outcomes in PLWD. National linked healthcare records were used to identify 1522 PLWD who attended psychological therapy services across England. Associations between various factors and therapy outcomes were explored. People with frontotemporal dementia were more likely to experience reliable deterioration in depression/anxiety symptoms compared with people with vascular dementia (odds ratio 2.98, 95% CI 1.08-8.22; P = 0.03) or Alzheimer's disease (odds ratio 2.95, 95% CI 1.15-7.55; P = 0.03). Greater depression severity (reliable recovery: odds ratio 0.95, 95% CI 0.92-0.98, P < 0.001; reliable deterioration: odds ratio 1.73, 95% CI 1.04-2.90, P = 0.04), lower work and social functioning (recovery: odds ratio 0.98, 95% CI 0.96-0.99, P = 0.002), psychotropic medication use (recovery: odds ratio 0.67, 95% CI 0.51-0.90, P = 0.01), being of working age (recovery: odds ratio 2.03, 95% CI 1.10-3.73, P = 0.02) and fewer therapy sessions (recovery: odds ratio 1.12, 95% CI 1.09-1.16, P < 0.001) were associated with worse therapy outcomes in PLWD. Dementia type was generally not associated with outcomes, whereas clinical factors were consistent with those identified for the general population. Additional support and adaptations may be required to improve therapy outcomes in PLWD, particularly in those who are younger and have more severe depression.

Cognitive behavioural therapy treatment for a fear of hypoglycaemia within a primary care psychological therapy service: a case study

AbstractMany individuals with type 1 diabetes (T1D) experience a fear of hypoglycaemia (FOH) which can have detrimental consequences on management of blood glucose (BG) levels and quality of life. A cognitive behavioural therapy (CBT) graded exposure approach has been recommended to treat FOH. The purpose of this case study is to examine the effectiveness of CBT in treating FOH within the context of a primary care psychological therapy service. It was found that CBT treatment led to: a reduction in threat beliefs related to FOH; lower BG levels; and reduced levels of depression and anxiety. Clinical implications are discussed for treating FOH within primary care. Copyright © 2024 John Wiley &amp; Sons.

Use and Engagement With Low-Intensity Cognitive Behavioral Therapy Techniques Used Within an App to Support Worry Management: Content Analysis of Log Data.

Low-intensity cognitive behavioral therapy (LICBT) has been implemented by the Improving Access to Psychological Therapies services across England to manage excessive worry associated with generalized anxiety disorder and support emotional well-being. However, barriers to access limit scalability. A solution has been to incorporate LICBT techniques derived from an evidence-based protocol within the Iona Mind Well-being app for Worry management (IMWW) with support provided through an algorithmically driven conversational agent. This study aims to examine engagement with a mobile phone app to support worry management with specific attention directed toward interaction with specific LICBT techniques and examine the potential to reduce symptoms of anxiety. Log data were examined with respect to a sample of "engaged" users who had completed at least 1 lesson related to the Worry Time and Problem Solving in-app modules that represented the "minimum dose." Paired sample 2-tailed t tests were undertaken to examine the potential for IMWW to reduce worry and anxiety, with multivariate linear regressions examining the extent to which completion of each of the techniques led to reductions in worry and anxiety. There was good engagement with the range of specific LICBT techniques included within IMWW. The vast majority of engaged users were able to interact with the cognitive behavioral therapy model and successfully record types of worry. When working through Problem Solving, the conversational agent was successfully used to support the user with lower levels of engagement. Several users engaged with Worry Time outside of the app. Forgetting to use the app was the most common reason for lack of engagement, with features of the app such as completion of routine outcome measures and weekly reflections having lower levels of engagement. Despite difficulties in the collection of end point data, there was a significant reduction in severity for both anxiety (t53=5.5; P<.001; 95% CI 2.4-5.2) and low mood (t53=2.3; P=.03; 95% CI 0.2-3.3). A statistically significant linear model was also fitted to the Generalized Anxiety Disorder-7 (F2,51=6.73; P<.001), while the model predicting changes in the Patient Health Questionnaire-8 did not reach significance (F2,51=2.33; P=.11). This indicates that the reduction in these measures was affected by in-app engagement with Worry Time and Problem Solving. Engaged users were able to successfully interact with the LICBT-specific techniques informed by an evidence-based protocol although there were lower completion rates of routine outcome measures and weekly reflections. Successful interaction with the specific techniques potentially contributes to promising data, indicating that IMWW may be effective in the management of excessive worry. A relationship between dose and improvement justifies the use of log data to inform future developments. However, attention needs to be directed toward enhancing interaction with wider features of the app given that larger improvements were associated with greater engagement.

How and Why the Choice of Success Criteria Can Impact Therapy Service Delivery: A Worked Example From a Psychological Therapy Service for Anxiety and Depression.

Well-defined measures of therapeutic benefit are essential for evaluating therapies and services. However, there is no single gold standard for defining 'successful' outcomes. We therefore examined the potential impact of adopting different success criteria. We analysed data for 7,064 patients undergoing psychological therapy in a single UK IAPT (Increasing Access to Psychological Therapy) Service, each patient being assessed for depression (PHQ-9) and anxiety (GAD-7) both at the start and end of treatment. Predictors of successful outcomes based on these measures were analysed separately for three different success criteria: based either on assessing clinically significant change, or reliable change, in depression and anxiety. The choice of criteria had little bearing on which variables predicted successful outcomes. However, the direction of the relationship between initial PHQ-9 or GAD-7 score and outcome success reverses when the criteria used to judge success are changed: successful outcomes are less probable under clinically significant change criteria for patients entering the service with more severe depression and/or anxiety but are more probable for such patients under reliable change criteria. Relevant for clinicians, researchers, and policymakers, the choice of success criteria adopted can substantially change the incentives for patient selection into a therapy service. Our analysis highlights how the methods used to evaluate treatment outcomes could impact the priorities and organisation of therapeutic services, which could then impact on who is offered treatment. We recommend further investigations of success criteria in other conditions or treatments to determine the reproducibility of the effects we found.

Predictors of primary care psychological therapy outcomes for treatment of depression and anxiety in people living with dementia: evidence from national healthcare records in England

AbstractBackgroundPrimary care psychological therapy services can be effective in reducing symptoms of depression and anxiety in people living with dementia (PLWD) and are recommended in national guidelines (e.g., NICE, UK). However, it is currently unknown which factors are associated with better psychological therapy outcomes in PLWD.MethodNational linked healthcare records (IAPT, HES, MHSD, HES‐ONS mortality data) were used to identify 1,522 PLWD who attended psychological therapy services across England. Associations between various factors (dementia‐specific and non‐dementia specific) and therapy outcomes on widely used anxiety (GAD7) and depression (PHQ9) measures (reliable improvement, recovery, deterioration, dropout) were explored.ResultPeople with FTD were more likely to experience a deterioration in depression or anxiety symptoms compared to people with vascular dementia (OR = 2.98, 95%CI[1.08,8.22], p = .03) and people with Alzheimer’s disease (OR = 2.95, 95%CI[1.15,7.55], p = .03). Age at dementia diagnosis did not predict any therapy outcomes after controlling for sociodemographic and clinical factors. Greater depression severity (recovery: OR = .95, 95%CI[.92,.98], p&lt;.001; deterioration: OR = 1.73, 95%CI[1.04,2.90], p = .04), lower anxiety severity (improvement: OR = 1.06, 95%CI[1.03,1.09], p&lt;.001; deterioration: OR = .89, 95%CI[.84,.94], p&lt;.001; dropout: OR = 1.06, 95%CI[1.02,1.11], p = .01), lower work and social functioning (improvement: OR = .98, 95%CI[.96,.99], p = .002; recovery: OR = .98, 95%CI[.96.99], p = .002; dropout: OR = 1.03, 95%CI[1.01,1.05], p = .01), psychotropic medication use (improvement: OR = .62, 95%CI[.46,.84], p = .002; recovery: OR = .67, 95%CI[.51,.90], p = .01; deterioration: OR = 1.73, 95%CI[1.04,2.90], p = .04), being working age (improvement: OR = 2.11, 95%ci[1.10, 4.04], p = .02; recovery: OR = 2.03, 95%CI[1.10,3.73], p = .02), and fewer therapy sessions (improvement: OR = 1.10, 95%CI[1.06,1.14], p&lt;.001; recovery: OR = 1.12, 95%CI[1.09,1.16], p&lt;.001) were all associated with worse psychological therapy outcomes in PLWD.ConclusionPredictors of psychological therapy outcomes in PLWD were largely in line with those identified for a general population above and beyond dementia‐specific factors. Additional support and adaptations, such as more therapy sessions and regular clinical reviews, may be required to improve therapy outcomes in PLWD, particularly in those who are younger and have more severe depression.

Measurement invariance and differential item functioning of the PHQ-9 and GAD-7 between working age and older adults seeking treatment for common mental disorders

BackgroundThe nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalised Anxiety Disorder (GAD-7) scale are widely used clinically and within research, and so it is important to determine how the measures, and individual items within the measures, are answered by adults of differing ages. This study sought to evaluate measurement invariance and differential item functioning (DIF) of the PHQ-9 and GAD-7 between working age and older adults seeking routine psychological treatment. MethodsData of working age (18–64 years old) and older (≥65) adults in eight Improving Access to Psychological Therapies (IAPT) services were used. Confirmatory factor analysis (CFA) was used to establish unidimensionality of the PHQ-9 and GAD-7, with multiple-group CFA to test measurement invariance and The Multiple Indicators, Multiple Causes Models approach to assess DIF. The employed methods were applied to a propensity score matched (PSM) sample in sensitivity analyses to control for potential confounding. ResultsData from 166,816 patients (159,325 working age, 7491 older) were used to show measurement invariance for the PHQ-9 and GAD-7, with limited evidence of DIF and similar results found with a PSM sample (n = 5868). LimitationsThe localised sample creates an inability to detect geographical variance, and the potential effect of unmeasured confounders cannot be ruled out. ConclusionsThe findings support the use of the PHQ-9 and GAD-7 measures for working age and older adults, both clinically and in research settings. This study validates using the measures for these age groups to assess clinically significant symptom thresholds, and monitor treatment outcomes between them.

Effectiveness of primary care psychological therapy services for treating depression and anxiety in autistic adults in England: a retrospective, matched, observational cohort study of national health-care records

Autistic adults report a higher prevalence of anxiety and depression than adults without identified autism but have poorer access to appropriate mental health care. Evidence-based psychological therapies are recommended in treatment guidelines for autistic adults, but no study has investigated their effectiveness in large samples representative of the autistic population accessing routine care. This study aimed to examine therapy outcomes for autistic adults in a primary care service. In this retrospective, matched, observational cohort study of national health-care records, we used the MODIFY dataset that used linked electronic health-care records, including national data, for individuals who accessed psychological therapy in primary care in Improving Access to Psychological Therapies (IAPT) services in 211 clinical commissioning group areas in England, UK. All adults aged 18 years or older who had completed a course of IAPT in 2012-19 were eligible, and were propensity score matched (1:1) with a comparison group without identified autism. Exact matching was used, when possible, for a range of sociodemographic factors. Primary outcomes were routine metrics that have been nationally defined and used to evaluate IAPT treatments: reliable improvement, reliable recovery, and reliable deterioration. Secondary outcomes were calculated pre-post treatment changes in scores for Patient Health Questionnaire-9, Generalised Anxiety Disorder Assessment-7, and Work and Social Adjustment Scale measures. Subgroup analyses investigated differential effects across a range of sociodemographic factors. Of 2 515 402 adults who completed at least two sessions of IAPT in 2012-19, 8761 had an autism diagnosis (5054 [57·7%] male and 3707 [42·3%] female) and 1 918 504 did not (631 606 [32·9%] male and 1 286 898 [67·0%] female). After propensity score matching, 8593 autistic individuals were matched with an individual in the comparison group. During IAPT treatment, symptoms of depression and generalised anxiety disorder decreased for most autistic adults, but symptoms were less likely to improve in the autism group than in the comparison group (4820 [56·1%] of 8593 autistic adults had reliable improvement vs 5304 [61·7%] of 8593 adults in the matched group; adjusted odds ratio [ORadj] 0·75, 95% CI 0·70-0·80; p<0·0001) and symptoms were more likely to deteriorate (792 [9·2%] vs 619 [7·2%]; ORadj 1·34, 1·18-1·48; p<0·0001). In the comparison group, improved outcomes were associated with employment and belonging to a higher socioeconomic deprivation category, but this was not the case for autistic adults. Evidence-based psychological therapy for depression or anxiety might be effective for autistic adults but less so than for adults without identified autism. Treatment moderators appear different for autistic individuals, so more research is needed to allow for better targeted and personalised care. Alzheimer's Society.

Measuring the impact of therapy on medication use: data-linkage study.

The psychological therapies service (PTS) in the Northern Health and Social Care Trust, in Northern Ireland, provides therapies to adults with moderate or severe mental health difficulties. Psychometric outcomes data are routinely collected to assess if a patient demonstrates significant improvement in their main presenting problem area following therapy. The wider impact of therapy is not fully measured in the outcomes database as this would be disproportionately burdensome for both patient and therapist. The present study, to our knowledge, is the first to use data linkage to link patient therapy outcomes data with prescriptions data. To widen our understanding of patient medication use before and after therapy. Using Health and Care Number as a unique identifier, the Psychological Therapies Service - Routine Outcome Measurement Database (n = 3625) and data from 72 500 controls were linked with data from the Enhanced Prescribing Database (EPD). The EPD data were sourced from the Honest Broker Service. Key findings from the study were: (a) the odds of PTS clients using antipsychotics in the year before therapy were 25 times greater compared with controls (odds ratio (OR) = 24.53, 95% CI 20.16-29.84); (b) in the 1st year post discharge, PTS clients who clinically improved post therapy discharge were more likely than 'non-engagers' and 'non-improvers' to come off antianxiety medication (OR = 0.61, 95%, CI 0.38-0.98); and (c) therapy did not have an impact on antidepressant use. The results highlight the need for discussion between therapy services, GPs and psychiatry about whether more engagement and collaboration is needed to plan phased reduction in medication.

Clinical presentation of psychotic experiences in patients with common mental disorders attending the UK primary care improving access to psychological therapies (IAPT) Programme

BackgroundImproving Access to Psychological Therapies (IAPT) services address anxiety and depression in primary care, with psychotic disorders typically excluded. Our previous research found 1 in 4 patients report distressing psychotic experiences (PE) alongside common mental disorders, yet little is known about their clinical presentation and impact on recovery. MethodsWe used the Community Assessment of Psychic Experiences — Positive Scale (CAPE-P15) to assess the clinical presentation and symptomatic profile of PE within IAPT settings across three National Health Service (NHS) trusts, serving a diverse population in Southern England. We identified different classes based on the reported PE frequencies using latent class analysis. ResultsA total of 2042 IAPT patients completed the CAPE-P15. The mean age was 39.8 (±15.3) years. We identified five distinct classes of symptom profiles, findings that PE were common, especially self-referential and persecutory ideas. Prevalence and intensity increased across classes, extending to bizarre experiences and perceptual abnormalities in the fifth and least common class. Perceptual abnormalities were a strong indicator of symptom severity, with patients being the least likely to achieve recovery by the end of treatment. LimitationsData were collected during a service evaluation. Replication of these findings across other IAPT services could prove beneficial. We did not collect information on negative PE. ConclusionsPatients seeking treatment for anxiety and depression in primary care commonly experience a wide range of positive PE. Self-referential and persecutory ideation were prevalent; perceptual abnormalities were infrequent. Providing information about prevalence and tailoring therapy may help reduce patient distress.

An investigation of treatment return after psychological therapy for depression and anxiety.

Some patients return for further psychological treatment in routine services, although it is unclear how common this is, as scarce research is available on this topic. To estimate the treatment return rate and describe the clinical characteristics of patients who return for anxiety and depression treatment. A large dataset (N=21,029) of routinely collected clinical data (2010-2015) from an English psychological therapy service was analysed using descriptive statistics. The return rate for at least one additional treatment episode within 1-5 years was 13.7%. Furthermore, 14.5% of the total sessions provided by the service were delivered to treatment-returning patients. Of those who returned, 58.0% continued to show clinically significant depression and/or anxiety symptoms at the end of their first treatment, while 32.0% had experienced a demonstrable relapse before their second treatment. This study estimates that approximately one in seven patients return to the same service for additional psychological treatment within 1-5 years. Multiple factors may influence the need for additional treatment, and this may have a major impact on service activity. Future research needs to further explore and better determine the characteristics of treatment returners, prioritise enhancement of first treatment recovery, and evaluate relapse prevention interventions.

Building resilience in the Improving Access to Psychological Therapy (IAPT) Psychological Wellbeing Practitioner (PWP) role: a qualitative grounded theory study.

Staff retention, particularly in the Psychological Wellbeing Practitioner (PWP) workforce, has historically been challenging for Improving Access to Psychological Therapy (IAPT) services. This study sought to develop an explanatory model of the resilience-building process in PWPs working within the IAPT programme. A qualitative design was conducted, using a grounded theory methodology. Participants were recruited from two IAPT services in the National Health Service (NHS), which were part of the same Mental Health Trust. Ten PWPs were interviewed via videoconferencing using semi-structured interviews. An explanatory model of resilience in PWPs encompassed three phases: the experience of work-related challenges, the connection with their values and the related appraisal of adversity in resilient ways, and the implementation of effective coping strategies. The model highlights that PWPs develop resilience through values-based sensemaking and by proactively engaging in effective coping mechanisms. This study contributes to the current understanding of the process of resilience in PWPs. More research is needed to explore the developmental processes underlying PWPs' resilience. The implications of the findings in relation to existing conceptualisations of resilience, staff wellbeing and retention are explored. Recommendations for future research are also given.

Therapist-assisted online psychological therapies differing in trauma focus for post-traumatic stress disorder (STOP-PTSD): a UK-based, single-blind, randomised controlled trial

Many patients are currently unable to access psychological treatments for post-traumatic stress disorder (PTSD), and it is unclear which types of therapist-assisted internet-based treatments work best. We aimed to investigate whether a novel internet-delivered cognitive therapy for PTSD (iCT-PTSD), which implements all procedures of a first-line, trauma-focused intervention recommended by the UK National Institute for Health and Care Excellence (NICE) for PTSD, is superior to internet-delivered stress management therapy for PTSD (iStress-PTSD), a comprehensive cognitive behavioural treatment programme focusing on a wide range of coping skills. We did a single-blind, randomised controlled trial in three locations in the UK. Participants (≥18 years) were recruited from UK National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) services or by self-referral and met DSM-5 criteria for PTSD to single or multiple events. Participants were randomly allocated by a computer programme (3:3:1) to iCT-PTSD, iStress-PTSD, or a 3-month waiting list with usual NHS care, after which patients who still met PTSD criteria were randomly allocated (1:1) to iCT-PTSD or iStress-PTSD. Randomisation was stratified by location, duration of PTSD (<18 months or ≥18 months), and severity of PTSD symptoms (high vs low). iCT-PTSD and iStress-PTSD were delivered online with therapist support by messages and short weekly phone calls over the first 12 weeks (weekly treatment phase), and three phone calls over the next 3 months (booster phase). The primary outcome was the severity of PTSD symptoms at 13 weeks after random assignment, measured by self-report on the PTSD Checklist for DSM-5 (PCL-5), and analysed by intention-to-treat. Safety was assessed in all participants who started treatment. Process analyses investigated acceptability and compliance with treatment, and candidate moderators and mediators of outcome. The trial was prospectively registered with the ISRCTN registry, ISRCTN16806208. Of the 217 participants, 158 (73%) self-reported as female, 57 (26%) as male, and two (1%) as other; 170 (78%) were White British, 20 (9%) were other White, six (3%) were Asian, ten (5%) were Black, eight (4%) had a mixed ethnic background, and three (1%) had other ethnic backgrounds. Mean age was 36·36 years (SD 12·11; range 18-71 years). 52 (24%) participants met self-reported criteria for ICD-11 complex PTSD. Fewer than 10% of participants dropped out of each treatment group. iCT-PTSD was superior to iStress-PTSD in reducing PTSD symptoms, showing an adjusted difference on the PCL-5 of -4·92 (95% CI -8·92 to -0·92; p=0·016; standardised effect size d=0·38 [0·07 to 0·69]) for immediate allocations and -5·82 (-9·59 to -2·04; p=0·0027; d=0·44 [0·15 to 0·72]) for all treatment allocations. Both treatments were superior to the waiting list for PCL-5 at 13 weeks (d=1·67 [1·23 to 2·10] for iCT-PTSD and 1·29 [0·85 to 1·72] for iStress-PTSD). The advantages in outcome for iCT-PTSD were greater for participants with high dissociation or complex PTSD symptoms, and mediation analyses showed both treatments worked by changing negative meanings of the trauma, unhelpful coping, and flashback memories. No serious adverse events were reported. Trauma-focused iCT-PTSD is effective and acceptable to patients with PTSD, and superior to a non-trauma-focused cognitive behavioural stress management therapy, suggesting that iCT-PTSD is an effective way of delivering the contents of CT-PTSD, one of the NICE-recommended first-line treatments for PTSD, while reducing therapist time compared with face-to-face therapy. Wellcome Trust, UK National Institute for Health and Care Research Oxford Health Biomedical Research Centre.

Investigation of Active Ingredients Within Internet-Delivered Cognitive Behavioral Therapy for Depression

There is limited understanding of how complex evidence-based psychological interventions such as cognitive behavioral therapy (CBT) for depression work. Identifying active ingredients may help to make therapy more potent, brief, and scalable. To test the individual main effects and interactions of 7 treatment components within internet-delivered CBT for depression to investigate its active ingredients. This randomized optimization trial using a 32-condition, balanced, fractional factorial optimization experiment (IMPROVE-2) recruited adults with depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) from internet advertising and the UK National Health Service Improving Access to Psychological Therapies service. Participants were randomized from July 7, 2015, to March 29, 2017, with follow-up for 6 months after treatment until December 29, 2017. Data were analyzed from July 2018 to April 2023. Participants were randomized with equal probability to 7 experimental factors within the internet CBT platform, each reflecting the presence vs absence of specific treatment components (activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, absorption, and self-compassion training). The primary outcome was depression symptoms (PHQ-9 score). Secondary outcomes include anxiety symptoms and work, home, and social functioning. Among 767 participants (mean age [SD] age, 38.5 [11.62] years; range, 18-76 years; 635 women [82.8%]), 506 (66%) completed the 6-month posttreatment follow-up. On average, participants receiving internet-delivered CBT had reduced depression (pre-to-posttreatment difference in PHQ-9 score, -7.79 [90% CI, -8.21 to -7.37]; 6-month follow-up difference in PHQ-9 score, -8.63 [90% CI, -9.04 to -8.22]). A baseline score-adjusted analysis of covariance model using effect-coded intervention variables (-1 or +1) found no main effect on depression symptoms for the presence vs absence of activity scheduling, functional analysis, thought challenging, relaxation, concreteness training, or self-compassion training (posttreatment: largest difference in PHQ-9 score [functional analysis], -0.09 [90% CI, -0.56 to 0.39]; 6-month follow-up: largest difference in PHQ-9 score [relaxation], -0.18 [90% CI, -0.61 to 0.25]). Only absorption training had a significant main effect on depressive symptoms at 6-month follow-up (posttreatment difference in PHQ-9 score, 0.21 [90% CI, -0.27 to 0.68]; 6-month follow-up difference in PHQ-9 score, -0.54, [90% CI, -0.97 to -0.11]). In this randomized optimization trial, all components of internet-delivered CBT except absorption training did not significantly reduce depression symptoms relative to their absence despite an overall average reduction in symptoms. The findings suggest that treatment benefit from internet-delivered CBT probably accrues from spontaneous remission, factors common to all CBT components (eg, structure, making active plans), and nonspecific therapy factors (eg, positive expectancy), with the possible exception of absorption focused on enhancing direct contact with positive reinforcers. isrctn.org Identifier: ISRCTN24117387.

Evaluating cognitive analytic therapy within a primary care psychological therapy service.

Cognitive analytic therapy (CAT) is used within UK mental health settings as a treatment for transdiagnostic complex psychological presentations. However, it is not routinely offered by the NHS Talking Therapies, for anxiety and depression (NHS Talking Therapies) programme which provides psychological treatments for common mental health difficulties. We aimed to evaluate the outcomes of providing CAT treatment to patients presenting with depression and/or anxiety, within the context of relational difficulties, adverse childhood experience or difficulty managing emotions, returning for further psychological treatment within NHS Talking Therapies. This was a pragmatic, real-world evaluation, involving routinely collected self-report measures of depression and anxiety, to examine the treatment outcomes of NHS Talking Therapies patients offered CAT over an 18-month period. Quantitative validated measures of depression and anxiety were administered at the beginning and end of CAT treatment, and at follow up. Within-group change in depression and anxiety scores were examined statistically, and rates of reliable improvement and recovery calculated. Statistically significant decreases in depression and anxiety scores were observed during the CAT active treatment phase. The recovery rate was 46.4%, and 71.4% of patients showed a reliable improvement post-treatment. Positive outcomes continued to be observed at follow-up, with a recovery rate of 50% and a reliable improvement rate of 79.4%. CAT shows promise as a treatment option for NHS Talking Therapies patients re-presenting with depression and/or anxiety. More research is required to determine if CAT should be offered more widely within NHS Talking Therapies services.

The significance of a sense of being in control for young people who received counselling for self‐harm

AbstractBackgroundInstances of self‐harm by young people are rising and are an increasing challenge for healthcare and mental health services. Young people's negative experiences of accessing help and support when they self‐harm are a contributing factor to them not seeking help in future episodes.MethodSemistructured interviews were conducted with 10 young people aged 17–20 years old who had received therapy relating to self‐harm from a National Health Service (NHS) Improving Access to Psychological Therapies (IAPT) service in the East of England. The data were analysed using reflective thematic analysis.Findings and DiscussionThis study provides a new understanding of how a greater sense of feeling in control over their lives is a common goal for therapy for young people who self‐harm. This investigation also shows that gaining understanding or reclaiming a sense of being in control results in the young person experiencing the therapy in a positive light and assessing it as successful. The results also show that an increased sense of being in control is sometimes overlooked and a missing aspect of therapy with young people who self‐harm.

Perspectives on an enhanced ‘Improving Access to Psychological Therapies’ (IAPT) service addressing the wider determinants of mental health: a qualitative study

BackgroundA new Health and Wellbeing pathway was introduced into the Improving Access to Psychological Therapies (IAPT) service in one geographical area of the UK in 2021 to address the wider determinants of mental health problems. It comprised assisted signposting to wider services and physical health promotion. This qualitative study aimed to understand stakeholders’ experiences of implementing and receiving this new support and the barriers and facilitators to its delivery.MethodsForty-seven interviews were conducted, with service developers (n = 6), service deliverers (n = 12), service users (n = 22) and community and clinical partners (n = 7), as part of a larger mixed-methods evaluation. Interviews were recorded, transcribed, and analysed using reflexive thematic analysis.ResultsThree themes spanned all participant groups and represented key aspects of the service: (1) identifying suitability, (2) a holistic service, and (3) moving forward. The sub-themes represent the barriers and facilitators to processes working in practice, lending insight into potential service improvements. These included strengthening the quality of communication during referral and assessment, tailoring the support and delivery mode, and increasing transparency around continued care to drive sustained benefits.LimitationsService users may have been selected due to their positive experiences of IAPT and were not demographically representative of the population, although participants’ experiences of the service did suggest variation in our sample.ConclusionsThe Health and Wellbeing pathway was perceived as having a positive impact on mental health and could reduce the burden on therapeutic services. However, service- and individual-level barriers need to be addressed to enhance statutory and community support links, manage service users’ expectations, and improve accessibility for certain groups.

Process mining to discover patterns in patient outcomes in a Psychological Therapies Service

In the mental health sector, Psychological Therapies face numerous challenges including ambiguities over the client and service factors that are linked to unfavourable outcomes. Better understanding of these factors can contribute to effective and efficient use of resources within the Service. In this study, process mining was applied to data from the Northern Health and Social Care Trust Psychological Therapies Service (NHSCT PTS). The aim was to explore how psychological distress severity pre-therapy and attendance factors relate to outcomes and how clinicians can use that information to improve the service. Data included therapy episodes (N = 2,933) from the NHSCT PTS for adults with a range of mental health difficulties. Data were analysed using Define-Measure-Analyse model with process mining. Results found that around 11% of clients had pre-therapy psychological distress scores below the clinical cut-off and thus these individuals were unlikely to significantly improve. Clients with fewer cancelled or missed appointments were more likely to significantly improve post-therapy. Pre-therapy psychological distress scores could be a useful factor to consider at assessment for estimating therapy duration, as those with higher scores typically require more sessions. This study concludes that process mining is useful in health services such as NHSCT PTS to provide information to inform caseload planning, service management and resource allocation, with the potential to improve client’s health outcomes.