The predictive value of patient, therapist, and in-session ratings of motivational factors early in remote cognitive behavioural therapy for severe health anxiety.

OBJECTIVES: Remote psychotherapy and the prevalence of Severe Health Anxiety (SHA) are both growing as a result of the COVID-19 pandemic. Remotely delivered Cognitive Behavioural Therapy (rCBT) for SHA is evidenced as effective, but many who seek help do not benefit. Motivational processes can influence outcomes, but it is unclear what assessment methods offer the best clinical utility in rCBT for SHA. DESIGN: This study compared the predictive validity of patient, therapist and in-session ratings of motivational factors taken at session two of rCBT for SHA among high healthcare users experiencing multimorbidity. METHODS: Motivational factors were assessed for 56 participants who attended at least two sessions of CBT for SHA delivered via video-conferencing or telephone. Following session two, therapists and patients completed online assessments of patient motivation. Two trained observers also rated motivational factors and therapeutic alliance from in-session interactions using session two recordings and transcripts. Multilevel modelling was used to predict health anxiety and a range of secondary health outcomes from motivation assessments. RESULTS: Where patients were more actively engaged in discussion of positive changes during session two, greater outcome improvements ensued in health anxiety and all secondary outcomes. Conversely, larger proportions of session two spent describing problems predicted poorer outcomes. Therapist and patient assessments of motivation did not predict health anxiety, but therapist assessments of client confidence and motivation predicted all secondary outcomes. CONCLUSIONS: Motivation remains an important process in CBT when delivered remotely, and motivational factors may predict outcomes more consistently from in-session interactions, compared to self-reports.

Predicting outcomes and sudden gains from initial in-session interactions during remote cognitive-behavioural therapy for severe health anxiety.

There has been a dramatic increase in remote psychotherapy since the onset of the COVID-19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID-19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive-behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome-improvement in remote-CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty-eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session-by-session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session-by-session outcomes and precede sudden gains in rCBT for SHA.

Patient activation in psychotherapy interactions: Developing and validating the consultation interactions coding scheme.

OBJECTIVE: We describe the development of an instrument aiming to offer interaction-level feedback based on "patient activation": client confidence and perceived ability to manage their health. METHOD: Twenty-two session-transcripts from cognitive behavioral therapy with high-users of healthcare were analyzed thematically, producing themes describing in-session interactions. Themes were subcategorized using patient activation theory into high and low activation presentations. Two coders new to the process were trained to use this consultation interactions coding scheme (CICS). Inter-rater reliability (IRR), convergent validity, and clinical utility were assessed and illustrated with extreme cases. RESULTS: Good-to-excellent IRR was achieved. The CICS, therapeutic alliance, and therapist competence were correlated. Client engagement in session-structuring interactions correlated with outcome. The highest CICS scorer showed multiple outcome-improvements, the lowest scorer reported deteriorations. CONCLUSIONS: This study presents the CICS's psychometric properties and indicates the value of client engagement in session-structuring.

Clinical and economic outcomes of remotely delivered cognitive behaviour therapy versus treatment as usual for repeat unscheduled care users with severe health anxiety: a multicentre randomised controlled trial.

BACKGROUND: It is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU). METHODS: A single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective. RESULTS: Of the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI -2.81; 95% CI -5.11 to -0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group. CONCLUSIONS: RCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care. TRIAL REGISTRATION: The trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036.

"Work is good for me": views of mental health service users seeking work during the UK recession, a qualitative analysis.

BACKGROUND: Individual placement and support (IPS) is an effective form of supported employment for people with severe mental illness. Little is known about service users' experiences of these programmes during economic recession. AIMS: Obtain service users' views of an IPS programme implemented in the UK during recession. METHOD: Thirty-one service users enrolled in an IPS programme were interviewed using a semi-structured protocol. The questions covered several areas of their experience, including problems faced in seeking work, perceived barriers in returning to work and what they found helpful in employment support. RESULTS: Unsurprisingly, a large number of service users had problems in finding work due to the number of appropriate jobs available. Nevertheless, many service users felt positively about the support they had received (90% were satisfied with IPS), and would advise others in their position to seek employment. Personal and practical support from employment specialists (ES) was the most useful aspect of the service. CONCLUSIONS: Despite economic recession, an IPS service was implemented and regarded as satisfactory to service users seeking work. Although many found obtaining employment difficult, they would still advise others that work is worthwhile, suggesting that the context of recession has not discouraged them.

Factors associated with strain in carers of people with traumatic brain injury.

OBJECTIVE: To explore factors associated with strain in carers of patients with traumatic brain injury. DESIGN: Cross-sectional cohort study. PARTICIPANTS: Forty-eight carers of patients with traumatic brain injury admitted to a neurosurgical unit over a 9-year period were assessed an average of 9.3 years after injury. MEASURES: Caregiver Strain Index (CSI), Neurobehavioral Functioning Inventory (NFI), Glasgow Outcome Scale (GOS), Virginia Prediction Tree Score, and carer and patient demographics. PROCEDURE: Carers were assessed via postal survey for levels of strain using the CSI and for their perception of the patients' disabilities using the NFI. RESULTS: Elevated levels of strain were found in 42% of carers. Using logistic regression, outcome as rated by the patients' general practitioner on the GOS and all subscales of the NFI (except Somatic) explained 41% to 57% of the variance in strain and predicted group membership correctly in 72.9% of cases. No individual variable contributed significantly to the explained variance in the model. CONCLUSION: A number of factors appear to combine to result in feelings of strain, but the GOS could be used as a crude screening tool. Interventions for cognitive, behavioral, and emotional difficulties may be most useful for carers.

Additional interventions to enhance the effectiveness of individual placement and support: a rapid evidence assessment.

Topic. Additional interventions used to enhance the effectiveness of individual placement and support (IPS). Aim. To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method. A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions. Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is difficult to establish. Some evidence suggests that work-related social skills and cognitive training are effective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence.