Assessing Patient Progress in Psychological Therapy Through Feedback in Supervision: the MeMOS* Randomized Controlled Trial (*Measuring and Monitoring clinical Outcomes in Supervision: MeMOS).

BACKGROUND: Psychological therapy services are often required to demonstrate their effectiveness and are implementing systematic monitoring of patient progress. A system for measuring patient progress might usefully 'inform supervision' and help patients who are not progressing in therapy. AIMS: To examine if continuous monitoring of patient progress through the supervision process was more effective in improving patient outcomes compared with giving feedback to therapists alone in routine NHS psychological therapy. METHOD: Using a stepped wedge randomized controlled design, continuous feedback on patient progress during therapy was given either to the therapist and supervisor to be discussed in clinical supervison (MeMOS condition) or only given to the therapist (S-Sup condition). If a patient failed to progress in the MeMOS condition, an alert was triggered and sent to both the therapist and supervisor. Outcome measures were completed at beginning of therapy, end of therapy and at 6-month follow-up and session-by-session ratings. RESULTS: No differences in clinical outcomes of patients were found between MeMOS and S-Sup conditions. Patients in the MeMOS condition were rated as improving less, and more ill. They received fewer therapy sessions. CONCLUSIONS: Most patients failed to improve in therapy at some point. Patients' recovery was not affected by feeding back outcomes into the supervision process. Therapists rated patients in the S-Sup condition as improving more and being less ill than patients in MeMOS. Those patients in MeMOS had more complex problems.

Manual-assisted cognitive therapy for self-harm in personality disorder and substance misuse: a feasibility trial.

Aims and method To assess the feasibility of conducting a larger, definitive randomised controlled trial of manual-assisted cognitive therapy (MACT), a brief focused therapy to address self-harm and promote engagement in services. We established recruitment, randomisation and assessment of outcome within a sample of these complex patients admitted to a general hospital following self-harm. We assessed symptoms of depressed mood, anxiety and suicidality at baseline and at 3 months' follow-up. Results Twenty patients were randomised to the trial following an index episode of self-harm, and those allocated to MACT demonstrated improvement in anxiety, depression and suicidal ideation. Clinical implications It is feasible to recruit a sample of these complex patients to a randomised controlled trial of MACT following an index episode of self-harm. There is preliminary support that MACT could be an acceptable and effective intervention in patients with personality disorder and substance misuse.

Impact of treatment intensity on suicidal behavior and depression in borderline personality disorder: a critical review.

The effectiveness of less versus more intensive psychological therapies in reducing suicidal behavior and depression in suicidal patients with borderline personality disorder (BPD) was examined. Electronic databases were searched. Trials were separated into less versus more intensive therapies. Suicidal acts and depression outcome data were assessed. Six trials met search criteria (cognitive-behavioral therapy for personality disorder, mentalization-based therapy, dialectical behavior therapy). Seven measures of suicidal acts and two measures of depression were used in studies. Both less and more intensive therapies report significant decreases in suicidal behaviors. Apart from one small trial, both less and more intensive therapies report decreases in depression with no differences between therapies and control conditions. Two follow-up studies showed that reductions in suicidal behavior and depression are maintained over time. The authors conclude that both less and more intensive therapies are effective in treating depression and suicidal behaviors in patients with BPD. Clinicians should deliver the least intensive interventions that will provide these significant health gains.

Conducting randomised controlled trials: finding better ways to explain research to people with anti-social personality disorder who have low literacy levels.

BACKGROUND: The involvement of people with anti-social personality disorder (ASPD) in clinical trials is necessary to developing effective treatment. Low literacy level, however, may be a barrier to their understanding and therefore their engagement in research. AIM: Our aim was to find a preferred and most easily understandable way of communicating about research participation with men who have ASPD. METHODS: Twenty-five men with ASPD who were using mental health services, research experienced and research naïve participated in the study. Literacy levels were assessed. A list of research terms was generated, and statements were developed to ascertain if the terms were understood. The research terms were 'randomisation', 'informed consent', 'confidentiality' and a research question 'why carry out research?' The participants ranked their preferred way of explaining these terms and the method of communicating these. RESULTS: Those with research experience understood the research terms better. The research naïve and the research experienced men differed in literacy level. Those with below average literacy preferred shorter wordings of research terms than those with average literacy and answered fewer questions correctly. The majority stated a preference for discussion with a researcher before agreeing to take part in research. The least preferred communication methods were those that relied on technology. CONCLUSIONS: Researchers should be able to find and use terms that are readily understood and do so. Low literacy levels impair understanding of research terms.

Cognitive therapy v. usual treatment for borderline personality disorder: prospective 6-year follow-up.

BACKGROUND: Longer-term follow-up of patients with borderline personality disorder have found favourable clinical outcomes, with long-term reduction in symptoms and diagnosis. AIMS: We examined the 6-year outcome of patients with borderline personality disorder who were randomised to 1 year of cognitive-behavioural therapy for personality disorders (CBT-PD) or treatment as usual (TAU) in the BOSCOT trial, in three centres across the UK (trial registration: ISRCTN86177428). METHOD: In total, 106 participants met criteria for borderline personality disorder in the original trial. Patients were interviewed at follow-up by research assistants masked to the patient's original treatment group, CBT-PD or TAU, using the same measures as in the original randomised trial. Statistical analyses of data for the group as a whole are based on generalised linear models with repeated measures analysis of variance type models to examine group differences. RESULTS: Follow-up data were obtained for 82% of patients at 6 years. Over half the patients meeting criteria for borderline personality disorder at entry into the study no longer did so 6 years later. The gains of CBT-PD over TAU in reduction of suicidal behaviour seen after 1-year follow-up were maintained. Length of hospitalisation and cost of services were lower in the CBT-PD group compared with the TAU group. CONCLUSIONS: Although the use of CBT-PD did not demonstrate a statistically significant cost-effective advantage, the findings indicate the potential for continued long-term cost-offsets that accrue following the initial provision of 1 year of CBT-PD. However, the quality of life and affective disturbance remained poor.

Cognitive-behavioral factors associated with sleep quality in chronic pain patients.

People with chronic pain commonly complain of sleep disturbance. This study reports the characteristics of the pain and sleep of a large sample of patients with chronic pain (n = 160). This study compared subgroups of good sleepers with pain (n = 48) and poor sleepers with pain (n = 108). Poor sleepers with pain were younger and reported more pain, pain-related disability, depression, pain-related anxiety, and dysfunctional beliefs about sleep. Using simultaneous regression analysis, this study examined the roles of pain, dysfunctional beliefs about sleep, pain-related disability, depression, and pain-related anxiety in predicting concurrent sleep quality. The findings are relevant to the development of models of sleep disturbance comorbid with chronic pain.

Specificity of autobiographical memory in depressed older adults and its relationship with working memory and IQ.

OBJECTIVES: The study investigated whether depressed older adults retrieve fewer specific memories and more categoric memories than non-depressed older adults on the autobiographical memory test (AMT). The second objective was to investigate the relationship between AMT performance and both working memory and intelligence quotient (IQ). DESIGN: The study was cross-sectional, involving a single interview with each participant. METHODS: A group of 17 depressed participants was matched for age, gender and education with a group of 17 non-depressed participants. All were screened for cognitive impairment. Participants completed the AMT, spatial span and letter-number sequencing subtests of the Wechsler Memory Scale III and the Wechsler Test of Adult Reading. RESULTS: The depressed group retrieved significantly fewer specific memories than the non-depressed group, but did not differ in their categoric memory recall. Specific memory scores were positively correlated with measures of working memory, but not with IQ. Categoric memory scores were negatively correlated with measures of working memory, but not with IQ. CONCLUSIONS: Depression adversely affects older adults' ability to retrieve specific memories. Working memory capacity was related to specific autobiographical memory retrieval independently of IQ. A strong relationship between AMT performance and spatial span is discussed.

Patient and clinician agreement on personality using the SWAP-200.

The Shedler Westen Assessment Procedure (SWAP-200; Westen & Shedler, 1999a) is a clinician-rated assessment providing descriptions of personality disorder prototypes using a Q-sort procedure. This study aims to investigate the degree to which there is agreement between patients' and clinicians' accounts of personality pathology on a modified version of the SWAP-200 using Bland Altman analysis with the data from 23 clinician-patient pairs. Poor agreement was found between clinicians and patients on personality prototypes. Even the best agreement found between patients and clinicians on the avoidant prototype was poor--the patients' ratings were up to 43.5 per cent below and 32.9 per cent above the clinicians' ratings. This is an unacceptable degree of variation. The difference between the clinician and patient ratings are large when expressed as a percentage of the possible scores (as obtained on the clinician rating scale). The patient ratings vary between being 40.8 to 91.1% below the clinician ratings, and 32.9 to 99.7% above the clinician ratings.

Hopelessness and the anticipation of positive and negative future experiences in older parasuicidal adults.

OBJECTIVES: This study examined whether older people who were depressed or had engaged in parasuicidal behaviour could be identified by a decrease in positive future-directed thinking in the absence of any increase in negative future-directed thinking, in comparison with a community control group. DESIGN: A mixed design was used that compared three groups (community controls, depressed controls and parasuicidal participants) in terms of future-directed thinking (positive and negative), in relation to three future time periods (one week, one year and 5-10 years). METHODS: In all, 22 participants over 65 years of age, who had been admitted to hospital following a non-fatal suicidal act, were compared with 22 older people being treated for depression and 22 older community volunteers who were not experiencing any significant psychological symptoms. The main measure was an adaptation of the traditional verbal fluency paradigm and attempted to quantify future-directed thinking. RESULTS: Parasuicidal and depressed participants showed decreased positive future thinking, but no increase in negative future thinking, in comparison with the community control group. CONCLUSIONS: The results confirm that older parasuicidal and older depressed participants are characterized by a reduction in positive anticipation and that this may be accounted for by depression rather than hopelessness.

Factors affecting GUM clinic attenders decisions and intentions to seek HIV testing.

OBJECTIVES: To evaluate factors that predict HIV testing using the model of health care utilisation as its conceptual framework and to analyse some of the factors that encourage or inhibit seeking an HIV test in this population. METHOD: A cross sectional questionnaire study in two Genito-Urinary Medicine (GUM) clinics in central Scotland. A final sample of 195 represented a 91% response rate. Participants were categorised by their HIV testing status (already tested, planning to be tested, no intention to seek testing). RESULTS: The 'already tested' and 'planning to be tested' groups were combined as there were no significant differences on reported risk behaviours. Analysis therefore compared two groups those 'testing' (n = 66) and 'not testing' (n = 129). 67% of those not tested for HIV reported at least one HIV risk factor. Perceived risk was the strongest predictor of HIV testing using our model. Perception of risk and actual risk were not correlated. Those not seeking testing endorsed less benefits of testing and more denial of the need to be tested. Same day testing and testing without an appointment were endorsed as factors to promote testing. CONCLUSION: To encourage people who have high risk factors to access HIV testing, programmes should: (1) highlight the benefits of testing which would be lost if people do not test, eg. effective drug treatments (2) increase the range of HIV testing services available (eg. same day testing). Furthermore, studies to determine the main predictors of perceived risk are needed if we are to increase testing in relevant populations.