The self-management of longer-term depression: learning from the patient, a qualitative study.

BACKGROUND: Depression is a common mental health condition now viewed as chronic or long-term. More than 50 % of people will have at least one further episode of depression after their first, and therefore it requires long-term management. However, little is known about the effectiveness of self-management in depression, in particular from the patients' perspective. This study aimed to understand how people with longer-term depression manage the condition, how services can best support self-management and whether the principles and concepts of the recovery approach would be advantageous. METHODS: Semi-structured in depth interviews were carried out with 21 participants, recruited from a range of sources using maximum variation sampling. Interpretative Phenomenological Analysis was used by a diverse team comprised of service users, practitioners and academics. RESULTS: Four super-ordinate themes were found: experience of depression, the self, the wider environment, self-management strategies. Within these, several prominent sub-themes emerged of importance to the participants. These included how aspects of themselves such as hope, confidence and motivation could be powerful agents; and how engaging in a wide range of chosen activities could contribute to their emotional, mental, physical, social, spiritual and creative wellbeing. CONCLUSIONS: Services in general were not perceived to be useful in specifically facilitating self-management. Increased choice and control were needed and a greater emphasis on an individualised holistic model. Improved information was needed about how to develop strategies and locate resources, especially during the first episode of depression. These concepts echoed those of the recovery approach, which could therefore be seen as valuable in aiding the self-management of depression.

Alcohol screening in people with cognitive impairment: an exploratory study.

OBJECTIVE: Alcohol misuse can coexist with and/or contribute to the development of cognitive impairment in the older adult population but continues to be underestimated and undetected in older people. This study aimed to examine the feasibility and acceptability of routine screening for alcohol misuse in a small sample of older people with cognitive impairment receiving services in memory clinics. METHODS: This study employed a qualitative and exploratory design, using a convenience sample of individuals attending a memory clinic in England. Ten service users older than 65 with a diagnosis of cognitive impairment (i.e., mild cognitive impairment or dementia) took part in the study. Individuals who met inclusion criteria were invited to take part in an hour-long interview, which included the interviewer administering the alcohol screening tools. Interview transcripts were analyzed using thematic analysis. RESULTS: Participants were able to engage with the screening tools and could, with assistance, complete them in a collaborative and timely manner without distress. All participants reported that these tools were acceptable as part of the clinic assessment. Administering the screening tools was not time-consuming or difficult, making their use feasible within the memory clinic setting. While there were some challenges (e.g., arithmetic, recall, language problems), these challenges could be overcome with the aid of the person administering the screening tool using standardized techniques for assessment administration. CONCLUSIONS: Routine screening for alcohol misuse in older people with cognitive impairment receiving services in memory clinics is feasible and acceptable. The process of completing alcohol screening tools with older adults receiving services at memory clinics may increase awareness of the potential impact of alcohol on cognitive functioning and provide practitioners with an opportunity to educate service users about the ways that their drinking is affecting their memory. Several techniques to facilitate completion of screening tools were identified. Future research should evaluate the reliability and validity of alcohol screening tools with older people through corroborating screening results with other assessment methods.

Cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: a systematic review and meta-analysis.

BACKGROUND: Depression is a common symptom in people with multiple sclerosis. We systematically reviewed published controlled trials on the effectiveness of cognitive behavioural therapy (CBT) for the treatment of depression in people with multiple sclerosis. METHODS: Publications were identified using MEDLINE, PsycINFO and the Cochrane Central Register of Controlled Trials to June/July 2013. We combined thesaurus and free-text terms which were synonyms of the concepts multiple sclerosis, depression and cognitive behavioural therapy. We included published controlled trials which compared individual, group CBT, conducted face-to-face or remotely, to no CBT. Two reviewers extracted data to calculate standardized mean differences (SMD) for self-reported symptoms of depression and weighted mean differences (WMD) for the Multiple Sclerosis Impact Scale (MSIS-29), with 95% Confidence Intervals (CIs). We investigated statistical heterogeneity using I². RESULTS: Seven eligible studies (n = 433) were identified, which evaluated the effect on depression of CBT delivered individually (3 studies), in a group (3 studies) and by computer (1 study). The summary effect (SMD -0.61, 95% CI -0.96 to -0.26, p=0.0006) was reduced (SMD -0.46, 95% CI -0.75 to -0.17, p=0.002) when an outlying study was removed in a sensitivity analysis to examine statistical heterogeneity. Three studies (n=213) observed a direction of effect using the MSIS-29 which was not statistically significant (WMD -4.36, 95% CI -9.33 to 0.62, p=0.09). There was no between-subgroup heterogeneity (I²=0). CONCLUSIONS: CBT can be an effective treatment for depression in MS. Further research should explore optimal durations and modalities of treatment for patients with different characteristics.

Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community.

BACKGROUND: The purpose of the analysis was to develop a health economic model to estimate the costs and health benefits of alternative National Health Service (NHS) service configurations for people with longer-term depression. METHOD: Modelling methods were used to develop a conceptual and health economic model of the current configuration of services in Sheffield, England for people with longer-term depression. Data and assumptions were synthesised to estimate cost per Quality Adjusted Life Years (QALYs). RESULTS: Three service changes were developed and resulted in increased QALYs at increased cost. Versus current care, the incremental cost-effectiveness ratio (ICER) for a self-referral service was £11,378 per QALY. The ICER was £2,227 per QALY for the dropout reduction service and £223 per QALY for an increase in non-therapy services. These results were robust when compared to current cost-effectiveness thresholds and accounting for uncertainty. CONCLUSIONS: Cost-effective service improvements for longer-term depression have been identified. Also identified were limitations of the current evidence for the long term impact of services.

Cognitive analytic therapy for borderline personality disorder: therapist competence and therapeutic effectiveness in routine practice.

This study sought to examine the competency of cognitive analytic therapy (CAT) delivered under routine care conditions and to identify the effectiveness of CAT for patients with borderline personality disorder (BPD). Ten cognitive analytic therapists in six National Health Service Trust sites treated 19 patients with BPD using the standard CAT BPD contract of 24 sessions plus four follow-ups. The methodology was small N repeated measures deign, with patients interviewed at the third follow-up session using the Change Interview. Results indicate a high treatment and follow-up compliance rate (89.47%). Significant reductions in psychological distress, risk and dissociation over the time course of the CAT occurred, with a significant increase in personality integration. Most sessions (92.85%) were delivered in a competent manner. Reductions to psychological distress occurred early in treatment and were sustained, whereas increases in personality integration typically occurred later on in treatment. Patients tended to attribute change to the therapy received. Benchmarking against extant CAT BPD evidence notes a moderate effect size across routine care and trial contexts. The results are discussed in terms of identified methodological shortcomings, clinical implications and the contribution made by the CAT model to the treatment of BPD.

Computerised cognitive behavioural therapy for the treatment of depression in people with multiple sclerosis: external pilot trial.

BACKGROUND: People with multiple sclerosis (MS) are at high risk of depression. We undertook a pilot trial of computerised cognitive behavioural therapy (CCBT) for the treatment of depression in people with MS to test the feasibility of undertaking a full trial. METHODS: Participants with a diagnosis of MS and clinical levels of depression were recruited through out-patient clinics and postal screening questionnaires at two UK centres and randomised to CCBT or usual care. Clinical outcomes included the Beck Depression Inventory (BDI-II) and Multiple Sclerosis Impact Scale (MSIS-29) at baseline, 8 and 21 weeks. Feasibility outcomes included: recruitment rate; reasons for refusal, withdrawal and dropout; feasibility and acceptability of the proposed outcome measures; sample size estimation and variation in and preferences for service delivery. RESULTS: Twenty-four participants were recruited. The recruitment rate, calculated as the proportion of those invited to fill in a screening questionnaire who were consented into the trial, was 4.1%. Recruitment through out-patient clinics was somewhat slower than through screening questionnaire mail-out but the overall recruitment yield was similar. Of the 12 patients in the CCBT arm, 9 (75%) completed at least four, and 6 completed all 8 CCBT sessions. For completers, the median time (IQR) to complete all eight CCBT sessions was 15 (13 to 20) weeks. Participants expressed concern about the face validity of the Beck Depression Inventory II for the measurement of self-reported depression in people with MS. The MSIS-29 was the patient-reported outcome measure which participants felt best reflected their concerns. The estimated sample size for a full trial is between 180 and 390 participants. NHS partners were not delivering CCBT in community facilities and participants preferred to access CCBT at home, with no one expressing a preference for use of CCBT in an alternative location. CONCLUSIONS: A definitive trial, with a recruitment window of one year, would require the participation of around 13 MS centres. This number of centres could be reduced by expanding the eligibility criteria to include either other neurological conditions or people with more severe depression. The MSIS-29 should be used as a patient-important outcome measurement. TRIAL REGISTRATION: ISRCTN: ISRCTN81846800.