Recent Submissions

  • Administration and Policy in Mental Health and Mental Health Services Research

    Firth, Nick
    Dropout during psychological intervention is a signifcant problem. Previous evidence for associations with socioeconomic deprivation is mixed. This study aimed to review the evidence for associations between deprivation and dropout from contemporary adult psychological interventions for common mental disorders (CMDs). Systematic review, narrative synthesis and random efects meta-analysis of peer-reviewed English language journal articles published June 2010–June 2020 was conducted. Data sources included medline, PsycInfo, databases indexed by web of science, ProQuest social science database and sociology collection, and the Cochrane Library, supplemented by forward and backward citation searching. Five studies were eligible for inclusion (mean N=170, 68% female, 60% White Caucasian, 32% dropout rate, predominantly cognitive behaviour therapy/cognitive processing therapy). Narrative synthesis indicated an overall non-signifcant efect of deprivation on dropout. Meta-analytic signifcance of controlled (k=3) and uncontrolled (k=4) efects depended on the measure of deprivation included for those studies using more than one measure (controlled OR 1.21–1.32, p=0.019–0.172, uncontrolled OR 1.28–1.76, p=0.024–0.423). The low number of included studies meant sub-group comparisons were limited, despite some tentative indications of potential diferential effects. A comparator set of excluded studies showed similar uncertainty. There was limited evidence that did not overall suggest a clear signifcant effect of deprivation on dropout from contemporary individual CMD interventions. However, more contemporary research is needed, as effects may vary according to clinical and methodological factors, and for dropout versus non-initiation.
  • Health psychology attendance: A multilevel analysis of patient-level predictors and therapist effects

    Firth, Nick; Holt, Rachel (2020-11)
    The study investigated adult outpatient Health Psychology Services appointment attendance, cancellation, and missed appointments (A/C/M). The first objective was to determine which demographic and process factors predicted the probability of A/C/M. The second objective was to determine whether there remained residual significant differences in A/C/M between therapists (i.e., a "therapist effect"), after controlling for explanatory variables. We conducted a practice-based retrospective 2-year cohort study. Three-level multilevel models were constructed and tested to analyze the probability of A/C/M at (1) assessment appointments (N = 1,175) and (2) follow-up appointments (N = 5,441). After controlling for predictor variables, significant therapist effects were found for attendance (10.0% to 13.0%) and cancellation (4.4%) at follow-up appointments (but not assessments), indicating significantly different attendance rates at follow-up between therapists. Predictors of attendance at follow-up included patient age, pretherapy symptom severity scores (including risk and symptom scores), and completion of intake questionnaires. Early morning follow-up appointments were least likely to be canceled, followed by late afternoon and finally midday appointments. Treatment intensity predicted attendance, but among qualified therapists, qualification type and pay level were nonsignificant. No significant predictors of attendance at assessment were detected. Attendance at Health Psychology Services outpatient appointments varies significantly according to patient, therapist, and appointment factors. Key routinely collected variables are predictive of attendance at follow-up. Clinical implications include the potential to identify patients at risk of nonattendance and target engagement interventions to these patients. Research directions include closer examination of variability in follow-up attendance between therapists. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
  • Deprivation, access, and outcomes in health psychology treatment

    Firth, Nick; Oates, Lloyd L (2020-06)
    Abstract Purpose Individuals living in areas of higher deprivation are more likely to have requested mental health treatment but are less likely to have received treatment or benefitted from it. Less is known about the extent of access equality and treatment outcomes for individuals with a long-term health condition who experience mental health difficulties. The study aimed to evaluate the extent to which the neighbourhood Index of Multiple Deprivation predicted access to treatment, appointment attendance, treatment completion, and clinical outcomes in a British health psychology clinic. Design Retrospective data were used from 479 individuals referred to a health psychology clinic over 12-months. Clinical outcomes were measured using the Clinical Outcomes in Routine Evaluation – Outcome Measure (CORE-OM). Patient data were linked with their neighbourhood Index of Multiple Deprivation decile. Data were analysed using correlation, linear regression, and Fisher’s exact test. Findings There were no significant associations between deprivation and whether an individual attended assessment, attended treatment, or completed treatment, or between deprivation and patients’ clinical outcomes. Exploratory evidence indicated that individuals from higher deprivation neighbourhoods may be over-represented in clinic referrals, and individuals from lower deprivation neighbourhoods may be under-represented, compared with local population distribution estimates. Originality This evaluation provides insights into treatment outcomes and deprivation in those with physical health difficulties. Further evaluation using a larger sample and comparing referrals with local prevalence estimates of comorbid mental and physical health problems would enable greater confidence in the conclusion that no evidence of inequality on the basis of neighbourhood deprivation was found.
  • Cognitive behavioural therapy for adults with dissociative seizures (CODES): a pragmatic, multicentre, randomised controlled trial

    Firth, Nick; Scholes, Karen; Bennett, Masha (2020-06)
    Abstract Background: Dissociative seizures are paroxysmal events resembling epilepsy or syncope with characteristic features that allow them to be distinguished from other medical conditions. We aimed to compare the effectiveness of cognitive behavioural therapy (CBT) plus standardised medical care with standardised medical care alone for the reduction of dissociative seizure frequency.Methods: In this pragmatic, parallel-arm, multicentre randomised controlled trial, we initially recruited participants at 27 neurology or epilepsy services in England, Scotland, and Wales. Adults (≥18 years) who had dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous 12 months were subsequently randomly assigned (1:1) from 17 liaison or neuropsychiatry services following psychiatric assessment, to receive standardised medical care or CBT plus standardised medical care, using a web-based system. Randomisation was stratified by neuropsychiatry or liaison psychiatry recruitment site. The trial manager, chief investigator, all treating clinicians, and patients were aware of treatment allocation, but outcome data collectors and trial statisticians were unaware of treatment allocation. Patients were followed up 6 months and 12 months after randomisation. The primary outcome was monthly dissociative seizure frequency (ie, frequency in the previous 4 weeks) assessed at 12 months. Secondary outcomes assessed at 12 months were: seizure severity (intensity) and bothersomeness; longest period of seizure freedom in the previous 6 months; complete seizure freedom in the previous 3 months; a greater than 50% reduction in seizure frequency relative to baseline; changes in dissociative seizures (rated by others); health-related quality of life; psychosocial functioning; psychiatric symptoms, psychological distress, and somatic symptom burden; and clinical impression of improvement and satisfaction. p values and statistical significance for outcomes were reported without correction for multiple comparisons as per our protocol. Primary and secondary outcomes were assessed in the intention-to-treat population with multiple imputation for missing observations. This trial is registered with the International Standard Randomised Controlled Trial registry, ISRCTN05681227, and ClinicalTrials.gov, NCT02325544. Findings: Between Jan 16, 2015, and May 31, 2017, we randomly assigned 368 patients to receive CBT plus standardised medical care (n=186) or standardised medical care alone (n=182); of whom 313 had primary outcome data at 12 months (156 [84%] of 186 patients in the CBT plus standardised medical care group and 157 [86%] of 182 patients in the standardised medical care group). At 12 months, no significant difference in monthly dissociative seizure frequency was identified between the groups (median 4 seizures [IQR 0-20] in the CBT plus standardised medical care group vs 7 seizures [1-35] in the standardised medical care group; estimated incidence rate ratio [IRR] 0•78 [95% CI 0•56-1•09]; p=0•144). Dissociative seizures were rated as less bothersome in the CBT plus standardised medical care group than the standardised medical care group (estimated mean difference -0•53 [95% CI -0•97 to -0•08]; p=0•020). The CBT plus standardised medical care group had a longer period of dissociative seizure freedom in the previous 6 months (estimated IRR 1•64 [95% CI 1•22 to 2•20]; p=0•001), reported better health-related quality of life on the EuroQoL-5 Dimensions-5 Level Health Today visual analogue scale (estimated mean difference 6•16 [95% CI 1•48 to 10•84]; p=0•010), less impairment in psychosocial functioning on the Work and Social Adjustment Scale (estimated mean difference -4•12 [95% CI -6•35 to -1•89]; p<0•001), less overall psychological distress than the standardised medical care group on the Clinical Outcomes in Routine Evaluation-10 scale (estimated mean difference -1•65 [95% CI -2•96 to -0•35]; p=0•013), and fewer somatic symptoms on the modified Patient Health Questionnaire-15 scale (estimated mean difference -1•67 [95% CI -2•90 to -0•44]; p=0•008). Clinical improvement at 12 months was greater in the CBT plus standardised medical care group than the standardised medical care alone group as reported by patients (estimated mean difference 0•66 [95% CI 0•26 to 1•04]; p=0•001) and by clinicians (estimated mean difference 0•47 [95% CI 0•21 to 0•73]; p<0•001), and the CBT plus standardised medical care group had greater satisfaction with treatment than did the standardised medical care group (estimated mean difference 0•90 [95% CI 0•48 to 1•31]; p<0•001). No significant differences in patient-reported seizure severity (estimated mean difference -0•11 [95% CI -0•50 to 0•29]; p=0•593) or seizure freedom in the last 3 months of the study (estimated odds ratio [OR] 1•77 [95% CI 0•93 to 3•37]; p=0•083) were identified between the groups. Furthermore, no significant differences were identified in the proportion of patients who had a more than 50% reduction in dissociative seizure frequency compared with baseline (OR 1•27 [95% CI 0•80 to 2•02]; p=0•313). Additionally, the 12-item Short Form survey-version 2 scores (estimated mean difference for the Physical Component Summary score 1•78 [95% CI -0•37 to 3•92]; p=0•105; estimated mean difference for the Mental Component Summary score 2•22 [95% CI -0•30 to 4•75]; p=0•084), the Generalised Anxiety Disorder-7 scale score (estimated mean difference -1•09 [95% CI -2•27 to 0•09]; p=0•069), and the Patient Health Questionnaire-9 scale depression score (estimated mean difference -1•10 [95% CI -2•41 to 0•21]; p=0•099) did not differ significantly between groups. Changes in dissociative seizures (rated by others) could not be assessed due to insufficient data. During the 12-month period, the number of adverse events was similar between the groups: 57 (31%) of 186 participants in the CBT plus standardised medical care group reported 97 adverse events and 53 (29%) of 182 participants in the standardised medical care group reported 79 adverse events. Interpretation: CBT plus standardised medical care had no statistically significant advantage compared with standardised medical care alone for the reduction of monthly seizures. However, improvements were observed in a number of clinically relevant secondary outcomes following CBT plus standardised medical care when compared with standardised medical care alone. Thus, adults with dissociative seizures might benefit from the addition of dissociative seizure-specific CBT to specialist care from neurologists and psychiatrists. Future work is needed to identify patients who would benefit most from a dissociative seizure-specific CBT approach
  • Protocol for a feasibility study of a self-help cognitive behavioural therapy resource for the reduction of dental anxiety in young people.

    Prasad, Suneeta (2016-03)
    BACKGROUND: Childhood dental anxiety is very common, with 10-20 % of children and young people reporting high levels of dental anxiety. It is distressing and has a negative impact on the quality of life of young people and their parents as well as being associated with poor oral health. Affected individuals may develop a lifelong reliance on general anaesthetic or sedation for necessary dental treatment thus requiring the support of specialist dental services. Children and young people with dental anxiety therefore require additional clinical time and can be costly to treat in the long term. The reduction of dental anxiety through the use of effective psychological techniques is, therefore, of high importance. However, there is a lack of high-quality research investigating the impact of cognitive behavioural therapy (CBT) approaches when applied to young people's dental anxiety. METHODS/DESIGN: The first part of the study will develop a profile of dentally anxious young people using a prospective questionnaire sent to a consecutive sample of 100 young people referred to the Paediatric Dentistry Department, Charles Clifford Dental Hospital, in Sheffield. The second part will involve interviewing a purposive sample of 15-20 dental team members on their perceptions of a CBT self-help resource for dental anxiety, their opinions on whether they might use such a resource with patients, and their willingness to recruit bparticipants to a future randomised controlled trial (RCT) to evaluate the resource. The third part of the study will investigate the most appropriate outcome measures to include in a trial, the acceptability of the resource, and retention and completion rates of treatment with a sample of 60 dentally anxious young people using the CBT resource. DISCUSSION: This study will provide information on the profile of dentally anxious young people who could potentially be helped by a guided self-help CBT resource. It will gain the perceptions of dental care team members of guided self-help CBT for dental anxiety in young people and their willingness to recruit participants to a trial. Acceptability of the resource to participants and retention and completion rates will also be investigated to inform a future RCT.
  • Development and Testing of a Cognitive Behavioral Therapy Resource for Children's Dental Anxiety.

    Prasad, Suneeta (2017-01)
    Cognitive Behavioral Therapy (CBT) is an evidence-based treatment for dental anxiety; however, access to therapy is limited. The current study aimed to develop a self-help CBT resource for reducing dental anxiety in children, and to assess the feasibility of conducting a trial to evaluate the treatment efficacy and cost-effectiveness of such an intervention. A mixed methods design was employed. Within phase 1, a qualitative "person-based" approach informed the development of the self-help CBT resource. This also employed guidelines for the development and evaluation of complex interventions. Within phase 2, children, aged between 9 and 16 y, who had elevated self-reported dental anxiety and were attending a community dental service or dental hospital, were invited to use the CBT resource. Children completed questionnaires, which assessed their dental anxiety and health-related quality of life (HRQoL) prior to and following their use of the resource. Recruitment and completion rates were recorded. Acceptability of the CBT resource was explored using interviews and focus groups with children, parents/carers and dental professionals. For this analysis, the authors adhered to the Mixed Methods Appraisal Tool criteria. There were 24 families and 25 dental professionals participating in the development and qualitative evaluation of the CBT resource for children with dental anxiety. A total of 56 children agreed to trial the CBT resource (66% response rate) and 48 of these children completed the study (86% completion rate). There was a significant reduction in dental anxiety (mean score difference = 7.7, t = 7.9, df = 45, P < 0.001, Cohen's d ES = 1.2) and an increase in HRQoL following the use of the CBT resource (mean score difference = -0.03, t = 2.14, df = 46, P < 0.05, Cohen's d ES = 0.3). The self-help approach had high levels of acceptability to stakeholders. These findings provide preliminary evidence for the effectiveness and acceptability of the resource in reducing dental anxiety in children and support the further evaluation of this approach in a randomized control trial. Knowledge Transfer Statement: This study details the development of a guided self-help Cognitive Behavioral Therapy resource for the management of dental anxiety in children and provides preliminary evidence for the feasibility and acceptability of this approach with children aged between 9 and 16 y. The results of this study will inform the design of a definitive trial to examine the treatment- and cost-effectiveness of the resource for reducing dental anxiety in children.
  • Challenges associated with implementation of a school-based tooth-brushing and fluoride varnish programme in a diverse and transient urban population.

    Braithwaite, M (2018-05)
    Public health competencies being illustrated; Planning, delivery and evaluation of health improvement programmes, addressing health inequalities, awareness of cultural impacts on health and wellbeing. Smile4Life, a schools-based, evidence informed oral health promotion programme, was designed to address high levels of oral health need and inequality within a UK City. The aims of the pilot described were to test the feasibility of delivering the programme (supervised tooth-brushing, take home kits, educational resources and application of fluoride varnish) in six culturally diverse schools in disadvantaged neighbourhoods, and evaluate its impact on caries prevalence. High levels of participation were achieved (98% positive consent) however only 44% received more than one application of fluoride varnish. A reduction in decay prevalence and improved oral hygiene was observed. This paper examines the challenges faced in working with transient and culturally diverse population groups, working effectively with schools to deliver an effective intervention for this population, and in responding effectively across agencies to address safeguarding concerns.
  • Children's experiences following a CBT intervention to reduce dental anxiety: one year on.

    Prasad, Suneeta (2018-08)
    Objective: To investigate children's ongoing experiences of dental care and use of strategies to manage their dental anxiety following cognitive behavioural therapy (CBT). Design: A child self-completed postal questionnaire. Settings: Hospital, community and general dental practice. Subjects: Questionnaires were sent to 44 children, aged 10–17 years who had been referred to specialist services due to their dental anxiety. Intervention: Children had all previously received a guided CBT self-help intervention to reduce their dental anxiety and, on completion of treatment, had been discharged to their referring dentist. Questionnaires were sent out 12–18 months later to ascertain dental attendance patterns and application of any strategies learnt from the previous CBT intervention. Results: 22 responses (50%) were received from 16 girls and six boys. Eighty-two percent had subsequently accessed follow-up care with a general dental practitioner and over half of these had undergone a dental procedure, other than a check-up. Ninety-one percent reported feeling less worried about dental visits, than previously, and described a change in cognition, behaviours, and feelings that allowed them to manage their anxiety better. Conclusions: CBT has positive immediate and longitudinal effects in reducing children's dental anxiety. The challenge of adopting this evidence-based approach within primary care settings remains.
  • Prevalence of active Charcot disease in the East Midlands of England

    Bunting, D (2018-10)
    AIMS: To undertake a prospective point prevalence study of the prevalence of active Charcot neuro-inflammatory osteoarthropathy (Charcot disease) in a circumscribed part of England and to audit the time elapsing between disease onset and first diagnosis. METHODS: The prevalence of active Charcot disease of the foot during a single month was assessed by specialist foot care teams at seven secondary care services in the East Midlands region of England. RESULTS: A total of 90 cases were identified, representing 4.3 per 10 000 of the 205 033 total diabetes population of the region. The time elapsed from first presentation to any healthcare professional until diagnosis was also assessed. While the diagnosis was suspected or confirmed in one-third of patients within 2 weeks, it was not made for 2 months or more in 23 patients (24%). CONCLUSIONS: Non-specialist professionals should have greater awareness of the existence of this uncommon complication of diabetes in the hope that earlier diagnosis will lead to lesser degrees of deformity.