Recent Submissions

  • Associations between treatment adherence-competence-integrity (ACI) and adult psychotherapy outcomes : a systematic review and meta-analysis.

    Power, Niall; Firth, Nick
    Objective: To provide a comprehensive assessment of the association between psychological treatment adherence/competence/integrity (ACI) and clinical outcomes. Method: The review protocol was pre registered (CRD42020193889). Studies that assessed ACI-outcome relationships for adult psychotherapy were searched across three databases (Scopus, PsycINFO, MEDLINE). Random effects meta-analyses were conducted on adherence-outcome, competence-outcome and integrity-outcome relationships. Separate analyses were performed for studies with hierarchical (i.e. patients nested within therapist) versus non-hierarchical study designs. Moderator analyses were performed according to pre defined clinical and methodological features. GRADE assessments rated the quality of each meta analytic comparison. Results: The review identified 62 studies suitable for inclusion (45 adherence outcome, 39 competence-outcome and 7 integrity-outcome effect sizes; N=8,210 across all analyses). No significant adherence-outcome association was found. A small significant positive association was found only in non-hierarchical studies between competence and outcome (r = 0.17, 95% CI [0.07- 0.26], p < 0.001, ~d = .34, GRADE = moderate). Small-to-moderate significant positive associations between integrity and outcome were found for both non-hierarchical (r = 0.15, 95% CI [0.06 – 0.23], p < 0.001, ~d = .30, GRADE = high) and hierarchical study designs (r = 0.23, 95% CI [0.01,0.43], p < 0.044, ~d = .47, GRADE = low). Diagnosis, treatment modality and year of publication significantly moderated the strength of ACI-outcome correlations. Conclusions: Competence and integrity are significantly associated with clinical outcome, with a magnitude comparable to wider common factors. Further research is required to study these process-outcome associations with greater precision in routine-care settings and to understand the role of moderating variables.
  • The effect of different degrees of lockdown and self-identified gender on anxiety, depression and suicidality during the COVID-19 pandemic: Data from the international COMET-G study.

    Mahalingappa, Sridevi
    INTRODUCTION: During the COVID-19 pandemic various degrees of lockdown were applied by countries around the world. It is considered that such measures have an adverse effect on mental health but the relationship of measure intensity with the mental health effect has not been thoroughly studied. Here we report data from the larger COMET-G study pertaining to this question. MATERIAL AND METHODS: During the COVID-19 pandemic, data were gathered with an online questionnaire from 55,589 participants from 40 countries (64.85% females aged 35.80 ± 13.61; 34.05% males aged 34.90±13.29 and 1.10% other aged 31.64±13.15). Anxiety was measured with the STAI, depression with the CES-D and suicidality with the RASS. Distress and probable depression were identified with the use of a previously developed cut-off and algorithm respectively. STATISTICAL ANALYSIS: It included the calculation of Relative Risk (RR), Factorial ANOVA and Multiple backwards stepwise linear regression analysis RESULTS: Approximately two-thirds were currently living under significant restrictions due to lockdown. For both males and females the risk to develop clinical depression correlated significantly with each and every level of increasing lockdown degree (RR 1.72 and 1.90 respectively). The combined lockdown and psychiatric history increased RR to 6.88 The overall relationship of lockdown with severity of depression, though significant was small. CONCLUSIONS: The current study is the first which reports an almost linear relationship between lockdown degree and effect in mental health. Our findings, support previous suggestions concerning the need for a proactive targeted intervention to protect mental health more specifically in vulnerable groups.
  • 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, 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