Subjective seizure symptom reporting in functional/dissociative seizures and epilepsy: Effects of sampling technique and patient characteristics.

BACKGROUND: Differences in subjectively reportable ictal experiences between epilepsy and functional/dissociative seizures (FDS) have received less attention than visible manifestations. Patients with FDS (pwFDS) tend to report seizure symptoms differently than patients with epilepsy (pwE). The effects of symptom elicitation method and mediation by psychopathological traits have not been examined and may aid in differentiating the disorders. METHOD: Analysis of responses of 24 pwE and 28 pwFDS in interviews exploring ictal experiences through open questioning followed by structured closed questioning using possible symptom prompts (74-item modified Psychosensory-Psychomotor Phenomena Interview, PPPI); self-report of psychological profile (HADS-A, HADS-D, PHQ-15, DES-T, THQ, PCL-C). RESULTS: Symptom prompting with PPPI elicited three times more seizure symptoms than open questions in pwE (median 34 vs. 11.5, p = 0.005) and over four times more in pwFDS (42.5 vs. 11, p = 0.001). Intra-ictal symptoms were reported freely more frequently by pwE (median 6.5 vs. 4, p = 0.005), while pwFDS reported more pre-ictal symptoms after prompts (median 6 vs 14.5, p = 0.004). The difference between freely reported and PPPI-elicited symptoms correlated with different psychopathological traits in pwE and pwFDS. Symptoms of anxiety (HADS-A) correlated more strongly with prompted symptoms among pwE than pwFDS (z = 2.731, p = 0.006). CONCLUSION: Prompting generates more detailed ictal symptom profiles than simply encouraging patients to narrate their subjective seizure experiences. While pwFDS freely reported fewer symptoms related to the intra-ictal period compared to pwE, pwFDS reported more pre-ictal symptoms than pwE when prompted. Differences in the psychopathological traits associated with the number of peri-ictal symptoms captured by symptom prompting in pwE and pwFDS possibly reflect etiological or psychological differences between these patient groups.

'So just to go through the options ': patient choice in the telephone delivery of the NHS Improving Access to Psychological Therapies services.

This article considers patient choice in mental healthcare services, specifically the ways that choice is enabled or constrained in patient-practitioner spoken interaction. Using the method of conversation analysis (CA), we examine the language used by practitioners when presenting treatment delivery options to patients entering the NHS Improving Access to Psychological Therapies (IAPT) service. Analysis of 66 recordings of telephone-delivered IAPT assessment sessions revealed three patterns through which choice of treatment delivery mode was presented to patients: presenting a single delivery mode; incrementally presenting alternative delivery modes, in response to patient resistance; and parallel presentation of multiple delivery mode options. We show that a distinction should be made between (i) a choice to accept or reject the offer of a single option and (ii) a choice that is a selection from a range of options. We show that the three patterns identified are ordered in terms of patient-centredness and shared decision-making. Our findings contribute to sociological work on healthcare interactions that has identified variability in, and variable consequences for, the ways that patients and practitioners negotiate choice and shared decision-making. Findings are discussed in relation to tensions between the political ideology of patient choice and practical service delivery constraints.

What influences practitioners' readiness to deliver psychological interventions by telephone? A qualitative study of behaviour change using the Theoretical Domains Framework.

BACKGROUND: Contemporary health policy is shifting towards remotely delivered care. A growing need to provide effective and accessible services, with maximal population reach has stimulated demand for flexible and efficient service models. The implementation of evidence-based practice has been slow, leaving many services ill equipped to respond to requests for non-face-to-face delivery. To address this translation gap, and provide empirically derived evidence to support large-scale practice change, our study aimed to explore practitioners' perspectives of the factors that enhance the delivery of a NICE-recommended psychological intervention, i.e. guided self-help by telephone (GSH-T), in routine care. We used the Theoretical Domains Framework (TDF) to analyse our data, identify essential behaviour change processes and encourage the successful implementation of remote working in clinical practice. METHOD: Thirty-four psychological wellbeing practitioners (PWPs) from the UK NHS Improving Access to Psychological Therapies (IAPT) services were interviewed. Data were first analysed inductively, with codes cross-matched deductively to the TDF. RESULTS: Analysis identified barriers to the delivery, engagement and implementation of GSH-T, within eight domains from the TDF: (i) Deficits in practitioner knowledge, (ii) Sub-optimal practitioner telephone skills, (iii) Practitioners' lack of beliefs in telephone capabilities and self-confidence, (iv) Practitioners' negative beliefs about consequences, (v) Negative emotions, (vi) Professional role expectations (vii) Negative social influences, and (viii) Challenges in the environmental context and resources. A degree of interdependence was observed between the TDF domains, such that improvements in one domain were often reported to confer secondary advantages in another. CONCLUSIONS: Multiple TDF domains emerge as relevant to improve delivery of GSH-T; and these domains are theoretically and practically interlinked. A multicomponent approach is recommended to facilitate the shift from in-person to telephone-based service delivery models, and prompt behaviour change at practitioner, patient and service levels. At a minimum, the development of practitioners' telephone skills, an increase in clients' awareness of telephone-based treatment, dilution of negative preconceptions about telephone treatment, and robust service level guidance and standards for implementation are required. This is the first study that provides clear direction on how to improve telephone delivery and optimise implementation, aligning with current mental health policy and service improvement.

'I didn't know what to expect': Exploring patient perspectives to identify targets for change to improve telephone-delivered psychological interventions.

BACKGROUND: Remote delivery of psychological interventions to meet growing demand has been increasing worldwide. Telephone-delivered psychological treatment has been shown to be equally effective and as satisfactory to patients as face-to-face treatment. Despite robust research evidence, however, obstacles remain to the acceptance of telephone-delivered treatment in practice. This study aimed to explore those issues using a phenomenological approach from a patient perspective to identify areas for change in current provision through the use of theoretically based acceptability and behaviour change frameworks. METHODS: Twenty-eight semi-structured interviews with patients experiencing symptoms of common mental health problems, waiting, receiving or having recently received telephone-delivered psychological treatment via the UK National Health Service's Improving Access to Psychological Therapies (IAPT) programme. Interviews were recorded, transcribed verbatim, and analysed using the Theoretical Domains Framework (TDF) and Theoretical Framework of Acceptability (TFA). RESULTS: The majority of data clustered within five key domains of the TDF (knowledge, skills, cognitive and interpersonal, environmental context and resources, beliefs about capabilities, beliefs about consequences) and mapped to all constructs of the TFA (affective attitude, ethicality, intervention coherence, self-efficacy, burden, opportunity costs, and perceived effectiveness). Themes highlighted that early stages of treatment can be affected by lack of patient knowledge and understanding, reservations about treatment efficacy, and practical obstacles such as absent non-verbal communication, which is deemed important in the development of therapeutic alliance. Yet post-treatment, patients can reflect more positively, and report gaining benefit from treatment. However, despite this, many patients say that if they were to return for future treatment, they would choose to see a practitioner face-to-face. CONCLUSIONS: Using a combination of theoretically underpinned models has allowed the identification of key targets for change. Addressing knowledge deficits to shift attitudes, highlighting the merits of telephone delivered treatment and addressing skills and practical issues may increase acceptability of, and engagement with, telephone-delivered treatment.

An Interactional Profile to Assist the Differential Diagnosis of Neurodegenerative and Functional Memory Disorders.

OBJECTIVE: Specialist services for dementia are seeing an increasing number of patients. We investigated whether interactional and linguistic features in the communication behavior of patients with memory problems could help distinguish between those with problems secondary to neurological disorders (ND) and those with functional memory disorder (FMD). METHODS: In part 1 of this study, a diagnostic scoring aid (DSA) was developed encouraging linguists to provide quantitative ratings for 14 interactional features. An optimal cut-off differentiating ND and FMD was established by applying the DSA to 30 initial patient-doctor memory clinic encounters. In part 2, the DSA was tested prospectively in 10 additional cases analyzed independently by 2 conversation analysts blinded to medical information. RESULTS: In part 1, the median score of the DSA was +5 in ND and -5 in FMD (P<0.001). The optimal numeric DSA cut-off (+1) identified patients with ND with a sensitivity of 86.7% and a specificity of 100%. In part 2, DSA scores of rater 1 correctly predicted 10/10 and those of rater 2 predicted 9/10 diagnoses. CONCLUSIONS: This study indicates that interactional and linguistic features can help distinguish between patients developing dementia and those with FMD and could aid the stratification of patients with memory problems.

Using routine outcome measures as clinical process tools: Maximising the therapeutic yield in the IAPT programme when working remotely.

OBJECTIVES: The objective of the study was to investigate the administration and use of routine outcome monitoring session by session in the context of improving guided-self-help interventions when delivered remotely at Step 2 care in the English Improving Access to Psychological Therapies (IAPT) services. DESIGN: Qualitative research using recordings of telephone-treatment sessions. METHOD: Participants (11 patients and 11 practitioners) were recruited from four nationally funded IAPT services and one-third sector organisation commissioned to deliver Step 2 IAPT services, in England. Data collection took place prior to the COVID-19 pandemic. Transcripts of telephone-treatment sessions were analysed using thematic analysis. RESULTS: Four themes were identified: (1) lack of consistency in the administration of outcome measures (e.g. inconsistent wording); (2) outcome measures administered as a stand-alone inflexible task (e.g. mechanical administration); (3) outcome measures as impersonal numbers (e.g. summarising, categorising and comparing total scores); and (4) missed opportunities to use outcome measures therapeutically (e.g. lack of therapeutic use of item and total scores). CONCLUSIONS: The administration of outcome measures needs to ensure validity and reliability. Therapeutic yield from session-by-session outcome measures could be enhanced by focusing on three main areas: (1) adopting a collaborative conversational approach, (2) maximising the use of total and items scores and (3) integrating outcome measures with in-session treatment decisions. Shifting the perception of outcome measures as impersonal numbers to being process clinical tools ensures a personalised delivery of psychological interventions and has the potential to enhance engagement from practitioners and patients what may reduce drop-out rates and improve clinical outcomes.

Enhancing the Behaviour Change Wheel with synthesis, stakeholder involvement and decision-making: a case example using the 'Enhancing the Quality of Psychological Interventions Delivered by Telephone' (EQUITy) research programme.

BACKGROUND: Using frameworks such as the Behaviour Change Wheel to develop behaviour change interventions can be challenging because judgement is needed at various points in the process and it is not always clear how uncertainties can be resolved. We propose a transparent and systematic three-phase process to transition from a research evidence base to a behaviour change intervention. The three phases entail evidence synthesis, stakeholder involvement and decision-making. We present the systematic development of an intervention to enhance the quality of psychological treatment delivered by telephone, as a worked example of this process. METHOD: In phase 1 (evidence synthesis), we propose that the capabilities (C), opportunities (O) and motivations (M) model of behaviour change (COM-B) can be used to support the synthesis of a varied corpus of empirical evidence and to identify domains to be included in a proposed behaviour change intervention. In phase 2 (stakeholder involvement), we propose that formal consensus procedures (e.g. the RAND Health/University of California-Los Angeles Appropriateness Methodology) can be used to facilitate discussions of proposed domains with stakeholder groups. In phase 3 (decision-making), we propose that behavioural scientists identify (with public/patient input) intervention functions and behaviour change techniques using the acceptability, practicability, effectiveness/cost-effectiveness, affordability, safety/side-effects and equity (APEASE) criteria. RESULTS: The COM-B model was a useful tool that allowed a multidisciplinary research team, many of whom had no prior knowledge of behavioural science, to synthesise effectively a varied corpus of evidence (phase 1: evidence synthesis). The RAND Health/University of California-Los Angeles Appropriateness Methodology provided a transparent means of involving stakeholders (patients, practitioners and key informants in the present example), a structured way in which they could identify which of 93 domains identified in phase 1 were essential for inclusion in the intervention (phase 2: stakeholder involvement). Phase 3 (decision-making) was able to draw on existing Behaviour Change Wheel resources to revisit phases 1 and 2 and facilitate agreement among behavioural scientists on the final intervention modules. Behaviour changes were required at service, practitioner, patient and community levels. CONCLUSION: Frameworks offer a foundation for intervention development but require additional elucidation at each stage of the process. The decisions adopted in this study are designed to provide an example on how to resolve challenges while designing a behaviour change intervention. We propose a three-phase process, which represents a transparent and systematic framework for developing behaviour change interventions in any setting.

Person-centred experiential therapy versus cognitive behavioural therapy delivered in the English Improving Access to Psychological Therapies service for the treatment of moderate or severe depression (PRaCTICED): a pragmatic, randomised, non-inferiority trial.

BACKGROUND: The UK Government's implementation in 2008 of the Improving Access to Psychological Therapies (IAPT) initiative in England has hugely increased the availability of cognitive behavioural therapy (CBT) for the treatment of depression and anxiety in primary care. Counselling for depression-a form of person-centred experiential therapy (PCET)-has since been included as an IAPT-approved therapy, but there is no evidence of its efficacy from randomised controlled trials (RCTs), as required for recommendations by the National Institute for Health and Care Excellence. Therefore, we aimed to examine whether PCET is cost effective and non-inferior to CBT in the treatment of moderate and severe depression within the IAPT service. METHODS: This pragmatic, randomised, non-inferiority trial was done in the Sheffield IAPT service in England and recruited participants aged 18 years or older with moderate or severe depression on the Clinical Interview Schedule-Revised. We excluded participants presenting with an organic condition, a previous diagnosis of personality disorder, bipolar disorder, or schizophrenia, drug or alcohol dependency, an elevated clinical risk of suicide, or a long-term physical condition. Eligible participants were randomly assigned (1:1), independently of the research team, and stratified by site with permuted block sizes of two, four, or six, to receive either PCET or CBT by use of a remote, web-based system that revealed therapy after patient details were entered. Those assessing outcomes were masked to treatment allocation. Participants were seen by appropriately trained PCET counsellors and CBT therapists in accordance with the IAPT service delivery model. Depression severity and symptomatology measured by the Patient Health Questionnaire-9 (PHQ-9) at 6 months post-randomisation was the primary outcome, with the PHQ-9 score at 12 months post-randomisation being a key secondary outcome. These outcomes were analysed in the modified intention-to-treat population, which comprised all randomly assigned patients with complete data, and the per-protocol population, which comprised all participants who did not switch from their randomised treatment and received between four and 20 sessions. Safety was analysed in all randomly assigned patients. The non-inferiority margin was set a priori at 2 PHQ-9 points. Patient safety was monitored throughout the course of therapy, adhering to service risk procedures for monitoring serious adverse events. This trial is registered at the ISRCTN Registry, ISRCTN06461651, and is complete. FINDINGS: From Nov 11, 2014, to Aug 3, 2018, 9898 patients were referred to step three treatments in the Sheffield IAPT service for common mental health problems, of whom 761 (7·7%) were referred to the trial. Of these, we recruited and randomly assigned 510 participants to receive either PCET (n=254) or CBT (n=256). In the PCET group, 138 (54%) participants were female and 116 (46%) were male, and 225 (89%) were White, 16 (6%) were non-White, and 13 (5%) had missing ethnicity data. In the CBT group, 155 (61%) participants were female and 101 (39%) were male, and 226 (88%) were White, 17 (7%) were non-White, and 13 (5%) had missing ethnicity data. The 6-month modified intention-to-treat analysis comprised 401 (79%) of the enrolled participants (201 in the PCET group; 200 in the CBT group) and the 12-month modified intention-to-treat analysis comprised 319 participants (167 in the PCET group; 152 in the CBT group). The 6-month per-protocol analysis comprised 298 participants (154 in the PCET group; 144 in the CBT group). At 6 months post-randomisation, PCET was non-inferior to CBT in the intention-to-treat population (mean PHQ-9 score 12·74 [SD 6·54] in the PCET group and 13·25 [6·35] in the CBT group; adjusted mean difference -0·35 [95% CI -1·53 to 0·84]) and in the per-protocol population (12·73 [SD 6·57] in the PCET group and 12·71 [6·33] in the CBT group; 0·27 [95% CI -1·08 to 1·62]). At 12 months post-randomisation, there was a significant adjusted between-group difference in mean PHQ-9 score in favour of CBT (1·73 [95% CI 0·26-3·19]), with a 95% CI exceeding the 2-point non-inferiority margin. There were two deaths, one death by suicide in the PCET group and one due to chronic obstructive pulmonary disease in the CBT group. Both were assessed by the responsible clinician to be unrelated to the trial. In terms of using emergency departments for depression-related events, four people (three in the PCET group; one in the CBT group) made more than a single use and six people (three in the PCET group; three in the CBT group) made a single use. One patient in the PCET group had inpatient treatment for a depression-related event. INTERPRETATION: This trial is the first to examine the two most frequently administered psychological therapies in the IAPT service. The finding of non-inferiority of PCET to CBT at 6 months supports the results from large, routine, non-randomised datasets from the IAPT programme. Given the high demand for psychological therapies and the need for patient choice, our findings suggest the need for continued investment in the training and delivery of PCET for improving short-term outcomes, but suggest that PCET might be inferior to CBT at 12 months. FUNDING: British Association for Counselling and Psychotherapy Research Foundation.