The identity of clinical associates in psychology: a cross sectional, national survey.

BACKGROUND: The Clinical Associate in Psychology (CAP) is a new psychological profession within the National Health Service (NHS) in the United Kingdom. This paper considers the processes developing the CAPs' professional identity, specifically how their roles are embedded within services. METHODS: This study utilised an online survey of CAPs and all academic, clinical and managerial staff involved with CAPs. An inductive thematic analysis was undertaken. RESULTS: A total of 164 participants responded to the survey. Five themes were identified: Widening Access to Psychology, Workforce Development, Navigating the Unfamiliar, Trained [Master's level] Professionals and An Emerging Ethos. In addition, key skills and unique contributions from CAPs were identified. CONCLUSIONS: A clear professional identity is emerging, with CAPs depicted as offering versatile interventions in diverse health care settings, fostering a positive and encouraging integration of psychological expertise into the healthcare service. The study highlights areas for development to facilitate the growth and advancement of the role within the psychological workforce.

Applying precision methods to treatment selection for moderate/severe depression in person-centered experiential therapy or cognitive behavioral therapy.

OBJECTIVE: To develop two prediction algorithms recommending person-centered experiential therapy (PCET) or cognitive-behavioral therapy (CBT) for patients with depression: (1) a full data model using multiple trial-based and routine variables, and (2) a routine data model using only variables available in the English NHS Talking Therapies program. METHOD: Data was used from the PRaCTICED trial comparing PCET vs. CBT for 255 patients meeting a diagnosis of moderate or severe depression. Separate full and routine data models were derived and the latter tested in an external data sample. RESULTS: The full data model provided the better prediction, yielding a significant difference in outcome between patients receiving their optimal vs. non-optimal treatment at 6- (Cohen's d = .65 [.40, .91]) and 12 months (d = .85 [.59, 1.10]) post-randomization. The routine data model performed similarly in the training and test samples with non-significant effect sizes, d = .19 [-.05, .44] and d = .21 [-.00, .43], respectively. For patients with the strongest treatment matching (d ≥ 0.3), the resulting effect size was significant, d = .38 [.11, 64]. CONCLUSION: A treatment selection algorithm might be used to recommend PCET or CBT. Although the overall effects were small, targeted matching yielded somewhat larger effects.

Out of pocket expenses in obsessive compulsive disorder.

BACKGROUND: Despite anecdotal evidence that the out of pocket costs of OCD can be substantial in some cases, there is no evidence on how many people they affect, or the magnitude of these costs. AIMS: This paper explores the type and quantity of out of pocket expenses reported by a large sample of adults with OCD. METHODS: Data on out of pocket expenses were collected from participants taking part in the OCTET multi-centre randomised controlled trial. Participants were aged 18+, meeting DSM-IV criteria for OCD, and scoring 16+ on the Yale Brown Obsessive Compulsive Scale. Individual-level resource use data including a description and estimated cost of out of pocket expenses were measured using an adapted version of the Adult Service Use Schedule (AD-SUS): a questionnaire used to collect data on resource use. RESULTS: Forty-five percent (208/465) reported out of pocket expenses due to their OCD. The mean cost of out of pocket expenses was £19.19 per week (SD £27.56 SD), range £0.06-£224.00. CONCLUSIONS: Future economic evaluations involving participants with OCD should include out of pocket expenses, but careful consideration of alternative approaches to the collection and costing of this data is needed.

Usability, Acceptability, and Effectiveness of Web-Based Conversational Agents to Facilitate Problem Solving in Older Adults: Controlled Study.

BACKGROUND: The usability and effectiveness of conversational agents (chatbots) that deliver psychological therapies is under-researched. OBJECTIVE: This study aimed to compare the system usability, acceptability, and effectiveness in older adults of 2 Web-based conversational agents that differ in theoretical orientation and approach. METHODS: In a randomized study, 112 older adults were allocated to 1 of the following 2 fully automated interventions: Manage Your Life Online (MYLO; ie, a chatbot that mimics a therapist using a method of levels approach) and ELIZA (a chatbot that mimics a therapist using a humanistic counseling approach). The primary outcome was problem distress and resolution, with secondary outcome measures of system usability and clinical outcome. RESULTS: MYLO participants spent significantly longer interacting with the conversational agent. Posthoc tests indicated that MYLO participants had significantly lower problem distress at follow-up. There were no differences between MYLO and ELIZA in terms of problem resolution. MYLO was rated as significantly more helpful and likely to be used again. System usability of both the conversational agents was associated with helpfulness of the agents and the willingness of the participants to reuse. Adherence was high. A total of 12% (7/59) of the MYLO group did not carry out their conversation with the chatbot. CONCLUSIONS: Controlled studies of chatbots need to be conducted in clinical populations across different age groups. The potential integration of chatbots into psychological care in routine services is discussed.

Acceptability and Effectiveness of NHS-Recommended e-Therapies for Depression, Anxiety, and Stress: Meta-Analysis.

BACKGROUND: There is a disconnect between the ability to swiftly develop e-therapies for the treatment of depression, anxiety, and stress, and the scrupulous evaluation of their clinical utility. This creates a risk that the e-therapies routinely provided within publicly funded psychological health care have evaded appropriate rigorous evaluation in their development. OBJECTIVE: This study aims to conduct a meta-analytic review of the gold standard evidence of the acceptability and clinical effectiveness of e-therapies recommended for use in the National Health Service (NHS) in the United Kingdom. METHODS: Systematic searches identified appropriate randomized controlled trials (RCTs). Depression, anxiety, and stress outcomes at the end of treatment and follow-up were synthesized using a random-effects meta-analysis. The grading of recommendations assessment, development, and evaluation approach was used to assess the quality of each meta-analytic comparison. Moderators of treatment effect were examined using subgroup and meta-regression analysis. Dropout rates for e-therapies (as a proxy for acceptability) were compared against controls. RESULTS: A total of 24 studies evaluating 7 of 48 NHS-recommended e-therapies were qualitatively and quantitatively synthesized. Depression, anxiety, and stress outcomes for e-therapies were superior to controls (depression: standardized mean difference [SMD] 0.38, 95% CI 0.24 to 0.52, N=7075; anxiety and stress: SMD 0.43, 95% CI 0.24 to 0.63, n=4863), and these small effects were maintained at follow-up. Average dropout rates for e-therapies (31%, SD 17.35) were significantly higher than those of controls (17%, SD 13.31). Limited moderators of the treatment effect were found. CONCLUSIONS: Many NHS-recommended e-therapies have not been through an RCT-style evaluation. The e-therapies that have been appropriately evaluated generate small but significant, durable, beneficial treatment effects. TRIAL REGISTRATION: International Prospective Register of Systematic Reviews (PROSPERO) registration CRD42019130184; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=130184.

Therapist personality traits as predictors of psychological treatment outcomes.

Aim: To investigate if therapists' personality influences their patients' treatment outcomes. Methods:N = 4,052 patients were treated by 69 therapists, including 36 Psychological Wellbeing Practitioners (PWPs) and 33 Cognitive Behavioural Therapists (CBTs). Therapists completed the NEO-PI-R personality inventory, they reported years of clinical experience, and expert assessors rated their clinical competence and reflective abilities. Their patients completed pre and post-treatment measures of depression (PHQ-9) and anxiety (GAD-7). Associations between therapist personality traits and patient treatment outcomes were examined using multilevel modelling, controlling for therapist demographics, clinical experience, technical competence and reflective ability. Results: Relative to other sources of variability, therapists accounted for 1% to 3% of overall variability in treatment outcomes. However, the magnitude of systematic heterogeneity in performance between therapists was around 6%, such that the best-performing therapists outperformed average therapists by a margin of moderate to large effects (g = .57-1.10). Clinical experience, technical competence and reflective ability were unrelated to treatment outcomes. Patients treated by PWPs with above-average agreeableness scores and CBTs with above-average openness to experience scores had poorer treatment outcomes. Conclusions: Therapist effects may be partly explained by the influence of their personality on their work with anxious and depressed patients.

The relationship between expected engagement and talking therapy outcome.

The aim of the study was to investigate whether client-reported expected engagement with therapy predicted therapy outcome. It was hypothesized that higher expected engagement with cognitive behavioural therapy (CBT) or person-centred experiential therapy (PCET) would predict more symptomatic improvement following therapy and higher likelihood of therapy completion. The Sheffield Expected Engagement with Therapy Scale was administered to 96 clients at pre-therapy assessment with all meeting a diagnosis of moderate or severe depression with 53 receiving CBT and 43 receiving PCET. Higher expected engagement predicted more symptomatic improvement in CBT but not PCET. Expected engagement only predicted improvement in CBT when clients rated the credibility of CBT as low or moderate. Expected engagement did not predict therapy completion in either therapy. Assessment of expected engagement could be a useful tool in prediction of symptomatic improvement in CBT.

The role of emotion in psychotherapeutic change for medically unexplained symptoms.

OBJECTIVES: Evidence of the contribution of emotional processes to the emergence, maintenance, and experience of medically unexplained symptoms (MUS) suggests that clinical approaches which target these processes could be beneficial. In this study, qualitative methods were used to examine patients' perspectives and subjective experiences of emotional processes in the context of a psychotherapy assessment and treatment service for MUS provided in a hospital emergency department (ED). METHODS: Seven semi-structured interviews were conducted with ED patients presenting with MUS who received a course of intensive short-term dynamic psychotherapy treatment. RESULTS: Interpretative phenomenological analysis was employed with three superordinate themes emerging: Barriers to examining emotional processes; reflections on the therapeutic process; psychological change; and improved well-being. Obstacles to clinical engagement in treatment for MUS were described in relation to patients' and therapists' ability to identify, address, and utilize emotion processes. Specific elements of this work were identified as integral components of the psychotherapy change process for MUS. CONCLUSIONS: Directly observing the physical effects of emotional experiencing in MUS provides sensory evidence that can enable patients to make mind-body connections. Psycho-emotional processes warrant further study to explore the applicability to other conceptual models for assessing and treating MUS. Clinical and methodological significance: In this article, we highlight that Medically Unexplained Symptoms (MUS) are a priority area for both physical and mental health care services. We present findings relevant to the effectiveness of a novel psychotherapy innovation within a hospital emergency department (ED). The use of interpretative phenomenological analysis to study the experiences of ED clients with MUS offers an established qualitative method for exploring the processes underlying therapeutic change. The results provide new insights around obstacles to engagement alongside potential solutions when addressing the psychological needs of clients with MUS. Although emotion processes have been described as a potentially important change process for MUS and in psychotherapy more generally, little empirical research has studied these two areas collectively.

Risk factors for negative experiences during psychotherapy.

BACKGROUND: It is estimated that between 3% and 15% of patients have a negative experience of psychotherapy, but little is understood about this. AIMS: The aim of this study was to investigate the factors associated with patients' negative therapy experiences. METHOD: The data comprised 185 patient and 304 therapist questionnaires, 20 patient and 20 therapist interviews. Patients reported on an unhelpful or harmful experience of therapy, and therapists on a therapy where they thought the patient they were working with had a poor or harmful experience. These were transcribed and analysed using thematic analysis. RESULTS: There was a Lack of fit between Patient needs, Therapist skills, and Service structures. This could result in Fault Lines, a tension between Safety and containment and Power and control. This tension led to Strain and Poor Engagement, which led to Consequences following the negative therapy experience. CONCLUSIONS: Patients require clear information, choice, involvement in decision-making, explicit contracting and clarity about sessions and progress. Opportunities for patient feedback should be the norm, where the therapist and service are vigilant for signs of deterioration and solutions considered. Clinical and methodological significance of this article: Estimates of "unwanted effects," including long-lasting effects, of psychotherapy have ranged from 3% to 15%. Few empirical studies have been conducted in this area. This study aimed to address this gap and provide clinicians with a model of risk factors for negative therapy effects. The findings of this study indicate the importance of providing patients with a supportive service structure that offers clear information, choice and involvement in decision-making. Explicit contracting at the beginning of therapy and clarity about sessions and progress are also important in managing patient expectations throughout. Opportunities for patient feedback should be provided.

Low-intensity cognitive-behaviour therapy interventions for obsessive-compulsive disorder compared to waiting list for therapist-led cognitive-behaviour therapy: 3-arm randomised controlled trial of clinical effectiveness.

BACKGROUND: Obsessive-compulsive disorder (OCD) is prevalent and without adequate treatment usually follows a chronic course. "High-intensity" cognitive-behaviour therapy (CBT) from a specialist therapist is current "best practice." However, access is difficult because of limited numbers of therapists and because of the disabling effects of OCD symptoms. There is a potential role for "low-intensity" interventions as part of a stepped care model. Low-intensity interventions (written or web-based materials with limited therapist support) can be provided remotely, which has the potential to increase access. However, current evidence concerning low-intensity interventions is insufficient. We aimed to determine the clinical effectiveness of 2 forms of low-intensity CBT prior to high-intensity CBT, in adults meeting the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) criteria for OCD. METHODS AND FINDINGS: This study was approved by the National Research Ethics Service Committee North West-Lancaster (reference number 11/NW/0276). All participants provided informed consent to take part in the trial. We conducted a 3-arm, multicentre randomised controlled trial in primary- and secondary-care United Kingdom mental health services. All patients were on a waiting list for therapist-led CBT (treatment as usual). Four hundred and seventy-three eligible patients were recruited and randomised. Patients had a median age of 33 years, and 60% were female. The majority were experiencing severe OCD. Patients received 1 of 2 low-intensity interventions: computerised CBT (cCBT; web-based CBT materials and limited telephone support) through "OCFighter" or guided self-help (written CBT materials with limited telephone or face-to-face support). Primary comparisons concerned OCD symptoms, measured using the Yale-Brown Obsessive Compulsive Scale-Observer-Rated (Y-BOCS-OR) at 3, 6, and 12 months. Secondary outcomes included health-related quality of life, depression, anxiety, and functioning. At 3 months, guided self-help demonstrated modest benefits over the waiting list in reducing OCD symptoms (adjusted mean difference = -1.91, 95% CI -3.27 to -0.55). These effects did not reach a prespecified level of "clinically significant benefit." cCBT did not demonstrate significant benefit (adjusted mean difference = -0.71, 95% CI -2.12 to 0.70). At 12 months, neither guided self-help nor cCBT led to differences in OCD symptoms. Early access to low-intensity interventions led to significant reductions in uptake of high-intensity CBT over 12 months; 86% of the patients allocated to the waiting list for high-intensity CBT started treatment by the end of the trial, compared to 62% in supported cCBT and 57% in guided self-help. These reductions did not compromise longer-term patient outcomes. Data suggested small differences in satisfaction at 3 months, with patients more satisfied with guided self-help than supported cCBT. A significant issue in the interpretation of the results concerns the level of access to high-intensity CBT before the primary outcome assessment. CONCLUSIONS: We have demonstrated that providing low-intensity interventions does not lead to clinically significant benefits but may reduce uptake of therapist-led CBT. TRIAL REGISTRATION: International Standard Randomized Controlled Trial Number (ISRCTN) Registry ISRCTN73535163.

The development of a change model of "exits" during cognitive analytic therapy for the treatment of depression.

OBJECTIVES: "Exits" in cognitive analytic therapy (CAT) are methods that change unhelpful patterns or roles during the final "revision" phase of the therapy. How exits are conceived and achieved is currently poorly understood. This study focussed on the revision stage to explore and define how change is accomplished in CAT. METHODS: Qualitative content analysis studied transcripts of sessions 6 and 7 of a protocol delivered 8-session CAT treatment for depression. Eight participants met the study inclusion criteria, and therefore, 16 sessions were analysed. RESULTS: The exit model developed contained 3 distinct (but interacting) phases: (a) developing an observing self via therapist input or client self-reflection, (b) breaking out of old patterns by creating new roles and procedures, and (c) utilisation of a range of methods to support and maintain change. Levels of interrater reliability for the exit categories that formed the model were good. CONCLUSIONS: The revision stage of CAT emerged as a complex and dynamic process involving 3 interacting stages. Further research is recommended to understand how exits relate to durability of change and whether change processes differ according to presenting problem. KEY PRACTITIONER MESSAGES: Exit work in cognitive analytic therapy is a dynamic process that requires progression through stages of insight, active change, and consolidation. Development of an "observing self" is an important foundation stone for change, and cognitive analytic therapists need to work within the client's zone of proximal development. A number of aspects appear important in facilitating change, such as attending to the process and feelings generated by change talk.

How do we know what makes for "best practice" in clinical supervision for psychological therapists? A content analysis of supervisory models and approaches.

Clinical supervision for psychotherapies is widely used in clinical and research contexts. Supervision is often assumed to ensure therapy adherence and positive client outcomes, but there is little empirical research to support this contention. Regardless, there are numerous supervision models, but it is not known how consistent their recommendations are. This review aimed to identify which aspects of supervision are consistent across models, and which are not. A content analysis of 52 models revealed 71 supervisory elements. Models focus more on supervisee learning and/or development (88.46%), but less on emotional aspects of work (61.54%) or managerial or ethical responsibilities (57.69%). Most models focused on the supervisee (94.23%) and supervisor (80.77%), rather than the client (48.08%) or monitoring client outcomes (13.46%). Finally, none of the models were clearly or adequately empirically based. Although we might expect clinical supervision to contribute to positive client outcomes, the existing models have limited client focus and are inconsistent. Therefore, it is not currently recommended that one should assume that the use of such models will ensure consistent clinician practice or positive therapeutic outcomes. KEY PRACTITIONER MESSAGES: There is little evidence for the effectiveness of supervision. There is a lack of consistency in supervision models. Services need to assess whether supervision is effective for practitioners and patients.

Does forming implementation intentions help people with mental health problems to achieve goals? A meta-analysis of experimental studies with clinical and analogue samples.

OBJECTIVE: People struggle to act on the goals that they set themselves, and this gap between intention and action is likely to be exacerbated by mental health problems. Evidence suggests that forming specific if-then plans (or 'implementation intentions') can promote goal attainment and a number of studies have applied such techniques in clinical contexts. However, to date, the extent to which planning can help people with mental health problems has not been systematically examined. METHOD: The present review used meta-analysis to investigate the effect of if-then planning on goal attainment among people with a DSM-IV/ICD-10 diagnosis (i.e., clinical samples) or scores above a relevant cut-off on clinical measures (i.e., analogue samples). In total, 29 experimental studies, from 18 records, met the inclusion criteria. RESULTS: Excluding one outlying (very large) effect, forming implementation intentions had a large-sized effect on goal attainment (d+ = 0.99, k = 28, N = 1,636). Implementation intentions proved effective across different mental health problems and goals, and in studies with different methodological approaches. CONCLUSIONS: Taken together, the findings suggest that forming implementation intentions can be a useful strategy for helping people with mental health problems to achieve various goals and might be usefully integrated into existing treatment approaches. However, further studies are needed addressing a wider range of mental health problems.

Developing Services for Patients with Depression or Anxiety in the Context of Long-term Physical Health Conditions and Medically Unexplained Symptoms: Evaluation of an IAPT Pathfinder Site.

BACKGROUND: There are national policy drivers for mental health services to demonstrate that they are effectively meeting the psychological needs of people with long-term health conditions/medically unexplained symptoms (LTC/MUS). AIMS: To evaluate the implementation of a stepped-care service delivery model within an Improving Access to Psychological Therapies (IAPT) service for patients with depression or anxiety in the context of their LTC/MUS. METHOD: A stepped-care model was designed and implemented. Clinical and organizational impacts were evaluated via analyses of LTC/MUS patient profiles, throughputs and outcomes. RESULTS: The IAPT service treated N = 844 LTC and N = 172 MUS patients, with the majority (81.81%) receiving a low intensity intervention. Dropout across the service steps was low. There were few differences between LTC and MUS outcome rates regardless of step of service, but outcomes were suppressed when compared to generic IAPT patients. CONCLUSIONS: The potential contribution of IAPT stepped-care service delivery models in meeting the psychological needs of LTC/MUS patients is debated.

An investigation of client mood in the initial and final sessions of cognitive-behavioral therapy and psychodynamic-interpersonal therapy.

OBJECTIVE: Our aim was to examine client mood in the initial and final sessions of cognitive-behavioral therapy (CBT) and psychodynamic-interpersonal therapy (PIT) and to determine how client mood is related to therapy outcomes. METHODS: Hierarchical linear modeling was applied to data from a clinical trial comparing CBT with PIT. In this trial, client mood was assessed before and after sessions with the Session Evaluation Questionnaire-Positivity Subscale (SEQ-P). RESULTS: In the initial sessions, CBT clients had higher pre-session and post-session SEQ-P ratings and greater pre-to-post session mood change than did clients in PIT. In the final sessions, these pre, post, and change scores were generally equivalent across CBT and PIT. CBT outcome was predicted by pre- and post-session SEQ-P ratings from both the initial sessions and the final sessions of CBT. However, PIT outcome was predicted by pre- and post-session SEQ-P ratings from the final sessions only. Pre-to-post session mood change was unrelated to outcome in both treatments. CONCLUSIONS: These results suggest different change processes are at work in CBT and PIT.

The Content, Quality and Impact of Cognitive Behavioural Case Formulation During Treatment of Obsessive Compulsive Disorder.

BACKGROUND: Case formulation (CF) is considered a core component of cognitive behavioural therapy (CBT). Despite this, few studies have explored the content and quality of CFs in routine practice and any associated impact on treatment outcome. AIMS: This study investigated (1) the content, timing and quality of CF for patients (N = 29) with Obsessive Compulsive Disorder; (2) the impact of CF on symptoms, distress and therapeutic alliance; and (3) the relationship between CF quality and treatment outcome. METHOD: CF content and quality were assessed from audiotapes of routine CBT sessions using a validated coding manual and evaluated against treatment outcomes at different stages of therapy. RESULTS: CFs were developed early during treatment and contained strong behavioural and cognitive components, with a focus on symptoms and maintaining factors. CF quality ratings ranged from rudimentary to excellent. A significant improvement in distress and the therapeutic alliance occurred following the introduction of CF, but no significant relationship was found between CF quality and outcome at any stage of treatment. CONCLUSION: CF may be valuable in reducing patient attrition, due to its impact early in treatment. Further research is needed to explore the most important components of CF. Theoretically sound and disorder specific measurement tools for evaluating CFs are required.

Treatment of paranoid personality disorder with cognitive analytic therapy: a mixed methods single case experimental design.

UNLABELLED: Paranoid personality disorder (PPD) presents as chronic and widespread interpersonal distrust, whereby the actions of others are interpreted as malevolent and malicious. This research details the assessment, formulation and treatment of a case of PPD within a 24-session contract of cognitive analytic therapy (CAT). The outcome methodology was an A/B with extended follow-up single case experimental design (SCED). The SCED was supplemented with qualitative patient interviewing via the Change Interview regarding their experience of CAT, whether change had taken place and detailing of any identified change mechanisms. Quantitative results show that five out of the six daily rated paranoia target complaint measures were extinguished during the treatment phase. Qualitatively, the patient attributed change to the therapy conducted. The results suggest that CAT was an effective intervention in this case of PPD and are discussed in terms of identified methodological shortcomings, treatment implications and the potential for generating a convincing evidence base for the psychotherapy of PPD. KEY PRACTITIONER MESSAGE: Narrative reformulation using a CAT model offers a key opportunity for the patient to achieve a new understanding of their paranoia. Psychotherapy for PPD requires a cognitive component, within a boundaried and relational therapy, that is able to reflect on paranoid enactments and ruptures within the therapeutic relationship.There is a large role for clinician-researchers in developing a PPD outcome evidence base.

Alliance ruptures and resolution during cognitive behaviour therapy with patients with borderline personality disorder.

OBJECTIVE: To explore the process of rupture resolution in cognitive behaviour therapy (CBT) with two good outcome clients with borderline personality disorder (BPD). METHOD: This study employed task-analytic methods to investigate whether the existing CBT rupture resolution model for depression could be validated. Quantitative analyses identified rupture-repair sequences and 41 rupture resolution attempts were systematically analysed. RESULTS: The final model shared similarities with the existing model although additional components, including an "external observer" were identified. Focus on affective experience was also hypothesized to be important. CONCLUSIONS: The final theoretical rupture resolution model may be a useful tool when working with BPD clients in CBT. It is however recognized that further research on data from larger samples is needed. Clinical implications for managing alliance ruptures with BPD clients are discussed.

The work and social adjustment scale: reliability, sensitivity and value.

OBJECTIVE: To investigate the psychometric properties of the Work and Social Adjustment Scale (WSAS) as an outcome measure for the Improving Access to Psychological Therapy programme, assessing its value as an addition to the Patient Health (PHQ-9) and Generalised Anxiety Disorder questionnaires (GAD-7). Little research has investigated these properties to date. METHODS: Reliability and responsiveness to change were assessed using data from 4,835 patients. Principal components analysis was used to determine whether the WSAS measures a factor distinct from the PHQ-9 and GAD-7. RESULTS: The WSAS measures a distinct social functioning factor, has high internal reliability, and is sensitive to treatment effects. CONCLUSIONS: The WSAS, PHQ-9 and GAD-7 perform comparably on measures of reliability and sensitivity. The WSAS also measures a distinct social functioning component suggesting it has potential as an additional outcome measure.

Cost-effectiveness of an improving access to psychological therapies service.

BACKGROUND: Effective psychological therapies have been recommended for common mental health problems, such as depression and anxiety, but provision has been poor. Improving Access to Psychological Therapies (IAPT) may provide a cost-effective solution to this problem. AIMS: To determine the cost-effectiveness of IAPT at the Doncaster demonstration site (2007-2009). METHOD: An economic evaluation comparing costs and health outcomes for patients at the IAPT demonstration site with those for comparator sites, including a separate assessment of lost productivity. Sensitivity analyses were undertaken. RESULTS: The IAPT site had higher service costs and was associated with small additional gains in quality-adjusted life-years (QALYs) compared with its comparator sites, resulting in a cost per QALY gained of £29 500 using the Short Form (SF-6D). Sensitivity analysis using predicted EQ-5D scores lowered this to £16 857. Costs per reliable and clinically significant (RCS) improvement were £9440 per participant. CONCLUSIONS: Improving Access to Psychological Therapies provided a service that was probably cost-effective within the usual National Institute for Health and Clinical Excellence (NICE) threshold range of £20 000-30 000, but there was considerable uncertainty surrounding the costs and outcome differences.