Youth Culturally adapted Manual Assisted Problem Solving Training (YCMAP) in Pakistani adolescent with a history of self-harm: protocol for multicentre clinical and cost-effectiveness randomised controlled trial.

INTRODUCTION: Suicide is a global health concern. Sociocultural factors have an impact on self-harm and suicide rates. In Pakistan, both self-harm and suicide are considered as criminal offence's and are condemned on both religious and social grounds. The proposed intervention 'Youth Culturally Adapted Manual Assisted Problem Solving Training (YCMAP)' is based on principles of problem-solving and cognitive-behavioural therapy. YCMAP is a brief, culturally relevant, scalable intervention that can be implemented in routine clinical practice if found to be effective. METHOD AND ANALYSIS: A multicentre rater blind randomised controlled trial to evaluate the clinical and cost-effectiveness of YCMAP including a sample of 652 participants, aged 12-18 years, presenting to general physicians/clinicians, emergency room after self harm or self referrals. We will test the effectiveness of 8-10 individual sessions of YCMAP delivered over 3 months compared with treatment as usual. Primary outcome measure is repetition of self-harm at 12 months. The seconday outcomes include reduction in suicidal ideation, hopelessness and distress and improvement in health related quality of life. Assessments will be completed at baseline, 3, 6, 9 and 12 months postrandomisation. The nested qualitative component will explore perceptions about management of self-harm and suicide prevention among adolescents and investigate participants' experiences with YCMAP. The study will be guided by the theory of change approach to ensure that the whole trial is centred around needs of the end beneficiaries as key stakeholders in the process. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the Ethics Committee of University of Manchester, the National Bioethics Committee in Pakistan. The findings of this study will be disseminated through community workshops, social media, conference presentations and peer-reviewed journals. TRIAL REGISTRATION NUMBER: NCT04131179.

Would continuous feedback of patient's clinical outcomes to practitioners improve NHS psychological therapy services? Critical analysis and assessment of quality of existing studies.

PURPOSE: Continuous outcome monitoring studies have been conducted by one group of researchers in the United States, mainly in university counselling clinics. We completed a systematic review of continuous outcome monitoring and feedback during psychological therapy and assessed the quality and methodological rigour of existing studies to examine if the findings might be applicable to psychological therapy settings in the United Kingdom. METHODS: An electronic database literature search was carried out on studies on or after 1990 to June 2013 using strict research criteria. Independent ratings of the quality of existing studies were undertaken. RESULTS: Ten studies with original data met inclusion criteria and two meta-analyses. Feedback improves outcomes for clients who are at risk of treatment failure but effect sizes diminish with more severe psychiatric populations. No study has followed up patients to assess maintenance of gains. Study quality is highly variable. Few studies included diagnostic information and details of randomization. Clinical Support Tools are thought to be helpful but how these were used was not described. CONCLUSIONS: Although research in continuous monitoring and feedback of clinical outcomes shows promising results in counselling settings, study quality, and methodological issues set limitations on the generalizability of the findings. PRACTITIONER POINTS: Feedback improves the outcome of therapy for young people with mild problems for those who are at risk of not improving with therapy. Feedback improves outcomes for those with more severe mental health problems but with reduced effect sizes. We do not know if improved outcomes are sustained. The generalizability of the findings may be limited.

Cognitive therapy v. usual treatment for borderline personality disorder: prospective 6-year follow-up.

BACKGROUND: Longer-term follow-up of patients with borderline personality disorder have found favourable clinical outcomes, with long-term reduction in symptoms and diagnosis. AIMS: We examined the 6-year outcome of patients with borderline personality disorder who were randomised to 1 year of cognitive-behavioural therapy for personality disorders (CBT-PD) or treatment as usual (TAU) in the BOSCOT trial, in three centres across the UK (trial registration: ISRCTN86177428). METHOD: In total, 106 participants met criteria for borderline personality disorder in the original trial. Patients were interviewed at follow-up by research assistants masked to the patient's original treatment group, CBT-PD or TAU, using the same measures as in the original randomised trial. Statistical analyses of data for the group as a whole are based on generalised linear models with repeated measures analysis of variance type models to examine group differences. RESULTS: Follow-up data were obtained for 82% of patients at 6 years. Over half the patients meeting criteria for borderline personality disorder at entry into the study no longer did so 6 years later. The gains of CBT-PD over TAU in reduction of suicidal behaviour seen after 1-year follow-up were maintained. Length of hospitalisation and cost of services were lower in the CBT-PD group compared with the TAU group. CONCLUSIONS: Although the use of CBT-PD did not demonstrate a statistically significant cost-effective advantage, the findings indicate the potential for continued long-term cost-offsets that accrue following the initial provision of 1 year of CBT-PD. However, the quality of life and affective disturbance remained poor.

Comparison of alternative methods of collection of service use data for the economic evaluation of health care interventions.

Economic evaluation of health care interventions usually requires the collection of service use data to estimate the total cost of participants in an evaluation. There are a number of methods available to measure the quantity of services used but little is known about the relative accuracy of alternative methods. In a multicentre randomised controlled trial of interventions for the treatment of adults with recurrent episodes of deliberate self-harm (the POPMACT trial), health service data were collected by patient self-report after six and twelve months and also from GP records by independent investigators. Agreement for overall costs was relatively high. However, this hides substantial variation in agreement between the two sources of information for different services. The results suggest that GP records provide more accurate data on the use of general practice-based contacts than patient report, but less reliable information on contacts with other health services. Thus reliance on GP records for data on hospital services and other community health services based outside of general practice surgeries is not recommended. Future research should explore the level of agreement between patient report and other providing sector records, such as hospital records.

The cost-effectiveness of cognitive behavior therapy for borderline personality disorder: results from the BOSCOT trial.

Borderline personality disorder places a significant burden on healthcare providers and other agencies. This study evaluated the cost-effectiveness of cognitive behavior therapy plus treatment as usual compared to treatment as usual alone for patients with borderline personality disorder. The economic analysis was conducted alongside a multi-center, randomized controlled trial. The costs of primary and secondary healthcare utilization, alongside the wider economic costs, were estimated from medical records and patient self-report. The primary outcome measure used was the quality-adjusted life year (QALY), assessed using EuroQol. On average, total costs per patient in the cognitive behavior therapy group were lower than patients receiving usual care alone (-689 pounds sterling), although this group also reported a lower quality of life (-0.11 QALYs). These differences were small and did not approach conventional levels of statistical significance. The use of cognitive therapy for borderline personality disorder does not appear to demonstrate any significant cost-effective advantage based on the results of this study.