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Behavioural Activation (BA)-a brief therapy based on the scheduling of enjoyable, purposeful and rewarding activities-is an effective and cost-effective treatment for depression in adults that shows promise for children and adolescents. We provide an update on a previous systematic review of evidence on BA-delivered in-person, telephone, or online-for depression and comorbid anxiety in children and adolescents. We conducted systematic literature searches in 6 databases up to February 2024. We included all study designs evaluating BA with participants up to 18 years old with diagnosable depression, as established by a validated screening tool or diagnostic manual. We used the Moncrieff Scale and the Cochrane Risk of Bias tool to assess study quality. We summarised the findings of all study types with a narrative synthesis and of randomised controlled trials (RCTs) with a meta-analysis. Overall, 24 studies (6 RCTs, 18 pre-post evaluations, n = 2,758) met our inclusion criteria. A meta-analysis of 4 RCTs (n = 156) showed that BA has a small effect of 0.24 (Hedge's adjusted g) in reducing depression symptoms compared to a waiting-list control, usual care and other therapies. Online and telephone-facilitated BA was shown to be feasible in 3 studies and effective in 1. Outcomes on comorbid anxiety were mixed. No economic evaluations met our inclusion criteria. BA shows sufficient promise as an intervention for reducing depression symptoms in children and adolescents to justify the need for further RCTs, providing that five conditions are met: studies are powered to detect a minimal clinically important difference; BA materials are fit-for-purpose to produce clinically meaningful change; follow-ups are longer than 6 months; primary outcomes are child-reported; and intervention costs, resource use and adverse events are reported.
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BACKGROUND: 5%-10% children and young people (CYP) experience specific phobias that impact daily functioning. Cognitive Behaviour Therapy (CBT) is recommended but has limitations. One Session Treatment (OST), a briefer alternative incorporating CBT principles, has demonstrated efficacy. The Alleviating Specific Phobias Experienced by Children Trial (ASPECT) investigated the non-inferiority of OST compared to multi-session CBT for treating specific phobias in CYP. METHODS: ASPECT was a pragmatic, multi-center, non-inferiority randomized controlled trial in 26 CAMHS sites, three voluntary agency services, and one university-based CYP well-being service. CYP aged 7-16 years with specific phobia were randomized to receive OST or CBT. Clinical non-inferiority and a nested cost-effectiveness evaluation was assessed 6-months post-randomization using the Behavioural Avoidance Task (BAT). Secondary outcome measures included the Anxiety Disorder Interview Schedule, Child Anxiety Impact Scale, Revised Children's Anxiety Depression Scale, goal-based outcome measure, and EQ-5DY and CHU-9D, collected blind at baseline and six-months. RESULTS: 268 CYPs were randomized to OST (n = 134) or CBT (n = 134). Mean BAT scores at 6 months were similar across groups in both intention-to-treat (ITT) and per-protocol (PP) populations (CBT: 7.1 (ITT, n = 76), 7.4 (PP, n = 57), OST: 7.4 (ITT, n = 73), 7.6 (PP, n = 56), on the standardized scale-adjusted mean difference for CBT compared to OST -0.123, 95% CI -0.449 to 0.202 (ITT), mean difference -0.204, 95% CI -0.579 to 0.171 (PP)). These findings were wholly below the standardized non-inferiority limit of 0.4, suggesting that OST is non-inferior to CBT. No between-group differences were found on secondary outcomes. OST marginally decreased mean service use costs and maintained similar mean Quality Adjusted Life Years compared to CBT. CONCLUSIONS: One Session Treatment has similar clinical effectiveness to CBT for specific phobias in CYP and may be a cost-saving alternative.
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Terapia Cognitivo-Comportamental , Transtornos Fóbicos , Criança , Humanos , Adolescente , Análise Custo-Benefício , Terapia Cognitivo-Comportamental/métodos , Transtornos Fóbicos/terapia , Resultado do TratamentoRESUMO
With international contributions from Denmark, Peru, Italy, Turkey, Estonia, Russia, Canada, the USA, Australia and the UK, this special issue offers insights and evidence about the technology's ability to act as a force of good and a source of harm for young people's mental health. As we better understand the complex and bidirectional relationship between technology and mental health, we need to move beyond dichotomous narratives about it being good or bad; it is both, depending on how it is used. Collective responsibility across technology companies, researchers, public services and community organisations, parents and the young people themselves can make a difference in the way technology is used to protect and improve mental health.
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Saúde da Criança , Saúde Mental , Humanos , Criança , Adolescente , Pais , Itália , EstôniaRESUMO
BACKGROUND: In the UK, around 93,000 (0.8%) children and young people (CYP) are experiencing specific phobias that have a substantial impact on daily life. The current gold-standard treatment-multi-session cognitive behavioural therapy (CBT) - is effective at reducing specific phobia severity; however, CBT is time consuming, requires specialist CBT therapists, and is often at great cost and limited availability. A briefer variant of CBT called one session treatment (OST) has been found to offer similar clinical effectiveness for specific phobia as multi-session CBT. The aim of this study was to assess the cost-effectiveness of OST compared to multi-session CBT for CYP with specific phobias through the Alleviating Specific Phobias Experienced by Children Trial (ASPECT), a two-arm, pragmatic, multi-centre, non-inferiority randomised controlled trial. METHODS: CYP aged seven to 16 years with specific phobias were recruited nationally via Health and Social Care pathways, remotely randomised to the intervention group (OST) or the control group (CBT-based therapies) and analysed (n = 267). Resource use based on NHS and personal social services perspective and quality adjusted life years (QALYs) measured by EQ-5D-Y were collected at baseline and at six-month follow-up. Incremental cost-effectiveness ratio (ICER) was calculated, and non-parametric bootstrapping was conducted to capture the uncertainty around the ICER estimates. The results were presented on a cost-effectiveness acceptability curve (CEAC). A set of sensitivity analyses (including taking a societal perspective) were conducted to assess the robustness of the primary findings. RESULTS: After adjustment and bootstrapping, on average CYP in the OST group incurred less costs (incremental cost was -£302.96 (95% CI -£598.86 to -£28.61)) and maintained similar improvement in QALYs (QALYs gained 0.002 (95% CI - 0.004 to 0.008)). The CEAC shows that the probability of OST being cost-effective was over 95% across all the WTP thresholds. Results of a set of sensitivity analyses were consistent with the primary outcomes. CONCLUSION: Compared to CBT, OST produced a reduction in costs and maintained similar improvement in QALYs. Results from both primary and sensitivity analyses suggested that OST was highly likely to be cost saving. TRIAL REGISTRATION: ISRCTN19883421 (30/11/2016).
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Terapia Cognitivo-Comportamental , Transtornos Fóbicos , Adolescente , Criança , Terapia Cognitivo-Comportamental/métodos , Análise Custo-Benefício , Humanos , Qualidade de Vida , Anos de Vida Ajustados por Qualidade de VidaRESUMO
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.
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Gastos em Saúde , Transtorno Obsessivo-Compulsivo , Adulto , Análise Custo-Benefício , Humanos , Estudos Multicêntricos como Assunto , Ensaios Clínicos Controlados Aleatórios como Assunto , Inquéritos e QuestionáriosRESUMO
Despite the many ways in which Internet-related technologies can affect psychology, research into the Internet's mental health consequences has disproportionately focussed on the narrow topics of online addiction and the closely related Internet gaming disorder. Over two decades into the online revolution, the Internet is being blamed for dramatic transformations, including a rise in extremism, social polarization and weakened democracies. In trying to understand how these shifts could have happened, or how they might be contained, society looks to mental health experts - after all, it is the interaction between technology and human psychology that is encouraging certain behaviours online and discouraging others. The field, however, has precious little to offer by way of explanations. To no small degree, this is due to the tendency to approach online psychological problems primarily through the addiction framework. The result has been to blind us to other important traits and phenomena that are playing out online and on social media, including impulsivity, aggression, inattention, narcissism and the psychological meaning of living in a postprivacy world. The article covers historical aspects of how the addiction model came to dominate the field; some insufficiently heeded early warning signals about other online ills and the big price society is paying today for this approach. We end with a call for a significant broadening of the focus of research when it comes to online psychopathology.
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Comportamento Aditivo , Jogos de Vídeo , Agressão , Atenção , Humanos , NarcisismoRESUMO
BACKGROUND: Behavioural Activation (BA) treatment effectively reduces symptoms of depression in adults and is more cost-effective than more complex therapies. Two recent systematic reviews of BA for depression in young people highlighted the need for more studies in this area. METHODS: In order to evaluate the acceptability of BA treatment for adolescents with depression and the feasibility of conducting a trial of this intervention in Child and Adolescent Mental Health Services (CAMHS), 22 patients from across three sites were randomised to BA or usual CAMHS care. Existing CAMHS staff were trained to deliver the manualised intervention via a brief course. Following treatment, young people and their parents/carers were asked to complete a feedback survey. Symptoms and functioning were assessed at 3- and 6-month follow-up. The trial was registered with the ISRCTN Registry (ref: ISRCTN52147450; https://www.isrctn.com/). RESULTS: Recruitment targets were achieved through screening large numbers of CAMHS service users. Intervention adherence by the participating adolescents was high (median number of completed BA sessions was seven out of a total of eight). There were tentative suggestions of improvements following treatment; a large change in a positive direction for the BA group, but not for usual care, was observed by visual comparisons of mean scores on measures of depression, self-esteem and functioning. No adverse events were reported. CONCLUSIONS: The findings suggest that BA in this setting is acceptable and warrants evaluation via a fully powered randomised controlled trial.
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Terapia Comportamental , Depressão , Adolescente , Adulto , Criança , Análise Custo-Benefício , Depressão/terapia , Estudos de Viabilidade , Humanos , Inquéritos e QuestionáriosRESUMO
Objectives: Numerous studies and reviews have explored the value of adding therapist support to internet self-help for improving client adherence and outcomes. This study is different as it explores the value of adding internet self-help to face-to-face therapy, from the perspective of practitioners who used both. This study explores practitioners' experiences of whether-and how-internet self-help blended with face-to-face therapy may confer an added value or become an added burden to their routine practice. Methods: Using a structured topic guide, we collected narrative data via 3 focus groups and 1 telephone interview from 11 practitioners across two sites in England. We carried out a thematic analysis within two domains, "value vs. burden". Results: Practitioners reported that internet self-help can confer added value to face-to-face therapy by: fostering client engagement with face-to-face sessions; making therapy ubiquitous beyond sessions; and preventing therapeutic drift between sessions. Conversely, internet self-help can add burden to face-to-face therapy when it is experienced as disruptive, overwhelming and time-consuming. Conclusions: Recognizing and mitigating factors that can turn internet self-help from an added value to an added burden will help practitioners adopt and make the most out of blended therapy.
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Terapia Cognitivo-Comportamental , Depressão/psicologia , Depressão/terapia , Comportamentos Relacionados com a Saúde , Intervenção Baseada em Internet , Pesquisa Qualitativa , Autocuidado , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Adulto JovemRESUMO
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.
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Terapia Cognitivo-Comportamental/métodos , Transtorno Obsessivo-Compulsivo/terapia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Reino Unido , Listas de Espera , Adulto JovemRESUMO
Virtual reality can be more effective and less burdensome than real-life exposure. Optimal virtual reality delivery should incorporate in situ direct dialogues with a therapist, discourage safety behaviours, allow for a mismatch between virtual and real exposure tasks, and encourage self-directed real-life practice between and beyond virtual reality sessions.
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Terapia Implosiva/métodos , Interface Usuário-Computador , Humanos , Terapia Implosiva/instrumentaçãoRESUMO
Among the one million suicide deaths worldwide each year, as many as 60% occur in Asia. The World Health Organization (WHO) found higher suicide rates among the elderly in rapidly industrialized Asian countries such as China, Hong Kong, Japan, South Korea, Malaysia, and Singapore, compared to the corresponding rates of recently industrializing Asian countries like Vietnam and Sri Lanka (WHO, 2014). As a case in point, suicide rates in South Korea have been the highest in the world since 2003 and are rising especially among older people (Hong and Knapp, 2014). Suicide attempts and older age are strong predictors of completed suicide (Szanto et al., 2002; Simon et al., 2013) and, as such, are important in guiding our efforts for suicide prevention; however, most epidemiological studies focus on completed suicides across all ages rather than understanding the reasons behind suicide attempts in older populations.
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Tentativa de Suicídio , Idoso , Idoso de 80 Anos ou mais , China , Estudos Transversais , Ásia Oriental , Hong Kong , Humanos , Japão , Malásia , Prevalência , República da Coreia , Fatores de Risco , SingapuraRESUMO
Delirium significantly increases morbidity and mortality in older people, especially those affected by other organic disorders, notably dementia (Siddiqi et al., 2006; Davis et al., 2012; Martins and Fernandes, 2012). Both delirium and dementia are characterized by cognitive decline through disintegration of brain functions, i.e. a "brain failure." Delirium has been described as an acute brain failure, in contrast to dementia being a chronic brain failure (Berrios, 1981). If we consider any other organ failure, for example that of kidneys, delirium superimposed on dementia resembles acute renal exacerbation superimposed on chronic renal failure. The timely recognition and treatment of acute renal failure can reverse its damaging effects, whereas chronic renal failure necessitates long-term and invasive or costly interventions (i.e. dialysis, kidney transplantation). Similarly, recognizing delirium and providing timely interventions can improve its symptoms to recover brain functions, delay cognitive decline, and alleviate distress and disability.
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Encéfalo/fisiopatologia , Delírio/diagnóstico , Demência/fisiopatologia , Idoso , Disfunção Cognitiva , Delírio/mortalidade , Humanos , Falência Renal Crônica/complicaçõesRESUMO
Abstract This case series compares patient experiences and therapeutic processes between two modalities of cognitive behaviour therapy (CBT) for depression: computerized CBT (cCBT) and therapist-delivered CBT (tCBT). In a mixed-methods repeated-measures case series, six participants were offered cCBT and tCBT in sequence, with the order of delivery randomized across participants. Questionnaires about patient experiences were administered after each session and a semi-structured interview was completed with each participant at the end of each therapy modality. Therapy expectations, patient experiences and session impact ratings in this study generally favoured tCBT. Participants typically experienced cCBT sessions as less meaningful, less positive and less helpful compared to tCBT sessions in terms of developing understanding, facilitating problem-solving and building a therapeutic relationship.
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Terapia Cognitivo-Comportamental/métodos , Transtorno Depressivo/terapia , Satisfação do Paciente , Processos Psicoterapêuticos , Terapia Assistida por Computador/métodos , Interface Usuário-Computador , Adulto , Estudos Cross-Over , Feminino , Humanos , Masculino , Adulto JovemRESUMO
BACKGROUND: User involvement is widely accepted as key for designing effective applied games for health. This especially holds true for children and young people as target audiences, whose abilities, needs, and preferences can diverge substantially from those of adult designers and players. Nevertheless, there is little shared knowledge about how concretely children and young people have been involved in the design of applied games, let alone consensus guidance on how to do so effectively. OBJECTIVE: The aim of this scoping review was to describe which user involvement methods have been used in the design of applied games with children and young people, how these methods were implemented, and in what roles children and young people were involved as well as what factors affected their involvement. METHODS: We conducted a systematic literature search and selection across the ACM Digital Library, IEEE Xplore, Scopus, and Web of Science databases using State of the Art through Systematic Review software for screening, selection, and data extraction. We then conducted a qualitative content analysis on the extracted data using NVivo. RESULTS: We retrieved 1085 records, of which 47 (4.33%) met the eligibility criteria. The chief involvement methods were participatory design (20/47, 43%) and co-design (16/47, 37%), spanning a wide range of 45 concrete activities with paper prototyping, group discussions, and playtesting being the most frequent. In only half of the studies (24/47, 51%), children and young people participated as true design partners. Our qualitative content analysis suggested 5 factors that affect their successful involvement: comprehension, cohesion, confidence, accessibility, and time constraints. CONCLUSIONS: Co-design, participatory design, and similar high-level labels that are currently used in the field gloss over very uneven degrees of participation in design and a wide variety of implementations that greatly affect actual user involvement. This field would benefit from more careful consideration and documentation of the reason of user involvement. Future research should explore concrete activities and configurations that can address the common challenges of involving children and young people, such as comprehension, cohesion, confidence, and accessibility.
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The studyWright B, Tindall L, Scott AJ, et al. One-session treatment compared with multisession CBT in children aged 7-16 years with specific phobias: the ASPECT non-inferiority RCT. Health Technol Assess 2022;26:1-174.To read the full NIHR Alert, go to: https://evidence.nihr.ac.uk/alert/one-session-cbt-treatment-effective-for-young-people-with-phobias/.
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Transtornos Fóbicos , Criança , Humanos , Adolescente , Transtornos Fóbicos/terapia , RegistrosRESUMO
BACKGROUND: Mental health problems among young people are a major global public health challenge. Psychological interventions may improve mental health, yet most are developed in western cultures, and it is unclear whether they are applicable to other geographical settings and can be delivered successfully to diverse populations. We identified empirical studies focusing upon cross-culturally adapted psychological interventions and examined the cultural adaptation process used and the effectiveness of the interventions in the treatment of depression and/or anxiety disorders among young people (defined here as children and adolescents aged between 8-18 years). METHOD: We conducted a scoping review aligning to the guidelines reported in the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Extension for Scoping Reviews (PRISMA-ScR) Statement. Stakeholder engagement enabled us to discuss the findings of the review and obtain feedback. RESULTS: We identified 17 studies of cross-culturally adapted psychological interventions that considered the appropriate language, metaphors, culturally appropriate terms, and cultural values of young people. Most studies (n = 11) adopted a randomised control trial (RCT) methodology. Six studies used the ecological validity and cultural sensitivity framework. Planned adaptation, cultural adaptation of content, and surface and deep structure level adaptations were used in other studies. Apart from one pilot study, all studies reported that culturally adapted interventions resulted in improvements in depression and/or anxiety symptoms in young people. The results suggest the potential effectiveness of cross-culturally adapted interventions within this context. Our stakeholder consultations demonstrated that engaging different community-level stakeholders in the adaptation process was highly recommended. CONCLUSIONS: Whilst most included studies indicated improvements in depression and/or anxiety symptoms in young people following a cross-culturally adapted intervention, more work is needed in this area. In particular, focus should be placed upon identifying the dimensions of interventions that should be culturally adapted to make them acceptable, engaging and effective.
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Depressão , Intervenção Psicossocial , Adolescente , Criança , Humanos , Depressão/terapia , Ansiedade/terapia , Transtornos de Ansiedade/terapia , Saúde Mental , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Adolescent depression is common, long-lasting and debilitating. Behavioural Activation (BA) is a brief, evidence-based therapy for depression in adults with promising outcomes for young people. OBJECTIVES: We sought to understand how young people, their parents and therapists experienced manualised BA for depression within Child and Adolescent Mental Health Services. DESIGN: Participants in a randomised controlled trial aged 12 to17 with depression, their parents and therapists were invited to a semi-structured interview with a researcher to explore their experiences of receiving, supporting or delivering BA. METHODS: Six young people, five parents and five therapists were interviewed. Verbatim interview transcripts were coded using thematic analysis. RESULTS: Factors that may optimise delivery of BA were: boosting the young person's motivation, tailoring parental input to the young person's needs/wishes and developing a positive collaboration between the young person and therapist. Engagement with treatment may be hindered by a mismatch between BA delivery and young person's preferences, concurrent mental health comorbidities that are not addressed within a wider care package, lack of parental support and therapist preconceptions against manualised therapy or BA. CONCLUSIONS: Manualised BA for young people requires flexibility and adjustment to meet individual and family needs. Therapist preparation could dispel hindering preconceptions about the suitability and potential value of this brief and simple intervention for young people with complex needs and different learning styles.
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Terapia Cognitivo-Comportamental , Depressão , Adulto , Criança , Adolescente , Humanos , Depressão/terapia , Depressão/psicologia , Resultado do Tratamento , Terapia Comportamental , ComorbidadeRESUMO
People with severe mental illness (SMI) have significantly poorer oral health compared to people without SMI and interventions targetted to improve oral health in this population failed to show any long-term improvement. Interventions are influenced by many contextual factors ranging from individual to systems level. This study aimed to understand the contextual factors, behaviour change techniques of the available oral health interventions and explore the barriers to and facilitators for engagement with these interventions from the perspectives of people with SMI (service users) and related service providers. Intervention details were extracted from 12 intervention studies identified from a previous systematic review using the template for intervention description and replication checklist (TIDieR) and behaviour change techniques (BCTs) were coded using the behaviour change technique taxonomy v1. Sixteen individual BCTs were identified and out of which "4.1 instructions on how to perform the behaviour" (n = 9) and "6.1 demonstration of behaviour" (n = 6) were most frequently used BCTs. Video vignettes prepared from the different intervention components identified from existing studies were shown to service users and service providers in dyadic or one-to-one interview format to elicit their views on barriers and facilitators for engagement with the intervention components. Interviews were analysed using Framework analysis and were guided by theoretical domains framework (TDF); and capability, opportunity and motivation (COM-B) model of behaviour change. Main facilitators identified to increase capability, opportunity and motivation of service users were the involvement of carers/care coordinators and integration of dental and mental health care, provision of oral health/hygiene information/products at an appropriate level and provision of tailored support according to individual needs and preferences. Barriers identified were related to lack of communication skills of the service providers, provision of coordinated care, lack of support in visiting a dentist and navigating the payment system and long follow up times. Appropriate training was considered as a facilitator, and staff turnovers and workload were considered as main barriers by the service providers. The findings suggest that comprehensive interventions that target barriers and enhance facilitators from individual to systems level are needed to improve oral health outcomes of people with SMI.
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BACKGROUND: Digital interventions (DIs) are increasingly being used in mental health care, despite limited evidence regarding their value for money. This study aimed to evaluate the cost effectiveness of DIs for generalised anxiety disorder (GAD), in comparison with alternative care options, from the perspective of the UK health care system. METHODS: An open-source decision analytic cohort model was used to extrapolate the results of a network meta-analysis over a patient's lifetime and estimate the costs and outcomes (quality-adjusted life-years) of DIs and their comparators. The net monetary benefit (NMB) and probability of cost effectiveness was estimated for each comparator, and we conducted a Value of Information analysis to evaluate the scale and drivers of uncertainty. RESULTS: DIs were associated with lower NMB compared with medication and with group therapy, but greater NMB compared with non-therapeutic controls and with usual care. DIs that were supported by a clinician, an assistant or a lay person had higher delivery costs than purely patient-self-directed DIs, yielding a greater NMB when opportunity cost was above £3000/QALY. There was considerable uncertainty in the findings driven largely by uncertainty in the estimated treatment effects. The value of further research to establish the effectiveness of DIs for GAD was substantial, at least £12.9 billion. CONCLUSIONS: The high uncertainty about these results does not allow for recommendations based on the cost effectiveness of DIs. However, the analysis highlights areas for future research, and demonstrates that apparent cost savings associated with DIs can be offset by reduced effectiveness.
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People with severe mental illness suffer from a high burden of oral diseases, which can negatively impact their physical and mental well-being. Despite the high burden, they are less likely to engage in oral health care including accessing dental services. We aimed to identify both the service users' and service providers' perspective on the barriers and facilitators for maintaining oral health and dental service use in people with severe mental illness. Qualitative exploration was undertaken using dyadic or one-to-one in-depth interviews with service users in the UK with a diagnosis of schizophrenia, schizoaffective disorder or bipolar disorder. Service providers, including mental health and dental health professionals, and informal carers (people identified as family or friend who are not paid carers) were also interviewed. Thematic analysis of the data revealed three main cross-cutting themes at the personal, inter-personal and systems level: amelioration of the problem, using a tailored approach and provision of comprehensive support. The main barriers identified were impact of mental ill-health, lack of patient involvement and tailored approach, and accessibility and availability of dental services including lack of integration of services. The main facilitators identified were service providers' effective communication skills and further support through the involvement of carers. The findings suggest that the integration of dental and mental health services to provide tailored support for overall health and well-being, including the oral health of the patient, can better support people with severe mental illness regarding their oral health needs.