Telephone treatments in Improving Access to Psychological Therapies services: an analysis of use and impact on treatment uptake.

BACKGROUND: There is debate about how best to increase access to psychological therapy and deliver mental healthcare effectively and efficiently at a national level. One trend is the increased use of the telephone to deliver therapy. However, there is the potential to disadvantage certain patient groups and/or impact on uptake of help. This study aims to answer three questions: (i) Which factors are associated with being offered an assessment by telephone? (ii) Which factors are associated with attendance at assessment? and (iii) What is the impact of an assessment by telephone on subsequent treatment appointment? METHODS: Routine outcome data was provided by seven UK Improving Access to Psychological Therapy services. The analysis sample comprised 49,923 patients who referred to 615 general practices in 2017. Multilevel modelling, including service and GP practice as random factors, was used to answer the three research questions. RESULTS: The offer of an initial assessment by telephone was strongly associated with local service configuration. Patient self-referral, a shorter wait, greater age and lower deprivation were associated with attendance at assessment and subsequent treatment session. Telephone mode assessment had no impact on the uptake of the assessment but may influence the uptake of further treatment if this was also by telephone. The practitioner carrying out the assessment had a significant effect on subsequent treatment uptake. CONCLUSION: Offering telephone assessments does not have a negative impact on uptake of assessment and services may benefit by facilitating and integrating telephone assessments into their systems. The COVID-19 pandemic has accelerated the use of telephone and other remote means of delivery, and results from this study can inform services to consider how best to re-configure post-pandemic.

Enhancing the quality of psychological interventions delivered by telephone in mental health services: increasing the likelihood of successful implementation using a theory of change.

BACKGROUND: The implementation of new and complex interventions in mental health settings can be challenging. This paper explores the use of a Theory of Change (ToC) for intervention design and evaluation to increase the likelihood of complex interventions being effective, sustainable, and scalable. Our intervention was developed to enhance the quality of psychological interventions delivered by telephone in primary care mental health services. METHODS: A ToC represents how our designed quality improvement intervention targeting changes at service, practitioner, and patient levels was expected to improve engagement in, and the quality of, telephone-delivered psychological therapies. The intervention was evaluated following implementation in a feasibility study within three NHS Talking Therapies services through a qualitative research design incorporating semi-structured interviews and a focus group with key stakeholders (patients, practitioners, and service leads) (N = 15). Data were analysed using the Consolidated Framework for Implementation Research (CFIR) and the ToC was examined and modified accordingly following the findings. RESULTS: CFIR analysis highlighted a set of challenges encountered during the implementation of our service quality improvement telephone intervention that appeared to have weakened the contribution to the change mechanisms set out by the initial ToC. Findings informed changes to the intervention and refinement of the ToC and are expected to increase the likelihood of successful future implementation in a randomised controlled trial. CONCLUSIONS: Four key recommendations that could help to optimise implementation of a complex intervention involving different key stakeholder groups in any setting were identified. These include: 1-developing a good understanding of the intervention and its value among those receiving the intervention; 2-maximising engagement from key stakeholders; 3-ensuring clear planning and communication of implementation goals; and 4-encouraging the use of strategies to monitor implementation progress.

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.

The effects of structure, process and outcome incentives on primary care referrals to a national prevention programme.

Despite widespread use, evidence is sparse on whether financial incentives in healthcare should be linked to structure, process or outcome. We examine the impact of different incentive types on the quantity and effectiveness of referrals made by general practices to a new national prevention programme in England. We measured effectiveness by the number of referrals resulting in programme attendance. We surveyed local commissioners about their use of financial incentives and linked this information to numbers of programme referrals and attendances from 5170 general practices between April 2016 and March 2018. We used multivariate probit regressions to identify commissioner characteristics associated with the use of different incentive types and negative binomial regressions to estimate their effect on practice rates of referral and attendance. Financial incentives were offered by commissioners in the majority of areas (89%), with 38% using structure incentives, 69% using process incentives and 22% using outcome incentives. Compared to practices without financial incentives, neither structure nor process incentives were associated with statistically significant increases in referrals or attendances, but outcome incentives were associated with 84% more referrals and 93% more attendances. Outcome incentives were the only form of pay-for-performance to stimulate more participation in this national disease prevention programme.

Conceptualising the social networks of vulnerable children and young people: a systematic review and narrative synthesis.

PURPOSE: The relationship between social networks and health and wellbeing is increasingly demonstrated in vulnerable adult populations. This relationship for vulnerable children and young people has not hitherto been systematically reviewed. This narrative synthesis aims to consolidate research to provide a foundational basis for future health-related social network research and interventions for children and young people. METHODS: This mixed methods systematic review synthesises research investigating whole, egocentric social networks of 32 vulnerable child groups with a mean age below 18. There were no setting, language or date restrictions. The quality was assessed using the Mixed Methods Appraisal Tool. Of 6360 search results, 49 were included for narrative synthesis. RESULTS: The majority of pertinent research originates from the USA; the most frequently investigated vulnerabilities were minority ethnic status, homelessness and the presence of special educational needs. Research aims and methodologies varied significantly between studies. Key findings included (i) vulnerable (excluding minority ethnic) children and young people have impoverished networks (ii) access to networks is a protective factor against negative outcomes (iii) social ties, primarily immediate family, provide access to personal resources and (iv) network ties are to a degree substitutable. CONCLUSIONS: Networks are associated with wellbeing and vulnerable children and young people commonly have impoverished networks, excluding cases where vulnerability classification relates to minority ethnic status. Network embeddedness is associated with positive outcomes, particularly for homeless children. Family are typically primary providers of support, but ties are substitutable when networks are restricted. Egocentric social network research is currently limited for vulnerable child populations. Further research could inform interventions that harness networks to improve health, wellbeing and functional outcomes for these child 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.

Effects of parental mental illness on children's physical health: systematic review and meta-analysis.

BACKGROUND: Children of parents with mental disorder face multiple challenges. AIMS: To summarise evidence about parental mental disorder and child physical health. METHOD: We searched seven databases for cohort or case-control studies quantifying associations between parental mental disorders (substance use, psychotic, mood, anxiety, obsessive-compulsive, post-traumatic stress and eating) and offspring physical health. Studies were excluded if: they reported perinatal outcomes only (<28 days) or outcomes after age 18; they measured outcome prior to exposure; or the sample was drawn from diseased children. A meta-analysis was conducted. The protocol was registered on the PROSPERO database (CRD42017072620). RESULTS: Searches revealed 15 945 non-duplicated studies. Forty-one studies met our inclusion criteria: ten investigated accidents/injuries; eight asthma; three other atopic diseases; ten overweight/obesity; ten studied other illnesses (eight from low-and middle-income countries (LMICs)). Half of the studies investigated maternal perinatal mental health, 17% investigated paternal mental disorder and 87% examined maternal depression. Meta-analysis revealed significantly higher rates of injuries (OR = 1.15, 95% CI 1.04-1.26), asthma (OR = 1.26, 95% CI 1.12-1.41) and outcomes recorded in LMICs (malnutrition: OR = 2.55, 95% CI 1.74-3.73; diarrhoea: OR = 2.16, 95% CI 1.65-2.84). Evidence was inconclusive for obesity and other atopic disorders. CONCLUSIONS: Children of parents with mental disorder have health disadvantages; however, the evidence base is limited to risks for offspring following postnatal depression in mothers and there is little focus on fathers in the literature. Understanding the physical health risks of these vulnerable children is vital to improving lives. Future work should focus on discovering mechanisms linking physical and mental health across generations. DECLARATION OF INTEREST: None.

'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.

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.

Correction to: A case of misalignment: the perspectives of local and national decision-makers on the implementation of psychological treatment by telephone in the Improving Access to Psychological Therapies Service.

In the original publication of this article [1], the article title should be revised as blow.

Testing the psychometric properties of the illness perceptions questionnaire for OCD (IPQ-O).

BACKGROUND: Previous research has shown that our perceptions about illness are important determinants of how we respond and adjust to health threats. To examine whether illness perceptions affect illness responses in OCD (e.g. help-seeking), this study aimed to develop and test the psychometric properties of a new OCD-specific tool to assess illness perceptions, the illness perceptions questionnaire for OCD (IPQ-O). METHODS: A cross-sectional questionnaire-based design was used. Following adaptation of the IPQ-R based on qualitative interviews with people with OCD, adults (age ≥ 16) with OCD completed the IPQ-O (online or postal), alongside measures of depression, anxiety, OCD severity, attitudes to seeking mental health services and behaviours (e.g. treatment seeking intentions). A sub-sample re-completed the IPQ-O after two-weeks to obtain test-retest reliability. Factor analysis was used to derive the IPQ-O factor structure; internal consistency of subscales was calculated. Convergent validity was explored. RESULTS: Three hundred forty-eight people with OCD completed the IPQ-O. After factor analysis, seven main sub-scales and four cause sub-scales were identified, explaining 45.5 and 41.6% of the variance after extraction and rotation respectively. Three sub-scales from the original IPQ-R were validated; other dimensions differed from original IPQ-R sub-scales. The new 'spectrum' sub-scale measures the strength of the view that OCD is a trait that presents to varying extents within the general population. The IPQ-O demonstrated internal consistency, test re-test reliability (Kendall's tau = .51-.75) and convergent validity. Illness perceptions were associated with important aspects of adjustment (depression, anxiety) and condition management (receipt of treatment, plans to seek help). In particular, emerging data showed that those who had not received medication for OCD endorsed stronger spectrum beliefs. Though longitudinal study is needed to verify the direction of this association, this raises the question of whether spectrum beliefs deter people with OCD from using pharmacological treatments. CONCLUSIONS: The IPQ-O provides a valuable tool for subsequent testing of whether illness perceptions drive outcomes as proposed by the CSM. If perceptions are found to drive adjustment and behaviour, therapists could elicit and subsequently challenge perceptions that have negative effects on adjustment and coping, as part of psychological therapy.

Implementing a national diabetes prevention programme in England: lessons learned.

BACKGROUND: Type 2 diabetes mellitus is preventable through lifestyle intervention. Diabetes prevention programmes (DPPs) aim to deliver prevention-based behaviour change interventions to reduce incidence. Such programmes vary from usual primary care in terms of where, how, and by whom they are delivered. Implementation is therefore likely to face new commissioning, incentive and delivery challenges. We report on the implementation of a national DPP in NHS England, and identify lessons learned in addressing the implementation challenges. METHODS: In 2017/18, we conducted 20 semi-structured telephone interviews covering 16 sampled case sites with the designated lead(s) responsible for local implementation of the programme. Interviews explored the process of implementation, including organisation of the programme, expectations and attitudes to the programme, funding, target populations and referral and clinical pathways. We drew on constant comparative methods to analyse the data and generate over-arching themes. We complemented our qualitative data with a survey focused on variation in the financial incentives used across sites to ensure usual primary care services recruited patients to new providers. RESULTS: We identified five over-arching areas of learning for implementing this large-scale programme: 1) managing new providers; 2) promoting awareness of services; 3) recruiting patients; 4) incentive payments; and 5) mechanisms for sharing learning. In general, tensions appeared to be caused by a lack of clear roles/responsibilities between hierarchical actors, and lack of communication. Both local sites and the national NHS coordination team gained experience through learning by doing. Initial tensions with roles and expectations have been worked out during implementation. CONCLUSIONS: Implementing a national disease prevention programme is a major task, and one that will be increasingly faced by health systems globally as they aim to adjust to demand pressures. We provide practical learning opportunities for the wider uptake and sustainability of prevention programmes. Future implementers might wish to define clear responsibilities for each actor prior to implementation, ensure early engagement with new providers, offer mechanisms/forums for sharing learning, generate evidence and provide advice on incentive payments, and prioritise public and professional awareness of the programme.

A case of misalignment: the perspectives of local and national decision-makers on the implementation of psychological treatment by telephone in the Improving Access to Psychological Therapies Service.

BACKGROUND: Psychological treatment delivered by telephone is recommended by the National Institute for Health and Care Excellence (NICE) for mild to moderate depression and anxiety, and forms a key part of the Improving Access to Psychological Therapy (IAPT) programme in the UK. Despite evidence of clinical effectiveness, patient engagement is often not maintained and psychological wellbeing practitioners (PWPs) report lacking confidence and training to deliver treatment by telephone. This study aimed to explore the perspectives of professional decision makers (both local and national) on the barriers and facilitators to the implementation of telephone treatment in IAPT. METHODS: Sixteen semi-structured qualitative telephone interviews and one focus group were carried out with decision makers (n = 21) who were involved locally and nationally in policy, practice and research. The interviews and focus group were coded thematically, and then mapped onto the four core constructs of Normalisation Process Theory (NPT). RESULTS: The use of telephone for psychological treatment was universally recognised amongst participants as beneficial for improving patient choice and access to treatment. However, at service level, motives for the implementation of telephone treatments are often misaligned with national objectives. Pressure to meet performance targets has become a key driver for the use of telephone treatment, with promises of increased efficiency and cost savings. These service-focussed objectives challenge the integration of telephone treatments, and PWP acceptance of telephone treatments as non-inferior to face-to-face. Ambivalence among a workforce often lacking the confidence to deliver telephone treatments leads to reluctance among PWPs to 'sell' treatments to a patient population who are not generally expecting treatment in this form. CONCLUSIONS: Perceptions of a need to 'sell' telephone treatment in IAPT persist from top-level decision makers down to frontline practitioners, despite their conflicting motives for the use of telephone. The need for advocacy to highlight the clinical benefit of telephone treatment, along with adequate workforce support and guidance on best practice for implementation is critical to the ongoing success and sustainability of telephone treatment in primary care mental health programmes.

Collaborative, individualised lifestyle interventions are acceptable to people with first episode psychosis; a qualitative study.

BACKGROUND: The adverse impact of unhealthy lifestyle choices and the prescription of antipsychotic medications contribute to weight gain, poor cardiovascular health and reduced life expectancy for people with psychosis. The present study aimed to explore the acceptability and perceived outcomes of a lifestyle intervention designed to prevent or reduce weight gain in people with first-episode psychosis. METHODS: This was a qualitative study using a data-driven approach. People recovering from first-episode psychosis recruited from UK early intervention services and taking part in the active arm of a randomised controlled trial of a lifestyle intervention (the InterACT trial), were interviewed using a semi-structured interview schedule. Interviews were transcribed verbatim and analysed using Framework Analysis. RESULTS: Participants valued the collaborative and individualised approach taken by the intervention deliverers, and formed high quality relationships with them. Aspects of the intervention that were positively appraised included goal setting, social opportunities, and progress monitoring. Benefits of the intervention, including increased levels of exercise; improved diet and physical health; increased psychological wellbeing (e.g. confidence, self-esteem); and improved social relationships, were identified by participants, independent of actual weight loss. CONCLUSIONS: Future interventions should ensure that workers have the skills to form high quality relationships with users, and to individualise the intervention according to users' needs and preferences. Future trials that test healthy living interventions should consider supplementing physical outcome measures with wider psychosocial outcome assessments, in particular social relationship quality, psychological wellbeing, self-esteem and self-efficacy. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN22581937 . Date of registration: 27 October 2010 (retrospectively registered).

A qualitative study of professional stakeholders' perceptions about the implementation of a stepped care pain platform for people experiencing chronic widespread pain.

BACKGROUND: Chronic widespread pain (CWP) is a major public health problem. Many people experiencing CWP experience mental health problems such as anxiety or depression. Complete relief of skeletal and body pain symptoms is unlikely but with appropriate treatment the impact upon quality of life, functioning and mental health symptoms can be reduced. Cognitive behavioural therapy (CBT) is widely used for a range of health conditions and can have short and long-term improvements in patients with CWP. This research aimed to explore, from a professional stakeholder perspective, the implementation of a local Pain Platform offering a stepped care approach for interventions including telephone delivered CBT (T-CBT). METHODS: Fourteen professional stakeholders holding various roles across primary and secondary care services within the Pain Platform took part in semi-structured interviews. Their views and experiences of the implementation of the Pain Platform were explored. Interviews were recorded, transcribed verbatim and analysed according to Normalisation Process Theory (NPT). RESULTS: Professional stakeholders were positive about the Pain Platform and its potential to overcome previously identified existing access issues to psychological interventions for CWP patients. It was considered a valuable part of ensuring that patients' preferences and needs are more readily addressed. In some circumstances, however, introducing psychological interventions to patients was considered challenging and the introduction of new referral processes was raised concerns. To ensure sustainability more work is required to reduce professional isolation and ensure efficient referral procedures between primary and secondary care services are established to reduce concerns over issues related to clinical governance and potential risk to patient. CONCLUSIONS: The findings provide professional insight into the key challenges of introducing a Pain Platform incorporating psychological support across primary and secondary care services within a local service. These included development of sustainable procedures and closer working relationships. Areas requiring future development are identified.

@Home eTherapy Service for People with Common Mental Health Problems: an Evaluation.

BACKGROUND: Ensuring rapid access to psychological interventions is a priority of mental health services. The involvement of peer workers to support the delivery of more accessible treatment options such as computerized cognitive behaviour therapy (CCBT) is recognized. AIMS: To evaluate the implementation of a third sector remote CCBT @Home eTherapy service for people experiencing common mental health problems supported by individuals with lived experience. METHOD: Supported CCBT packages with telephone support were delivered over a 30-month period. Self-complete measures identifying levels of depression, anxiety and functioning were administered at each treatment appointment. RESULTS: Over 2000 people were referred to the @Home eTherapy service; two-thirds attended an initial assessment and 53.4% of referrals assigned to CCBT completed treatment. Statistically significant improvements in anxiety, depression and functioning were found, with 61.6% of treated clients meeting recovery criteria. CONCLUSIONS: The service meets Improving Access to Psychological Therapies (IAPT) key performance targets, and is comparable to other IAPT services using CCBT. Evidence for the successful implementation of such a service by a third sector organization is 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.

Low intensity interventions for Obsessive-Compulsive Disorder (OCD): a qualitative study of mental health practitioner experiences.

BACKGROUND: Obsessive-compulsive disorder (OCD) is a debilitating mental health disorder that can substantially impact upon quality of life and everyday functioning. Guidelines recommend pharmacological and psychological treatments, using a cognitive behaviour therapy approach (CBT) including exposure and response prevention, but access has generally been poor. Low intensity psychological interventions have been advocated. The evidence base for these interventions is emerging but there is a paucity of information regarding practitioners' perceptions and experiences of supporting individuals with OCD using this approach. METHODS: Qualitative interviews were undertaken with psychological wellbeing practitioners (PWPs) (n = 20) delivering low intensity psychological interventions for adults with OCD within the context of a large pragmatic effectiveness trial. Interviews explored the feasibility and acceptability of delivering two interventions; guided self-help and supported computerised cognitive behaviour therapy (cCBT), within Improving Access to Psychological Therapies (IAPT) services in NHS Trusts. Interviews were recorded with consent, transcribed and analysed using thematic analysis. RESULTS: PWPs acknowledged the benefits of low intensity psychological interventions for individuals experiencing OCD symptoms on an individual and population level. Offering low intensity support provided was perceived to have the opportunity to overcome existing service barriers to access treatment, improve patient choice and flexibility. Professional and service relevant issues were also recognised including self-beliefs about supporting people with OCD and personal training needs. Challenges to implementation were recognised in relation to practitioner resistance and intervention delivery technical complications. CONCLUSIONS: This study has provided insight into the implementation of new low intensity approaches to the management of OCD within existing mental health services. Benefits from a practitioner, service and patient perspective are identified and potential challenges highlighted. TRIAL REGISTRATION: Current Controlled Trials: ISRCTN73535163 . Date of registration: 5 April 2011.

Decision making in stepped care: how do therapists decide whether to prolong treatment or not?

BACKGROUND: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to "step up" patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. AIMS: To investigate factors that influence psychological therapists' decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. METHOD: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of "holding" non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. RESULTS: A 4-factor solution indicated that clinicians' decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. CONCLUSIONS: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

Conceptualizing the social networks of children of parents with serious mental illness: a thematic analysis.

Aims: Social networks, defined as the set of active and significant ties surrounding an individual, influence the wellbeing of vulnerable children. The best evidenced mechanism through which this occurs is where networks act as a vehicle to access social support. Little is known about the content and function of social networks of children of parents with severe and enduring mental illness (COPMI). COPMI are a frequently under-identified vulnerable child population at risk of negative outcomes. This qualitative study investigates the structure, role and function of these children's networks. Methods: Researchers conducted 17 semi-structured egocentric social network interviews. Interviews incorporated personal network mapping as a data collection method. COPMI were recruited through third sector organizations and interviewed across three sites in England. Data was analyzed using an inductive thematic analysis. Results: Five network features were identified (i) parents as primary providers of support (i) limited networks and diminished connections over time (iii) substitutable ties (formal and informal) (iv) peer connections as source of both support and strain (v) coping strategies: self-censorship, avoidance and animals. Conclusion: Children of parents with severe and enduring mental illness networks are structurally typical of vulnerable children in that they are limited, rely on parents as primary ties but allow for some substitution of support ties. COPMI-specific features included peer relationships at times as source of strain and network level coping strategies used to manage wellbeing, including pets. This latter reflects previous findings in vulnerable adult populations so far unevidenced in children. Little evidence as to the mechanistic effect at work within networks was collected. However, COPMI were clearly shown to be engaged in active management and strategising in network navigation approaches, indicating the need to engage with children in this capacity, rather than approaching them as passive recipients of support. As such, effective network level interventions for this group are likely to prioritize access to beneficial substitute ties when support is limited. Additionally, interventions that promote network navigation skills and help foster productive coping strategies can capitalize on the child's active management role within their network.