A meta-analysis of targeted interventions for reducing suicide-related behaviour and ideation in adolescents: Implications for trial design.

INTRODUCTION: Suicidality among young people is a significant societal issue. The current study conducted a meta-analysis of community and clinical interventions targeting suicide attempts, self-harm, and suicidal ideation in adolescents. METHODS: Interventions targeting suicide attempts, self-harm and suicidal ideation were identified by searching PsychINFO, Medline, CINAHL and Embase in line with the PRISMA statement. Study quality was determined using a risk of bias tool. Meta-analyses examined the efficacy of the interventions. Effect sizes were calculated for suicidal ideation data (continuous data) using Hedge's g for standardised mean differences. Suicide attempts and self-harm (dichotomous data) were calculated using odds ratios (ORs). RESULTS: Seventeen RCTs were included in the meta-analysis. No significant differences were found between treatment and control groups on measures of suicide attempts or self-harm. A small effect-size was observed on measures of suicidal ideation (g = 0.47). A secondary meta-analysis investigated change over time in treatment as usual conditions, finding significant large effect-sizes for suicide attempts (OR = 18.67), self-harm (OR = 12.77), and suicidal ideation (g = 0.86). LIMITATIONS: The methodological decision to focus on specific outcomes over a broad definition of self-harm excluded some papers, which have been included in other reviews. It is unlikely to have significantly affected the overall results. The review was not preregistered. CONCLUSIONS: These twin findings highlight the importance overcoming the methodological difficulty of discerning effective interventions during a period of baseline improvement. We suggest that future trials should move away from broadly addressing "suicidality/self-harm" and encourage a greater targeting of at-risk individuals.

Effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression: Meta-analysis.

OBJECTIVE: To investigate the effectiveness of a freely available computerised cognitive behavioural therapy programme (MoodGYM) for depression (primary outcome), anxiety and general psychological distress in adults. METHOD: We searched PsycINFO, CINAHL Plus, MEDLINE, EMBASE, Social Science Citation Index and references from identified papers. To assess MoodGYM's effectiveness, we conducted random effects meta-analysis of identified randomised controlled trials. RESULTS: Comparisons from 11 studies demonstrated MoodGYM's effectiveness for depression symptoms at post-intervention, with a small effect size ( g = 0.36, 95% confidence interval: 0.17-0.56; I2 = 78%). Removing the lowest quality studies ( k = 3) had minimal impact; however, adjusting for publication bias reduced the effect size to a non-significant level ( g = 0.17, 95% confidence interval: -0.01 to 0.38). Comparisons from six studies demonstrated MoodGYM's effectiveness for anxiety symptoms at post-intervention, with a medium effect size ( g = 0.57, 95% confidence interval: 0.20-0.94; I2 = 85%). Although comparisons from six studies did not yield significance for MoodGYM's effectiveness for general psychological distress symptoms, the small effect size approached significance ( g = 0.34, 95% confidence interval: -0.04 to 0.68; I2 = 79%). Both the type of setting (clinical vs non-clinical) and MoodGYM-developer authorship in randomised controlled trials had no meaningful influence on results; however, the results were confounded by the type of control deployed, level of clinician guidance, international region of trial and adherence to MoodGYM. CONCLUSIONS: The confounding influence of several variables, and presence of publication bias, means that the results of this meta-analysis should be interpreted with caution. Tentative support is provided for MoodGYM's effectiveness for symptoms of depression and general psychological distress. The programme's medium effect on anxiety symptoms demonstrates its utility for people with this difficulty. MoodGYM benefits from its free accessibility over the Internet, but adherence rates can be problematic and at the extreme can fall below 10%. We conclude that MoodGYM is best placed as a population-level intervention that is likely to benefit a sizeable minority of its users.

The effectiveness of interventions targeting the stigma of mental illness at the workplace: a systematic review.

BACKGROUND: The majority of people experiencing mental-health problems do not seek help, and the stigma of mental illness is considered a major barrier to seeking appropriate treatment. More targeted interventions (e.g. at the workplace) seem to be a promising and necessary supplement to public campaigns, but little is known about their effectiveness. The aim of this systematic review is to provide an overview of the evidence on the effectiveness of interventions targeting the stigma of mental illness at the workplace. METHODS: Sixteen studies were included after the literature review. The effectiveness of anti-stigma interventions at the workplace was assessed by examining changes in: (1) knowledge of mental disorders and their treatment and recognition of signs/symptoms of mental illness, (2) attitudes towards people with mental-health problems, and (3) supportive behavior. RESULTS: The results indicate that anti-stigma interventions at the workplace can lead to improved employee knowledge and supportive behavior towards people with mental-health problems. The effects of interventions on employees' attitudes were mixed, but generally positive. The quality of evidence varied across studies. CONCLUSIONS: This highlights the need for more rigorous, higher-quality evaluations conducted with more diverse samples of the working population. Future research should explore to what extent changes in employees' knowledge, attitudes, and supportive behavior lead to affected individuals seeking help earlier. Such investigations are likely to inform important stakeholders about the potential benefits of current workplace anti-stigma interventions and provide guidance for the development and implementation of effective future interventions.

Capturing patients' needs in casemix: a systematic literature review on the value of adding functioning information in reimbursement systems.

BACKGROUND: Contemporary casemix systems for health services need to ensure that payment rates adequately account for actual resource consumption based on patients' needs for services. It has been argued that functioning information, as one important determinant of health service provision and resource use, should be taken into account when developing casemix systems. However, there has to date been little systematic collation of the evidence on the extent to which the addition of functioning information into existing casemix systems adds value to those systems with regard to the predictive power and resource variation explained by the groupings of these systems. Thus, the objective of this research was to examine the value of adding functioning information into casemix systems with respect to the prediction of resource use as measured by costs and length of stay. METHODS: A systematic literature review was performed. Peer-reviewed studies, published before May 2014 were retrieved from CINAHL, EconLit, Embase, JSTOR, PubMed and Sociological Abstracts using keywords related to functioning ('Functioning', 'Functional status', 'Function*, 'ICF', 'International Classification of Functioning, Disability and Health', 'Activities of Daily Living' or 'ADL') and casemix systems ('Casemix', 'case mix', 'Diagnosis Related Groups', 'Function Related Groups', 'Resource Utilization Groups' or 'AN-SNAP'). In addition, a hand search of reference lists of included articles was conducted. Information about study aims, design, country, setting, methods, outcome variables, study results, and information regarding the authors' discussion of results, study limitations and implications was extracted. RESULTS: Ten included studies provided evidence demonstrating that adding functioning information into casemix systems improves predictive ability and fosters homogeneity in casemix groups with regard to costs and length of stay. Collection and integration of functioning information varied across studies. Results suggest that, in particular, DRG casemix systems can be improved in predicting resource use and capturing outcomes for frail elderly or severely functioning-impaired patients. CONCLUSION: Further exploration of the value of adding functioning information into casemix systems is one promising approach to improve casemix systems ability to adequately capture the differences in patient's needs for services and to better predict resource use.

Effectiveness of cognitive behavioural therapy for anxiety and depression in primary care: a meta-analysis.

BACKGROUND: Cognitive behavioural therapy (CBT) is increasingly being delivered in primary care, in a variety of delivery formats such as guided self-help CBT, telephone-based CBT, computerized CBT and standard, one-to-one CBT. However, the vast majority of research has focused on CBT in specialized services, and no previous meta-analysis has examined CBT's effectiveness across delivery formats in primary care. OBJECTIVE: To determine the effectiveness of multi-modal CBT (i.e. CBT across delivery formats) for symptoms of anxiety and depression, in primary care. METHODS: A meta-analysis of CBT-focused RCTs, for symptoms of anxiety or depression, in primary care. The authors searched four databases. To be included, RCTs had to be set in primary care or have primary care participants. RESULTS: Twenty-nine RCTs were included in three separate meta-analyses. Results showed multi-modal CBT was more effective than no primary care treatment (d =0.59), and primary care treatment-as-usual (TAU) (d = 0.48) for anxiety and depression symptoms. Moreover, multi-modal CBT in addition to primary care TAU was shown to be more effective than primary care TAU for depression symptoms (no comparisons of this kind were available for anxiety) (d = 0.37). CONCLUSIONS: The results from conducted meta-analyses indicate that multi-modal CBT is effective for anxiety and depression symptoms in primary care. Furthermore, based on CBT's economic viability, increasing the provision of CBT in primary care seems justified. Future research should examine if varying levels of qualification among primary care CBT practitioners impacts on the effectiveness of CBT in this setting.

A randomized controlled trial of the computerized CBT programme, MoodGYM, for public mental health service users waiting for interventions.

OBJECTIVES: To evaluate the effectiveness of the computerized CBT (cCBT) programme, MoodGYM, for the reduction in symptoms of general psychological distress (the primary outcome), depression, anxiety, stress, and impaired daily functioning. DESIGN: A randomized controlled trial, with a waiting list control condition, in a routine clinical setting. METHODS: Participants were 149 public mental health service users (aged 18-61 [M = 35.3 years; SD = 10.3]) waiting for interventions. Self-report outcome measures were administered online at baseline and post-intervention (i.e., after 32 days). RESULTS: After high dropout rates, a post-intervention completers analysis examined 28 MoodGYM participants and 38 waiting list control participants. MoodGYM was significantly more effective than the waiting list control for the reduction of symptoms of general psychological distress (F[1, 64] = 4.45; p < .05) and stress (F[1, 64] = 5.35; p < .05) but not depression, anxiety, or impaired daily functioning. CONCLUSIONS: Due to their high associated dropout rates, self-help cCBT programmes such as MoodGYM should not be provided as front-line treatments. However, as it is likely to be agreeable and beneficial to some service users, perhaps self-help cCBT should be provided as an additional treatment option.

Does affect mediate the relationship between interpersonal trauma and psychosis? A systematic review and meta-analysis.

INTRODUCTION: The relationship between interpersonal trauma and psychosis is well established, and research is now focused on identifying mechanisms that may explain this relationship. Models of trauma and psychosis increasingly emphasize a broad range of affective processes, yet the overall effect of these affective processes is not well understood. AIM: This review systematically examined the effect of any form of long-term affective dysfunction on the relationship between interpersonal trauma and psychosis. Where possible, it used meta-analytic techniques to quantify the overall magnitude of this effect. METHOD: Searches were conducted using PsychINFO, MEDLINE and CINAHL databases, and eligible studies were appraised for methodological quality. Narrative synthesis and meta-analytic methods were used to evaluate evidence. RESULTS: Twenty-nine studies met criteria for inclusion. Five affective mediators were found; depression, anxiety, affective dysregulation, loneliness and attachment. Findings from both the narrative synthesis (n = 29) and meta-analysis (n = 8) indicated that, overall, affect is a small but significant mediator of the relationship between interpersonal trauma and psychosis (pooled Cohen's d = 0.178; pooled 95 % CI: 0.022-0.334). CONCLUSIONS: Overall, findings support affective pathways to psychosis, though highlight the need for further research on broader affective mediators (loneliness, shame). The small effect size found in the meta-analysis also points to the potential importance of non-affective mediators. Clinically, these findings highlight the value of treatment modalities that attend to multiple mechanisms in the relationship between interpersonal trauma and psychosis. Future research should focus on the interplay and causal sequence between these mechanisms to further understand pathways between interpersonal trauma and psychosis.

Consensus on the perceived presence of transtheoretical principles of change in routine psychotherapy practice: A survey of clinicians and researchers.

Goldfried (1982) hypothesized that there are five transtheoretical principles of change that guide routine psychotherapy practice. This survey investigated if there is consensus on the perceived presence of these principles in the approaches of a professionally diverse pool of psychotherapy clinicians and researchers. One thousand nine hundred ninety-eight participants, aged 21-85 years (M = 50.4 years, SD = 15.59) and representing a wide variety of theoretical orientations, completed an online survey. For consensus to be indicated, 95% confidence intervals of mean agreement scores had to be above 4.0 (out of 5). Mean agreement levels in response to "the extent to which you agree that the following principles are present in your own approach to psychotherapy" indicated consensus for all five principles: (a) fostering hope, positive expectations, and motivation (M = 4.58; 95% CI [4.53, 4.62]); (b) facilitating the therapeutic alliance (M = 4.76; 95% CI [4.73, 4.80]); (c) increasing awareness and insight (M = 4.66; 95% CI [4.63, 4.70]); (d) encouraging corrective experiences (M = 4.44; 95% CI [4.39, 4.48]); (e) emphasizing ongoing reality testing (M = 4.15; 95% CI [4.09, 4.20]). These findings were unaffected by age, gender, working patterns, practice (clinician or researcher), and years of experience; however, consensus on the final two principles was not indicated for both psychodynamic and experiential psychotherapists. The demonstrated consensus surrounding the transtheoretical principles of change corresponds with their consistently yielded outcome associations in previous research. The combination of these evidence sources points to the importance of the principles in routine psychotherapy practice, which warrants further investigation. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The effectiveness of the loci method as a mnemonic device: Meta-analysis.

The "loci method" is a popular mnemonic device that involves visualising and recalling items at specific points along a familiar route. The loci method has been used for thousands of years, and by many successful memory athletes; yet there have been relatively few educational and clinical applications, possibly owing to empirical uncertainty. The current meta-analysis of 13 randomised controlled trials (RCTs) mostly based in university settings demonstrated the effectiveness of the loci method as a mnemonic device, with a medium effect size (g = 0.65, 95% confidence interval [CI] = [0.45, 0.85]; I2 = 45.5%). The effect size remained at similar levels in further analyses adjusting for publication bias, the impact of removing each study, setting, control conditions, outliers, and number of loci method sessions. High risk of experimental bias was indicated, however, as the vast majority of studies did not report procedures to minimise biases relating to random sequence generation and allocation concealment. Overall, this meta-analysis of predominantly university-based RCTs has provided good initial support for the loci method as a mnemonic device and this may encourage future investigations and applications, particularly in educational settings, where it has the potential to improve recall of information relevant to academic success.

Effectiveness of a tailored, integrative Internet intervention (deprexis) for depression: Updated meta-analysis.

Digitally delivered interventions for depression vary in many aspects, including their therapeutic orientation, depth of content, interactivity, individual tailoring, inclusion of multimedia, cost, and effectiveness. However, their effectiveness is rarely examined in intervention-specific meta-analyses. An earlier meta-analysis of eight randomized controlled trials (RCT) demonstrated the effectiveness of a tailored, integrative digital intervention (deprexis), which is delivered via the Internet. This updated meta-analysis of twelve deprexis-specific RCT with a total of N = 2901 participants confirmed the effectiveness of deprexis for depression reduction at post-intervention (g = 0.51, 95% CI: 0.40-0.62, I2 = 26%). Results were analogous when study quality, screening and randomization procedure were taken into account. Clinician guidance, developer-involvement, setting (community vs. clinical), and initial symptom severity did not have statistically significant effects on the effect size, and there was no evidence of publication bias. Thus, these findings demonstrate that deprexis can facilitate clinically relevant reduction of depressive symptoms over 8-12 weeks across a broad range of initial symptom severity, and that the intervention can be combined with other forms of depression treatment. There is now a need to study the intervention's implementation in routine care settings as well as its long-term effectiveness and cost-effectiveness in diverse cultural and linguistic settings.

The association of 'self-monitoring' with depression in help-seeking Facebook users.

BACKGROUND: 'Self-monitoring' refers to the extent to which people control how they act in social situations. Some evidence suggests that those with various mental health issues engage in less self-monitoring than those without such issues. In the current study, we investigated the association of (offline and online) self-monitoring with depression in help-seeking Facebook users. METHODS: We conducted a cross-sectional analysis of an anonymised dataset generated using the myPersonality Facebook application ( N = 1,857). Participants were those who accessed an application for depressive symptom-reporting that was linked to the myPersonality application. RESULTS: The odds of depression were 1.85 times greater in low self-monitors than high self-monitors (odds ratio = 1.85; 95% confidence interval (CI) = [1.50, 2.27]). The association remained significant after adjusting for 'big five' personality traits (odds ratio = 1.48; 95% CI = [1.18, 1.86]). In fully adjusted analyses involving different operationalisations of self-monitoring, (1) the odds of depression were 1.38 times greater in low acquisitive self-monitors than high acquisitive self-monitors (odds ratio = 1.38; 95% CI = [1.10, 1.74]) and (2) the odds of depression were 1.48 times greater in low protective self-monitors than high protective self-monitors (odds ratio = 1.48; 95% CI = [1.18, 1.85]). CONCLUSION: The utility of self-monitoring in interventions for depression is worthy of investigation. Moreover, the assessment of self-monitoring may offer insights into clients' social skills, motivation and self-awareness.

Utility of an abbreviated version of the stanford-binet intelligence scales (5th ed.) in estimating 'full scale' IQ for young children with autism spectrum disorder.

The fifth edition of the Stanford-Binet Intelligence scales allows 'full scale' IQ (FSIQ) to be estimated using an abridged version of the test-the abbreviated battery IQ (ABIQ). Set within a public early intervention team service, the current cross-sectional study investigated the utility of the ABIQ in estimating FSIQ for 40 children with autism spectrum disorder (ASD) aged 3-5 years. A strong ABIQ-FSIQ association was yielded (r = 0.89; r2 = 0.808) and the ABIQ did not over-estimate mean FSIQ above a clinically-relevant threshold; however, clinically significant over-estimation occurred in 17.5% of individual cases. While the findings provide support for the utility of the ABIQ in estimating FSIQ for young children with ASD, caution relating to the over-estimation of FSIQ is warranted. Careful clinical judgment-ideally based on examination of previous cognitive assessment results (if available), thorough interactional observations, and close multi-disciplinary consultation-is necessary to determine the applicability of the ABIQ to individual cases. Autism Res 2018, 11: 503-508. © 2017 International Society for Autism Research, Wiley Periodicals, Inc. LAY SUMMARY: We investigated the utility of a shortened version of the Stanford-Binet Intelligence Scales in estimating IQ for 40 young children with autism spectrum disorder (ASD). The findings provide qualified support for the instrument: acceptably accurate IQ estimation was achieved for most cases; but not so for a sizeable minority (17.5%). Careful clinical judgment is necessary to determine the applicability of the ABIQ to individual cases.

Association of cannabis use with the development of elevated anxiety symptoms in the general population: a meta-analysis.

BACKGROUND: The directionality and magnitude of the association of cannabis use with elevated anxiety symptoms in the general population is unclear. The aim of this meta-analysis was to investigate the association of cannabis use with the development of elevated anxiety symptoms in the general population. METHODS: A 'random effects' meta-analysis of prospective longitudinal studies was undertaken in line with Meta-analysis Of Observational Studies in Epidemiology (MOOSE) guidelines. Six databases were systematically searched up until 20 May 2016: PsycINFO, MEDLINE, EMBASE, CINAHL Plus, Social Science Citation Index and System for Information on Grey Literature in Europe (SIGLE). Searching ceased on 20 May 2016. The exposure was cannabis use (or use frequency), measured at baseline and the outcome was anxiety, using diagnosis or cut-off points on standardised scales measuring symptoms. RESULTS: The main analysis (k=10; N=58 538) demonstrated an association of cannabis use with anxiety, with a very small OR of 1.15 (95% CI 1.03 to 1.29). Restricting the analysis to high-quality studies (k=5) decreased the OR considerably (OR=1.04; 95% CI 0.91 to 1.19), as did adjusting for publication bias (OR=1.08; 95% CI 0.94 to 1.23). Studies with a baseline in the last 10 years yielded a lower pooled OR than studies with an earlier baseline and studies set in the Americas yielded a markedly higher pooled OR than European studies and Australasian studies. CONCLUSIONS: The findings indicate that cannabis use is no more than a minor risk factor for the development of elevated anxiety symptoms in the general population. They may inform the debate surrounding the legalisation of cannabis.

Associations of Self-Presentation on Facebook with Mental Health and Personality Variables: A Systematic Review.

Many investigations of the associations of self-presentation on Facebook with mental health and personality variables exist, but their findings have not yet been synthetized. We therefore carried out a narrative synthesis of 21 observational studies (combined N = 7,573) obtained from a systematic search of four academic databases. Significant self-presentation associations were yielded for self-esteem, perceived social support, social anxiety, well-being, depression, bipolar/mania, stress, self-consciousness, and insecure attachment. Significant associations were also yielded for all of the big five personality variables and narcissism. The clearest trends-based on the number of times significant associations were yielded across included studies-were as follows: (1) inauthentic self-presentation was consistently associated with low self-esteem and elevated levels of social anxiety; (2) inauthentic self-presentation was consistently more likely to occur in people high in neuroticism and narcissism; and (3) authentic/positive self-presentation was consistently associated with increased levels of self-esteem and perceived social support. The assessment of online self-presentation may offer clinicians important insights into how clients are functioning in relation to various domains of mental health and personality. For example, clients who present inauthentic versions of themselves on Facebook could be experiencing social anxiety or have maladaptive personality traits such as neuroticism and narcissism, all of which could be targeted in intervention.

Effectiveness of an individually-tailored computerised CBT programme (Deprexis) for depression: A meta-analysis.

Computerised cognitive behavioural therapy (cCBT) programmes differ widely but have rarely been evaluated separately through meta-analysis. Through a meta-analysis of randomised controlled trials, we investigated the effectiveness of 'Deprexis', an unconventional and individually-tailored cCBT programme for depression. Comparisons from eight studies (N = 2402) demonstrated the effectiveness of Deprexis for depressive symptoms at post-intervention, with a medium effect size (g = 0.54, 95% CI: 0.39-0.69). Analogous results arose when study quality, screening, and randomisation procedure were taken into account. The level of guidance provided alongside Deprexis had a statistically non-significant impact upon the effect size. There was no significant difference in the performance of Deprexis in developer-led trials compared with non-developer trials, and no publication bias was detected. The weighted-average dropout rate for participants allocated to Deprexis treatment arms in included studies was 26.5%. Based primarily on trials in naturalistic community settings, the findings support the effectiveness of Deprexis for depressive symptoms. The positive findings add to the growing evidence-base for individually-tailored cCBT programmes and point to the need for further investigations of apparent systematic differences in the effectiveness of specific cCBT programmes.

Utility of functioning in predicting costs of care for patients with mood and anxiety disorders: a prospective cohort study.

Development of payment systems for mental health services has been hindered by limited evidence for the utility of diagnosis or symptoms in predicting costs of care. We investigated the utility of functioning information in predicting costs for patients with mood and anxiety disorders. This was a prospective cohort study involving 102 adult patients attending a tertiary referral specialist clinic for mood and anxiety disorders. The main outcome was total costs, calculated by applying unit costs to healthcare use data. After adjusting for covariates, a significant total costs association was yielded for functioning (e=1.02; 95% confidence interval: 1.01-1.03), but not depressive symptom severity or anxiety symptom severity. When we accounted for the correlations between the main independent variables by constructing an abridged functioning metric, a significant total costs association was again yielded for functioning (e=1.04; 95% confidence interval: 1.01-1.09), but not symptom severity. The utility of functioning in predicting costs for patients with mood and anxiety disorders was supported. Functioning information could be useful within mental health payment systems.

Transdiagnostic computerised cognitive behavioural therapy for depression and anxiety: A systematic review and meta-analysis.

An increasing number of computerised transdiagnostic cognitive behavioural therapy programs (TD-cCBT) have been developed in the past decade, but there are no meta-analyses to explore the efficacy of these programs, nor moderators of the effects. The current meta-analysis focused on studies evaluating TD-cCBT interventions to examine their effects on anxiety, depression and quality of life (QOL). Results from 17 RCTs showed computerised TD-cCBT outperformed control conditions on all outcome measures at post-treatment, with large effect sizes for depression (g's=.84), and medium effect sizes for anxiety (g=.78) and QOL (g=.48). RCT quality was generally good, although heterogeneity was moderate to high. Further analyses revealed that studies comparing TD-cCBT to waitlist controls had the largest differences (g=.93) compared to active (g=.59) and usual care control groups (g=.37) on anxiety outcomes, but there was no influence of control group subtype on depression outcomes. Treatment length, symptom target (mixed versus anxiety only), treatment design (standardised versus tailored), and therapist experience (students versus qualified therapists) did not influence the results. Preliminary evidence from 4 comparisons with disorder-specific treatments suggests transdiagnostic treatments are as effective for reducing anxiety, and there may be small but superior outcomes for TD-cCBT programs for reducing depression (g=.21) and improving QOL (g=.21) compared to disorder-specific cCBT. These findings show that TD-cCBT programs are efficacious, and have comparable effects to disorder-specific cCBT programs.

Utility of the Health of the Nation Outcome Scales (HoNOS) in Predicting Mental Health Service Costs for Patients with Common Mental Health Problems: Historical Cohort Study.

BACKGROUND: Few countries have made much progress in implementing transparent and efficient systems for the allocation of mental health care resources. In England there are ongoing efforts by the National Health Service (NHS) to develop mental health 'payment by results' (PbR). The system depends on the ability of patient 'clusters' derived from the Health of the Nation Outcome Scales (HoNOS) to predict costs. We therefore investigated the associations of individual HoNOS items and the Total HoNOS score at baseline with mental health service costs at one year follow-up. METHODS: An historical cohort study using secondary care patient records from the UK financial year 2012-2013. Included were 1,343 patients with 'common mental health problems', represented by ICD-10 disorders between F32-48. Costs were based on patient contacts with community-based and hospital-based mental health services. The costs outcome was transformed into 'high costs' vs 'regular costs' in main analyses. RESULTS: After adjustment for covariates, 11 HoNOS items were not associated with costs. The exception was 'self-injury' with an odds ratio of 1.41 (95% CI 1.10-2.99). Population attributable fractions (PAFs) for the contribution of HoNOS items to high costs ranged from 0.6% (physical illness) to 22.4% (self-injury). After adjustment, the Total HoNOS score was not associated with costs (OR 1.03, 95% CI 0.99-1.07). However, the PAF (33.3%) demonstrated that it might account for a modest proportion of the incidence of high costs. CONCLUSIONS: Our findings provide limited support for the utility of the self-injury item and Total HoNOS score in predicting costs. However, the absence of associations for the remaining HoNOS items indicates that current PbR clusters have minimal ability to predict costs, so potentially contributing to a misallocation of NHS resources across England. The findings may inform the development of mental health payment systems internationally, especially since the vast majority of countries have not progressed past the early stages of this development. Discrepancies between our findings with those from Australia and New Zealand point to the need for further international investigations.

A systematic review of the predictors of health service utilisation by adults with mental disorders in the UK.

OBJECTIVES: To identify variables that predict health service utilisation (HSU) by adults with mental disorders in the UK, and to determine the evidence level for these predictors. DESIGN: A narrative synthesis of peer-reviewed studies published after the year 2000. The search was conducted using four databases (ie, PsycINFO, CINAHL Plus with full text, MEDLINE and EMBASE) and completed on 25 March 2014. SETTING: The majority of included studies were set in health services across primary, secondary, specialist and inpatient care. Some studies used data from household and postal surveys. PARTICIPANTS: Included were UK-based studies that predicted HSU by adults with mental disorders. Participants had a range of mental disorders including psychotic disorders, personality disorders, depression, anxiety disorders, eating disorders and dementia. PRIMARY OUTCOME: A wide range of HSU outcomes were examined, including general practitioner (GP) contacts, medication usage, psychiatrist contacts, psychotherapy attendances, inpatient days, accident and emergency admissions and 'total HSU'. RESULTS: Taking into account study quality, 28 studies identified a range of variables with good preliminary evidence supporting their ability to predict HSU. Of these variables, comorbidity, personality disorder, age (heterogeneous age ranges), neurotic symptoms, female gender, a marital status of divorced, separated or widowed, non-white ethnicity, high previous HSU and activities of daily living, were associated with increased HSU. Moreover, good preliminary evidence was found for associations of accessing a primary care psychological treatment service and medication use with decreased HSU. CONCLUSIONS: The findings can inform decisions about which variables might be used to derive mental health clusters in 'payment by results' systems in the UK. The findings also support the need to investigate whether combining broad diagnoses with care pathways is an effective method for mental health clustering, and the need for research to further examine the association between mental health clusters and HSU.