Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis.

OBJECTIVES: The study investigated whether psychological wellbeing practitioners (PWPs) working within the UK government's Improving Access to Psychological Therapies (IAPT) initiative are differentially effective (i.e., therapist effect size) and differentially efficient (i.e., rate of clinical change), and the moderating effect of demographic and process factors on outcomes. DESIGN AND METHODS: Routine clinical outcome data (depression, anxiety, and functional impairment) were collected from a single IAPT service. A total of 6111 patients were treated by 56 PWPs. Multilevel modelling (MLM) determined the size of the therapist effect and examined significant moderators of clinical outcomes. PWPs were grouped according to below average, average, and above average patient outcomes and compared on clinical efficiency. RESULTS: Therapist effects accounted for 6-7% of outcome variance that was moderated by greater initial symptom severity, treatment duration, and non-completion of treatment. Clinically effective PWPs achieved almost double the change per treatment session. As treatment durations increased beyond protocol guidance, outcomes atrophied. Treatment non-completion was particularly detrimental to outcome. CONCLUSIONS: PWPs appear to be differentially effective and efficient despite ostensibly delivering protocol driven interventions. Implications for services, training, and supervision are outlined.

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

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

The effectiveness of routinely delivered cognitive behavioural therapy for obsessive-compulsive disorder: a benchmarking study.

OBJECTIVES: There is often difficulty in generalizing the results of randomized controlled trials (RCTs) to routine clinical practice given the rigid design features of such studies. The purpose of this study is to describe the effectiveness of routinely delivered, formulation-based cognitive behavioural therapy (CBT) within a publicly funded clinic for adults with obsessive-compulsive disorder (OCD) and offer a comparison against the outcomes achieved in efficacy studies for the same population. METHOD: Practice-based prospective study. Routine data collected from a National Health Service out-patient clinic for adult clients with OCD is benchmarked against the findings of RCTs. The comparison RCTs were identified using a systematic review methodology. RESULTS: The mean (95% confidence interval) change in Yale-Brown Obsessive Compulsive Scale score pre- to post-therapy in the Sheffield clinic was 10.2 (7.1 - 13.3), which compares well with changes of 11.4 (10.5 - 12.2) for exposure and response prevention trials, 12.9 (11.2 - 14.7) for cognitive therapy trials, and 10.6 (8.5 - 12.8) for CBT trials. The Sheffield results fell within the benchmarks derived from the included RCTs. CONCLUSION: These results indicate that CBT for adults with OCD delivered outside the constraints of a clinical trial is equivalently effective but that this conclusion should be tested further on a larger group of patients.

An evaluation of large group CBT psycho-education for anxiety disorders delivered in routine practice.

OBJECTIVE: To determine the clinical utility and acceptability of a brief CBT psycho-educational course delivered in an NHS psychotherapy service. METHODS: All patients referred, found suitable for CBT, and who had an anxiety disorder, were invited to enrol in a psycho-education course, delivered in an outpatient mental health clinic by two mental health nurses with post-registration training in CBT. There were up to 24 patients in each course. Outcome measures used were CORE-OM and Fear Questionnaire administered pre-course and at 12-week follow-up and Client Satisfaction Questionnaire administered post-course. RESULTS: One-hundred and ninety one patients were referred. Of these 120 remained in contact with the service to the follow-up meeting. Ninety-seven patients were discharged at the follow-up point and 92 requested further individual psychotherapy. A number of patients made a clinical and reliable change as measured by CORE-OM and Fear Questionnaire. One-hundred and two patients completed the CSQ-8 reporting high satisfaction with the intervention. CONCLUSIONS: The intervention appears to be helpful for a number of patients and largely acceptable for most patients that attend. PRACTICE IMPLICATIONS: Large group psycho-educational interventions for anxiety disorders could be increasingly used as a method of delivering low intensity treatments within a stepped care model of the treatment of anxiety disorders. The intervention is relatively simple to deliver and potentially could be delivered by primary care clinicians.