Collecting Routine Outcome Data in a Psychotherapy Community Clinic for Young People: Findings from an Ongoing Study

Background:  The paper reports on the collection of routine outcome data from an ongoing audit at a voluntary sector psychotherapy service for young people aged 12 to 21 years in London offering once-weekly psychotherapy.
Method:  The study uses intake and follow-up data from an ongoing audit of the psychotherapy service that started in 1993; 1608 young people were included in the study. Measures and areas of interest include the Youth Self Report Form, a significant other (SO) version of the Teacher's Report Form, the Young Adult Self Report Form, and the Young Adult Behaviour Check List.
Results:  Percentage returns at intake were 94% (self), 66% (SO) and 80% (therapist), but became 35%, 21% and 38% at 3-month follow-up, and decreased further at 6- and 12-month follow-up. At all time points, significant other report rates were lower than self or therapist report rates. Young people who did not provide data at intake were more likely to have dropped out of treatment. Over the 15-year period of the audit, intake self-report data rates remained stable (about 94%) whereas SO and especially therapist report rates increased. However, there was a reduction in self, significant other and therapist report rates at 3- and 6-month follow-up.
Conclusions:  Collecting routine outcome data was compromised by a variety of factors, and systematic efforts, including introducing initiatives for participation are needed to increase follow-up data rates and improve their quality.     

Chronic Fatigue Syndrome: An Evaluation of a Community Based Management Programme for Adolescents and their Families

Background:  Young people with chronic fatigue syndrome (CFS), families and clinicians may differ in their attributions about CFS and consequently in their approach to treatment. Research that clarifies the best treatment approaches is clearly needed. We have sought to develop a model that engages young people and their families in a collaborative way. The approach adopts an optimistic and holistic stance using an active rehabilitation model paying attention to the integrated nature of the physiological and psychological aspects of the illness.
Method:  This small study set out to evaluate this approach from a service user perspective. Semi-structured interviews were carried out with young people and their parents separately in order to elicit their views on key treatment elements and their perceived degree of recovery.
Results:  Improvements are indicated in all key areas addressed and qualitative information suggests that families value this approach.
Conclusion:  Further research is needed to address treatment issues for families who choose not to opt into the service model.     

Psychotherapy as monotherapy for the treatment of bipolar II depression: a proof of concept study

Objectives:  We conducted a proof of concept study to determine the feasibility of using an individual psychotherapy, Interpersonal and Social Rhythm Therapy (IPSRT), as monotherapy for the acute treatment of bipolar II depression.
Methods:  Unmedicated individuals (n = 17) meeting DSM-IV criteria for bipolar II disorder and currently depressed received weekly psychotherapy (IPSRT) for 12 weeks. After 12 weeks of acute treatment, individuals received an additional 8 weeks of follow-up treatment consisting of continued weekly IPSRT with supplementary lamotrogine for IPSRT non-responders.
Results:  By week 12, 41% (n = 7) of the sample responded to IPSRT monotherapy (defined as ≥50% reduction in depression scores without an increase in mania scores), 41% (n = 7) dropped out of or were removed from the study, and 18% (n = 3) did not respond to treatment. By week 20, 53% (n = 9) had achieved a response and 29% (n = 5) achieved a full remission of symptoms.
Conclusions:  Interpersonal and Social Rhythm Therapy appears to be a promising intervention for a subset of individuals with bipolar II depression. A randomized controlled trial is needed to systematically evaluate the efficacy of IPSRT as an acute monotherapy for bipolar II depression.     

Five Years On: Public Sector Service Use Related to Mental Health in Young People with ADHD or Hyperkinetic Disorder Five Years After Diagnosis

Background:  Little is known about ongoing service use among young people with ADHD, but this information is important to the development of services to support these young people.
Methods:  A cohort of young people with ADHD or hyperkinetic disorder ( n  = 115) was followed up five to seven years after diagnosis. Details are presented of their use of public sector services over the 12 months preceding reassessment, compared to young people with ADHD from a large epidemiological study.
Results:  Most children remained in contact with CAMHS, with high rates of contact with schools, educational professionals and the criminal justice system. Nearly all had taken medication at some point, while many still were using it. There were low reported rates of psychological and group interventions within the last twelve months, but this does not rule out earlier access to such treatments.
Conclusions:  Children with ADHD utilise long-term support from public sector services, and cross agency strategies or clinics may help to optimise functioning.     

Illness Beliefs in Chronic Fatigue Syndrome: A Study Involving Affected Adolescents and their Parents

Background:  The aim of the study was too investigate the beliefs of young people with Chronic Fatigue Syndrome/Myalgic Encephalomyelitis (CFS/ME) and their parents, about illness causes and management.
Method:  Twenty-one young people with CFS/ME and their parents participated in an open-ended interview.
Results:  Infective causes were identified by the majority of respondents, and psychological ones by a minority. Many highlighted reducing activity and resting in symptom management. Positive and negative experiences of psychiatric and psychological treatments were recorded.
Conclusion:  Professionals should carefully explore the illness related beliefs of young people with CFS/ME and parental beliefs in order to agree treatment plans.     

Competencies and problems of Irish children and adolescents

This study set out to investigate the behavioural and emotional problems and competencies of Irish children and adolescents using Achenbach's Child Behaviour Checklist (CBCL) and Youth Self Report (YSR). The Child Behaviour Checklist was completed by parents of 481 Irish school children aged 7–9 years and 13–15 years, and the Youth Self Report was completed by 240 adolescents. The schools were selected to represent a wide social and cultural spread. Irish young people of all ages scored significantly lower than their American counterparts on measures of competence, whether rated by themselves or their parents. The parents of the 7–9 year olds rated their children as having significantly lower total problem scores than their American counterparts, but for 13–15 year olds there were no differences in total problem scores between the Irish and American samples, whether rated by parents or the adolescents themselves. Total problem scores and externalizing scores increased with age on the CBCL and the YSR, a pattern in which Irish young people differed from those in most other cultures. Despite differences in sampling and methodology, the Irish results are similar in many respects to those seen in a number of other European studies. Accepted: 22 July 1998     

Eliciting Children's and Young People's Views of Child and Adolescent Mental Health Services: A Systematic Review of Best Practice

Background:  A systematic review of children's and young people's views of Child and Adolescent Mental Health Services (CAMHS) was undertaken to identify the methods used, the 'best practice' methods, and the methods most effective in leading to service changes.
Method:  Electronic databases and grey literature were systematically searched. Both authors independently quality-appraised studies using a standard framework. Of 381 studies identified, only 13 were both relevant and of sufficient quality to be included in the review. Interviews, focus groups, brainstorming exercises, and questionnaires were the methods used.
Results:  No study reported a change of practice as a result of hearing children's and young people's views.
Key Practitioner Message:  So few studies have been adequately reported in the literature that it is difficult to make recommendations about good practice for undertaking views studies in CAMHS. Practitioners should use age-appropriate and rigorous methods, report findings clearly, and check beforehand that their organisation is willing and able to implement changes suggested by the young people.     

The relationship between intellectual disability, Indigenous status and risk of reoffending in juvenile offenders on community orders

Background   Intellectual disability (ID), age and aboriginal status have been independently implicated as risk factors for offending to varying degrees. This study examined the relationship between age, ID and the Indigenous status of juvenile offenders. It also examined the outcomes of the sample's offending in terms of court appearances and sentencing, criminogenic needs and risk of reoffending.
Method   The sample comprised 800 juvenile offenders on community orders of whom 19% were Indigenous, who completed the New South Wales Young People on Community Order Health Survey between 2003 and 2005. Risk and criminogenic needs were evaluated using the Youth Level of Service/Case Management Inventory (Australian Adaptation) (YLS/CMI: AA).
Results   Those with an ID were found to have a higher risk of reoffending than those without an ID. Those with an ID were also more likely to be younger and Indigenous. For Indigenous young offenders, there was no difference between those with and without an ID in risk category allocation or number of court dates. For non-Indigenous young offender, those with an ID had higher risk scores and more court dates.
Conclusions   This study provided evidence that Indigenous status may play a significant role in the relationship between ID and offending in juvenile offenders on community orders. These findings have clear implications for the 'risk', 'needs' and 'responsivity' principles of offender classification for treatment. Emphasis is placed on the requirement for addressing the needs of Indigenous juvenile offenders with an ID.     

ADHD ‐ Do Guidelines Translate Into Service?

Background:  ADHD is a condition with wide ranging implications for children diagnosed with it, health professionals and the agencies setting benchmarks for good practice.
Aim:  We set out to measure the adherence of our service to guidelines and to identify service needs.
Method:  An audit of cases referred and diagnosed with ADHD during 2004–2005.
Results:  The service scored well in areas of assessment and management with stimulants. Potential areas to be addressed included age of referral, differences in referrals across ethnic groups, providing psychosocial interventions coupled with medication and shared care.
Conclusion:  It is possible to provide a service that adheres as closely as possible to the guidelines.     

Broad Outcome Measures May Underestimate Effectiveness: An Instrument Comparison Study

Background:  Outcome measures are routinely used in child and adolescent mental health services to demonstrate the effectiveness or otherwise of interventions.
Methods:  We followed up a consecutive sample from a large teaching hospital's Obsessive Compulsive Disorder (OCD) service for young people, comparing improvements using instruments of differing broadness.
Results:  The effect size of improvement decreased as the breadth of the questionnaire increased.
Conclusion:  Specialist clinics are recommended to use two questionnaires: a broad one to facilitate comparability with other clinics, and a narrow one to maximise power to detect significant changes.     

Acute antimanic efficacy and safety of oxcarbazepine in an open trial with an on-off-on design

Rationale and Objectives:  Carbamazepine has shown reasonable antimanic properties, but its use has been limited because of enzyme-inducing effects. The keto-derivative oxcarbazepine (OXC) is very similar to carbamazepine, however, the metabolic pathway is different. OXC is not metabolized to the 10, 11–epoxide, which seems to be responsible for several undesirable side-effects of carbamazepine and furthermore OXC has less enzyme-inducing properties.
Methods:  In this non-random open label study, patients were treated with OXC for 14 days, crossed over to no OXC for 7 days, and then crossed back over to OXC for the remaining 14 days. OXC was titrated to a final dose in a range of 900–2100 mg due to individual response. Treatment success was defined as a reduction of the original Young Mania Rating Scale (YMRS) score of more than 50% at the end of study period.
Results:  Four of the 12 included patients (33%) met defined response criteria at the end of study period. Fifty percentage of the patients had to be prematurely excluded from the trial. The mean YMRS scores of the on-periods were obviously different from the off-period. Forty-two percentage of the patients experienced side-effects leading to premature discontinuation in two of 12 patients.
Conclusion:  Antimanic activity of OXC was demonstrated in this pilot study only for patients with mild or moderate manic symptoms. Further studies are encouraged to clarify OXC's role as mood-stabilizer and assess whether it has a profile similar to that of carbamazepine.     

Who is treated,and how,for depression?

BACKGROUND: Studies on the treatment of depression using epidemiological survey methods suggest a high level of under-treatment. Little is known about the characteristics of those people receiving treatment and indeed what kind of treatment they are likely to receive. METHOD: Analysis of the data of a statutory health insurance company in Germany. RESULTS: In middle-aged groups, about 50% of those diagnosed as being depressed in outpatient care are prescribed antidepressants and/or psychotherapy in the course of a year. There is more pharmacologic treatment provided in rural areas and more psychotherapy in cities, suggesting that treatment is dependent upon service availability rather than evidence-based treatment decisions. Treatment rates are considerably lower in the very young and the very old and show gender bias. Young females receive less pharmacologic treatment than young males, and elderly men are, in general, treated less than women, suggesting under-treatment at least for these groups. CONCLUSIONS: The low treatment rates following the diagnosis of depression in the young and the old require attention, in particular with respect to gender aspect.     

Parental Perceptions of the Assessment of Autistic Spectrum Disorders in a Tier Three Service

Background:  Little is known about the satisfaction of the parents of children receiving child and adolescent mental health services in general, and autistic spectrum services in particular.
Method:  This audit examined parent and carer perceptions of the Autistic Spectrum Disorder assessments undertaken by the multi-agency team in a Tier Three CAMHS in Manchester. Forty families completed a brief questionnaire.
Results:  The majority of parents and carers reported satisfaction with the service (95%), although responses highlighted areas in both the assessment process and the service facilities that needed improvement.
Conclusions:  Useful information with both local and national applications can be gathered quickly in an easily replicated manner.     

Cognitive Therapy for Children, Young People and Families: Considering Service Provision

Background:  This article presents a case for the development of cognitive therapy services for children, adolescents and their families.
Method:  The theoretical basis of cognitive therapy is described, and illustrated with a case. The article continues by exploring the context for service development, with a specific emphasis on evaluating the evidence-base for using cognitive therapy with children and adolescents. Consideration is also given to adapting cognitive therapy to the child's developmental level, and the evidence for the efficacy of cognitive-behavioural family approaches.
Conclusions:  The article concludes by arguing that there is a need to address mental health difficulties in young people by providing effective treatment approaches. The development of cognitive therapy services would support the further evaluation of this therapeutic approach.     

Rates of response,euthymia and remission in two placebo-controlled olanzapine trials for bipolar mania

Objective:  Clinically meaningful recovery from acute mania may not be captured by conventionally reported response categorizations. We defined new and stringent criteria for remission in bipolar mania. Using a cohort of patients with acute mania randomized to treatment with either olanzapine or placebo, we contrasted remission rates to findings using previously reported but more lenient categorical outcome measures of response and euthymia.
Methods:  We pooled and reanalyzed results through 3 weeks from two published randomized double-blind trials of olanzapine versus placebo for treating acute bipolar mania ( 1, 2 ). Response was previously defined as ≥ 50% decrease from baseline to endpoint total Young Mania Rating Scale ( 3 ) (Y-MRS) scores, and euthymia as an endpoint total Y-MRS score of ≤ 12. In this report, remission required an endpoint total Y-MRS score of ≤ 7, and an endpoint total Hamilton Depression Rating Scale, (HAM-D21) ( 4 ) score of ≤ 7 and an endpoint Clinical Global Impression Scale – Bipolar version, CGI-BP ( 5 ), overall severity score of ≤ 2.
Results:  Olanzapine treated subjects achieved statistically significantly greater rates of clinical response, euthymia and remission than those assigned to placebo, 55% versus 29.5%, 50% versus 27%, and 18% versus 7%, respectively.
Conclusions:  Olanzapine monotherapy resulted in discernable clinical improvements in mania in over 50% of subjects and just under 20% of subjects achieved a near complete resolution of manic and accompanying depressive symptoms after 3 weeks of treatment. Full remission is an important but potentially elusive goal during short-term management of acute mania.     

Treatment-emergent mania/hypomania in unipolar patients

Objective:  The aim of this study was to estimate the incidence of treatment-emergent mania/hypomania (TEMH) and to describe the clinical characteristics of patients with major depression experiencing this event during treatment with a selective serotonin reuptake inhibitor (SSRI) and/or interpersonal psychotherapy (IPT).
Methods:  Following an algorithm-based protocol, 344 patients with major depression confirmed with the Structured Clinical Interview for DSM-IV disorders were treated with an SSRI, interpersonal psychotherapy, or their combination for nine months. The emergence of mania/hypomania was carefully monitored throughout the study using the Young Mania Rating Scale and clinical assessment.
Results:  Overall, eight patients experienced TEMH. The incidence of this event was 3.0% in patients treated with an SSRI and 0.9% in patients treated with IPT alone. Among patients treated with an SSRI, the difference between sites was higher than expected by chance alone (6.8% at Pisa and 0% at Pittsburgh, p = 0.002). Despite the adoption of an identical protocol at the two sites, some demographic and clinical characteristics of participants may account for this unexpected result. Alternatively, the greater number of episodes and earlier age of onset at the Pittsburgh site suggests that the unipolar course of illness was more clearly established prior to study entry.
Conclusions:  TEMH is an infrequent event, occurring in 2.3% of patients treated for major depression. Nevertheless, its consequences are clinically relevant and require prompt and appropriate therapeutic interventions. For this reason, recognising those patients at risk for such an event is of paramount clinical significance. The observed difference in the incidence of TEMH between the two sites requires further investigation.     

A pilot study of loading versus titration of valproate in the treatment of acute mania

Objective:  This double-blind pilot study compares the effectiveness and incidence of adverse effects of oral loading versus titration schedules of valproate in acute mania.
Method:  Consecutive new admissions for an acute manic episode were prescribed either an oral loading dose (20 mg/kg/day; n=5; mean age=33.4) or slower titration dose (10 mg/kg/day; n=6, mean age=30.6) of valproate for 7 days without other psychotropic agents, with the exception of benzodiazepines. Daily outcome measures included: serum valproic acid levels, the Young Mania Rating Scale (YMRS), the Brief Psychiatry Rating Scale (BPRS), the Clinical Global Impression Scale (CGI) and the Adverse Effect Rating Scale.
Results:  The mean serum valproic acid levels were significantly higher in the loading group when compared with the titration group after 1 and 2 days following the initiation of treatment (p < 0.05). After 3 days of treatment there was a trend for the group that received the loading regimen to have slightly more improvement in YMRS scores compared with the titration group. Side-effects were minor for both treatments, however, a higher incidence of side-effects was reported in the titration group, with 50% of patients reporting sedation most likely because of increased use of benzodiazepines.
Conclusion:  This suggests that a loading dose of valproate is likely safe and may provide an earlier onset of antimanic effects in patients with bipolar disorder. Future studies with larger sample sizes are indicated.     

Augmentative repetitive navigated transcranial magnetic stimulation (rTMS) in drug-resistant bipolar depression

Objectives:  The efficacy of transcranial magnetic stimulation (TMS) has been poorly investigated in bipolar depression. The present study aimed to assess the efficacy of low-frequency repetitive TMS (rTMS) of the right dorsolateral prefrontal cortex (DLPFC) combined with brain navigation in a sample of bipolar depressed subjects.
Methods:  Eleven subjects with bipolar I or bipolar II disorder and major depressive episode who did not respond to previous pharmacological treatment were treated with three weeks of open-label rTMS at 1 Hz, 110% of motor threshold, 300 stimuli/day.
Results:  All subjects completed the trial showing a statistically significant improvement on the 21-item Hamilton Depression Rating Scale (HAM-D), Montgomery-Åsberg Depression Rating Scale, and Clinical Global Impression severity of illness scale (ANOVAs with repeated measures: F  =   22.36, p < 0.0001; F  =   12.66, p < 0.0001; and F  =   10.41, p < 0.0001, respectively). In addition, stimulation response, defined as an endpoint HAM-D score reduction of ≥50% compared to baseline, was achieved by 6 out of 11 subjects, 4 of whom were considered remitters (HAM-D endpoint score ≤ 8). Partial response (endpoint HAM-D score reduction between 25% and 50%) was achieved by 3/11 patients. No manic/hypomanic activation was detected during the treatment according to Young Mania Rating Scale scores (ANOVAs with repeated measures: F  =   0.62, p = 0.61). Side effects were slight and were limited to the first days of treatment.
Conclusions:  Augmentative low-frequency rTMS of the right DLPFC combined with brain navigation was effective and well tolerated in a small sample of drug-resistant bipolar depressive patients, even though the lack of a sham controlled group limits confidence in the results.     

Cost-Effectiveness of Individual versus Group Psychotherapy for Sexually Abused Girls

Background:  Children who have been sexually abused may suffer from emotional and behavioural difficulties. Recent research found that individual and group psychotherapy have similar outcomes. In this study we compare the costs and cost-effectiveness of the two therapies and support for carers.
Methods:  Subjects were recruited to two clinics in London and randomly allocated to the two treatments. The different components of each intervention were identified and costed.
Results:  Total mean costs of individual therapy were found to be £1246 greater than for group therapy. Costs as they would apply in routine practice were relatively unchanged. Group therapy was thus more cost-effective than individual therapy.
Discussion:  Carefully considering the impact of different therapies could allow more treatment to be offered from available staff resources and budgets. However, this is a single small study and further work is required to strengthen the evidence-base before change in practice is readily undertaken.