Cost-effectiveness of brief cognitive behaviour therapy versus treatment as usual in recurrent deliberate self-harm: a decision-making approach

BACKGROUND: Deliberate self-harm can be costly, in terms of treatment and subsequent suicide. Any intervention that reduces episodes of self-harm might therefore have a major impact on the costs incurred by service providers and the productivity losses due to illness or premature death. METHOD: Four hundred and eighty patients with a history of recurrent deliberate self-harm were randomized to manual-assisted cognitive behaviour therapy (MACT) or treatment as usual. Economic data were collected from patients at baseline, 6 and 12 months, and these data were complete for 397 patients. Incremental cost-effectiveness was explored using the primary outcome measure, proportion of patients having a repeat episode of deliberate self-harm, and quality of life. The uncertainty surrounding costs and effects was represented using cost-effectiveness acceptability curves. RESULTS: Differences in total cost per patient were statistically significant at 6 months in favour of MACT (pounds sterling -897, 95 % CI -1747 to -48, P=0.04), but these differences did not remain significant at 12 months (pounds sterling -838, 95% CI -2142 to 466, P=0.21). Nevertheless, exploration of the uncertainty surrounding these estimates suggests there is >90% probability that MACT is a more cost-effective strategy for reducing the recurrence of deliberate self-harm in this population over 1 year than treatment as usual. The results for quality of life were not conclusive. CONCLUSION: Cost-effectiveness acceptability curves demonstrate that, based on the evidence currently available, to reject MACT on traditional grounds of statistical significance and to continue funding current practice has <10% chance of being the correct decision in terms of cost-effectiveness.     

Manual-assisted cognitive-behaviour therapy (MACT): a randomized controlled trial of a brief intervention with bibliotherapy in the treatment of recurrent deliberate self-harm

BACKGROUND: The treatment of deliberate self-harm (parasuicide) remains limited in efficacy. Despite a range of psychosocial, educational and pharmacological interventions only one approach, dialectical behaviour therapy, a form of cognitive-behaviour therapy (CBT), has been shown to reduce repeat episodes, but this is lengthy and intensive and difficult to extrapolate to busy clinical practice. We investigated the effectiveness of a new manual-based treatment varying from bibliotherapy (six self-help booklets) alone to six sessions of cognitive therapy linked to the booklets, which contained elements of dialectical behaviour therapy. METHODS: Thirty-four patients, aged between 16 and 50, seen after an episode of deliberate self-harm, with personality disturbance within the flamboyant cluster and a previous parasuicide episode within the past 12 months, were randomly assigned to treatment with manual-assisted cognitive-behaviour therapy (MACT N = 18) or treatment as usual (TAU N = 16). Assessment of clinical symptoms and social function were made at baseline and repeated by an independent assessor masked to treatment allocation at 6 months. The number and rate of all parasuicide attempts, time to next episode and costs of care were also determined. RESULTS: Thirty-two patients (18 MACT; 14 TAU) were seen at follow-up and 10 patients in each group (56% MACT and 71% TAU) had a suicidal act during the 6 months. The rate of suicidal acts per month was lower with MACT (median 0.17/month MACT; 0.37/month TAU; P = 0.11) and self-rated depressive symptoms also improved (P = 0.03). The treatment involved a mean of 2.7 sessions and the observed average cost of care was 46% less with MACT (P = 0.22). CONCLUSIONS: Although limited by the small sample, the results of this pilot study suggest that this new form of cognitive-behaviour therapy is promising in its efficacy and feasible in clinical practice.     

Online randomized controlled trial of brief and full cognitive behaviour therapy for depression

BACKGROUND: Effective internet-based programs for depression usually incorporate a component that provides telephone or email contact. Open access websites, without such contact, show high rates of attrition and poorer outcomes. The present study was designed as an exploratory investigation of the parameters that influence the effectiveness and retention of users on open access websites. We investigated whether brief cognitive behaviour therapy (CBT) was as effective as an extended version, whether add-on components of behaviour therapy or stress management contributed to positive outcomes, and whether longer programs were associated with greater attrition. METHOD: An online randomized controlled trial (RCT) was conducted between 13 January 2005 and 26 May 2005 (19 weeks). A total of 2794 registrants (1846 women and 948 men; median age category 35-44 years) with elevated scores on the Goldberg Depression Scale of 5.96 (S.D.=2.09) elected online to be randomized to one of six versions of a CBT website. The versions were compiled consisting of various components of brief CBT, extended CBT, behaviour strategies, stress management and problem solving. RESULTS: A total of 20.4% of participants completed the assigned intervention. The interaction of measurement occasion and treatment version was significant [F(13,131)=2.20, p=0.01]. A single module of brief introductory CBT was not effective in reducing depression symptoms. However, extended CBT with or without the addition of behaviour strategies resulted in the reduction of depression. CONCLUSIONS: Brief CBT-based interventions are not as effective as extended interventions. However, longer programs are associated with higher rates of dropout.     

Randomized controlled trial of cognitive behaviour therapy for repeated consultations for medically unexplained complaints: a feasibility study in Sri Lanka

BACKGROUND: Research on the management and the outcome of treatment of medically unexplained symptoms is very limited. Development of simple but effective techniques for treatment and demonstration of their effectiveness when applied in primary health care are needed. METHODS: A randomized controlled trial was carried out with follow-up assessments at 3 months after baseline assessments using the Short Explanatory Model Interview (SEMI), General Health Questionnaire (GHQ-30), Bradford Somatic Inventory (BSI) and patient satisfaction on a visual analogue scale. The study was carried out in a general out-patient clinic in Sri Lanka. The intervention group received six, 30 min sessions based on the principles of cognitive behavioural therapy over a period of 3 months. The control group received standard clinical care. RESULTS: Eighty patients out of the 110 patients referred, were eligible. Sixty-eight were randomly allocated equally to the control and treatment groups. All 34 in the treatment group accepted the treatment offer and 22 completed between three and six sessions. At 3 months, 24 in the treatment and 21 in the control group completed follow-up assessments. Intention-to-treat analysis revealed significant differences in mean scores of outcome measures (adjusted for baseline scores) between control and intervention groups respectively--complaints 6.1 and 3.8 (P = 0.001), GHQ 10.4 and 6.3 (P = 0.04), BSI score 15.6 and 132 (P < 0-01), visits 7.9 and 3.1 (P = 0.004). CONCLUSIONS: Intervention based on cognitive behavioural therapy is feasible and acceptable to patients with medically unexplained symptoms from a general out-patients clinic in Sri Lanka. It had a significant effective in reducing symptoms, visits and distress, and in increasing patient satisfaction.     

Preventing relapse/recurrence in recurrent depression with cognitive therapy: a randomized controlled trial

This article reports on the outcome of a randomized controlled trial of cognitive group therapy (CT) to prevent relapse/recurrence in a group of high-risk patients diagnosed with recurrent depression. Recurrently depressed patients (N = 187) currently in remission following various types of treatment were randomized to treatment as usual, including continuation of pharmacotherapy, or to treatment as usual augmented with brief CT. Relapse/recurrence to major depression was assessed over 2 years. Augmenting treatment as usual with CT resulted in a significant protective effect, which intensified with the number of previous depressive episodes experienced. For patients with 5 or more previous episodes (41% of the sample), CT reduced relapse/recurrence from 72% to 46%. Our findings extend the accumulating evidence that cognitive interventions following remission can be useful in preventing relapse/recurrence in patients with recurrent depression.     

Randomized controlled trial of internet-based cognitive behavior therapy for distress associated with tinnitus

OBJECTIVE: The aim of this study was to investigate if cognitive behavior therapy (CBT) provided via the Internet results in significant decreases of distress in individuals with tinnitus. METHODS: Participants were recruited through Web pages and newspaper articles and thereafter randomly allocated to a CBT self-help manual in six modules or to a waiting-list control group (WLC). All treatment and contact with participants were conducted via the Internet with Web pages and E-mail correspondence. Participants were 117 individuals with tinnitus of duration of more than 6 months. In the first randomized controlled phase of the study, 26 completed all stages of treatment (51% dropout), and 64 of the WLC group completed measures. At 1-year follow-up, all participants had been offered the program and 96 provided outcome measures (18% dropout rate from baseline). Tinnitus-related problems were assessed before and after treatment and at the 1-year follow-up. Daily diary ratings were included for 1 week before and 1 week following the treatment period. RESULTS: Tinnitus-related distress, depression, and diary ratings of annoyance decreased significantly. Immediately following the randomized controlled phase (with a WLC), significantly more participants in the treatment group showed an improvement of at least 50% on the Tinnitus Reaction Questionnaire. At the uncontrolled follow-up, 27 (31%) of all participants had achieved a clinically significant improvement. CONCLUSIONS: CBT via the Internet can help individuals decrease annoyance associated with tinnitus. High dropout rates or delay in completing treatment can be a characteristic of treatment studies using the Internet but should be contrasted with the cost effectiveness and accessibility of the Internet.     

A randomized controlled trial of cognitive therapy versus intensive behavior therapy in obsessive compulsive disorder

BACKGROUND: The study was designed to compare cognitive therapy (CT) with intensive behavior therapy (BT) in obsessive-compulsive disorder (OCD) and to study their change process. METHODS: Sixty-five outpatients with DSM-4 OCD were randomized into 2 groups for 16 weeks of individual treatment in 3 centers. Group 1 received 20 sessions of CT. Group 2 received a BT program of 20 h in two phases: 4 weeks of intensive treatment (16 h), and 12 weeks of maintenance sessions (4 h). No medication was prescribed. RESULTS: Sixty-two patients were evaluated at week 4, 60 at week 16 (post-test), 53 at week 26 and 48 at week 52 (follow-up). The response rate was similar in the 2 groups. The Beck Depression Inventory (BDI) was significantly more improved by CT (p = 0.001) at week 16. The baseline BDI and Obsessive Thoughts Checklist scores predicted a therapeutic response in CT, while the baseline BDI score predicted a response in BT. At week 16, only the changes in Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and a scale measuring the interpretation of intrusive thoughts correlated in CT, while the changes in Y-BOCS, BDI, and interpretation of intrusive thoughts correlated in BT. Improvement was retained at follow-up without a between-group difference. The intent-to-treat analysis (last observation carried forward) found no between-group differences on obsessions, rituals and depression. CONCLUSIONS: CT and BT were equally effective on OCD, but at post-test CT had specific effects on depression which were stronger than those of BT. Pathways to improvement may be different in CT and BT. The outcomes are discussed in the light of an effect size analysis.     

Randomized trial of cognitive behavior therapy versus supportive psychotherapy for HIV-related peripheral neuropathic pain

The feasibility and acceptability of cognitive behavior therapy for HIV-related peripheral neuropathic pain was examined and the potential efficacy of the intervention was compared with that of supportive psychotherapy in reducing pain, pain-related interference with functioning, and distress. Sixty-one patients were randomly assigned to receive six weekly sessions of cognitive behavior therapy or supportive psychotherapy. Thirty-three subjects completed the protocol. Both groups showed significant reductions in pain. The cognitive behavior group improved in most domains of pain-related functional interference and distress; the supportive psychotherapy group showed fewer gains. The high dropout rate suggests that psychotherapeutic treatments for HIV-related pain may have limited feasibility and acceptability.     

Interpersonal psychotherapy versus brief supportive therapy for depressed infertile women: first pilot randomized controlled trial

Infertility is strongly associated with depression, yet treatment research for depressed infertile women is sparse. This study tested for the first time the feasibility and preliminary efficacy of interpersonal psychotherapy (IPT), the evidence-based antidepressant intervention with the greatest peripartum research support, as treatment for depressed women facing fertility problems. Patients who met DSM-IV criteria for major depressive disorder of at least moderate severity were randomized to either 12 sessions of IPT (n?=?15) or brief supportive psychotherapy (BSP; n?=?16), our control intervention. Eighty percent of IPT and 63 % of BSP patients completed the 12 sessions of therapy. Patients in both treatments improved. IPT produced a greater response rate than BSP, with more than two-thirds of women achieving a >50 % reduction in scores on the Montgomery-?sberg Depression Rating Scale (MADRS). IPT also tended to have lower posttreatment scores on the Beck Depression Inventory, Clinical Global Impression-Severity Scale, and anxiety subscale of the Hamilton Depression Rating Scale, with between-group effect sizes ranging from 0.61 to 0.76. Gains persisted at 6-month follow-up. This pilot trial suggests that IPT is a promising treatment for depression in the context of infertility and that it may fare better than a rigorous active control condition. Should subsequent randomized controlled trials support these findings, this will inform clinical practice and take an important step in assuring optimal care for depressed women struggling with infertility.     

Randomized controlled trial comparing brief dynamic and supportive therapy with waiting list condition in minor depressive disorders

BACKGROUND: Although many evidences suggest the presence of specific therapeutic factors in brief dynamic therapy (BDT), few studies have investigated its efficacy in the treatment of depressive disorders in comparison to other psychotherapies. The aim of this study was to determine whether BDT is more effective than brief supportive psychotherapy (BSP) and waiting list condition in the treatment of minor depressive disorders. METHOD: Thirty patients with primary DSM-IV dysthymic disorder, depressive disorder not otherwise specified or adjustment disorder with depressed mood completed a randomized controlled trial with three treatment groups (BDT, BSP, waiting list condition). A 6-month follow-up was performed for patients treated with both psychotherapeutic approaches. Other psychiatric treatments were not permitted throughout the treatment period and the 6-month follow-up. Symptoms were assessed at baseline, at the end of treatment, and after 6 months of follow-up. RESULTS: Patients treated with both psychotherapeutic approaches showed a significant improvement after treatment in comparison to non-treated controls, but BDT was more effective at follow-up evaluation. CONCLUSIONS: BDT is a promising treatment for minor depressive disorders. This study also suggests that BDT is more effective than supportive psychotherapy in improving the long-term outcome of depressive disorders.     

Randomized controlled trial for behavioral smoking and weight control treatment: effect of concurrent versus sequential intervention

The authors compared simultaneous versus sequential approaches to multiple health behavior change in diet, exercise, and cigarette smoking. Female regular smokers (N = 315) randomized to 3 conditions received 16 weeks of behavioral smoking treatment, quit smoking at Week 5, and were followed for 9 months after quit date. Weight management was omitted for control and was added to the 1st 8 weeks for early diet (ED) and the final 8 weeks for late diet (LD). ED lacked lasting effect on weight gain, whereas LD initially lacked but gradually acquired a weight-suppression effect that stabilized (p = .004). Behavioral weight control did not undermine smoking cessation and, when initiated after the smoking quit date, slowed the rate of weight gain, supporting a sequential approach.     

Attachment as moderator of treatment outcome in major depression: a randomized control trial of interpersonal psychotherapy versus cognitive behavior therapy

Anxiety and avoidance dimensions of adult attachment insecurity were tested as moderators of treatment outcome for interpersonal psychotherapy (IPT) and cognitive- behavioral therapy (CBT). Fifty-six participants with major depression were randomly assigned to these treatment conditions. Beck Depression Inventory--II, Six-Item Hamilton Rating Scale for Depression scores, and remission status served as outcome measures. Patients higher on attachment avoidance showed significantly greater reduction in depression severity and greater likelihood of symptom remission with CBT as compared with IPT, even after controlling for obsessive-compulsive and avoidant personality disorder symptoms. Results were replicated across treatment completers and intent-to-treat samples. These results suggest that it is important to consider the interaction between attachment insecurity and treatment type when comparing efficacy of treatments.     

Randomized controlled trial of general practitioner versus usual medical care in a suburban accident and emergency department using an informal triage system.

We determined if care provided by general practitioners (GPs) to non-emergency patients, in a suburban accident and emergency (A&E) department using an informal triage system, differs significantly from care provided by usual A&E staff. One thousand eight hundred and seventy-eight patients participated. By comparison with usual A&E staff, GPs prescribed significantly more often (percentage relative difference [% RD] = 12 [95% confidence interval = 1-23]) and referred more patients to hospital (% RD = 21 [95% CI = 9-33]). This is the first study to report that sessional GPs working in an A&E department utilize similar or more resources than usual A&E staff. It emphasizes the need for the continued audit of initiatives that have been introduced into new settings.     

Brief antenatal cognitive behaviour therapy group intervention for the prevention of postnatal depression and anxiety: a randomised controlled trial

BACKGROUND: The majority of randomised controlled trials examining the effectiveness of antenatal group interventions at preventing postnatal depression in "at risk" women have used a "psychoeducational" intervention. The aim of the present study is to evaluate the effectiveness of an antenatal cognitive behavioural group intervention in a primary care setting for pregnant women identified with mild to moderate symptoms in pregnancy and/or at risk of developing depression or anxiety in the perinatal period. METHOD: Subjects were randomised to a CBT group intervention or control condition (information booklet) and administered the EPDS and STAI at pre (Time 1) and post intervention (Time 2), and at 2 months (Time 3) and 4 months postpartum (Time 4). MINIs were administered at Times 1, 3 and 4. RESULTS: Of the 774 women approached, 277 accepted and were suitable; thus 191 were randomised to the CBT intervention and 86 to the control condition. The subsequent 52% drop-out left 89 women "completing" the CBT groups and 43 in the control group; these two groups were well matched on demographic variables. Intention to treat analyses revealed relatively low mean baseline EPDS scores (means 6.88 -8.16) with no reduction in EPDS scores in either group from Time 1 to Time 4. MINI depression criteria were fulfilled by 19% of all participants at Time 1 but there was no reduction in depression in either group; in contrast those with MINI anxiety diagnoses reduced from 28% in late pregnancy to 16% at four months postpartum in the CBT group with similar reductions in the control group. Analyses on the 132 "completers" showed significant symptomatic improvement over time for both the CBT group and control condition. Depression scores in the most symptomatic women (EPDS>12; N=19) decreased steadily by over 50% over the total time course but there were no differences in improvement between the CBT and control groups. LIMITATIONS: A number of methodological factors may have obscured our results including a tendency to natural remission in mildly symptomatic subjects and the possibility that our control condition was therapeutic in itself. CONCLUSION: While a modest reduction in depression scores was noted in study "completers", both the CBT group intervention control condition were equally beneficial. The reasons for this finding include the low symptom level at baseline; the potential effectiveness of the control condition; and the brevity of the intervention.     

Randomized controlled trial of a brief intervention for increasing participation in parent management training

Evidence-based treatments exist for a range of child and adolescent behavior problems; however, effects are often limited by poor treatment attendance and adherence. The authors developed and evaluated the efficacy of a brief (5 to 45 min) intervention designed to increase treatment attendance and adherence in a sample of 76 parents referred for treatment of their child's oppositional, aggressive, and antisocial behavior. The results of this randomized controlled trial showed that parents who received this brief intervention had greater treatment motivation, attended significantly more treatment sessions, and had greater adherence to treatment according to both parent and therapist report. This study provides researchers and clinicians with a brief and efficacious method of increasing motivation, attendance, and adherence for treatment.