Enhancing recovery rates: Lessons from year one of IAPT

BackgroundThe English Improving Access to Psychological Therapies (IAPT) initiative aims to make evidence-based psychological therapies for depression and anxiety disorder more widely available in the National Health Service (NHS). 32 IAPT services based on a stepped care model were established in the first year of the programme. We report on the reliable recovery rates achieved by patients treated in the services and identify predictors of recovery at patient level, service level, and as a function of compliance with National Institute of Health and Care Excellence (NICE) Treatment Guidelines.MethodData from 19,395 patients who were clinical cases at intake, attended at least two sessions, had at least two outcomes scores and had completed their treatment during the period were analysed. Outcome was assessed with the patient health questionnaire depression scale (PHQ-9) and the anxiety scale (GAD-7).ResultsData completeness was high for a routine cohort study. Over 91% of treated patients had paired (pre-post) outcome scores. Overall, 40.3% of patients were reliably recovered at post-treatment, 63.7% showed reliable improvement and 6.6% showed reliable deterioration. Most patients received treatments that were recommended by NICE. When a treatment not recommended by NICE was provided, recovery rates were reduced. Service characteristics that predicted higher reliable recovery rates were: high average number of therapy sessions; higher step-up rates among individuals who started with low intensity treatment; larger services; and a larger proportion of experienced staff.ConclusionsCompliance with the IAPT clinical model is associated with enhanced rates of reliable recovery.     

Development and Validation of the Xhosa Translations of the Beck Inventories: 1. Challenges of the Translation Process

This article describes the translation of the Beck Depression Inventory-II, the Beck Hopeless Scale, and the Beck Anxiety Inventory, into Xhosa the language spoken in the Eastern Cape of South Africa. The processes of translation, back-translation and committee discussion failed to yield trustworthy translations because of practical difficulties in working with translators. Critical words and phrases were identified which gave rise to lack of agreement. For each, a range of options was generated and the advantages and disadvantages evaluated in terms of criteria such as conceptual and idiomatic equivalence, and extensiveness of usage. Examples are given of the problems encountered and the way in which final decisions were made. A pilot clinical trial demonstrated the acceptability of the translated instruments. Two further articles report the psychometric evaluation of the translated scales.     

Development and Validation of the Xhosa Translations of the Beck Inventories: 2. Item Analysis,Internal Consistency and Factor Analysis

The Beck Depression Inventory-II (BDI-II), the Beck Anxiety Inventory (BAI), and the Beck Hopelessness Scale (BHS) were translated into Xhosa, a language widely spoken in South Africa to yield translated scales referred to as the XBDI-I (Xhosa BDI-II), the XBAI (Xhosa BAI) and the XBHS (Xhosa BHS). These scales were administered to a sample of 122 Xhosa respondents which included students and patients. The psychometric properties of the translated scales were comparable to those of the original English versions. Measures of internal consistency were as high as those for the validation studies in the USA and good item-scale correlations were obtained. This suggests that the translation yielded clinically useful scales which tap symptoms that are largely culturally universal.     

Counselling in a culture of competence

In this article, a counsellor working in the public sectors of health and education considers her work in the light of the contemporary political context. Describing the trend towards what she is calling a ‘culture of competence’, she notes recent changes to the identity of the professional, whose authority, once taken for granted, is increasingly limited and subject to evaluation and proof of effectiveness. She then considers some ways in which counsellors working in the public sector are now experiencing such measures, noting both the benefits that can accrue from evaluating their work, but also the dangers when certain pressures and anxieties are not taken into account.     

Anxiety in Swedish School Children: Situational Specificity,Informant Variability and Coping Strategies

In a school sample, 463 Swedish children aged between 8 and 12 years reported their experience of anxiety during 11 "typical" home and school setting activities. In addition to rating the frequency and type of anxiety experienced, the children reported whether they used coping strategies to reduce their anxiety. Parents and teachers also rated the anxiety levels in the same children. Nine percent of the children reported that they experienced anxiety "often" during at least 1 of the 11 home and school activities and 1.5% reported an anxiety level of "often" averaged across all of the 11 activities. The parents reported that 9% of the children experienced "moderate" to "very much" anxiety levels averaged across the home-related activities, whereas the teachers reported that 38.5% of the children had such anxiety levels at school. Overall, the children's ratings of their frequency levels of anxiety were found to depend more on age than on gender. The children and their parents both regarded anxiety to be most common during "leaving home for school" and "going to bed at night" activities. The correspondence between child, parent and teacher reports of overall anxiety in the children was low; similar findings were obtained for anxiety among children in the various setting activities. The 8-year-old children reported a higher use of various coping strategies than did the 12-year-olds. The results are discussed in view of the current literature on anxiety and fears in children.     

Cognitive Coping vs Emotional Disclosure in the Treatment of Anxious Children: A Pilot-Study

The present pilot-study was a first attempt to examine the effectiveness of the cognitive component of cognitive behaviour therapy for children with anxiety problems. A total of 24 highly anxious children were assigned to 1 of 2 intervention conditions: a Cognitive Coping intervention, which focussed primarily on the cognitive component of cognitive behaviour therapy, or an Emotional Disclosure intervention in which children were invited to write about their fears and anxious experiences. Children completed self-report questionnaires of anxiety disorders symptoms and worry at 3 points in time: (i) 6 weeks before treatment (i.e. baseline), (ii) at pre-treatment, and (iii) at post-treatment. The results showed, firstly, that levels of anxiety disorder symptoms and worry remained relatively stable over a 6-week waiting period and then decreased substantially after the interventions. This suggests that the children did not suffer from momentary anxiety and worry complaints and that treatments generally were effective in reducing these symptoms. Secondly, although within-group comparisons suggested that treatment effects were somewhat larger in the Cognitive Coping condition than in the Emotional Disclosure condition (effects sizes for anxiety disorders symptoms and worry were, respectively, 1.03 and 0.87 for Cognitive Coping vs 0.54 and 0.39 for Emotional Disclosure), statistical tests could not substantiate this impression, probably due to a lack of power as a result of the small numbers of children in both intervention conditions.     

Fear response to dissociation challenge

Abstract

Participants (N = 101) scoring high or low on a new scale for assessing fear of dissociative sensations (Dissociation Sensitivity Index) underwent an audio/visual sensory challenge using a device called the D.A.V.I.D. Participants' report of subjective fear and level of dissociation were measured before and after completing the audio/visual sensory challenge. Consistent with prediction, participants scoring high on the DSI responded to the challenge with significantly greater increases in subjective fear and dissociative symptoms relative to those scoring low on the DSI. Contrary to prediction, the DSI performed poorer than the Anxiety Sensitivity Index in predicting participants' response to the audio/visual sensory challenge. Theoretical and clinical implications of the findings are discussed.     

Test anxiety and metacognitive skillfulness: Availability versus production deficiencies

Abstract

This paper focuses on the role of metacognition in test anxiety. In two experiments, the metacognitive skillfulness of high vs. low test-anxious secondary school students was contrasted. Low test-anxious subjects exhibited a superior metacognitive skillfulness during math performance relative to high test-anxious subjects. Furthermore, differences in metacognitive skillfulness were performance related. In order to unravel causality in the relation between metacognition and test anxiety, two types of test-anxious students may be distinguished analogous to Naveh-Benjamin (1991). Type-1 students would lack metacognitive skills (availability deficiency), through which they experience failure and develop test anxiety. Type-2 students would experience task irrelevant thoughts, which causes cognitive interference with available metacognitive skills (production deficiency). Results of Study 1 reveal that metacognitive cueing may represent an adequate method for the identification of both types. Due to time-constraints, metacognitive cueing in Study 2 failed to do so.     

Test anxiety,emotional responding under guided imagery,and self-talk during an academic examination

Abstract

This investigation examined the assumption that phenomenological responses created by guidedimagery procedures pertinent to test anxiety are topographically similar to emotional responses experienced during an actual examination. Participants were divided on facilitating versus debilitating test anxiety and exposed to subclinical doses of stimulus-response propositions that involved test-taking, fear, and physical activity using the induction technique employed by Lang et al. (1980). Patterns of emotional responses obtained after each induction were compared to the pattern elicited immediately prior to students' final course examination as well as self-talk during the examination. Results indicated that exposure to test-related imagery elicited a pattern of emotional responding that was different than exposure to fear or action imagery but was nearly identical to emotional responses found before examinations. Negative emotional states before the examination also were associated with higher frequencies of negative self-statements during the examination. Treatment implications of these findings were explored.     

Traditional group therapy and computer-administered treatment for test anxiety

Abstract

Traditional group therapy for test anxiety, modelled after Weissberg (1976), was compared with the computer-administered treatment of Thoresen, Insel, Roth, Ross, and Seyler (1986). Both treatments contained cognitive and behavioral elements including systematic desensitization and Jacobsonian relaxation techniques. The participants were 36 test-anxious students seeking treatment within a university counseling center. Effectiveness of each treatment was assessed by studying changes in test anxiety (total, worry, emotionality), as measured by the Test Anxiety Inventory (Spielberger, 1980). and changes in grade point average (GPA). There was a statistically significant reduction in the three test anxiety measures for both treatments. No significant differences in GPA, as a result of the treatment, were found. There was no significant difference in reduction of test anxiety between the treatments. These findings support the efficacy of the computerized treatment which may be a suitable alternative to group therapy and, in some situations, may be the treatment of choice.