Towards evidence based selfhelp provision

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Towards evidence based self-help provision

• Stephen Pilling
• Joint Director NCCMH,
• Director CORE
• University College London

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LI a range (continuum) of interventions

• Health promotion
• Pure self-help (accessed by various routes)
• Bibliotherapy (including Books on Prescription)
• Some CCBT
• Facilitated self-help (accessed by various
  routes)
• Guided self-help using written materials
• CCBT (with support)
• Psycho-educational groups
• Exercise
• Signposting (community links)
• Medication management
• NICE 2009 (Consultation Document)

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What is the evidence for low intensity
interventions? (1)

• CCBT - NCCMH (2009)
• SMD -0.46 (95 CI -0.66, -0.25)
• GSH - Hirai and Clum, 2006 - Anxiety
• SMD 0.68 (95 CI 0.57, 0.79) - Waitlist
• SMD -0.23(95 CI -0.16, 0.62) - Monitoring
• Comparable drop-out rates
• Panic, specific phobia and social anxiety
  most improved
• - Ekers et al, 2008 BA in depression
• SMD -0.70(95 CI -1.00, -0.39)
• SMD -0.60(95 CI -1.8, 0.40)

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What is the evidence for low intensity
interventions? (2)

• Exercise Mead et al, (2008)
• SMD -0.82 (95 CI -1.12, -0.51) -
  all trials
• SMD was -0.42 (95 CI -0.88, 0.03)
• - high quality trials
• Community Links Grant et al, (2000)
• Pre-Post SMD Anxiety 1.9, (95 CI -3.0
  to -0.7)
• No effect on depression

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Who do low intensity interventions help?

• Positive
• Depression
• Mild to moderate depression
• Anxiety
• Panic disorder (mild to moderate)
• GAD (mild to moderate)
• Recent onset phobias (mild to moderate)
• Negative
• Depression
• Severe and chronic depression
• Anxiety
• PTSD
• Chronic anxiety disorders

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Harm possible with all interventions

• Inappropriate treatment choice
• Critical incident de-briefing
• Misapplied treatment
• Couples therapy were one partner benefits at the
  expense of the other
• Sub-optimal therapy
• Applying technique in the absence of an alliance
• Mistakes -
• We all make them

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The nature of the materials (1)

• Technically quality
• Contextualise the intervention
• Peoples understanding of their problem
• Position in the service
• CBT based
• Function is to act as facilitator/coach not as
  therapist
• Focus on effective use of materials
• Focus on defined problems not disorders
• Knowing what does not work as important as what
  does
• Facilitates learning
• Dangers of drifting into the therapist mode

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The nature of the materials (2)

• Common factors
• Relates to how the problems are set out
• Not just materials but support to those who
  supporting material
• Acceptability/engagement (metaphor/narrative)
• Choice/targeting of populations
• Readability and beyond
• Usability keep it simple

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Methods of delivery - many and varied

• Face to Face
• Written materials
• Telephone
• Computer
• Desk top
• Web based
• Chat room
• Combinations of the above
• Patient choice - ? the preferred way to learn

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Knowledge of the system

• How does the system present low intensity
  interventions
• What does it say
• What methods are used (link with health
  promotion)
• How it is accessible
• In what framework is it presented
• How does the system relate to other systems
  (formal and informal) for helping people

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Therapist factors

• In high interventions associated with wide (and
  unacceptable) range of outcomes
• Brown et al (2005)
• 10,000 patients, 281 therapists
• 71 (25) identified as highly effective
• 53 greater improvement
• Not explained by diagnosis, age, sex, severity,
  prior treatment history, length of treatment, or
  therapist training/experience.
• Okiishi et al (2006)
• 7,500 patients, 149 therapists
• Most effective 22.40 recovered 5.20
  deteriorated
• Least effective 10.61 recovered 10.56
  deteriorated
• Likely to be the same for low interventions

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Therapist skills

• Common factors
• Necessary but not sufficient (the alliance is a
  key pan-theoretical determinant of change
  (association with outcome is small albeit robust
  (0.25 Martin et al, 2001)
• Nature of the alliance in LI work
• Competence frameworks
• Exist for LI interventions
• Critical appraisal of materials
• In conjunction with the patient
• the services materials
• the rest of the world

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Some Challenges (1)

• Increasing the range of interventions
• to other disorders especially anxiety disorders
• to specific sub-groups e.g. chronic depression
• to meet other functions e.g. prevention of
  relapse
• Increasing the accessibility of interventions
• different settings
• different providers
• Increasing the evidence for the effectiveness of
  LI interventions (particularly long-term outcomes)

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Some Challenges (2)

• Working with service users who have already used
  materials (good and bad)
• Increasing the accessibility of interventions
• different settings
• different providers
• different languages
• Integration with high intensity interventions
• LI CBT, like HI CBT, is a many-headed beast but
  needs to move from myth to evidence

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Supporting the effective delivery of LIs (1)

• Set LI in context
• Health promotion to high intensity interventions
  (public to private)
• Develop a taxonomy (not a definition) for LI
  interventions
• Acknowledge and promote divergence
• Suggest a framework for LI interventions
• Variable front ends populations and context
• CBT core
• Local information
• Develop an accessible tool for their evaluation
  by
• Staff
• Public

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Supporting the effective delivery of LIs (1)

• Shared database of reference materials
• Range of interventions
• Shared database of reference protocols
• Delivery of materials
• Critical appraisal
• Integration with HI interventions
• Fund research LI effectiveness
• Quality assured?

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Low Intensity Interventions

• Another Savoy Declaration
• We might be criticized for falling so willingly
  to the whims of our guests and that by going to
  the extreme of simplifying our methods of
  presentation and service we are debasing our art
  and turning it into craft. This is not so because
  simplicity does not rule out beauty. (Auguste
  Escoffier 1846 1935)