ISRCTN - 44615689.

[266 words]Background: Only one-third of patients with depression respond fully to antidepressant medication

This is the first in a series

Computerized Self-help (CSH) has recently been the subject of a NICE (National Institute of Clinical Excellence) review. This increase in interest is also reflected in the increase in advertising for CSH programmes. We report a national survey of a random sample of 500 therapists accredited with the British Association for Behavioural and Cognitive Psychotherapies, which is the lead organization for CBT in the UK. A total of 329 therapists responded (65.8%). A surprisingly small number of CBT therapists were using CSH (12 or 2.4%) and only 5 or 1% were using it as an alternative to patient-therapist contact. Despite this, over 90% of the responding therapists had not ruled out using CSH in the future, but the majority of these would use it to supplement rather than as an alternative to individual face-to-face therapy. The need to know more about computerized self-help and the need for training in therapy using this modality were seen as the main factors that would have to change to allow the therapists to use CSH. Knowledge of and ability to use computers did not appear to be an important factor as most therapists in this sample used computers on a regular basis. Most therapists were not aware of evidence of the effectiveness of CSH but the minority who did feel able to express views stated that CSH would be less effective than individual face-to-face therapy and result in less client satisfaction.

SummaryBackgroundPsychological therapies are first-line interventions for depression, but existing provision is not accessible for many adults with intellectual disabilities. We investigated the clinical and cost-effectiveness of a behavioural activation intervention (BeatIt) for people with intellectual disabilities and depression. BeatIt was compared with a guided self-help intervention (StepUp).MethodsWe did a multicentre, single-blind, randomised, controlled trial with follow-up at 4 months and 12 months after randomisation. Participants aged 18 years or older, with mild to moderate intellectual disabilities and clinically significant depression were recruited from health and social care services in the UK. The primary outcome was the Glasgow Depression Scale for people with a Learning Disability (GDS-LD) score at 12 months. Analyses were done on an intention-to-treat basis. This trial is registered with ISCRTN, number ISRCTN09753005.FindingsBetween Aug 8, 2013, and Sept 1, 2015, 161 participants were randomly assigned (84 to BeatIt; 77 to StepUp); 141 (88%) participants completed the trial. No group differences were found in the effects of BeatIt and StepUp based on GDS-LD scores at 12 months (12·03 [SD 7·99] GDS-LD points for BeatIt vs 12·43 [SD 7·64] GDS-LD points for StepUp; mean difference 0·26 GDS-LD points [95% CI −2·18 to 2·70]; p=0·833). Within-group improvements in GDS-LD scores occurred in both groups at 12 months (BeatIt, mean change −4·2 GDS-LD points [95% CI −6·0 to −2·4], p<0·0001; StepUp, mean change −4·5 GDS-LD points [–6·2 to −2·7], p<0·0001), with large effect sizes (BeatIt, 0·590 [95% CI 0·337–0·844]; StepUp, 0·627 [0·380–0·873]). BeatIt was not cost-effective when compared with StepUp, although the economic analyses indicated substantial uncertainty. Treatment costs were only approximately 3·6–6·8% of participants' total support costs. No treatment-related or trial-related adverse events were reported.InterpretationThis study is, to our knowledge, the first large randomised controlled trial assessing individual psychological interventions for people with intellectual disabilities and mental health problems. These findings show that there is no evidence that BeatIt is more effective than StepUp; both are active and potentially effective interventions.FundingNational Institute for Health Research.

National Institute for Health Research Health Technology Assessment.

Background

PSH/GSH may have some utility as a first step in treatment and may have potential as an alternative to formal therapist-delivered psychological therapy. Future research should focus on producing large well-conducted studies of self-help treatments in eating disorders including health economic evaluations, different types and modes of delivering self-help (e.g. computerised versus manual-based) and different populations and settings.