No abstract

BackgroundComputerised cognitive–behavioural therapy (CCBT) might offer a solution to the current undertreatment of depression.AimsTo determine the clinical effectiveness of online, unsupported CCBT for depression in primary care.MethodThree hundred and three people with depression were randomly allocated to one of three groups: Colour Your Life; treatment as usual (TAU) by a general practitioner; or Colour Your Life and TAU combined. Colour Your Life is an online, multimedia, interactive CCBT programme. No assistance was offered. We had a 6-month follow-up period.ResultsNo significant differences in outcome between the three interventions were found in the intention-to-treat and per protocol analyses.ConclusionsOnline, unsupported CCBT did not outperform usual care, and the combination of both did not have additional effects. Decrease in depressive symptoms in people with moderate to severe depression was moderate in all three interventions. Online CCBT without support is not beneficial for all individuals with depression.

Major depression is a common mental health problem in the general population 1 and is associated with substantial reductions in quality of life.2,3 Cost-of-illness studies reveal that the economic burden of depression is considerable. 4 However, many people with depression attending primary care do not receive the care they need. There is little evidence about the effectiveness of pharmacotherapy in patients with mild to moderate depression 5 and psychological treatments in primary care are scarce and costly. Consequently, effective treatments like cognitive-behavioural therapy (CBT) 6,7 are not offered to all patients and many people with depression in primary care remain untreated. 8 An effective, acceptable and feasible solution for such individuals might be computerised CBT (CCBT). 9 The National Institute for Health and Clinical Excellence (NICE) recommended the use of two CCBT software programs for depression and anxiety, 10 and these programs are now in use in England, Wales and Northern Ireland. In the Netherlands, an online CCBT program is currently being used as part of an ongoing implementation study (www.kleurjeleven.nl/). However, evidence about the costeffectiveness of CCBT is still limited.9 To our knowledge, only one study conducted an economic evaluation of CCBT for depression and it showed that CCBT (delivered on a personal computer in the general practice) can be highly cost-effective compared with usual care by a general practitioner (GP) in the UK setting.11 In a recent study, we compared the clinical effectiveness of unsupported, online CCBT (i.e. Colour Your Life) with treatment as usual (TAU) by a GP and a combination of both CCBT and TAU for depression (CCBT plus TAU). 12 In the present study, we assess the cost-effectiveness of these interventions, focusing on the research question: for mild to moderate depression, is CCBT compared with TAU or CCBT plus TAU preferable in terms of cost-effectiveness from a societal perspective? The Medical and Ethical Committee approved the study protocol. The study is registered at the Netherlands Trial Register, part of the Dutch Cochrane Centre (ISRCTN47481236) Method Design and participantsIn a randomised trial, 303 participants were recruited from the general population by means of a large-scale internet-based screening in the South of the Netherlands. Inclusion criteria were: age 18-65; access to the internet at home (for optimal use of the CCBT program, a broad-band connection was required and not dial-up connection); at least mild to moderate depressive complaints (Beck Depression Inventory II (BDI-II) 13 score516); duration of depressive complaints 3 months or more; no current psychological treatment for depression; no continuous antidepressant treatment for at least 3 months prior to entry; fluent in Dutch language; no alcohol and/ or drug dependence; and no severe psychiatric comorbidity (e.g. psychotic disorders). During a 1-year follow-up period, participants were asked to fill in monthly internet questionnaires. 12,14 InterventionsComputeri...

No abstract

Dutch healthcare professionals perceived the MCD outcomes related to collaboration as most important. The empirical findings can contribute to shared ownership of MCD and a more specific use of MCD in different contexts. They can inform international comparative research on different CES types and contribute to normative discussions concerning CES outcomes. Future studies should reflect upon important MCD outcomes after having experienced MCD.

Moral case deliberation (MCD) is a specific form of clinical ethics, aiming to stimulate ethical reflection in daily practice in order to improve the quality of care. This article focuses on the implementation of MCD in nursing homes and the questions how and where to organize MCD. The purpose of this study was to evaluate one way of organizing MCD in two Dutch nursing homes. In both of these nursing homes the MCD groups had a heterogeneous composition and were organized apart from existing institutional communication structures. As part of a naturalistic evaluation, systematic observations, interviews and focus groups were completed. The findings indicate that the heterogeneous composition and MCD meetings separate from existing structures have benefits. However, the participants also reported negative experiences. This gives rise to the question whether a mixed MCD group which meets separately is an effective way to embed MCD as an instrument for reflection on moral issues in daily practice. We conclude that there is no single answer to that question. In the end, the two implementation strategies (i.e. within existing communication structures and a mixed MCD group) can be complementary to each other.

Our study presents an overview of the issues that were brought forward by participants of a moral case deliberation (MCD) project in two elderly care organizations. The overview was inductively derived from all case descriptions (N = 202) provided by participants of seven mixed MCD groups, consisting of care providers from various professional backgrounds, from nursing assistant to physician. The MCD groups were part of a larger MCD project within two care institutions (residential homes and nursing homes). Care providers are confronted with a wide variety of largely everyday ethical issues. We distinguished three main categories: ‘resident’s behavior’, ‘divergent perspectives on good care’ and ‘organizational context’. The overview can be used for agendasetting when institutions wish to stimulate reflection and deliberation. It is important that an agenda is constructed from the bottom-up and open to a variety of issues. In addition, organizing reflection and deliberation requires effort to identify moral questions in practice whilst at the same time maintaining the connection with the organizational context and existing communication structures. Once care providers are used to dealing with divergent perspectives, inviting different perspectives (e.g. family members) to take part in the deliberation, might help to identify and address ethical ‘blind spots’.

This approach results in more attention to processes of interpretation, deliberation and joint learning.