BackgroundIt is challenging to engage repeat users of unscheduled healthcare with severe health anxiety in psychological help and high service costs are incurred. We investigated whether clinical and economic outcomes were improved by offering remote cognitive behaviour therapy (RCBT) using videoconferencing or telephone compared to treatment as usual (TAU).MethodsA single-blind, parallel group, multicentre randomised controlled trial was undertaken in primary and general hospital care. Participants were aged ≥18 years with ≥2 unscheduled healthcare contacts within 12 months and scored >18 on the Health Anxiety Inventory. Randomisation to RCBT or TAU was stratified by site, with allocation conveyed to a trial administrator, research assessors masked to outcome. Data were collected at baseline, 3, 6, 9 and 12 months. The primary outcome was change in HAI score from baseline to six months on an intention-to-treat basis. Secondary outcomes were generalised anxiety, depression, physical symptoms, function and overall health. Health economics analysis was conducted from a health service and societal perspective.ResultsOf the 524 patients who were referred and assessed for trial eligibility, 470 were eligible and 156 (33%) were recruited; 78 were randomised to TAU and 78 to RCBT. Compared to TAU, RCBT significantly reduced health anxiety at six months, maintained to 9 and 12 months (mean change difference HAI –2.81; 95% CI –5.11 to –0.50; P = 0.017). Generalised anxiety, depression and overall health was significantly improved at 12 months, but there was no significant change in physical symptoms or function. RCBT was strictly dominant with a net monetary benefit of £3,164 per participant at a willingness to pay threshold of £30,000. No treatment-related adverse events were reported in either group.ConclusionsRCBT may reduce health anxiety, general anxiety and depression and improve overall health, with considerable reductions in health and informal care costs in repeat users of unscheduled care with severe health anxiety who have previously been difficult to engage in psychological treatment. RCBT may be an easy-to-implement intervention to improve clinical outcome and save costs in one group of repeat users of unscheduled care.Trial registrationThe trial was registered at ClinicalTrials.gov on 19 Nov 2014 with reference number NCT02298036Electronic supplementary materialThe online version of this article (10.1186/s12916-019-1253-5) contains supplementary material, which is available to authorized users.

(2016) Individual placement and support versus individual placement and support enhanced with work-focused cognitive behaviour therapy: feasibility study for a randomised controlled trial. British Journal of Occupational Therapy, 79 (5).

Despite economic recession, an IPS service was implemented and regarded as satisfactory to service users seeking work. Although many found obtaining employment difficult, they would still advise others that work is worthwhile, suggesting that the context of recession has not discouraged them.

A number of factors appear to combine to result in feelings of strain, but the GOS could be used as a crude screening tool. Interventions for cognitive, behavioral, and emotional difficulties may be most useful for carers.

Topic. Additional interventions used to enhance the effectiveness of individual placement and support (IPS). Aim. To establish whether additional interventions improve the vocational outcomes of IPS alone for people with severe mental illness. Method. A rapid evidence assessment of the literature was conducted for studies where behavioural or psychological interventions have been used to supplement standard IPS. Published and unpublished empirical studies of IPS with additional interventions were considered for inclusion. Conclusions. Six published studies were found which compared IPS alone to IPS plus a supplementary intervention. Of these, three used skills training and three used cognitive remediation. The contribution of each discrete intervention is difficult to establish. Some evidence suggests that work-related social skills and cognitive training are effective adjuncts, but this is an area where large RCTs are required to yield conclusive evidence.

There has been a dramatic increase in remote psychotherapy since the onset of the COVID‐19 crisis. There is also expected to be an increase in mental health problems in the wake of the COVID‐19 pandemic. An increase in severe health anxiety (SHA) is particularly anticipated, for which cognitive–behavioural therapy (CBT) is a frontline treatment. However, it is unclear what interaction types are associated with outcome‐improvement in remote‐CBT (rCBT) for SHA. This study aimed to identify interaction types that predict outcomes and sudden gains in rCBT for SHA using initial therapy session content. Forty‐eight participants in rCBT for SHA had interactions at their first sessions categorized and rated in terms of patient activation: an individual's confidence and ability to manage their health. Multilevel modelling assessed whether early interaction types predicted session‐by‐session wellbeing. For participants experiencing sudden gains (n = 12) interactions at the session directly prior to the gain were similarly categorized and rated. The scores were then compared with ratings for the preceding session. A smaller proportion of early sessions was taken up with problem descriptions among those with greater outcome improvements. There was also a significant reduction in the proportion of the session spent describing problems in the session directly prior to a sudden gain, as compared with the previous session. Conversely, clients with better outcomes made more positive evaluations of themselves and therapy, noticed more positive changes and made more contributions to structuring interactions at initial sessions. Specific early interaction types predict session‐by‐session outcomes and precede sudden gains in rCBT for SHA.

Objective We describe the development of an instrument aiming to offer interaction‐level feedback based on “patient activation”: client confidence and perceived ability to manage their health. Method Twenty‐two session‐transcripts from cognitive behavioral therapy with high‐users of healthcare were analyzed thematically, producing themes describing in‐session interactions. Themes were subcategorized using patient activation theory into high and low activation presentations. Two coders new to the process were trained to use this consultation interactions coding scheme (CICS). Inter‐rater reliability (IRR), convergent validity, and clinical utility were assessed and illustrated with extreme cases. Results Good‐to‐excellent IRR was achieved. The CICS, therapeutic alliance, and therapist competence were correlated. Client engagement in session‐structuring interactions correlated with outcome. The highest CICS scorer showed multiple outcome‐improvements, the lowest scorer reported deteriorations. Conclusions This study presents the CICS's psychometric properties and indicates the value of client engagement in session‐structuring.

Purpose – The purpose of this paper is to draw out the lessons learned from the implementation of the Individual Placement and Support (IPS) approach to supported employment in two contrasting adult mental health teams; one “standard” CMHT, and one early intervention in psychosis (EIP) team. Design/methodology/approach – These inferences are based on the evidence from a four-year study of IPS in one mental health care provider in the UK, which began by setting up a new service, and went on to run a RCT looking at the impact of psychological input as an adjunct to IPS alone. Findings – In attempting to introduce IPS to mental health teams in Nottingham the authors came across numerous barriers, including service reorganisation, funding cuts and the wider context of recession. Differences were observed between mental health teams in the willingness to embrace IPS. The authors argue that this variability is due to differences in caseload size, recovery priorities and client profiles. The authors have learnt that perseverance, strenuous efforts to engage clinical staff and the use of IPS fidelity reviews can make a positive difference to the implementation process. Practical implications – The experience suggests that setting up an IPS service is possible even in the most challenging of times, and that EIP services may be a particularly fertile ground for this approach. The authors also discuss potential barriers to implementing new services in mental health teams. Originality/value – This paper will be of value to service development and the science of implementation in mental health.