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News
and events
News
Comment on NICE CCBT guidelines February 2006
Comment on NICE CCBT update review
Reference: http://www.nice.org.uk/pdf/word/TA097guidance.doc
We are disappointed to read the principle recommendation by
NICE about the Overcoming Depression CD Rom that:
1.2 There is insufficient evidence to recommend the use of COPE and Overcoming
Depression as a clinically or cost-effective option for the management of depression,
except as part of ongoing or new clinical trials that are designed to generate
robust and relevant data on the clinical effectiveness of these specific CCBT
packages.
The first thing to note is that this affects only the CD Rom version - and
has no relevance for the workbooks, group, College or any other versions of
the course.
A note on the NICE approach
NICE recommendations are based on only two things- clinical and cost effectiveness.
This needs to be borne in mind in understanding the report. It also explains
the fairly regular statements in the media of "outrage" from various
patient/user groups and professionals concerning NICE recommendations. NICE
aren't predominantly interested in whether things are well-designed, are
deliverable, get good satisfaction ratings from users and professionals.
What is required are high quality evidence and evidence of cost effectiveness.
Without this a standard NICE recommendation is that such evidence is required
and research is needed. This is exactly what has happened in the recommendation
for Overcoming Depression. All NICE state in their somewhat "technical" language
is that Randomised Controlled Studies (RCT's) with linked economic analyses
are required for Overcoming Depression.
Leaving aside the whole issue of whether good evidence always
means an RCT/economic evaluation (most of medical practice
does not have this and would not be recommended by NICE, and
also evidence other than RCT's are used by NICE and also Cochrane
in other settings to make recommendations), the main concern
we have is that the everyday way of reading the NICE CCBT review
is that many practitioners and patients may think this states
that Overcoming Depression should not be used - except in RCT's.
This is not technically what NICE have recommended, however
the way the recommendation is phrased remains ambiguous to
many readers. NICE have unfortunately failed to clarify this
point in spite of requests to do so.
Our understanding is that NICE cannot recommend Overcoming
Depression based on the lack of RCT and economic evidence -
which is entirely fair. However our main concern is that the
NICE statement takes a situation that is really a neutral finding
(ie we don't know, so more research is needed), and makes it
appear like a negative statement that Overcoming Depression
should not be used except in research. The everyday way of
reading this that we perceive here is that many people will
come to the incorrect conclusion it should not be used clinically.
A RCT and economic evaluation is currently underway of the
CD Rom in a Psychology setting. However it is important to
note that small players which are University-based like Media
Innovations cannot hope to self-fund studies in a way similar
to Ultrasis PLC - the producer of Beating the Blues. The main
outcome studies to date of Beating the Blues have been funded
by the developers.
There are a number of related issues:
1). Absence of RCT evidence is not the same as evidence of no impact. Overcoming
Depression was in fact recommended in the very first NICE draft of the current
review which makes this point. It is important to recognise that evidence
comes in many forms. The only published study to date of Overcoming Depression
by Whitfield et al (2006) suggests effectiveness. There was no evidence of
harm. It is noteworthy that this was seen as sufficient evidence for recommendation
in the first draft of the NICE report. Such levels of evidence have in the
past been enough to be included in Cochrane and also some other NICE reviews.
It was not in this case however. We believe a fair conclusion should have
led to a neutral "Further research is required" verdict by NICE.
The current statement is clear "technical" language, but fails
the general standard for understandability and fairness.
Ref: Whitfield, G, Hinshelwood, R, Pashley, A., Campsie, L,
Williams C. The impact of a novel computerised CBT CDRom (Overcoming
Depression) offered to patients referred to clinical psychology.
Behavioural and Cognitive Psychotherapy, 2006, 34, 1-11
2).
Overcoming Depression is the only CCBT package that comes
in a range of forms - including the freely available Living
life to the Full Life skills site (with a million hits in the
first 7 months), a written manual and series of workbooks,
a treatment group and a public education college course. In
services where CBT stepped care is offered it is a reasonable
choice - simply because it is one component of a wider flexible
package. It is in our view nonsense to publish a recommendation
that can be seen to suggest that this single component is made
unavailable. A simple clarification of the recommendation would
have avoided this situation. Unfortunately this has not occurred.
3) Another format of the same materials (the Overcoming Depression
book) appears to be as effective in terms of patient outcome
as Beating the Blues in a recent effectiveness study (Reference:
study presented at the BABCP annual conference in Canterbury
by Mark Kenwright of the Ealing CBT service). It was more likely
to be taken up than Beating the Blues and led to equivalent
outcomes. This is interesting - especially given the differences
in terms of cost.
What we know at present:
The Overcoming Depression CD Rom has good patient acceptability and shows improved
mood and other key symptoms in an open study with no comparison group. Clear
gains in knowledge about depression and its treatment occur. This data was
in a small pilot study however the results were statistically "strong".
A RCT with a comparison group is clearly required - and this is being done.
However we believe that there is enough available data to
say that Overcoming Depression is a viable and reasonable option
for clinical use as part of a stepped care system - and that
the current NICE recommendations confuses things by making
it appear that use of the CD Rom should restricted to clinical
studies research only.
Overall summary:
We still believe that the basis on which the Overcoming Depression CD Rom has
been developed (i.e. the accessible CBT model) is likely to be effective.
We do not think that Overcoming Depression should be widely recommended by
NICE at present. However there is sufficient evidence that it may work and
that RCT's are required. Until these are completed and show (or don't show
) usefulness, clinicians should still be able to use Overcoming Depression
if they feel it may be appropriate for their services and patients. We call
on NICE to make this clearer and clarify this response.
Finally, NICE cannot see its work within a bubble separate
from service delivery and users. Many services are currently
using Overcoming Depression as part of the choices available
to patients. We believe that enough evidence is available to
make this choice a reasonable one.
21 March
2005
Overcoming
Bulimia, nominated for E-Health Innovation Awards
Bulimia
Sufferers offered online treatment BBC News Scotland
Press Releases
Calipso December 2004
Click on the below links to read the
full news articles
Spin-out launches self-help
system
New Version
of Overcoming Bulimia launched ::
Features and Improvements include:
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SELFSERVE CBT
Dr Chris Williams is a senior lecturer in Psychiatry
at the University of Glasgow and Director
of the Glasgow Institute of Psychosocial
Interventions (GIPSI). He has for some
time been involved in developing access
to cognitive behavioural therapy (CBT)
through innovative self-help approaches.
Here he gives us some background to CBT
and self-help and describes some of the
innovative work in this area being carried
out in Glasgow.
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WHAT IS CBT?
Cognitive
Behavioural Therapy is a short-term psychotherapy
that was devised initially by Professor Aaron Beck
in the 1950's. It provides a focus on current problems,
has a clear underlying structure/plan to treatment
and is built upon an effective relationship with
a practitioner. In a recent Department of Health
treatment guideline [1], CBT stands out as having
the largest current evidence base for effectiveness
across the widest range of mental health difficulties.
It is an effective treatment for depression, panic
disorder, generalised anxiety, health anxiety and
obsessive-compulsive disorder.
ADDRESSING PROBLEMS OF ACCESS TO CBT
There
are currently fewer than 850 CBT practitioners
accredited by the lead body for CBT in the UK.
Given the increasing need for treatment and problems
of access to CBT and other evidence-based psychosocial
interventions a major challenge is to adapt CBT
to make it more widely available. One suggested
approach is to provide a range of interventions
ranging from self-help to long-term individual
treatments.
In
the UK, two respected nurse practitioners and researchers,
Karina Lovell & David Richards, have argued
that current services are too focused upon secondary
or tertiary services, offering specialist CBT to
a highly selected number of patients. The result
is long waiting lists and limited access to treatment.
This leads to frustrations for patients and their
referring practitioners. They argue that the solution
is to routinely deliver services at three broad
levels of entry to CBT. These levels should be
flexible and accessible to a far more inclusive
range of people than at present, and address a
range of common mental health problems.
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- Level
1: Treatments should be routinely initiated
by the provision of brief therapies such as self-help,
delivered, for example, as structured written
self-help or computer-based materials. These
treatments could be widely offered in primary
care alongside the wide range of self-help provided
by voluntary sector groups and organisations.
- Level
2: Where the person has more severe or complex
problems, or is at risk, more intensive, therapist
guided packages of care should be provided.
- Level
3: For more complex or treatment resistant
cases, full specialist CBT could be offered by
experts.
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WHY PROVIDE SELF-HELP TREATMENTS?
Self-help
approaches are popular and used by both users and
practitioners. Surveys have shown that between 60%
and 90% of practitioners recommend, or use, self-help
materials. Self-help approaches are also popular
with the general public. Any large bookshop now has
a sizeable self-help section addressing a range of
mental and physical health issues. Large population-based
surveys confirm that self-help is more positively
endorsed than treatment with medication or psychotherapy,
or by a health care practitioner [2].
WHAT IS SELF HELP?
Clinicians
and members of the public use the term self-help
in various ways. These include attending a self-help
group or using self-help materials/resources such
as books or tapes. However delivered, self-help materials
aim to increase the users knowledge and understanding
of a particular problem, and also to equip the person
with skills to better self-assess and self-manage
their difficulties. Self-help treatments may either
be provided independently of, or in addition to,
sessions with a practitioner or other supporter such
as a voluntary sector worker.
SELF-HELP IN GLASGOW
Glasgow
has become one of the UK's leading centres of CBT
self-help techniques with an unrivalled training
programme in using self-help in secondary care settings.
At present a number of resources are being used in
the city, including:
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- A
series of written CBT self-help workbooks - Overcoming
Depression: A Five Areas Approach and Overcoming
Anxiety: A Five Areas Approach. These aim to provide
a user-friendly accessible form of self-help, supported
by a practitioner or voluntary sector support worker.
- CD
Rom computerised self-help treatments for bulimia
and depression. These are being delivered currently
to a clinical psychology waiting list at the Lansdowne
clinic in Glasgow (depression) and in Leicester
and London (bulimia). There are plans to offer
the bulimia CD Rom to patients referred to the
child and adolescent services at the Parry Jones
Eating Disorders clinic at Gartnavel Royal Hospital.
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In
secondary care, the SPIRIT (Structured Psychosocial
InteRventions In Teams) project has trained 219 practitioners
(nurses, doctors and occupational therapists) in
both community and inpatient teams to use structured
CBT self-help materials. This large project, funded
by the Greater Glasgow Health Board under the Modernising
Mental Health initiative, aims to train staff to
use the Overcoming Depression self-help resources.
The second stage of this is commencing shortly and
is moving on to consider the use of CBT self-help
in psychosis, obsessive-compulsive disorder, treatment
resistant depression and to help people who are feeling
suicidal.
Finally,
a joint bid from Greater Glasgow Health Board and
the Primary Care Trust, led by Depression Alliance
Scotland (DAS) and GIPSI, has just been funded by
the Scottish Executive under the Doing Well by People
with Depression initiative. This will extend this
work into primary care settings and develop a primary/community
care resource to deliver written and computerised
self-help in primary care and voluntary sector settings.
This will include developing new DAS groups and also
supporting new primary mental health care teams to
deliver self-help treatments around the city. If
funded, this proposal will help develop still further
links in joint working between the NHS and voluntary
sector in the area of self-help.
REFERENCES
1. Department of Health (2001). Treatment choice in psychological
therapies and counselling. London: HMSO.
2. Jorm, A.F., Korten, A.E., Jacomb, P.A., Rodgers, B.,
Pollitt, P., Christensen, H. and Henderson, S. (1997).
Helpfulness of interventions for mental disorders: beliefs
of health professionals compared with the general public.
British Journal of Psychiatry, 171, 233-237.
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Overcoming
Anxiety - Training in CBT self-help materials for use in
primary & secondary care with patients/clients experiencing
anxiety - Wednesday 12 November 2003
For
more information download the PDF 
OUT
NOW..new anxiety self-help book
Overcoming
Anxiety a Five Areas Approach, a new CBT-based self-help
book containing a series of structured self-help workbooks
for patients to use will shortly be available from Calipso.
The book
is written by Dr Chris Williams, author of the highly regarded
and successful Overcoming Depression book and Calipso mental
health training and self-help CD-ROMs.
Published
by Hodder-Arnold, the book will be available on the Calipso
website.
For more
information click
here
7 February
2003
The
hidden costs of eating disorders
A new report
by the Eating Disorders Association reveals the true impact
that eating disorders have on 1.1 million UK sufferers, their
parents, partners and carers as well as on health and social
services.
Published
as part of Eating Disorders Awareness week, the report looks
at why and how an eating disorder can have a devastating
effect as well as prevention strategies.
To read
the report click here
How
can primary carers help sufferers of eating disorders to
manage their condition?
The Overcoming
Bulimia CD-ROM from Calipso offers healthcare professionals
a cost-effective treatment resource delivers a course of
self-help treatment to patients. The course is based on Cognitive
Behaviour Therapy. To read click on self-help at the top
of the page.
24 January
2003
And
the winner is...
The calipso.co.uk
free prize draw to win a copy of the new Overcoming Depression
CD-ROM has now closed and the winning entry picked.
The lucky
winner is Joanne Nicholson, an assistant psychologist from
Nottinghamshire.
The Calipso team would like to thank everyone who took time to
enter the competition.
Look out
for more chances to win Calipso CD-ROMs and special member
discounts over the coming months.
14 January
2003
Primary
carers need more training in mental health, says major
new report
A independent
report on the development of primary care mental health services
in the UK says that healthcare professionals need more training
if primary care is to play a central role in the provision
of mental health services.
The report,
Primary Solutions, published by The Sainsbury Centre for
Mental Health in association with the NHS Alliance, reviews
the development of mental health services in primary care.
It looks at the different structures for how primary and
secondary care work together and the skills required by the
workforce to meet these challenges.
To find
out how Calipso training CD-ROMs can help primary carers
to identify and manage mental health conditions more effectively,
click on courses.
For more
on the report, go to the Sainsbury
Centre for Mental Health website
22 October
2002
Calipso
CD-ROM identified in new NHS report
Calipso's
Overcoming Depression CD-ROM has been identified in a new
guidance document issued by The National Institute for Clinical
Excellence (NICE) into computerised Cognitive Behaviour Therapy
(CBT) for depression and anxiety.
NICE issues
guidance documents to provide patients, health professionals
and the public with authoritative, robust and reliable guidance
on current “best practice”.The guidance covers
both individual
health technologies (including medicines, medical devices, diagnostic
techniques, and procedures) and the clinical management of specific
conditions.
As well
as providing details on six computerised CBT programs, the
new guidance document states that the benefits of computerised
CBT to the NHS, healthcare professionals and patients are:
- more
availability of CBT
- reduced
overall burden of care for patients with anxiety and depression
who may otherwise be waiting for prolonged periods for
treatment
- free-up
existing resources through a reduction in repeat primary
care consultations and waiting times for psychological
services.
Commenting
on the report's publication, Calipso creator, Dr Williams
said " The Calipso team is delighted to hear that both
computerised CBT and our own CD-ROM Overcoming Depression
have been identified by NICE as treatments for depression. " He
added" The Overcoming Depression CD-ROM aims to allow
far greater access to effective psychological treatments
and has been designed to be easy to use - even by people
who have not used a computer before"
To find
out more about NICE guidance click
here.
Read more
on the Overcoming
Depression CD-ROM and the Overcoming
Depression book
4 September
2002
Patients
get quicker access to CBT
The
release of our Overcoming Depression Self-help CD-ROM means
that you can now offer Cognitive Behaviour Therapy (CBT)
to an unlimited number of your patients.
Easy-to-use,
even by patients who have not used a computer before, this
interactive CD-ROM delivers a complete course of CBT - an
effective form of treatment for patients with mild to moderate
forms of depression. Click here for more on the course.
Exhibitions
Exhibition
diary for 2006 to be announced
Training
events
The Andrew
Sims Centre for Professional Development organises education
and training events to equip healthcare professionals
with the skills to ensure best patient practice in the
modern health service.
The Centre
based in Leeds, runs a number of mental health-related course
throughout the year.
For more
information on course dates contact:
The Andrew
Sims Centre
Andrew Sims Centre
The Mount
44 Hyde Terrace
Leeds LS2 9LN
Tel: 0113
305 5639
Fax: 0113 305 5632
Email: Louise.Gardham@leedsmh.nhs.uk
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