Showing papers on "Psychological intervention published in 2004"

How stigma interferes with mental health care.

Abstract: Many people who would benefit from mental health services opt not to pursue them or fail to fully participate once they have begun. One of the reasons for this disconnect is stigma; namely, to avoid the label of mental illness and the harm it brings, people decide not to seek or fully participate in care. Stigma yields 2 kinds of harm that may impede treatment participation: It diminishes self-esteem and robs people of social opportunities. Given the existing literature in this area, recommendations are reviewed for ongoing research that will more comprehensively expand understanding of the stigma-care seeking link. Implications for the development of antistigma programs that might promote care seeking and participation are also reviewed.

Effectiveness and efficiency of guideline dissemination and implementation strategies

Abstract: OBJECTIVES: To undertake a systematic review of the effectiveness and costs of different guideline development, dissemination and implementation strategies. To estimate the resource implications of these strategies. To develop a framework for deciding when it is efficient to develop and introduce clinical guidelines. DATA SOURCES: MEDLINE, Healthstar, Cochrane Controlled Trial Register, EMBASE, SIGLE and the specialised register of the Cochrane Effective Practice and Organisation of Care (EPOC) group. REVIEW METHODS: Single estimates of dichotomous process variables were derived for each study comparison based upon the primary end-point or the median measure across several reported end-points. Separate analyses were undertaken for comparisons of different types of intervention. The study also explored whether the effects of multifaceted interventions increased with the number of intervention components. Studies reporting economic data were also critically appraised. A survey to estimate the feasibility and likely resource requirements of guideline dissemination and implementation strategies in UK settings was carried out with key informants from primary and secondary care. RESULTS: In total, 235 studies reporting 309 comparisons met the inclusion criteria; of these 73% of comparisons evaluated multifaceted interventions, although the maximum number of replications of a specific multifaceted intervention was 11 comparisons. Overall, the majority of comparisons reporting dichotomous process data observed improvements in care; however, there was considerable variation in the observed effects both within and across interventions. Commonly evaluated single interventions were reminders, dissemination of educational materials, and audit and feedback. There were 23 comparisons of multifaceted interventions involving educational outreach. The majority of interventions observed modest to moderate improvements in care. No relationship was found between the number of component interventions and the effects of multifaceted interventions. Only 29.4% of comparisons reported any economic data. The majority of studies only reported costs of treatment; only 25 studies reported data on the costs of guideline development or guideline dissemination and implementation. The majority of studies used process measures for their primary end-point, despite the fact that only three guidelines were explicitly evidence based (and may not have been efficient). Respondents to the key informant survey rarely identified existing budgets to support guideline dissemination and implementation strategies. In general, the respondents thought that only dissemination of educational materials and short (lunchtime) educational meetings were generally feasible within current resources. CONCLUSIONS: There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances. Decision makers need to use considerable judgement about how best to use the limited resources they have for clinical governance and related activities to maximise population benefits. They need to consider the potential clinical areas for clinical effectiveness activities, the likely benefits and costs required to introduce guidelines and the likely benefits and costs as a result of any changes in provider behaviour. Further research is required to: develop and validate a coherent theoretical framework of health professional and organisational behaviour and behaviour change to inform better the choice of interventions in research and service settings, and to estimate the efficiency of dissemination and implementation strategies in the presence of different barriers and effect modifiers.

Building academic success on social and emotional learning: What does the research say?

Abstract: In this book, nationally recognized interdisciplinary leaders examine the relationships between social-emotional education and school success - specifically focusing on interventions that enhance student learning. Offering scientific evidence and practical examples, this volume points out the many benefits of SEL programs.

Mental health provider attitudes toward adoption of evidence-based practice: the Evidence-Based Practice Attitude Scale (EBPAS).

Abstract: Mental health provider attitudes toward organizational change have not been well studied. Dissemination and implementation of evidence-based practices (EBPs) into real-world settings represent organizational change that may be limited or facilitated by provider attitudes toward adoption of new treatments, interventions, and practices. A brief measure of mental health provider attitudes toward adoption of EBPs was developed and attitudes were examined in relation to a set of provider individual difference and organizational characteristics. Methods: Participants were 322 public sector clinical service workers from 51 programs providing mental health services to children and adolescents and their families. Results: Four dimensions of attitudes toward adoption of EBPs were identified: (1) intuitive Appeal of EBP, (2) likelihood of adopting EBP given Requirements to do so, (3) Openness to new practices, and (4) perceived Divergence of usual practice with research-based/academically developed interventions. Provider attitudes varied by education level, level of experience, and organizational context. Conclusions: Attitudes toward adoption of EBPs can be reliably measured and vary in relation to individual differences and service context. EBP implementation plans should include consideration of mental health service provider attitudes as a potential aid to improve the process and effectiveness of dissemination efforts.

Cognitive Behavioural Processes across Psychological Disorders: A Transdiagnostic Approach to Research and Treatment

Abstract: Cognitive Behavioural Therapy (CBT) has established itself as one of the most effective therapies for treating a wide range of psychological disorders. However, research and treatment in this field typically adopts a DSM driven 'disorder-focused' approach - researchers and clinicians target a specific disorder, try to understand its aetiology and maintenance, and try to develop more effective strategies to treat the disorder. This book proposes an insightful and original approach to understanding these disorders, one that focuses on what they have in common. Instead of examining in isolation, for example, obsessive compulsive disorders, insomnia, schizophrenia, it asks - what do patients with these disorders have in common? It takes each cognitive and behavioural process - attention, memory, reasoning, thought, behaviour, and examines whether it is a transdiagnostic process - i.e., serves to maintain a broad range of psychological disorders. Having shown how these disorders share several important processes, it then describes the practical implications of such an approach to diagnosis and treatment. Importantly it explores why the different psychological disorders can present so differently, despite being maintained by the same cognitive and behavioural processes. It also provides an account of the high rates of comorbidity observed among the different disorders. This book provides a novel review and integration of the empirical literature and gives clinicians and researchers a valuable new theoretical base for assessing and treating psychological disorders. Cognitive Behavioural Therapy (CBT) has established itself as one of the most effective therapies for treating a wide range of psychological disorders. However, research and treatment in this field typically adopts a DSM driven 'disorder-focused' approach - researchers and clinicians target a specific disorder, try to understand its aetiology and maintenance, and try to develop more effective strategies to treat the disorder. This book proposes an insightful and original approach to understanding these disorders, one that focuses on what they have in common. Instead of examining in isolation, for example, obsessive compulsive disorders, insomnia, schizophrenia, it asks - what do patients with these disorders have in common? It takes each cognitive and behavioural process - attention, memory, reasoning, thought, behaviour, and examines whether it is a transdiagnostic process - i.e., serves to maintain a broad range of psychological disorders. Having shown how these disorders share several important processes, it then describes the practical implications of such an approach to diagnosis and treatment. Importantly it explores why the different psychological disorders can present so differently, despite being maintained by the same cognitive and behavioural processes. It also provides an account of the high rates of comorbidity observed among the different disorders. This book provides a novel review and integration of the empirical literature and gives clinicians and researchers a valuable new theoretical base for assessing and treating psychological disorders.

Complex interventions: how "out of control" can a randomised controlled trial be?

Abstract: Complex interventions are more than the sum of their parts, and interventions need to be better theorised to reflect this Many people think that standardisation and randomised controlled trials go hand in hand. Having an intervention look the same as possible in different places is thought to be paramount. But this may be why some community interventions have had weak effects. We propose a radical departure from the way large scale interventions are typically conceptualised. This could liberate interventions to be responsive to local context and potentially more effective while still allowing meaningful evaluation in controlled designs. The key lies in looking past the simple elements of a system to embrace complex system functions and processes. The suitability of cluster randomised trials for evaluating interventions directed at whole communities or organisations remains vexed.1 It need not be.2 Some health promotion advocates (including the WHO European working group on health promotion evaluation) believe randomised controlled trials are inappropriate because of the perceived requirement for interventions in different sites to be standardised or look the same.1 3 4 They have abandoned randomised trials because they think context level adaptation, which is essential for interventions to work, is precluded by trial designs. An example of context level adaptation might be adjusting educational materials to suit various local learning styles and literacy levels. Lead thinkers in complex interventions, such as the UK's Medical Research Council, also think that trials of complex interventions must “consistently provide as close to the same intervention as possible” by “standardising the content and delivery of the intervention.”5 By contrast, however, they do not see this as a reason to reject randomised controlled trials. These divergent views have led to problems on two fronts. Firstly, the field of health promotion is being turned away from randomised …

Designing randomized, controlled trials aimed at preventing or delaying functional decline and disability in frail, older persons: a consensus report.

Abstract: The discovery of effective interventions to prevent or delay disability in older persons is a public health priority. Most likely to benefit from such interventions are frail individuals who are not yet disabled and those with early disability who are at high risk of progression. In spite of this frail older persons have often been excluded from research on the assumption that they would not tolerate testing or benefit from treatment. The Interventions on Frailty Working Group developed recommendations to screen, recruit, evaluate, and retain frail older persons in clinical trials. Specific recommendations are: Eligibility screening should include a multistage process, to quickly exclude those who are too well and those who are too sick. Inclusion criteria should target those most likely to benefit, be meaningful to clinicians, and reflect advancements in the frailty research area. Disability outcome measures should include self-reported, objective, and proxy measures. Strategies to improve retention and compliance and to monitor their effectiveness should be an integral part of the study design. Estimation of cost and sample size should contemplate high dropout rates and interference by competing outcomes. Additional research is needed to refine criteria for screening frail older persons, identify objective measures of disability that are reliable and valid in frail older persons, and improve the informed consent process for high-risk participants, recognizing that research in this subgroup is essential to improving their health outcomes.

The effectiveness of Web-based vs. non-Web-based interventions: a meta-analysis of behavioral change outcomes

Abstract: BACKGROUND: A primary focus of self-care interventions for chronic illness is the encouragement of an individual's behavior change necessitating knowledge sharing, education, and understanding of the condition. The use of the Internet to deliver Web-based interventions to patients is increasing rapidly. In a 7-year period (1996 to 2003), there was a 12-fold increase in MEDLINE citations for “Web-based therapies.” The use and effectiveness of Web-based interventions to encourage an individual's change in behavior compared to non-Web-based interventions have not been substantially reviewed. OBJECTIVE: This meta-analysis was undertaken to provide further information on patient/client knowledge and behavioral change outcomes after Web-based interventions as compared to outcomes seen after implementation of non-Web-based interventions. METHODS: The MEDLINE, CINAHL, Cochrane Library, EMBASE, ERIC, and PSYCHInfo databases were searched for relevant citations between the years 1996 and 2003. Identified articles were retrieved, reviewed, and assessed according to established criteria for quality and inclusion/exclusion in the study. Twenty-two articles were deemed appropriate for the study and selected for analysis. Effect sizes were calculated to ascertain a standardized difference between the intervention (Web-based) and control (non-Web-based) groups by applying the appropriate meta-analytic technique. Homogeneity analysis, forest plot review, and sensitivity analyses were performed to ascertain the comparability of the studies. RESULTS: Aggregation of participant data revealed a total of 11,754 participants (5,841 women and 5,729 men). The average age of participants was 41.5 years. In those studies reporting attrition rates, the average drop out rate was 21% for both the intervention and control groups. For the five Web-based studies that reported usage statistics, time spent/session/person ranged from 4.5 to 45 minutes. Session logons/person/week ranged from 2.6 logons/person over 32 weeks to 1008 logons/person over 36 weeks. The intervention designs included one-time Web-participant health outcome studies compared to non-Web participant health outcomes, self-paced interventions, and longitudinal, repeated measure intervention studies. Longitudinal studies ranged from 3 weeks to 78 weeks in duration. The effect sizes for the studied outcomes ranged from -.01 to .75. Broad variability in the focus of the studied outcomes precluded the calculation of an overall effect size for the compared outcome variables in the Web-based compared to the non-Web-based interventions. Homogeneity statistic estimation also revealed widely differing study parameters (Qw16 = 49.993, P ≤ .001). There was no significant difference between study length and effect size. Sixteen of the 17 studied effect outcomes revealed improved knowledge and/or improved behavioral outcomes for participants using the Web-based interventions. Five studies provided group information to compare the validity of Web-based vs. non-Web-based instruments using one-time cross-sectional studies. These studies revealed effect sizes ranging from -.25 to +.29. Homogeneity statistic estimation again revealed widely differing study parameters (Qw4 = 18.238, P ≤ .001). CONCLUSIONS: The effect size comparisons in the use of Web-based interventions compared to non-Web-based interventions showed an improvement in outcomes for individuals using Web-based interventions to achieve the specified knowledge and/or behavior change for the studied outcome variables. These outcomes included increased exercise time, increased knowledge of nutritional status, increased knowledge of asthma treatment, increased participation in healthcare, slower health decline, improved body shape perception, and 18-month weight loss maintenance. [J Med Internet Res 2004;6(4):e40]

Health-enhancing physical activity and sedentary behaviour in children and adolescents

Abstract: We provide a wide-ranging review of health-related physical activity in children and adolescents using a behavioural epidemiology framework. In contrast to many other reviews, we highlight issues associated with true sedentary behaviours alongside physically active behaviours. Specifically, we review the evidence concerning the links between physical activity and cardiovascular disease, overweight and obesity, psychosocial measures, type II diabetes, and skeletal health. Although the evidence is unconvincing at times, several factors lead to the conclusion that promoting physical activity in youth is desirable. A review of the prevalence of physical activity and sedentary behaviours shows that many young people are active, but this declines with age. A substantial number are not adequately active for health benefits and current trends in juvenile obesity are a cause for concern. Prevalence data on sedentary behaviours are less extensive but suggest that total media use by young people has not changed greatly in recent years. Most children and adolescents do not exceed recommended daily hours of TV viewing. Physical activity is unrelated to TV viewing. We also identified the key determinants of physical activity in this age group, highlighting demographic, biological, psychological, behavioural, social and environmental determinants. Interventions were considered for school, family and community environments. Finally, policy recommendations are offered for the education, governmental, sport and recreation, health, and mass media sectors.

Delivering interventions for depression by using the internet: randomised controlled trial

Abstract: Objective To evaluate the efficacy of two internet interventions for community-dwelling individuals with symptoms of depression—a psychoeducation website offering information about depression and an interactive website offering cognitive behaviour therapy. Design Randomised controlled trial. Setting Internet users in the community, in Canberra, Australia. Participants 525 individuals with increased depressive symptoms recruited by survey and randomly allocated to a website offering information about depression (n = 166) or a cognitive behaviour therapy website (n = 182), or a control intervention using an attention placebo (n = 178). Main outcome measures Change in depression, dysfunctional thoughts; knowledge of medical, psychological, and lifestyle treatments; and knowledge of cognitive behaviour therapy. Results Intention to treat analyses indicated that information about depression and interventions that used cognitive behaviour therapy and were delivered via the internet were more effective than a credible control intervention in reducing symptoms of depression in a community sample. For the intervention that delivered cognitive behaviour therapy the reduction in score on the depression scale of the Center for Epidemiologic Studies was 3.2 (95% confidence interval 0.9 to 5.4). For the “depression literacy” site (BluePages), the reduction was 3.0 (95% confidence interval 0.6 to 5.2). Cognitive behaviour therapy (MoodGYM) reduced dysfunctional thinking and increased knowledge of cognitive behaviour therapy. Depression literacy (BluePages) significantly improved participants9 understanding of effective evidence based treatments for depression (P Conclusions Both cognitive behaviour therapy and psychoeducation delivered via the internet are effective in reducing symptoms of depression.

The Schizophrenia Patient Outcomes Research Team (PORT): Updated Treatment Recommendations 2003

Abstract: Since publication of the original Schizophrenia Patient Outcomes Research Team (PORT) treatment recommendations in 1998, considerable scientific advances have occurred in our knowledge about how to help persons with schizophrenia. Today an even stronger body of research supports the scientific basis of treatment. This evidence, taken in its entirety, points to the value of treatment approaches combining medications with psychosocial treatments, including psychological interventions, family interventions, supported employment, assertive community treatment, and skills training. The most significant advances lie in the increased options for pharmacotherapy, with the introduction of second generation antipsychotic medications, and greater confidence and specificity in the application of psychosocial interventions. Currently available treatment technologies, when appropriately applied and accessible, should provide most patients with significant relief from psychotic symptoms and improved opportunities to lead more fulfilling lives in the community. Nonetheless, major challenges remain, including the need for (1) better knowledge about the underlying etiologies of the neurocognitive impairments and deficit symptoms that account for much of the disability still associated with schizophrenia; (2) treatments that more directly address functional impairments and that promote recovery; and (3) approaches that facilitate access to scientifically based treatments for patients, the vast majority of whom currently do not have such access.

Self-esteem in a broad-spectrum approach for mental health promotion

Abstract: Self-evaluation is crucial to mental and social well-being. It influences aspirations, personal goals and interaction with others. This paper stresses the importance of self-esteem as a protective factor and a non-specific risk factor in physical and mental health. Evidence is presented illustrating that self-esteem can lead to better health and social behavior, and that poor self-esteem is associated with a broad range of mental disorders and social problems, both internalizing problems (e.g. depression, suicidal tendencies, eating disorders and anxiety) and externalizing problems (e.g. violence and substance abuse). We discuss the dynamics of self-esteem in these relations. It is argued that an understanding of the development of self-esteem, its outcomes, and its active protection and promotion are critical to the improvement of both mental and physical health. The consequences for theory development, program development and health education research are addressed. Focusing on self-esteem is considered a core element of mental health promotion and a fruitful basis for a broad-spectrum approach.

Interventions to change health behaviours: evidence-based or evidence-inspired?

Abstract: This critical review assesses whether evaluation studies can answer three key questions about behaviour change interventions: ‘Do they work? How well do they work? How do they work?’ Reviews of intervention evaluations are examined, particularly those addressing decreasing unprotected sexual intercourse and smoking. Selection of outcome measures and calculation of effect sizes are discussed. The article also considers the extent to which evaluation reports specify (i) discrete intervention techniques and (ii) psychological mechanisms that account for observed behavioural change. It is concluded that intervention descriptions are often not specific about the techniques employed and that there is no clear correspondence between theoretical inspiration and adoption of particular change techniques. The review calls for experimental testing of specific theory-based techniques, separately and in combination.

Review of Child and Adolescent Refugee Mental Health

Abstract: Objective To review stressful experiences and stress reactions among child and adolescent refugees, as well as interventions and ethical considerations in research and clinical work, within the framework of the chronological experiences of child refugees; namely, the phases of preflight, flight, and resettlement. Highlighted are special refugee populations such as unaccompanied minors, asylum seekers, and former child soldiers. Pertinent medical findings are summarized. Method The authors reviewed articles from 1990 to 2003 addressing the topics above. Literature was gathered from databases including PsycINFO, Medline, and SocioFile . Pertinent earlier papers and those from other disciplines cited in database-identified articles were also included. Results Child and adolescent refugees suffer from significant conflict-related exposures. Reactions to stress may be mediated by coping strategies, belief systems, and social relations. Conclusions More research is needed on interventions, specifically on efficacy and cultural relevance. Interventions that have an impact on multiple ecological levels need further development and evaluation.

Behavioral Counseling Interventions in Primary Care to Reduce Risky/Harmful Alcohol Use

Abstract: Context Excessive alcohol consumption increases risks for numerous chronic diseases, injuries, disabilities, mortality, and for a host of social and interpersonal problems. Many drinkers who do not meet diagnostic criteria for alcohol use disorders nonetheless consume alcohol at levels or in patterns that increase the risks of negative health and social consequences. Primary health care visits offer opportunities to identify and briefly intervene with these drinkers to reduce their consumption below at-risk levels and patterns. Objective To systematically review evidence for the efficacy of brief behavioral counseling interventions conducted in primary care settings to reduce risky/harmful alcohol consumption or patterns, and to link this evidence to results from other systematic reviews of alcohol screening in primary care populations. Data Sources We searched the Cochrane Database of Systematic Reviews and Database of Research Effectiveness (DARE) (2001, issues 2 and 3; 2002 issue 1), using an inclusive search strategy (alcohol* or drink*) to identify recent, high-quality, English-language systematic reviews of primary care interventions to reduce risky/harmful alcohol use. We searched MEDLINE, Cochrane Controlled Clinical Trials, PsychInfo, HealthSTAR, and CINAHL databases from 1994 through April 2002, using a similarly inclusive search strategy. We also retrieved all recent systematic reviews of screening for alcohol disorders in primary care and all relevant screening and intervention literature reviewed in the 1996 Guide to Clinical Preventive Services or included in other systematic reviews of brief alcohol interventions for risky/harmful use. Study Selection We identified 12 controlled alcohol intervention trials conducted with general adult patients, 3 with pregnant women, and 1 with adolescents that took place in primary care settings and were of good or fair internal validity according to US Preventive Services Task Force (USPSTF) criteria. Data Extraction Data elements were abstracted on standardized forms and included information about the setting, study design, participant inclusion and exclusion criteria, randomization process (if applicable), size and composition of study groups, intervention components (rationale, behavioral techniques, length and number of sessions, provider), follow-up period(s), loss to followup, and alcohol consumption and other outcomes. Data Synthesis Good evidence supports the efficacy of brief, multi-contact primary care interventions for risky/harmful alcohol use in primary care patients identified through screening and screening-related assessment of at-risk drinking and alcohol use disorders. Patients in these trials underwent screening to identify those possibly in need of alcohol misuse intervention in primary care or elsewhere, followed by screening-related clinical assessment to qualify patients appropriate for primary care-based intervention or for referral to specialty treatment of abuse/dependence. Patients were screened generally using standardized self-report instruments alone (e.g., AUDIT), or in combination, (e.g., CAGE with standardized quantity and frequency questions) that have been found to be valid in primary care populations. After primary care brief, multi-contact interventions, patients reduced average drinks per week by 13%–34% and increased the proportion drinking at moderate or safe levels by 10%–19% compared with controls. Similar population-level reductions in average alcohol consumption have been projected to reduce the prevalence of alcohol abuse/dependence by 3%, while use of alcohol within safe/recommended levels has been epidemiologically related to reduced short-term (e.g., injuries, alcohol-related problems) and long-term (e.g., cirrhosis, total mortality) health risks. Conclusions Brief, multi-contact behavioral counseling interventions among adult primary care patients are feasible and potentially highly effective components of an overall public health approach to reducing alcohol misuse. Future research should focus on developing implementation strategies that facilitate the adoption of these practices as a regular part of routine health care. Additional research is needed to develop effective interventions among sub-populations such as pregnant women, ethnic minorities, and adolescents.

Behavioral counseling interventions in Primary care To reduce risky/harmful alcohol use by adults: A summary of the evidence for the U.S. preventive services task force

Abstract: Behavioral counseling interventions are effective and could be part of a public health approach to reducing harmful use of alcohol by adult primary care patients. Future research should test strate...

Parents are key players in the prevention and treatment of weight-related problems.

Abstract: There is growing agreement among experts that an obesogenic environment, which encourage excess food intake and idealizes thinness, plays a crucial role in the epidemic of childhood obesity and eating disorders. Because parents provide a child's contextual environment, they should be considered key players in interventions aimed at preventing or treating weight-related problems. Parenting style and feeding style are crucial factors in fostering healthy lifestyle and awareness of internal hunger and satiety cues and de-emphasizing thinness. Effective interventions for prevention and treatment of weight-related problems should be approached from a health-centered rather than a weight-centered perspective, with the parents as central agents of change. This paper reviews the environmental risk factors and parents' role in the prevention and treatment of children's weight-related problems.

The European Study of the Epidemiology of Mental Disorders (ESEMeD) project: an epidemiological basis for informing mental health policies in Europe.

Abstract: Mental disorders are increasingly recognized as a major source of disability in the world. The costs associated with mood and anxiety disorders are very high. Forecasted future increase in the magnitude of mental disorders (1) will most likely be associated with higher costs. Nevertheless, population-based knowledge about the prevalence and distribution of mental disorders, their risk factors and their social and economic consequences is still limited. As is evidence about the efficiency of health services in managing the burden of these disorders. Whilst one would hope that our knowledge base will improve in the future it has to be noted that, for instance, the funding for depression research by the US National Institute of Health was significantly lower than might be expected based on the criterion of disability adjusted life years, when compared to 29 other conditions (2). The main sources of information about the prevalence and the burden of mental disorders diagnostic categories at the community level originated in work carried out in the United States. The Epidemiological Catchment Area (ECA) (3, 4) and the subsequent National Comorbidity Survey (NCS) (5) have provided key epidemiological data that have been used to estimate the burden of mental disorders everywhere. These seminal studies clearly showed that mood and anxiety disorders are frequent, and suggested that the level of unmet need for care is high. Similar findings have been reported in subsequent national studies (6, 7), but several studies have indicated that there may be substantial international variability in the prevalence of mental disorders (8, 9) as well as important differences in the provision and access to mental health care (9, 10). A number of previous population-based studies of mental disorders have been carried out in European countries, among these are the DEPRES study, carried out in six European countries (11), the NEMESIS study, in the Netherlands (12) the National Survey, in the UK (13), and the mental health supplement to the German National Health Interview and Examination Survey (14). Although they have provided valuable information on the epidemiology of mental disorders within Europe, each was conducted in one country or addressed a narrower scope of mental disorder, somewhat limiting their usefulness for informing health policy across Europe as a whole. The variation in the way European countries deliver their care to people with mental disorders is high. There are huge differences in personnel, settings, financing, as well as liaison with the wider health system across Europe (15). Several mental health policy reforms are ongoing on the continent. Successful policies must be based on valid and reliable knowledge of the relative efficiency of alternative organizational systems in order to reduce mental health disability. This knowledgebased approach is especially important for the emerging reality of the European Union, where economy, policy, and legislation, all of them affecting mental health care delivery, are called to converge in the near future.

Cognitive-behavioral psychotherapy for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review.

Abstract: Objective To review the literature on the cognitive-behavioral treatment of children and adolescents with anxiety and depressive disorders within the conceptual framework of evidence-based medicine. Method The psychiatric and psychological literature was systematically searched for controlled trials applying cognitive-behavioral treatment to pediatric anxiety and depressive disorders. Results For both anxiety and depression, substantial evidence supports the efficacy of problem-specific cognitive-behavioral interventions. Comparisons with wait-list, inactive control, and active control conditions suggest medium to large effects for symptom reduction in primary outcome domains. Conclusions From an evidence-based perspective, cognitive-behavioral therapy is currently the treatment of choice for anxiety and depressive disorders in children and adolescents. Future research in this area will need to focus on comparing cognitive-behavioral psychotherapy with other treatments, component analyses, and the application of exportable protocol-driven treatments to divergent settings and patient populations.

Physical activity and older adults: a review of health benefits and the effectiveness of interventions

Abstract: The purpose of this multidisciplinary review paper is to critically review evidence from descriptive, efficacy and effectiveness studies concerned with physical activity and older people. Both levels of fitness (aerobic power, strength, flexibility and functional capability) and measures of physical activity involvement decline with age, and the extent to which this is due to a biological ageing processes or disuse (physical inactivity) is critically examined. The review will consider the evidence for a causal relationship between sedentary behaviour/physical activity programmes and cardiovascular, musculoskeletal and psycho-social health, independent living and health-related quality of life into old age. The review also considers the effectiveness of different physical activity interventions for older people and issues relating to cost-effectiveness. The implications for future policy in terms of research, health care services, and education and training are briefly discussed.

The Lambeth Early Onset (LEO) Team: randomised controlled trial of the effectiveness of specialised care for early psychosis

Abstract: Objective To evaluate the effectiveness of a service for early psychosis. Design Randomised controlled clinical trial. Setting Community mental health teams in one London borough. Participants 144 people aged 16-40 years presenting to mental health services for the first or second time with non-organic, non-affective psychosis. Interventions Assertive outreach with evidence based biopsychosocial interventions (specialised care group) and standard care (control group) delivered by community mental health teams. Primary outcome measures Rates of relapse and readmission to hospital. Results Compared with patients in the standard care group, those in the specialised care group were less likely to relapse (odds ratio 0.46, 95% confidence interval 0.22 to 0.97), were readmitted fewer times (β 0.39, 0.10 to 0.68), and were less likely to drop out of the study (odds ratio 0.35, 0.15 to 0.81). When rates were adjusted for sex, previous psychotic episode, and ethnicity, the difference in relapse was no longer significant (odds ratio 0.55, 0.24 to 1.26); only total number of readmissions (β 0.36, 0.04 to 0.66) and dropout rates (β 0.28, 0.12 to 0.73) remained significant. Conclusions Limited evidence shows that a team delivering specialised care for patients with early psychosis is superior to standard care for maintaining contact with professionals and for reducing readmissions to hospital. No firm conclusions can, however, be drawn owing to the modest sample size.

Effect on Health-Related Outcomes of Interventions to Alter the Interaction Between Patients and Practitioners: A Systematic Review of Trials

Abstract: PURPOSE We wanted to identify published randomized trials of interventions to alter the interaction between patients and practitioners, develop taxonomies of the interventions and outcomes, and assess the evidence that such interventions improve patients’ health and well-being. METHODS Undertaking a systematic review of randomized trials, we sought trials in primary and secondary care with health-related outcomes, which we found by searching MEDLINE, HealthSTAR, and PsycINFO bibliographic databases through 1999. We also completed one round of manual citation searching. RESULTS Thirty-five trials were included. Most were set in primary care in North America. Trials were heterogeneous in populations, settings, interventions, and measures. Interventions frequently combined several poorly described elements. Explicit theoretical underpinning was rare, and only one study linked intervention through process to outcome measures. Health outcomes were rarely measured objectively (6 of 35), and only 4 trials with health outcomes met predefined quality criteria. Interventions frequently altered the process of interactions (significantly in 73%, 22 of 30 trials). Principal outcomes favored the intervention group in 74% of trials (26 of 35), reaching statistical significance in 14 (40%). Positive effects on health outcomes achieved statistical significance in 44% of trials (11 of 25); negative effects were uncommon (5 of 25, 20%). Simple approaches to increasing the participation of patients in the clinical encounter, such as providing practitioners with a note from patients about their concerns beforehand, showed promise, as did more complex programs providing specific information about disease and attention to emotion. Apparently similar interventions varied in effectiveness across studies. CONCLUSIONS Successful interactions between patients and their practitioners lie at the heart of medicine, yet there are few rigorous trials of well-specified interventions to inform best practice. Trial evidence suggests that a range of approaches can achieve changes in this interaction, and some show promise in improving patients’ health. To advance knowledge further, we need to replicate promising studies using rigorous methods. These should include explicit theoretical frameworks designed to link effects on key communication and interaction characteristics through to effects on health outcomes.

A conceptual framework for adaptive preventive interventions

Abstract: Recently, adaptive interventions have emerged as a new perspective on prevention and treatment. Adaptive interventions resemble clinical practice in that different dosages of certain prevention or treatment components are assigned to different individuals, and/or within individuals across time, with dosage varying in response to the intervention needs of individuals. To determine intervention need and thus assign dosage, adaptive interventions use prespecified decision rules based on each participant's values on key characteristics, called tailoring variables. In this paper, we offer a conceptual framework for adaptive interventions, discuss principles underlying the design and evaluation of such interventions, and review some areas where additional research is needed.

Psychological distress: concept analysis.

Abstract: Background. The term ‘distress’ is frequently used in nursing literature to describe patient discomfort related to signs and symptoms of acute or chronic illness, pre- or post-treatment anxiety or compromised status of fetuses or the respiratory system. ‘Psychological distress’ may more accurately describe the patient condition to which nurses respond than does the term ‘distress’. Psychological distress is seldom defined as a distinct concept and is often embedded in the context of strain, stress and distress. This creates confusion for nurses attempting to manage the care of people experiencing psychological distress. Aims. This paper is a concept analysis of psychological distress based on Walker and Avant's (1995) criteria that identifies the attributes, antecedents, and consequences of psychological distress based upon the findings of the literature review. In addition, empirical references are identified and constructed cases presented. Methods. A literature search was conducted using MEDLINE, CINAHL, Ovid, PsychINFO, and Cancer Lit databases over the last 50 years. The purposes of this concept analysis were: (1) to establish the concept of psychological distress as a clear and distinct concept, separate from strain, stress and distress, and (2) to provide nurses with a base of knowledge from which to plan effective clinical interventions. Findings. Content analysis of the literature revealed that, although used frequently in health care literature, the origin of the concept of psychological distress has not been clearly articulated and is ill-defined. Conclusions. Psychological distress is a serious problem faced by many of the people whom nurses encounter on a daily basis. An understanding of the concept of psychological distress will help nurses ameliorate this problem in patients. Nursing research related to the exploration of psychological distress is also needed.

Bridging the implementation gap between knowledge and action for health

Abstract: There is widespread evidence of failure to implement health interventions that have been demonstrated to be cost-effective by high-quality research; this failure affects both high-income and low-income countries. Low-income countries face additional challenges to using research evidence including: the weakness of their health systems, the lack of professional regulation and a lack of access to evidence. There is a need to strengthen institutions and mechanisms that can more systematically promote interactions between researchers, policy-makers and other stakeholders who can influence the uptake of research findings. The concept of public engagement with health research requires a public that is both informed and active. Even when systematic reviews are available further work is needed to translate their findings into guidelines or messages that are understandable to patients and health professionals. Many of the commonly used approaches for keeping health professionals' knowledge up-to-date appear to have small or inconsistent effects. The evidence-base is more extensive for interventions directed towards professionals, such as education, reminders or feedback, than for those directed at organizations or patients. The effect of interventions varies according to the setting and the behaviour that is targeted. Case studies in low-income settings suggest that some strategies can result in increased coverage of evidence-based interventions, but there is a lack of evidence from systematic reviews of rigorous research. Given the potential for near-term improvements in health, finding more effective ways of promoting the uptake of evidence-based interventions should be a priority for researchers, practitioners and policy-makers.

Combined Pharmacotherapy and Psychological Treatment for Depression: A Systematic Review

Abstract: Background Adherence to antidepressant medication use is a problem in clinical practice. Some authors have posited that combined psychological treatment facilitates adherence to pharmacotherapy. Objectives To study the relationship between adherence to use of and efficacy of antidepressant drugs plus psychological treatment vs drug treatment alone in depressive disorders. Data Sources MEDLINE, Current Contents, PsychInfo, Cochrane Library, and reference lists were searched, from January 1980 to November 2002. Study Selection Randomized clinical trials comparing antidepressant treatment alone with antidepressant treatment in combination with a psychological intervention in depressive disorders were considered. The decision to include studies in the meta-analysis was performed by 2 reviewers. Data Extraction Three independent reviewers extracted the data, using a precoded form. Methodological quality of the studies was evaluated in terms of allocation concealment and independence of evaluators. Data Synthesis Sixteen trials met the inclusion criteria, with 932 patients randomized to pharmacotherapy alone and 910 to combined treatment. Overall, patients receiving combined treatment improved significantly compared with those receiving drug treatment alone (odds ratio [OR], 1.86; 95% confidence interval [CI], 1.38-2.52), but dropouts and nonresponders did not differ in distribution between the 2 treatment modalities (OR, 0.86; 95% CI, 0.60-1.24). Studies longer than 12 weeks showed a significant advantage of combined treatment over drug treatment alone (OR, 2.21; 95% CI, 1.22-4.03), with a significant reduction in dropouts compared with nonresponders (OR, 0.59; 95% CI, 0.39-0.88). These estimates were not affected by study quality. Conclusions Psychological treatment combined with antidepressant therapy is associated with a higher improvement rate than drug treatment alone. In longer therapies, the addition of psychotherapy helps to keep patients in treatment. Further studies are needed to investigate whether the improvement in response attributable to the combination of drug treatment and psychotherapy can be achieved by a combination of pharmacotherapy and a compliance-enhancing intervention.