Optimum number of sessions for depression and anxiety

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1 NTResearch Opimum number of for depression and anxiey Auhors Frances Forde, BA, RMN, is communiy psychiaric nurse, Bellshill focused inervenion eam, NHS Lanarkshire; Marie Frame, BA, RMN, is communiy psychiaric nurse, Clydesdale focused inervenion eam, NHS Lanarkshire; Pauline Hanlon, BNspq, PGD (managemen), RMN, RMNH, is clinical governance coordinaor, Moherwell/Clydesdale clinical managemen eam, NHS Lanarkshire; Gus MacLean, RMN is communiy psychiaric nurse, Moherwell focused inervenion eam, NHS Lanarkshire; Des Nolan, RMN, RGN, BA, is communiy psychiaric nurse, Wishaw focused inervenion eam, NHS Lanarkshire; Polash Shajahan, MBChB, MPhil, MRCCP/VK, MRCPsych, is consulan psychiaris, Moherwell/Clydesdale Disric, NHS Lanarkshire; Elizabeh Troy, RMN, is depuy charge nurse, Airbles Road day hospial, NHS Lanarkshire. Absrac Forde, F. e al (2005) Opimum number of for depression and anxiey. Nursing Times 101: 43, Aim To examine he relaionship beween he Up o 50 per cen of all individuals presening o heir GP have sympoms of depression or anxiey (Freeling and Tylee, 1992). Mos of hese individuals are managed in general pracice and i is esimaed ha fewer han 10 per cen are referred o secondary menal healh services (Royal College of General Praciioners, 1993). The recen Naional Insiue for Healh and Clinical Excellence guidelines (NICE, 2004) recommend shor-erm psychological reamen for mild and moderae depression as a key prioriy for implemenaion: Psychological reamen specifically focused on depression such as problem-solving herapy, brief cogniive behavioural herapy and counselling of 6 8 over weeks should be considered. Esablished pracice in our local secondary menal healh services, in paricular he focused inervenion eams, included managing paiens wih depression and anxiey disorders using focused ime-limied psychological inervenions. These combined elemens of he herapies in he NICE guidelines. This sudy considers he clinical oucome measures from he focused inervenion eams in our localiy and he relaionship wih NICE guidelines on he issue of 6 8 being adequae herapy for hese disorders. number of psychological reamen compleed by paiens (1 5, 6 8, >8 ) and he change in selfraed depressive and anxiey sympoms using he Hospial Anxiey and Depression Scale (HADS). Mehod Recording demographic characerisics and various clinical oucome measures for all referrals o he service and examining he relaionship beween changes in self-repored anxiey and depression sympoms. Resuls For depression, he sudy shows ha having 6 8 offers more benefi han 1 5. Having more han eigh does no confer any addiional benefi. Indeed, here is lile difference beween 1 5 and more han eigh for depression. For anxiey, sympoms appear o coninue o improve wih increasing numbers of reamen. Conclusion Beyond eigh reamen, here appears o be no addiional improvemen. This is no he case for anxiey, where coninuing reamen appear o reduce sympoms. Lanarkshire menal healh services are spli ino secions. The Moherwell/Clydesdale disric, wih a oal populaion of approximaely 200,000, is one of hree disrics in Lanarkshire. Menal healh services are organised around he resource nework model (Lanarkshire Healh Board, 1999) and hree such resource neworks wihin he disric provide he hub for all secondary menal healh referrals. Weekly referral and allocaion meeings are held a each resource nework. Referrals suggesing ha an individual migh be suiable for focused psychological inervenion for her or his menal healh problem (usually depressive and anxiey-relaed disorders) are aken up by he focused inervenion eams and assessed for reamen suiabiliy. Mehods Since 2003 he focused inervenion eams in he Moherwell/Clydesdale disric have been recording demographic characerisics and various clinical oucome measures for all referrals o heir service. In his sudy he relaionship beween changes in selfrepored anxiey and depression sympoms were examined using he Hospial Anxiey and Depression Scale (HADS) and number of communiy psychiaric nurse (CPN) reamen.

2 keywords n Menal healh n Depression n Anxiey Fig 1. Pahway of referrals enered, assessed and compleed reamen 785 no aken on for reamen 2,714 referrals recorded 1,255 assessmens recorded 318 final scores available (all condiions) 142 final scores for primary problem = depression The HADS was principally designed for deecing anxiey and depressive saes in medical oupaiens (Zigmond and Snaih, 1983). I has been employed in many medical and psychiaric seings in numerous languages and has been shown o have high es-rees reliabiliy (Spinhoven e al, 1997). There are reservaions abou he use of he HADS in such a ubiquious manner bu is use was decided upon due o paien accepabiliy and ease of 1,459 nonaenders 470 aken on for reamen 152 scores no available 113 final scores for primary problem = anxiey adminisraion by a large number of clinicians (24 CPNs were involved in collecing and enering daa over a 1 2 year ime period). The HADS has been used by ohers (Whie e al, 1999) for similar reasons. Furhermore, here is evidence o suppor ha HADS, as a screening insrumen for deecing cases, is comparable wih oher self-raing schedules such as he General Healh Quesionnaire (Lewis and Wessely, 1990). The HADS provides subscale scores for anxiey and depressive sympoms. The change in HADS from ime of assessmen o end of reamen was examined in relaion o he number of one-o-one CPN reamen. The clinical problems were idenified on a descripive raher han an operaional basis. The problems were hen classified ino he main or primary problem and secondary or eriary problems. For example, anxiey, panic, depression, posnaal depression and sress. We considered depression and anxiey separaely. Alhough he condiions overlap in sympomaology, from a reamen poin of view, approaches may differ. For example, here may be emphasis on depression managemen raher han anxiey managemen and vice versa. During he period of daa collecion, usual clinical pracice did no change. The conen of anxiey and depression managemen varies wih praciioner bu a number of common feaures are idenifiable. From a no means exhausive range, hese include cogniive and behavioural change, problem-solving, educaion, advice on inerpersonal skills, general suppor, medicaion monioring and healh promoion. These feaures overlap wih hose References Freeling, P., Tylee, A. (1992) Depression in general pracice. In: Paykel, E.S. (ed) Handbook of Affecive Disorders. Edinburgh: Churchill Livingsone. Lanarkshire Healh Board (1999) A Sraegy for Developing Menal Healh Services in Norh Lanarkshire Moherwell: Norh Lanarkshire Council. Lewis, G., Wessely, S. (1990) Comparison of he General Healh Quesionnaire and he Hospial Anxiey and Depression Scale. The Briish Journal of Psychiary; 157: Naional Insiue for Clinical Excellence (2004) Depression: Managemen of Depression in Primary and Secondary Care. CG023NICEguideline.doc Table 1. Duraion of daa collecion and compleed oucomes by individual Focused Inervenion Teams Team sar of daa end of daa number of days number of recorded referrals number of assessmens number of final oucomes 1 07/05/03 10/03/ /01/03 09/12/ /01/03 26/10/ /05/03 02/11/ /11/02 07/03/ Toal=2,714 Toal=1,255 Toal=318 This aricle has been double-blind peer-reviewed. For relaed aricles on his subjec and links o relevan websies see 37

3 RESEARCH References Powell, T. (1992) The Menal Healh Handbook. Oxford: Winslow Press. Royal College of General Praciioners (1993) Shared Care of Paiens wih Menal Healh Problems. (Occasional paper no 60) London: RCGP. Spinhoven, P. e al (1997) A Validaion sudy of he Hospial Anxiey and Depression Scale (HADS) in differen groups of Duch subjecs. Psychological Medicine; 27: 2, Whie, D. e al (1999) Validaion of he Hospial Anxiey and Depression Scale for use wih adolescens. The Briish Journal of Psychiary; 175, Zigmond, A.S., Snaih, R.P. (1983) The Hospial Anxiey and Depression Scale. Aca Psychiarica Scandinavica; 67, Fig 2. Mean change in HADS scores for paiens primarily suffering from depression (n=142) (anxiey (depression >8 menioned in he NICE guidelines. The majoriy of CPNs used herapy maerial derived from The Menal Healh Handbook (Powell, 1992). Based upon clinical experience, he eam prediced ha more han eigh reamen would no confer any addiional benefi for eiher depressed or anxious paiens. Analysis of variance (ANOVA) was used o examine he difference beween he hree groups (1 5, 6 8, eigh or more ) and iniial sympom severiy, duraion, and sympom reducion. Saisical ess were used o examine he difference beween groups and he number of individuals on medicaion, sex disribuion and referral urgency (soon or rouine). A scaergraph was ploed for prediced number of a assessmen agains he number of compleed. Resuls Fig 1 (p37) shows he pahway and number of paien referrals recorded. Of he 2,714 referrals recorded, 1,459 (54 per cen) did no aend for assessmen so 1,255 assessmens (46 per cen of he oal referrals) were subsequenly recorded. Of hese 1,255 iniial assessmens, 785 (63 per cen) were no aken on for reamen. Of he 470 who were aken on, final scores were available in 318 (68 per cen). The analysis was based on hose who were idenified as experiencing a primary problem of depression (n=142) or anxiey (n=113). Table 1 shows he duraion of daa collecion and compleed oucomes by individual focused inervenion eams. The collecion inervals vary, ranging from 537 o 850 days. There was also variaion in he proporion of final oucomes o assessmens performed, ranging from 19 per cen (eam 1) o 38 per cen (eam 2). Table 2 shows demographic, referral and clinical characerisics for paiens wih depression. There were no saisically significan differences among he hree groups in erms of sex disribuion, age, urgency of referral, duraion of illness episode, severiy of iniial sympoms or likelihood of being on anidepressans a discharge. Noe ha for paiens who were idenified as primarily suffering from depression, posnaal depression was idenified in 40 paiens (28 per cen) and anxiey was idenified as he second problem in 43 (30 per cen). Fig 2 shows he mean change in HADS scores for depression. A greaer reducion in self-raed anxiey and depressive sympoms ( and ) for 6 8 compared wih 1 5 was seen. These differences are saisically significan for HADS A (=3.0, df=139; p<0.003) and represen a rend for (=1.8, df=139; p=0.07). The group ha received eigh or more did no improve as much as he group ha received 6 8. Table 3 (p40) shows demographic, referral and clinical characerisics for paiens wih depression. There were no saisically significan differences beween he hree groups in erms of sex disribuion, age, urgency of referral or duraion of illness episode. However, here were fewer paiens aking anidepressan medicaion a he ime of discharge from reamen in he group ha had 6 8 Fig 3. Mean change in HADS scores for paiens primarily suffering from anxiey (n=113) (anxiey (depression >

4 (χ 2 =7.6, df=2; p=0.02) and iniial anxiey severiy was greaer for hose people in he group ha received eigh or more (F (2,169) =58.7; p<0.0001). Noe ha for paiens who were idenified as primarily suffering from anxiey, depression was idenified as he second problem in 41 (36 per cen). Fig 3 shows greaer reducion in self-repored anxiey () wih increasing number of compleed, F (2,112) =4.7; p= who were less likely o be on anidepressans were argeed for more. In pracice his was no he case, which suggess oher facors may be conribuing o he selecion process. One consideraion is personaliy facors. Are herapiss argeing more reamen for hose whose personaliy rais predic a requiremen for prolonged reamen? Abiliy or willingness o engage in psychological herapy should also be considered bu are no easy o measure. Table 2. Demographic, referral and clinical characerisics for paiens primarily suffering from depression Group Female :Male raio Mean Age in years *soon: rouine (% soon) Medianduraion problem, weeks On anidepressans a discharge Iniial Iniial : :33 (40%) 32 (342) 89% 13.9 (4.1) 13.6 (3.9) : :32 (33%) 40 (152) 79% 14.5 (3.9) 12.8 (3.7) >8 32: :27 (31%) 32 (76) 83% 14.5 (3.9) 13.1 (4.6) Saisical significance beween groups no no no no no no no SD = sandard deviaion * urgency of referral (local guidelines: soon = o be seen wihin 10 days, rouine = wihin 28 days) Self-raed depressive sympoms () improved furher wih more han eigh compared wih 1 5 or for 6 8 F (2,112) =5.7; p< Discussion Depression The NICE guidelines recommend ha 6 8 herapy should be offered for individuals wih mild and moderae depression. Our sudy is consisen wih his and shows ha, a leas in he shor-erm, 6 8 offers more benefi han 1 5. Ineresingly, more han eigh does no confer any addiional benefi over 6 8. Indeed, here is lile difference beween 1 5 and more han eigh for depression. The selecion of paiens for differing numbers of compleed is of imporance. I migh be expeced ha paiens who had more severe or longer duraion of depressive sympoms or hose Furhermore, he willingness of he herapis o engage wih or coninue prolonged reamen should be considered. In his sudy nurses prediced quie accuraely a he onse of herapy he number of ha will be compleed. However, he mechanism for his predicion is based more on clinical inuiion and experience and is also difficul o measure. There remains a possibiliy ha hose and/or oher unknown facors, raher han random selecion, were imporan reasons for he number of compleed. Anxiey Anxiey appears o coninue o improve wih greaer numbers of reamen. This phenomenon requires furher invesigaion. For example, wha is he maximum number of ha can be given before here is a ail-off in response? Therapis ime and resource issues are 39

5 RESEARCH Table 3. Demographic referral and clinical characerisics for paiens primarily suffering from anxiey Group F:M Mean Age years soon: rouine (% soon) Median duraion problem, weeks On anidepressans a discharge Iniial Iniial : :38 (37%) 52 (115) 81% 14.7 (3.3) 10.3 (4.5) :11 40 (13) 10:27 (27%) 52 (115) 58% 15.8 (2.9) 10.6 (4.0) >8 21:5 40 (10) 7:9 (44%) 73 (151) 93% 17.0 (2.5) 12.6 (4.4) Saisical significance beween groups no no no no yes a yes b no SD=sandard deviaion a: χ 2 =7.6, df=2; p=0.02 b: F (2,169) =58.7; p< imporan consideraions if prolonged reamen is indeed beneficial for anxiey. The mean reducion in depressive subscale sympoms was greaer for hose individuals who had compleed more han eigh compared wih 1 5 or 6 8. One poenial explanaion is ha depressive sympoms wihin anxiey disorder can only be addressed and reduced afer anxiey reducion has aken place, for example, in paiens wih agoraphobia where desensiisaion work is required beforehand. The mean iniial HADS score (anxiey and depression subscales) for hose receiving more han eigh was higher han for he groups receiving 1 5 or 6 8. This suggess ha more were argeed accuraely for hose wih more severe sympoms. The group receiving 6 8 were less likely o be on anidepressan medicaion a discharge (58 per cen) compared wih oher groups (81 per cen and 93 per cen). Again, he inerpreaion of his is complex. I is possible ha hose aken on for 6 8 were referred because of heir preference for psychological reamen or heir relucance o ake medicaion. Perhaps he group receiving 1 5 required fewer because hey were on anidepressans. The group receiving more han eigh may have had more opporuniy for heir herapis o recommend medicaion by he ime heir reamen was compleed. Conclusion Beyond eigh reamen here appears o be no addiional improvemen for depression. This is no he case for anxiey, where coninuing reamen appear o be associaed wih furher sympom reducion. There are a few reasons o be cauious wih hese findings. Jus over half of all individuals did no aend following referral. Of hose ha aended for an assessmen (n=1,255), he majoriy 63 per cen (n=785) were considered unsuiable for focused inervenion. Final HADS scores were unavailable in 12 per cen (n=152). One-quarer managed o complee final scores (n=318). The conclusions are based on a more selecive populaion wih anxiey and depression, which represens 20 per cen (n=255) of all hose who were assessed. Wha happened o he res of hese individuals and heir longer-erm oucomes are imporan quesions. These scores reflec self-raed and no observerraed sympoms. Addiionally, he final scores reflec shor-erm oucome only. We have shown ha rouine collecion of oucome daa by a number of healh eams is feasible on a reasonably large scale over a 1 2 year period. The benefis of his are ha furher sudy on he medium o longer-erm oucome of individuals who have compleed hese reamens, re-referrals and non-aenders will be possible. n 40

6 References Reference name. (1999) Reference ile of he source documen follows he auhors name. Publishers name follows in Ref. body ex syle. Noe all righ hand side-ex columns conaining reference informaion always have he copy range lef. For Journal aricles Reference name. (1999) individual references for each aricle in he Clinical secion is welve. NT 00 Monh 2005 Vol 101 No xx 00