By Steve Wood, Cardiff & Vale NHS Trust/ Cardiff University
Providing help for anxiety and depression - the most common mental health problems - is a huge challenge to health services, in the primary and secondary care sectors. Such help needs to be accessible, as well as clinically and cost-effective.
Between 2003, when we first made presentations to GPs, and 2005, two mental health nurses and an occupational therapist introduced an adult educational intervention for anxiety and secondary depression in primary care. This was in an urban area with high levels of social deprivation.
Preparatory work included presentations to GP practices, production of a poster, client information leaflet and GP information sheet. The course consists of 6 weekly sessions, each of two hours. We ran eight courses, at different times of day, days of the week, and using different adult education venues. In all, 108 people attended the course.
Our aims were to evaluate the acceptability and clinical effectiveness of the intervention for people self-referring from primary care and, depending on the outcomes, to make it available as part of a tiered approach to treating common mental health problems.
The intervention was developed to help people who, for whatever reason, could not benefit from a purely self-help approach. Its efficacy was demonstrated by a randomised controlled trial comparing three different versions with a placebo and a waiting list control group (White et al, 1992).
All conditions showed highly significant improvement at six-month follow-up compared to the waiting list. At two-year follow-up, 66% of people showed clinically significant change, defined as a level of functioning closer to the mean of the normal population than to the mean of the dysfunctional population (White, 1998).
A similar, shorter intervention was developed and piloted in secondary care (Houghton & Forrest, 2004), although its effectiveness has not been demonstrated in a controlled trial. NICE (2004) recommended that large group CBT should be considered for generalised anxiety disorder.
We evaluated acceptability and client satisfaction through retention and attendance rates, and post-course questionnaires.
Retention and attendance
Retention and attendance rates suggested that the approach was highly acceptable.
Drop-out was defined as not returning after session 1 or 2. Twenty-six students (24%) were in this category. Average attendance, including those who dropped out, was 4.2 sessions. This rose to 5.1 sessions if those who dropped out are excluded. Sixty-three students (58%) attended 5 or more sessions, and a further nine attended 4 sessions. In all, 66% of all students attended four or more sessions.
The Client Satisfaction Questionnaire (CSQ) (Larsen et al, 1979) was used. This has eight questions, each with four possible responses, scored from 1, indicating least, to 4, indicating most, satisfaction. This was given out, with a prepaid return envelope, at the end of the final session, to allow students to reflect before completing and returning the form anonymously.
The questionnaire was returned by 54 students, 66% of those who completed. The mean score on the eight items of the CSQ ranged from 3.31 to 3.91. All students who completed the CSQ felt that the course had helped them 'somewhat? or 'a great deal? to tackle their problems more effectively.
Thirty-seven students, 45% of completers, added written comments to the CSQ.
These offered useful insight into what students found helpful. Most comments fell into four broad categories.
The largest group concerned confidence, sense of control and coping strategies. Illustrative examples were:
?I still get anxious, but knowing I have the skills to control it helps enormously and I know I will never let it get as bad as it was,? and
?Before the course I didn?t know what to do. I was in such a state, I thought the only solution was medication and I was against this. My problem is still there but I am in control.?
The second main category was general appreciation. A typical comment was:
?I was pleased I attended the course. I am hoping I shall stay as 'good? as I feel today! Many thanks.?
The third category concerned how the course was presented. A typical comment was: 'I found the course very informative and helpful. The teachers were helpful, friendly and knowledgeable.?
The fourth category included comments on course structure and content. An example was, 'The course helped me to understand stress, etc. Although a very hard course, so much to learn in a short time. I?m pleased to have the folder to read and learn more. I appreciate the chance I had to take part in this course.?
We used the Hospital Anxiety & Depression Scale (HADS) (Zigmond & Snaith, 1983). HADS is a 14-item questionnaire with anxiety and depression sub-scales and is widely used to screen for anxiety and depression. Scores greater than 7 on each sub-scale are categorised as mild (8-10), moderate (11-14) or severe (15-21). We amalgamated the measures from the 8 courses and made analyses in respect of those who completed (n=82), and those who dropped out (n=26).
Before the intervention, those who subsequently dropped out had mean scores of 13.34 (SD 4.2) for anxiety and 9.14 (SD 4.33) for depression. This did not differ significantly from those who completed the course - mean 12.97 (SD 4.04) for anxiety and 9.40 (SD 4.28) for depression. Those scores indicated moderate anxiety combined with mild depression. After the intervention, the group mean was in the mild range for anxiety and lower than the mild range for depression. The improvements in anxiety and depression were statistically significant.
Of those who completed, 78 per cent (n=53) showed reductions in both anxiety and depression. A small proportion remained unchanged (9%), or showed an increase on one or other sub-scale (11%). The proportion of students who were 'not anxious? or 'mildly anxious? rose from 28% to 61%, while those who were 'severely anxious? decreased from 34% to 4%.
In respect of depression, the proportion that was 'not depressed? or 'mildly depressed? rose from 59% to 90%, while those who were 'severely depressed? decreased from 10% to 1%.
The course is now being run regularly, with average group sizes of 20-25 students, albeit only in one area of the city.
We have disseminated the outcomes locally and nationally through publication (Wood, Morgan and Bowen 2006) and conference papers. We are liaising with mental health service development agencies, locally and nationally, to incorporate the intervention as part of a comprehensive, stepped care approach to common mental health problems, in line with NICE guidance.
Houghton S, Forrest J (2004) The development of a psycho-educational course for clients with anxiety disorders. Mental Health Practice. 8, 4, 18-20.
Larsen D et al (1979) Assessment of client/patient satisfaction: development of a general scale. Evaluation and Program Planning 2, 197-207.
National Institute for Clinical Excellence (2004a) Clinical Guideline 22 Anxiety: management of anxiety (panic disorder, with or without agoraphobia, and generalised anxiety disorder) in adults in primary, secondary and community care. London: National Institute for Clinical Excellence.
White J (1998) 'Stress Control? large group therapy for generalized anxiety disorder: two year follow-up. Behavioural and Cognitive Psychotherapy. 26, 237-245.
White J et al (1992) 'Stress Control?: a controlled comparative investigation of large group therapy for generalized anxiety disorder. Behavioural and Cognitive Psychotherapy. 20, 97-114.
Wood S, Morgan P, Bowen, M (2006) Managing stress and anxiety: education for adults in primary care. Primary Health Care. 16, 1, 34-40
Zigmond A, Snaith R (1983) The Hospital Anxiety and Depression Scale. Acta Psychiatrica Scandinavica. 67, 361-370.