Cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment resistant depression in primary care: the CoBalT randomised controlled trial protocol.

BACKGROUND: Antidepressants are often the first-line treatment for depression but only one third of patients respond fully to pharmacotherapy. This paper describes the protocol for a randomised controlled trial (RCT) designed to evaluate the clinical and cost effectiveness of cognitive behavioural therapy (CBT) as an adjunct to pharmacotherapy for patients with treatment resistant depression in primary care. METHODS/DESIGN: CoBalT is a two parallel group multi-centre pragmatic RCT. Eligible participants were those who: (i) were aged 18-75years; (ii) were currently taking antidepressant medication (for at least 6weeks at an adequate dose); (iii) scored ≥14 on the Beck Depression Inventory (BDI-II); (iv) had adhered to their medication; and (v) met ICD-10 criteria for depression (assessed using the Clinical Interview Schedule - revised version). Those who gave written informed consent were randomised to one of two treatment groups: usual care or usual care plus CBT. The primary outcome is depressive symptoms assessed using the BDI-II at 6months post-randomisation. Secondary outcomes measured at 6 and 12months include quality of life, antidepressant use and health care utilisation. Outcomes will be analysed on an intention-to-treat basis. DISCUSSION: The CoBalT trial will provide evidence on the clinical and cost effectiveness of CBT as an adjunct to antidepressant medication in the treatment of depression that has not responded to pharmacotherapy. Given the move to widen access to 'talking therapies', the results of this study will be timely

Cost-effectiveness of cognitive-behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: economic evaluation of the CoBalT Trial.

BACKGROUND: Depression is expensive to treat, but providing ineffective treatment is more expensive. Such is the case for many patients who do not respond to antidepressant medication. AIMS: To assess the cost-effectiveness of cognitive-behavioural therapy (CBT) plus usual care for primary care patients with treatment-resistant depression compared with usual care alone. METHOD: Economic evaluation at 12 months alongside a randomised controlled trial. Cost-effectiveness assessed using a cost-consequences framework comparing cost to the health and social care provider, patients and society, with a range of outcomes. Cost-utility analysis comparing health and social care costs with quality-adjusted life-years (QALYs). RESULTS: The mean cost of CBT per participant was £910. The difference in QALY gain between the groups was 0.057, equivalent to 21 days a year of good health. The incremental cost-effectiveness ratio was £14 911 (representing a 74% probability of the intervention being cost-effective at the National Institute of Health and Care Excellence threshold of £20 000 per QALY). Loss of earnings and productivity costs were substantial but there was no evidence of a difference between intervention and control groups. CONCLUSIONS: The addition of CBT to usual care is cost-effective in patients who have not responded to antidepressants. Primary care physicians should therefore be encouraged to refer such individuals for CBT

A survey of school nursing provision in the UK

Aim.  This paper is a report of a study to map school nursing provision across the health and education sectors in Wales to identify the number, age, qualifications, terms of employment, location, functions and access to continuing professional development and clinical supervision of school nurses. Background.  School nurses are important in promoting the health of school-aged children. Increased demands have arisen from changes in patterns of health, illness and lifestyles. Methods.  An interview survey was conducted with a purposive sample of school nursing/health visiting managers from 13 healthcare sector providers, senior personnel officers from 22 Local Education Authorities and 45 head teachers/school nurses from independent schools. Data were collected between March and June 2004 and the overall response rate exceeded 80%. Results.  A total of 249 school nurses were identified: 90% employed by the healthcare sector and 10% by the education sector. An ageing, under-developed and under-resourced service was identified. Disparity in practice within and across the sectors was evident, resulting from lack of policy direction regarding the scope and content of school nursing services. Workforce size, age and educational profile pose challenges for service delivery. Conclusion.  Investment in recruitment and education is required if school nurses are to meet increasing demands and fulfil their public health role. The low percentage of school nurses aged under 30 years may reflect lack of a career pathway and understanding of school nursing. The findings enable national and international comparisons in terms of numbers, size of caseload, age, qualifications, terms of employment and activities and functions

‘No Choice at All’: Destitution or Deportation? A Commentary on the Implementation of Section 9 of the Asylum and Immigration (treatment of claimants, etc) Act 2004

Despite the controversy surrounding the passage of Section 9 of the Asylum and Immigration (Treatment of Claimants, etc.) Act into law, the Home Office is piloting it in a number of local authorities across England and Wales, with a view to implementing it nationally. The Home Office is conducting its own evaluation of the pilot, but stake-holders remain unconvinced as to its objectivity and validity. This article analyses the implementation of Section 9 and finds that it has been a spectacular failure. Quite apart from failing to achieve its desired aim of securing the return of failed asylum seekers to their country of origin, Section 9 has brought about immeasurable suffering and misery. Attention is drawn to the human impact of the policy, and profiled are some of the families who have faced the impossible choice of destitution or deportation. On a more positive note, the article recognizes the unprecedented and overwhelming support that families have received from local people and the media