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donderdag 12 oktober 2017

RCGP: Research paper of the Year Winner

Research paper of the Year Winner

Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression is the subject of the Research Paper of the Year 2016 award winner. Learn more about this paper, also category winner for Neurology, Mental Health and Dementia   

Dr Nicola Wiles, University of Bristol 

Cognitive behavioural therapy (CBT) is an effective treatment for patients with depression who have not responded to antidepressant medication1. The latter represent a substantial proportion of those treated with antidepressants in primary care2. CBT is an educational approach that teaches patients skills to help them better manage their depression and hence there is the potential for benefit to be sustained beyond the end of therapy. However, prior to this study, evidence on the effectiveness of CBT was restricted to outcomes over the short-to medium term (6-12 months) and, despite the substantial cost of depression to health services and society3, data on long-term cost-effectiveness were sparse.

In this paper, we reported the long-term follow-up of the multi-centre NIHR-HTA funded CoBalT randomised controlled trial (RCT)4. We examined whether CBT (given in addition to usual care that included antidepressants) was effective and cost-effective in reducing depressive symptoms and improving quality of life over the long-term (3-5 years) compared with usual care alone in primary care patients with treatment resistant depression. 

In total, 469 eligible participants were randomised within the CoBalT trial. Those who had not withdrawn during the 12-month follow-up and had consented to further contact were eligible to participate in the long-term follow-up (n=430). Data were collected by postal questionnaire. The primary outcome was depressive symptoms on the self-report Beck Depression Inventory (BDI-II). Health and social care costs were compared with quality-adjusted life years (QALYs) in a cost-utility analysis. 

Two hundred and forty-eight individuals completed a long-term follow-up questionnaire and provided primary outcome data. The long-term follow-up was, on average, 46 months after randomisation and 40 months after the end of therapy. At follow-up, the mean BDI-II score (the primary outcome) for the intervention group (n=136) was 19.2 compared with 23.4 for the usual care group (n=112). Thus, the intervention group had a mean BDI-II score nearly 5 points lower (less depressed) than the usual care group over the 46 months (adjusted difference in means: -4.7 (95% confidence interval: -6.4, -3.0) p<0.001). Regarding a selection of other outcomes, those in the intervention group were also more likely to experience remission of symptoms (BDI-II score<10) and a reduction in symptoms of anxiety over the 46 months compared with those in the usual care group. 

Beneficial effects were also found in terms of quality of life over the entire follow-up period. In terms of value for money, the cost per QALY of £5374 was well below the threshold of £20,000 per QALY that is used by the National Institute for Health and Care Excellence (NICE) to judge cost-effectiveness. 

Many of the CoBalT participants had severe and chronic depression, often with physical and/or psychological co-morbidity. Given these long-term benefits it is important that GPs discuss referral for CBT with all patients with depression who do not respond to treatment with antidepressants. 

Our results also highlight the importance of investment in psychological services. The focus of initiatives to increase access to such treatments (in both England and Australia) has been in increasing the provision of 'low intensity' treatments, such as computerised CBT packages and guided self-help. Patients in CoBalT received 12-18 sessions of 'high intensity' CBT, substantially more than recent data indicate are provided by Improving Access to Psychological Therapy (IAPT) services5. However, the CoBalT participants gained greater benefits in terms of the reduction in depressive symptoms, and the intervention represented better value for money over the long-term, compared with low intensity treatments6. 

Since the study was published, the NHS Five Year Forward View for mental health7 has highlighted the need for parity of esteem between services for mental and physical health. Within this was recognition of the need for greater investment to increase access to "evidence-based psychological therapies" and in July 2017, the Government announced plans to recruit an additional 2900 therapists to support adult talking therapies www.bbc.co.uk/news/health-40752060.

Only through greater investment will we be able to reduce the significant burden to patients and health care systems that is associated with non-response to the most common treatment for depression. 

Funding: This research was funded by the National Institute for Health Research Health Technology Assessment (NIHR HTA) programme (project number:  06/404/501). The views expressed in this summary are those of the authors and do not necessarily reflect those of the HTA programme, NIHR, NHS, or the Department of Health. 

Full citation: Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. The lancet Psychiatry. 2016;3(2):137-44.

Winners of Research Paper of the Year

Category 1: Cancer

Lim AW, Landy R, Castanon A, Hollingworth A, Hamilton W, Dudding N, et al. Cytology in the diagnosis of cervical cancer in symptomatic young women: a retrospective review. The British journal of general practice: the journal of the Royal College of General Practitioners. 2016;66(653):e871-e9. 

Category 2: CVD, Renal, Respiratory, Oral, ENT & Ophthalmology

Jordan RE, Adab P, Sitch A, Enocson A, Blissett D, Jowett S, et al. Targeted case finding for chronic obstructive pulmonary disease versus routine practice in primary care (TargetCOPD): a cluster-randomised controlled trial. The Lancet Respiratory medicine. 2016;4(9):720-30. 

Category 3: Children, Reproduction, Genetics, Infections

Hay AD, Sterne JA, Hood K, Little P, Delaney B, Hollingworth W, et al. Improving the Diagnosis and Treatment of Urinary Tract Infection in Young Children in Primary Care: Results from the DUTY Prospective Diagnostic Cohort Study. Annals of family medicine. 2016;14(4):325-36. 

Category 4: Neurology, Mental Health and Dementia

Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. The Lancet Psychiatry. 2016;3(2):137-44. 

Category 5: Health Service Delivery and Public Health (includes generic primary care topics)

Dreischulte T, Donnan P, Grant A, Hapca A, McCowan C, Guthrie B. Safer Prescribing--A Trial of Education, Informatics, and Financial Incentives. The New England journal of medicine. 2016;374(11):1053-64. 

Category 6: Endocrinology (inc Diabetes), Gastroenterology, Musculoskeletal and Trauma, and Dermatology

Muller S, Hider SL, Helliwell T, Lawton S, Barraclough K, Dasgupta B, et al. Characterising those with incident polymyalgia rheumatica in primary care: results from the PMR Cohort Study. Arthritis research & therapy. 2016;18:200. 

Research Paper of the Year Overall Winner

Wiles NJ, Thomas L, Turner N, Garfield K, Kounali D, Campbell J, et al. Long-term effectiveness and cost-effectiveness of cognitive behavioural therapy as an adjunct to pharmacotherapy for treatment-resistant depression in primary care: follow-up of the CoBalT randomised controlled trial. The Lancet Psychiatry. 2016;3(2):137-44.

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Work with the RCGP on clinical projects to advance primary healthcare

Dr Imran Rafi, Chair of the RCGP Clinical Innovation and Research Centre

As Chair of the Clinical Innovation and Research Centre (CIRC) I am delighted to announce that applications are now open to work in collaboration with us on one of a number of high profile 12 month clinically focused projects. Each year, we select new projects which complement our existing work, changing the face of primary healthcare.

In CIRC we work in partnership with a variety of funders, including charities and government bodies across England, Wales, Scotland and Northern Ireland, to develop practical support and resources for GPs and practices.

We allow applications from college members, country councils, faculties, committees, boards and groups, affiliated primary care societies, other royal colleges, charities, and patients. Individuals from organisations, whether members of the RCGP or not, are also encouraged to apply. Applications are particularly welcomed that include quality improvement, innovation, and research elements, as well as having a clear clinical focus. 

Examples of CIRC clinical projects have included Cancer, End of Life Care, Person-Centred Care, Quality Improvement in Diabetes and Research Fellowships. The outputs these projects produce is as varied as the projects themselves, such as e-Learning modules, resource toolkits, national and regional events, video case studies and publications. 

The number of funding partners for these projects is unlimited however, CIRC and the RCGP do not source funding for projects so proposals that cannot evidence funding by the deadline will not be considered.

I look forward to working with our funders and delivery partners throughout 2018 to continue creating innovative and practical solutions for GPs.

If this is of interest to you please complete and return an Expression of Interest Form to circ@rcgp.org.uk and we will be in touch to work with you to further develop your application and support you through the process. 

The deadline for initial expressions of interest is Wednesday 31 January 2018

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RCGP welcomes proposals for state-funded indemnity scheme for GPs

RCGP chair Professor Helen Stokes-Lampard said:

"Jeremy Hunt's presence at our conference acknowledges the critical role of GPs to the NHS and he addressed many of the issues pertinent to the working lives of hard pressed GPs right across the country.

"We're particularly encouraged by the proposal for a state-funded medical indemnity scheme for GPs in England, to be in place within 18 months.

"This is one of the burning issues bothering GPs and our GPs in training.

"Medical insurance costs are an issue that the College has been campaigning on for some time so we hope today's announcement will be a glimmer of hope for all GPs.

"Of course, with all of the proposals outlined by the Health Secretary, the devil will be in the detail.

"But the Health Secretary has underlined his commitment to ensuring that all the pledges in the GP Forward View are delivered fully.

"The College will continue to work constructively with the Government in England, NHS England and our colleagues at the BMA to ensure they become a reality and that GPs feel the difference on the frontline of patient care.

"We will also continue to work with the administrations in Scotland, Wales and Northern Ireland to ensure that any benefits to the working lives of GPs are replicated across the UK and that GPs have the support they need to do their jobs wherever they work."

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