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| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Severe and enduring - recently diagnosed | All | Low | “Beating Bipolar” internet-based psycho-educational programme | B8,9 |
| Severe and enduring - in recovery and taking medication | Secondary care | High | CBT focused on relapse prevention | A1,6,7 |
| Group psycho-education (e.g., Bipolar Education Programme Cymru) | A1,6 | |||
| Family intervention | B6 | |||
| Severe and enduring - in an acute episode of bipolar disorder and taking medication | Secondary care | High | CBT for patients with fewer than 12 previous episodes | A2,3 |
| Interpersonal and social rhythm therapy | A4 | |||
| Severe and enduring | Secondary care | High | Functional remediation for improvement in functional outcomes | A10 |
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Moderate/Severe | All | Low | Group CBT | B3 |
| Exposure response prevention (ERP) | B4 | |||
| Disorder specific CBT | B5 | |||
| Eye movement desensitisation and reprocessing (EMDR) | C1 |
Some dissatisfaction with one’s body is a common phenomenon and therefore would not necessarily be expected to come to the attention of mental health services. It is only when the degree of distress caused by this is significant and it begins to impact on an individual’s functioning that it might warrant NHS treatment. As such, services are only likely to see individuals who are moderate/severe in presentation. The evidence base that exists does not distinguish between these levels of severity.
CBT has been tested within RCTs (e.g., 5). The group CBT (3) was tested against waiting list and was conducted in small groups for eight two-hour sessions. 82% of trial participants no longer met diagnostic criteria by end of treatment and 77% at follow up; the study sample was of women. Individual CBT was tested (5), albeit with a small sample of only 19 individuals; a 50% reduction in symptoms on the Yale-Brown obsessive compulsive scale
(Y-BOCS) was achieved.
Behavioural Therapy (BT) in the form of ERP has been tested, albeit only in small trials, most of which were uncontrolled (4). Suggestions that it could be effective were supported by significant outcomes, which were maintained in those who participated in a maintenance programme.
A number of case studies have also been published. EMDR recommendation is based on a case series in which six of seven individuals experienced significant improvement and five maintained this over time (1). In general, the studies appear to indicate that psychotherapy has an improved effect when compared with trials of medication alone (2, 6).
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Severe | Secondary care or specialist outpatient | High | Dialectical behaviour therapy (DBT) | A1,2 |
| Schema‑focused CBT | A1,2 | |||
| Systems training for emotional predictability and problem‑solving (STEPPS) | A1,2 | |||
| Transference‑focused psychotherapy | A1,2 | |||
| CBT for personality disorders – individual therapy (30 sessions over one year) | A4 | |||
| Cognitive analytic therapy (CAT) | B3 – One RCT for a less severely affected group with minimal/low self‑harm. | |||
| Secondary/Specialist partial day hospital | High | Mentalisation based day Hospital | A1,2 |
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild–Moderate | Primary care | Low | Computerised CBT (CCBT) within the context of guided self-help | A |
| Guided self-help based on CBT behaviour principles | A30,31,32 | |||
| Multi modal CBT | A33 | |||
| High | Behavioural activation (BA) | A1,2 | ||
| CBT | A7**, 8*, 15*, 17 | |||
| Interpersonal psychotherapy (IPT) | A3, 8*, 15*, 16, 17 | |||
| Problem-solving therapy | A8*, 15*, 17 | |||
| Brief psychodynamic therapy | A13 | |||
| Nondirective supportive therapies / person-centred counselling | A5,6,8*,9,10 | |||
| Couples therapy | A5,6,8*,9,10 | |||
| Interpersonal counselling | B18*** | |||
| Art therapy | C24 | |||
| Severe (non-chronic) | Secondary Care | High | CBT | A19 |
| Treatment-resistant depression (lack of response after six weeks on standard antidepressant medication) | Primary care | High | CBT | A12,12a |
| Chronic (>2yrs) major depression | Secondary care | High | Psychological therapies (in general) + antidepressant medication | B4 |
| Music therapy | C28,29 | |||
| Prevention of relapse in recurrent depression | Primary/Secondary care | High | Mindfulness-based cognitive therapy (MBCT) | A14, 22****27 |
* Statistically significant effect, but effect size [ES] is small
** ES=0.71, but lower in higher quality studies (0.53) than in lower quality studies (0.90)
*** Advantage for IPC was clearest for first episode, less severely depressed patients
**** But almost half in either condition relapsed in two year follow-up
Therapies which have been specifically developed to treat depression, such as CBT (D), IPT and BA are all clearly and about equally efficacious, but the effect sizes are not large. Using methods of delivery, other than face-to-face individual therapy, appears to be no less effective in delivering CBT within primary care settings (15).
Less condition-specific therapies, such as problem-solving therapy, nondirective supportive therapies/person-centred counselling and brief psychodynamic therapy appear to have some efficacy. MBCT has some efficacy in the prevention of relapse in recurrent depression, but the most recent study shows less positive results (27). In treating chronic depression and “treatment-resistant” depression, psychological therapies may have some additional benefit to medication. However, “treatment-resistant depression” is itself a protean concept (26). It is unclear whether psychological therapies are efficacious in the treatment of dysthymia. In treating severe, but non-chronic depression, CBT enhances recovery rates as compared with antidepressant medication alone (19), but Axis II co-morbidity, which was present in half of the participants and is typical of patients in secondary care services, resulted in much lower recovery rates in both conditions.
In considering factors associated with outcome, there is some evidence that higher initial depression severity, early improvement in therapy and completing therapy as intended all predict better outcomes, while a personality disorder and negative expectations for treatment predict poorer response (23). It seems possible that more frequent sessions early on, plus positive preparation for therapy, will enhance outcomes.
Cochrane Reviews are currently in development for the psychological treatment of depression and it is recommended that these are consulted when they become available.
Erkkila, J. et al (2011) Individual Music Therapy for Depression: Randomised Controlled Trial. British Journal of Psychiatry, 199, 132-139.
Scottish Intercollegiate Guidelines Network (SIGN) Non-pharmaceutical management of depression. Edinburgh: SIGN; 2010.(SIGN publication no. 114)[cited 10 June 2010]
Gellatly, J., Bower, P., Hennessy, S., Richards, D., Gilbody, S., Lovell, K. What makes self-help interventions effective in the management of depressive symptoms? Meta-analysis and meta-regression. [References]. Psychological Medicine. 2007; 37(9):1217-28.
National Institute for Health and Clinical Excellence. Depression: The treatment and management of depression in adults. NICE: 2009. Available from url: http://guidance.nice.org.uk/CG90/NICEGuidance/doc/English.
de Mello, M,F., de Jesus Mari, J., Bacaltchuk J., Verdeli, H. & Neugebauer, R. A. systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. European Archives of Psychiatry & Clinical Neuroscience 2005; 255(2):75-82.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild (PSWQ < 45) | Primary care | Low | Multi‑Modal CBT | A11 |
| Guided self‑help | B2,4 | |||
| Large group psychoeducation based on CBT principles | B10 | |||
| Moderate – Severe (PSWQ 45–60) | Primary care / Secondary care | High | Disorder‑specific CBT (8–16 sessions) | A1,3,6,7 |
| Applied relaxation (8–16 sessions) | A3,6 |
The Penn State Worry Questionnaire (PSWQ, 8) assesses severity of generalised anxiety disorder (GAD) and the Work and Social Adjustment Scale (WSAS, 9) can help to assess the impact of GAD on functioning. In treating GAD, both CBT and applied relaxation appear to be equally effective in the short-term, but two recent high-quality meta-analyses (3, 6) suggest that CBT is more effective in the longer term. The research also suggests that there may be better results from newer CBT therapies for GAD, including meta-cognitive therapy, intolerance of uncertainty therapy and acceptance-based behaviour therapy (5). The mean number of CBT sessions is reported in one meta-analysis as 16 and in another as no more than 12 (3, 6). Another found no superior efficacy of 15 sessions over 9 sessions (4).
This condition is also known in DSM-V as illness anxiety disorder and was previously known as hypochondriasis.
This evidence table is not intended to apply to individuals experiencing somatic symptom disorder, or medically unexplained disorders such as chronic fatigue syndrome.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild (BAI = 10–18) | Primary | Low | Internet‑based CBT/mindfulness programme for health anxiety | A4 |
| Behavioural stress management | A7 | |||
| Bibliotherapy using CBT literature | B1 | |||
| Disorder‑specific, group‑based CBT | B2,3 | |||
| Moderate (BAI = 19–29) | Primary | High | Exposure and response prevention (ERP) | A6 |
| Disorder‑specific individual CBT of 6–12 sessions | A6,7,11,14,15,16 | |||
| Severe (BAI = 30+) | Primary / Secondary care | High | Disorder‑specific individual CBT of 12–16 sessions | A13,16 |
| Disorder‑specific mindfulness‑based cognitive therapy group (MBCT) | A8,10 |
All the studies included were based on protocols designed specifically to target health anxiety as opposed to more generic treatment packages.
Mild
The Bibliotherapy trial (1) was small (40 participants) though was randomised, with a TAU control group. The information used was Understanding Health Anxiety: A self-help guide for sufferers and their families written by Kuchemann and Sanders (1999). The self-help was not guided.
The group-based interventions were very small trials (2, 3), only one of which was randomised against a waiting list control. The interventions were variable in terms of content though both were based on CBT protocols.
The internet-based programme is based on one study (4) using a protocol designed by the research group based in Sweden. Though the title of the paper suggests it is aimed at ‘severe health anxiety’, we recommend caution as the cut-offs for health anxiety on specific measures are not clear and the sample group appear to be chronically affected (as opposed to severely affected). It was a guided programme including elements of internet contact between participants.
Behavioural stress management (BST) was considered by the Cochrane Review to be sufficiently different from CBT to be regarded as a separate form of treatment. It involves a form of systematic desensitisation using applied relaxation along with assertiveness, time management and worry control strategies. It gained a significant positive result in one study (7).
Moderate
A Cochrane Review in 2009 (5) was based on six studies considered acceptably rigorous in terms of design. Two studies compared cognition therapy (CT) v waiting list (6, 7), reporting that CT did significantly better than waiting list. Three studies looked at CBT vs other controls, also providing significant results. There are a number of other studies suggesting efficacy using CBT and it is clearly the most studied form of psychotherapy for use with health anxiety as discussed in a meta-analysis of CBT trials (16). One study looked at behavioural therapy [ERP] with significant outcomes. It was commented that generally candidates found the treatments acceptable.
Severe
The Cochrane Review also assessed any relationship between effect size within studies and the number of treatment sessions offered. It was found that increasing the treatment sessions to 16 resulted in a greater effect, so that it would appear sensible to recommend higher session numbers of CBT for those experiencing more severe problems.
MBCT has only recently been studied in terms of health anxiety. There has been one pilot study (10), a qualitative study and a randomised control study
(8). The overall impression is that there appears to be a high rate of acceptability of the treatment, with lower dropout rates than in CBT studies. The randomised study looked at a chronically affected population, many of whom had received psychological treatments previously. As such, it may be that as with depressed mood, there is a suggestion that mindfulness-based CBT could be useful for a treatment resistant population.
Other interventions
One study (15) compared a short-term psychodynamic against CBT and waiting list. Those receiving CBT made significant gains, whilst the psychodynamic approach failed to do so.
Other aspects
Health anxiety is a phenomenon that straddles physical healthcare environments as well as mental health. As such, some studies (e.g., 12) have made attempts to look at treating health anxiety in physical healthcare environments. These demonstrate promise and further studies would be useful to expand on the flexibility of the interventions in terms of location, as well as the practitioners delivering the interventions in Wales.
Maternal mental health problems during pregnancy and the postpartum present a major public health problem that requires urgent attention1,2. Depressive and anxiety disorders are the most common mental health problems during pregnancy and the first postnatal year. A meta-analysis has estimated the prevalence of minor and major depression17 across the nine months of pregnancy at 18.4%3, with a 12.7% prevalence estimate for a clinical diagnosis of major depression. Similarly, a second meta-analysis has estimated the prevalence of depression during the first three postnatal months at 19.4%4, with a prevalence estimate of 7.1% for major depression. Less is known about the prevalence of perinatal anxiety disorders. Prevalence estimates for antenatal anxiety disorders range between 11.8% and 15.3%, whereas for postnatal anxiety disorders estimates range between 8% and 20.4%5,6,7,8,9,10,11. The high comorbidity between perinatal depression and anxiety is well recognised and antenatal anxiety is a strong predictor of postnatal depression5,12.
Psychological interventions for the treatment of perinatal mental health problems are strongly indicated2, with such indications most pertinent in the perinatal context given the potential risks to foetal and infant development associated with psychotropic medication exposure2,13. Yet the evidence base for psychological interventions for the treatment of perinatal mental health problems is underdeveloped and large RCTs are largely lacking in this area2. The existing evidence base is focused on the prevention and treatment of postnatal depression. The systematic literature search that informed the current evidence table did not identify any RCTs that specifically targeted perinatal anxiety disorders. Similarly, there are few large scale RCTs for the treatment of antenatal depression. In line with the most recent NICE guidance2 for antenatal and postnatal mental health problems and in the absence of perinatal-specific psychological interventions for a particular presenting problem (e.g., obsessive compulsive disorder (OCD)), the reader is referred to the other disorder specific evidence tables specified in Matrics Cymru. The evidence table below does not cover interventions that specifically target either difficulties in the mother-infant relationship or in the infant’s mental health and wellbeing. Please see the Scottish Matrix for Children and Young People (2014)14.
In line with the Scottish Matrix (2015)15 and NICE (2014)2, psychological therapies for non-psychotic affective disorders during the perinatal period should:
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild / Moderate | Primary care / Third sector | Low | Guided self-help: Internet or booklet behavioural activation or CBT-informed with telephone or face-to-face support for antenatal or postnatal depression | A16,17,18 |
| Group-delivered mindfulness intervention for antenatal anxiety and depression (8 weeks) | C19,20 | |||
| Prevention / Early intervention | Primary care / Third sector / Specialist perinatal community mental health service | Low | Individual or group-delivered psychoeducational intervention to prevent postnatal depression | A21,22,23 |
| Individual or group-delivered IPT to prevent postnatal depression | A21,23 | |||
| Individual or group-delivered CBT to prevent postnatal depression | A21,24,25 | |||
| Group-delivered mindfulness-based CBT to prevent postnatal depression | B26 | |||
| Antenatal hypnotherapy to improve postnatal psychological wellbeing | C27 | |||
| Group-delivered CBT for perinatal anxiety | C28 | |||
| Moderate / Severe | Secondary care / Specialist perinatal community mental health service | High | Individual CBT for postnatal depression | A25,29 |
| Individual or group-delivered IPT for antenatal or postnatal depression | A25,29 | |||
| Individual CBT for antenatal depression | B30 | |||
| Individual CBT for postnatal OCD | C31 |
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild | Primary care | Low | Self-help | B1 |
| CCBT | B2,4,5 | |||
| Telephone intervention | B3 | |||
| High | Group CBT | B6,9 | ||
| Group exposure response prevention (ERP) | B7 | |||
| Moderate | Secondary care | High | CBT (incl. ERP) | A10,11,12 |
| ERP | A13 | |||
| Severe | Secondary care | High | CBT / ERP | B14 |
| Chronic | Secondary care | High | CBT / ERP + antidepressant medication | B15,16 |
| Treatment-resistant OCD | Secondary care | High | CBT – Intensive session protocol | C17 |
| Hoarding | Secondary care | High | Specialised CBT for hoarding | B18,19 |
Main Findings
Main conclusions: Guidelines
Some new studies have been conducted since both the NICE guidelines for OCD, 200514 and the NICE Guidance Update for OCD, 2013 (e.g., 3, 4, 5, 16). However, overall recommendations remain largely the same:
Main conclusions: Research base
Few studies assess the relative effectiveness of CBT/ERP vs. medication; many studies allow for the concurrent use of psychotropic medication and most RCTs consist of small sample sizes with <30 participants per group10. This presents major confounds in assessing the relative and independent effectiveness of CBT/ERP. Thus, although there are some exceptions (e.g., 13), more research needs to be done in this area.
Open Dialogue (OD) is a whole systems approach to providing interventions and organising services for people presenting with a first episode of psychosis or other mental health crisis. It involves continuity of care as a key organising principle, delivered through regular ‘network meetings’ with the service user, their key family or friends and a consistent group of mental health professionals. There is an explicit aim to provide an alternative to traditional models of mental health service provision, which can, for some people, exacerbate a sense of powerlessness about their care and to seek to reduce the risk of over-medicalising mental health problems. Seven key principles are widely agreed to define the model1: (1) Immediate Help; (2) A Social Network Perspective; (3) Flexibility and Mobility; (4) Responsibility; (5) Psychological Continuity; (6) Tolerance of Uncertainty and (7) Providing a forum for change through Dialogue.
OD was initially developed and evaluated mainly in Finland and Western Lapland1-3, subsequently the approach has been developed widely with published studies in other Scandinavian countries4, the United States (US)5-6 and Canada7. Most of the published literature has reported on the delivery of OD to young people with acute psychosis, in both primary and secondary care contexts and some recent adaptions have expanded this to people in a wider range of acute mental health crises, who are experiencing a significant impact on personal or social functioning. These published studies have involved considerable variation in both the implementation of and fidelity to the key principles. No randomised control trials (RCTs) have yet compared the effectiveness of OD in producing clinical or functional benefits with any alternative treatments. Most studies have involved non-experimental designs and only one has included a control group2. Methodological issues include lack of randomisation, small samples, unblinded assessment of outcomes and retrospective diagnosis8. The evidence for clinical or functional benefits for adolescents and adults presenting with an acute episode of psychosis or a mental health crisis is summarised in the evidence table below.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| Severe | Usually Part 2 | High | Open Dialogue | C | Unknown |
Evidence from non-randomised studies suggests that OD may help recovery from acute psychosis and lead to improved long-term outcomes3. Qualitative studies indicate that service users report positive experiences of OD, the benefits of openness and transparency within OD network meetings and more constructive relationships with mental health staff. There are interesting findings relating to how change occurs within open dialogue meetings, through valuing and tolerating uncertainty, improving trust and facilitating multiple perspectives within the network meetings9. Currently there are no published evaluations of OD applications in other mental health conditions, for older adults, or people with neurodiversity and or intellectual difficulties.
Given its systemic nature and the challenges of implementation in different health care cultures (discussed further below), OD will require evaluation in high quality studies in a UK NHS context to clarify its effectiveness. The ODDESSI (Open Dialogue: Development and Evaluation of a Social Network Intervention for Severe Mental Illness) research programme10, which is currently in progress, includes a multi-site, two-arm cluster randomised controlled trial to assess clinical and cost effectiveness in comparison with treatment as usual. The primary outcome is time to relapse after recovery, with secondary outcomes including service costs, user defined recovery, service user satisfaction and staff experience. It is expected to report in 2023.
In Wales, there are currently two implementation sites which have been successful in gaining transformational funding to train mental health professionals in OD. Evaluation of these programmes is currently ongoing.
Practical and systemic issues, barriers and challenges to adherence involved in the implementation of OD in the NHS mental health service context
OD is intended to be a radical alternative to established practice and some of its characteristics may make retaining integrity to the original model challenging to implement in traditional mental health settings. Some studies have reported a number of specific difficulties in achieving high quality implementation within an American context. These include:
To meet these challenges, organisational willingness and readiness need to be clearly present before OD implementation and careful consideration should be given to possible systemic obstacles which can threaten fidelity to the model, such as time pressures preventing access to adequate training and supervision for staff; rigidity in referral and allocation processes and traditional hierarchical structures.
Recommendations for practice-based evidence collection in Welsh implementation of OD. Core outcome measures and systemic considerations
OD operates as a relational, dialogical, whole systems approach and a way to organise services. Over and above symptom resolution for the patient, it aims for improvements in social functioning and in the relationships between people accessing support, professionals, families and social networks. These changes cannot all be captured through standard RCT methodologies and more comprehensive evaluation requires a range of research methods, including qualitative approaches8.
To evaluate the effectiveness of OD systems in helping individuals in crisis, it will be critical for practice-based evidence to evaluate broader outcomes beyond symptomatology and relapse, to include quality of life e.g., Manchester Short Assessment of Quality of Life (MANSA11), user defined recovery e.g., the service user defined questionnaire about the Process of Recovery (QPR12), extent and quality of social networks and purposeful time use. Evaluation projects might helpfully reference the current “Outcome Measures Companion Guide”13 as devised by Improvement Cymru (2021) as a relevant and current framework for quality, person centred evaluation. It is recommended that future evaluations also make use of qualitative as well as quantitative data, with clear reference to practice and the experience of individuals, families and networks of support.
The Panic Disorder Severity Scale (PDSS) provides a measurement of the severity of panic (5).
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Subclinical (prevention of PD among those presenting with panic attacks but not meeting PD diagnostic criteria) | Primary care | Low | Stepped‑care programme comprising educational booklet; detailed self‑help manual; five × 2‑hour group CBT | A32 |
| Mild | Primary care | Low | Minimal therapy contact CBT (4–6 hours) – Bibliotherapy | A6,18 |
| Minimal therapy contact CBT (4–6 hours) – Internet delivery | A2,3,12,13,26 | |||
| Moderate | Primary care | Low | Therapist‑supported self‑help CBT (6–12 hours) – Bibliotherapy | A7,15,22 |
| Therapist‑supported self‑help CBT – Computer assisted (e.g., Fear Fighter) | A10,19 | |||
| Therapist‑supported self‑help CBT – Internet‑delivered with therapist contact (up to 6 hours) | A3,8,12,13,26 | |||
| Group CBT (8–18 hours) | A15,23,25 | |||
| Moderate to severe, following positive response to CBT | Primary care / Secondary care | High | Maintenance CBT following CBT (reduces relapse; reduces impairment) | A33 |
| Severe | Primary care / Secondary care | High | Individual therapist‑directed CBT (16–20 sessions) with supplementary written material | A1,6,17,18,20,23 |
| Group CBT (14 sessions) | A23 | |||
| Exposure & relaxation / breathing training | A24 | |||
| Virtual reality exposure | A21 | |||
| Brief CBT (7 sessions) | A23 | |||
| Chronic or treatment‑resistant | Secondary care / Specialist service; in‑patient care | High | Individual therapist‑directed CBT (up to 20 sessions) | C |
“For ease and clarity of writing, we use the terms woman/women within these documents. Within this we acknowledge that not all birthing people identify as women”.
Common mental health problems in the perinatal period are mental health problems that occur during pregnancy (antenatal) and within one-year after birth (postnatal). This overall timeframe is referred to as the perinatal period. These presentations, commonly depression and anxiety disorders, show a high degree of comorbidity (e.g., coexisting perinatal depression and anxiety), have strong predictive capacity (e.g., antenatal depression is a predictor of postnatal depression)1 and require further assessment and monitoring2.
The management of common mental health problems in the perinatal period involves addressing a wide range of often interconnected challenges. These include the risk of harm (to mother and foetus/baby) associated with untreated mental health disorders3 ; possible risks associated with the use of psychotropic medication in the perinatal period4, and some degree of uncertainty related to the potential benefits, risks and harm of pharmacological and psychological interventions for perinatal mental health disorders2. Hence, healthcare professionals should have the capacity to understand these challenges, as well as to recognise, routinely assess, refer and provide interventions for perinatal mental health disorders as required. A coordinated care approach should be adopted, inclusive of service user preference and acceptability of interventions during pregnancy and post-natally, particularly in terms of pharmacology. This approach should include the development of an integrated care plan that specifies the treatment plan for the mental health disorder and the roles of healthcare professionals involved in coordinating care, monitoring schedules and providing treatment2. View Perinatal Mental Health Good Practice Principles guide.
This review covers approaches that can help prevent and treat non-psychotic mental health disorders in the perinatal period, with particular focus on common mental health difficulties such as depression and anxiety. Full guidance on identifying, assessing and managing mental health disorders in the perinatal period can be found in the National Institute for Health and Care Excellence (NICE) guidance2. The management of psychosis and bipolar disorder in the perinatal period is covered in the sections on bipolar disorder and schizophrenia/psychosis. Please refer to relevant recommendations for the management of specific mental health conditions not covered within the perinatal recommendations elsewhere in this document.
For Post Traumatic Stress Disorder (PTSD) and birth related trauma [from miscarriage, traumatic birth, stillbirth, or neonatal death] the evidence tables for PTSD apply, trauma symptoms are often overlooked or mis-identified as depression. Prevention of trauma and PTSD in the perinatal period is contingent on psychologically informed maternity care5. Single-session high-intensity psychological interventions that focus on ‘debriefing’/ ‘guided reliving’ of the trauma experience are not recommended for women who have experienced traumatic births2.
Prevalence: The prevalence of perinatal mental health disorders varies in relation to both the mental health condition and the perinatal period. In the UK, prevalence estimates for perinatal depression have ranged from 7.4% to 14.8% for antenatal depression (higher levels reported in the third trimester), with prevalence estimates of 7.4% - 12.8% reported in the postnatal period6. Prevalence estimates for perinatal anxiety disorders, across its multiple classifications, have ranged between 11.8% to 15.3% for antenatal anxiety, with an estimated 8% prevalence rate reported for postnatal anxiety6.
The antenatal and postnatal periods provide a window of opportunity for healthcare providers to identify women who might be at risk of developing mental health problems, or women with presentations that might be of concern to healthcare practitioners. It presents an opportunity to deliver psychological interventions for the prevention, early intervention and treatment of mental health disorders.
There is high-level evidence to support the delivery of cognitive behavioural based approaches for universal prevention of antenatal depression. The moderate effect sizes demonstrated by these interventions make these approaches viable options for the prevention of depression in the antenatal period without the need to identify high-risk pregnant women.
E-health interventions have also been shown to be effective in the universal prevention of perinatal depression. The emerging evidence supporting the use of e-health interventions, as well as the advantages of anonymity and increased access to care, could make this remotely accessed intervention particularly attractive for mental health disorders characterised by high prevalence7.
In addition to universal preventive interventions, there is evidence to support the delivery of psychological interventions to prevent depression in women at high-risk, e.g., women with a history of depression, or those facing socioeconomic situations that place them at high risk of depression. Such interventions include psychoeducation and counselling interventions based on Cognitive Behavioural Therapy (CBT)/Interpersonal Psychotherapy (IPT).
Other CBT based interventions include facilitated self-help interventions (recommended by NICE) for women in the perinatal period with subthreshold depressive or anxiety symptoms. Based on NICE’s recommendations, guided CBT based interventions can be delivered either face-to-face or remotely; consist of six to eight sessions and be supported by a trained practitioner.
Ambiguity exists as to what is classed as prevention or early intervention. To ensure consistency and clarity, interventions are classed as preventive if; (I) explicitly stated in evaluation studies; (II) delivered universally as preventive interventions; (III) delivered to women (in the perinatal period) at high-risk of depression or anxiety. Interventions are classed as early interventions if delivered to women (in the perinatal period) with subthreshold symptom levels. Given the ambiguity and overlap, prevention/early intervention are combined in the table.
Prevention of Common Mental Health Problems in the Perinatal Period
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Prevention / Early Intervention | Part 1 services | Low | Psychoeducation to prevent postnatal depression in at‑risk women8 | A |
| Psychoeducation to prevent postnatal depression7,9 | A | |||
| Individual or group‑delivered IPT for postnatal depression10-12 | A | |||
| Individual or group‑delivered CBT for postnatal depression12-14 | A | |||
| Counselling interventions based on CBT/IPT for perinatal depression in at‑risk women13,15 | A | |||
| CB‑based approaches for universal prevention of antenatal depression16 | A | |||
| E‑health interventions for universal prevention of perinatal depression7 | A | |||
| Facilitated / guided self‑help interventions based on CBT principles for perinatal depression17 | B | |||
| Group‑delivered mindfulness‑based CBT for postnatal depression in at‑risk pregnant women18 | B | |||
| Acceptance and Commitment Therapy for antenatal anxiety19 | C |
Interventions are classed as treatment if; (I) explicitly stated in evaluation studies; (II) delivered to women (in the perinatal period) with above threshold symptom levels; or (III) delivered to women with diagnosis of depressive or anxiety disorder. Psychological interventions with medium to high levels of evidence have been included in the evidence table below. These are classified as A-C. This is to be consistent with the aim to focus on interventions with the highest levels of efficacy and the strongest levels of evidence where this exists.
There is high-level evidence for facilitated self-help based on CBT principles for the treatment of perinatal depression and anxiety. For such interventions, NICE recommends the use of self-help materials, with in-person or remote support provided by a trained practitioner2. This approach to delivery of care provides a flexible, cost-effective option that has the potential to increase choice for women in the perinatal period with common mental health problems and be provided primarily in Part 1 services as part of a stepped/stratified approach to the treatment. There is also high-level evidence for psychologically informed sessions (based on cognitive behavioural or person-centred principles) for the treatment of postnatal depression20. This offers another first-step alternative for use in primary care settings.
There is strong evidence of high efficacy for CBT and IPT for the treatment of perinatal depression. In contrast, there is evidence suggestive of potential benefits for CBT and IPT for the treatment of perinatal anxiety, but does not translate to significant efficacy, as evidenced by the small effect sizes in meta-analyses of between-group comparisons. The NICE Guideline Development Group considered it reasonable to extrapolate from a nonpregnant population² and recommended that low-intensity or high-intensity psychological interventions be offered in line with recommendations, as set out in existing guidelines for Generalised Anxiety Disorder, Panic Disorder, Obsessive-Compulsive Disorder, Social Anxiety Disorder and Post Traumatic Stress Disorder in these Evidence tables and referenced in NICE²¹,²⁴.
Systematic literature reviews and meta-analysis have assessed the effectiveness of mindfulness-based interventions for the treatment of non-psychotic perinatal mental health disorders. The results from these reviews were inconsistent and did not unilaterally report the efficaciousness of mindfulness-based interventions for this purpose. Deviation from traditional mindfulness-based interventions i.e., cognitive therapy based e.g., Mindfulness-Based Cognitive Therapy (MBCT) and stress reduction based e.g., Mindfulness-Based Stress Reduction (MBSR) may have contributed to some of the negligible effect sizes observed. However, based on the overview of results, a low efficacy level has been attributed to mindfulness-based interventions (in general) for the treatment of perinatal anxiety and depression. There is also evidence that these interventions are reasonably well accepted by women.
Evaluation of Acceptance Commitment Therapy (ACT) in women in the perinatal period has shown promising results for depression outcomes, but these estimates are subject to substantial methodological variation. The absence of high-quality RCTs, systematic literature reviews and meta-analysis assessing ACT’s effectiveness limit the strength of evidence for this intervention. NICE recommends low-intensity psychological intervention (e.g., facilitated self-help) for anxiety disorders in the perinatal period. However, for specific anxiety disorders e.g., social anxiety.
Treatment of Common Mental Health Problems in the Perinatal Period
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild/Moderate | Usually part 1 | Low | Individual guided self-help based on CBT principles (including behavioural activation and problem-solving techniques) for perinatal depression25-27 | A |
| All levels | Usually part 1 | Low | Psychologically informed sessions based on cognitive behavioural or person-centred principles for postnatal depression20 | A |
| Mild/Moderate | Usually part 1 | Low | Facilitated self-help for perinatal anxiety (includes e‑health interventions)28 | A |
| Mindfulness-based interventions for perinatal anxiety and depression29-31 | A | |||
| Moderate/Severe | Part 1 and part 2 | High | CBT for perinatal depression32-34 | A |
| IPT for perinatal depression35 | A | |||
| CBT for perinatal anxiety36-38 | A | |||
| IPT for perinatal anxiety35 | A | |||
| Low | Acceptance and Commitment Therapy for perinatal depression39-42 | B | ||
| High | Individual CBT for postnatal OCD36, 43 | B |
In the UK, in a recent study1 , just over 30% of young people experienced trauma and 7·8% developed post traumatic stress disorder (PTSD) by the age of 18 years. There is a greater likelihood of PTSD and Complex PTSD (CPTSD)2 in ‘at risk’ child populations, i.e., those who have experienced adverse childhood experiences (highly stressful, potentially traumatic events) such as abuse or neglect3.
Early identification of symptoms is important in children and young people. Questions about exposure to commonly experienced potentially traumatic events should be included during any mental health assessment of children and young people, with screening for the presence of PTSD symptoms, if confirmed. There are many freely available structured interviews and questionnaires available to assess post-traumatic stress symptoms and PTSD in children and young people. The International Trauma Questionnaire for Children and Adolescents (ITQ-CA)4,5 is a freely available measure of PTSD and CPTSD symptoms in children and adolescents according to ICD-112 diagnostic criteria. A measure based on the DSM-56 diagnostic manual is the Child and Adolescent Trauma Screen (CATS)7. Should screening measures be utilised, it is important that when a child or adolescent screens positively for PTSD or CPTSD symptoms, this is used alongside a robust clinical assessment of endorsed difficulties.
Assessment of children and adolescents should include assessment of the system in which they live, as their symptoms will both influence and be influenced by what else is happening within the system. It is important to consider whether parent(s)/caregiver(s) are experiencing mental health problems, in particular in instances of shared trauma. There is some evidence that parental distress can negatively impact a child’s outcomes in treatment8,9. Trauma-focused cognitive behavioural therapy (TF-CBT) was found to be less effective in reducing children’s PTSD symptoms when both children’s pre-treatment PTSD symptoms and caregivers’ depression or unhelpful trauma-related beliefs were more severe8.
Where assessment involves very young children (0-3 years), this should include an evaluation of the behaviour of the child with particular reference to developmental stage and attachment status. An understanding of attachment theory is important for clinicians. In all children, the range of potential post-traumatic mental health problems includes behavioural and attentional problems as well as problems with anxiety and mood. Interventions for comorbid problems such as depression, anxiety and substance use in children and young people who have experienced trauma are as important as for PTSD/CPTSD10.
Parents/caregivers need to be involved to some degree to promote continued engagement in therapy such as ensuring that the rationale for the work and strategies is understood (particularly true in TF-CBT) and to have the opportunity to answer questions. Parents and carers play varied and important roles in therapy, including supporting children and young people to attend the sessions, to help them complete any homework tasks and to be able to ‘self-regulate’. They often act as co-therapists in order to support practice tasks (such as exposure hierarchies, behavioural experiments), to support generalising learning and reduce dropout rates11,12.
Interventions need to be tailored to meet the developmental needs of an individual child. There are many well validated protocols developed specifically for children and young people and these should be used in preference to modifying an adult protocol13. The developmental stage and capabilities of the child should be kept in mind - chronological age does not necessarily equate to levels of cognitive functioning and developmental mastery. Even children as young as 5 can engage with cognitive therapy given age appropriate material14 and EMDR may be adapted to match a child or young person’s developmental stage, attention span, language abilities, verbal reasoning skills and level of insight.
Matrics Plant (NHS Wales)15 highlights the importance of utilising creative and developmentally appropriate ways of engaging children and young people, including engagement with adults in the young person’s system, as children may be dependent on adults to access and benefit from services.
Currently there is limited research informing early interventions to reduce traumatic stress symptoms in children and young people. In line with the NICE guidelines16, Matrics Cymru recommends against individual single session psychological debriefing based on two studies17,18 which did not demonstrate any benefit in the reduction of PTSD symptoms and suggested that the intervention may slow recovery. One RCT19 identified a significant reduction in developing PTSD with a targeted family psychosocial intervention. Whilst not reaching level B evidence rating, one small pilot study20 demonstrated that self-directed online psychoeducation involving young people exposed to acute trauma was feasible to deliver and was engaging for children. More research is required to explore the effectiveness and reach of web-based interventions.
There are a number of pragmatic approaches that are likely to be helpful for infants, children and young people after a traumatic event. Key is the presence of a safe, respectful, predictable and regulated adult21. Re-establishing routines around mealtimes and sleeping can be reassuring and provide a sense of stability and safety to a young person. Encouraging social connections within family members and the extended family is important, as well as keeping connected to religious communities, school communities and youth groups. It is helpful to adopt an approach of active listening to a child or young person and to value a young person’s cultural identity as part of the healing process. A period of “active monitoring” in the first month may be appropriate to see if symptoms naturally improve and to allow professionals to target those children and young people with impairing traumatic symptoms to access targeted support16.
Prevention (0-3 Months Post Trauma)
The Panic Disorder Severity Scale (PDSS) provides a measurement of the severity of panic (5).
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| All levels | Parts 1 & 2 | High | Psychosocial intervention: Child and Family Traumatic Stress Intervention (CFTSI) | B | Medium |
There is more evidence for the treatment of PTSD in children and young people than for its prevention, although there is less evidence for children than is available for the treatment of PTSD in adults. There are several effective psychological treatments for PTSD in children and young people, including TF-CBT, cognitive therapy for PTSD (CT-PTSD) and prolonged exposure therapy for adolescents (PE-A).
Although there is a greater weight of grade A evidence supporting TF-CBT as an effective treatment for PTSD in children and young people, EMDR also achieves an A grade level of evidence due to the growing amount of research meeting this standard. NICE guidelines16 recommend EMDR as a second line intervention for children and young people with PTSD who have not responded to or engaged with TF-CBT. A meta-analysis22 found TF-CBT marginally more effective in reducing PTSD symptoms post treatment than EMDR and therefore, EMDR is graded as ‘medium to high’ for efficacy.
There are a number of other therapies with lower strength efficacy that are not included in the table but are of emerging interest. For example, there is insufficient research currently to recommend narrative exposure therapy for children (KIDNET) as an effective therapy for children and young people with PTSD. However, a multi-centre RCT (YOURTREAT)23 exploring the efficacy of KIDNET as a treatment for young refugees with PTSD versus treatment as usual is underway.
There is also growing evidence to support group-based interventions for young people in the youth justice system (Target-A)24. Transdiagnostic or modular approaches that target underlying mechanisms common to different mental health problems is an area of research interest and development.
Potential targets for intervention in these approaches might include improving social support, or working with maladaptive coping styles, cognitive biases and behavioural avoidance.
Currently, there is a lack of evidence for the treatment of CPTSD in children and young people. It is unclear if specific interventions are required to treat CPTSD as compared with PTSD in children and young people. In the absence of a current evidence base for the treatment of CPTSD, it may be helpful to use the current recommended first line treatments for PTSD, whilst taking into account the disturbances in self-organisation which are a feature of CPTSD. That may result in longer courses of treatment being required25. It may be helpful to consider the need for stabilisation work before recommending delivery of a trauma-focused intervention to a child or young person with CPTSD.
Finally, it is important to note that it is beyond the scope of this document to differentiate recommendations around direct psychological therapy provision based on specific age groups, however, consideration should be given to this as evidence continues to emerge.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| Individual intervention All levels |
Part 1 & 2 | High | TF‑CBT with child; TF‑CBT with child and parent/carer26,27 | A | High |
| EMDR28,29,30 | A | Medium to high | |||
| Pre‑school TF‑CBT | B | Medium | |||
| CT‑PTSD31,32 | B | Medium | |||
| Prolonged exposure for adolescents (PE‑A)33,34 | B | Medium | |||
| Stepped or phased care approach* All Levels |
Part 1 or 2 | High | Developmentally adapted version of cognitive processing therapy (D‑CPT)35 | B | High |
*Standard care is the reasonable amount of care a person should provide to another. Stepped care is providing the least intrusive and most effective treatment initially, only stepping up to provide more intensive input as clinically needed.
The consequences to the individual of exposure to psychologically traumatic events vary widely. For most people there will be no lasting adverse impact on wellbeing. In others it may cause, or contribute to, a range of psychological disorders as well as social and physical problems. The nature and timing of the traumatic exposure may, in part, determine the individual’s response to it. Psychological disorders caused, or contributed to, by exposure to traumatic events include PTSD, complex PTSD, depressive disorders, anxiety disorders, substance use disorders, somatic symptom disorders, psychosis and personality disorders. Over 50% of people with PTSD will experience at least one comorbid psychological disorder1.
Mental health clinicians should routinely explore for trauma history as part of their assessment and consider trauma history in their formulation of a service user’s difficulties. A full and comprehensive assessment of mental health needs, undertaken by an individual who has the skills required to do so, is vital in order to determine the nature of an individual’s difficulties and needs, an assessment of risk and the co-production of an appropriate management plan.
Currently, there is insufficient evidence to support any single universal intervention (one provided to everyone exposed) to prevent PTSD in the immediate aftermath of a traumatic event2. The National Institute for Health and Care Excellence recommends against psychological debriefing but the current evidence for this is not considered strong enough for Matrics Cymru to specifically recommend against its delivery. There is evidence that single session individual debriefing may cause harm to some people3; whilst this is not the case for group debriefing, overall there is insufficient evidence to recommend any form of psychological debriefing. It is, therefore, recommended that people involved in traumatic events are offered practical, pragmatic support in an empathic manner.
There is some level B evidence for universal interventions such as single session EMDR, brief dyadic therapy and a self-guided internet-based intervention2, but the level of efficacy of these interventions is unknown and further evidence would be required before such interventions can be recommended for inclusion in the Matrics Cymru PTSD Prevention Table.
There is better, albeit still limited, evidence for interventions that aim to prevent PTSD by treating early symptoms of PTSD or acute stress disorder. Stepped/Collaborative care involves screening and direct assessment, followed by the provision of flexible and modular interventions (psychological, pharmacological and/or case management) based on an individual’s needs4.
All people presenting with symptoms within the first few months of traumatic events should be offered an assessment of mental health needs prior to being offered an intervention. A period of “watchful waiting” may be appropriate to see if symptoms naturally improve. All decisions should be coproduced with the affected individual.
Prevention (1-3 Months Post Trauma)
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| All levels | Parts 1 & 2 | High | Individual CBT with a trauma focus for acute stress disorder and PTSD symptoms | A | Medium |
| All Levels | Parts 1 & 2 | High | Stepped / Collaborative care | A | Low |
| All levels | Parts 1 & 2 | High | EMDR for PTSD symptoms | B | Medium |
There is much better evidence for the treatment of PTSD than its prevention, in terms of both strength of evidence and efficacy5. It can be argued that detecting and treating PTSD as early as possible is likely to represent a more clinically and cost-effective use of available resources/services than focusing on prevention. That said, the most effective interventions for the prevention of PTSD are also the most effective interventions for its treatment.
There are a wide range of different interventions that now have enough evidence to be included in the Matrics Cymru Tables with A or B level evidence5. In order to be consistent with the aim of Matrics Cymru to focus on interventions with the highest levels of efficacy and the strongest levels of evidence, only those psychological interventions with A strength evidence of a medium or high level of efficacy have been included. There are a number of psychological treatments with lower strength evidence of efficacy that are not included in the Table, such as couples CBT6 with a trauma focus and reconsolidation of traumatic memories7.
As highlighted by the Table, five specific individual face to face therapies with a trauma focus have the highest levels of efficacy. Other psychological therapies with a trauma focus, namely narrative exposure therapy and group CBT with a trauma focus, have demonstrated a lower level of efficacy but may still have a role in the treatment of people with PTSD5. The same is true for non-trauma-focused CBT and present centred therapy, non-trauma-focused psychological therapies with medium levels of efficacy5 , especially for people with PTSD who are in unstable situations (e.g., ongoing domestic violence) that mean trauma-focused work is inappropriate, people with PTSD who do not want to engage in trauma-focused work and those who are unable to tolerate it.
There is also strong evidence of medium efficacy for guided internet-based CBT with a trauma focus for people with mild to moderate PTSD8. This provides a flexible, cost-effective alternative approach that has the potential to increase choice for people with PTSD and be provided primarily in Part 1 services as part of a stepped/stratified approach to the treatment of PTSD.
The recommended therapies listed in the Table are indicated for people with PTSD as opposed to complex PTSD, which is now formally recognised as a parallel diagnosis to PTSD in the ICD-11 classification system9. With the exception of guided internet-based CBT with a trauma focus, the listed therapies have been shown to be helpful to some people with more complex presentations of PTSD10,11. Given the current absence of a formal evidence base for the treatment of complex PTSD12, the Table should help inform possible treatment approaches for complex PTSD. It is particularly important to consider the need for stabilisation work before recommending delivery of a trauma-focused intervention to someone with complex PTSD. Some people with PTSD may also benefit from emotional stabilisation work before trauma-focused treatment. This and additional considerations, also applies to people with PTSD with significant comorbidity. For example, in the case of comorbid PTSD and substance use disorder, although there is evidence that some individuals may benefit from trauma-focused work, stabilisation of substance use is often required before trauma-focused treatment is likely to be optimally beneficial. It is important to note that the evidence the tables is based on is primarily drawn from studies of working age adults and it is unclear how applicable the evidence is to other groups, for example, older people and people with learning disabilities.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| All levels | Parts 1 & 2 | High | Cognitive processing therapy, cognitive therapy, EMDR*, individual CBT with a trauma focus (undifferentiated), prolonged exposure | A | High |
| All levels | Parts 1 & 2 | High | CBT without a trauma focus, group CBT with a trauma focus, narrative exposure therapy, present‑centred therapy | A | Medium |
| Mild to moderate | Part 1 | High | Guided internet‑based CBT with a trauma focus | A | Medium |
* NICE recommend EMDR only after a non-combat-related trauma. A marked difference in response to EMDR in adults exposed to combat-related trauma compared to non-combat-related trauma is not supported by practice-based evidence, but more work is needed and it is important that practitioners and people with PTSD are aware that the current, albeit limited, research evidence suggests that EMDR is not effective for combat-related trauma.
Courtois and Ford1 have defined complex psychological trauma as “involving traumatic stressors that (i) are repetitive or prolonged; (ii) involve direct harm and/or neglect and abandonment by caregivers or ostensibly responsible adults; (iii) occur at developmentally vulnerable times in the victim’s life, such as early childhood and (iv) have great potential to compromise severely a child’s development”. Traumatic experiences early in childhood have been particularly associated with poor mental health in adulthood. Repeated exposure to interpersonal stressors in adulthood such as domestic violence, torture, sex trafficking and other forms of organised violence are also associated with complex psychological trauma responses 2. Effects may include affect deregulation and impaired self-concept, dissociation, somatic dysregulation and disorganised attachment patterns leading to interpersonal and intra-personal difficulties in adult life3, 4. These are in addition to DSMV PTSD symptoms of re-experiencing of the traumatic events, avoidance of the reminders, negative alterations in cognitions and mood and hyper arousal. There is limited treatment outcome research on interventions for complex traumatic stress and further research in the area is required1. The expert consensus task force established by the International Society for Traumatic Stress Studies identified nine RCTs in which complex trauma symptoms were the target of treatment in individuals with complex trauma resulting from childhood physical and/or sexual abuse2. The models evaluated in these studies were all based on phase based programmes. Although evidence is limited, it is widely thought that a phase based intervention approach is indicated for treatment of complex traumatic stress disorders. A prolonged assessment and formulation process is essential initially along with the development of the therapeutic relationship. It is also recommended that interventions that specifically target problem areas such as affect deregulation, dissociation and somatic dysregulation are addressed first, with an initial focus on safety, emotion regulation and patient education. Medication can sometimes aid the stabilisation process. When sufficient sense of safety and stabilisation has been achieved, the treatment can move on to the processing of traumatic memories using CBT or EMDR. Some service users will choose not to undertake this phase and careful consideration of the pros and cons of undertaking processing is needed before this begins. Finally the patient can be helped to reintegrate with others in their life.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Moderate – Severe | Specialist trauma service | High | Phase‑based intervention programme: 16–30 sessions (some treatment may be much longer) | |
| Phase 1 – Safety and stabilisation Establish therapeutic alliance. Training in affect regulation. Education about trauma and its impacts. |
A18,19 | |||
| Phase 2 – Processing of traumatic memories Narrative reconstruction with CBT interventions and/or EMDR, including exposure where appropriate. |
C14,15 | |||
| Phase 3 – Reintegration Continued development of trustworthy relationships; work on intimacy, sexual functioning, parenting, etc. |
C14,15 |
Psychosis is a term used to represent a range of major mental health problems, of which the commonest is schizophrenia and which includes schizoaffective disorder, schizophreniform disorder, delusional disorder and non-affective psychoses1. These conditions comprise a cluster of signs and symptoms which reflect changes in perception, mood, behaviour, thinking and speech. There is considerable overlap with other conditions and this gives rise to diagnostic uncertainty and a lack of predictive utility2. The causes of these conditions remain uncertain, although an integrated socio-developmental-cognitive model is favoured3.
The onset of the condition is characterised by a prodromal phase typified by a dysphoric state with attenuated or brief psychotic symptoms4. Approximately a fifth of those at high risk will transition to psychosis within the first year5, giving rise to a predicted rate for Wales of around three hundred new presentations a year, of which 80% will be between the ages of 16 and 256. Outcome in schizophrenia is variable, with symptomatic relapse within the first year post diagnosis ranging from 30% to 60%. Only between 17% and 40% of those diagnosed reach fully symptomatic recovery at seven years post diagnosis (with the variation representing different treatment regimes7,8). The societal and personal costs of schizophrenia and psychosis are high, with low rates of employment, social participation, lower life expectancy and longer years lived with disability, victimisation and suicide9–14.
Treatments for schizophrenia and psychosis have been the subject of considerable empirical study, which is summarised through the various iterations of the UK guidelines published by NICE15 and SIGN16. These broad guidelines include psychological and psychosocial therapies that target physical health and behaviour change, symptoms, recovery, social functioning and occupation. Psychological therapies should be seen in the context of overall approaches to health gain and social participation. Despite a recent update, the NICE recommendations addressing psychological and psychosocial therapies date back to 200917 and since then there have been a number additional trials and meta-analysis18–30 which report on additional studies and the risk of bias and its influence on effect size31,32.
Reviews of CBT for negative and positive symptoms report small to moderate effect sizes for hallucinations and very small effect sizes for delusions. When the risk of study bias is accounted for, the effect size falls to very small or no effect depending on the intervention and its target symptom16,18–20,20,23,24. A large pragmatic trial of arts therapy (MATISSE) did not support the previous NICE recommendation for arts therapy for negative symptoms16,18. Also, supportive therapy and befriending are unlikely to be superior to treatment as usual24,25. Finally, whilst cognitive remediation therapy demonstrates improvements in cognition, these are unlikely to be transferred into improved functioning outside of a rehabilitation framework28,29.
In spite of this, there are positive outcomes for the use for family intervention and CBT for people at risk of psychosis or in the early stages of the condition22,33. Family intervention is likely to reduce relapse rates and may reduce family burden across all phases of the condition15,34,35. Social skills training24 and group psychotherapies may improve negative symptoms and social functioning30. PTSD, anxiety and depression are prevalent in schizophrenia and psychosis and therapies targeting these should be offered15,36,37. There is also emerging evidence (with a risk of bias) of the benefits of offering low intensity interventions targeting distress, worry and sleep which although have a small to moderate effect size, may be cost effective if delivered at scale33,38–42.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Ultra-high risk of psychosis (attenuated or brief limited/intermittent symptoms) |
Secondary care | High | Family intervention | A15,34,35 |
| CBT for psychosis | A22 | |||
| Low | Worry‑reduction & sleep‑improvement CBT; progressive relaxation | A38,39,42 | ||
| First episode psychosis, relapse or persistent symptoms |
Secondary care | High | Family intervention for reducing relapse & burden | A15,34,35 |
| NICE‑recommended treatments (depression, PTSD) | A15,36,37 | |||
| Reasoning & rehabilitation programmes for verbal aggression and problem-solving in offenders with psychosis. | A43 | |||
| Cognitive remediation with a rehabilitation programme for social & cognitive functioning ¥ | A28 | |||
| Formulation‑based CBT for positive symptoms (greater effect for voices compared to delusions) ¥ | A19,20,24 | |||
| For negative symptoms - Social skills training ¥ + group psychotherapy ¥* | A24,30 | |||
| Group art psychotherapy | B46,49 | |||
| Music therapy | A47,48 | |||
| Mindfulness for positive & negative symptoms ¥ | A45, C44 | |||
| Worry‑reduction and sleep‑improvement CBT; progressive relaxation; relapse prevention training; yoga and distraction techniques | A38–42 | |||
| Early signs of monitoring | A50,51,52 |
¥ Interventions with small or very small effect sizes.
* The benefits appear equal across psychotherapies and attributable to nonspecific effects for which non-psychotherapeutic groups may be equally effective i.e., discussion or support groups.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild | Primary care | Low | Group treatment based on BT principles | A1, 6 |
| Exposure-based therapy (BT) | A4, 5 | |||
| Manualised self-guided therapy based on behaviour therapy (BT) principles | B2 | |||
| Supportive counselling | B4 | |||
| Moderate – Severe | Primary care | High | Disorder-specific CBT | A5, 9, 10 |
| EMDR | B3 | |||
| Emotion Freedom Technique (EFT) | B7 |
Mild
Manualised self-guided therapy has been tested with spider phobics, using a specific handout for use with spider phobia2.
Group treatment has again been tested in a number of small trials1, 6. Groups of 3/4 are recommended and format varies. Basing this on exposure treatments appears to be the most effective.
Supportive counselling (based on a dynamic and non-directive approach) has been tested and gained significant results in one trial4. The caution here is that many of the candidates could also have achieved forms of exposure during the treatment process.
Moderate/Severe
Variations on the method of administration are noted. Ost’s well studied 3 hour sessions appear to have a wide evidence base. His development of the applied tension technique8 has also been tested with good results and would be recommended for use as an adjunct with exposure for certain presentations of blood/injury phobia.
Cognitive restructuring within a CT or CBT format has also been tested with good outcomes, particularly with claustrophobia. The results vary, with one study suggesting no further impact beyond those of the exposure based model9, 10.
EMDR has been tested in case studies, one uncontrolled study and one controlled study3. The results of the latter were not significant. This form of treatment could be considered if there is a traumatic event associated with the phobia’s development, or the phobia is difficult to confront (e.g., flying, wasps, thunderstorms). There is a suggestion though, that other forms of imaginal exposure may perform just as well. EFT has been tested in one small RCT7 with significant outcomes controlled against a breathing technique. Although based on contested theoretical principles, this alone should not necessarily warrant its exclusion. Virtual reality guided phobia treatment has been well studied with some good outcomes. It does not appear in this guidance though, as the protocol is likely to be expensive compared to other treatments.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild | Opportunistic contact | Low | Opportunistic brief intervention (motivationally based) | A1, 2 |
| Mild–Moderate Cannabis with comorbid anxiety and/or depression Stimulants with comorbid anxiety and/or benzodiazepines with panic disorder |
Primary/Secondary care | High | CBT | A1, 2 |
| Group CBT + gradual tapering (10 weeks) | A1, 2 | |||
| Moderate – Severe | Community / Inpatient / Residential / Criminal Justice | High | Contingency management | A1, 2 |
| Behavioural couples therapy | A1, 2 | |||
| Moderate – Severe Stimulants with comorbid anxiety and/or depression |
Primary care / Community | High | CBT | A1, 2 |
Individuals with comorbid drug and/or alcohol misuse are often excluded from studies evaluating interventions for PTSD. There is some evidence to suggest that they can benefit from TFCBT but there is also increased risk of disengagement from treatment. There is a consensus that drug/alcohol misuse should be stabilised before trauma-focused treatment is offered.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Mild | Primary care | Low | Advice about the help and support available such as self-help groups and internet resources. | C31 |
| Medication should not be used as the sole or primary treatment for anorexia nervosa | C30,34 | |||
| Mild - Moderate | Secondary care / Specialist eating disorders services | High | CBT-enhanced (CBT-E) | A11,14,15 |
| Moderate - Severe | Secondary care / Specialist eating disorders services | High | Family interventions | A8,10,19,20,21,27,32,37 |
| Choice of psychological treatments for anorexia nervosa should be available as part of mental health services in all areas. These may include: CBT, IPT, psychodynamic therapy, CAT and motivational enhancement therapy (MET). | C30,31 |
Binge Eating Disorder (BED) is a disorder in which individuals engage in uncontrollable episodes of binge eating but do not use compensatory behaviours (National Institute for Health and Care Excellence)30.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence |
|---|---|---|---|---|
| Subclinical / Mild | Primary care | Low | Evidence-based self-help programme | A6,9,30,35,38 |
| Guided self-help | A3,29,33 | |||
| Internet based guided self-help | A1,12,13 | |||
| Moderate – Severe | Secondary care / Specialist eating disorders services | Low | Guided CBT self-help | A3,29,33 |
| Internet based guided self-help | A1,12,13 | |||
| High | CBT for binge eating disorder (CBT-BED) | A17,21,30 | ||
| Cognitive behavioural therapy enhanced (CBT-E) | A11,14,15 | |||
| IPT | A30 |
Bulimia is a severe form of eating disorder that can result in serious medical morbidity and a range of psychosocial comorbidities1,2. The impact of living with and caring for an individual who has bulimia can also be severe. For many people who have bulimia, the long-term course of the condition is chronic, with less than half of people with bulimia who seek treatment achieving full recovery3,4. Research indicates that the higher the frequency of binge eating and purging behaviours, the poorer the prognosis for recovery5,6. The prevalence of bulimia among women is 0.5% and 0.1% among men8.
There are many forms of behavioural presentations of bulimia. The condition is characterised by cycling patterns of restriction of food intake, followed by uncontrolled and distressing episodes of binge eating, followed by purging behaviours. Purging behaviours can include a range of compensatory behaviours, including voluntarily vomiting, use of laxatives and excessive exercise, or a combination of these behaviours by the same individual. There is also increasing awareness in clinical services, accompanied by increased need to provide appropriate care and treatment for individuals with Type 1 diabetes who restrict their insulin intake as a method of managing their weight. Detailed screening and assessment are therefore required in order to obtain an accurate profile of how each person is experiencing bulimia as presentations vary extensively. Sensitive and supportive assessment is crucial. Early intervention has been shown to improve outcomes and reduce the cost of treatment for bulimia8. The review of services for people with eating disorders by Welsh Government in 20189 included a recommendation that treatment for eating disorders should begin within four weeks of referral and within one week in urgent cases. All treatment for bulimia should be undertaken alongside clinically appropriate monitoring of the person’s physical health where the severity of their condition warrants this.
There are two forms of therapy that are consistently reported to be effective in the treatment of bulimia with high efficacy among children and young people. These are family-based treatments10 and models of CBT11 that are specifically tailored to address bulimia. The evidence indicates that these approaches are equally effective in the long-term for children and young people who have bulimia12. However, if there is a high level of conflict within the family, then a family-based approach is less likely to be helpful and in such circumstances, CBT is more effective13. There are a range of other therapies that are supported by evidence for their effectiveness, though less extensively than with family-based treatment and CBT. Dialectical behavioural therapy14 is supported by a limited amount of evidence for its effectiveness for bulimia, though no direct RCT has as yet been undertaken with children and young people with bulimia. Similarly, emotion-focused family therapy is supported by case reviews but has not yet been studied in a controlled manner. Psychodynamic therapy15 is supported for use with this population by evidence from a single RCT. These latter three therapies are therefore recommended in circumstances where family-based treatment and CBT are considered by the clinician to not be appropriate for the child or young person, are declined or they prove not to be effective.
Children and young people are often ambivalent about engaging in psychological treatment for bulimia and attempting therapeutic change. Clinicians should therefore assess, monitor and seek to improve motivation, where necessary, throughout the treatment process. Whereas evidence exists to support the delivery of motivation-focused therapy for adults with bulimia, evidence is not available for the delivery of such therapy with children and young people at this stage. It is important that the child and the family are fully supported throughout the process by eating disorders specialist staff and therefore, when a child is engaged in one-to-one therapy, their family should receive concurrent direct support from the eating disorders team16. Moreover, children and young people and their families should have access to peer support when needed17, which could be available through NHS Wales services or third sector organisations.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| All levels | Parts 1 & 2 | High | Family-based treatment for bulimia | A18,19,20,21,22 | High |
| A form of CBT that is specific to eating disorders (e.g., CBT‑E etc.) | A22 | High | |||
| If the above therapies are considered by the clinician to not be appropriate for the service user, are declined or prove not to be effective, then the following therapies should be considered: | |||||
| All levels | Parts 1 & 2 | High | Psychodynamic therapy | B15 | High |
| Emotion‑focused family therapy | C23 | Undocumented | |||
| Dialectical behavioural therapy‑informed | D22 | Undocumented | |||
A range of therapies have consistent support from the literature as being highly effective in addressing bulimia among adults. These are guided self-help (based on CBT specific to bulimia)24,25,26,27 models of CBT, specifically tailored to addressing bulimia24,25,26,28,29,30,31,32,33,34,35,36 and interpersonal psychotherapy24,31,37,38. Interpersonal psychotherapy should be available to service users, particularly where the condition is assessed to be a maladaptive interpersonal coping strategy as part of a psychological formulation. As the literature on the effectiveness of family-based treatment for bulimia that has been previously cited extends to late adolescence, this therapy approach is included as a recommendation for adult services to make available for the young adults on their caseloads. This is particularly relevant when they are transitioning from children’s services and have successfully engaged with that treatment approach under children’s services. In addition, virtual-reality based cue exposure intervention is supported by RCT evidence as effective in addressing any residual episodes of binge eating at the conclusion of an episode of psychological therapy. In circumstances where these therapies are considered by the clinician not to be appropriate for the service user, are declined by the service user or prove not to be effective, then a range of other therapies can be considered. For instance, motivation-focused therapy is supported by a range of RCTs. Both integrated cognitive affective therapy and a mindfulness-based modified form of dialectical behavioural therapy are supported by evidence of high efficacy, though only from a small number of RCTs. Currently, compassion-focused therapy is supported by a series of case studies and an uncontrolled trial and psychodynamic therapy has a number of RCTs indicating its effectiveness, though estimates of its effectiveness is slightly less than that reported for CBT and interpersonal therapy.
Based on the evidence for the effectiveness of guided self-help for bulimia, services sometimes recommend self-help books based on a cognitive behavioural model. Whilst service users often value reading recommendations and report anecdotally that this has been beneficial, clinicians should be aware that there is little research into this unguided approach to self-help for bulimia. Service users should also have access to peer support based on emerging evidence of peer mentorship as an effective adjunctive intervention39 for people with bulimia. Such peer support could be available through NHS Wales services or third sector organisations.
| Level of Severity | Level of Service | Intensity of Intervention | What Intervention? | Level of Evidence | Level of Efficacy |
|---|---|---|---|---|---|
| All levels | Parts 1 & 2 | Low | Guided self-help based on a form of CBT that is specific to bulimia | A24,25,26,27 | High |
| High | A form of CBT that is specific to bulimia (e.g., CBT‑E; CBT‑T etc.) | A24,25,26,28,29,30,31,32,33,34,35,36,40,41 | High | ||
| Interpersonal psychotherapy | A24,31,37,38 | High | |||
| Family‑based treatment | A18,19,20,21,22 | High | |||
| Virtual‑reality based cue exposure for residual symptoms following completion of other therapy | B42,43 | High | |||
| If the above therapies are considered unsuitable, are declined, or prove ineffective, the following therapies should be considered: | |||||
| All levels | Parts 1 & 2 | High | Motivation‑focused therapy | B44,45,46 | High |
| Integrated cognitive affective therapy | B47 | High | |||
| Mindfulness‑based dialectical behavioural therapy | A14 | High | |||
| Psychodynamic therapy | A48 | Medium‑High | |||
| Compassion‑focused therapy | C49,50 | Undocumented | |||
Guidelines for Specific Service User Groups
There are a number of issues relating to comorbidities that need to be considered in the delivery of psychological therapies for bulimia, as follows:
When working with service users from black and minority ethnic communities, consideration should be given to including their family members in any psychological therapy that is being undertaken54,55,56,57,58. Clinicians delivering psychological therapies may also need to consider making adaptations to the treatment that take account of any relevant cultural and/or religious practices that relate to food and/or eating patterns. There is no evidence available regarding the effectiveness of the various psychological therapies cited in these recommendations for males, older adults or adults with learning disabilities, or whether the effectiveness of the therapies is influenced by sexual orientation or gender identity.
Guidelines for the Delivery of Psychological Therapies
Delivery of the psychological therapies outlined in these recommendations needs to take account of the following principles:
Social Anxiety Disorder (2017)
The Social Phobia Inventory (SPIN)8 assesses severity of social phobia and the Work and Social Adjustment Scale (WSAS)20 can help to assess the impact of social phobia on functioning.
Evidence Table
N.B. Group CBT is significantly less effective than individual CBT and is not clinically or cost‑effective.
There is no Cochrane Review for social anxiety disorder. There have been two recent and significant meta-analyses, one commissioned by The National Collaborating Centre for Mental Health (NCCMH) and published in 201321 and one by Mayo-Wilson et al. published in The Lancet in 201419. The recommendations in the table above are largely based on these two reviews. Individual CBT is the only psychological treatment that is better than a placebo control19 and therefore no others are included in this evidence table.
References