Workshop on Well-Being VI

Yesterday I attended the sixth and final of the series of “Workshops on Well-being” taking place at the LSE (I missed the fifth workshop as I was away and so the last one I attended was the fourth workshop back in April). This time the presentations were given by David Clark of KCL and Martin Knapp of LSE and KCL. Below are some heavily impressionistic notes.

Presentation by David Clark (KCL): Developing Effective Psychological Treatments for Common Mental Health Problems

1. Anxiety disorders

   • ~ 1/2 of mental health problems
   • overly pessimistic view on outcomes etc
   • can become obsessional (+ fear that thoughts are self-realizing)
   • If beliefs are inconsistent why do they persist
   • panic attacks (~ 30% have them once/v. occasionally but realize that they are not dying). But in the disorder people might have had them 5000 times — how can they still think they are dying when it happens again?

2. Research Strategy:

   • identify core cog. abnormality
   • …

3. Example: social phobia

   • most common anxiety disorder (lifetime prevalence: 12%)
   • persistent: natural recovery rate is 37% over 12 years
   • marked underachievement
   • persists because:
   • shift to internal focus (which means ignore external)
   • use of internal information to infer how one appears to others (and as they are anxious this unreliable)
   • safety behaviour
   • test some of this
   • Do high socially anxious individuals have an internal attentional bias (Mansell, Clark, Ehlers 2003)
   • Evidence that socially anxious individuals have a distorted external perspective (Hackmann, Surawy and Clark 1999)
   • Evidence that onset of phobia correlated some stressful (bad) social event
   • Does negative self-image affect relation with others. Yes, to some extent (another Clark paper)
   • treatment (Cognitive Therapy)
   • attention training
   • drop safety behaviours (to test no adverse consequences)
   • video feedback
   • rescripting early memories
   • does CT pass the randomized controlled trial: YES
   • compare against no treatment
   • placebo
   • at least as effective as medication

4. Common disorders where CBT is effective as a sole treatment (recovery rate, controlled effect size):

   • Major depressive disorder: 50%, -
   • Panic disorder 75%, 2.8
   • PTSD: 80%, 2.3/1.2
   • Social phobia: 75% 2.6
   • Generalized anxiety disorder: 50% (77%)
   • OCD: 45%, 1.5
   • Also show that effects of CBT persist for anxiety (unlike psychotropic interventions where there is a high relapse rate)
   • depression slightly different as naturally recurrent — though CBT still effective (and complementary to medication). Hollon et al (2005) (Arch Gen Psychiat) compare medication vs CBT over long-term and shows CBT better.

5. Evidence that benefits of CBT extend outside of targeted syndrome. Beneficial effects for:

   • other mental health problems
   • work, family, social adjustment
   • employment (less sick days, moving to work)
   • but these effect sizes are lower bound (overall want SWB scores …)

6. Developing more effective (shorter) treatments

   • Traditional approach is 1h/w for 3-4 months
   • but 1-2h of ‘homework’ per day between visits
   • Now trying intensive 1w course (~ as effective at least for PTSD)
   • Also treatments with extra-focus (e.g. social phobia + work: found big impact on time to get back to work)
   • CBT with well-being emphasis. Fava et al (2005) (Psychotherapy and Psychomatics). Find CBT-WB > CBT but tiny sample, no blind assessment etc.

7. Major policy changes underway to increase access to CBT

Martin Knapp (LSE + KCL): Economics of Mental Health: Some Open Research Questions

1. Why mental health is different

   • breadth/multiplicity of need
   • association with crime + violence
   • associated with suicide
   • compulsion, stigma, complex links with ethnicity

2. Leading policy/practice themes

   1. stigma/rights/social exclusion
   2. funding
   3. Balance of Care
   4. Treatments
   5. Prevention

3. Social exclusion, stigma, etc

   • Participation-based approach
   • opportunities, socio-economics roles
   • Rights-based approach
   • stigma, discrimination, compulsory treatment
   • If i were suffering from mental health problems I don’t want anyone to know (Scotland): 50% in 2002 to 41% in 2006 (following a big campaign)
   • evidence in UK actually may be getting worse (16% 2000 to 22% in 2007 on similar question)
   • Equity: great variations (inequality greater for mental health than for income), esp by ethnicity.
   • Costs:
   • total cost of depression £9 billion (Thomas and Morris, Brit J Psychiatry 2003)
     • mostly productivity effects (not service or morbidity)
     • prob. underestimate as also have staff turnover, presenteeism
   • major impact of psychosis on life-time development [ed: not exactly surprising ...]
   • homicide: Taylor and Gunn (Brit J Psychiatry) show that across various European countries between 5 and 20% or homicides committed by those who are mentally ill

4. Funding

   • Mental health spend as %tage of total public spend: England is highest in EU [ed: is this good or just that England has a lot of mental health issues]
   • Good efficiency arguments for intervening (cost-effective)
   • Schizophrenia: total cost ~ £54k per person per year (only a 1/3 hits the health system)

5. Balance of Care

   • Massive reduction in number psychiatric beds (personal preferences, social preferences etc)

6. Treatments

   • Does it work?
   • Is it cost-effective? etc
   • In 2000 only 53% of people with depression received treatment compatible with NICE guidelines
   • More attention to non-health interventions
   • particularly risk factors such as bullying, family violence, uncontrolled debt

7. Prevention

   • Inner London Longitudinal Study (ILLS)
   • Study of all 10y old in part of London in 1970
   • Categorise into groups from: “no problems at school” to “conduct disorder”
   • Estimate costs to society per child from 10 to 28 (education, criminal justice, social services etc)
     • no problems: ~ 7k, conduct: ~ 24k, conduct disorder: ~70k (mostly criminal justice)
   • 1970 British Cohort Study
   • earnings at age 30 by childhood need at age 10
   • no probs: ~24k, behavioural (lowest quartile): same, Cognitive (lowest quartile): 15k, emotional (not a great effect but interacts in a minor way with cognitive). Another study finds same effects for behavioural at age 32 but extended to 48 finds same -ve effect of cognitive issues.