SummaryBackgroundInternationally, the clinical outcomes of routine mental health services are rarely recorded or reported; however, an exception is the English Improving Access to Psychological Therapies (IAPT) service, which delivers psychological therapies recommended by the National Institute for Health and Care Excellence for depression and anxiety disorders to more than 537 000 patients in the UK each year. A session-by-session outcome monitoring system ensures that IAPT obtains symptom scores before and after treatment for 98% of patients. Service outcomes can then be reported, along with contextual information, on public websites.MethodsWe used publicly available data to identify predictors of variability in clinical performance. Using β regression models, we analysed the outcome data released by National Health Service Digital and Public Health England for the 2014–15 financial year (April 1, 2014, to March 31, 2015) and developed a predictive model of reliable improvement and reliable recovery. We then tested whether these predictors were also associated with changes in service outcome between 2014–15 and 2015–16.FindingsFive service organisation features predicted clinical outcomes in 2014–15. Percentage of cases with a problem descriptor, number of treatment sessions, and percentage of referrals treated were positively associated with outcome. The time waited to start treatment and percentage of appointments missed were negatively associated with outcome. Additive odd ratios suggest that moving from the lowest to highest level on an organisational factor could improve service outcomes by 11–42%, dependent on the factor. Consistent with a causal model, most organisational factors also predicted between-year changes in outcome, together accounting for 33% of variance in reliable improvement and 22% for reliable recovery. Social deprivation was negatively associated with some outcomes, but the effect was partly mitigated by the organisational factors.InterpretationTraditionally, efforts to improve mental health outcomes have largely focused on the development of new and more effective treatments. Our analyses show that the way psychological therapy services are implemented could be similarly important. Mental health services elsewhere in the UK and in other countries might benefit from adopting IAPT's approach to recording and publicly reporting clinical outcomes.FundingWellcome Trust.

BackgroundRandomised controlled trials have established that face-to-face cognitive therapy for posttraumatic stress disorder (CT-PTSD) based on Ehlers and Clark's cognitive model of PTSD is highly effective and feasible with low rates of dropout. Access to evidence-based psychological treatments for PTSD is insufficient. Several studies have shown that therapist-assisted treatment delivery over the Internet is a promising way of improving access to cognitive behavioural therapy interventions.ObjectiveTo develop an Internet version of CT-PTSD that significantly reduces therapist contact time without compromising treatment integrity or retention rates.MethodsWe describe the development of an Internet version of CT-PTSD. It implements all the key procedures of face-to-face CT-PTSD, including techniques that focus on the trauma memory, such as memory updating, stimulus discrimination and revisiting the trauma site, as well as restructuring individually relevant appraisals relating to overgeneralisation of danger, guilt, shame or anger, behavioural experiments and planning activities to reclaim quality of life. A cohort of 10 patients meeting DSM-IV criteria for PTSD worked through the programme, with remote guidance from a therapist, and they were assessed at pre- and post-treatment on PTSD outcome, mood, work and social adjustment and process measures.ResultsNo patients dropped out. Therapists facilitated the treatment with 192 min of contact time per patient, plus 57 min for reviewing the patient's progress and messages. Internet-delivered CT-PTSD was associated with very large improvements on all outcome and process measures, with 80% of patients achieving clinically significant change and remission from PTSD.ConclusionsInternet-delivered cognitive therapy for PTSD (iCT-PTSD) appears to be an acceptable and efficacious treatment. Therapist time was reduced to less than 25% of time in face-to-face CT-PTSD. Randomised controlled trials are required to evaluate systematically the acceptability and efficacy of iCT-PTSD.Highlights of the articleiCT-PTSD was acceptable to patients and associated with very large improvements on PTSD outcome and process measures.iCT-PTSD required substantially less therapist time than CT-PTSD.iCT-PTSD may be associated with changes in employment status.Randomised controlled trials are required to systematically evaluate the acceptability and efficacy of iCT-PTSD.

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Patients with Social Anxiety Disorder (SAD) often report elevated levels of self-focussed evaluative attention (SFEA), and seem excessively concerned with being observed by others. This study tested whether SFEA increases the perception of being observed by others. A sample of 52 high and 52 low socially anxious participants estimated the percentage of people 'looking at you' in several matrices of faces. A control task used matrices of clocks. SFEA was manipulated. As predicted, increasing SFEA led to significantly higher estimates of people 'looking at you' in both groups. Estimates on the control task were not affected by SFEA, thus the effects appear specific to social stimuli. These findings suggest that the increased levels of SFEA that characterise patients with SAD could contribute to their enhanced perception of being observed by others. The findings have implications for the role of attention training in the treatment of SAD.