Psychology Department, Institute of Psychiatry
Greenwich University
Health Services Research Department, Institute of Psychiatry
Psychology Department, Institute of Psychiatry, London,UK
Correspondence: Dr June Brown, Psychology Department (PO77), Institute of Psychiatry, De Crespigny Park, London SE5 8AF, UK. Tel: 020 7848 5004; fax: 020 7919 2473; e-mail: June.Brown{at}iop.kcl.ac.uk
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ABSTRACT |
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Aims To examine the effectiveness of a psycho-educational intervention designed to be easily accessible.
Method Large-scale, self-referral How to improve your self-confidence workshops were run in a leisure centre at weekends. The day-long programme used a cognitivebehavioural approach. A randomised controlled trial design using waiting-list controls was employed. Three months after the workshop, results of workshop participants were compared with those of the waiting list control group.
Results Among 120 people who self-referred, 75% of participants had General Health Questionnaire scores of 3 and above. Over 39% had never previously consulted their general practitioners about their depression. At 3-month follow-up, members of the experimental group were significantly less depressed, less distressed and reported higher self-esteem.
Conclusions Workshops were shown to be accessible and effective; a larger, more rigorous trialis now needed.
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INTRODUCTION |
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METHOD |
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The workshops were free and took place on a Sunday to reduce the possibility of work or domestic arrangements affecting attendance. To reduce the possibility of stigmatisation, and consequent reluctance to seek help (Hayward & Bright, 1997), they were held in a leisure centre rather than a mental health care setting. The workshops began in October 2001. All individuals who enquired were invited to an introductory talk which gave further information about the workshop process and an opportunity to participate in the study.
Up to 25 people could attend each of the workshops, which were run by two clinical psychologists and two assistant psychologists. The programme started at 09.30 h and finished at 16.30 h, with refreshment breaks. The workshops used cognitive-behavioural techniques adapted into an educational programme based on previous workshop programmes and on Fennells book Overcoming Low Self-esteem (Fennel, 1999). The main aim of the programme was to help participants understand problems of low self-confidence and to teach them techniques of improving their self-confidence and self-esteem.
The days programme was structured into four sessions. In the first session, information was given about the development of low self-confidence and its emotional aspects, including depression. The second session consisted of cognitive aspects of low self-confidence, specifically identifying and challenging negative thoughts. Behavioural methods for improving low self-confidence, including problem-solving and assertiveness, were taught in the third session. The final session was devoted to action planning, with participants setting their own homework targets to start improving their confidence. To reduce the possibility of participants becoming bored or tired, training methods were varied and included didactic sections, large-group exercises, role-play demonstrations and discussions of vignettes of people with low self-confidence.
Three months after each workshop, a 2 h follow-up meeting was organised for participants to complete the self-assessment forms, report on their progress and discuss any problems.
Study design
A randomised controlled trial design was used to evaluate the efficacy of
the self-confidence workshops. The 3-month outcomes of people attending a
workshop were compared with those of a control group waiting to attend one.
The design can be summarised as two group x two time periods with
repeated measures on the time variable. It was predicted that the workshops
would lead to lower depression and increased self-esteem among workshop
participants compared with the people on the waiting list. In addition, it was
predicted that self-confidence workshops would be more likely than the
Coping with depression workshops
(Watkins et al, 2000)
to attract people who had depressive problems but who might not have consulted
their general practitioner. This hypothesis was tested using specific items in
the initial questionnaire given to all participants. One question was
Have you ever seen your GP about your depression? A similar
question was asked in relation to anxiety.
Procedure
Consent and baseline data were collected at the introductory talk.
Participants were each given a unique identifier and were randomly allocated,
using computerised random numbers, to experimental and control groups. A
research worker who was not part of the clinical team carried out the
randomisation process and informed participants by post of the workshop to
which they had been allocated. The experimental workshops took place 2-3 weeks
after the introductory talks, and the control workshops took place after 3
months. Participants in the experimental group completed assessments at the
introductory talks and at 3-month follow-up. Those who did not attend the
follow-up meeting were sent the assessment forms and asked to return them in
pre-addressed envelopes. Control participants were asked to complete
assessments at the introductory talk and again 3 months later, during a
half-hour period immediately before the start of their workshop. Two
experimental and two control workshops were run. Each participant attended
only one workshop.
Measures
Socio-demographic details and information about past contact with
psychiatric and primary care services were recorded on the initial self-report
questionnaire. Outcome variables were:
Analyses
Data were analysed using a two-way analysis of variance with repeated
measures. A power calculation using a two-tailed significance level of 0.05 to
achieve 80% power in a two-group comparison indicated that a sample size of 64
in each group is needed for a medium effect size of 0.5. Categorical data were
analysed using the chi-squared test.
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RESULTS |
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Demographic details
Compared with the general population in the area, those who attended the
introductory talks were much more likely to be female (83%), aged 35-44 years
(35%) and single (46%). They were, however, reasonably representative in
employment status (58% employed, 14% unemployed and 31% unoccupied, e.g.
retired or studying) and ethnic origin (61% White, 22% Black and 5% Asian).
Occupational classes II (28%) and III (non-manual) (36%) were overrepresented;
class IV (8%) was representative of the local population; and classes I (2%),
III (manual) (7%), V (1%) and the unoccupied category (19%) were
underrepresented.
Previous treatment
Data on previous consultation for depression were missing for 8
participants. Of the remaining 112 participants, 44 (39%) had never consulted
their general practitioner about their depression and 72 (64%) had not done so
in the previous 3 months. This contrasts with 90.2% (37 out of a total of 41
participants) who had already consulted their general practitioner when they
referred themselves to the Coping with depression workshops
(Watkins et al,
2000). Thus it appears that changing the title of the workshop
from Depression to Self-confidence attracted more
people who had not sought medical help.
Severity of problems
Three-quarters of the 120 participants had GHQ-12 scores of 3 or above.
Depressive problems were most commonly reported as recurrent (58%) and lasting
over 5 years (41%). Categorised by BDI score, 31% (n=37) had mild
depression, 37% (n=44) had moderate/severe depression and 18%
(n=21) had extremely severe depression. Of the 15% (n=18)
who scored below 10 and did not have current depression, almost half
(n=8) said that they had experienced recurrent anxiety problems for
over a year and more than a quarter (n=5) said they had had
depressive problems for over 5 years.
Severity of problems and consultation for depression
A further analysis of the 112 participants for whom data were available
showed that those who had consulted their general practitioner had
significantly higher GHQ-12 scores (mean 7.5) compared with those who had not
consulted (mean 5.16; t=2.99, d.f.=110, P<0.01). Of the
39% (n=44) of participants who had not previously consulted their
general practitioner, 70 (n=31) had current depression, with a mean
BDI score of 20.26. The 13 participants who scored below 10 on the BDI (mean
5.23) and who had not consulted appeared to have some anxiety problems, as
they had a mean score of 39.23 on the STAI-T scale.
Table 1 shows an analysis of
consultation according to the severity of depression.
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Evaluation of intervention
The experimental and control groups did not differ in background
socio-demographic details or scores at baseline.
Table 2 shows the baseline and
outcome scores for the 79 participants who completed the 3-month assessment,
and the results of the analyses, which showed significantly superior outcomes
on the BDI, GHQ-12 and RSES for the experimental group, as indicated by group
x time interactions. No other group x time interaction was
significant. Changes in BDI score of at least 10 points were used to indicate
clinically significant improvement, and by this criterion 45% of the
experimental group improved compared with 8% of the control group
(2=14.1, d.f.=1, P<0.001).
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Given the attrition rate, an intention-to-treat analysis was carried out (Table 3). This used scores from the introductory talks for non-attenders in the experimental and control groups at the 3-month stage, assuming no change for these individuals. The results from this analysis also showed significantly superior outcomes on the BDI, GHQ-12 and RSES for the experimental group, as indicated by group x time interactions.
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DISCUSSION |
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Methodological considerations
This is a small preliminary study and is underpowered. In addition,
attrition rates were higher than desirable. Much of the attrition occurred
between the introductory talks and the workshops, with 27% of the experimental
group and 35% of the control group not attending. Although the 3-month wait
could explain the attrition rate in the control group, it is not clear why
over a quarter of the experimental group said they would like to attend a
workshop but did not do so. This issue is being currently investigated in a
separate study. However, no difference was found between the baseline scores
of those who did not attend and those who did. Intention-to-treat analyses
also supported the effectiveness findings.
Effectiveness
The self-confidence workshops led to statistically significant reductions
in depression and distress as well as improvements in self-esteem. Although
the controlled effect size on the BDI score was small at 0.28 and the clinical
significance quite modest, this was in part at least likely to be due to the
broad range of scores of the workshop participants. When those with initial
BDI scores of less than 14 were excluded, the controlled effect size increased
to 0.46. The slightly lower, albeit not significantly different, initial
scores of the control group participants who were followed up might also have
contributed to this result. Further developments of the workshop programme can
be expected to improve its effectiveness.
Recruitment to workshops
These workshops appeared to support the prediction that the change of title
from Depression to Self-confidence would help
reach the rather elusive group of people with depression who do not seek
medical help. Of the people who attended the introductory talks for whom we
had information about previous consultation, 39% had never previously
consulted about their depressive problems but nevertheless referred themselves
to these workshops and the majority of them (70%) scored above 10 on the BDI.
The other 30% had not consulted their general practitioner, scored below this
threshold but none the less wished to self-refer, perhaps because they had
experienced previously unresolved anxiety and/or depressive problems in the
past. Finally, over 94% of those who had previously consulted their general
practitioner about their depression scored above the threshold but presumably
wanted something more by self-referring.
Given the problems of offering effective treatment to people, this is an important finding, as this route might overcome the reluctance to seek help for depression evinced in the general public and therefore help meet this unmet need. The problem of reluctance is common both in the UK (Bebbington et al, 1997, 1999) and in Europe, where 43% of those diagnosed with depression failed to seek treatment for their problems (Lepine et al, 1997). A major public education campaign in the UK (Paykel et al, 1998) left people unconvinced, with 62% admitting they would still be reluctant to consult their general practitioner about their depression for fear of embarrassment and 47% for fear of being judged to be unbalanced or neurotic.
Three-quarters of those who self-referred were identified as probable cases on the GHQ-12, indicating that those self-referring were not just a group of the worried well. These workshops also appeared to attract a population reasonably representative of the local community in terms of ethnicity, employment status and, to a large extent, occupational class. These results have also been found in a more detailed analysis (further details available from the authors on request), which further showed that workshop participants generally had significant mental health problems.
Implications
The results support the hypothesis that this brief, large-scale, day-long
psychological intervention can lead to statistically significant improvements
in depression, although the attrition rates are higher than desirable and the
effect size is relatively small. There was also a statistically significant
reduction in distress and improvement in self-esteem with a tendency for
associated improvements in anxiety. This approach could consequently have the
potential to help address the problem of limited capacity for psychological
treatments.
A larger, more rigorous randomised controlled trial is required to confirm the preliminary indication of effectiveness and potential cost-effectiveness. If these are confirmed, this large-capacity intervention might well have the potential to help meet the challenge of reducing the prevalence of this important health problem.
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Clinical Implications and Limitations |
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LIMITATIONS
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ACKNOWLEDGMENTS |
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REFERENCES |
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Paykel, E. S., Hart, D. & Priest, R. G. (1998) Changes in public attitudes to depression during the Defeat Depression Campaign. British Journal of Psychiatry, 173, 519 -522.[Abstract]
Rosenberg, M. (1965) Society and the Adolescent Self-image. Princeton, NJ: Princeton University Press.
Spielberger, C., Gorsuch, R. & Lushens, R. (1970) Manual for the StateTrait Anxiety Inventory. Oxford: Oxford University Press.
Watkins, E., Elliott, S., Stanhope, N., et al (2000) Meeting the needs for psychological treatment of people with common mental disorders: an exploratory study. Journal of Mental Health, 9, 445 -456.
World Health Organization (2001) The World Health Report 2001. Geneva: WHO (http://www.who.int/whr/2001/en/contents.htm).
Received for publication January 12, 2004. Revision received August 10, 2004. Accepted for publication August 11, 2004.
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