In Collections, health and social care staff and service users tell us what research is important to them and why they feel others need to know about it.
In this collection, we asked nine mental health practitioners and members of the public to tell us which Alerts have interested them most.
A former journalist and PR consultant, Michelle now pours her creative energy into bringing up two young sons. Life is always busy and slightly chaotic, but she wouldn’t change a thing.
Michelle struggles with depression and gets help through medication and counselling, both of which have been very beneficial and make the difficult days easier.
One type of drug for depression during pregnancy may be linked to a small increase in pre-term births
This Alert jumped out to me as both my sons were born pre-term and I was taking SSRI’s (selective serotonin reuptake inhibitors) throughout the pregnancies. The results of the research are not clear or conclusive enough to say women should not take SSRI’s during pregnancy and this needs to be made clear to pregnant women suffering depression, but it does add new insights into the possible outcome.
I think more research in this area is essential as women want to make the safest, best choices for themselves and their babies, but to do this we need to weigh up the risks involved. I I thought long and hard about whether I should continue with the SSRI’s during pregnancy, but without strong evidence to the contrary, I decided the risk of severe depression recurring outweighed what I knew about risks to the baby.
Psychological therapies may improve parenting skills in parents of children with chronic illness
My kids are currently being investigated for various chronic conditions which have caused a range of problems over the years from poor growth to feeding issues, fatigue and gross motor delays. This has put a strain on our family and it would be helpful if more health professionals (including GP’s) recognised that some parents may be struggling with these medical pressures, in addition to everyday parenting.
For those already dealing with depression, challenges like this can make things even harder and you can be left feeling like you are not the parent you would like to be. I think recognising the psychological needs of parents in these situations would help the whole family.
A fifth of people, who have no improvement on antidepressants at four weeks, respond if given more time
I found this research very interesting as I’ve always been told that it takes 6-8 weeks for antidepressants to take full effect and your body needs to get used to the medication. It seems that four weeks is not enough time for patients to know if the medication is helping, so of course they are more likely to respond if given more time.
The other thing to consider is that most of these medications cause a range of side effects and by chopping and changing medications too quickly, your body does not have a chance to adjust to the side effects and it becomes very difficult to distinguish what problems are being caused by which medication, or if it is even helping.
Dr. Thomas Richardson
Tom is a Clinical Psychologist working in a community mental health team for adults at Solent NHS Trust. He is an active researcher and has published on psychological therapies for Bipolar disorder and the impact of financial difficulties on depression. He is also a former service user with lived experience of Bipolar Disorder. Tom is passionate about combining high-quality research with a clinician’s opinion and patient preference to help deliver evidence-based treatment for those with mental health problems. He believes research can be hard to read and apply to practice which is why he feels NIHR Alerts are important to make research concise and easily accessible.
Antidepressants and talking therapies offer similar benefits for new-onset major depression
I have experienced depression and know how challenging it can be. I use CBT in my work with those with severe depression. CBT has become much more accessible thanks to the Adult Improving Access to Psychological Therapies Programme (IAPT), however the number of antidepressants prescriptions has been increasing with more than 70 million prescriptions in the NHS last year. This Alert is important because the study it looked at conducted a meta-analysis on how antidepressants are compared to CBT for those with a recent depression diagnosis – it found that they were equally effective. I know lots of people find medication helpful, but I hope that this paper helps patients and clinicians consider CBT when they first experience depression.
Mindfulness therapy may provide an alternative to continuing antidepressants in preventing recurrence of depression
The first Alert I looked at showed that CBT is as effective as antidepressants in a first episode of depression. This Alert adds to this that psychological therapies are as effective as antidepressants in preventing depressive relapse. This is really key: sadly some people are very prone to relapse in depression which can often be triggered by difficult life events such as money, work, health or relationship problems. The therapy examined here is mindfulness-based which I use a lot in my clinical practice, as well as personally to help my mood deteriorating. Many of my clients find mindfulness helps them to identify early warning signs for depression and stop their mood spiralling down, and I am glad that this Alert adds some evidence to how helpful this can be in long-term management.
Guided online interventions can help people recover from depression
This Alert follows on from the above papers: Psychological therapies are effective but often hard to come by. IAPT has of course much improved the situation, but availability and waiting times can vary depending on where you live. I have had long been interested in computer-based therapies and have myself found these helpful. What is really important about the meta-analysis from the study in this Alert is that it looked at how many people have a clinically meaningful improvement in their symptoms. It was also food for thought for me that age and ethnicity appear to impact outcomes, so though it can really increase access, it might not be for everyone.
Dr Sarah Markham
Sarah is a mental health service user and an academic mathematician with a keen interest in promoting research and its translation into meaningful healthcare treatments, techniques and therapies.
Supported employment helps people with severe mental illness to obtain work
As someone who struggles with depression I am only too aware of the value of behavioural activation and meaningful activity to distract me from the worst of my symptoms and give me a sense of achievement and self-worth.
I, like many others in my position would love the diversion and financial security that comes with regular employment. This NIHR Alert reports that supported employment increases the chances of obtaining a job and seems most effective when augmented used in addition with other interventions such as social or cognitive skills training. This is a very important finding for anyone with a long-term mental disorder aspiring to (re)enter the workforce.
Better evaluation of physical health services for people with severe mental illness is needed
As a long-term sufferer of treatment-resistant depression I have come to rely on exercise - mainly walking and running to get me through the worst of times (and celebrate the best of times). Exercise seems to reach the parts of the human brain that other interventions can only hope to touch. This NIHR Alert highlights that there are currently no clear solutions to integrated physical health care for people with serious mental illness. This is a huge gap in the research literature and I hope this Alert will serve to prompt academics and clinicians alike to resolve this sad situation.
Education and support groups help carers of people with severe mental illness
This NIHR Alert highlights a dearth in research into how to support and educate carers in their roles. It has been found that psychoeducation and support group-style interventions delivered by health and social care services lead to improvements in carer outcomes such as how positively they rated their experience of caregiving.
However, more research is needed to improve the situation of carers and consequentially the ones they care for. The Alert also reinforces the economic significance of supporting carers. Without the sustained assistance of informal carers, community care for severe mental illness can be unaffordable if not downright impractical. An important case for further research well made.
Della was diagnosed with breast cancer in 2010 and now works as a patient representative at the Royal Marsden and Cancer Research UK. Della acts an independent trainer, facilitator and
mentor to patients and their families affected by cancer. Della also helped coproduce a living with and beyond cancer programme focusing on the impact of depression after cancer treatment.
Aerobic exercise is an effective treatment for depression
I can relate to this Alert as I suffered depression after my cancer diagnosis in 2010. I didn’t get a quick referral to talk about my depression and I was told I had a very high BMI which knocked my confidence and obesity so I experienced severe depression. However, I was also reluctant to ask for help because of the stigma around mental health, especially in the Black and Asian Ethnic Minority community.
I was offered a few sessions of counselling by the Macmillan psychologist at St George’s hospital and I plucked up the courage to join the gym to help motivate me and improve my mental health and balance my well–being.I joined the gym two years ago now and I remember my friend telling me “Please do not go down that dark part again [depression] we were unable to contact you.”
My moral is more positive now and my outlook on life in general is very positive as a result of doing exercise. I do aqua aerobics, Zumba and Pilates and I am a happier person. I am also able to support people by advocating exercise and I enjoy my sessions at the gym where I promote fighting cancer with fitness.
Anya has used mental services for a number of years having lived with depression and anxiety for over 10 years. Anya has been involved in service user groups contributing to the research process and is interested in research into depression. She feels that health research conducted with the involvement of service users is more rich and informed than that which excludes it. She would like to see greater diversity of perspective in mental health research.
Online CBT is no more effective than usual GP care for people with depression
I found the results of this study fascinating. I was offered an online Cognitive Behavioural Therapy (CBT) programme by my GP so I can relate to the findings that people typically signed up, completed one or two sessions and then did not participate further. The nature of some symptoms of depression can make it very hard to feel and stay motivated to do things. Trying to engage with a computer programme with no face-to-face support encouraging and helping you understand what you are doing can be a challenge. So the results of the study are not that surprising.
It would be interesting to know what the ‘treatment as usual’ group experienced as usual care as this could vary widely, and also to have explored qualitatively why people couldn’t engage for the entire programme. The findings are important to consider in the context of emerging digital technologies and their presence in the NHS Mental Health Long Term Plan. Understanding who might engage and benefit from online CBT is key to its future development and implementation.
Johnny is an experienced family physician with a history of working in the primary and health care industry. He is an Associate Dean GP Education in Wessex, Honorary Professor at the University of Winchester and an active medical education researcher. He also works as an International Development Advisor for MRCGP[INT] for Kosovo and facilitator for primary care physicians in Kuwait.
The most effective antidepressants for adults revealed in major review
This Alert revealed that several drugs were more effective and stopped by fewer people than others - Escitalopram, Paroxetine, Sertraline, Agomelatine and Mirtazapine.
Reboxetine, Trazadone and Fluvoxamine were found to have lower effectiveness and higher drop-out rates. There was no comparison between medication and other therapies – psychological or exercise.
This gives me a clear steer on first line SSRIs, a decision that in the past has usually been made by local guidelines, cost, personal anecdote and familiarity. It also includes Agomelatine, which is not routinely used as an antidepressant first line in primary care but as one of the most effective it may encourage me and other GPs to become more familiar with its use (perhaps for use when resistant to the other medications), understanding i’s considerably more expensive that the others.
Social exclusion heightens risk of death across many health conditions
Socially excluded men have a mortality rate that is nearly eight times higher than the average for other men, and almost 12 times higher than for excluded women. These health inequities in outcomes exist across a wide range of health conditions, particularly in infectious diseases and mental health. This Alert brings robust evidence of the scale of the effect of social exclusion.
Deaths due to poisoning, injury and other external causes were eight times higher in socially excluded men and 19 times higher in women. The research is directly applicable to the UK and the NHS and provides strong evidence for health inequality in socially excluded people.
Unless working within a homeless/vulnerable person health unit or as a prison services doctor, most GPs consult with this patient group on an irregular basis but this Alert brings to the forefront of our minds, the decreased health outcomes for patients who are socially excluded, so that we can attempt to redress the enormous health inequality they encounter.
Antidepressants do not help treat depression in people living with dementia
Over prescribing for the elderly is a common issue and one of the prime aims in the care of older people is to de-prescribe unnecessary medications. This Alert looked at a study that compared antidepressants with placebo for the treatment of depression in patients with established dementia. This review supported NICE guidelines, which state that antidepressants should not be routinely offered unless they are indicated for a pre-existing severe mental health problem.
This Alert is useful as it showed no difference between the antidepressant and placebo groups after 6 weeks.. Patients on antidepressants were no more likely to be able to carry out daily living tasks but were more likely to suffer from at least one adverse event. There was not enough evidence to draw conclusions about specific antidepressants or different types of dementia.
I see patients with dementia during practice and changes in mood are commonplace. Intervention is often reactive and a trial of antidepressant started as a result of the history and mental state examination. Once prescribed, the medication is continued rather than a reassessment made. This Alert will give impetus for clinicians (including GPs, clinical pharmacists and CPNs) to reconsider the benefit of antidepressants in people living with dementia.
Angela Kinn is a Senior Peer Recovery Trainer at the CNWL Recovery and Wellbeing College and a Peer Researcher at the McPin Foundation, a leading independent sector mental health researcher organisation. She has lived experience of recovery from mental health challenges including bipolar and addiction and is passionately committed to co-production and recovery working.
Cognitive behavioural therapy may help ease depression in the workplace
I’m constantly learning from the people I work with, but I’m often concerned that so much of what I’m learning could be seen as anecdotal because so much in the mental health field is under-researched. This is why NIHR Alerts are so important and valuable in my work. The Alert I’ve chosen demonstrates the effectiveness of early short term workplace interventions, including cognitive behavioural therapy and supervised exercise programs, in preventing depressive episodes.
This Alert has increased my confidence and determination in the work I have been doing with employers. It emphasises why working with employers to increase their mental health awareness and increase workplace support is such a priority. We spend most of our lives at work and employers can have a significant positive impact in challenging stigmatising attitudes and in facilitating prevention and early intervention. This is firmly in employers’ interests as it also increases productivity and reduces re-recruitment costs and sickness absence. It is such a clear win/win and this Alert identifies why.
Simon is a newly qualified mental health nurse, currently working in Child and Adolescent Mental Health. He has a particular interest in talking therapies and ways that new research on therapies can be implemented into practice.
Simpler, cheaper therapy (behavioural activation) can be as good as CBT for treating depression
Working in mental health it is clear that low mood and depression are very common in themselves, and are often associated symptoms with other mental health issues such as psychosis and personality disorders. It is also very clear that talking about these issues can be helpful for people. In our current mental health care system it can be difficult for service users to access talking therapies, and it is much more likely that they will be treated with medication.
This research stood out to me because, as a newly qualified mental health nurse, I see people that need these types of therapies but don’t get them. As mental health nurses we are not qualified in CBT or talking therapies, but if this behavioural activation therapy was part of the nurse’s skillset, it could be beneficial to our service users. CBT training is currently quite costly to the Trust and not every ward offers nurses the opportunity to train, and so if this cheaper alternative works it would allow more access to talking therapies for service users.
Depression and anxiety common in people with heart disease
I have worked with people who have had serious heart conditions and it appeared to me their physical symptoms may in part be a result of an unhealthy lifestyle due to depression and anxiety. Depression takes all your energy so that you spend most of the day in bed or on the sofa watching TV.
When it comes to eating, preparing and cooking a meal is out of the question. You rely on ready meals and takeaways. Once this habit is started it is hard to break. This research is important as it shows that the mental health of people with long term conditions is often overlooked. Being more aware of mental health issues, and treating depression and anxiety earlier could help mitigate the potential problems associated with heart disease. This would not only increase the quality of life of these people but could also save money in the long run for the health service which is struggling financially and making cuts to vital services.
Talking therapies may prevent relapse of depression
This research stood out to me as, having experienced depression myself, and having had therapy and having benefitted greatly from it, encouraging people to engage in talking therapies is something I think is important in mental health care.
I have met many service users who have experienced depression and found medication helpful to an extent, but are put off attending therapy due thinking it doesn’t work for them, or because of the stigma attached with ‘attending therapy’. Attending therapy and engaging with that therapy for a longer time period has been shown to reduce the chance of depression relapse. This would benefit the mental wellbeing of the individual and could allow for change in the way mental health issues are treated, moving away from a medical model of care that often comes with unwanted side effects, towards a more psychosocial model.
Catherine is a senior occupational therapist in a community perinatal mental health service. She founded a non-profit occupational therapy service, which provides interventions to young people in rural Norfolk and is trained in Eye Movement Desensitisation and Reprocessing Therapy (EMDR). She has worked in youth mental health, early intervention psychosis, NHS research and perinatal services.
Workplace interventions may support return to work after sick leave
I have recently trained to be a Health and Work Champion with the Royal College of Occupational Therapists and have been delivering Work as a Health Outcome training to NHS staff. This Alert reflects the low quality research around the subject of returning to, or remaining at work whilst living with, or recovering from mental health difficulties. However, evidence demonstrates the positive health impact of a person participating in meaningful work (including volunteering) as well as the impact this has on the economy.
Due to the low number of studies included in this review the training of the providers was unclear, as was what workplace interventions were provided. With the introduction of the Allied Health Professionals (AHPs) Health and Work Report it is hoped that more occupational therapists and AHPs will complete training to support those with mental health conditions return to and sustain work. A study on the effectiveness of these recommendations would be beneficial to inform workplaces of the type of adaptations and adjustments that could be provided.
Aerobic exercise moderately reduces depressive symptoms in new mothers
SIGN, The Royal College of Psychiatrists and NICE (2015) all recommend regular mild to moderate exercise as beneficial for postnatal depression and taking care of yourself post-birth. In my experience, the recommendation of moderate exercise three or more times a week is an unrealistic goal for many mothers. The exercise would need to be accessible and meaningful to both the mother and baby as a co-occupation. The desire and motivation to exercise is often low, along with personal and physical restraints - especially immediately postpartum
The study discussed that exercise alone had a significant trend, but not statistically significant. However, if exercise was combined with other lifestyle and social interventions it was effective. There are a number of buggy fit groups across the country, but these are often not accessible to women experiencing postnatal mental health difficulties due to low motivation, anxiety and perceived stigma.
An increasing number of occupational therapists are working in perinatal services. Their knowledge of mental and physical health,of adapting exercises for an individual and delivering socially meaningful interventions, can be an asset in supporting mothers to introduce moderate exercise into their lives.
Peter B. Jones is Professor of Psychiatry at the University of Cambridge, honorary consultant psychiatrist with the Cambridgeshire & Peterborough Foundation NHS trust and Director of the NIHR Applied Research Collaboration East of England. He works clinically in the CAMEO early intervention service supporting young people with disorders spanning depression, anxiety and psychosis; his research includes the NIHR TYPPEX programme evaluating new therapeutic approaches to severe depression and anxiety presenting to IAPT services.
The role of talking therapies in depression
Several Alerts, which keep clinical questions alive despite high quality trial evidence, are about talking therapies/CBT and depression. A 2015 review of evidence published in the BMJ shows that cognitive behavioural therapy and antidepressant treatment are similarly effective for major depression (useful to know and helpful for patient choice), but the vogue for on-line treatments gets less clear support. Results of a large trial also published in 2015 show that online CBT (two popular commercial packages head-to-head) was no more effective than usual GP care for people with mild to moderate depression. Will sales fall? Perhaps they shouldn’t if such results simply mean that patients and clinicians are better informed.
Combined drug therapy for at least 36 weeks reduces relapse after psychotic depression
The STOP-PD II trial of combined antidepressant and antipsychotic drug treatments for people with psychotic depression reached definitive positive conclusions, filling a gap in NICE guidance. Psychotic depression is a malignant mental disorder but gets little research airtime; now we know that pressing on with combined treatment for at least 36 weeks after remission keeps people well but at the cost of weight gain. I shall alter my practice.
Produced by the University of Southampton on behalf of NIHR through the NIHR Dissemination Centre