Summary of the impact

An estimated one in four people in the UK will experience depression or anxiety at some point in their lives. Cognitive behavioural therapy (CBT) is the most widely recommended non-medication- based treatment for common mental health problems, although access to this treatment is limited because of low numbers of expert practitioners. Self-help CBT resources developed by researchers at the University of Glasgow have been integrated into routine clinical practice delivered by health services and the voluntary sector in the UK, Ireland and Canada. Since 2008, these practical user-friendly resources have provided support to over 200,000 users online and an estimated 250,000 people on a one-to-one basis or within a class.

Underpinning research

CBT is an evidence-based form of psychotherapy that aims to educate patients with common mental health problems (such as depression and anxiety) about their condition and to provide them with the skills to manage it. Although CBT is recommended by clinical guidelines such as those published by the National Institute of Health and Care Excellence and the Scottish Intercollegiate Guidelines Network, access to treatment has typically been limited by the low number of expert CBT practitioners, resulting in long waiting times. Consequently, more recently published clinical guidelines recommend new ways of delivering CBT, such as self-help books, computerised training, classes and group sessions, as well as a stepped-care delivery approach — a tiered system that directs patients to the lowest intensity form of therapy requiring less practitioner support time. Here, the self-help materials deliver some of the work of therapy. Using this system, most people with mild or moderate depression can undergo a brief period of self-help CBT as a first step, before deciding on longer-term care options. The challenge with adopting this approach is to determine how best to deliver such a service within existing clinical settings.

Since 2000, Professor Chris Williams (Professor of Psychosocial Psychiatry, 2000-present) and his team at the University of Glasgow have focused on evaluating new ways of delivering evidence-based CBT in a non-clinical setting. At the heart of this research is the `five areas' model, a CBT assessment tool that Williams developed at the University of Leeds between 1997-1999, which enables mental health practitioners to offer focused interventions for individual patients. A series of workbooks entitled `Overcoming depression and low mood: a five areas approach', first published in 2001, explains this model and provides a structured and educational guide to self-help CBT intervention that can be used by both practitioners and patients.¹

Briefly, this involves individuals using either written, DVD or computer based formats, to work through a checklist identifying how low mood or anxiety is affecting them in five key areas of life: people and events around them, their thinking, feelings, physical symptoms and behaviour. Users then choose which areas to work on first, addressing the most common problems encountered in that area using the appropriate workbook module, which cover, for example, practical problem solving, being assertive, and identifying then changing upsetting thoughts.

Since 2001, Williams has refined and updated content in response to feedback from clinical mental health teams in Glasgow and elsewhere, with new editions and also new books addressing medically unexplained symptoms, postnatal depression, and depression in young people. Development has ensured that the content, structure and language of the model can be easily understood by healthcare practitioners from a range of different specialties and patients with a broad range of cognitive abilities. For example, terms such as "selective abstraction" and "negative automatic thoughts" were replaced with "putting a negative slant on things" and "unhelpful thinking", respectively. The second edition of the book (which was published in 2006) was subsequently shown to have an average reading age of 12.6 years, which is lower than the reading ages of almost all other widely recommended self-help books for depression (generally ranging from age 13.1-15.4 years). This is an important consideration given that 16% of the adult UK population has a reading age of less than 11 years.^2,3

In the largest randomised controlled trial of a book-based CBT resource to date, Williams' team evaluated the efficacy of providing the "Overcoming depression and low mood: a five areas approach" series of workbooks to 203 adult patients in a primary-care setting from 2004 to 2007. With brief support from a person who was not a mental-health expert, the approach was highly effective, with 43% of patients considered to have recovered after 4 months, compared with 25% of those who received usual care (such as antidepressant medication) only.⁴

The introduction of guided self-help CBT approaches into clinical services requires specialised staff training, and Williams' research led to the first accredited course to address this requirement. The Structured Psychosocial InteRventions in Teams (SPIRIT) course was designed to train mental health practitioners in Glasgow. It consists of nearly 40 hours of workshops on the use of the five areas CBT self-help resources and 5 hours of staff supervision to support their use of the Overcoming depression series of workbooks in clinical practice. When given to community and inpatient mental health teams in NHS Greater Glasgow, this course led to both short-term and long-term improvements in the knowledge and skills of trained staff, as well as high levels of practitioner satisfaction of the usefulness of the approach in clinical practice.⁵

References to the research

Grant funding:

An evaluation of the effectiveness of structured Cognitive Behaviour Therapy self-help materials delivered by a self-help support worker within Primary care. (Williams, Morrison, Wilson, Whitfield, Walker, McMahon, Wallace). Chief Scientists Office CZH/4/61. April 2004 - June 2007. Local PI £144,850.

Details of the impact

Professor Williams has produced one of the most accessible and positively evaluated CBT models for treating mild to moderate depression and anxiety disorders. His core series of workbooks, `Overcoming depression and low mood: a five areas approach' has sold 10,734 copies since 2008<sup>a</sup> and his approach to guided self-help CBT has been shown in clinical research and practice to effectively treat depression. Williams has achieved significant local, national and international recognition for the pioneering dissemination of his `five areas' model through two complementary approaches — practitioner training and the provision of online resources.

Practitioner training

Courses to train healthcare practitioners in using the `Overcoming depression and low mood' materials with patients have been developed, and then evaluated in the Glasgow team's research, facilitating the implementation of self-help CBT treatments within existing clinical settings.

The SPIRIT programme has operated since 2002, during which time it has received (and continues to receive) NHS funding of around £127,000 per annum. The first accredited course of this kind, it delivers training to teams operating within NHS Greater Glasgow & Clyde (GG&C). Currently, all `adult' and `older adult' mental health teams in Glasgow have been trained in SPIRIT, with 287 practitioners trained since 2008.^b This focus on team-based training has enhanced the assimilation of new practice into wards and, since 2008, mental health clinical admissions in GG&C have undergone `five areas' assessment, with use of the SPIRIT programme recorded in the electronic patient record/PIMS system.

Widening access to Self-Help and Psychological Interventions (WISH) is a programme funded by the Scottish Government to provide short-course training to healthcare and community practitioners, carers and physiotherapists, using a low-intensity application of the `five areas' approach. In a pilot study performed from 2009 to 2010, WISH provided training for 597 healthcare professionals practicing across three Scottish NHS boards (Highland, Dumfries & Galloway and Lanarkshire) and employees of a national charity "Action on Depression" (AOD), in how to support patients using the `five areas' resources. AOD staff and volunteers lead small groups and provide telephone support for online versions of the five areas approach. Since the beginning of April 2011, a further 985 practitioners have been trained with WISH, including clinicians from two additional NHS boards (Lothian and GG&C)^c and funding has been extended a further year until March 2014.

Online resource

Williams' second approach was to develop a free-access CBT-related website called "Living Life to the Full" (LLTTF). This was based upon the original `Overcoming depression and low mood' book plus new resources to increase accessibility. LLTTF was established in 2004 (and re-launched in 2011) to widen and expedite the delivery of an adult life skills course; it can be used alone or together with books, DVDs and face-to-face classes in both clinical and non-clinical settings. Since 2008, 208,604 members have registered with the website,^d which receives an average of over 45,000 visits per month^d and has a Google page ranking of 5 (on a 0-10 logarithmic scale that reflects both the number and quality of other webpages referring to the site). Put into the context of other popular websites, a ranking of 5 is considered to be a good score; for example, the bbc.co.uk website has a ranking of 9 and the scot.nhs.uk website has a ranking of 6. Since 2008, Williams has supported a number of national and international projects that roll out local delivery of LLTTF, which are outlined in the subsections below.

NHS Living Life is a telephone support line for people with low mood or anxiety that is funded by the Scottish Health Department and available in Scotland since 2011. Operated by GP referral or self-referral, patients are directed towards the LLTTF website and the "Overcoming depression and low mood: a five areas approach" workbook, and receive support using these from SPIRIT-trained therapists. An independent audit of the 2008-2010 pilot study of 224 patients who completed the online treatment course found that 83% were either in remission or had recovered upon completion of this course.^e Feedback was overwhelmingly positive, with responses including:

• "The course is helping me think things through and I'm coping better. I'm better able to catch and stop negative thoughts." (Student, aged 22 years)
• "The online course with the follow-up phone calls is genius! It has helped me so much and helped me get back to work." (Teacher, aged 40 years)
• "The anxiety session was a real eye-opener for me. Thanks for your support. It has been a great resource." (Social worker, aged 46 years)

NHS Choices is the online `front door' to the NHS, and is the largest health website in the UK. The site hosts a webpage called the `moodzone', which offers practical information and interactive tools for people with subclinical mood-related issues. Williams was invited to create a suite of eight CBT- based podcasts relating to low mood and depression, which are based on the original `Overcoming depression and low mood' series materials. The podcasts have been available online since February 2013, and been collectively viewed 45,803 times by 31^st July 2013.^f

AWARE Defeat Depression is a charity based in Northern Ireland and the Republic of Ireland that delivers LLTTF life skills classes to groups. In 2009 and 2010, the pilot course was delivered to 46 groups (with a combined total of 356 people), including groups representing ex-prison-officers, lesbian, gay, bisexual and transgender individuals, carers and women. The proportion of participants identified as being depressed (according to a standardised depression questionnaire) dropped from 73% at the start of the course to 12% after completion of the course.^f All participants said they would recommend the course to friends. The success of the pilot study led to the uptake of LLTTF classes in the Republic of Ireland by the Irish charity AWARE, which, in partnership with the Tesco supermarket chain, provides ongoing financial support for CBT classes in both urban and rural areas. Since June 2012, 1,336 people have completed the six-week programme of life- skills classes, the completion of which was associated with a 50% improvement in low mood (based on a validated clinical questionnaire to assess severity of depression) and high levels of satisfaction with the course, as suggested by the following comments:^h

• "It changed how I dealt with situations and I have stuck with the information given and been using it."
• "Realising my thoughts cause my feelings means I can now control my feelings and make myself feel better."
• "Beneficial in terms of improving my understanding and providing practical steps to take."

Highlighting the value of self-help CBT, and improved access to it by practitioner training and online resources, the Canadian Mental Health Association (CMHA) adapted the "Overcoming depression and low mood: a five areas approach" workbook with support and training from Professor Williams.ⁱ Bounce Back, a CAN $6 million initiative, employs 26 staff members in British Columbia who offer on-referral, low-intensity self-help CBT telephone support for patients in primary care with mild or moderate depression.

There have been 22,475 patient referrals since the launch of this programme in June 2008.^j In a survey of 2,903 patients who completed at least one of the 3-5 sessions offered, only 56% were considered to be depressed after completion of the LLTTF course (compared with 91% prior to the course).^j Bounce Back also offers a DVD version of the LLTTF course and has distributed about 67,000 copies.^j The CMHA also run life skills classes modelled on those run by AWARE and people can self-book onto the classes at http://www.llttf.ca. In 2010 and 2011, the CMHA piloted the website and classes; of the 228 participants who were surveyed in the pilot study, 85% found the course to be useful and 91% said that they would recommend it to their friends.ⁱ The LLTTF Canadian website provides on-going certified training to a nationwide network of facilitators who provide CBT coaching for the same LLTTF classes described above that AWARE offer; so far, 120 facilitators from five Canadian states have been trained.^k

In recognition of his sustained outstanding contribution to CBT and its dissemination in the UK and internationally, in 2013 Williams was awarded an Honorary Fellowship by the British Association for Behavioural & Cognitive Psychotherapies (BABCP), the leading body for CBT provision in the UK. He is one of only 16 other people to have received this highly prestigious Fellowship since the founding of BABCP in 1972.^l

Sources to corroborate the impact

a. Information from Taylor and Francis Group publishers; available on request.

b. SPIRIT figures provided by Administrator, WISH and SPIRIT; available on request.

c. WISH figures provided by the WISH programme manager; available on request.

d. LLTTF website usage statistics; available upon request or directly from the www.llttf.com site.

e. NHS Living Life/NHS 24 CBT Telephone support service and a NHS Living Life audit from NMAHP Research Unit, University of Stirling; available on request.

f. Information on NHS Choices Moodzone from NHS Choices; available on request.

g. Pilot evaluation presentation from AWARE (Northern Ireland); available on request.

h. Training numbers from AWARE (Republic of Ireland); available on request.

i. Canadian Mental Health Association website.

j. Data on Bounce Back provided by British Columbia Cognitive Behaviour Therapy Network; available on request.

k. `Become a facilitator', Living life to the full, Canada

l. BABCP Honorary Fellows webpage.