Impact case study database

1) The RCT results were used to inform European and American depression guideline recommendations

The long-term outcomes reported in the Tavistock RCT [R7] are the basis of recommendations for LTPP for TRD in the following guidelines:

• European Psychiatric Association (EPA) guideline on PTs for persistent forms of depression [S1a]

• American Psychological Association (APA) guideline for depression [S1b]

• European Community based Mental Health Service Providers (EUCOMS) Network [S1c]

The EPA guideline used the Tavistock RCT [R7] to conclude that “ both observer-based and self-reported depression scores showed steeper declines in the LTPP group, alongside greater improvements on measures of social adjustment. These data suggest that LTPP can be useful in improving the long-term outcome of treatment-resistant depression” [S1a]. The guideline recommends LTPP as a third-line treatment. The recommendation could not be first- or second-line because the Tavistock RCT was “ published after closure of literature search and not included into database for evidence grading and the Delphi process”. The EPA has 44 National Psychiatric Association members representing over 80,000 psychiatrists across Europe. The EPA collaborates with WHO Europe and the EU Compass project to promote evidence-based practice in member states informed by its portfolio of peer-reviewed published guidelines.

EUCOMS, comprising 61 organisations from 21 countries, used the Tavistock RCT [R7] as a basis for recommending psychodynamic psychotherapy as an evidence-based treatment for community mental health care [S1b].

The APA 2019 guideline [S1c] was developed based on systematic reviews only (rather than reviewing primary research). Of the systematic reviews included, one was on the effectiveness of psychodynamic psychotherapies [S1d] and was the source for several statements about LTPP in the guideline. The conclusions in this review concerning LTPP for depression were based solely on the Tavistock RCT [R7]. The APA guideline recommends psychodynamic psychotherapies as an option among first and second-line treatments; it notes that “ psychotherapies seem to have longer term effects” and that “ LTPP relative to treatment-as-usual (which could include antidepressant medication) may have similar effects as well” (p55-6). It also notes “ some evidence suggests that effects of some psychotherapies persist longer than the effects of medication” (p88). The APA is the registration and accrediting body for clinical psychologists in the US and has 121,000 members.

2) Essex research led NICE to commit to a change in approach to analysis of long-term outcome data and quality-of-life/functioning outcomes for the depression guideline update (due 2022).

In February 2017 McPherson was invited to speak at the Association for Psychoanalytic Psychotherapy in the NHS ‘Annual Phil Richardson Memorial Lecture’ [S2a]. In this talk McPherson anticipated some of the methodological issues that might arise in the forthcoming draft of the NICE depression guideline and encouraged mental health professional bodies concerned with these methodological issues to work together to identify and raise key concerns with NICE jointly and constructively [S2a].

The 2017/8 consultation drafts of the guideline had analysed end-of-treatment symptom outcomes only. The recommendations concerning PTs for depression were therefore based on end-of treatment symptom outcomes, which concerned several professional bodies because this significantly narrowed the choice of therapies that will be made available for patients to choose among (which is important because patient choice and preference is known to impact on outcomes). McPherson engaged with various professional bodies and patient organisations, supporting them to engage jointly with NICE around key methodological issues, thus influencing and shaping the debate around guideline methodologies concerning PTs for depression. This resulted in:

• Key stakeholders (Royal College of Psychiatrists [RCPsych], British Psychoanalytic Association and Society for Psychotherapy Research UK) cited Essex research [including R3, R4 and R7] in their stakeholder responses to NICE’s 2017 consultation draft. Citing this Essex research, RCPsych specifically requested that functional outcomes be given more priority [S2b p259-60] and that “ Proper weight should be given to outcomes reported at long-term follow-ups/observation periods, where these are available, rather than exclusively treatment endpoint.” [S2b p416]

• McPherson was invited to co-author (with the President of the Society for Psychotherapy Research UK) a joint stakeholder response to a second stakeholder consultation [S2c]. This was signed by 14 organisations (including the RCPsych, MIND, UK Council for Psychotherapy, British Association for Counselling and Psychotherapy and National Survivor User Network) plus 6 individuals (including Prof Sir Simon Wessely and Prof Clare Gerada MBE), submitted June 2018. This was resubmitted to NICE in May 2019, having been signed by 40 organisations (now including the British Psychological Society and Association for Clinical Psychologists) plus 53 individuals. The response highlighted 6 methodological issues, including the importance of examining long-term outcomes and QOL/F outcomes because of the importance of these outcomes to patients and because prioritising these outcomes in developing recommendations would lead to greater patient choice of PTs [R4, R5] [S2c p7,17].

• McPherson attended and took a key role in stakeholder discussions with NICE executives (including Sir Andrew Dillon and Paul Chrisp), to explore methodological issues (April 2018 and May 2019) [S2d]. Subsequently, in December 2019, NICE confirmed their response to these discussions [S2e]. NICE committed to a substantial new programme of work to address stakeholder methodological concerns. Concerning long-term outcomes NICE stated: “NICE will now include long-term follow-up data in all its treatment reviews. The committee has previously considered that long-term follow up data were not available across all comparisons of interests in the guideline and consequently long-term effectiveness would be subject to large potential biases. However, we accept that long-term effectiveness is an important outcome and we will now look for it in all treatment reviews.” Stating similar reasons, NICE also committed to “include quality of life and functional status as outcomes in the treatment reviews”. [S2e] The third consultation draft including this additional work is now due in May 2022. Essex research shows that analysis of QOL/F outcomes [R5] and long-term outcomes [R4] will change the range of PTs recommended and therefore made available to people presenting with depression.