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Health Technology Assessment 2010; Vol. 14: No.

44

Group cognitive behavioural therapy


for postnatal depression: a systematic
review of clinical effectiveness, cost-
effectiveness and value of information
analyses
MD Stevenson, A Scope, PA Sutcliffe,
A Booth, P Slade, G Parry, D Saxon,
E Kalthenthaler and the group cognitive
behavioural therapy for postnatal depression
advisory group

September 2010
10.3310/hta14440

Health Technology Assessment


NIHR HTA programme
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Group cognitive behavioural therapy
for postnatal depression: a systematic
review of clinical effectiveness, cost-
effectiveness and value of information
analyses

MD Stevenson,* A Scope, PA Sutcliffe,


A Booth, P Slade, G Parry, D Saxon,
E Kalthenthaler and the group cognitive
behavioural therapy for postnatal depression
advisory group

School of Health and Related Research (ScHARR), The University of


Sheffield, Sheffield, UK

*Corresponding author

Declared competing interests of authors: none

Published September 2010


DOI: 10.3310/hta14440

This report should be referenced as follows:

Stevenson MD, Scope A, Sutcliffe PA, Booth A, Slade P, Parry G, et al. Group cognitive
behavioural therapy for postnatal depression: a systematic review of clinical effectiveness,
cost-effectiveness and value of information analyses. Health Technol Assess 2010;14(44).

Health Technology Assessment is indexed and abstracted in Index Medicus/MEDLINE,


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Contents /Clinical Medicine.
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Printed on acid-free paper in the UK by Henry Ling Ltd, The Dorset Press, Dorchester. G
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Abstract
Group cognitive behavioural therapy for postnatal
depression: a systematic review of clinical
effectiveness, cost-effectiveness and value of
information analyses
MD Stevenson,* A Scope, PA Sutcliffe, A Booth, P Slade, G Parry,
D Saxon, E Kalthenthaler and the group cognitive behavioural therapy
for postnatal depression advisory group
School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, UK

*Corresponding author

Background: Postnatal depression (PND) describes standardised clinical assessment tool used to define
a wide range of distressing symptoms that can occur PND. All full papers were read by two reviewers (AS
in women following childbirth. There is substantial and DS) who made independent decisions regarding
evidence to support the use of cognitive behaviour inclusion or exclusion, and consensus, where possible,
therapy (CBT) in the treatment of depression, and was obtained by meeting to compare decisions. In the
psychological therapies are recommended by the event of disagreement, a third reviewer (EK) read the
National Institute for Health and Clinical Excellence paper and made the decision. All data from included
as a first-line treatment for PND. However, access is quantitative studies were extracted by one reviewer
limited owing to expense, waiting lists and availability (AS) using a standardised data extraction form. All
of therapists. Group CBT may, therefore, offer a data from included qualitative studies were extracted
solution to these problems by reducing therapist by two reviewers (AS and AB) using a standardised
time and increasing the number of available places for data extraction form with disagreements resolved by
treatment. discussion. Two different data extraction forms were
Objectives: To evaluate the clinical effectiveness used, one for the quantitative papers and a second for
and cost-effectiveness of group CBT compared with the qualitative papers.
currently used packages of care for women with PND. Results: Six studies met the inclusion criteria for
Data sources: Seventeen electronic bibliographic the quantitative review. Three were randomised
databases were searched (for example MEDLINE, controlled trials (RCTs) and three were non-
MEDLINE In-Process & Other Non-Indexed Citations, randomised trials. Two studies met the inclusion
EMBASE, PsycINFO, etc.), covering biomedical, health- criteria for the qualitative review. These were both
related, science, social science and grey literature treatment evaluations incorporating qualitative
(including current research). Databases were searched methods. Only one study was deemed appropriate
from 1950 to January 2008. In addition, the reference for the decision problem; therefore a meta-analysis
lists of relevant articles were checked and various was not performed. This study indicated that the
health services related resources were consulted via reduction in the EPDS score through group CBT
the internet. compared with routine primary care (RPC) was 3.48
Review methods: The study population included [95% confidence interval (CI) 0.23 to 6.73] at the end
women in the postpartum period (up to 1 year), of the treatment period. At 6-month follow-up the
meeting the criteria of a standardised PND diagnosis relative reduction in EPDS score was 4.48 (95% CI
using the Diagnostic and Statistical Manual of Mental 1.01 to 7.95). Three studies showed the treatment to
Disorders-Fourth Edition, or scoring above cut-off on be effective in reducing depression when compared
the Edinburgh Postnatal Depression Scale (EPDS). No to RPC, usual care or waiting list groups. There was
exclusion was made on the basis of the standardised no adequate evidence on which to assess group CBT
depression screening/case finding instrument of compared with other treatments for PND. Two
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Abstract

studies of group CBT for PND were included in the evidence to assess the effectiveness of group CBT
qualitative review. Both studies demonstrated patient for PND. The evidence that was available was of low
acceptability of group CBT for PND, although negative quality in the main because of poor reporting of the
feelings towards group CBT were also identified. A results. Furthermore, little information was reported
de novo economic model was constructed to assess on concurrent treatment used in the studies, which
the cost-effectiveness of group CBT. The base-case was controlled for in only two of the studies.
results indicated a cost per quality-adjusted life-year Conclusions: Evidence from the clinical effectiveness
(QALY) of 46,462 for group CBT compared with review provided inconsistent and low quality
RPC. The 95% CI for this ratio ranged from 37,008 information on which to base any interpretations
to 60,728. There was considerable uncertainty in for service provision. Although three of the included
the cost per woman of running a CBT course, of studies provided some indication that group psycho-
the appropriateness of efficacy data to the decision education incorporating CBT is effective compared
problem, and the residual length of benefit associated with RPC, there is enough doubt in the quality of the
with group CBT. These were tested using univariate study, the level of CBT implemented in the group
sensitivity analyses. Supplementary analyses that fitted programmes, and the applicability to a PND population
distributions to the cost of treatment and the duration to limit any interpretations significantly. It is also
of comparative advantage reported a cost per QALY of considered that the place of group CBT in a stepped
36,062 (95% CI 20,464 to 59,262). care programme needs to be identified, as well as
Limitations: The cost per QALY ratio for group CBT there being a need for a clearer referral process for
in PND was uncertain because of gaps in the evidence group CBT.
base. There was little quantitative or qualitative RCT

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Contents
Glossary and list of abbreviations ........... vii 7 Conclusions ............................................... 53
Implications for service provision .............. 53
Executive summary .................................. ix Suggested research priorities ..................... 53

1 Background ............................................... 1 .................................. 55


Acknowledgements
Description of health problem ................... 1
Current service provision ........................... 3 ................................................. 57
References
Description of technology under
assessment .............................................. 6 Appendix 1 Literature search strategies .. 61

2 Definition of the decision problem ......... 9 Appendix 2 Data abstraction tables


Decision problem ........................................ 9 quantitative review ...................................... 65
Overall aims and objectives of assessment . 9
Appendix 3 Data abstraction tables
3 Assessment of clinical effectiveness ....... 11 qualitative review ........................................ 81
Methods for reviewing effectiveness ........... 11
Results ......................................................... 13 Appendix 4 Summary of excluded trials
Discussion ................................................... 35 quantitative review ................................... 89

4 Assessment of cost-effectiveness ........... 37 Appendix 5 Summary of excluded trials


Systematic review of existing cost- qualitative review ..................................... 95
effectiveness evidence ............................ 37
Independent economic assessment ............ 37 Appendix 6 References for excluded
studies ......................................................... 99
5 Assessment of factors relevant to the
NHS and other parties ............................. 49 Health Technology Assessment
reports published to date ........................ 109
6 Discussion .................................................. 51
Statement of principal findings .................. 51 Health Technology Assessment
Strengths and limitations of the programme ............................................... 131
assessment .............................................. 51
Uncertainties .............................................. 52

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Glossary and list of abbreviations

Glossary

Postnatal depression (also known as Primipara A woman who is pregnant for the
postpartum depression) A non-psychotic first time, or has given birth to only one child.
depressive episode meeting standardised
diagnostic criteria for a minor or major The Beck Depression Inventory A 21-item
depressive disorder, beginning in or extending self-report scale used to determine depression
into the postnatal period. The term puerperal is severity. Items are scored on a 03 scale giving a
also used to describe the postnatal period. total range of 063. Total scores within the 19
range indicate minimal depression, 1018 mild
Cognitive behaviour therapy (CBT)The depression, 1929 moderate depression, and
pragmatic combination of concepts and 3063 severe depression.
techniques from cognitive and behaviour
therapies common in clinical practice. CBT The Edinburgh Postnatal Depression
aims to facilitate, through collaboration and Scale The most widely used self-report scale
guided discovery, recognition and re-evaluation designed to measure postnatal depression
of negative thinking patterns and practising new symptomology. The scale consists of 10-item
behaviours. Likert format relating to depression and anxiety
symptomology. Items are scored on a 03 scale
Interpersonal psychotherapy A time-limited, to give a total range of 030. Total scores within
structured and psycho-educational therapy the 1230 range suggest significant depression.
which links depression to role transitions,
interpersonal disputes, interpersonal sensitivity The Center for Epidemiological Studies
or losses. It facilitates understanding of recent Depression Scale A short self-report scale
events in these interpersonal terms and explores designed to measure depressive symptomology
alternative ways of handling interpersonal in the general population. The 20-item scale
situations. has a possible range of score from 0 to 60,
with higher scores indicating more symptoms,
Multipara A woman who has given birth two or weighted by frequency of occurrence during the
more times. past week.

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Glossary and list of abbreviations

List of abbreviations

BDI Beck Depression Inventory IPT interpersonal psychotherapy


CASP Critical Appraisal Skills ITT intention to treat
Programme MCI multicomponent intervention
CBT cognitive behavioural therapy MITG motherinfant therapy group
CEAC cost-effectiveness acceptability NHS EED NHS Economic Evaluations
curve Database
CES-D The Center for Epidemiological NICE National Institute for Health
Studies Depression Scale and Clinical Excellence
CI confidence interval PCT Primary Care Trust
CINAHL Cumulative Index to Nursing PEG psycho-educational group
and Allied Health Literature
PND postnatal depression
DSM-IV Diagnostic and Statistical Manual
of Mental Disorders-Fourth PSA probabilistic sensitivity analyses
Edition QALY quality-adjusted life-year
EPDS Edinburgh Postnatal Depression QUORUM quality of reporting of meta-
Scale analyses
EVPI expected value of perfect RCT randomised controlled trial
information
RPC routine primary care
EVPPI expected value of partial perfect
SF-6D Short Form questionnaire-6
information
Dimensions
GP general practitioner
UC usual care
HEED Health Economic Evaluations
WLG waiting list group
Database
ICD-10 International Classification of
Diseases-Tenth Edition

All abbreviations that have been used in this report are listed here unless the abbreviation is well
known (e.g. NHS), or it has been used only once, or it is a non-standard abbreviation used only in
figures/tables/appendices, in which case the abbreviation is defined in the figure legend or in the
notes at the end of the table.

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Executive summary
Background Results
Postnatal depression (PND) describes a wide Number and quality of studies
range of distressing symptoms that can occur in Clinical effectiveness
women following childbirth. A clinical diagnosis Six studies met the inclusion criteria for the
of the disorder is often made using the Diagnostic quantitative review. Three were randomised
and Statistical Manual of Mental Disorders-Fourth controlled trials (RCTs) and three were non-
Edition which describes a range of diagnostic randomised trials. Two studies met the inclusion
categories indicative of a depressive disorder. criteria for the qualitative review. These were both
There is substantial evidence to support the use of treatment evaluations incorporating qualitative
cognitive behaviour therapy (CBT) in the treatment methods.
of depression, and psychological therapies are
recommended by the National Institute for Health Cost-effectiveness
and Clinical Excellence as a first-line treatment for No studies were identified that were deemed
PND. However, access is limited owing to expense, relevant to the decision problem.
waiting lists and availability of therapists. Group
CBT may, therefore, offer a solution to these Evidence of effectiveness
problems by reducing therapist time and increasing
the number of available places for treatment. Clinical effectiveness
Six studies of group CBT for PND were included
in the quantitative review as part of a narrative
Objectives analysis. Only one study was deemed appropriate
for the decision problem; therefore a meta-analysis
The overall aims of the review were to evaluate the was not performed. This study indicated that the
clinical effectiveness and cost-effectiveness of group reduction in the Edinburgh Postnatal Depression
CBT compared with currently used packages of Scale (EPDS) score through group CBT compared
care for women with PND. with routine primary care (RPC) was 3.48 [95%
confidence interval (CI) 0.23 to 6.73] at the end
of the treatment period. At 6-month follow-up the
Methods relative reduction in EPDS score was 4.48 (95% CI
1.01 to 7.95). Three studies showed the treatment
Clinical effectiveness
to be effective in reducing depression when
A systematic review of the literature was performed compared to RPC, usual care or waiting list groups.
to identify all studies describing trials of group There was no adequate evidence on which to assess
CBT for PND. Databases were searched (for group CBT compared with other treatments for
example MEDLINE, MEDLINE In-Process PND. Two studies of group CBT for PND were
& Other Non-Indexed Citations, EMBASE, included in the qualitative review. Both studies
PsycINFO, etc.) from 1950 to January 2008 for demonstrated patient acceptability of group CBT
both quantitative and qualitative studies. for PND, although negative feelings towards group
CBT were also identified.
Cost-effectiveness
Cost-effectiveness
A systematic review of the literature was performed A de novo economic model was constructed to
to identify all cost-effectiveness studies of group assess the cost-effectiveness of group CBT.
CBT for PND. Databases were searched from 1950
to January 2008.

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Executive summary

Summary of cost-effectiveness such as time postpartum. These factors may have


The base-case results indicated a cost per quality- significant implications for the generalisability of
adjusted life-year (QALY) of 46,462 for group the findings. Furthermore, the potentially small
CBT compared with RPC. The 95% CI for this number of health visitors involved in delivering the
ratio ranged from 37,008 to 60,728. There was group CBT assumed applicable to the UK setting
considerable uncertainty in the cost per woman may provide severe limitations in generalising the
of running a CBT course, of the appropriateness results to other health visitors.
of efficacy data to the decision problem, and the
residual length of benefit associated with group No robust comparisons between group CBT and
CBT. These were tested using univariate sensitivity individual CBT, or between group CBT and other
analyses. Supplementary analyses that fitted group therapies, were found. For the quantitative
distributions to the cost of treatment and the analyses only one RCT was considered appropriate
duration of comparative advantage reported a cost for meta-analysis and this had only 45 participants.
per QALY of 36,062 (95% CI 20,464 to 59,262). A further limitation is that utility measurements
were not recorded in the RCTs, thus benefits were
Sensitivity analyses estimated from a regression of the relationship
between EPDS and SF-6D.
The cost of running a group CBT course, the
assumed efficacy of group CBT and the length of As such there is considerable uncertainty in the
residual benefit all markedly affected the results; estimated efficacy of group CBT compared with
plausible combinations of these values would RPC. This, and uncertainties in the costs of
produce cost per QALY values below currently used conducting group CBT and in the duration of
thresholds. Expected value of information analyses benefit, mean that the cost-effectiveness of group
were undertaken. These showed that there was CBT for PND is uncertain.
expected to be a considerable benefit in conducting
further research, particularly regarding the cost of
treatment and the relationship between changes in Conclusions
values of the EPDS and changes in the value of the
Implications for service
Short Form questionnaire-6 Dimensions (SF-6D).
provision
Evidence from the clinical effectiveness review
Discussion provides inconsistent and low quality information
on which to base any interpretations for service
Strengths, limitations and
provision. Although three of the included studies
uncertainties of the analyses provide some indication that group psycho-
A strength of our work is that an estimation of the education incorporating CBT is effective compared
cost-effectiveness of group CBT for PND in the UK with RPC, there is enough doubt in the quality of
has been calculated; previously such estimates have the study, the level of CBT implemented in the
not been published. Furthermore, a relationship group programmes, and the applicability to a PND
between a change in EPDS score and utility has population to limit any interpretations significantly.
been estimated, although the correlation is only
moderate. We believe that such a relationship has It is also considered that the place of group CBT in
not previously been published. The analyses have a stepped care programme needs to be identified,
shown that the cost per QALY is heavily dependent as well as there being a need for a clearer referral
on the cost per women treated with group CBT and process for group CBT. There is also a requirement
the assumed relationship between changes in EPDS to make clearer assessments of the facilitators
values and changes in SF-6D values. and resources required for group CBT, including
training needs, and to provide a clear method of
Limitations include the dearth of RCT evidence to assessing suitable participants for the treatment.
assess the effectiveness of group CBT for PND. The
available evidence was in some cases of low quality Suggested research priorities
due to poor reporting. Some of the included
studies failed to provide adequate information The key research priorities would be to determine
about the exact nature of the CBT element of the cost per woman of providing group CBT
the intervention, concurrent treatment in the were it to be widely available, collection of paired
intervention group, and patient characteristics data for EPDS and a utility measure such as the
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SF-6D, to determine the effectiveness of group of the size of the participant group; the effect of
CBT compared with RPC and individual CBT the session duration; the effect of the setting; the
(preferably in terms of a utility measure to obviate qualifications and involvement of the facilitator;
the transformation from the EPDS) and to the effectiveness of group CBT on the different
determine the duration of comparative advantage subtypes of PND; whether effectiveness is
by following up the women 1 year, or longer, after dependent on patient background, comorbidity,
randomisation. the number of children, previous PND, pre-
pregnancy or antenatal depression; and the
If the sample size is large enough, data on the indirect effects of the treatment on the infant and
following aspects should be recorded: the effect other family members.

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Chapter 1
Background

Description of health tearful, or (2) markedly diminished interest or


problem pleasure, plus five (or more) of the criteria in
Table 1 for at least a 2-week period, nearly every
The term postnatal depression (PND) has been day. PND can range in severity and can include
used to describe a wide range of distressing the symptoms of major or minor depression as
symptoms following childbirth. This has led some described in the DSM-IV. An additional symptom
clinicians to describe women as suffering from specific to PND is guilt about the sufferers inability
PND on the basis of the symptom of lowered or to look after their baby.
depressed mood.1 It is more common, however,
for a clinical diagnosis to be made based on the Neither of these classification systems provides
pattern and severity of symptoms. PND is also a category specifically for PND. The ICD-10
referred to as puerperal depression, postpartum recommends that depression in the postnatal
depression and perinatal depression, and is period be categorised as one of the usual categories
defined as a non-psychotic depressive episode of depression, but does make provision for a mental
meeting standardised diagnostic criteria for a disorder beginning within 6 weeks of the delivery,
minor or major depressive disorder, beginning in if the symptoms do not fit the other criteria for
or extending into the postnatal period, which is depression. The DSM-IV accepts a postpartum
usually defined at up to 12 months postpartum.2 onset specifier. This refers to the same symptoms
as those associated with major depression, but
Current criteria for the measurement of is used when onset in within 4 weeks of the
depression are provided in two major international delivery of the child (p. 386). However, it should
classifications, International Classification of be noted that in some cases women with sub-
Diseases-Tenth Edition (ICD-10) and Diagnostic threshold symptoms are referred to services,1
and Statistical Manual of Mental Disorders-Fourth and current National Institute for Health and
Edition (DSM-IV). The ICD-103 divides depression Clinical Excellence (NICE) guidance for antenatal
into three categories: mild, moderate and severe, and postnatal mental health5 suggests that if the
and 10 symptoms of depression are identified. In health-care professional or patient has significant
the DSM-IV,4 nine symptoms of depression are concerns regarding a possible mental disorder
identified. in a women during pregnancy or the postnatal
period, the woman should be referred for further
DSM-IV criteria for a major depressive disorder assessment to her general practitioner (GP). In
require the presence of either (1) depressed mood addition to, or as an alternative to, these diagnostic
most of the day, nearly every day with self-reports criteria, self-report scales such as the Edinburgh
of sadness, emptiness or observation of appearing Postnatal Depression Score (EPDS) are used to

TABLE 1 Diagnostic criteria for a major depressive episode DSM-IV

1 Markedly diminished interest or pleasure in all, or almost all, activities


2 Significant weight loss when not dieting, weight gain, or decrease or increase in appetite
3 Insomnia or hypersomnia
4 Psychomotor agitation or retardation (observable by others, not merely subjective feelings of restlessness
or being slowed down)
5 Fatigue or loss of energy
6 Feelings of worthlessness or excessive or inappropriate guilt
7 Diminished ability to think or concentrate, or indecisiveness
8 Recurrent thought of death (not just fear of dying) or recurrent suicidal ideation
1

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Background

identify PND; although this scale is the most widely longer periods tend to identify higher prevalence.
used self-report scale for the identification of It is noted, however, that the EPDS is not, in
PND administered by the health-care provider, it itself, a diagnostic test. It should be followed by a
should be noted that further research is required diagnostic interview or longer structured measure
to establish the measure as a tool of identification if a diagnosis of PND is required.
or diagnosis for PND. The scale consists of 10-item
Likert format relating to depression symptomology Mental illness associated with childbirth can
and has also been shown to measure anxiety occur in the form of new episodes but also as a
symptomology.6 Items are scored on a 03 scale, recurrence of pre-existing illnesses.7 The risk of
giving a total range of 030. Total scores within suffering from severe affective disorders, including
the range 1230 suggest significant depression. PND, is elevated in women who have recently given
The Beck Depression Inventory (BDI) is also used birth compared to the general population.7 Women
in the screening of PND. It is a 21-item self-report with a history of severe mental illness, whether
scale used to determine depression severity. Items associated with childbirth or not, have an increased
are scored on a 03 scale, giving a total range of risk of a recurrence of their condition of between
063. Total scores within the 19 range indicate 33% and 50% following the birth of a child. This
minimal depression, 1018 mild depression, 1929 risk is at its greatest during the first 30 days after
moderate depression, and 3063 severe depression. birth.17 PND is distinguished from both postnatal
blues and postnatal psychosis: PND is considered
A clinical definition in use in the UK is non- to be more severe and has a longer duration of
psychotic depression occurring during the first depressive symptoms in comparison to postnatal
3 months postpartum.7 Symptoms of PND may or maternity blues, as they are sometimes called.1
spontaneously resolve 36 months after onset,8 However, Beck18 suggests that it is the timing of the
although some symptoms of depression are depressive symptoms that differentiates PND and
common in sufferers up to a year after delivery.9 postnatal blues.
It should also be noted that there are strong links
between prenatal depression and anxiety, and PND Up to 80% of women experience emotional
and anxiety,10,11 and that the presentation of PND lability, known as postnatal blues, in the first
may be comorbid with other mental disorders. 2 weeks postpartum, making this experience
extremely common.1 For those with postnatal blues,
Morrell et al.12 provide UK data on EPDS levels symptoms occur in the first few days after delivery
at 6 weeks postpartum. Based on a sample of and can last for up to 10 days. Evaluation should
3449 postnatal women, 595 had an EPDS13 take place if symptoms continue beyond 10 days to
score of 12 or more at 6 weeks postpartum; an identify PND. However, the symptoms of postnatal
estimated proportion of 17.3% [95% confidence blues and PND can be difficult to distinguish at this
interval (CI) 16.0 to 18.5]. However, it should be early stage. Symptoms of postnatal blues include
noted that the EPDS does not yet have a proven crying, irritability, fatigue, anxiety and emotional
role in the identification, screening or diagnosis lability, and it is suggested that maternity blues
of PND. Therefore, prevalence rates based on may be a normal reaction following the physiologic
the EPDS should be treated with caution. This changes associated with childbirth.18
is comparable with previous reports that have
suggested PND affects approximately 14.5% of Postnatal depression is also distinguished
women in developed countries during the first from postpartum psychosis which has a much
3 months postpartum,14 and 13% of new mothers less frequent incidence and is more severe.1
in developing countries.15 At 6 months postpartum The prevalence of postpartum psychosis has
it is reported that the prevalence of PND in the been reported as one to two women per 1000
UK is 9.1% in new mothers compared to 8.2% in deliveries.19 Symptoms can include delusions,
women who had not given birth within the previous hallucinations, extreme agitation, confusion,
6 months.2 Milgrom et al.1 report that prevalence inability to eat or sleep, exhilaration and rapid
rates of PND are affected by the measurement tool mood swings, and women with postpartum
used such as self-report measures of depression psychosis are regarded as a danger to themselves
including the EPDS and BDI;16 sampling; timing and their infant.18
of the assessment; differing diagnostic criteria
used in clinical interviews, including the DSM-IV A multifactorial aetiology of PND has been
criteria and the ICD-103 criteria; and by the length suggested as no single causative factor has
of the postpartum period under evaluation, as emerged. There is little evidence for a biological
2
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basis of PND;9,20 however, a number of psychosocial month, have you often been bothered by having
factors have emerged as risk factors. Prenatal little interest or pleasure in doing things?. If the
depression and anxiety, a history of previous woman answers yes to either question then a third
depression, and maternity blues have been shown question should be considered, Is this something
to be strongly related to PND.10,11,15,21 Further, that you feel you need or want help with?. Health-
psychosocial variables, such as self-esteem,10 care professionals may also consider the use of
stressful life events,11,15,21,22 childcare stress,10 marital self-report measures such as the EPDS, Hospital
conflict,10,15,21,22 a lack of social support,10,11,15,23 Anxiety and Depression Scale or Patient Health
low social status,10,15 infant temperament10 and Questionnaire-9 items.
unplanned or unwanted pregnancy,10 have emerged
as significant predictors of PND. In Sheffield, midwives visit postnatal women up
to 28 days after the birth, although they do not
Impact of health problem necessarily have to visit the women at home every
day, and often only visit until the 10th day. They
Significance for patients in terms of ill- do not usually use any formal tool for the detection
health (burden of disease) of PND, but are required to ask questions (as
Postnatal depression is a major health issue for the outlined in the previous paragraph) to assess how
affected individual but also represents a significant the woman is feeling. If the midwife feels there is
risk to the child of the sufferer. Impaired maternal a significant mental health problem he or she can
infant interactions24 can lead to attachment refer the woman to her GP for further assessment.
insecurity,25 and impaired cognitive26 and social- Women should not be discharged by the midwife
emotional development.27 Fewer positive mother until the health visitor has made contact, which
child interactions are reported in dyads where the usually occurs by 28 days after birth, although
mothers depression persists beyond 6 months practice is variable. Some health visitors use self-
postpartum than in those whose depressive report measures such as the EPDS typically at
symptoms end before 6 months.28 In addition 6 weeks postpartum if they feel PND may be an
to the impacts on mother and child, findings issue, although use of the EPDS is not a universal
have shown that there are links between womens practice. If they are concerned about the mental
depression and their partners mental health.29,30 health of the women and believe this is beyond
In men, partner depression has been found to be their scope they may consult the GP who could
associated with a higher probability of reporting refer the patient to the community mental health
depression,29 and PND in men has been reported team. Diagnosis is usually undertaken by the GP,
as associated with depression in their partners using a formal diagnostic framework, such as
during pregnancy and after delivery.30 DSM-IV criteria, for depression (source: Sheffield
Teaching Hospitals, Jessop Wing).

Current service provision If a possible mental disorder is identified in a


woman during pregnancy or the postnatal period,
Postnatal care typically involves a short stay further assessment is recommended. If there are
in hospital followed by at least two visits by a significant concerns about the mental health of
midwife. The woman remains under the care of the the woman, she should be referred to her GP
midwife for up to 6 weeks postpartum when care for further assessment. Targeted psychosocial
is transferred to the health visiting service.31 In interventions are recommended for women who
practice this transfer is likely to occur much earlier, have symptoms of depression and/or anxiety,
often within 14 days. The current NICE clinical but who do not meet the threshold for a formal
guideline for antenatal and postnatal mental diagnosis. Women who have a severe mental illness
health32 (p. 96) outlines the recommended care (such as bipolar disorder or schizophrenia) can
pathway to identify and treat women with PND. At expect to be referred to a specialist mental health
a womans first antenatal contact with primary care, service, including, if appropriate, a specialist
then at two postnatal contacts (usually at 46 weeks perinatal mental health service. Women who
and 34 months), health-care professionals need inpatient care for a mental disorder within
(including midwives, obstetricians, health visitors 12 months of childbirth should normally be
and GPs) routinely ask questions to identify admitted to a specialist mother and baby unit,
possible depression: (1) during the past month although these are not always available. For a
have you often been bothered by feeling down, woman who develops mild or moderate depression
depressed or hopeless? and (2) during the past during pregnancy or the postnatal period it is
3

2010 Queens Printer and Controller of HMSO. All rights reserved.


Background

stated that self-help strategies [guided self-help, managed in a particular NHS trust and how this
computerised cognitive behaviour therapy (CCBT) may potentially contrast with the management of
or exercise], non-directive counselling delivered at PND in other areas of the UK. Rotherham Primary
home (listening visits), brief cognitive behaviour Care Mental Health Service provides a service
therapy (CBT) or interpersonal therapy (IPT) are based in GP practices for common mental health
recommended by NICE.5 problems, including PND. Women can be referred
to the service by any practitioner, obstetrician,
Antidepressant drugs are considered for women midwife, health visitor or other health professional
with mild depression during pregnancy or the during both the antenatal and postnatal periods,
postnatal period if they have a history of severe if it is felt necessary. Rotherham Primary Care
depression and they decline, or their symptoms do Mental Health Service provides a service based in
not respond to psychological treatments. However, GP practices for common mental health problems,
it is noted that, to minimise the risk of harm to including PND. Women can be referred to the
the fetus or child, drugs should be prescribed service by any practitioner, obstetrician, midwife,
cautiously.5 There is also evidence that women health visitor or other health professional during
prefer non-pharmacological modes of intervention both the antenatal and postnatal periods, if it is
at this time.33 felt necessary. The NICE clinical guidance for
antenatal and postnatal mental health is used by
For women with a moderate depressive episode practitioners where PND is suspected and they are
or a history of depression, or those with a severe aware of the primary care mental health service
depressive episode during pregnancy or in the and how to refer into it (although it should be
postnatal period, it is recommended by NICE that noted that this service is not specific to PND). The
structured psychological treatment specifically for EPDS is not used. Once referred to the service,
depression (CBT or IPT) should be considered. women may attend the GP practice or be visited at
If the woman has expressed a preference for it home for assessment; women may then be offered
antidepressant treatment will be considered as six to eight sessions of individual treatment in
an alternative, or combination treatment will which CBT approaches and counselling are utilised
be considered if there is no response, or there by the primary care mental health service staff (J
is a limited response to psychological or drug Hunter, Head of Service, Primary Care Mental
treatment alone. Health Service, Rotherham Community Health
Services, 2008, personal communication). This
Services are ideally provided in a timely fashion service may differ from other services provided
to ensure that adverse effects on the health in the UK in the following ways: health visitors in
of the woman and her baby can be avoided.34 other services may routinely administer the EPDS,
Specifically, it is recommended that women which was previously used in the Rotherham service
requiring psychological treatment for PND should and may be used again in the future; there may
be seen for treatment normally within 1 month of not be a dedicated GP-based service for common
initial assessment, and no longer than 3 months mental health disorders; and individual CBT may
afterwards.5 not be routinely administered. The applicability
of the Rotherham model to other areas is also
Variation in services and/or likely to be limited owing to the wide variation in
uncertainty about best practice health service provision amongst Primary Care
Trusts (PCTs) with a reported range of whole time
The NICE guidance states that the structure of equivalent health visitors per child under 5 years
services varies in different parts of the country old of 165 in County Durham PCT to 894 in
because of local factors including the organisation Lambeth PCT.35
of existing mental health services, the demographic
profile of the population and geographical issues. As the section on current service provision
Recommendations are made to ensure local indicates, psychological interventions to treat
needs are met and integrated care is delivered, by pregnant and breastfeeding women are preferable
developing managed clinical networks involving to the use of psychotropic medication because of
linked groups of services in primary, secondary and the risks of harm to the fetus or child. However,
tertiary care. in reality there is a significant mismatch between
provision of psychological therapies and the
As services vary widely across the UK it is recommendations for their provision.34 Although
appropriate to provide details of how PND is undocumented it is widely held that conventional
4
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antidepressants are the usual first-line treatment with a psychiatric disorder (21%). Forty-two per
prescribed by GPs for women with PND. However, cent of trusts had no access to a specialist perinatal
women have been found to prefer psychological mental health service. Midwives provided most
intervention, rather than antidepressants, during antenatal and postnatal care but only 70% of trusts
the postnatal period.33,36 Furthermore, it is were able to refer women directly to mental health
common to prescribe antidepressants and provide specialists, this was not possible for the remaining
psychological therapies together, although a report 30%. Ninety-five per cent of trusts had access to a
suggests that there is no advantage in receiving mother and baby unit, it is assumed that the other
both, and that cognitive behavioural counselling 5% do not have any access to a mother and baby
and a separate antidepressant are equally unit, although this is not detailed in the report.
effective.33
The Healthcare Commission report concluded that
Previous attempts to improve services have there are inadequate provisions for mental health
had only limited success. A Royal College of needs in many trusts maternity services, including
Psychiatrists report suggests that, despite efforts to booking, speciality training, streamlining referral
improve the recognition of and screening for PND pathways and access to specialist services. If services
in primary care, little has changed.37 In a more are lacking for those with severe postnatal illnesses,
recent report by the Healthcare Commission31 the likelihood is that this will be the case with those
(now known as the Care Quality Commission) treated only in primary care for mild to moderate
it is stated that the recording of mental health depression associated with pregnancy and the
needs by maternity staff in trusts is inconsistent, postpartum period, although this is not explicitly
making it problematic to assess the prevalence covered in the Healthcare Commission report.
of mental health problems associated with child
birth. It reported the number of women receiving There is also uncertainty around the number of
a postnatal check-up of their own health and well- women with PND who may be undiagnosed or
being at 6 weeks postpartum as ranging between unidentified. It is reported that women are often
71% and 97%. Half of the trusts reported a rate of reluctant to pursue health care for PND for a
89% or below, showing that many women may not variety of reasons. These include a lack knowledge
be receiving postnatal checks with the GP. about the condition meaning they are not aware
they have it, thinking they could or were expected
The Healthcare Commission report in relation to cope with it without help, stigma and a fear of
to mental health focuses on input from perinatal failure a fear of losing their baby if they admit
psychiatry and puerperal psychosis and suggests to having PND, the fear of giving the family
that PND can be treated with support from a bad name, and the fear of being labelled as
mainstream services and does not usually require mentally ill.13,36 Cultural reasons have also been
specialist services. As women with a previous reported, these include the fact that the family may
history of mental health problems and those with discourage women from obtaining help as it is seen
depression during pregnancy are reported as at as unacceptable to discuss such issues with people
higher risk of developing postnatal illnesses,15,21 the external to the family. Furthermore, it is reported
data reported by the Healthcare Commission may that health professionals may limit the number of
have some relevance to PND. women who come forward for treatment for PND
by making inappropriate assessments and having
Data for the Healthcare Commission report31 were insufficient knowledge of PND to provide adequate
provided from 40 trusts, and of these the median care. It is also reported that women with PND feel
trust reported that 8% of women were identified health professionals have a tendency to normalise
at booking as having personal or family history depressive symptoms making women less likely to
of mental illness (range 230% across trusts). pursue treatments. They also feel that they have
Twenty-nine trusts provided data on referrals limited time with health professionals and are not
to mental health teams following booking; the taken seriously.36 These reports suggest that there
median number of women referred by these may be a significant number of women with PND
trusts to a mental health team was 1.6% (range who remain undiagnosed and that a clearer referral
07%). It was also reported that about a third of process may help address this.
trusts had joint clinics with mental health teams
for previous puerperal psychosis, and some had It is beneficial to improve the commissioning of
specialist midwives for women with previous effective antenatal and postnatal mental health
puerperal psychosis (19%) or to support women services for a number of reasons outlined in the
5

2010 Queens Printer and Controller of HMSO. All rights reserved.


Background

commissioning guide. These include improving the Trust, 2008, personal communication). The cost of
motherchild relationship, reducing inequalities a CBT session has been estimated as 6238 (based
and improving timely access to services in primary on a 55-minute session), therefore we estimate
care, mental health and maternity services; the cost per hour to be 68. Assuming 25 hours
reducing the risk of relapse; reducing the risk of of treatment and clinical supervision, the cost per
women stopping medication in an unplanned way; patient would be 1700. An alternative method
reducing the number of inappropriate referrals and based on health visitor hourly rate provides a
readmissions and the length of inpatient stays, and larger cost; the cost per hour of health visitor time
offering alternatives to admission; reducing the was estimated at 89 (based on information from
risk of self-harm and suicide; preventing avoidable Morrell et al.13 amended using inflation indices
separation of mother and baby; and improving to represent current prices), which equates to an
performance and person-centred clinical care.34 estimated cost of 2225 assuming a health visitor
was required for 25 hours per patient, although it
Current service cost is unclear whether these resources would be used in
reality and may be an overestimation.
It is assumed that usual care (UC) for PND includes
visits by midwives and health visitors, visits to
the GP, prescriptions for medication, and other Description of technology
health contacts, such as community mental health under assessment
contacts, clinical mental health contacts and social
services contacts. Based on these contacts, Morrell Summary of intervention
et al.13 report that costs at 6 months postpartum Cognitive behavioural therapy is a psychotherapy
for women scoring 12 or above on the EPDS are commonly practised in the NHS. CBT refers to
374 per patient. Health visitor costs per hour of a combination of concepts and techniques from
client time were reported as 77 for UC, and 79 cognitive and behaviour therapies. Cognitive
for those trained in using a cognitive behavioural therapy is derived from cognitive theories and
or person-centred approach. Overall costs at seeks to challenge negative automatic thoughts
6 months were 339 for those receiving CBT or with an aim of changing maladaptive thoughts
person-centred therapy. These prices were based and beliefs.39 Behavioural therapy refers to
on 20034 unit costs: prices using 20078 inflation a therapy derived from learning theory and
indices38 would equate to health visitor costs of works on symptoms by changing behaviour and
86 for UC and 89 for those trained to deliver an environmental factors that control behaviour. The
intervention, and overall costs as 419 for UC and patient works collaboratively with a therapist to
380 for intervention care. The findings of Morrell identify the types and effects of thoughts, beliefs
et al.13 provide some evidence that a psychological and interpretations on current symptoms, feelings
intervention delivered by health visitors is cost- states and/or problem areas. They develop skills to:
effective compared to UC. The costs related to UC identify, monitor and then counteract problematic
did not include any formal CBT treatment. thoughts, beliefs and interpretations related to the
target symptoms/problems; learn a repertoire of
The current NICE guidance recommends coping skills appropriate to the target thoughts,
psychological intervention such as CBT or beliefs and/or problem areas; and test out new
IPT for women with PND. On occasions where behavioural patterns.40
formal CBT is provided it is assumed in current
practice to be on an individual basis. If a course Cognitive behavioural therapy has an important
of individual CBT were offered this would most role to play in helping people with mental
likely be delivered by a CBT therapist, and would health problems. There is evidence to support
consist of around 12 sessions, 90 minutes in the use of CBT in the treatment of several
duration. One or two follow-up sessions may be mental health problems (e.g. depression, panic/
included and the therapist would be required to agoraphobia, social phobia, generalised anxiety
undertake clinical supervision for approximately disorder, obsessive compulsive disorder, bulimia,
1030 minutes per session; however, it should be etc.).39 However, it has also been reported that
noted that the current service provision of CBT psychological therapy is effective in the treatment
may vary widely (P Slade, Professor of Clinical of mild to moderate, non-childbirth related
Psychology, University of Sheffield and J Curran, depression.41 There is no evidence that CBT is
Consultant Cognitive Behavioural Psychotherapist, more effective than other psychological therapies
Sheffield Health and Social Care NHS Foundation in the treatment of the same condition. Specific
6
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to PND, a systematic review has indicated that include a flip chart, audio-visual equipment, and
psychosocial and psychological interventions are equipment to display powerpoint presentations (J
effective treatments.42 Furthermore, a recent trial Curran, personal communication). It is likely that
has demonstrated that psychologically informed services of this kind are very limited.
treatments delivered by trained health visitors are
clinically effective at 6 and 12 months for women The resources required using the delivery methods
with PND compared with UC.12 deemed by the authors to be most likely were group
CBT to become widely available would include
Cognitive behavioural therapy can be practised two group facilitators, a recently qualified clinical
in an individual or group setting; the potential psychologist and a health visitor.
benefits of providing CBT in a group setting
include increasing the availability of therapists, The criteria used for entry to the treatment
reducing waiting times and reducing costs. Group would normally include a diagnosis of DSM-IV
CBT differs from individual CBT only in the depression, or an elevated score on a self-report
respect that participants are treated in small measure such as the EPDS. However, those with
groups of around eight people, rather than in a subthreshold symptoms of PND or those with
one-to-one situation with their therapist. Group a history of depression may also be referred at
CBT treatment usually runs for 12 weeks, and the discretion of the GP (J Curran, personal
is often preceded by one individual session of communication).
2-hour duration with the purpose of assessing the
patient and briefing the patient regarding group Identification of important
treatment, and one or two sessions follow-up the subgroups
treatment. Thus, approximately 13 sessions are
required for the group treatment, each typically From a clinical perspective, PND includes four
of 2-hour duration. The group facilitators are subgroups of women whose management may
likely to require 12 hours for preparation and differ: (1) those who develop depression only after
supervision. Follow-ups may take place at 6 months childbirth; (2) those who have developed antenatal
and sometimes at 12 months, but may vary to depression which continues into the postnatal
a large extent. Group psycho-educational CBT period; (3) those with pre-existing chronic or
is lower impact than normal group CBT and is relapsing depression; and (4) subthreshold groups.
usually delivered in a smaller number of sessions, It was not possible to assess the efficacy of group
four to six opposed to 1012 (J Curran, personal CBT for these subgroups separately because of a
communication). lack of available data.

There is little available evidence on the service Anticipated costs associated


provision of group CBT specifically for PND. For with intervention
this reason we have provided details of service
provision from two sources. The first from a UK As detailed in the Summary of intervention
study which has reported data on the efficacy of section, because of the little available evidence on
group CBT for PND,43 and the second based on the service provision of group CBT specifically
the delivery methods deemed by the authors to for PND, details of service provision have been
be most likely were group CBT to become widely provided both from a UK randomised controlled
available. trial (RCT)43 and also based on the delivery
methods deemed by the authors to be most likely
The UK study43 indicates that it is likely that were group CBT to become widely available.
two health visitors trained to use a cognitive
behavioural approach would normally deliver Based on the UK RCT43 it is estimated that one
group CBT for PND. Clinical psychologists, mental programme of group CBT treatment would
health workers and nurses may also be involved in include eight sessions, occurring once per week
supervision or run groups, but this is less likely to for a duration of 2 hours. It is assumed that the
occur. Although not reported in this study, group group sessions would also be preceded by a 2-hour
CBT for PND would usually take place at the individual session for the initial assessment of each
health visitor base which is often the GP surgery. participant. The average number of participants
In some situations the setting could also be a for the treatment was reported as five. It is assumed
health centre or another community-based facility. that preparation time would be required for
Minimal equipment would be required, but would each session and this would equate to 1 hour per
7

2010 Queens Printer and Controller of HMSO. All rights reserved.


Background

health visitor per session, and a further hour per per session per health visitor would be required
session per health visitor would be required for for travelling to and from the sessions (G Parry,
travelling to and from the sessions. Based on these University of Sheffield, P Slade, University
parameters the health visitor time required would of Sheffield, J Hamilton, St Johns Hospital,
be 74 hours, cost per hour of health visitor time West Lothian, Clinical experts, 2008, personal
was estimated at 89 (based on information from communication). Facilitator time required would
Morrell et al.13 amended using inflation indices to be 112 hours, cost per hour of facilitator time
represent 20078 prices). This equates to a total was estimated at 89 (based on information from
health visitor cost of 6586 and a total cost per Morrell et al.13 amended using inflation indices
participant of 1317. to represent current prices). This equates to a
total facilitator cost of 9968 and a total cost per
The authors estimated that two group facilitators participant of 1246.
would be required, a recently qualified clinical
psychologist and a health visitor. The programme We assume the group facilitators would be
would consist of 12 sessions occurring once per undertaking their normal duties relating to UC
week for a duration of 2 hours. These would during the rest of the week. The costs presented
be preceded by a 2-hour individual session for may be slightly underestimated as they do not
the initial assessment. The average number of include any set up costs or additional running
participants for the treatment was estimated as costs, such as room hire and crche facilities, which
eight. Preparation time was estimated as 1 hour may be incurred (J Hamilton, Psychiatrist, personal
per health visitor per session, and a further hour communication).

8
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Chapter 2
Definition of the decision problem

Decision problem Overall aims and objectives


Interventions The focus of this report is on of assessment
the use of CBT; however, this may form
only a component of an overall treatment The overall aim of the review was to evaluate the
package. All interventions that incorporate a clinical effectiveness and cost-effectiveness of group
form of psycho-education (i.e. any psycho- CBT compared with currently used packages of
educational activity that is informed by care for women with PND. The purpose of the
cognitive behavioural theory or technique) in a project was to apply rigorous methods of systematic
group setting were included. All settings were reviewing, evidence synthesis and decision analytic
included. The included studies therefore were modelling to evaluate group CBT for PND.
required to specifically refer to the use of CBT
when describing their intervention. Therefore, The objectives of the review were:
when we refer to group CBT we are referring
to a group programme which incorporates, To determine the relative clinical efficacy of
or claims to incorporate, some level of CBT group CBT treatment compared with currently
theory or technique. The degree to which each used packages of care for women with PND. A
study actually reflects and incorporates CBT full systematic review of the literature will be
theory or technique will be assessed. undertaken to provide evidence on efficacy.
Population including subgroups The population To provide a detailed user perspective on
was defined as women meeting the criteria the acceptability and potential harms of
of a standardised PND diagnosis through group CBT, a second systematic review will
using DSM-IV, or women designated at being be undertaken on the available qualitative
at risk of depression through their scores on research literature.
the EPDS, subthreshold women referred by To undertake a full synthesis of available
their GP, women with PND in the postpartum evidence. This will include the use of a
period (up to 1 year) and women with no higher level synthesis of the data with mixed-
other comorbid psychiatric disorder or major treatment comparisons if appropriate.44
medical problems. From a clinical perspective, To estimate the cost-effectiveness of group
PND includes four subgroups of women whose CBT for PND. This will include a systematic
management may differ: (1) those who develop review of published economic evaluations in
depression only after childbirth; (2) those who the area and identification of other evidence
have developed antenatal depression which needed to populate an economic model. Cost-
continues into the postnatal period; (3) those effectiveness will be assessed in terms of the
women with pre-existing chronic or relapsing incremental cost per quality-adjusted life-year
depression; and (4) subthreshold groups. (QALY) gained. Uncertainty will be explored by
Relevant comparators All comparators were probabilistic sensitivity analyses (PSA) with data
considered (e.g. comparators that function as displayed using cost-effectiveness acceptability
specific comparisons as well as controls). These curves (CEACs).45
included routine primary care (RPC) and To determine the value of collecting further
individual CBT. data on all or some of the input parameters, an
Outcomes All outcome measures were expected value of information analysis will be
considered in both reviews of the quantitative performed, if deemed appropriate.4648
and qualitative research literature.

2010 Queens Printer and Controller of HMSO. All rights reserved.


DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Chapter 3
Assessment of clinical effectiveness

Methods for reviewing the same strategy was used with minor alterations
effectiveness necessary for specific databases. The searches were
Identification of studies undertaken in January 2008. The databases were
searched from 1950 to 2008, the actual date range
Search strategies for each of the databases searched depended on
The search aimed to identify all references relating the coverage of the individual database.
to the clinical effectiveness of group CBT for PND.
The original intention was to synthesise evidence Search restrictions
within the framework of a mixed-treatment The searches were intended to be as broad as
comparison;44 however, during the early stages possible, and whilst they were restricted to human
of the research it became clear that the clinical studies where possible, they were not restricted by
evidence regarding group CBT was relatively language, date, publication type or study design.
poor. As such, confidence in building a coherent Non-English papers were excluded at the sifting
network that contained comparable study designs stage rather than setting this as an inclusion
and homogeneous participants was low. The use criterion.
of substantial resources to construct a comparison
with potential low internal validity was not deemed Inclusion and exclusion criteria
appropriate.
Population
Sources searched Included: Women in the postpartum period (up
Seventeen electronic bibliographic databases were to 1 year), meeting the criteria of a standardised
searched, covering biomedical, health-related, PND diagnosis using DSM-IV, or scoring above
science, social science and grey literature (including cut-off on the EPDS. No exclusion was made on
current research). A list of the databases searched is the basis of the standardised depression screening/
provided in Appendix 1. case finding instrument of standardised clinical
assessment tool used to define PND.
In addition, the reference lists of relevant articles
were checked and various health service-related Excluded: Prenatal women, women with other
resources were consulted via the internet. comorbid psychiatric disorders or major medical
These included health technology assessment problems, and women who have been involved in a
organisations, guideline producing bodies, generic previous psychological programme.
research and trials registers, and specialist mental
health sites. A list of these additional resources is Intervention
given in Appendix 1. Included: All interventions that included elements
designated as deriving from cognitive behavioural
Search terms principles including those that are purely psycho-
A combination of free-text and thesaurus terms education (i.e. any psycho-educational activity
were used. Key papers identified through initial which is informed by cognitive behavioural theory
scoping searches were used to develop keyword or techniques) in a group setting.
strategies. Population search terms (e.g.
depression, postpartum, postnatal depression and Setting
post pregnancy depression) were used to identify Included: All settings.
any references related to this population. The
searches were not restricted by intervention because Comparator
of the complexity of defining the intervention and Included: All comparators were considered. These
to prevent omission of relevant references. Copies included RPC, waiting list, individual CBT, group-
of the search strategies used in the major databases based counselling, medication, group behaviour
are included in Appendix 1, for the other databases therapy and group IPT.
11

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

Outcomes psychosocial interventions, and group IPT).


Included: All outcomes measures were considered The CBT studies were analysed in full and the
for reviews of the quantitative and qualitative support group studies were presented only as
research literature. The outcomes analysed for a comparator, noting that there were inherent
the quantitative review were depression measured differences between support groups and
using the EPDS and the BDI. Both of these structured time-limited intervention groups.
depression measures have been demonstrated as Child development outcome measures were not
valid and reliable in identifying symptoms of PND analysed because of the lack of available data
and depression, respectively.49,50 Outcomes for the contained in the included studies.
qualitative review included case study, interview, Three subgroups of women whose management
and observational data gathered from group may differ have been highlighted: (1) those
participants and group facilitators. who develop depression only after childbirth;
(2) those who have developed antenatal
Study type depression which continues into the postnatal
Included: The quantitative review papers were period; (3) those with pre-existing chronic or
assessed according to the accepted hierarchy of relapsing depression; and (4) subthreshold
evidence, whereby systematic reviews of RCTs women. Owing to the lack of available data in
were taken to be the most authoritative forms of the included studies these subgroups were not
evidence, and uncontrolled observational studies separated in either the clinical effectiveness or
the least authoritative.51 Unpublished studies cost-effectiveness analyses.
were considered for inclusion. Non-RCT evidence
was included in this review to supplement the Quality assessment strategy
limited amount of RCT evidence. Case studies
were not included in the quantitative review. For Deeks et al.54 suggest that the Downs and Black55
the qualitative review, any papers incorporating a checklist for the assessment of the methodological
qualitative approach were included. quality both of randomised and non-randomised
studies of health-care interventions is the most
It was necessary to make a number of alterations to appropriate checklist to assess non-RCTs. As this
the original protocol, these are outlined below. checklist can be applied to both RCTs and non-
RCTs, all included papers were assessed using this
Although it was stated in the inclusion criteria checklist. Qualitative studies were assessed using
that only studies investigating women in the the qualitative version of the Critical Appraisal
postpartum period of up to 1 year would Skills Programme (CASP).56 Key components of
be included it proved difficult to ascertain the quality appraisal are listed as part of the data
the time postpartum for a number of the extraction tables in Appendices 2 and 3.
included studies. A number of studies either
failed to report time postpartum or included Data extraction strategy
both women who were less than and greater
than 1-year postpartum. These studies were All full papers were read by two reviewers (AS and
included in the review with clear details on the DS) who made independent decisions regarding
postpartum status of the participants where inclusion or exclusion, and consensus, where
information was available. possible, was obtained by meeting to compare
The definition of the intervention was decisions. In the event of disagreement, a third
modified such that at least a component of the reviewer (EK) read the paper and made the
intervention had to be explicitly described as decision. All data from included quantitative
CBT or informed by CBT. studies were extracted by one reviewer (AS) using
A further addition related only to the a standardised data extraction form. All data from
qualitative review. The searches produced included qualitative studies were extracted by two
only two qualitative papers examining group reviewers (AS and AB) using a standardised data
CBT for PND,52,53 the inclusion criteria were extraction form with disagreements resolved by
therefore broadened to include any non- discussion. Two different data extraction forms
specific group treatment for PND, with the were used, one for the quantitative papers and a
exclusion of group treatments based on other second for the qualitative papers.
specific theoretical frameworks (e.g. group

12
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Data synthesis table to form themes with supporting quotations.


Quantitative review Themes were assessed to ascertain whether they
Studies were assessed for suitability of pooling could be structured, whether they may inter-relate,
results with regard to populations, comparators and whether they could be organised hierarchically,
outcomes and study type. Both RCTs and non- to produce synthesised findings. Synthesised
RCTs were considered for data synthesis. The findings could be used to inform practice or policy
main outcome measure of interest was change in in the form of standardised documentation.
depression. It was considered important to provide
a meta-analysis of the studies using the depression
outcome measure if possible and to undertake a Results
narrative analysis of the studies in addition to the
Quantitative papers
meta-analysis or as an alternative approach.
Quantity and quality of research
Qualitative review available
A qualitative evidence synthesis was undertaken For this review a total of six relevant quantitative
for data extracted from the included qualitative studies of clinical effectiveness were identified,
papers. A thematic data-driven approach was of which three were RCTs43,58,59 and three were
employed in recognition that the review did not non-randomised trials.6062 The evidence tables
start from a theoretical stance. For similar reasons for these studies are presented in Appendix 2.
the team judged an integration/aggregation The qualitative studies are considered later in
approach to the synthesis of the data as more this section with evidence tables in Appendix 3.
appropriate than an interpretive approach.57 This Figure 1 shows the quality of reporting of meta-
approach entailed data from each study being analyses (QUOROM) flowchart for the included
extracted and grouped together in a meta-synthesis quantitative studies.

Potentially relevant papers identified


and screened for retrieval
n = 7633
Studies excluded at title sift
n = 4182

Total abstracts screened


n = 3451
Studies excluded at abstract sift
n = 3298

Total full papers screened


n = 153
Studies excluded at full paper sift
n = 130

Studies potentially relevant


n = 23
Studies excluded on the basis of
inclusion/exclusion criteria
n = 17
Total included full papers
n=6
RCTs n = 3
Non-RCTs n = 3

FIGURE 1 Summary of study selection and exclusion of quantitative papers.


13

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

Tables relating to those studies excluded at full that the groups followed a structured format;
paper sift with reasons for exclusion are presented however, the use of a manual was not reported.
in Appendix 4 (see Tables 4750). The use of antidepressants also formed part of
the intervention and medication use proved to be
Study characteristics much higher in the intervention group than in the
Study characteristics for the six studies are control group. The Clark et al.61 study examined
described in Appendix 2, and a summary of this a group that provided therapeutic intervention
information is provided in Table 2. RCTs are and peer support. Exercises and strategies were
presented followed by non-randomised trials in drawn from CBTs, although it was reported that
date order. the intervention was not proscribed by a manual.
In addition to the 1-hour womens group, there
Description of group CBT was an additional motherinfant dyadic group
Included studies were those whose interventions which lasted 30 minutes; therefore the findings
incorporated any psycho-educational activity which of the study may be confounded by this co-
is informed by cognitive behavioural theory or therapy. Information on the content of the group
technique, in a group setting. The included studies interventions extracted from the studies is provided
therefore were required to specifically refer the use in Appendix 2 (Tables 18 and 19).
of CBT when describing their intervention. Varying
degrees of detail regarding the description of the In summary, three studies43,59,60 specifically referred
group programmes were provided and in the main to at least a CBT component which appeared to
these descriptions were brief. Therefore, when we be a core, predefined aspect of the treatment. It
refer to group CBT we are referring to a group should be noted that this could not be claimed
programme that states that it incorporates some with any certainty for the Highet and Drummond60
level of CBT theory or technique. study because of poor reporting. The definitions
used in the other three studies58,61,62 were somewhat
It was deemed important to assess the degree ill-specified and it was unclear whether CBT was a
to which the interventions used in each study core aspect of the group treatment.
actually reflected and incorporated CBT theory or
technique. The CBT components of the studies are Study quality
described here and studies are presented in order The Downs and Black checklist55 was used to assess
of relevance to group CBT. The Milgrom et al.59 both the randomised and non-randomised studies.
study was judged to most accurately reflect group Key components of the quality assessment are listed
CBT for a number of reasons. The intervention in Table 3 and in Appendix 2 (see Tables 18 and 19).
was termed group-based CBT rather than a group The components of the checklist used to assess the
incorporating CBT theory or techniques, and studies included (1) the standard of reporting, (2)
it was reported to be clinic-based and delivered the external validity of the study, (3) the internal
according to detailed manuals. The Highet validity of the study, and (4) power to detect
and Drummond60 study specifically reported changes in depression.
the use of group CBT; however, no further
details were reported. The Honey43 study used 1. To assess the standard of reporting the
the term brief psycho-educational group and following issues were examined: whether there
specifically referred to use of cognitive behavioural were clearly described objectives, outcomes,
techniques as one of the three aspects of the patient characteristics, interventions and
group intervention; it also stated that although findings; whether estimates of random
the intervention was not proscribed by a manual, variability for main outcomes were assessed;
a predefined programme was employed. Meager and whether adverse events had been reported.
and Milgrom62 referred to their intervention as a 2. For external validity, the representativeness
cognitive behavioural treatment programme, and of the sample and representativeness of the
the cognitive behavioural component was reported intervention and its setting were assessed.
as one of eight components of the programme, 3. The following issues were considered to assess
they did not refer to the use of a manual. The internal validity (bias): blinding; whether
Rojas et al.58 study was less specific in describing data dredging had been used; whether follow-
the group intervention. The group was referred to up time was equivalent for controls and
as a psycho-educational group (PEG) and among experimental groups; whether appropriate
other aspects included behavioural activation statistical analyses had been applied; the
and cognitive techniques. The authors stated compliance with interventions; and the
14
TABLE 2 Summary of study characteristics for the six included studies
DOI: 10.3310/hta14440

Author (date), Dates of Duration, numbers in


study type, setting Sample size measurement group, etc. Intervention (s) Comparator
58
Rojas et al. (2007), 114 MCI group; Baseline prior to Group treatment one MCI included PEG and structured UC all services
RCT, Chile 116 UC randomisation; 3 months session per week for 8 pharmacotherapy if needed normally available in
after randomisation; weeks; 50 minutes in the clinics, including
and 6 months after duration; maximum 20 antidepressant drugs,
randomisation attendees brief psychotherapeutic
interventions, medical
consultation or external
referral for speciality
treatment
Milgrom et al. 46 group- Baseline prior to Group-based CBT one- Group-based CBT designed to address RPC the routine care
(2005), 59 RCT, based CBT; 47 randomisation; 12 weeks session per week for 9 specific target behaviours within the context of provided via the states
Australia group-based after treatment began; 12 weeks, 90 minutes in general components recognised as important in universal Maternal and Child

2010 Queens Printer and Controller of HMSO. All rights reserved.


counselling; months after the end of duration; 510 attendees determining the success of cognitive behavioural Health Service
66 individual treatment (although too intervention. Each session involved psycho-
counselling; 33 few data for analysis) education, review of homework exercises, role
RPC playing and discussion1
Group-based counselling designed for depression
Individual counselling
Honey (2002),43 RCT, 23 controlled Baseline prior to Controlled PEG one- Controlled PEG educational information on RPC further details not
UK PEG; 22 RPC randomisation; at the end session per week for PND, strategies for coping, use of cognitive provided
of treatment 8 weeks; 8 weeks, 2 hours in behavioural techniques, relaxation
6 months after the end of duration; four to six
treatment (i.e. 8 months) attendees

continued
Health Technology Assessment 2010; Vol. 14: No. 44

15
16
TABLE 2 Summary of study characteristics for the six included studies (continued)

Author (date), Dates of Duration, numbers in


study type, setting Sample size measurement group, etc. Intervention (s) Comparator
Highet and 136 in combined Baseline; following NR Eight different, not mutually exclusive, treatment WLG participants who had
Assessment of clinical effectiveness

Drummond (2004),60 treatment treatment (which differed groups to wait at least 3 weeks to
non-RCT, Australia groups; 10 WLG in duration); 6 months receive group intervention
after end of treatment
Clark et al. (2003),61 13 MITG; 15 Baseline prior to MITG one session per MITG, IPT and infant development group WLG those waiting to
non-RCT, USA IPT; 11 WLG treatment; at the end of week for 12 weeks, 90 occurred simultaneously, followed by mother receive MITG
treatment 12 weeks minutes in duration (60 infant dyadic group. Based on interpersonal,
minutes for mothers psychodynamic, family systems, and cognitive
group, 30 minutes for behavioural approaches
motherinfant dyadic IPT group individual therapy, relating to partners,
activities); number of children and others
attendees not reported
Meager and Milgrom 10 group Baseline prior to Group treatment one Group treatment programme consisting WLG had the opportunity
(1996),62 non-RCT, treatment; 10 allocation and beginning session per week for of targets which take into consideration the to participate in the
Australia WLG of treatment; at the end 10 weeks, 90 minutes in risk factors for postpartum depression. An treatment programme
of treatment 10 weeks duration; 10 attendees environment of social and emotional support, an once the participants in
educational component, a cognitive behavioural the treatment group had
component, encouragement of networking, completed the programme
examination of patterns of communication,
normalising of feelings, involvement of spouse in
the group, practical homework

MCI, multicomponent intervention; MITG, motherinfant therapy group; NR, not reported; PEG, psycho-educational group; RPC, routine primary care; WLG, waiting list group.
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

TABLE 3 Assessment of study quality for the six included studies

Author (date),
study type, setting Quality
Rojas et al. (2007), 58
Reporting: Objectives, outcomes, patient characteristics and interventions clearly described, results
RCT, Chile difficult to interpret. Estimates of random variability given for main outcomes. Adverse events were
not reported
External validity: Baseline characteristics of participants were not compared across groups using a
statistical test although they appeared to be well matched. The intervention was not representative
of UC for this population
Internal validity: Participants could not be blinded; recruiters and assessors were blind to treatment
allocation. Data dredging was not used. Follow-up times were equivalent for each group.
Appropriate statistical analyses were employed. It is unclear whether compliance with interventions
was reliable, as the experimental intervention was multicomponent making the assessment of the
effects of group treatment difficult, and the control group were not receiving identical treatment,
as is the case in UC. Outcome measures were reliable and valid. Participants were in different
intervention groups. Randomisation was individually based with use of computer-generated random
numbers. Numbers lost to follow-up were reported, but reasons for loss to follow-up not reported
Power: Calculation reported
Milgrom et al. Reporting: Objectives, outcomes, patient characteristics and interventions clearly described, results
(2005), 59 RCT, difficult to interpret as combined scores used. Estimates of random variability given for main
Australia outcomes although only for combined scores. Adverse events were not reported
External validity: Baseline characteristics of participants were not compared across groups, reported
for all participants together. The interventions were not representative of UC for this population
Internal validity: Assessors blinded. Participants blinded until treatment started. Data dredging was
not used. Follow-up times were equivalent for each group. Appropriate statistical analyses were
employed, although combined analyses were performed making interpretation regarding individual
interventions difficult. It is unclear whether compliance with interventions was reliable, as it is not
clear whether participants in the experimental conditions were receiving other treatment. The
control group may not have been receiving identical treatment, as is the case in routine primary
care. Outcome measures were reliable and valid. Participants were in different intervention groups.
Randomisation was performed by cycling allocation and by drawing lots (one coded slip of paper
drawn from a bag containing multiple slips coded in equal number for each of the four treatment
conditions). Numbers lost to follow-up were reported, but reasons for loss to follow-up not
reported
Power: Calculation reported
Honey (2002),43 RCT, Reporting: Objectives, outcomes, patient characteristics, interventions and results clearly described.
UK Estimates of random variability given for main outcomes. Adverse events were not reported
External validity: Baseline characteristics of participants were compared across groups using a
statistical test. The intervention was not representative of UC for this population
Internal validity: Details of blinding were not reported. Data dredging was not used. Follow-up times
were equivalent for each group. Appropriate statistical analyses were employed. It is not clear
whether compliance with interventions was reliable; antidepressant use was included as a covariate
in the analyses. However, the control group may not have been receiving identical treatment,
as is the case in routine primary care. Outcome measures were reliable and valid. Participants
were in different intervention groups. Randomisation was performed using a block randomisation
procedure. Numbers lost to follow-up were reported, but reasons for loss to follow-up not
reported
Power: Calculation not reported
Highet and Reporting: Objectives and outcomes clearly described, limited patient characteristics reported and
Drummond (2004),60 not clearly described, and interventions were not clearly described. The results were difficult to
non-RCT, Australia interpret because of participants being included in more than one intervention group. Estimates of
random variability given for main outcomes. Adverse events were not reported
External validity: Baseline characteristics of participants were not compared across groups using
a statistical test and it was difficult to ascertain whether they were well matched because of
the limited detail reported. The interventions were representative of the array of UC for this
population, due to the retrospective nature of the trial

continued

17

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Assessment of clinical effectiveness

TABLE 3 Assessment of study quality for the six included studies (continued)

Author (date),
study type, setting Quality
Internal validity: No blinding was employed as the study was retrospective. Data dredging was
used. Follow-up times differed depending on the treatment given. Appropriate statistical analyses
were employed, although these were combined analyses making interpretations regarding specific
interventions difficult. Compliance with interventions was not reliable as the intervention groups
were overlapping, although data for some intervention groups were presented separately. The
control group was very small and participants were not receiving any treatment. Outcome
measures were reliable and valid. Participants were not in different intervention groups in all cases.
No randomisation took place because of the retrospective nature of the study. Numbers lost to
follow-up were reported and not included in the study, reasons for loss to follow-up were reported
Power: No power calculation was reported
Clark et al. (2003),61 Reporting: Objectives, outcomes, patient characteristics, interventions and results clearly described.
non-RCT, USA Estimates of random variability given for main outcomes. Adverse events were not reported
External validity: Baseline demographic characteristics of participants were compared across groups
using a statistical test, pretreatment depression scores were included as a covariate in the analyses.
The interventions were not representative of UC for this population
Internal validity: No blinding was reported. Data dredging was not used. Follow-up times were
equivalent for each group. Appropriate statistical analyses were employed. It was not clear
whether compliance with interventions was reliable; other treatments may have been prescribed
simultaneously. The motherinfant dyadic activities may have confounded the group intervention.
It was not clear whether the control group were receiving any treatment during the waiting period.
Outcome measures were reliable and valid. Participants were in different intervention groups. No
randomisation was performed; participants were matched and sequentially assigned to groups.
Numbers lost to follow-up were reported, but reasons for loss to follow-up not reported
Power: No power calculation was reported
Meager and Milgrom Reporting: Objectives, outcomes, patient characteristics and interventions clearly described, results
(1996),62 non-RCT, difficult to interpret because of statistical tests used. Estimates of random variability not given for
Australia main outcomes. Adverse events were not reported
External validity: Baseline characteristics of participants were compared across groups using a
statistical test. The intervention was not representative of UC for this population
Internal validity: No blinding was reported. Data dredging was not used. Follow-up times were
equivalent for each group. Appropriate statistical analyses were not employed or not reported.
Compliance with interventions appeared reliable. Medication use was reported and post hoc
examination revealed no significant differences between the groups on medication usage. Outcome
measures were reliable and valid. Participants were in different intervention groups. The study was
reported to be randomised but method was not reported. Numbers and reasons for loss to follow-
up provided
Power: No power calculation reported

reliability and validity of outcome measures. To all three RCTs, blinding of participants is not
assess internal validity confounding (selection possible for psychological interventions owing
bias), the following were considered: whether to their nature; however, two studies reported
participants were in different intervention blinded assessment,58,59 and two58,59 reported power
groups, whether randomisation had been calculations. All three RCTs reported numbers lost
used, whether adjustment for confounding in to follow-up, but none reported reasons for loss to
the analyses were employed [were intention- follow-up.
to-treat (ITT) analyses employed], and the
reporting of loss to follow-up. Non-randomised controlled
4. Power was also considered by assessing whether trials
the study had employed a power calculation.
The three non-randomised studies were Meager
Randomised controlled trials and Milgrom,62 Clark et al.61 and Highet and
Drummond.60 Participants included in the Meager
Of the six included studies three43,58,59 were RCTs. and Milgrom62 study were volunteers and were
The method of randomisation was reported in reported to be randomly assigned to either the
18
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

group treatment or a waiting list group (WLG); CBT to IPT (and RPC). One RCT59 compared
however, the randomisation method was not group CBT to group counselling and individual
detailed. The Highet and Drummond study60 was a counselling (and RPC). One non-RCT60 compared
retrospective study which examined patient records; a number of different conditions (with overlapping
therefore, no randomisation had taken place. populations); non-overlapping conditions were
In the Clark et al.61 study, suitable participants group CBT only, individual CBT only and
were referred for the treatment by a health-care medication only (but not to RPC as noted above).
provider. Sequential assignment to group treatment
or to the waiting list was performed on the basis Sample size and drop-out rates
of matching for sociodemographic variables. A Sample sizes are shown in Table 2. The sample sizes
third individual treatment group was added later. for the included studies were relatively large for two
Owing to the retrospective nature of the Highet of the RCTs58,59 and relatively small for Honey,43
and Drummond60 study, no blinded assessment Clark et al.61 and Meager and Milgrom.62 The
was performed. Meager and Milgrom62 and Clark Highet and Drummond60 study had a relatively
et al.61 did not report that the assessment had large sample size due to its retrospective nature
been blinded. None of the non-RCTs presented a and the large number of conditions analysed, but
power calculation. Meager and Milgrom62 detailed as noted above participants who dropped out of
numbers and reasons for loss to follow-up, these treatments were not included in the analyses. Of
included physical illness, need to support de facto the RCTs, Rojas et al.58 had a large sample size
husband who was on a methadone programme, (>200) with relatively low drop-out rates (21 at
difficulty in organising attendance and distance to 3 months, 22 at 6 months), Milgrom et al.59 had
travel. Clark et al.61 gave numbers but not reasons a large sample size (>192) but had a relatively
for loss to follow-up. Highet and Drummond60 was large number of dropouts prior to the start of
a retrospective study therefore participants who the interventions (52). Honey43 had a moderate
had been lost to follow-up were not included in sample size (<50) and relatively low drop-out rates
the study at all. Reasons were provided for loss to before intervention (four) but these participants
follow-up, these included not being contactable were followed-up, although three participants in
post treatment, not considered to have PND by each condition who did participate could not be
their health-care provider, refusal to take part followed-up (six). Of the non-RCTs, Meager and
in the study and stopping treatment prior to Milgrom62 had a small sample size (20) with only
completion. one dropout prior to intervention; Clark et al.61 had
a relatively small sample size (40) with a relatively
Co-therapy or medication low drop-out rate before intervention for the group
Concurrent use of antidepressants was reported in treatment (four). The Highet and Drummond60
Rojas et al.,58 Honey,43 and Meager and Milgrom,62 study had a relatively large sample size overall;
although not controlled for in Rojas et al.,58 however, the relevant treatment condition sample
making interpretations regarding the effects of was of moderate size (<60).
group treatment problematic. Both cotherapy
and medication use was reported in Highet Therapy details
and Drummond60 and was controlled for in the
analyses. No medication was detailed in Milgrom Table 3 and Tables 22 and 23 in Appendix 2 describe
et al.59 and Clark et al.,61 although the intervention the details of therapy for the three RCTs and three
group participants in the Clark et al.61 study were non-RCTs.
also receiving motherinfant dyadic therapy.
Recruitment
Comparators For the RCTs, participants were recruited from
Comparators are shown in Table 3 and in Appendix a community screening programme of newly
2 (see Tables 18 and 19). All six included studies delivered mothers at 618 weeks postnatal, and
had a comparison arm.43,5862 Five of the studies, the were invited to take part if they scored 12 or
three RCTs43,58,59 and two non-RCTs61,62 compared above59 on the EPDS (the cut-off used for the Rojas
group CBT to RPC or a WLG [although it should et al.58 study was 10 or above), from three clinics
be noted that definitions of RPC and waiting list at any stage during the first postnatal year,58 or
vary across the studies, details are provided in referred by health visitors if they were attending
Table 3 and in Appendix 2 (see Tables 20 and 21)]. mother and baby clinics.43 For the non-RCTs,
Only one non-RCT60 compared group CBT to recruitment was through health-care provider
individual CBT. One non-RCT61 compared group referrals and newspaper advertisements,61 and
19

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

through advertisements in local hospitals and Therapist background


maternal and child health centres; some of these Of the six included studies, five gave details of the
women were already attending outpatients for therapist who ran the group sessions and their
treatment of mood disorders.62 The final non- background.43,58,59,61,62 One study did not provide
RCT60 was a retrospective study of women who had any details.60 Milgrom et al.59 reported that one of
sought or been referred to treatment for PND from two senior therapists delivered the interventions,
clinics and through a range of health professionals. supported by cotherapists with professional
The treatments included medication, group registrations and backgrounds in clinical
and individual CBT, and group and individual psychology, postgraduate psychology researcher
behaviour therapy. and nurse with postgraduate qualifications in
counselling and/or psychology. All received
Number and length of sessions and one-to-one instruction in the use of the therapy
number of attendees manuals and regular, intensive supervision from
Of the six included studies, five43,58,59,61,62 gave the principal investigator. Honey43 reported that
details of the number and length of sessions, and health visitors administered the programme, no
four43,58,59,62 gave details of the number of attendees further details were given. Rojas et al.58 reported
for the CBT group intervention. The number of that midwives or nurses with 8 hours of training
sessions ranged from 8 to 12 weekly sessions, the ran the sessions and that a medical doctor was
length of sessions ranged from 50 to 120 minutes responsible for the group. The midwives and
and the number of attendees ranged from 4 to nurses were given supervision every week. Meager
20. One study did not provide any details,60 and and Milgrom62 reported that a clinical psychologist
a further study did not provide details of number ran the sessions. Clark et al.61 reported that three
of attendees per group session.61 The five studies licensed psychologists, three social workers,
that provided details all ran sessions once per three psychology interns and three postdoctoral
week. Rojas et al.58 reported that group treatment fellows with at least 2 years of clinical experience
was administered for 8 weeks, with each session administered the sessions. Variability in therapist
50 minutes in duration and the maximum number effectiveness can account for variance in treatment
of attendees per group was 20. Milgrom et al.59 outcomes.63 Given that few therapists were involved
reported that the treatment programme ran for in facilitating the interventions reported in each
9 weeks, with each session 90 minutes in duration study it should be noted that a particularly good
and each group had 510 attendees. Honey43 or poor therapist could have markedly affected the
reported that the treatment group ran for 8 weeks, results.
was 2 hours in duration and had four to six
attendees. Clark et al.61 reported that the group Study site, follow-up and
treatment was administered for 12 weeks and was inclusion/exclusion criteria
90 minutes in duration, although 60 minutes was
devoted to the group intervention and 30 minutes Tables 24 and 25 in Appendix 2 describe the details
to the motherinfant dyadic intervention. The of study site, follow-up and inclusion/exclusion
number of attendees was not reported. Meager and criteria for the three RCTs and three non-RCTs.
Milgrom62 reported that sessions ran for 10 weeks,
were 90 minutes in duration and had 10 attendees. Study site and setting
It should be noted that none of these studies has One of the studies was conducted in the UK,43 one
used a group CBT structure that matches exactly was conducted in Chile,58 three were conducted in
the assumed structure of group CBT for PND in Australia,59,60,62 and the final study61 did not report
the UK. However, one study43 is similar in terms of the study site, although it is assumed that the study
length of the treatment programme and duration took place in the USA as this was the place of
of the sessions, although the number of attendees funding.
was much lower with four to six than would be
expected for CBT groups which are currently Follow-up
provided in the UK. These would typically Reasons for loss to follow-up were not reported in
include an average of eight participants (G Parry, five43,5861 of the six included studies. Meager and
P Slade, J Hamilton, Clinical experts, personal Milgrom62 did provide reasons for loss to follow-
communication). up, including physical illness and difficulty in
organising attendance. Follow-up exceeded 60% in
all studies.

20
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Inclusion and exclusion criteria six had a semi-professional occupation, six were
Five43,58,59,61,62 studies included in the review had in sales or business management, two worked in
clearly stated inclusion criteria; however, one skilled occupations and four were housewives.62
study61 did not report exclusion criteria. The sixth The final study reported the mean educational
study60 did not report selection of participants level for each group; this was 14.9 years for the
using a standardised diagnostic measure as part of motherinfant therapy group (MITG), 15.5 years
the inclusion criteria. for the IPT group and 16 years for the WLG.61 Two
studies did not report this information.43,60
Patient characteristics
Some details of patient history were reported in
Tables 26 and 27 in Appendix 2 describe the details four studies. These included mean number of
of patient characteristics for the three RCTs and children as 1.859 and two,58 and the percentage
three non-RCTs. of primiparas in each group, which was 50% for
the PEG and 59% for the RPC groups.43 A further
Diagnosis of disorder study also reported the mean number of children
For the RCTs, PND was indicated using the in each group, which was two in the treatment
EPDS in one study,43 and a DSM-IV diagnosis of group and 1.6 in the control group, the average
major or minor depression was given in the other age of the infant was 10.6 months, and the marital
two studies.58,59 For the non-RCTs diagnosis was status of the women was 15 married, four in de
performed using the DSM-IV criteria for major facto relationships and one separated.62 No details
depression in the Clark et al.61 study. Diagnosis of patient history were reported in the remaining
information was not supplied in the Highet and two studies.60,61
Drummond60 or Meager and Milgrom62 studies
other than that the participants had been referred Time postpartum was reported only in four43,5861
for treatment of PND, although all participants of the studies. In Honey,43 Rojas et al.58 and
included in the trials had an EPDS score of 12 or Milgrom et al.,59 all participants were <12 months
above. postpartum, and the time postpartum in the Clark
et al.61 study ranged from 1 to 24 months. Details of
Age, gender, ethnicity, background and time postpartum were not reported in Meager and
patient history Milgrom62 and Highet and Drummond.60
As PND follows childbirth, those diagnosed with
the disorder are exclusively female. The mean Baseline comparability
age of the women taking part in the treatment Four studies reported baseline comparability.43,6062
was around 30 years across five of the studies, the In one study it was reported that groups did
sixth60 did not provide details of participants ages. not differ significantly on sociodemographic
Three studies provided standard deviations around and baseline self-report measures,43 a second
the mean age.43,58,59 reported that groups had been matched on
sociodemographic characteristics and baseline
Information regarding ethnicity was reported in depression scores had been used as a covariate in
only two of the studies, indicating in one study the analyses,61 the third reported that groups were
that 80% of the participants were Australian born similar in terms of clinical status and social support
with the remaining born in Ireland or the UK62 across all scales,60 and the fourth reported no
and in the other that one participant was African significant differences between the groups on mean
American and the remaining participants were age of infant, medication usage, pretest BDI scores
Caucasian.61 or occupational background.62 Two studies did not
report any details of baseline comparability.58,59
Four studies provided information on either
the education or socioeconomic background of Outcomes and results
participants. It was reported in one study59 that
62.7% had received 12 or more years of education, Tables 28 and 29 in Appendix 2 describe the details
with 30.5% receiving higher education. The of the outcomes and results for the three RCTs and
majority of the participants in the Rojas et al.58 three non-RCTs.
study had received 812 years of education [73%
in the multicomponent intervention (MCI) group, Improvement in psychological symptoms
75% in the UC group]. A further study reported The outcomes to be reported in the quantitative
that two women had a professional background, part of the review were clinical effectiveness in
21

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Assessment of clinical effectiveness

terms of improvement in psychological symptoms to these requests but were not able to provide
of PND. these additional data.
One paper58 included a confounding factor,
Instruments antidepressant treatment in the intervention
All six studies reported outcome measures relating group, making it insufficiently similar to the
to depression. The main outcomes related to other studies.
improvement in depression symptoms in five of The delivery settings varied widely for each of
the six studies. The main outcome in the Clark the studies.
et al. study61 was infant development, although There was a mix of RCT and non-RCT data.
depression was measured. Studies reported various The level of CBT use was undetermined in a
other outcome measures such as social support, number of the studies.
self-esteem, mood, parenting stress and infant
development; however, these were not consistently Only one study was deemed appropriate for data
reported across all included studies and therefore extraction relevant to our decision problem. This
the data were not available to review these outcome was due to the lack of appropriate data in two
measures. The full range of outcome measures cases,59,62 and the lack of sufficient similarity in
reported is listed in Tables 30 and 31 of Appendix study type and comparator in one,60 a retrospective
2. Measures of depression were reported in each of study which did not provide appropriate data
the six included studies using either the EPDS or for the WLG. Two studies were suitable for the
the BDI. These are well-recognised and frequently meta-analysis of change in depression between
used scales to measure depression. baseline and follow-up;43,58 the third study61 did
not report follow-up data. A final study58 included
Results for psychological a confounding factor in the intervention arm.
symptoms Therefore, it was concluded that there was not
enough commonality of intervention, service
Meta-analysis setting, population and antidepressant use to
Meta-analyses using the six quantitative studies perform a meta-analysis.
were considered. Data were available to assess
group CBT against RPC. However, data were not For the study that was deemed appropriate, the
available to assess group CBT against individual reduction in the EPDS score through group CBT
CBT, or any other intervention. The suitability of compared with RPC was 3.48 (95% CI 0.23 to 6.73)
these data for meta-analysis was assessed and the at the end of the treatment period. At 6-month
following issues were encountered: follow-up the relative reduction in EPDS score was
4.48 (95% CI 1.01 to 7.95).
The outcome measure, depression, was
measured using two different scales, the EPDS Narrative analysis
and the BDI. Although this could be overcome As meta-analyses could not be performed the
using a standardised mean difference statistic, results are presented in narrative format.
assumptions regarding the standard deviation
of each scale would be required. Group psycho-education incorporating
Depression is measured at baseline, after CBT versus RPC, UC or WLG
treatment or at 3 months, and at follow-up Honey43 reported that depression symptomatology
(usually 6 months); however, this was not the as measured by the EPDS was significantly reduced
case for all six papers. Some of the studies only in the intervention group compared to the RPC
measured depression twice.59,61,62 See Tables 28 group. Depression scores improved over time for
and 29 in Appendix 2 for details. those in the intervention group, but not for those
One paper62 did not provide any measures in the RPC group. Six months after the end of
of variability around the mean (standard the intervention, significantly more women scored
deviations or CIs) and attempts were made below cut-off than in the RPC group, although
to gain this information from the author. there were no differences immediately post
A further paper59 did not provide separate intervention. The benefit in terms of improved
means and measures of variability around the depression score was not related to antidepressant
mean for each treatment group, again further use and was maintained 6 months after the
information was requested from the author. group had ended. However, some women in the
The authors of these papers have responded intervention group continued to show evidence
of depressive symptomatology at this 6-month
22
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

follow-up. Improvements in EPDS score were not When further examining these findings they do
accompanied by changes in coping, perceptions give an indication that group CBT may be just
of social support or the marital relationship. as effective as individual treatment. Clark et al.61
Rojas et al.58 reported that the MCI group had reported that the two treatment groups did not
significantly improved scores on EPDS and Short differ from each other on any of the measures
Form questionnaire-36 items measures compared administered, although the small sample size may
to the UC group overall, and when examining have contributed to the null findings.
simple effects this was true at 3 months post
randomisation, significant simple effects were not Other comparisons
reported at the 6-month follow-up. Meager and Highet and Drummond60 reported that receiving
Milgrom62 reported significant improvements treatment, compared with being part of the WLG,
on the EPDS and BDI in the intervention group achieved significant decreases in depression
compared with the control group. Clark et al.61 between pre and post treatment; a decrease in
reported no significant differences between the psychological anxiety also approached statistical
groups on the BDI, although BDI was lower post significance (p=0.081). There were no differences
treatment in both intervention groups than in between the groups for physiological anxiety
the control group. Also, both the women in the following treatment. Highet and Drummond60
MITG and those in the IPT condition reported also reported that for CBT versus behaviour
significantly fewer symptoms on the Center for therapy, following treatment, there were significant
Epidemiological Studies Depression Scale (CES-D) reductions in depression, psychological anxiety
measure post treatment than did those in the WLG, and physiological anxiety. Treatment gains were
there were no differences between the intervention maintained 6 months later for both treatment
groups. Specific analyses comparing group CBT conditions. The study suggested that whilst CBT
with the WLG or RPC group were not reported by was no more effective than behavioural-based
Highet and Drummond60 or Milgrom et al.59 supportive counselling, confounding effects of
greater medication use and greater treatment
Group versus individual treatment duration for those in the latter group may have
Highet and Drummond60 reported comparisons resulted in underestimation of the efficacy
of participants receiving individual treatment with and efficiency of CBT. It was also reported
those receiving treatment in groups. Depression that medication was no more effective than
decreased significantly following treatment for both CBT. Participants treated with CBT (alone or
groups and these treatment gains were maintained in combination with medication) had greater
at follow-up. Comparison of participants treated in decreases in depression and psychological anxiety
groups (alone and in conjunction with individual following treatment than those who received
treatment) versus those treated individually medication alone. Milgrom et al.59 reported that
revealed that depression was significantly lower changes in depression and anxiety immediately
at post treatment in subjects treated individually post intervention significantly differed between
than in those who received group or combined psychological interventions (combined data)
intervention. At follow-up there was also a compared with RPC, although it was not possible to
significant decrease in depression particularly in assess effects of the group CBT intervention alone
those treated in both group and individual settings. as data for the interventions were not presented
Depression continued to decrease for those separately. Milgrom et al.59 also reported data
who had been treated in the combined settings, showing that interventions based on a counselling
whilst there was no change for those treated in approach may be more effective when delivered on
groups only. Psychological anxiety declined at an individual rather than a group basis.
post treatment and during the 6 months follow-
up, particularly in those who received individual Patient preference, satisfaction and
treatment only. Specifically, anxiety decreased acceptability
more for those treated only on an individual basis Only one of the six studies provided data on
than for subjects treated in groups. The Milgrom et patient satisfaction.60 Similar ratings of satisfaction
al.59 study reported significantly better BDI scores were reported when comparing CBT with
for those undertaking individual treatment than medication, with neither being preferred over the
for those receiving group treatment, although other. Individual treatment was preferred to group
these were combined group treatment scores treatment, and similar ratings of satisfaction were
and they did not provide direct comparisons of reported when comparing group CBT with group
specific group CBT versus individual treatment. behaviour therapy, with neither being preferred
23

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Assessment of clinical effectiveness

over the other. These data are summarised in Tables Study characteristics
32 and 33 in Appendix 2. Study characteristics for the two support group
with a specific CBT basis are described in Table 36
Qualitative papers of Appendix 3, and a summary of this information
Quantity and quality of papers available is provided in Table 4. Study characteristics for
support groups without any theoretical CBT basis
Figure 2 shows the QUOROM flowchart for the are provided in Table 37 of Appendix 3.
included qualitative studies. A table of excluded
studies with reasons for exclusion is presented Description of the treatment
in Appendix 5 (see Tables 52 and 53), with the As in the quantitative review, included studies
reference for these studies provided in Appendix 6. were those where interventions incorporated any
psycho-educational activity informed by cognitive
Included studies behavioural theory or technique, in a group
Details of those studies included in the qualitative setting. Therefore, when we refer to group CBT
review are provided in Tables 34 and 35 of we are referring to a group programme which
Appendix 3. The support groups without any states that it incorporates some level of CBT theory
theoretical CBT basis were used as a collective or technique. Only two52,53 papers examined a
comparator against CBT groups, and are detailed group treatment that was informed using CBT
at the end of this section. The following sections techniques. Included studies reported varying
relate to the two CBT studies. degrees of thickness64 regarding the description
of the support groups, although in the main

Number of papers included at


qualitative title sift
n = 759
Papers excluded at abstract sift
n = 646

Total full papers screened


n = 113
Papers excluded at full paper sift
n = 106

Unavailable papers
n=5
Unavailable through interlibrary loans
Total full papers included from or via the authors. From the details
qualitative sift available to the authors, it is unlikely
n=2 that these papers would contain data
relevant to this project

Total included full papers


n=6
CBT support groups n = 2 Papers at full sift in the quantitative
Support groups with non-theoretical review which report qualitative data
basis n = 4 n=4
to be used as a collective comparator

24 FIGURE 2 Summary of study selection and exclusion of qualitative papers.


DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

TABLE 4 Postnatal depression support group with a CBT basis

Author (date), Sample Duration,


setting size numbers in group, etc. Intervention(s)/Facilitator
Davies and Jasper 8 12 weekly sessions, 90 minutes CBT-based support group for women with PND.
(2004), 52 UK in duration; eight attendees Health visitor led, primary mental health worker
provided clinical supervision
Morgan et al. 34 Eight weekly sessions, 2 hours Support group for women with PND. Incorporating
(1997), 53 Australia in duration; average of six cognitive behavioural exercises. Occupational
attendees therapist led with the assistance of a nurse

these descriptions were brief; this information is study53 is not clear. The qualitative methodology
provided in Appendix 3. Most included detail of was therefore appropriate for evaluation purposes
the number of sessions, their frequency, duration, in both cases. Both studies provided explanation
the number of participants per group and details and justification of the recruitment strategy and
of the group facilitator. The degrees to which the setting for data collection. Data collection methods
interventions used in each study actually reflected were clearly explained in one study;52 however, such
and incorporated CBT theory or technique are detail was lacking in the second.53 Reflexivity and
detailed here in order of relevance to group CBT. ethical issues were addressed in only one of the
studies.52 Data analysis was presented in a rigorous
The Davies and Jasper52 study termed the way in only one of the studies,52 although there was
intervention as a therapeutic group, known as The no reference to particular qualitative methods of
Lifeskills Group. The group programme had aims analysis in either study. Findings were clearly stated
to encourage cognitive restructuring and self-help. in both studies.52,53
Although the use of a manual was not stated, the
group had a predefined programme based on the Co-therapy or medication
CBT model. The Morgan et al.53 study examined Only one of the studies provided information on
a group programme for postnatally distressed cotherapy or medication.53
women and their partners. Psychotherapeutic and
cognitive behavioural strategies were employed Comparators
as part of the group programme, although a Neither of the studies utilised a comparator group.
particular manualised or predefined structure was
not reported. Little information was provided on Numbers of participants
the level of CBT used in the programme. The Morgan et al.53 study had a reasonable number
of participants (34), whilst the Davies and Jasper52
Study quality study had numbers of participants that reflected
The CASP checklist for qualitative studies56 was the size of the group taking part in the treatment
used to assess the quality of the studies. The key (8).
components of quality assessment are listed in
Appendix 3. The studies were assessed on the Therapy details
following criteria: justification of the research
design; whether the recruitment strategy and Tables 38 and 39 in Appendix 3 describe the details
setting for data collection were explained and of therapy for the six studies.
justified; whether the data collection methods
were explained and justified; whether reflexivity Recruitment
and ethical issues were addressed; whether data In one study the women were referred to the group
analysis was sufficiently rigorous; and whether treatment by health visitors,52 in the other study53
findings were clearly stated. Neither study could the women were referred from another treatment.
be defined as a qualitative research study, although
both incorporated a qualitative approach and Number and length of sessions
were included on this basis. Both studies were One study ran eight weekly 2-hour sessions,53 whilst
evaluations of a group treatment and the research the other ran 12 weekly sessions of 90 minutes in
design was justified in one of the studies,52 duration.52
although justification of the design in the second

25

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Assessment of clinical effectiveness

Therapist background Morgan et al.53 study also included 20 males as part


Both studies provided information regarding the of couples sessions. One of the studies did not
background of the therapist facilitating the group report details of ethnicity52 and the other reported
treatment. Health visitors facilitated the group in that it included four women and seven men from
one of the studies,52 and were supported and given a non-English speaking background.53 One study
clinical supervision by a primary mental health did not report detail regarding the background of
worker. In the other study53 the group was led by an the participants,53 whilst the other reported that
occupational therapist with the support of a nurse. participants came from a range of backgrounds.52
Neither study reported details of comorbidity.52,53
Study site, follow-up and One study reported that all participants were
inclusion/exclusion criteria married,53 the other did not report details of
relationship status. There were 16 primiparas and
Tables 40 and 41 in Appendix 3 describe the details 18 multiparas in one study,53 and four primiparas
of study site, follow-up and inclusion/exclusion and four multiparas in the other study.52 Time
criteria for the studies. postpartum was <18 months for Davies and
Jasper,52 and between 2 and 24 months for Morgan
Study site and setting et al.53 As such, neither could be strictly considered
One study was carried out in the UK,52 and one in as a postnatal population.
Australia.53
Outcomes and results
Follow-up
For one study, qualitative data were collected Tables 5 and 6 below and Tables 44 and 45 in
only during the treatment sessions, quantitative Appendix 3 summarise the findings with themes
follow-ups took place at 6, 9 or 12 months (not presented by findings related specifically to
all participants were followed up at all three time PND and those related to depression in general.
points).53 The other study had a follow-up at These are followed by a narrative summary of the
6 weeks after the end of the intervention.52 findings.

Inclusion and exclusion criteria The environment


One of the studies required an EPDS score of 13 Davies and Jasper52 reported:
or above for entry to the study,53 and also specified
adequate spoken English as an inclusion criterion. All seven mothers who completed the course
The final study used the EPDS for participant were able to identify positive changes, and five
selection, although a cut-off was not given; recorded several. Some examples were joining
participants also had to meet DSM-IV criteria for a new group, enjoying their baby more and
depression and have an infant aged <18 months.52 starting a new job. These findings suggest that
This is beyond the typical cut-off of 12 months for the mothers were regaining a sense of control
postnatal depression. Exclusion criteria were not and purpose in their lives.
reported for either of the studies.52,53 (p. 431)

Patient characteristics Such comments demonstrated that the women


attending the group were able to make positive
Tables 42 and 43 in Appendix 3 describe the details gains with their depression, and they attributed
of patient characteristics for the six studies. these changes to group attendance. More
specifically, some of these gains related to their
Diagnosis of disorder relationship with their baby, thus illustrating the
Both studies reported depression as the diagnosed use of group treatment for PND and its symptoms,
disorder,52,53 based on the EPDS in one study53 and such as a poor relationship with the baby. Women
the DSM-IV in the other.52 were not specific as to whether they viewed the
CBT element as instrumental in this change or
Age, gender, ethnicity, background and whether they viewed more general group processes
patient history as responsible for these results.
One of the studies did not report the age of the
participants.52 The age range for the other study Social comparisons
was 2336 years.53 The Davies and Jasper52 study A quotation from one study demonstrated that the
included only female participants, whilst the women valued the opportunity to normalise their
26
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TABLE 5 Themes and findings directly relating to the PND, motherhood and the context of having a baby

Synthesis Category/Theme Finding (author)


The environment Positive Positive benefits from sessions (Davies and Jasper)52
Social comparisons Normalising Opportunity to normalise their experience (Davies and Jasper)52
Practicalities and Knowledge Role as wife and mother (Morgan et al.)53
knowledge Tasks Initial difficulty with practical task (Morgan et al.)53

feelings specifically relating to PND.52 The women The leaders are careful to praise even meagre
reported: attempts at self-care. Clearly as the weeks pass
they are rethinking their roles as wife and
you feel that you are the only one and mother. As well as emotional outpouring and
that the feelings and thoughts you have are frequent tears, sound cognitive work begins to
dreadful, yes, to people who have not had this take place.
they are, but to people who had PND these (p. 915)
feelings are normal.
(p. 431) The authors of this study also reported:

Being around others with PND enabled them to the women were set the weekly task of
feel more normal by applying social comparisons caring for themselves in some practical way.
and prototyping. The quotation emphasises how Initially some members found this difficult.
women specifically needed to compare themselves They became irritated when their own or their
to others with PND to achieve this effect, thus partners behaviour was not perfect. They had
illustrating the value of a group treatment difficulty too when their babies did not behave
specifically for PND. perfectly.
(p. 915)
Practicalities and knowledge
Author comments from one study53 appeared to This appeared to illustrate that the participants
show that issues with PND were being addressed initially found practical tasks difficult, but the
with the implication that CBT processes were group was instrumental in overcoming this.
responsible for the changes.

TABLE 6 Themes and findings more generally relating to depression

Synthesis Category/Theme Finding (author)


The environment Support Supportive facilitation (Davies and Jasper)52
Solace, trust and safety Sharing experiences and getting to know each other (Davies and
Jasper)52
Honesty Honesty within group (Davies and Jasper)52
Community Isolation Reduction in isolation (Davies and Jasper)52
Value Being valued (Davies and Jasper)52
Practicalities and Time Womens concerns/protected time and attention (Morgan et al.)53
knowledge Helpfulness Helpfulness of group sessions (Davies and Jasper)52
Adverse effects Inhibitive effect of group Group environment inhibitive (Davies and Jasper)52
Difficulties in application Difficulty in applying approaches in practice (Davies and Jasper)52
Other considerations Partners Emotional tension with partners (Morgan et al.)53
Usefulness of session in relationship to partner (Morgan et al.)53
27

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

The environment demonstrated that it was not always easy for group
The authors of one study reported:52 members to participate fully in the treatment:52

The leadership qualities most appreciated were she found it difficult to participate in the
the caring and supportive attitudes and the group commenting I have been depressed
provision of a safe environment for the sharing for over 2 years I found it hard to talk openly
of feelings. within a large group after a long period of
(p. 431) depression.
(p. 431)
They further reported:52
The same study further demonstrated that
All eight members found small group work these difficulties were specifically related to the
helpful for sharing experiences and getting application of the CBT techniques learned in the
to know each other. Other peoples honesty. sessions:52
Sharing their darkest thoughts, not being alone
any more. Additionally she found it difficult to apply the
(p. 430) CBT techniques at home, commenting I find it
hard to put anything into practice with others
These comments appeared to illustrate the around.
utility of the group environment for overcoming (p. 431)
depression.
Other considerations
Community Data were also reported on the partner sessions
Author comments from one of the studies which occurred only as part of one study.53 These
illustrated the value of the development of findings appeared to demonstrate the usefulness of
community:52 partners attending the group at some point during
the programme. Author comments illustrated that
These were thereduction in isolation not the relationship with partners may be an important
being alone anymore. aspect of depression/treatment:
(p. 430)
The sessions on relationships are often
A case study also demonstrated this value: emotionally arduous often sad, angry tones
accompany their attempt to understand
Additionally, the experiential process of being the meaning of their current emotional
a valued group member improved her sense of experiences. Relationships with partners are
self-worth, and increased her self confidence. often perceived by the women as strained.
(p. 914)
Practicalities and knowledge
The practical aspects of the group were also Author comments also confirmed the impression of
acknowledged as being important in the treatment the usefulness of the couples session:
process. A second study confirmed that the group
sessions were of practical use. Author comments, Some women report their partner is now more
supported by study data, revealed:52 supportive; some men now look after the infant
for specified times, releasing the women to
Every session in the programme was have time to herself. One father has expressed
acknowledged as being helpful by at least one the desire to have counselling for himself.
group member. Even sessions that I didnt Another couple said that they were now more
expect to be helpful were helpful in ways that I appreciative of each others efforts and said so
didnt expect so I was glad to come. to each other.
(p. 429)
The men also report that their session was
Adverse effects and limitations useful, both from understanding more about
Adverse effects and limitations of the group their partners mood state, and from hearing
treatment were also reported. Author comments how other men experienced similar difficulties.
supported by study data from one study

28
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Findings specific to PND expected. Additional helpful aspects attributed


Some of the author comments and reported to the treatment concerned the flexibility of the
participant quotations related specifically to PND, session, participants appreciated that they did not
whereas others can be interpreted as related feel limited to time and the structure of the session
to depression more generally. Themes relating could be accommodating to their needs.
specifically to PND are summarised in Table 5, and
can be split into three synthesised findings: Findings relating more generally to
depression
1. The environment The group environment Themes relating more generally to depression are
enabled women to develop better relationships summarised in Table 6, and can be split into five
with their baby. synthesised findings.
2. Social comparisons and prototyping Women with
PND made social comparisons that allowed 1. The environment The caring and supportive
participants to understand that their feelings environment served to facilitate the sharing of
associated with PND were normal. feelings.
3. Practicalities and knowledge The group allowed 2. Community The development of a community
the women to assess their roles as wife and served to reduce isolation.
mother. 3. Practicalities and knowledge The practical aspects
of the group were also acknowledged as being
Findings specific to CBT important in the treatment process.
Some of the findings related specifically to the CBT 4. Adverse effects Some participants found it
content of the group programmes. Some women difficult to talk openly in the group setting,
reported that they found difficulty in applying whilst others found difficulty in applying CBT
the CBT techniques, whereas others found the techniques.
cognitive components of the course particularly 5. Other considerations Partner sessions were rated
helpful and were able to put them into practice:52 as helpful.

The study found that the group members Comparison of the positive and negative
who practised the CBT techniques positively aspects of the group treatment
appraised the approach and appeared to Group members also provided information
gain more benefit from the overall group on positive and negative aspects of the group
programmeopinions can change after treatment. These are reported in Table 7 for each
reflecting and applying the techniques of the studies. Comments generally related to the
discussed and practised during the sessions. practical aspects of the group, such as the format
(p. 432) of the sessions, although the supportive aspects of
the group were raised as important. The comments
There were, however, a number of common were in the large part positive; however, some of
factors which may be attributed to any type of the comments raised were negative and related to
psychological intervention rather than specifically both the format of the sessions and personal issues
to CBT. Participants reported feeling that every associated with sharing concerns in a group.
session had been helpful in ways they had not

TABLE 7 Summary of the positive and negative aspects of the CBT group treatment

Author Positive Negative


Davies and Jasper (2004)52 Time for feedback sessions and flexibility Too long spent on
CBT group feedback
Smaller subgroup session for sharing experiences and getting to Difficulty in sharing with
know each other large group
Supportive facilitation
Supportive group environment
Morgan et al. (1997) CBT
53
Encourages participants to take a step towards getting better
group The group meets a need
Usefulness of couples session
29

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

Comparison of CBT support groups Diagrammatic representation of the


against non-theoretically based support synthesised findings
groups The supportive environment enabled a sense of
As outlined at the beginning of this section, initially community to be built with group facilitators being
six studies were identified which examined group instrumental in this. This created an environment
treatment for PND.43,5862 Of these six papers where social comparisons and prototyping could
only two referred to a specific basis in CBT;52,53 take place. Adverse effects could disrupt this flow.
therefore, the analysis has focused on these two Practicalities and knowledge, and the improvement
studies. However, it was deemed useful to provide of practical issues via the resolution of partner
some information about the other four studies difficulties, could be gained as a result of the social
to provide a comparison of components that are comparison and community. This is shown in Figure
common to support groups and those that are 3 as a diagrammatic representation.
unique to CBT groups.
Assessment of effectiveness
Table 8 gives brief details of the four support group Critical review and synthesis of
studies, further details can be found in Appendix 3, information of both quantitative and
Tables 35, 37, 39, 41, 43, 45 and 46. qualitative studies

Table 9 shows the components of the group Quantitative review


treatments which were either specific to the A number of the six included papers lacked the
CBT groups or common to both CBT and high level of detail and experimental control
non-theoretically-based support groups. There that would be expected from a high-quality
appeared to be little difference between the RCT (for example, randomisation, blinding and
groups in terms of the user perspectives. As power calculations).6062 However, this is to be
would be expected, issues around the use of CBT expected given the nature of the populations
techniques were raised by members of the CBT and interventions being examined. It can be
groups, but were not relevant to members of the difficult to perform blinding and randomisation
non-theoretically based support groups. However, appropriately because of the type of interventions
there were a number of common components, being offered. Compliance with interventions can
suggesting that the effects of support groups may also be difficult to monitor because of ethical issues
rely more heavily on common factors rather than as the population is a natural group that cannot be
specific factors relating to the particular theoretical prevented from accessing concurrent treatments.
basis of the techniques being applied. The factors A further difficulty related to this population is the
common to both types of support group related to difficulty in gaining large sample sizes, owing to
community, social comparison, the environment, the sensitive nature of the condition; therefore it is
and practicalities and knowledge. unlikely that power calculations and ITT analyses

TABLE 8 Postnatal depression support groups without a theoretical basis

Author (date), Sample


setting size Duration, numbers in group, etc. Intervention(s)/Facilitator
Duskin (2006), 65
5 Open-ended support group. Frequency and duration Support group for women with
USA of meetings were not reported. Participants included PND. Graduate researcher led
had attended the group four or more times. Five of the
attendees took part
Beck (1993),66 12 Twice monthly sessions, open-ended duration. Up to Support group for women with
USA 12 attendees PND. Nurse led
Pitts (1999),67 48 NR Support group for women with
UK PND (some participants below
cut-off for PND on EPDS); health
visitor led
Eastwood 13 12 sessions, length and frequency NR. 13 women in Support group for women with
(1995),68 UK the group (eight completers) PND. Health visitor led

NR, not reported.


30
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TABLE 9 A comparison of components specific to CBT-based support groups and non-theoretically based support groups

Components specific to CBT-based support groups Component common to CBT and non-theoretically-
referenced by CBT group based support groups referenced by support group
Adverse effects; difficulties in application (of CBT Community; solace, trust and safety (Beck66 and Pitts67 );
approaches) (Davies and Jasper)52 reduction of isolation (Duskin65)
Finding CBT techniques helpful (Davies and Jasper)52 Social comparison and prototyping; normalising (Duskin,65
Beck66 and Pitts67 )
Practicalities and knowledge; knowledge (Eastwood68)
Environment; trust and safety (Eastwood68); support
(Eastwood68)

will be used or reported. Finally, it is not typical to The design of the Milgrom et al.59 paper was shown
report adverse events in studies of psychological to be of high quality in the main, although a few
interventions. problems were noted. The reporting of results was
unclear as scores were combined across a number
There were further difficulties specific to the of interventions meaning specific comparisons
studies reported here which may also constrain of group CBT with RPC were not possible. BDI
interpretations. These included difficulties of scores for those receiving individual treatment
ascertaining the use and effects of concurrent were significantly better than for those receiving
treatments, the reporting and effects of the time a group treatment, although it should be noted
postpartum of the participants, and the definitions that this was a combined score relating to various
of the CBT aspects of each treatment. These issues different forms of group treatment which included
are outlined for each of the included studies. A a CBT group. The paper gave an indication (in
summary of the clinical effectiveness findings is the presented figures) that individual treatment
provided in Table 10. was similarly effective to group CBT treatment;
however, the statistics were not available to

Environment
Social
comparison
facilitators Practicalities
group members and knowledge

Adverse effects/
positive effects
Community

Partners
session

Allows for

Facilitates

FIGURE 3 Diagrammatic representation of the synthesised findings. 31

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

TABLE 10 Summary of clinical effectiveness data

Study (date), Study Total Evidence for group psycho-education


setting type study size Comparator(s) incorporating CBT
Rojas et al. (2007), 58 RCT 230 UC MCI more effective than UC at 3 months post
Chile randomisation (p=0.001 for EPDS). NR at follow-up
Milgrom et al. RCT 192 Group-based Individual treatment (combined score) more effective
(2005), 59 Australia counselling; than group treatment (combined score) at end of
individual treatment (p=0.02 for BDI). No follow-up. No
counselling; RPC individual comparisons reported
Honey (2002),43 UK RCT 45 RPC Psycho-educational group more effective than
RPC (p=0.01 for EPDS). Simple effects NS at end
of treatment; marginally significant at follow-up
(p=0.058 for EPDS)
Highet and Non- 146 Eight different Individual treatments (combined score) more effective
Drummond (2004),60 RCT not mutually than group treatments (combined score) at end of
Australia exclusive treatment (p=0.05 for EPDS); at follow-up (p=0.05
treatment groups for EPDS). No individual comparisons reported
Clark et al. (2003),61 Non- 39 IPT; WLG MITG and IPT more effective than WLG post
USA RCT treatment (p=0.02, p=0.04 for CES-D). No
differences on the BDI. No follow-up. No differences
between the intervention groups
Meager and Milgrom Non- 20 WLG Group CBT more effective than WLG at end of
(1996),62 Australia RCT treatment (p<0.02 for EPDS). No follow-up

NR, not reported; NS, not significant.

confirm this. Furthermore, there was no baseline conducted in the UK, therefore it is likely to best
comparison, and it was unclear whether compliance reflect current UK practice. When assessing the
with interventions was reliable as it was unclear CBT component of the treatment it appeared that
whether participants were receiving other forms of CBT was one of three core components of the
treatment, such as antidepressants, concurrently. treatment. The treatment was also predefined and
The intervention used in the Milgrom et al.59 clearly reported. All participants were <12 months
study was clearly defined as group CBT and was a postpartum, indicating a genuine PND group.
manualised treatment. Therefore, generalisations
may be made to the PND population. All The Meager and Milgrom study,62 again not
participants were <12 months postpartum, an RCT, appeared to have a good-quality
indicating a genuine PND group. Whilst the design, although other aspects were poor. The
method of randomisation was not ideal (one coded reporting of the results was very unclear, failing
slip of paper drawn from a bag containing multiple to report estimates of random variability, making
slips coded in equal number for each of the four interpretations very difficult. Therefore, although
treatment conditions), it was preferable to studies they report significant improvements on the EPDS
that did not attempt to randomise the participants. and BDI in the intervention group compared
to the control group it was difficult to make any
The Honey43 paper was shown to be high quality conclusions based on these findings. The authors
and showed that at the end of treatment the did report that there were no significant differences
EPDS score for those receiving group CBT had between the groups on medication usage, giving
been reduced by 3.48 points (95% CI 0.23 to an indication that the intervention group was not
6.73) more than those receiving RPC. At follow- confounded. The CBT aspect of the treatment was
up this difference was even more apparent, with ill-specified and was one of eight components of
the intervention group reporting an EPDS score the treatment; therefore it was difficult to make any
of 4.48 points lower (95% CI 1.01 to 7.95) than interpretations regarding the effects of group CBT.
those receiving RPC. However, both values had Further, the time postpartum was not reported,
wide CI ranges. Honey43 also reported that these making it difficult to ascertain whether the
differences were not related to antidepressant experimental group was a genuine PND group.
use. Honey43 was the only included study that was
32
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The critical appraisal of Rojas et al.58 showed that However, these differences were not significant
it was generally a high-quality paper, although on the BDI. The treatment groups did not differ.
baseline characteristics were not compared Again, this study was not UK based; therefore
across groups and it did have further significant generalisations should be made with caution with
limitations relating to our objectives/analyses. The regard to UK practice. The definition and use of
compliance with the intervention may not have CBT in the treatment was ill-specified and it was
been reliable as participants in both the control impossible to ascertain whether CBT was a core
and intervention groups were taking concurrent component of the treatment. The time postpartum
medications which were not controlled for in the ranged from 1 to 24 months, therefore it was
analyses. Participants in the MCI group received unclear whether all participants could be defined
antidepressants as part of the intervention, and as having PND, and generalisations to PND should
this resulted in more participants in this group be made with caution.
taking antidepressants at both time points (59%;
36%) compared to those in the UC group (17%; The final non-RCT, Highet and Drummond,60 was
11%). This greater use of antidepressants made of low quality. All aspects of reporting were poor,
interpretations relating specifically to the group particularly the reporting of the results which was
CBT aspect of the intervention difficult. However, in part due to the retrospective, quasi-experimental
as most other studies do not report concurrent nature of the study. As such, group CBT was not
medication use and it is likely that in reality directly compared against the WLG, or against
women with PND will be offered antidepressants individual treatment. However, they did report
in addition to psychological interventions we comparisons of those treated in groups, either
concluded that this study provided important alone or with individual treatment in addition,
information on the effectiveness of the group CBT against those treated individually only, showing
aspect of the intervention. This limitation should that those receiving only individual treatment had
be kept in mind when making inferences regarding significantly better depression outcomes than those
group CBT. Rojas et al.58 demonstrated that at receiving group only or a combined treatment.
the end of treatment the EPDS score for those The design of the study also resulted in difficulties
receiving the MCI had been reduced by nearly five ascertaining compliance with interventions as most
points more than for those receiving UC. At follow- participants were receiving more than one type
up this difference was still apparent, although of treatment. They also did not report baseline
to a lesser degree, and this difference was not comparisons. No definitions were provided for
significant with the MCI group reporting an EPDS the group CBT intervention. It is likely that CBT
score of 2.2 points lower than those receiving UC, was a core component as it was termed group
which may be of questionable clinical significance. CBT. However, it was impossible to ascertain
The Rojas et al.58 study was based in Chile, this information because of poor reporting.
therefore this may have further implications for the Further, time postpartum was not reported for
interpretations of the findings given that current the participants, making generalisations to PND
practice may differ from that available in the UK. difficult.
The definition and use of CBT in the treatment was
ill-specified and it was unclear whether CBT was a Milgrom et al.,59 Meager and Milgrom,62 and
core component of the treatment. Furthermore, the Highet and Drummond60 were all Australian
number of participants taking part in each group studies constraining generalisations to UK practice.
session was 20, a much higher number than would
be expected for group CBT, and much higher The strongest evidence on which to base an
than used in the other studies presented here. assessment of clinical effectiveness was the data
All participants were <12 months postpartum, comparing group psycho-education incorporating
indicating a genuine PND group. CBT treatment with RPC, UC or WLG. However,
a number of caveats need to be put in place prior
The design of the Clark et al.61 study was found to to making any assertions. Honey43 and Rojas
be of high quality. The only significant problem et al.58 supported the idea that group psycho-
noted was with ascertaining compliance with education incorporating CBT is more effective
interventions as it was unclear whether participants than UC, although the interpretations by Rojas et
were receiving concurrent treatment. The findings al.58 may relate to concurrent group therapy and
demonstrated that both group and individual antidepressant use and the level of CBT in the
treatment resulted in lower BDI and CES-D intervention was very unclear. Honey43 seemed
scores post treatment than for the control group. more likely to reflect a group CBT treatment as
33

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

CBT was one of three pre-defined core components was some indication that individual treatment was
of the treatment. Meager and Milgrom62 also as effective as group CBT although the statistics
provided an indication that group CBT is more were not available to confirm this. The Honey43
effective than UC; however, because of the study was of high quality and demonstrated that
low quality of the reporting of the results, the those receiving group CBT had lower depression
uncertainty that the treatment accurately reflects scores than RPC, but wide CIs made interpretations
CBT and the fact that time postpartum was not difficult. However, as the only UK study it may be
reported, this interpretation should be treated most relevant. Meager and Milgrom62 reported
with caution. It should also be noted that Honey43 a high-quality design although the reporting of
was the only UK study, making the applicability of the results was poor. Significant improvements in
findings to practice in the UK particularly relevant. depression scores compared to the control group
The Clark et al. study61 reported that group were ascertained, but it was difficult to make firm
treatment was more effective than UC, although it interpretations because of poor reporting. The
did not differ from individual treatment. However, Rojas et al. study58 found lowered depression
because of difficulties in ascertaining levels of scores in the intervention group compared to
concurrent treatment and the wide range of time UC but the study had significant limitations.
postpartum, these findings should be treated with Clark et al.61 reported a high-quality study but
caution. there were problems ascertaining compliance
with interventions. Both group and individual
The Milgrom et al.59 study did not provide evidence treatment resulted in lower depression scores than
that group CBT was more effective than UC, for control, but interventions did not differ. Highet
although it was difficult to ascertain whether this and Drummond60 reported a low-quality study with
was the case because of reporting. No comparisons poor quality reporting. Therefore, although they
against UC were made for the treatments examined demonstrated that individual treatment resulted
in the Highet and Drummond study.60 in better outcomes than group or combined
treatments, any interpretations had to be treated
There was very little evidence to compare with caution.
group CBT with individual treatment, and any
interpretations should be treated with caution. Qualitative review
Clark et al.,61 a study of reasonable quality, and The two qualitative studies included in the
Milgrom et al.,59 which had a design of high quality, review52,53 differed in quality. Neither study could
showed that although intervention was more be classed as a qualitative research study, but both
effective than UC, individual counselling was not were evaluations that incorporated a qualitative
superior to group CBT. The findings reported approach. The Davies and Jasper study52
by Highet and Drummond,60 a poor-quality appeared fairly well conducted and reported, and
study, showed that individual treatment was more considerations of reflexivity and ethical issues were
effective than either group or combined individual dealt with, the data analysis showed some rigor
and group treatment. Therefore, overall it was not and findings were clearly stated. The Morgan et
appropriate to make firm assertions about group al.53 study failed to report the design and methods
CBT compared with individual interventions more of data collection clearly. They did not report that
generally or individual CBT more specifically. reflexivity and ethical issues had been addressed,
and the data analysis was not rigorous, although
Patient preferences, satisfaction and acceptability findings were clearly stated. A positive aspect was
were reported by only one study.60 There were that in the main the evidence reported was from
no preferences for CBT over medication, and no direct quotes or author interpretation supported by
preference for group CBT over group behaviour direct quotes.
therapy; however, individual treatment was
preferred to group treatment (combined score). The studies also differed in the extent to which
However, because of the poor reporting we could we could be confident that the group treatment
not be certain that this treatment did accurately included a CBT component. Davies and Jasper52
reflect group CBT, also the postpartum status of stated that the treatment was predefined and
the participants was not reported, therefore it was based on a CBT model, whereas Morgan et al.53
difficult to make interpretations with any certainty. stated that cognitive behavioural strategies were
employed as part of the group programme,
In summary, the Milgrom et al.59 study was of high and these were not reported as predefined or
quality although the reporting was unclear. There manualised and did not give an indication of the
34
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level of CBT employed. Furthermore, neither PND. Participants found the caring and supportive
study restricted the sample to those who were environment served to facilitate the sharing of
<12 months postpartum. Included participants feelings, and the development of a community
were <18 months postpartum in the Davies and served to reduce isolation; the practical aspects
Jasper study52 and between 2 and 24 months in of the group were also acknowledged as being
the Morgan et al. study.53 This raised issues of important in the treatment process.52 It was also
whether the treatment groups in these studies were reported by some participants that it was difficult
representative of a PND population. to talk openly in the group setting, whilst others
found difficulty in applying CBT techniques.
There were also inherent limitations in the Participants also reported that partner sessions
studies described here and some of these were were helpful.
acknowledged by some authors. There seemed
to be a tendency for participants to give overly In comparing the CBT groups with support
optimistic views of an episode of care. This may groups, other than issues around the use of CBT
have influenced the reporting of results toward techniques there appeared to be little difference
the positive aspects of the group treatment. In in user perspectives. The findings suggested that
the main, data were only reported for those the effects of support groups may rely more heavily
participants who had been referred as suitable for on common factors rather than specific factors
the group, had attended and had found the group relating to the particular theoretical basis of the
a positive experience. Again this would influence techniques being applied.
findings in a positive direction. Extraneous factors
may have also had an impact on the findings. In summary, the Davies and Jasper study52 was
Cotherapy was not consistently reported across of reasonable quality and demonstrated that
the studies, making it difficult to disentangle the participants found the group treatment helped
effects of the psychological intervention and other them to develop better relationships with their
treatment the women may have been receiving. baby and facilitated social comparisons relating to
It was also difficult to assess whether the natural PND. Although participants in the Morgan et al.
remission of depression may have occurred study53 reported that cognitive components of the
during the study period. Authors may have under- course were particularly helpful as the study details
reported negative opinions as the objective of the were not clearly reported, interpretations had to be
studies was to identify the positive aspects of group treated with caution.
treatment. For these reasons it was important to
assess the interpretations made on the basis of
these studies with caution. Discussion
Women reported that the group environment Group psycho-education incorporating CBT
enabled them to develop better relationships with appeared to be clinically effective when compared
their baby.52 Women with PND used the groups to RPC, UC or WLG in three studies.43,58,62 The
to make social comparisons allowing them to reduction in depression scores was not consistent
understand that their feelings associated with PND across time: one58 demonstrated a significant
were normal, and the group allowed the women to reduction in depression scores at end of treatment
assess their roles as wife and mother.52 The findings but did not report this effect at follow-up, whilst
that related specifically to the CBT content of another43 did not find a significant reduction
the group programmes included reports that at end of treatment but did at follow-up. The
some women had difficulty in applying the CBT remaining three studies5961 could not demonstrate
techniques;52 however, others found the cognitive such reductions specific to group CBT. Further,
components of the course particularly helpful and interpretations should be made with caution as
were able to put them into practice.53 There were a number of the included studies may include
also common factors which may be attributed to concurrent therapy, the effects of which are difficult
any type of psychological intervention rather than to separate from the group treatment. There
specifically to CBT. It was reported that every is also uncertainty surrounding how accurately
session had been helpful in ways they had not the treatment reflects CBT in some studies, and
expected.52 uncertainty around whether generalisations
can be made to the PND population because of
There were also findings which may relate participants being at different times postpartum
generally to depression rather than specifically to in some studies. Furthermore, only one of the
35

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of clinical effectiveness

included was conducted in the UK making the the sharing of feelings, the development of a
applicability of findings from the other studies community which served to reduce isolation, and
questionable.43 There is not enough evidence the practical aspects of the group which were also
to adequately compare group treatment with acknowledged as being important in the treatment
individual treatments or other comparators. process. Participants also reported that partner
sessions were helpful, and it was reported that men
The qualitative review showed that participants also benefited from group sessions, resulting in
had positive views of group treatment. However, increased practical help for women.
it is important to note that it is difficult to assess
how accurately the groups reflected group A further consideration related to both the
CBT and, further, whether the participants quantitative and qualitative studies surrounds
reflected a genuine PND population. Specific therapist variability. As previously noted, variability
benefits of CBT were reported, with participants in therapist effectiveness can account for variance
commenting that cognitive components were in treatment outcomes.69 As a relatively small
helpful. Findings specific to PND included number of therapists were involved in facilitating
comments that participants were able to develop the group interventions it is likely that the
better relationships with their baby, understand performance of the therapist could have had a
their feelings associated with PND and assess significant affect on the results.
their roles as wife and mother. Some negative
aspects were also reported although these were It is acknowledged that although all eight included
in the minority; these included difficulty in studies record that at least an element of CBT was
applying the CBT techniques and difficulty in employed in the group treatment, they may not
talking openly in the group setting. It is unclear fully represent CBT in its most widely recognised
whether CBT in particular or factors common form. However, owing to the high level of common
to any group activities are instrumental in the factors operating in psychological therapies, such
treatment. More general findings demonstrated as engendering hope, the conclusions we draw
that group members appreciated the caring and may be applicable to many psychological group
supportive environment which served to facilitate treatments.

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Chapter 4
Assessment of cost-effectiveness

Systematic review of populate the model, which were deemed to be


existing cost-effectiveness only those data from the Honey RCT.43 This RCT
was selected as it was UK based, had a clear CBT
evidence component and reported data at baseline, at end of
Identification of studies treatment and at a 6-month follow-up period.

To retrieve papers on cost-effectiveness the search Unfortunately this trial did not incorporate an
terms for clinical effectiveness were rerun on individual CBT arm; therefore this comparison was
MEDLINE, the Cumulative Index to Nursing and not explicitly modelled. Only the cost-effectiveness
Allied Health Literature (CINAHL) and EMBASE of group CBT compared with RPC was evaluated.
using an economics filter. The economics filters
used are provided in Appendix 1. The literature When modelling the cost-effectiveness of group
retrieved in the searches on the NHS Economic CBT it was assumed that benefit would be
Evaluation Database (NHS EED) and the Health accrued only on initiation of the treatment. Once
Economic Evaluations Database (HEED) was also treatment had commenced it was assumed that
reviewed. The searches were undertaken in January there would be a linear increase in the benefit of
2008. Databases were searched from 1950 to 2008 group CBT compared with RPC, peaking at the
with the actual date range for each of the databases end of treatment. Although the CIs were wide, data
searched depending on coverage of the individual from the Honey RCT43 provided relatively strong
database. The searches were not restricted by evidence that any gain would persist throughout a
language. 6-month follow-up period (Figures 4 and 5).

Pertinent economic literature was planned to We assumed that any gain would be maintained
be assessed using the Drummond and Jefferson over the 6-month period and would then be
checklist.70 However, no applicable publications followed by a linear decline in the advantage of
were found. group CBT compared with RPC that was assumed
to be reduced to zero 1 year after treatment.
That is, a linear decline over a 14-week period.
Independent economic The duration of this decline was chosen as the
assessment authors understand that after 12 months PND
would be reclassified as general depression. This
No existing models of the cost-effectiveness may be conservative as the focus of CBT is on
of group CBT for PND were identified in the developing skills that may provide longer benefits;
systematic review of the literature. As such, a de longer time periods are evaluated in sensitivity
novo economic model was constructed. analyses. A linear decline was chosen as it appeared
reasonable, other distributions may be applicable,
Methods however, given the large uncertainty in the model
parameters, particularly length of comparative
Given the scarcity of the data identified within the advantage associated with group CBT, it was
clinical effectiveness section, a pragmatic approach believed that fitting other distributions would be
was taken when constructing the mathematical introducing unnecessary complexity.
model, with the intention to provide indicative
estimations of likely cost-effectiveness ratios rather These assumptions would lead to a gain in EPDS
than a definitive answer. scores associated with group CBT compared with
RPC as depicted in Figure 6; the base-case values
A conceptual model was constructed which would have been used in this figure. Because of the small
investigate the benefits associated with group CBT time period of the model neither benefits nor costs
for PND. The design of the conceptual model were discounted.
was influenced by the data that were available to
37

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of cost-effectiveness

RPC Group CBT


Study or Mean difference Mean difference
subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI

Honey (2002)43 1 5.29 22 4.48 5.83 23 100.0% 3.48 (6.73 to 0.23)

Total (95% CI) 22 23 100.0% 3.48 (6.73 to 0.23)


Heterogeneity: not applicable
Test for overall effect: z = 2.10 ( p = 0.04)

4 2 0 2 4
Favours Favours
experimental control

FIGURE 4 Efficacy data at the end of treatment.

RPC Group CBT


Study or Mean difference Mean difference
subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI

Honey (2002)43 2.32 6.75 22 6.8 4.94 23 100.0% 4.48 (7.95 to 1.01)

Total (95% CI) 22 23 100.0% 4.48 (7.95 to 1.01)


Heterogeneity: not applicable
Test for overall effect: z = 2.53 ( p = 0.01)

4 2 0 2 4
Favours Favours
experimental control

FIGURE 5 Efficacy data at 6-month follow-up.

4.5
Comparative advantage in EPDS

4.0
associated with group CBT

3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0
0 4 8 12 16 20 24 28 32 36 40 44 48 52 56
Time since randomisation (weeks)

FIGURE 6 The conceptual model of the effects of group CBT on EPDS compared with RPC.

In the Figure 6, 8 weeks relates to the end of the The assumed effectiveness of group CBT
treatment period, 26 weeks the assumed time compared with RPC
at which maximum comparative advantage As previously noted, the CIs for the effects of group
declines and 52 weeks the period at which there CBT compared with RPC at end of treatment
was assumed to be no comparative advantage of and follow-up in the Honey RCT43 were large. In
group CBT compared with RPC. The duration order to reduce the uncertainty and to provide an
of comparative advantage was altered within estimation of the constant benefit assumed from
sensitivity analyses. the end of treatment to 6 months thereafter all
38
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data points for Honey43 were pooled together to (i.e. became lower) the SF-6D score improved (i.e.
produce a single estimate. It is acknowledged that became higher). It was also noted that regardless of
this will remove any correlation between the two any change in EPDS score, the utility of a woman
time points, but this was deemed a worthwhile was 0.0625 higher at 6 months than at 6 weeks.
sacrifice. The assumed efficacy is depicted in This result was not surprising given that the EPDS
Figure 7. does not include a sleep component and it is likely
that women would be achieving more hours of
Thus it was expected that a woman who received sleep at 6 months than at 6 weeks.
group CBT would have at the end of treatment
and for the following 6-month period, on average, A plot of the residuals versus the fitted values
an EPDS score that was 3.98 lower than a similar is provided in Figure 9 and visually displays no
woman who received only RPC. The 95% CI marked bias within the fit.
ranged from a reduction of 4.69 to a reduction of
3.27. Tests for heteroskedasticity were conducted in
stata version 9 (StataCorp LP, College Station,
Mapping from changes in EPDS scores TX) using the BreuschPagan/CookWeisberg test.
to changes in utility This showed that the variance was not constant
In order that the cost-effectiveness ratios calculated (p=0.008) and therefore robust standard errors
can be compared with those estimated for were used when sampling from the regression
other interventions in other disease areas NICE equation.
recommends that QALYs be used as the metric
for health gain.71 A methodology was thus needed The stata output is provided in Table 11.
to translate between changes in EPDS scores and
changes in utility. This was achieved by using data In order that the correlation between the slope
from the PoNDER trial13 which had recorded both and constant of the regression was maintained
EPDS scores and utility scores [as measured using the variancecovariance matrix was identified.
the Short Form questionnaire-6 Dimensions (SF- Cholesky decomposition techniques73 were used,
6D)] for women following childbirth at 6 weeks and assuming that the coefficients for both the EPDS
6 months. The SF-6D is a preference-based scoring change and the constant were normally distributed,
system that provides a utility value for a patient.72 in order to preserve correlation. The variance
covariance matrix is provided in Table 12.
Data were taken for those woman (n=401),
regardless of arm in the RCT, who had an EPDS Sampling parameters for the slope and
score of 12 or greater at 6 weeks following constant of the regression equation and
childbirth and who had values for both EPDS and for the efficacy of group CBT
SF-6D at both 6 weeks and 6 months. The change In order to estimate the overall utility gain
in EPDS and SF-6D between 6 weeks and 6 months associated with group CBT, PSA were conducted.74
was recorded; these data are plotted in Figure 8. One thousand Monte Carlo estimations of the
distribution of the efficacy of group CBT were
A moderate relationship was observed (r2=0.27) sampled along with 1000 pairs of correlated
that indicated that as the EPDS score improved slope and constant coefficients describing the

RPC Group CBT


Study or Mean difference Mean difference
subgroup Mean SD Total Mean SD Total Weight IV, random, 95% CI IV, random, 95% CI
Honey (2002)43 1.66 1.83 44 5.64 1.59 46 100.0% 3.98 (4.69 to 3.27)

Total (95% CI) 44 46 100.0% 3.98 (4.69 to 3.27)


Heterogeneity: not applicable
Test for overall effect: z = 10.99 (p < 0.00001)

4 2 0 2 4
Favours Favours
experimental control

FIGURE 7 The efficacy of group CBT used within the model.


39

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of cost-effectiveness

0.6
y = 0.0113x + 0.0625
R2 = 0.2687
0.5

0.4

0.3
Change in SF-6D

0.2

0.1

0.0
30 25 20 15 10 5 0 5 10 15

0.1

0.2
Change in EPDS

FIGURE 8 A regression of change in SF-6D against change in EPDS.

0.4

0.2
Residuals

0.0

0.2

Title: 06-83-01 Proof Stage: 2 Figure Number: 00.08.ai


0.4
Cactus Design and Illustration Ltd
0.1 0.0 0.1 0.2 0.3
Fitted values

FIGURE 9 A plot of the residuals versus the fitted values from the change in SF-6D versus change in EPDS regression.

40
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TABLE 11 stata output when regressing change in utility with change in EPDS score

Robust 95% CI

12+ Coefficient SE t p>(t) Lower Upper


EPDS change 0.01134 0.000984 11.52 0 0.01327 0.0094
Constant 0.062505 0.006818 9.17 0 0.049101 0.07591

SE, standard error.

TABLE 12 The variancecovariance matrix associated with the regression of change in utility with change in EPDS score

EPDS change Constant


EPDS change 9.6810 7
Constant 4.1110 6 4.6510 5

linear relationship between change in EPDS and The estimated costs per woman
change in utility, thus forming 1000 parameter completing a group CBT course
configurations. The gain in utility for each woman The costs for two scenarios of delivering group
associated with each configuration was calculated CBT for PND were explored: one if the Honey
algebraically using the assumptions depicted in RCT43 regime was to be replicated; and the second
Figure 6. The range of the 1000 utility estimates is being the delivery methods deemed by the authors
provided in Figure 10. to be most likely were group CBT to become widely
available. The resources expected to be associated
The mean value of the utility gain was 0.032 with with each strategy are detailed in Table 13 and
a 95% CI, using a percentile method of 0.025 to Table 14, respectively. These values were relatively
0.041. similar, being 1317 and 1246 per woman.

0.20
Percentage of samples

0.10

0.00
0.020 0.025 0.030 0.035 0.040 0.045 0.050
Utility gain

FIGURE 10 The distribution of sampled utility gains per woman receiving group CBT.
41

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Assessment of cost-effectiveness

TABLE 13 The resources required to duplicate the group CBT regimen used in Honey43

Source
A Number of weekly sessions 8 Honey43
B Length of sessions (hours) 2 Honey43
C Number of health visitors required 2 Honey43
D Preparation time required per session 2 Assumed 1 hour per session per health visitor
E Additional time required in excess of the 2 Assumed 1 hour per session per health visitor
session
F Average number of participants 5 Honey43
G Time for initial assessment per 2 Assumed 2 hours per participant
participant (hours)
H Health visitor time required 74 (ABC)+A(D+E)+FG
I Cost per hour of health worker time () 89 Morrell et al.13 cost per hour of client time including
training costs for psychological therapies (79 in
20034, this has been amended using inflation indices
to represent current prices)
J Total cost of health visitor 6586 HI
K Total cost per person () 1317 J/F

TABLE 14 The resources required using the delivery methods deemed by the authors of this report to be most likely were group CBT
to become widely available (see Chapter 1 for more detail)

Source
A Number of weekly sessions 12 Authors
B Length of sessions (hours) 2 Authors
C Number of facilitators required 2 Authors one health visitor and one newly qualified
clinical psychologist (same salary assumed)
D Preparation time required per session 2 Authors assumed 1 hour per session per facilitator
E Additional time required in excess of the 2 Assumed 1 hour per session per facilitator
session
F Average number of participants 8 Authors
G Time for initial assessment per 2 Assumed 2 hours per participant
participant (hours)
H Health visitor time required 112 (ABC)+A(D+E)+FG
I Cost per hour of health worker time () 89 Morrell et al.13 cost per hour of client time including
training costs for psychological therapies (79 in
20034, this has been amended using inflation indices
to represent 20078 prices)
J Total cost of facilitators 9968 HI
K Total cost per person () 1246 J/F

The costs presented in Tables 13 and 14 may be estimated that 1500 per woman completing a
underestimates as they did not include any set-up group CBT course would be approximately correct
costs or additional running costs, such as room regardless of the calculation method.
hire and crche facilities, which may have been
incurred. With the additional likelihood that Base-case results
women receive initial assessment (hence incurring
costs) but do not progress to group CBT and other The estimated cost per QALY result for the base
miscellaneous costs that would be incurred we case is provided in Table 15.

42
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TABLE 15 The estimated cost per QALY of group CBT compared with RPC

Mean cost per Mean QALY gain per Mean cost per 95% cost per QALY using
woman () woman QALY () a percentile method
1500 0.032 46,462 37,008 to 60,728

These results are displayed in Figure 11 with a was particularly of importance when analysing the
CEAC.45 The mean cost per QALY results were length of time that group CBT would provide a
high when compared with recommended NICE benefit compared with RPC, as the duration used
thresholds of 20,000 and 30,000 per QALY,71 within the base case (of 1 year after initiating group
indicating that group CBT was unlikely to be cost- CBT) was particularly uncertain. If the benefits of
effective based on present assumptions. group CBT persisted for longer periods then the
cost per QALY estimated in the base case would be
Sensitivity analyses unfavourable to group CBT when compared with
There was uncertainty in the assumptions RPC.
regarding the modelled results that were explored
in univariate sensitivity analyses (Table 16). These A further sensitivity analysis was conducted
included altering the costs per woman of running where combinations of parameter values that
the service, changing the estimated utility gain per were plausible but favourable to group CBT were
woman and extending the length of time during selected. This gave a value below 20,000, a
which a woman would receive a utility benefit to a common threshold of cost-effectiveness used by
period of 18 months. A further sensitivity analysis NICE.71 This indicated that whilst the base case did
was also undertaken assuming arbitrarily that an not appear to be cost-effective there were plausible
additional 0.02 QALYs were gained as a crude scenarios that were cost-effective, and a definitive
exploratory analysis of estimation of potential answer could only be made once there was more
utility gains associated with the womans partner or certainty in the costs of conducting group CBT, in
by the baby. the efficacy of pure group CBT and in the duration
of residual benefit.
It was seen that each altered variable had the ability
to alter markedly the cost per QALY ratios. This

1.0

0.9

0.8
Probability of being cost-effective

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0
0 10 20 30 40 50 60 70 80
Cost per QALY threshold (000)

FIGURE 11 The CEAC for group CBT compared with RPC. 43

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Assessment of cost-effectiveness

TABLE 16 The base-case results following sensitivity analyses

Mean cost per woman Mean QALY gain per Mean cost per QALY
Sensitivity analysis () woman ()
Base case 1500 0.032 46,462
Cost per woman decreased to 750 750 0.032 23,231
Cost per woman increased to 2000 2000 0.032 61,948
Lower 95% of efficacy assumed (EPDS 1500 0.027 56,626
decrease of 3.27)
Upper 95% of efficacy assumed (EPDS 1500 0.038 39,481
decrease of 4.69)
Linear decline in advantage extended to 1500 0.044 34,382
18 months
Additional QALY gain of 0.02 applied 1500 0.052 28,846
Cost per woman decreased to 1000, 1000 0.047 19,230
EPDS decrease of 4.3 assumed, linear
decline in advantage extended to
18 months

Exploration of the expected case, as the mean cost was 1418 compared with
value of information within the 1500 and the duration of comparative advantage
decision problem was 16 months compared with 12 months. The
As discussed previously there was considerable mean of the probabilistic values were not surprising
uncertainty within the decision problem. This given that it was commented that the comparative
uncertainty was initially explored using sensitivity advantage in the base case was likely to be
analyses assuming remaining parameters in the conservative, and that were group CBT to become
base case remained constant. Such analyses showed more widespread the cost per participant would be
that there were plausible scenarios where group likely to fall.
CBT would be deemed cost-effective compared
with RPC. The estimated cost per QALY result having fitted
distributions to data on comparative advantage
Further analyses were undertaken using formal and cost of group CBT per woman is provided in
expected value of perfect information (EVPI) Table 17 with a CEAC presented in Figure 12.
techniques, which indicate the most that a decision-
maker would pay to remove all uncertainty from It was seen that the cost per QALY value had
the decision problem.46,47 This analysis required fallen to 36,062, but this value still fell outside
that distributions were assigned to variables subject the recommended cost-effectiveness threshold.
to uncertainty. The uncertainty in the efficacy However, some scenarios fell below a value of
had previously been estimated; however, the 30,000 per QALY,71 which may be deemed a more
uncertainties in the costs of group CBT per woman appropriate threshold than 20,000 as only utility
and the duration of comparable advantage had gains relating to the woman (neither the partner
not addressed using scenario analyses rather than or baby) were considered, indicating that there was
a distribution. It was deemed that a triangular uncertainty in the correct decision.
distribution for costs ranging from 750 to 2000
with a mode of 1500 was not unreasonable The EVPI methodology evaluates in monetary
considering potential economies of scale and terms the cost of potentially making the wrong
also that a triangular distribution for duration of decision using a net benefit approach.75 Given
comparative advantage ranging from 1 to 2 years our chosen parameter distributions, the EVPI per
with a mode of 1 year was also not unreasonable. woman receiving group CBT was calculated to be
The authors recognised that these distributions 53.50.
were arbitrary but believed that the exploratory
results provided from this analysis would provide The number of births in 2003 in the UK was
an indication of the likely value of information. 695,500;76 assuming that 17.3% of women had
It was also commented that these values did not an EPDS score of 12 or over13 this equates to an
match identically those in the deterministic base estimated 120,000 women suffering from PND
44
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TABLE 17 The estimated cost per QALY of group CBT compared with RPC having fitted statistical distributions to uncertain
parameters

Mean cost per Mean QALY gain per Mean cost per 95% cost per QALY using
woman () woman QALY () a percentile method
1418 0.039 36,062 20,464 to 76,293

per annum. It was assumed that CBT may be the benefit of removing all uncertainty from one of
most appropriate treatment for the forthcoming four variables: the assumed efficacy of group
10 years. If the birth rate and the prevalence of CBT in increasing EPDS values; the assumed cost
PND stay constant this would equal 1,200,000 per woman treated of group CBT; the assumed
women with an incident case of PND over the next duration of comparative advantage of group CBT;
10 years. For simplicity, we have assumed that each and the assumed gradient in the relationship
case of PND represents a new episode. Therefore, between EPDS values and the SF-6D. Figure 13
1,200,000 women were estimated to benefit from depicts the EVPI and the EVPPI of the four
increased knowledge regarding the efficacy, cost selected variables.
and duration of comparative advantage of group
CBT compared with RPC. Combining the number It was seen that variables with the biggest influence
of women who could benefit and the EVPI per on the cost-effectiveness of group CBT were
woman would mean that decision-makers would be the cost of treating a woman and the assumed
willing to pay a maximum of 64M to remove all relationship between EPDS values and the SF-
uncertainty in the decision problem. This amount 6D. By contrast, there was less to be gained by
appeared more than sufficient to adequately researching the increase in EPDS associated with
fund an RCT to assess the value of the uncertain group CBT and the length of comparative benefit.
parameters as well as to explicitly incorporate However, even the variable with the lowest EVPPI
individual CBT within the RCT. value per woman (the efficacy in terms of EPDS)
when multiplied by the number of women affected
Furthermore, the expected value of partial perfect would still equate to an estimated maximum cost of
information (EVPPI)48 was used to estimate the 500,000 to remove all uncertainty in this variable.

1.0

0.9

0.8
Probability of being cost-effective

0.7

0.6

0.5

0.4

0.3

0.2

0.1

0.0
0 10 20 30 40 50 60 70 80 90
Cost per QALY threshold (000)

FIGURE 12 The CEAC for group CBT compared with RPC having fitted statistical distributions to uncertain parameters. 45

2010 Queens Printer and Controller of HMSO. All rights reserved.


Assessment of cost-effectiveness

60
53.50
Value of perfect information per woman

50

40
treated ()

30 26.59
22.70
20

10
4.10
0.42
0
All variables Efficacy of Cost of Duration of Gradient of
group CBT in group CBT per comparative relationship
EPDS terms woman benefit of between
group CBT EPDS and SF-6D

FIGURE 13 The value of perfect information associated with parameters in the model.

Discussion Expected value of perfect information analyses


The current work provides the first published were undertaken to provide an indication of the
estimate of the cost-effectiveness of group CBT maximum value that would be placed on removing
for PND in the UK. The base-case cost per all uncertainty in the decision problem, this value
QALY is relatively high (46,462) compared with was >64M and would appear sufficient to fund
currently used thresholds,71 although there is the further research required to provide more
considerable uncertainty in the model parameters. accurate data on input parameters and to produce
The sensitivity analyses have shown that relatively more robust estimates of cost-effectiveness. EVPPI
small QALY gains compared with the base case analyses show that the variables that have the
bring the cost per QALY into values that would largest influence on uncertainty are the cost per
potentially be considered cost-effective. The costs woman treated and the assumed relationship
of treating a woman with group CBT also markedly between EPDS values and the SF-6D.
affect the cost per QALY ratio. Were the costs
estimated here to be larger than those that would The results reported are for the UK, as studies in
arise if group CBT were widely implemented other countries (such as Chile) have been excluded
then the cost per QALY value of 46,462 would because of the differences in delivering CBT
be an overestimate. It is further noted that any between countries. As such, generalising our results
health benefits that are achieved in addition to to other countries may not be possible.
women with postnatal depression, such as partners
and children as previously reported,26,27,29,30 have A strength of our analyses is that an indicative
not been included, which may also overestimate cost-effectiveness ratio for group CBT for PND
the cost-effectiveness ratio. There is enough has been reported, although it is cautioned that
uncertainty in the parameters that we cannot this is subject to uncertainty due to gaps within the
provide more than an exploratory indication of current knowledge base. An additional strength has
the likely cost-effectiveness of group CBT for PND; been the relationship between changes in EPDS
Title: 06-83-01
when reasonable distributions were fitted to the Proofscores
Stage: 2
and changes inFigure Number: 00.13.ai
SF-6D; such a relationship
costs of treatment and the
Cactus Design and Illustration Ltd duration of comparative has not previously been reported. Our analyses
advantage, the cost per QALY fell to 36,062. indicate that the SF-6D value typically increases
between 6 weeks and 6 months even though the
EPDS remains constant, which could be explained
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by the lack of a sleep component in the SF-6D. woman, could not be analysed using PSA, and only
Furthermore, the exploratory analyses have selected combinations were tested. Furthermore,
indicated those parameters to which the cost- utility measurements were not recorded in the
effectiveness ratio is most sensitive, allowing future appropriate RCT, thus relying on a regression
research to be more targeted. of EPDS to SF-6D, which introduces further
uncertainty. The sensitivity analyses undertaken
The primary limitation of our analysis is caused by indicate that the cost per QALY can change
the uncertainty in key model inputs. Whilst some, markedly with plausible combinations of values,
such as the efficacy of group CBT could be tested which means that a definitive answer on whether
using PSA, others, such as the residual benefit group CBT is likely to be cost-effective cannot be
of group CBT or the costs of group CBT per provided given current data.

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Chapter 5
Assessment of factors relevant to
the NHS and other parties

I t is acknowledged by NICE5,34 that there is


considerable variation in the provision of
antenatal and postnatal mental health services
to improve resources for existing psychological
therapies or the addition of a new service. An
increase in resource use may relate to increased
across England. Inconsistent provision of services use of health visitors, CBT therapists and clinical
and referral and care pathways is likely to have a psychologists time in the provision of group CBT,
detrimental impact on the provision of group CBT any training needs for the treatment, and the
given that it may not be available across the UK. potential increased use of community space.
This may need to be addressed to facilitate the
introduction of a new service such as group CBT. Postnatal depression can have a detrimental effect
on the family members of those with the condition
To ensure women are seen within 1 month of initial and there may also be implications for the
assessment and no longer than 3 months after, the treatment of these family members, particularly the
NICE commissioning guide34 suggests that the level infant and partners of women with PND.26,27,29,30
of service may need to be increased by the PCT

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Chapter 6
Discussion

Statement of principal was relatively high (46,462); however, this


findings value changes markedly with changes in other
Clinical effectiveness parameters such as assumed cost of CBT per
woman and the duration of any residual benefit.
In total 12 studies were identified in the clinical An analysis using plausible, but favourable,
effectiveness review. Six of these studies were assumptions to group CBT for PND produced
included in the quantitative review43,5862 and six a cost per QALY value that would generally be
in the qualitative review.52,53,6568 The six studies considered cost-effective. The analysis excluded
in the quantitative review comprised three any benefits or cost implications associated with
RCTs43,58,59 and three non-randomised trials.6062 partners and children, which may mean that the
The studies were found to be unsuitable for meta- cost per QALY ratio has been overestimated. These
analysis, and a narrative analysis of the findings uncertainties mean that a definitive assessment
was undertaken. The findings were inconsistent of the cost-effectiveness could not be provided.
across the studies but three studies, two RCTs43,58 However, EVPI analyses indicate that the monetary
and one non-RCT62 did provide an indication that cost of potentially making the wrong decision is
groups incorporating CBT principles and ranging large (our estimate is >64M). This value should
from intervention to purely psycho-education were be sufficient to fund an RCT to provide robust data
more effective than RPC in reducing depression in on the variables that are currently uncertain. In the
women with PND. Data were too limited to provide interim, EVPPI analyses show that the uncertainty
an assessment of group CBT against any other in the cost of treating a woman with group CBT
comparator. and the gradient of the relationship between EPDS
values and SF-6D values have a large influence on
The six studies in the qualitative review included potentially making an incorrect decision regarding
two studies52,53 investigating a group treatment with the cost-effectiveness of group CBT.
a specified CBT component, and four studies6568
investigating a group treatment without a specific
theoretical basis. These four studies were used Strengths and limitations of
as a collective comparator against the two group the assessment
CBT studies. Women in the CBT groups reported
that the group environment allowed women to Clinical effectiveness
develop better relationships with their baby, to One strength is the presented summary of both
understand that their feelings as a result of PND quantitative and qualitative evidence for group
were normal, and to assess their role as a wife and CBT in PND. However, any conclusions drawn
mother. More generally they appreciated the caring from this summary will be subject to limitations
and supportive environment, the development of which have been detailed in the section below,
a community and practical aspects of the group. Uncertainties.
Negative aspects included difficulty in applying
CBT techniques and difficulty in talking openly in Cost-effectiveness
a group setting. In terms of the comparison of CBT
groups against the non-theoretically-based groups, A further strength of our analyses is that a
other than comments specifically relating to mathematical model has been constructed and an
practical issues around the use of CBT techniques, indicative cost-effectiveness ratio for group CBT for
the user perspective did not appear to differ. PND has been reported, although it is cautioned
that this is subject to uncertainty due to gaps
Cost-effectiveness within the current knowledge base. An additional
strength includes an analysis of the relationship
An indicative cost per QALY of group CBT for between changes in EPDS scores and changes in
PND has been provided. The base-case value SF-6D; such a relationship has not previously been
51

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Discussion

reported. Finally, the value of information analyses health visitors. User perspectives assessed in the
guide the development of future research agendas. qualitative review may have been biased toward
positive comments, although this was difficult to
The primary limitation of our analyses is caused ascertain because of the limited detail provided on
by the uncertainty in key model inputs. Whilst the methods incorporated.
some inputs, such as the efficacy of group CBT,
could be tested using PSA, others, such as the Although NICE guidelines for antenatal and
residual benefit of group CBT or the costs of postnatal care exist,5 these provide little detail
group CBT per woman, could not be analysed on the referral process and the content of
using PSA, and only selected combinations treatment programmes. Therefore, it was also
were tested. Furthermore, utility measurements difficult to ascertain whether group treatments
were not recorded in the appropriate RCT, thus and the comparators reflect current practice in
relying on a regression of EPDS to SF-6D which the UK. Only two of the studies43,52 assessed in
introduces further uncertainty. The sensitivity the review had a UK setting and both were pilot
analyses undertaken show that the cost per QALY investigations.
can change markedly with plausible combinations
of values, which means that a definitive answer on Impacts on the family and child have been
whether group CBT is likely to be cost-effective highlighted as important outcomes in the
cannot currently be provided. EVPPI analyses have treatment of PND. However, they could not be
indicated where further research should initially be assessed here because of limited available data.
focused.
Based on the evidence presented here it is unclear
whether drop-out and withdrawal rates have
Uncertainties implications for group interventions. Although
reasons for loss to follow-up are presented in some
Clinical effectiveness
cases, it is unclear whether patient acceptability of
There was little quantitative or qualitative RCT group treatment is a causal factor in the drop-out
evidence to assess the effectiveness of group CBT rates reported.
for PND. The evidence that was available was of
low quality in the main because of poor reporting It has been reported that variability in therapist
of the results. Furthermore, little information was effectiveness can account for variance in treatment
reported on concurrent treatment used in the outcomes, and is independent of both the
studies, which was controlled for in only two of the therapists professional background and patient
studies.43,62 factors at the start of treatment.69 Given the small
number of participants, and therefore the small
The evidence from the clinical effectiveness review number of therapists involved in facilitating the
provides inconsistent and low-quality information interventions reported here, it is possible that a
on which to base any interpretations for service particularly good or poor therapist could have
provision. Although three of the included markedly affected the results. As such there may
studies43,58,62 provide some indication that group be severe limitations in generalising the results
psycho-education incorporating CBT is effective observed in the RCTs to other settings.
compared with RPC, there is enough doubt in
the quality, the level of CBT implemented in Cost-effectiveness
the group programmes, and the applicability
to a PND population to significantly limit any The cost per QALY ratio for group CBT in PND
interpretations. Some studies lacked important is uncertain because of gaps in the evidence base.
detail of the intervention, making it difficult Research is urgently needed to populate key
to assess whether the treatment did genuinely parameters in the model including the effectiveness
reflect group CBT. Further, the time postpartum of group CBT compared with both RPC and
of the participants varied to a great extent individual CBT in terms of a utility measure rather
across the studies, making generalisations to a than EPDS, the costs of conducting CBT courses
PND population problematic. Furthermore, the and the duration of residual benefit associated
potentially small number of health visitors involved with CBT treatment. The cost-effectiveness ratio
in delivering the group CBT in the RCT assumed reported should be treated with caution until more
applicable to the UK setting may provide severe robust data become available.
limitations in generalising the results to other
52
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Chapter 7
Conclusions

Implications for service than relying on a mapping of the EPDS. It is also


provision recommended that individual CBT be assessed
within any prospective RCT to allow a robust
A number of implications for service provision comparison between group CBT and individual
which would be applicable to group CBT are CBT.
suggested. These include the clearer identification
of the place of group CBT in a stepped care Further research is required to compare group CBT
programme, the need for a clearer referral with individual treatment as this may be preferable
process for group CBT, the need to make clearer or more efficacious in some cases, and with other
assessments of the facilitators and resources psychological therapies. Furthermore, particular
required for group CBT, including training aspects of the group will require assessment,
needs, and a clear assessment process to identify including the effect of the size of the group of
participants suitable for the treatment. participants, the duration of the sessions, the
setting, and the qualifications and optimal level of
involvement of the facilitator.
Suggested research
priorities There is also a need for more research on
patient preference for group CBT. In particular,
The variable with the largest impact on the results which groups are likely to benefit, and whether
was the cost of treating a woman with group CBT. effectiveness is dependent on patient background,
This can be estimated within the trial, or primary comorbidity, the number of children, previous PND
research can be undertaken to obtain a more robust or antenatal depression; further, how participants
figure than was obtained within this report. with different subtypes of PND respond to the
treatment.
Most of the included studies in the review were
pilot investigations of group CBT for PND. This Specific aspects of the group interventions may also
is a relatively new treatment for PND and as such benefit from future research. Sessions including
large-scale trials are yet to be performed. Until partners were rated as important, and as previous
these data are available it is difficult to make an research has shown that there is a detrimental
assessment of effectiveness. The EVPI and EVPPI impact on the partners of women with PND29,30
analyses undertaken in this report suggest that this may be a particularly important area for
funding trials to ascertain the comparative efficacy future research. A related concern is the impact
and duration of the advantage of group CBT of PND on other family members including the
compared with RPC and the costs of providing infant and siblings. It has been demonstrated that
group CBT appear cost-effective. The efficacy PND can result in impaired cognitive26 and social-
should be assessed using a utility measure rather emotional27 development in the infant.

53

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Acknowledgements

T he group CBT for PND advisory team


consisted of Professors Tony Kendrick, Michael
Barkham, Simon Gilbody and John Brazier;
Alison Scope and Paul Sutcliffe [in conjunction with
Anna Cantrell (Systematic Reviews Information
Officer)] developed the search strategy and
Doctors Tracey Young and Joe Curran; Ms Eleni undertook searches; Alison Scope, Andrew Booth
Chambers, Ms Jane Hamilton and Mrs Anna (Director of Information Resources, ScHARR),
Cantrell. These members attended meetings, David Saxon (Research Fellow) and Paul Sutcliffe
provided guidance where appropriate and screened the search results. Alison Scope and
commented on drafts of the report. Andrew Booth screened retrieved papers against
the inclusion criteria. Alison Scope developed the
Danny Hind, Research Fellow, and Katy Cooper, critical appraisal tool, appraised the quality of
Research Fellow, provided advice on meta-analysis. papers and abstracted data from them.
Julie Hunter, Head of Service, Primary Care
Mental Health Service, Rotherham Community Matt Stevenson, Alison Scope and Andrew Booth
Health Services, provided advice on resource use. analysed the data. Matt Stevenson and Alison
Gill Rooney, Project Administrator at the School of Scope wrote the background and discussion
Health and Related Research (ScHARR), organised chapters. Alison Scope wrote the chapter on the
the retrieval of papers and helped in preparing quantitative systematic review. Alison Scope and
and formatting the report. Andrew Booth wrote the chapter on the qualitative
systematic review. Matt Stevenson wrote the chapter
We acknowledge Jane Morrell and the PoNDER on cost-effectiveness modelling. Eva Kalthenthaler,
team for permission to use the data that allowed Senior Research Fellow, provided advice on the
a relationship between changes in the EPDS and quantitative review and commented on drafts of the
changes in the SF-6D to be established. report. Pauline Slade, Professor of Psychology, and
Glenys Parry, Professor of Applied Psychological
Therapies, commented on drafts of the report.
Contributions of authors
Matt Stevenson, Senior Research Fellow, Alison
Scope, Research Fellow, and Paul Sutcliffe, Senior
Research Fellow, co-ordinated the review.

55

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DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

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60
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Appendix 1
Literature search strategies
A list of the electronic Copies of the search strategies
bibliographic databases used in the major databases
searched
Search strategy used on MEDLINE
1. MEDLINE and MEDLINE In-Process & Other
2. MEDLINE In-Process & Other Non-Indexed Non-Indexed Citations
Citations 1. Depression, Postpartum/
3. CINAHL 2. post-partum depression.tw.
4. Cochrane Database of Systematic Reviews 3. post partum depression.tw.
(CDSR) 4. postpartum depression.tw.
5. Cochrane Central Register of Controlled Trials 5. depression, post partum.tw.
(CENTRAL) 6. depression, post-partum.tw.
6. EMBASE 7. depression, postpartum.tw.
7. Database of Abstracts of Reviews of Effects 8. post-natal depression.tw.
(DARE) 9. post natal depression.tw.
8. NHS EED 10. postnatal depression.tw.
9. NHS Health Technology Assessment (HTA) 11. depression, post natal.tw.
10. PsycINFO 12. depression, post-natal.tw.
11. Science Citation Indexes 13. depression, postnatal.tw.
12. Social Sciences Citation Indexes 14. post pregnancy depression.tw.
13. Applied Social Sciences Index and Abstracts 15. postpregnancy depression.tw.
(ASSIA) 16. post-pregnancy depression.tw.
14. BIOSIS 17. or/1-16
15. British Nursing Index 18. Depression/
16. Social Care Online 19. depress$.tw.
17. Office of Health Economics Economic 20. 18 or 19
Evaluations database. 21. Postpartum Period/
22. post-partum.tw.
A list of additional sources 23. post partum.tw.
24. postpartum.tw.
1. National Research Register (NRR) 25. postnatal$.tw.
2. Research Findings Register (ReFeR) 26. post natal$.tw.
3. Current Controlled Trials and its links 27. post-natal$.tw.
4. Health Services Research Projects in Progress 28. postpregnancy.tw.
(HSRProj) and index to theses 29. post pregnancy.tw.
5. health service research and guideline 30. child birth.tw.
producing bodies (e.g. Scottish Intercollegiate 31. childbirth.tw.
Guidelines Network, NICE, National 32. labor and delivery.tw.
Guidelines Clearinghouse, etc.) have been 33. labour and delivery.tw.
consulted via the internet and other key 34. puerperal.tw.
organisations (e.g. Association for Postnatal 35. or/21-34
Illness, Postnatal illness-Support & Help 36. 20 and 35
Association) have been contacted 37. 17 or 36
6. grey literature has been identified from 38. antenatal depression.tw.
searches of databases including dissertation 39. ante-natal depression.tw.
abstracts. 40. ante natal depression.tw.
41. or/38-40

61

2010 Queens Printer and Controller of HMSO. All rights reserved.


Appendix 1

42. ante-natal$.tw. Search strategy used on Cochrane


43. antenatal$.tw. Library (CDSR, CENTRAL)
44. ante natal$.tw. 1. MeSH descriptor Depression, Postpartum
45. or/4244 explode all trees
46. 20 and 45 2. (post-partum depression):ti,ab,kw or (post
47. 37 or 41 or 46 partum depression):ti,ab,kw or (postpartum
48. limit 47 to humans depression):ti,ab,kw
3. (post-natal depression):ti,ab,kw or
Search strategy used on CINAHL (postnatal depression):ti,ab,kw or (post natal
1. Depression, Postpartum/ depression):ti,ab,kw
2. post-partum depression.tw. 4. (post pregnancy depression):ti,ab,kw or
3. post partum depression.tw. (postpregnancy depression):ti,ab,kw or (post-
4. postpartum depression.tw. pregnancy depression):ti,ab,kw
5. depression, post partum.tw. 5. (#1 OR #2 OR #3 OR #4)
6. depression, post-partum.tw. 6. (depress*):ti,ab,kw
7. depression, postpartum.tw. 7. MeSH descriptor Depression explode all trees
8. post-natal depression.tw. 8. (#6 OR #7)
9. post natal depression.tw. 9. MeSH descriptor Postpartum Period, this term
10. postnatal depression.tw. only
11. depression, post natal.tw. 10. (post-partum):ti,ab,kw or (postpartum):ti,ab,kw
12. depression, post-natal.tw. or (post partum):ti,ab,kw
13. depression, postnatal.tw. 11. (postnatal* OR post natal* OR post-
14. post pregnancy depression.tw. natal*):ti,ab,kw
15. postpregnancy depression.tw. 12. (postpregnancy OR post pregnancy OR post-
16. post-pregnancy depression.tw. pregnancy):ti,ab,kw
17. or/1-16 13. (childbirth OR child birth):ti,ab,kw
18. Depression/ 14. (labor and delivery OR labour and
19. depress$.tw. delivery):ti,ab,kw
20. 18 or 19 15. (puerperal):ti,ab,kw
21. Postpartum Period/ 16. (#9 OR #10 OR #11 OR #12 OR #13 OR
22. post-partum.tw. #14 OR #15)
23. post partum.tw. 17. (#8 AND #16)
24. postpartum.tw. 18. (#5 OR #17)
25. postnatal$.tw. 19. (antenatal depression OR ante natal depression
26. post natal$.tw. OR ante-natal depression):ti,ab,kw
27. post-natal$.tw. 20. (ante-natal* OR ante natal* OR
28. postpregnancy.tw. antenatal*):ti,ab,kw
29. post pregnancy.tw. 21. (#8 AND #20)
30. child birth.tw. 22. (#18 OR #19 OR #21)
31. childbirth.tw.
32. labor and delivery.tw. Search strategy used on EMBASE
33. labour and delivery.tw. 1. Puerperal Depression/
34. puerperal.tw. 2. post-partum depression.tw.
35. or/21-34 3. post partum depression.tw.
36. 20 and 35 4. postpartum depression.tw.
37. 17 or 36 5. depression, post partum.tw.
38. antenatal depression.tw. 6. depression, post-partum.tw.
39. ante-natal depression.tw. 7. depression, postpartum.tw.
40. ante natal depression.tw. 8. post-natal depression.tw.
41. or/38-40 9. post natal depression.tw.
42. ante-natal$.tw. 10. postnatal depression.tw.
43. antenatal$.tw. 11. depression, post natal.tw.
44. ante natal$.tw. 12. depression, postnatal.tw.
45. or/42-44 13. depression, post-natal.tw.
46. 20 and 45 14. post pregnancy depression.tw.
47. 37 or 41 or 46 15. postpregnancy depression.tw.
62
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16. post-pregnancy depression.tw. 14. child AND birth OR childbirth


17. or/116 15. labor and delivery OR labour and delivery
18. DEPRESSION/ 16. puerperal
19. depress$.tw. 17. #9 OR #10 OR #11 OR #12 OR #13 OR #14
20. 18 or 19 OR #15 OR #16
21. puerperium/ 18. #8 AND #17
22. post-partum.tw. 19. #5 OR #18
23. postpartum.tw. 20. ante-natal AND depression OR antenatal
24. post partum.tw. AND depression OR ante AND natal AND
25. postnatal$.tw. depression
26. post natal$.tw. 21. ante-natal OR antenatal OR ante AND natal
27. post-natal$.tw. 22. #8 AND #21
28. postpregnancy.tw. 23. #19 OR #20 OR #22
29. post pregnancy.tw.
30. childbirth.tw. Search strategy used on PsycINFO
31. child birth.tw. 1. postpartum depression/
32. labor and delivery.tw. 2. post-partum depression.tw.
33. labour and delivery.tw. 3. post partum depression.tw.
34. puerperal.tw. 4. postpartum depression.tw.
35. or/21-34 5. depression, post partum.tw.
36. 20 and 35 6. depression, post-partum.tw.
37. 17 or 36 7. depression, postpartum.tw.
38. antenatal depression.tw. 8. post-natal depression.tw.
39. ante natal depression.tw. 9. post natal depression.tw.
40. ante-natal depression.tw. 10. postnatal depression.tw.
41. 38 or 39 or 40 11. depression, post natal.tw.
42. antenatal.tw. 12. depression, post-natal.tw.
43. ante natal.tw. 13. depression, postnatal.tw.
44. ante-natal.tw. 14. post pregnancy depression.tw.
45. 42 or 43 or 44 15. postpregnancy depression.tw.
46. 20 and 45 16. post-pregnancy depression.tw.
47. limit 46 to humans 17. or/116
18. major depression/
Search strategy used on Centres of 19. depress$.tw.
Reviews and Dissemination databases 20. 18 or 19
(DARE, NHS EED and NHS HTA) 21. postnatal period/
1. post-partum AND depression OR post AND 22. post-partum.tw.
partum AND depression OR postpartum AND 23. post partum.tw.
depression 24. postpartum.tw.
2. post-natal AND depression OR postnatal 25. postnatal$.tw.
AND depression OR post AND natal AND 26. post natal$.tw.
depression 27. post-natal$.tw.
3. post AND pregnancy AND depression OR 28. postpregnancy.tw.
postpregnancy AND depression OR post- 29. post pregnancy.tw.
pregnancy AND depression 30. child birth.tw.
4. MeSH Depression, Postpartum EXPLODE 1 2 31. childbirth.tw.
5. #1 OR #2 OR #3 OR #4 32. labor and delivery.tw.
6. MeSH Depression EXPLODE 1 33. labour and delivery.tw.
7. depress* 34. puerperal.tw.
8. #6 OR #7 35. or/21-34
9. MeSH Postpartum Period EXPLODE 1 36. 20 and 35
10. post-partum OR postpartum OR post AND 37. 17 or 36
partum 38. antenatal depression.tw.
11. postnatal* OR post AND natal* OR post-natal* 39. ante-natal depression.tw.
12. postpregnancy OR post AND pregnancy 40. ante natal depression.tw.
13. post-pregnancy 41. or/38-40
63

2010 Queens Printer and Controller of HMSO. All rights reserved.


Appendix 1

42. ante-natal$.tw. Economics filters used to


43. antenatal$.tw. retrieve cost-effectiveness
44. ante natal$.tw. literature
45. or/42-44 MEDLINE
46. 20 and 45 1. Economics/
47. 37 or 41 or 46 2. exp Costs and Cost Analysis/
3. economic value of life/
Search strategy used on BIOSIS and the 4. exp economics hospital/
Science and Social Sciences Citation 5. exp economics medical/
Index 6. economics nursing/
1. TI=(Depression, Postpartum OR post-partum 7. exp models economic/
depression OR post partum depression OR 8. Economics, Pharmaceutical/
postpartum depression OR depression, 9. exp Fees and Charges/
post partum OR depression, post-partum 10. exp budgets/
OR depression, postpartum OR post-natal 11. ec.fs.
depression OR post natal depression OR 12. (cost or costs or costed or costly or costing$).tw.
postnatal depression OR depression, post natal 13. (economic$or pharmacoeconomic$or price$or
OR depression, post-natal OR depression, pricing$).tw.
postnatal OR post pregnancy depression OR 14. quality adjusted life years/
postpregnancy depression OR post-pregnancy 15. (qaly or qaly$).af.
depression) 16. or/1-15
2. TS=(post-partum OR post partum OR
postpartum child birth OR childbirth OR CINAHL
labor and delivery OR labour and delivery 1. exp Financial Management/
OR puerperal OR post-natal* OR postnatal* 2. exp *economics/
OR post natal*) 3. exp financial support/
3. TI=depress* 4. exp financing organized/
4. #3 AND #2 5. exp business/
5. TS=(antenatal depression OR ante-natal 6. (cost or costs or economic$or
depression OR ante natal depression) pharmacoeconomic$or price$or pricing$).tw.
6. TS=(ante-natal* OR antenatal* OR ante 7. Health resource allocation.sh.
natal*) 8. Health resource utilization.sh.
7. #6 AND #3 9. (editorial or letter or news).pt.
8. #7 OR #5 OR #4 OR #1 10. (1 or 2 or 3 or 4 or 6 or 7 or 8) not (5 or 9)

Search strategy used on ASSIA EMBASE


Query: ((antenatal OR ante natal OR ante- 1. exp SOCIOECONOMICS/
natal) and ((depress*) or (DE=depression))) or 2. exp Cost Benefit Analysis/
(antenatal depression OR ante natal depression 3. exp Cost Effectiveness Analysis/
OR ante-natal depression) or (((postpregnancy 4. exp Cost of Illness/
OR post pregancy OR childbirth OR child birth 5. exp Cost Control/
OR labor and delivery OR labour and delivery 6. exp Economic Aspect/
OR puerperal) or (post-partum OR postpartum 7. exp Financial Management/
OR post partum OR postnatal* OR post natal* 8. exp Health Care Cost/
OR post-natal*) or (DE=postpartum women)) 9. exp Health Care Financing/
and ((depress*) or (DE=depression))) or 10. exp Health Economics/
((post pregnancy depression OR post-pregnancy 11. exp Hospital Cost/
depression OR postpregnancy depression) or 12. (financial or fiscal or finance or funding).tw.
(depression post natal OR depression postnatal OR 13. exp Cost Minimization Analysis/
depression post-natal) or (post-natal depression 14. (cost adj estimate$).mp.
OR postnatal depression OR post natal depression) 15. (cost adj variable$).mp.
or (depression post partum OR depression post- 16. (unit adj cost$).mp.
partum OR depression postpartum) or (post- 17. or/1-16
partum depression OR postpartum depression
OR post partum depression) or (DE=postnatal
depression))
64
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Appendix 2
Data abstraction tables quantitative review

TABLE 18 Included randomised controlled trials

Outcome
Study Funding Methods Participants Interventions measures
Milgrom et al. National Health Design: RCT; Sample size: Intervention Depression: BDI
(2005)59 & Medical three intervention 192 (group group: group- Anxiety: BAI
Research council, arms and one CBT=46), (group based CBT, group-
Austin Hospital control arm counselling=47), based counselling, Social support:
Medical Research (individual individual SPS
Tool of
Foundation identification: counselling=66), counselling
EPDS, DSM-IV (RPC=33) Control group:
minor or major Diagnosed condition: RPC
depression depression
Method of diagnosis:
DSM-IV
Honey Wales Office of Design: RCT with Sample size: 45 (23 Intervention Depression:
(2002)43 Research and a treatment arm controlled PEG), (22 group: controlled EPDS
Development for and a control arm RPC) PEG Social support:
Health and Social Tool of Diagnosed condition: Control group: Duke UNC;
Care identification: PND RPC DAS; WCC-R
EPDS Method of diagnosis:
EPDS
Rojas et al. Fondo de Ciencia Design: RCT; one Sample size: 230 Intervention Depression:
(2007)58 y Tecononlogia intervention arm (MCI=114, UC=116) group: MCI EPDS; SF-36
(FONDECYT- and one control Diagnosed condition: Control group: UC
Chile) Grant arm major depression
Tool of Method of diagnosis:
identification: DSM-IV
EPDS

BAI, Beck Anxiety Inventory; DAS, Dyadic Marital Adjustment Scale; Duke UNC, Duke UNC Social Support
questionnaire; PEG, psycho-educational group; SF-36, Short Form questionnaire-36 items; SPS, Social Provisions Scale;
WCC-R, Ways of Coping Checklist-Revised.

65

2010 Queens Printer and Controller of HMSO. All rights reserved.


Appendix 2

TABLE 19 Included non-randomised studies

Outcome
Study Funding Methods Participants Interventions measures
Highet and NR Design: Sample size: Intervention group: Depression: EPDS
Drummond community-based 146=136 eight different Physiological and
(2004)60 study; between treatment group, treatment conditions, psychological
groups for 10 WLG participants may be anxiety: State Trait
treatment vs wait Diagnosed included in one or Anxiety Inventory;
list; within groups condition: PND more groups but this GHQ
across treatments is not clearly stated
Method of which participants are Social support:
Tool of diagnosis: Social Support
identification: in which groups; CBT,
not detailed CBT and medication, Scales
pretreatment considered
questionnaire, medication only,
by health-care group CBT only,
EPDS provider to have group and individual
PND CBT, individual CBT
only, group cognitive
and behaviour
therapy, group
behaviour therapy
only
Control group: WLG
Meager and NR Design: between Sample size: 20 Intervention group: Depression: EPDS;
Milgrom groups, two (group=10), group treatment BDI
(1996)62 groups (WLG=10) (including CBT) Self-esteem:
Tool of Diagnosed Control group: WLG Coopersmith Self-
identification: condition: PND esteem inventory
EPDS, BDI Method of Mood: Profile of
diagnosis: EPDS, Mood States
BDI Social support: SPS
Parenting: PSI
Relationship
adjustment: DAS
Clark et al. Perinatal Design: between Sample size: Intervention group: Depression: BDI;
(2003)61 Foundation, groups; three 39=13 MITG, MITG CES-D
Madison, WI, and groups 15 IPT, 11 WLG Individual therapy Stress: PSI
the Research and Tool of Diagnosed group: IPT
Development Child: BSID;
identification: condition: major Control group: WLG PCERA
Fund, Department DSM-IV, BDI depression
of Psychiatry,
University of Method of
Wisconsin Medical diagnosis: DSM-
School IV

BSID, Bayley Scales of Infant Development; CES-D, The Center for Epidemiological Studies Depression Scale; DAS, Dyadic
Marital Adjustment Scale; GHQ, General Health Questionnaire; NR, not reported; PCERA, The ParentChild Early
Relational Assessment; PSI, Parenting Stress Index; SPS, Social Provisions Scale.

66
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TABLE 20 Study characteristics of the RCTs

Co-therapy or
Study Description of treatment medication Comparator Sample size
Milgrom et al. Group-based CBT designed to NR RPC: the routine care 192: 52 of those
(2005)59 address specific target behaviours provided via the states allocated to
within the context of general universal Maternal and a treatment
components recognised as Child Health Service condition did
important in determining the not attend; 121
success of cognitive behavioural completed post-
intervention. Each session intervention
involved psycho-education, measures
review of homework exercises,
role playing and discussion
Group-based counselling
designed for depression
Individual counselling
Honey PEG; educational information on Antidepressant use, RPC: further details not 45 (four dropped
(2002)43 PND; strategies for coping; use of details not given provided out of PEG group
cognitive-behavioural techniques; but were followed
relaxation up)
Rojas et al. MCI included PEGs and Participants were UC: all services 230: 101
(2007)58 structured pharmacotherapy if excluded if receiving normally available in participants in
needed or had received the clinics, including MCI completed
treatment for antidepressant dugs, assessment at
depression during brief psychotherapeutic 3 months and
current postnatal interventions, medical 106 completed
period, but were consultation or external assessment at
offered medication referral for speciality 6 months; 108
as part of the treatment (although participants in UC
intervention and psychotherapy and group completed
control groups speciality treatments rarely assessment at
numbers given in offered) 3 months and
results section 102 completed
assessment at 6
months

NR, not reported; PEG(s), psycho-educational group(s).

67

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Appendix 2

TABLE 21 Study characteristics of the non-RCTs

Co-therapy or
Study Description of treatment medication Comparator Sample size
Highet and Varied by GP/health visitor. Not Various: see WLG: participants 188 participants
Drummond detailed. Community sample description of who had to wait initially involved in
(2004)60 treatment at least 3 weeks the study, 42 were
to receive group excluded from the
intervention final sample leaving
146 participants
Meager and Group treatment programme Participants could WLG: had the 20: four
Milgrom consisting of targets which take receive any other opportunity to participants
(1996)62 into consideration the risk factors treatments at any participate in dropped out of
for postpartum depression. time. Eight of the 20 the treatment each group leaving
An environment of social and participants were on programme once 12 participants (six
emotional support, an educational medication but it is the participants per group). These
component, a cognitive behavioural not stated how many in the treatment participants did not
component, encouragement of of these eight were group had complete follow-up
networking, examination of patterns in the experimental completed the measures
of communication, normalising of group. Post hoc programme
feelings, involvement of spouse in the analyses revealed no
group, practical homework significant differences
between the groups on
medication usage
Clark et al. MITG mothers therapeutic NR WLG those 39: four
(2003)61 intervention and peer support waiting to receive participants in the
group and infant development group MITG MITG were lost
occurred simultaneously, followed by to follow-up
motherinfant dyadic group. Based
on interpersonal, psychodynamic,
family systems, and cognitive
behavioural approaches
IPT group individual therapy,
relating to partners, children and
others

NR, not reported.

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TABLE 22 Treatment details for the RCTs

Number Length
of Number of Professional background of
Study Recruitment sessions in group sessions therapist
Milgrom Recruitment was via a community Nine, 510 90 One of two senior therapists
et al. screening programme conducted weekly minutes delivered the interventions,
(2005)59 at 47 maternal and child health supported by cotherapists with
centres in northern metropolitan professional registrations and
Melbourne and rural eastern VIC, backgrounds in clinical psychology,
Australia postgraduate psychology research
and nursing with postgraduate
qualifications in counselling and/
or psychology. All received one-
to-one instruction in use of the
therapy manuals and regular,
intensive supervision from the
principal investigator
Honey Women were referred by Eight, Four to six 2 hours Health visitors
(2002)43 their health visitor if they were weekly per group
attending mother and baby clinics
in Gwent, scoring above 12 on
the EPDS
Rojas Recruited mothers at any stage Eight, Maximum 50 Midwives or nurses with 8 hours
et al. during first postnatal year from weekly 20 minutes of training and supervision every
(2007)58 three clinics in Santiago, Chile. week. A medical doctor was
Approached whilst waiting for responsible for the group
health-related consultations.
Screened using EPDS, those
scoring 10 or above were asked
to return for another assessment
2 weeks later. Those still scoring
10 or above were invited to
a baseline clinical assessment
(DSM-IV)

TABLE 23 Treatment details for non-RCTs

Number of Number Length of Professional background


Study Recruitment sessions in group sessions of therapist
Highet and Recruited via clinics and a range NR NR NR NR
Drummond of health professionals offering
(2004)60 treatment for PND
Meager and Advertisements for the 10, weekly 10 1.5 hours Clinical psychologist
Milgrom programme in local hospitals and
(1996)62 maternal and child health centres
Clark et al. Through health-care provider MITG: 12, NR 1.5 hours Three licensed
(2003)61 referrals and newspaper weekly psychologists, three social
advertisements. Screened by IPT: 12, workers, three psychology
telephone using a questionnaire weekly interns and three
based on the DSM-IV criteria. postdoctoral fellows with
Women who met the criteria at least 2 years of clinical
for major depression during the experience
postpartum period were included

NR, not reported.

69

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Appendix 2

TABLE 24 Study site, follow-up and inclusion/exclusion criteria for RCTs

Reasons
Length of Numbers lost for loss to
Study Study site follow-up to follow-up follow-up Inclusion criteria Exclusion criteria
Milgrom Northern 12 weeks, 52 did not NR DSM-IV diagnosis of Depression affecting
et al. metropolitan and 12 attend; 121 depression; 37- to competence to give
(2005)59 Melbourne months after completed 42-week pregnancy; informed consent
and rural treatment postintervention infant birth weight (e.g. psychotic
eastern VIC, began measures 2.5kg and above; depression); risk
Australia no congenital requiring crisis
abnormality; no management;
major health participation in
problem; no other psychological
concurrent major programmes and
psychiatric disorder significant difficulty
with English
Honey Gwent, Wales, 8 weeks Three in each NR Attending mother Exhibiting psychotic
(2002)43 UK (after PEG condition and baby clinics. symptoms
finished) and (equals six) at >12 on EPDS.
6 months time three (6 Most recent child
after first months) <12 months
assessment
Rojas Santiago, Chile Baseline, At three months NR Mothers within their Women who had
et al. 3 months, 21 (13 from MCI, first postnatal year. received any form
(2007)58 6 months 8 from UC), at Meeting criteria for of treatment for
6 months 22 (8 major depression on depression during
from MCI, 14 DSM-IV their current
from UC) postnatal period;
those who were
pregnant; or those
with psychotic
symptoms, serious
suicidal risk, history
of mania, or alcohol
or drug abuse

NR, not reported; PEG, psycho-educational group.

70
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TABLE 25 Study site, follow-up and inclusion/exclusion criteria for non-RCTs

Numbers Reasons for


Length of lost to loss to follow- Exclusion
Study Study site follow-up follow-up up Inclusion criteria criteria
Highet and Perth Baseline 28 (these Not contactable Women sought for Not considered
Drummond metropolitan (prior to had already post treatment; or been referred to to have PND
(2004)60 area, Western treatment), been not considered treatment for PND by their health-
Australia immediately removed to have PND care provider
following from initial by their health-
treatment sample) care provider;
and at 6 refused to take
months part in the
follow-up study; stopped
treatment prior
to completion
Meager and VIC, Australia At 10 weeks Eight Physical illness; Subjects included in Subjects
Milgrom after the last need to support the trial had developed excluded from
(1996)62 treatment de facto husband their depressive the study were
session who was on condition within those who had
a methadone 6 months postpartum, a concurrent
programme; had a rating of above major
difficulty in 12 on the EPDS, and psychiatric
organising a BDI score reflecting disorder or
attendance; and a moderate to severe insufficient
distance to travel depression (i.e. a score command
above 15) of English to
follow group
discussions
Clark et al. NR assume Pre- Four NR Women who met NR
(2003)61 USA due to assessment the criteria for major
funding and following depression during the
the 12-week postpartum period.
interventions. Scores of 16 or higher
12 weeks on the BDI
apart for
WLG

NR, not reported.

71

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72
Appendix 2

TABLE 26 Patient characteristics for RCTs

Methods for
Diagnosed diagnosis of Education/socioeconomic Baseline
Study condition disorder Age Ethnicity background Patient history comparability
Milgrom et al. Condition: DSM-IV Mean=29.7 NR Family income AUS$41,400 Number of children [mean NR
(2005)59 depression years; SD=5.4 (SD=20,500). 62.7% with 12 (SD)]: 1.8 (0.8)
Time after years or more years of school. 30.5% Comorbidity: NR, but
diagnosis: NR with higher education exclusion criteria no
concurrent major psychiatric
disorder
Honey (2002)43 Condition: EPDS PEG: NR NR Number of children: PEG Groups did not
PND not mean=29.3 50% primiparous; RPC 59% differ significantly
confirmed years; primiparous on socio-
by diagnostic SD=5.36 years Comorbidity: NR demographic and
interview RPC: time 1 self-report
Time after mean=26.48 measures
diagnosis: NR years;
SD=5.68 years
Rojas et al. (2007)58 Condition: DSM-IV MCI: NR Number of years in education: Number of children [mean NR
depression mean=26.7 MCI, 0<8=20 (18%), (SD)]: MCI=2 (1), UC=2 (1.2)
Time after years; SD=6.4 812=82 (73%), >12=11 Comorbidity: NR, but
diagnosis: NR years (10%). UC, 0<8=17(15%), exclusion criteria no
UC: 812=87 (75%), >12=12 (10%) concurrent major psychiatric
mean=26.6 Main occupation: housewife, disorder
years; SD=7.4 MCI=94 (83%), UC=105
years (91%); student, MCI=3 (3%),
UC=4 (3%); employed,
MCI=16(14%), UC=5 (4%);
unemployed, MCI=1 (1%),
UC=2 (2%)

NR, not reported; PEG, psycho-educational group; SD, standard deviation.


TABLE 27 Patient characteristics for non-RCTs

Methods for Education/


Diagnosed diagnosis of socioeconomic Baseline
Study condition disorder Age Ethnicity background Patient history comparability
Highet and Condition: EPDS no other NR NR NR Number of children: Groups similar in
Drummond depression information given NR terms of clinical
(2004)60 Time after diagnosis: Comorbidity: NR status and social
NR support received
DOI: 10.3310/hta14440

across all scales and


level of support also
remained consistent
for both groups
across assessment
intervals
Meager and Condition: PND EPDS, BDI Mean age of all 80% of the women Two women had The mean number of Post hoc examination
Milgrom Time after diagnosis: participants 29.6 were Australian a professional children per mother of the two groups
(1996)62 NR years (31.3 years for born, and the background; six had in the treatment revealed no
the treatment group remainder were from a semi-professional group was 2.0, in the significant differences
and 27.9 years for the Ireland and the UK occupation; a further control group it was between groups on
control group, NS) six were engaged 1.6. Average infant mean age of infant,
in sales/business age was 10.6 months. medication usage,
management; two Fifteen women pretest BDI scores
worked in skilled were married, four or occupational

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occupations; and four were in de facto background
were housewives. relationships and one
None fell into the was separated
unskilled category
Clark et al. Condition: major Questionnaire Mean=31.4 years MITG: 13 Caucasian Educational level: NR WLGs were accrued
(2003)61 depression based on DSM-IV Median=NR WLG: 11 Caucasian 2.6% (n=1) some high on the basis of their
Time after diagnosis: diagnostic criteria for school; 7.7% (n=3) socio-demographic
major depression (via SD=NR IPT: 14 Caucasian, high school diploma; characteristics
NR one African
telephone) Range=1944 years 23.1% (n=9) some indicating a match
American college; 23.1% (n=9) with participants of
graduate degree the MITG cohort.
Mean educational Subsequently, IPT
level: MITG 14.9 participants were
years; IPT 15.5 years; also matched to
WLG 16 years. the MITG cohort
in a similar fashion.
Family income range Baseline depression
$6000120,000, scores were not
mean $33,353 clearly reported,
although they were
used as a covariate in
the analyses
Health Technology Assessment 2010; Vol. 14: No. 44

NR, not reported; NS, not significant; SD, standard deviation.

73
Appendix 2

TABLE 28 Outcomes and analysis information for RCTs

Measurement
Study Outcomes Instruments periods ITT analysis
Milgrom Depression BDI Baseline, after Yes. Analyses were executed twice: once
et al. Anxiety BAI 12 weeks using only observed cases (121/192 possible
(2005)59 intervention, and cases), and once using multiple imputation
Social support SPS after 12 months under multivariate normal assumptions using
methods given by Schafer,77,78 employing
available demographic and psychometric data.
Conducted analyses to test the assumption
that missing data were missing at random (SAS
and winbugs)
Honey Sociodemographic NR Baseline Yes. Data missing for three participants in each
(2002)43 questionnaire condition at time 3. Missing data replaced by
Depression EPDS Baseline, after the group mean of each measure

Social support Duke UNC intervention (8


weeks after baseline),
Marital adjustment DAS 6 months after end of
Coping WCC-R intervention
Rojas Depression EPDS Baseline, 3 months, Yes. For between group comparisons
et al. Mental health SF-36 6 months
(2007)58
Emotional role
Social function
Vitality

BAI, Beck Anxiety Inventory; DAS, Dyadic Marital Adjustment Scale; Duke UNC, Duke UNC Social Support
questionnaire; NR, not reported; SAS, Statistical Analysis System; SF-36, Short Form questionnaire-36 items; SPS, Social
Provisions Scale; WCC-R, Ways of Coping Checklist-Revised.

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TABLE 29 Outcomes and analysis information for non-RCTs

Study Outcomes Instruments Measurement periods ITT analysis


Highet and Depression EPDS Prior to treatment, immediately following No. Only participants
Drummond Physiological and State Trait treatment, 6 months follow-up who completed
(2004)60 psychological Anxiety treatment and
anxiety Inventory assessment at all three
time points were
GHQ included
Social support Social Support Unclear whether this was measured at all
Scales three times
Meager and Depression EPDS Baseline and at end of week 10 when the No. Those lost to
Milgrom BDI treatment group had completed their follow-up were not
(1996)62 programme and the WLG commenced analysed
Self-esteem Coopersmith treatment. Measures were also
Self-esteem administered at week 22 to subjects
Inventory in the wait list control group who had
Mood Profile of mood completed the treatment programme
states
Social support SPS
Parenting stress PSI
Marital conflict DAS
Clark et al. Depression BDI Pre and post assessment (i.e. before and No. Those lost to
(2003)61 CES-D after the 12-week intervention) follow-up were not
analysed
Parenting stress PSI
Infant BSID
development
Motherinfant PCERA
interaction

BSID, Bayley Scales of Infant Development; CES-D, The Center for Epidemiological Studies Depression Scale; DAS, Dyadic
Marital Adjustment Scale; GHQ, General Health Questionnaire; PCERA, The ParentChild Early Relational Assessment;
PSI, Parenting Stress Index; SPS, Social Provisions Scale.

75

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76
TABLE 30 Results of reported outcomes (psychological symptoms and interpersonal and social functioning RCTs)

Study Results Other outcome information


Appendix 2

Milgrom Outcome Measure Baseline C1 (RPC vs C2 (CBT vs Changes in depression and anxiety immediately post intervention
et al. other three counselling) significantly differed between psychological intervention vs routine
(2005)59 interventions care. No evidence that CBT and counselling led to different outcomes
combined) in terms of depressive symptoms
Depression BDI (observed) Difference in 0.580 6.94 0.065 Intervention based on a counselling approach may be more effective
BDI scores when delivered on an individual basis. Percentages of women in
each treatment condition whose post-intervention BDI scores fell
SE 0.108 2.29 1.86 below the threshold for clinical depression (17) were: CBT 55%,
df 82 34 34 group counselling 64%, individual counselling 59% and RPC 29%.
Social support measure post intervention levels of perceived social
p-value <0.0001 0.005 0.97 support increased in each intervention group but fell for the RPC
BDI Difference in 0.510 4.06 0.75 group (although there appear to be no statistics)
(imputations) BDI Scores
SE 0.11 2.08 1.83
df 290.2 556.8 673.7
p-value <0.001 0.05 0.68
Honey Outcome Measure PEG RPC Statistical analysis For the EPDS there was a main effect of group F(1,36)=7.62,
(2002)43 (n=23) (n=22) p=0.01; main effect of time F(2,43)=12.06, p<0.001; and a significant
Mean (SD) interaction F(2,43)=3.16, p<0.05
Depression EPDS (time 19.35 (4.39) 17.95 (3.95) Main effect of group Simple effects; effect of time for the PEG F(2,86)=13.76, p<0.001; not
1 pre F(1,36)=7.62, p=0.01; main for RPC; marginally significant effect of group at time 3 F(1,107)=3.68,
intervention) effect of time F(2,43)=12.06, p=0.058
p<0.001; and a significant At time 3 there was a significant association between group and
EPDS (time 14.87 (5.97) 16.95 (5.44)
interaction F(2,43)=3.16, percentage scoring below cut-off [X 2 (1, N=45)=3.75, p<0.05],
2 post
p<0.05 significantly more women scored below cut-off in the PEG but not in
intervention 8
Simple effects; effect of time the RPC group. No differences at time 2. No differences between the
weeks)
for the PEG F(2,86)=13.76, groups on the social support measures
EPDS (time 3 12.55 (4.62) 15.63 (7.28) The brief PEG significantly reduced EPDS scores compared with
p<0.001; not for RPC;
6 months after RPC. This was not related to antidepressant use and was maintained
marginally significant effect of
intervention) 6 months after the group had ended. However, some women in the
group at time 3 F(1,107)=3.68,
p=0.058 PEG continued to show evidence of depressive symptomatology
6 months later. Improvements in mood were not accompanied
% women 35 27 NS
by changes in coping, perceptions of social support or the marital
scoring below
relationship
cut-off (time 2)
% women 65 36 2 (1, N=45)=3.75, p<0.05
scoring below
cut-off (time 3)
DOI: 10.3310/hta14440

Study Results Other outcome information


Rojas Outcome Measure MCI mean UC mean Grouptime interaction ANOVA and linear regression performed on data for each group
et al. (95% (95% effect (95% CI; p-value) and across the three time periods. There were significant interaction
(2007)58 CI) (SD CI) (SD effects for grouptime for EPDS and the four SF-36 measures. Simple
calculated) calculated) effects analysis showed that the MCI group had significantly improved
(n=114) (n=116) scores on each of these measures compared to the UC group at
3 months (simple effects not presented for 6 months). The number
Depression EPDS baseline 17.7 (16.8 to 17.1 (16.4 to 2.3 (0.8 to 3.8; p=0.002) of participants who had improved in both group was more similar at

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18.7) (3) 17.9) (4.12) 6 months than at 3 months, with all difference in favour of MCI
EPDS 3 8.5 (7.2 to 12.8 (11.3 to
months 9.7) (6.8) 14.1) (7.7)
EPDS 6 10.9 (9.6 to 12.5 (11.1 to
months 12.2) (7.07) 13.8) (7.43)

ANOVA, analysis of variance; df, degrees of freedom; NS, not significant; PEG, psycho-educational group; SE, standard error; SF-36, Short Form questionnaire-36 items.
Health Technology Assessment 2010; Vol. 14: No. 44

77
78
Appendix 2

TABLE 31 Results of reported outcomes (psychological symptoms and interpersonal and social functioning) for non-RCTs

Pre treatment Post treatment Follow-up Receiving treatment resulted in significant decreases in depression
Treatment Clinical between pre and post treatment [grouptime interaction
Study condition scale n Mean SD n Mean SD n Mean SD F(1,137)=11.89, p<0.05]
Highet and Medication EPDS 15 19.27 4.38 15 14.47 6.80 Medication was no more effective than CBT. Participants treated with
Drummond only CBT (alone or in combination with medication) had greater decreases
(2004)60 in depression [grouptime interaction F(1,82)=11.08, p<0.05] and
psychological anxiety [grouptime interaction F(1,79)=5.98, p<0.05]
Group CBT EPDS 23 15.39 4.39 22 9.32 3.67 12 8.15 4.63 following treatment than those who received medication alone
only Comparison of subjects treated in groups (alone and in conjunction with
individual treatment) vs those treated individually revealed a significant
grouptime interaction [F(1,83)=16.98, p<0.05]. Depression was
significantly lower at post treatment in subjects treated individually
as opposed to those who received group or combined intervention
[t(84)=3.9, p<0.05]. At follow-up there was also a significant decrease
in depression [main effect for time, F(1,63)=11.36, p<0.05], particularly
in those treated in both group and individual settings [grouptime
interaction, F(1,63)=5.95, p<0.05]. Depression continued to decline
for those who had been treated in the combined setting [t(34)=5.26,
p<0.05], while there was no change for those treated in groups only
While CBT was no more effective than behavioural-based supportive
counselling, confounding effects of greater medication use and
greater treatment duration for those in the latter group may result in
underestimation of the efficacy and efficiency of CBT for this sample
Study Week
DOI: 10.3310/hta14440

Meager and Outcome Measure Group 0 (control n=10) 10 (control n=6) Least Actual difference
Milgrom (treatment n=10) (treatment n=6) significant
(1996)62 (mean) (mean) difference
Depression BDI Control 29.00 29.14
Treatment 29.70 16.80 10.27 12.90
(p<0.05)a
11.26 12.34
(p<0.10)b
EPDS Control 27.50 28.00
Treatment 24.80 15.80 7.92 9.0
(p<0.02)a
10.74 12.2

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(p<0.05)b
Clark et al. MITG (n=9) IPT (n=15) WLG (n=11) F p Other outcome information
(2003)61 Measure Pre Post (3 Pre Post (3 Pre Post (3 Both the women in the MITG and
months) months) months) those in the IPT condition reported
BDI 26.9 (7.3) 15.9 (8.5) 26.2 (8.2) 16.4 (10.2) 24.5 (6.4) 20.6 (9.2) 1.67 NS fewer symptoms on the CES-D post
treatment than did those in the
WLG (ps=0.02 and 0.04), but the
two treatment groups did not differ
from each other on this variable
CES-D 41.1 (7.6) 19.2 (10.2) 36.2 (9.2) 20.1 (12.9) 32.4 (6.9) 26.6 (10.0) 3.60 0.04

a Significant difference within group.


b Significant difference between groups.
CES-D, The Center for Epidemiological Studies Depression Scale; NS, not significant; ps, probability values; SD, standard deviation.
Health Technology Assessment 2010; Vol. 14: No. 44

79
Appendix 2

TABLE 32 Patient preferences and conclusions for RCTs

Study Patient preference, satisfaction and acceptability of treatment Conclusions


Milgrom et al. (2005)59 NR
Honey (2002) 43
NR
Rojas et al. (2007)58 NR

NR, not reported.

TABLE 33 Patient preferences and conclusions for non-RCTs

Study Patient preference, satisfaction and acceptability of treatment Conclusions


Highet and Sharp Consumer Satisfaction Questionnaire (Tanner 1982) administered Individual treatment
79

Drummond (2004)60 by telephone 2 weeks after completion of treatment preferred to group


CBT vs medication similar ratings of satisfaction with treatment treatment
received
Individual vs group treatment generally high but significantly higher for
those receiving individual treatment alone than those receiving treatment
in group settings
Group CBT vs group behaviour therapy similar in terms of satisfaction
with treatment services
Meager and Milgrom NR
(1996)62
Clark et al. (2003)61 NR

NR, not reported.

80
DOI: 10.3310/hta14440 Health Technology Assessment 2010; Vol. 14: No. 44

Appendix 3
Data abstraction tables qualitative review

TABLE 34 Studies included in the review CBT-based group treatment

Study Funding Methods Participants Interventions Outcomes


Morgan et Funding: Design: examination of Sample size: 34 Support group Depression EPDS,
al. (1997)53 NR a group intervention; no women, 20 men programme for Coopersmith Self-
control arm Diagnosed women with PND esteem Questionnaire
Method of condition: incorporating couples for women, GHQ-30
randomisation: not depression sessions for men
randomised Method of Qualitative, survey
Tool of identification: identification: and case study data
EPDS EPDS
Davies Funding: Design: evaluation of a Sample size: eight Support group Depression EPDS
and Jasper NR group programme for women. programme for Qualitative, three
(2004)52 the treatment of PND; Diagnosed women with PND open-ended
no control arm condition: questionnaires
Method of depression
randomisation: not Method of
randomised diagnosis: DSM-IV
Tool of identification:
EPDS

GHQ, General Health Questionnaire; NR, not reported.

81

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Appendix 3

TABLE 35 Studies included in the review non-theoretically-based group treatment

Study Funding Methods Participants Interventions Outcomes


Duskin Funding: Design: examination of Sample size: five Support group Qualitative, in-depth
(2006)65 dissertation a group intervention; no women programme for interviews and
NR control arm Diagnosed women with PND questionnaire
Method of condition: NR
randomisation: not Method of
randomised diagnosis: NR
Tool of identification:
NR
Beck (1993)66 Funding: NR Design: development Sample size: 12 Postpartum Observations
of a theory of PND women depression support In-depth interviews
using grounded theory; Diagnosed group
interviews with women condition: NR
attending a PND
support group; no Method of
control arm diagnosis: NR
Method of
randomisation: not
randomised
Tool of identification:
NR
Pitts (1999)67 Funding: NR Design: qualitative Sample size: 48 Support group for Depression EPDS
evaluation; no control women women with PND Qualitative, survey
arm Diagnosed data
Method of condition:
randomisation: not depression
randomised Method of
Tool of identification: diagnosis: EPDS
EPDS (not all women
were above the
cut-off)
Eastwood Funding: NR Design: examination of Sample size: 13 Support group Depression EPDS;
(1995)68 a group intervention; no women programme for BDI; HADS
control arm Diagnosed women with PND Qualitative
Method of condition: NR questionnaire
randomisation: not Method of
randomised diagnosis: NR
Tool of identification:
EPDS, HADS, BDI

HADS, Hospital Anxiety and Depression Scale; NR, not reported.

82
TABLE 36 Study characteristics CBT-based group treatment

Total sample
DOI: 10.3310/hta14440

Study Description of treatment Study quality Cotherapy or medication Comparator size


Morgan et Group programme: eight sessions in Not a research study, an evaluation 17 of the women were being seen None 34 women, 20
al. (1997)53 which discussions took place around: of group programme only; qualitative individually by another health professional men
the myths of motherhood; the womens methodology appropriate for evaluation and some were on antidepressant
relationships with their mothers; purposes; research design not justified; medication. 25 of the women had spent
information regarding PND; their own recruitment strategy and setting for data approximately 1 week in a residential unit
experiences; their relationships with collection explained and justified; data for help with mothercraft issues (such
their partners; their expectations collection methods not fully explained as feeding, sleeping or settling difficulties
of themselves; and information on and justified; reflexivity and ethical issues in their infant). Two other women spent
motherinfant attachment. Cognitive not addressed; data analysis not rigorous, approximately 4 weeks in a different
and behavioural exercises are used no qualitative analysis method specified; mothercraft unit
to challenge some of their beliefs and findings clearly stated, credibility/
help them to participant in rewarding reliability aspects not discussed although
activities authors acknowledge need for more

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rigorous evaluations
Davies The group programme was based on the Not a research study, an evaluation of NR None Eight
and Jasper CBT model, and aimed to encourage the group programme; aims reported for
(2004)52 cognitive restructuring and self-help. To appraising group programme; research
provide an opportunity to meet with design justified for an evaluation;
other PND mothers, in order to share recruitment strategy and setting for
experiences, reduce isolation and for data collection explained and justified;
mother to give and receive support; data collection methods explained and
to reduce depressive symptomatology justified, although some detail missing;
thereby enabling group members to reflexivity and ethical issues addressed;
regain their sense of emotional well- some data analysis shows rigour,
being; to encourage group members however, use of particular qualitative
to begin to clarify individual goals to methods in analysis not reported; findings
maintain their progress on completion of clearly stated and explicit, credibility/
group programme reliability aspects discussed

NR, not reported.


Health Technology Assessment 2010; Vol. 14: No. 44

83
84
Appendix 3

TABLE 37 Study characteristics non-theoretically-based group treatment

Cotherapy or Total sample


Study Description of treatment Study quality medication Comparator size
Duskin Open-ended postpartum depression support group. Research design justified; recruitment strategy and NR None Five
(2006)65 Facilitated by graduate clinical psychology researchers setting for data collection explained and justified; data
collection methods explained and justified; reflexivity
addressed; ethical issues addressed; rigorous data
analysis; findings clearly stated
Beck Postpartum depression support group. Facilitated by Research design justified; recruitment strategy and NR None 12
(1993)66 researcher (nurse) setting for data collection explained and justified; data
collection methods explained and justified; reflexivity
addressed; ethical issues addressed; rigorous data
analysis; findings clearly stated
Pitts Support group for women with PND, providing peer Research design not justified; recruitment strategy and NR None 48
(1999)67 identity and support, addressing feelings of isolation setting for data collection explained and justified; data
and loneliness collection methods explained and justified; reflexivity
not addressed; ethical issues addressed; data analysis
not rigorous; findings could have been more clearly
stated
Eastwood PND support group offering five components of peer Research design not justified; recruitment strategy and NR None 13
(1995)68 support: confidentiality, being able to discuss their setting for data collection explained and justified; data
depression in a safe setting; counselling, talking to other collection methods explained and justified; reflexivity
women with PND; focus, focusing on their own needs, not fully addressed; ethical issues addressed; data
thought and feelings; sharing and support, being cared analysis could have been more rigorous; findings could
for and being caring to other in the group; sessions on have been more clearly stated
PND, feelings and expectations about self, children and
partners, anger and anxiety management, self-support
and evaluation

NR, not reported.


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TABLE 38 Treatment details CBT-based group treatment

Number
of Number Length of Therapist Professional background of
Study Recruitment sessions in group sessions contact therapist
Morgan et Women were Eight, Average of 2 hours NR Groups led by a female
al. (1997)53 referred from weekly six occupational therapist, with the
mothercraft units assistance of either a registered or
or from family enrolled female nurse, the couples
care cottages and session was led by these and a
community health male clinical psychologist
Davies Women were Twelve, Eight 90 minutes NR Health visitors with a registered
and Jasper referred by health weekly mental health nursing qualification
(2004)52 visitors and a family centre worker
facilitated the life skills group. A
primary mental health worker
provided the group leaders with
clinical supervision

NR, not reported.

TABLE 39 Treatment details non-theoretically-based group treatment

Number Professional
of Number in Length of Therapist background of
Study Recruitment sessions group sessions contact therapist
Duskin Participants were NR NR NR NR Graduate students
(2006)65 recruited to take part in on a clinical
interviews from those psychology course
who already attended
the postpartum
depression support
group
Beck Participants were those Twice Number of Open- NR Nurse
(1993)66 attending the support monthly attendees ranged ended
group from 1 to 12
Pitts Women were referred NR NR NR NR Health visitor
(1999)67 to the group by health
visitors
Eastwood Women were referred 12 13 (eight NR NR Health visitors
(1995)68 to the group by health completed the led the group,
visitors course, only supervision was
four attended all provided by a clinical
sessions) psychologist

NR, not reported.

85

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Appendix 3

TABLE 40 Study site, follow-up and inclusion/exclusion criteria CBT-based group treatment

Numbers Reasons for


lost to loss to follow- Exclusion
Study Study site Length of follow-up follow-up up Inclusion criteria criteria
Morgan South-western End of treatment One of the NR An EPDS score NR
et al. Sydney, Australia (8 weeks), some 34 women of 13 or above.
(1997)53 participants followed dropped Adequate spoken
up at 6 months, some out English to enable
9 and some 12 months participation in the
for quantitative groups
measures. Qualitative
data, via a group
evaluation form were
collected only during
sessions
Davies Portsmouth, UK 6-week reunion after One Lack of rapport EPDS (cut-off not NR
and end of programme with group given). Meeting
Jasper members DSM-IV criteria for
(2004)52 depression. Have
an infant aged <18
months

NR, not reported.

TABLE 41 Study site, follow-up and inclusion/exclusion criteria non-theoretically-based group treatment

Numbers Reasons
lost to for loss to Inclusion Exclusion
Study Study site Length of follow-up follow-up follow-up criteria criteria
Duskin CA, USA No follow-up NA NA Those taking NR
(2005)65 part in the
support group
Beck FL, USA Data collected during No follow-up NA Those taking NR
(1993)66 sessions, and during part in the
interviews conducted in support group
participants home
Pitts Southampton, Survey data collected 14 women did NR Those taking NR
(1999)67 UK only once during a not return the part in the
2-year period after survey support group
intervention
Eastwood Bexley, UK End of course and at a Five by end of NR An EPDS score Those
(1995)68 10-week recall course, seven of 13 or above suffering from
at 10-week psychotic
recall depression
were excluded

NA, not applicable; NR, not reported.

86
TABLE 42 Patient characteristics CBT-based group treatment

Methods for Education/


Diagnosed diagnosis of socioeconomic
Study condition disorder Age Sex Ethnicity background Patient history
Morgan et al. Condition: EPDS Range= Female 17 couples had at least one NR Number of children: mean
(1997)53 depression 2336 years n=34, partner from an NESB, six of (SD)=NR
Time after male n=20 these had both partners from 16 primiparas, 18 multiparas
diagnosis: NR an NESB, seven had an NESB
All married or in a de facto
DOI: 10.3310/hta14440

man and an ESB women, four


had an NESB woman and an relationship
ESB man Comorbidity: some women
were also taking antidepressants
Davies and Jasper Condition: EPDS, DSM-IV NR Female n=8 NR From a range of Number of children: four
(2004)52 depression backgrounds primiparas, four multiparas
Time after Comorbidity: NR
diagnosis: NR

ESB, English speaking background; NESB, non-English speaking background; NR, not reported; SD, standard deviation.

TABLE 43 Patient characteristics non-theoretically based group treatment

Methods for Education/

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Diagnosed diagnosis of socioeconomic
Study condition disorder Age Sex Ethnicity background Patient history
Duskin (2006)65 Condition: PND NR Range 3742 Female n=5 Four Caucasian, one Latina NR Number of children: all
Time after diagnosis: years primiparas
NR All married
Comorbidity: three participants
had a history of depression
Beck (1993)66 Condition: NR NR Range 2038 Female White NR Number of children: five
Time after diagnosis: years n=12 primiparas, seven multiparas
NR All married
Comorbidity: NR
Pitts (1999)67 Condition: EPDS NR Female NR NR Number of children: mean
depression n=48 (SD)=NR
Time after diagnosis: Comorbidity: NR
NR
Eastwood (1995)68 Condition: NR NR Range 1935 Female NR Social class II to Number of children: two
Time after diagnosis: years n=13 V, majority IIIM primiparas, 11 multiparas
NR and IIIN Comorbidity: NR
Health Technology Assessment 2010; Vol. 14: No. 44

NR, not reported.

87
Appendix 3

TABLE 44 Outcomes and analysis information CBT-based group treatment

Study Outcomes Instruments Measurement periods ITT analysis


Morgan et al. Depression EPDS (women only) Baseline, after 8 weeks intervention, NR
(1997)53 GHQ-30 (men and and after either 6, 9 or 12 months (only
women) baseline data collected for men)

Self-esteem Coopersmith Self-Esteem


Questionnaire (women
only)
Qualitative Group Evaluation Form During intervention NA
data
Davies Depression EPDS Baseline and at 6-week reunion NR
and Jasper Qualitative Questionnaire 1 At the end of each session NA
(2004)52 data Questionnaire 2 At the end of the programme
Questionnaire 3 At group reunion 6 weeks after end of
programme

GHQ, General Health Questionnaire; NA, not applicable; NR, not reported.

TABLE 45 Outcomes and analysis information Non-theoretically-based group treatment

Study Outcomes Instruments Measurement periods ITT analysis


Duskin Qualitative Questionnaire At baseline NA
(2006)65 data In-depth interviews After intervention
Beck (2003)66 Qualitative Observation During each group, twice monthly NA
data In-depth interviews Check paper
Pitts (1999)67 Depression EPDS (women only) Baseline and follow-up (any time during NR
a 2-year period)
Qualitative Evaluation survey At follow-up (any time during a 2-year NA
data period)
Eastwood Depression EPDS Baseline NR
(1995)68 BDI Baseline, end of course, 10-week recall
HADS
Qualitative Questionnaire At 10-week recall NA
data

HADS, Hospital Anxiety and Depression Scale; NA, not applicable; NR, not reported.

TABLE 46 Results of reported outcomes (psychological symptoms and interpersonal and social functioning) non-theoretically-based
group treatment

Study Results
Pitts EPDS of the 34 replies, 28 women had reduced scores, four had increased scores and two were
(1999)67 unchanged. 23 women scored below the cut-off of 12, and 11 above it

88
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Appendix 4
Summary of excluded trials
quantitative review

T his is not intended to be an exhaustive list of every


study examining the intervention. However, it
includes studies that passed the first screening but on
A total of 118 papers were excluded at full paper
sift. A summary of the reasons for exclusion are
shown in Table 47. The name of the first author,
closer inspection were not deemed to be relevant and/or year, journal and reason for exclusion are reported
valid. in Table 48. Note that in both tables only the
primary reason for exclusion is shown. Many were
excluded on several criteria.

TABLE 47 Summary of reasons for excluding studies from the quantitative review

Primary reason for exclusion n


Not a group intervention 42
Not a research study 22
Not a depressed sample 12
Prevention study 10
Abstract only 6
Review article 6
Commentary only 3
Qualitative study 3
Not PND 3
Not a treatment study 2
Did not assess intervention 2
Not clinical effectiveness 1
Not English language 1
No group data 1
Economic analysis 1
No depression measures included 1
More than 1 year since childbirth 1
Not an intervention to address depression 1

89

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Appendix 4

TABLE 48 Studies excluded from the quantitative review with rationale

First author (date) Journal Primary reason for exclusion


Abramov (1998) American Journal of Medical Genetics Not a research study
Ammerman (2007) Clinical Case Studies Not a group intervention
Anon (1996) Groups dont help Australian Nursing Journal Not a research study
postnatal blues
Anon (2006) Psychological Nurses Drug Alert Abstract only
intervention for postpartum
depression
Anon (2007) Counselling to prevent Nurses Drug Alert Abstract only
postnatal emotional problems
Appleby (1997) British Medical Journal Not a group intervention
Appleby (1997) New Zealand Medical Journal Not a group intervention
Appleby (2003) Journal of Affective Disorders Did not assess intervention
Austin (2008) Journal of Affective Disorders Prevention study
Ayers (2007) Journal of Psychomatic Obstetrics aand Not a group intervention
Gynecology
Berchtold (1990) NAACOGS Clinical Issues in Perinatal & Qualitative study
Womens Health Nursing
Bledsloe (2006) Research on Social Work Practice Review article
Boath (1999) Journal of Affective Disorders Not a group intervention
Boath (2001) Journal of Reproductive and Infant Psychology Review article
Boath (2003) Journal of Affective Disorders Not a group intervention
Bruga (1998) Psychological Medicine Not a group intervention
Bruga (2000) Psychological Medicine Prevention study
Buist (1999) Archives of Womens Mental Health Prevention study
Buist (2007) Journal of Psychosomatic Obstetrics & Not a depressed sample
Gynecology
Camdeviron (2007) Expert Systems with Applications Not clinical effectiveness
Carroll (2005) Canadian Medical Association Journal Prevention study
Casiano (1990) NAACOGS Clinical Issues in Perinatal and Not a research study
Womens Health Nursing
Chung (1999) Psychologia Not a group intervention
Chun-Lui (2005) Chinese Mental Health Journal Not English Language
Cooper (1997) Postpartum depression and child development Not a treatment study
(book chapter)
Cooper (2003) The British Journal of Psychiatry: the Journal of Not a group intervention
Mental Science
Corral (2007) Archives of Womens Mental Health Not a group intervention
Creedy (1993) The Australian Journal of Rural Health Not a research study
Cuijpers (2008) Journal of Clinical Psychology Review article
Currie (2001) Australian College of Midwives incorporated Not a depressed sample
Dennis (2003) The Canadian Journal of Psychiatry Not a group intervention
Dennis (2004) Canadian Journal of Psychiatry Revue Review article
Canadienne de Psychiatrie
Dennis (2006) Evidence-based Mental Health Commentary only
Elliott (1988) Marshaling social support (book chapter) Prevention study
Elliott (2000) British Journal of Clinical Psychology Prevention study

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TABLE 48 Studies excluded from the quantitative review with rationale (continued)

First author (date) Journal Primary reason for exclusion


Escobar (2001) Pediatrics Prevention study
Fairchild (1995) Social Work with Groups Qualitative study
Field (1996) Adolescence Not a group intervention
Flynn (2006) Journal of Womens Health Not a group intervention
Fones (1984) Birth Not a research study
Free (1991) International Journal of Group Psychotherapy Not PND
Gjerdingen (2008) Womens Health Issues Review article
Grote (2004) Research on social work practice Not a group intervention
Grote (2004) Clinical Social Work Journal Not a research study
Gruen (1993) International Journal of Group Psychotherapy Not a research study
Gutteridge (2002) MIDIRS Midwifery Digest Not a research study
Hagan (2004) International Journal of Obstetrics and Not a depressed sample
Gynaecology
Halonen (1985) Journal of Consulting and Clinical Psychology Not a depressed sample
Hayes (2001) Birth Not a group intervention
Hayes (2004) Research and Theory for Nursing Practice: An Not a group intervention
International Journal
Heh (2003) Journal of Advanced Nursing Not a group intervention
Holden (1989) British Medical Journal Not a group intervention
Honikman (1999) Postpartum mood disorders (book chapter) Not a research study
Horowitz (2006) Nursing Research No group data
Hynd (2004) Journal of Psychiatric and Mental Health Not a group intervention
Nursing
Johnston (2006) Zero to Three Not a depressed sample
Jung (2007) Journal of Affective Disorders Not an intervention to address
depression
Kersting (2003) Psychiatry Not PND
Klier (2000) Infant Mental Health Abstract only
Kopelman (2005) Psychiatric Annals Not a research study
Lane (2001) Social Work Health and Mental Health Not a research study
Lau (2005) The Hong Kong Nursing Journal Not a research study
Lee (2001) Evidence-based Mental Health Commentary only
Lembke (2002) Psychiatric Times Qualitative study
Lockhart (1988) The Lamp Not a research study
Loendersloot (1983) Journal of Psychosomatic Obstetrics and Not a research study
Gynaecology
Magalhaes (2007) The Journal of Nervous and Mental Disease Not a group intervention
Maley (2002) AWHONN Not a research study
Markou (1999) Australian and New Zealand Journal of Not a research study
Psychiatry
Matthey (2004) Journal of Affective Disorders Not a depressed sample
McClendon (2005) Journal of Clinical Psychiatry Not a research study

continued

91

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Appendix 4

TABLE 48 Studies excluded from the quantitative review with rationale (continued)

First author (date) Journal Primary reason for exclusion


Milgrom (1996) International Journal of Psychology Abstract only
Milgrom (2003) Journal of Psychosomatic Research Abstract only
Milgrom (2004) International Journal of Psychology Abstract only
Miller (2003) International Journal of Technology Economic analysis
Assessment in Health Care
Misri (2000) Canadian Journal of Psychiatry Not a group intervention
Misri (2004) Journal of Clinical Psychiatry Not a group intervention
Misri (2006) American Journal of Orthopsychiatry Not a group intervention
Morrell (2000) British Medical Journal Not a group intervention
Morris (1987) British Journal of Medical Psychology More than 1 year after childbirth
Murray (2003) British Journal of Psychiatry Not a group intervention
OBrien (2002) International Journal of Psychiatry In Clinical Not a group intervention
Practice
OHara (1982) Journal of Abnormal Psychology Not a treatment study
OHara (2000) Archives of General Psychiatry Not a group intervention
OHara (1995) Womens Health Issues Not a group intervention
Olson (1991) Canadian Journal of Public Health Not a research study
Pendrina (2004) Group Analysis Not a research study
Prendergast (2001) Australasian Psychiatry Not a group intervention
Reay (2002) Australasian Psychiatry Did not assess intervention
Rees (1995) Journal of Holistic Nursing Not a depressed sample
Reid (2002) BJOG: an International Journal of Obstetrics Not a depressed sample
and Gynaecology
Reid (2003) British Journal of Midwifery Not a depressed sample
Ryding (2004) Birth Not a depressed sample
Saltzberg (2003) Group Not a research study
Seeman (2001) Evidenced Based Mental Health Commentary only
Spinelli (1997) The American Journal of Psychiatry Not a group intervention
Spinelli (2001) Management of psychiatric disorders in Not a research study
pregnancy (book chapter)
Spinelli (2003) American Journal of Psychiatry Not a group intervention
Stamp (1995) Birth Prevention study
Steinberg (1999) International Journal of Psychiatry in Medicine Not a group intervention
Stuart (1995) Archives of General Psychiatry Not a group intervention
Stuart (1995) The Journal of Psychotherapy Practice and Not a group intervention
Research
Stuart (2001) Ten Review article
Tam (2004) Evidence-based Obstetrics and Gynecology Not a group intervention
Tam (2003) BJOG: an International Journal of Obstetrics Not PND
and Gynaecology
Tezel (2006) Patient Education and Counseling Not a group intervention
Thoppil (2005) American Journal of Obstetrics and Gynecology Not a group intervention

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TABLE 48 Studies excluded from the quantitative review with rationale (continued)

First author (date) Journal Primary reason for exclusion


Ugarriza (2004) Archives of Psychiatric Nursing Not a depressed sample
Ugarriza (2006) Journal of Psychosocial Nursing Not a group intervention
Webster (2003) BJOG: an International Journal of Obstetrics Not a group intervention
and Gynaecology
Wickberg (1996) Journal of Affective Disorders Not a group intervention
Wiggins (2005) Journal of Epidemiology and Community Not a depressed sample
Health
Wilkinson (2003) Journal of Family Health Care No depression measures included
Wheatley (2003) MIDIRS Midwifery Digest Not a research study
Zayas (2004) Annals of Family Medicine Not a group intervention
Zlotnick (2001) American Journal of Psychiatry Prevention study
Zlotnick (2006) American Journal of Psychiatry Prevention study

A further 17 were excluded at full paper sift, on the summary of the reasons for exclusion are shown in
basis of inclusion and exclusion criteria regarding Table 49. The name of the first author, year, journal
the CBT component of the intervention being and reason for exclusion are reported in Table 50.
investigated, or included only qualitative data. A

TABLE 49 Summary of reasons for excluding studies from the quantitative review because of CBT component

Reason for exclusion n


Not a psychological therapy 10
Not CBT 5
Qualitative study 2

93

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Appendix 4

TABLE 50 Studies excluded from the quantitative review because of CBT component with rationale

First author (date) Journal Reasons for exclusion


Alder (2002) Psychology and Psychotherapy: Theory, Not CBT
Research and Practice
Armstrong (2003) International Journal of Mental Health Not a psychological therapy
Nursing
Armstrong (2004) International Journal of Nursing Practice Not a psychological therapy
Chen (2000) Journal of Psychosomatic Research Not a psychological therapy
Davies (2004) Community Practitioner Qualitative study
Eastwood (1995) Health Visitor Not a psychological therapy
Fleming (1992) Journal of Child Psychology and Psychiatry Not a psychological therapy
Harner (2004) Effectiveness of Professionally led postpartum Not a psychological therapy
support groups among depressed postpartum
women (clinical psychology doctorate
dissertation)
Klier (2001) Journal of Psychotherapy and Practice Not CBT
Research
Kurzweil (2008) International Journal of Group Psychotherapy Not CBT
MacInnes (2000) Community Practitioner Not a psychological therapy
May (1995) Health Visitor Not a psychological therapy
Morgan (1997) Journal of Advanced Nursing Qualitative study
Okano (1998) Journal of Mental Health Not CBT
Onozawa (2001) Journal of Affective Disorders Not a psychological therapy
Pitts (1999) Community Practitioner Not a psychological therapy
Reay (2006) Archive of Womens Mental Health Not CBT

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Appendix 5
Summary of excluded trials qualitative review

A total of 106 papers were excluded at full paper


sift. A summary of the reasons for exclusion
are shown in Table 51. The name of the first author,
in Table 52. Note that in both tables only one
reason for exclusion is shown. Many were excluded
on several criteria.
year, journal and reason for exclusion are reported

TABLE 51 Summary of reasons for excluding studies from the qualitative review

Primary reason for exclusion n


Not a group intervention 59
Not a PND population 19
Not a qualitative study 12
Not about PND 6
Antenatal population 3
Not a research study 3
Group interpersonal psychotherapy 1
Review paper 1
Audit 1
Screening study 1

95

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Appendix 5

TABLE 52 Studies excluded from the qualitative review with rationale

First author (date) Journal Primary reason for exclusion


Ahmad (1994) The Arab Journal of Psychiatry Not about PND
Albertsson-Karlgren (2001) Child Abuse Review Not a qualitative study
Amankwaa (2000) Dissertation Abstracts International Not a group intervention
Amankwaa (2003) Issues in Mental Health Nursing Not a group intervention
Andajani-Sutjahjo (2007) Culture Not a group intervention
Arborelius (2003) Scandinavian Journal of Caring Sciences Not a group intervention
Bagedahl-Strindlund (1997) Acta Psychiatrica Scandinavica Not a PND population
Baker (2005) Feminism and Psychology Not a PND population
Beck (1992) Nursing Research Not a group intervention
Beck (1995) JOGNN Not a group intervention
Beck (1998) Journal of Nursing Scholarship Not a PND population
Bennett (1991) British Journal of Medical Psychology Not a qualitative study
Benoit (2007) Journal of Mental Health Not a group intervention
Benvenuti (2001) Archives of Womens Mental Health Not about PND
Berggren-Clive (1998) Canadian Journal of Community Mental Health Not a group intervention
Brown (1972) Psychiatry Not a group intervention
Buchwald (1982) Journal of preventive psychiatry Not a group intervention
Buultjens (2007) Midwifery Not a group intervention
Campbell (1995) Developmental Psychology Not a qualitative study
Campbell (1997) Postpartum depression and child development Not a group intervention
(book chapter)
Chan (2002) Journal of Advanced Nursing Not a group intervention
Chen (1999) Kaoshing Journal of Medical Science Not a group intervention
Chen (2006) Journal of Advanced Nursing Not a group intervention
Clark (2000) British Journal of Community Nursing Not a group intervention
Clemmens (2002) Adolescence Not a group intervention
Creedy (1999) Birth Issues Not a group intervention
Cubison (2005) Screening for perinatal depression (book chapter) Not about PND
Edborg (2005) Scandinavian Journal of Public Health Not a group intervention
Edge (2004) Health and Social Care in the Community Not a group intervention
Edge (2006) British Journal of Midwifery Not a PND population
Edwards (2005) Journal of Mental Health Not about PND
Engqvist (2007) Journal of Clinical Nursing Not a PND population
Everingham (2006) Social Science and Medicine Not a group intervention
Field (2002) Early Child Development and Care Not a qualitative study
Fisher (1997) Austalian and New Zealand Journal of Psychiatry Not a PND population
Fisher (2004) BJOG: an International Journal of Obstetrics and Not a qualitative study
Gynaecology
Fooladi (2006) Holistic Nursing Practice Not a group intervention
Gaff-Smith (2003) Birth Issues Not a qualitative study
Garel (2007) Child Care, Health and Development Not a qualitative study
Giovannini (1992) Gender constructs and social issues (book chapter) Review paper
Hall (2006) Community Practitioner Not a group intervention

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TABLE 52 Studies excluded from the qualitative review with rationale (continued)

First author (date) Journal Primary reason for exclusion


Hanley (2006) Midwifery Not a group intervention
Hanley (2007) Community Practitioner Not a group intervention
Holopainen (2002) Australian Journal of Advanced Nursing Not a group intervention
Horowitz (2001) International Nursing Perspectives Not a group intervention
Kane (2006) Dissertation Abstracts International Not a group intervention
Kazi (2006) Social Science and Medicine Not a PND population
Kim (2007) Archives of Womens Mental Health Not a qualitative study
Ketler (1997) Dissertation Abstracts International Not a PND population
Lauer-Williams (2001) Dissertation Abstracts International Not a group intervention
Lawler (2003) The Royal College of Midwives Evidence Based Not a group intervention
Midwifery
Lesser (1997) Dissertation Abstracts International Not a PND population
Letouneau (2007) JOGNN Not a group intervention
Leung (1985) Bulletin of the Hong Kong Psychological Society Not a group intervention
Leung (2005) Journal of Advanced Nursing Not a group intervention
Lewis (1998) Journal of Reproductive and Infant Psychology Not a group intervention
Luepker (1972) Hospital and Community Psychiatry Not a group intervention
Maloney (1998) Australian College of Midwives Incorporated Not a group intervention
Mauthner (1993) Feminism and Psychology Not a research study
Mauthner (1995) Womens Studies International Forum Not a group intervention
Mauthner (1997) Midwifery Not a group intervention
Mauthner (1998) Journal of Reproductive and Infant Psychology Not a group intervention
Mauthner (1998) Feminism and Psychology Not a group intervention
Mauthner (1998) Feminist Dilemmas in Qualitative Research Not a group intervention
Mauthner (1999) Canadian Psychology Not a group intervention
Mayes (2007) Infant Mental Health Journal Not a qualitative study
Nahas (1999) Journal of Transcultural Nursing Not a group intervention
Nahas (1999) Journal of Nurse-Midwifery Not a group intervention
Nath (2001) Dissertation Abstracts International Not a group intervention
Nicolson (199) Counselling Psychology Quarterly Not a group intervention
Nicolson (1999) Canadian Psychology Not a PND population
Oates (2004) British Journal of Psychiatry Not a group intervention
OHara (1983) The Journal of Nervous and Mental Disease Not a qualitative study
Olshansky (2003) Journal of Nursing Scholarship Not a research study
Parvin (2004) Family Practice Not a PND population
Phillips (1986) Journal of Behaviour Therapy and Experimental Not a group intervention
Psychiatry
Poole (2006) Community Practitioner Not a PND population
Regev (2003) Dissertation Abstracts International Not a group intervention
Regmi (2002) Tropical Medicine and International Health Not a qualitative study
Rodrigues (2003) Social Science and Medicine Not a group intervention
Ross (2005) Journal of Midwifery and Womens Health Not a PND population

continued

97

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Appendix 5

TABLE 52 Studies excluded from the qualitative review with rationale (continued)

First author (date) Journal Primary reason for exclusion


Roux (2002) The Journal of Perinatal Education Not a group intervention
Scott (1992) Child Abuse and Neglect Not about PND
Scrandis (2005) Journal of the American Psychiatric Nurses Not a group intervention
Association
Setse (2008) Maternal and Child Health Journal Not PND population
Shakespeare (2002) Community Practitioner Audit
Shakespeare (2003) British Journal of General Practice Screening study
Shakespeare (2004) Midwifery Not about PND
Shakespeare (2006) Journal of Reproductive and Infant Psychology Not a group intervention
Shanok (2007) Archives of Womens Mental Health Group inter-personal psychotherapy
Sleath (2005) Patient Education and Counseling Antenatal population
Small (1997) Birth Not a qualitative study
Steinfield (1999) Journal of Psychotherapy Integration Not a group intervention
Stewart (1996) Healthcare for women international Not a PND population
Tammentie (2004) Journal of Clinical Nursing Not a group intervention
Templeton (2003) Ethnicity and Health Not a group intervention
Thomas (2004) Health Care for Women International Not a PND population
Thurtle (2003) Community Practitioner Not a group intervention
Uddenberg (1978) Acta Psychiatrica Scandinavia Not a group intervention
Ugarriza (2007) Issues in Mental Health Nursing Not a group intervention
Ward (2003) Contemporary Nurse Not a PND population
Wheatley (1999) International Journal of Mental Health Promotion Antenatal population
White (2004) Health Care for Women International Not a PND population
Williamson (2002) Singapore Nursing Journal Not a research study
Woollett (1997) Journal of Reproductive and Infant Psychology Not PND population

98
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Appendix 6
References for excluded studies
References for Table 48 Boath E, Henshaw C. The treatment of postnatal
Counseling to prevent postnatal emotional problems. depression: A comprehensive literature review. J Reprod
Nurses Drug Alert 2007;31:40. Infant Psychol 2001;19:21548.

Groups dont help postnatal blues. Aust Nurs J 1996;3:16. Boath E, Major K, Cox J. When the cradle falls II: The
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Health Technology Assessment reports


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Newborn screening for inborn errors of Effectiveness of hip prostheses in
metabolism: a systematic review. primary total hip replacement: a critical
No. 1 By Seymour CA, Thomason MJ, review of evidence and an economic
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Routine preoperative testing: a No. 7
No. 2 systematic review of the evidence. Antimicrobial prophylaxis in colorectal
Diagnosis, management and screening By Munro J, Booth A, Nicholl J. surgery: a systematic review of
of early localised prostate cancer. randomised controlled trials.
A review by Selley S, Donovan J, No. 13 By Song F, Glenny AM.
Faulkner A, Coast J, Gillatt D. Systematic review of the effectiveness of
laxatives in the elderly. No. 8
No. 3
By Petticrew M, Watt I, Sheldon T. Bone marrow and peripheral
The diagnosis, management, treatment
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and Wales. No. 14 malignancy.
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Moss S, Brown J. technologies: a comparative study of Simnett SJ, Sweetenham JW, Morgan GJ,
medical applications of four generic Stewart LA.
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Systematic review of outpatient services A review by Wald NJ, Kennard A,
Hackshaw A, McGuire A. By Sculpher MJ, Petticrew M,
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No. 9 No. 13
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Implications of socio-cultural contexts
A costutility analysis of interferon beta Choosing between randomised and
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hearing screening in the detection of of dialysis therapy for end-stage renal Evaluating patient-based outcome
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No. 15 No. 4 No. 15


Ethical issues in the design and conduct A randomised controlled trial of Near patient testing in diabetes clinics:
of randomised controlled trials. different approaches to universal appraising the costs and outcomes.
antenatal HIV testing: uptake and
A review by Edwards SJL, Lilford RJ, By Grieve R, Beech R, Vincent J,
acceptability. Annex: Antenatal HIV
Braunholtz DA, Jackson JC, Hewison J, testing assessment of a routine Mazurkiewicz J.
Thornton J. voluntary approach.
By Simpson WM, Johnstone FD, No. 16
No. 16 Boyd FM, Goldberg DJ, Hart GJ, Positron emission tomography:
Qualitative research methods in health Gormley SM, etal. establishing priorities for health
technology assessment: a review of the technology assessment.
literature. No. 5
A review by Robert G, Milne R.
By Murphy E, Dingwall R, Methods for evaluating area-wide and
Greatbatch D, Parker S, Watson P. organisation-based interventions in
health and health care: a systematic No. 17 (Pt 1)
review. The debridement of chronic wounds: a
No. 17 By Ukoumunne OC, Gulliford MC, systematic review.
The costs and benefits of paramedic Chinn S, Sterne JAC, Burney PGJ. By Bradley M, Cullum N, Sheldon T.
skills in pre-hospital trauma care.
By Nicholl J, Hughes S, Dixon S, No. 6
No. 17 (Pt 2)
Turner J, Yates D. Assessing the costs of healthcare
technologies in clinical trials. Systematic reviews of wound care
A review by Johnston K, Buxton MJ, management: (2) Dressings and topical
No. 18 agents used in the healing of chronic
Jones DR, Fitzpatrick R.
Systematic review of endoscopic wounds.
ultrasound in gastro-oesophageal No. 7 By Bradley M, Cullum N, Nelson EA,
cancer. Cooperatives and their primary care Petticrew M, Sheldon T, Torgerson D.
By Harris KM, Kelly S, Berry E, emergency centres: organisation and
Hutton J, Roderick P, Cullingworth J, impact. No. 18
etal. By Hallam L, Henthorne K.
A systematic literature review of
spiral and electron beam computed
No. 19 No. 8 tomography: with particular reference
Screening for cystic fibrosis. to clinical applications in hepatic
Systematic reviews of trials and other A review by Murray J, Cuckle H,
studies. lesions, pulmonary embolus and
Taylor G, Littlewood J, Hewison J. coronary artery disease.
By Sutton AJ, Abrams KR, Jones DR,
Sheldon TA, Song F. No. 9 By Berry E, Kelly S, Hutton J,
Harris KM, Roderick P, Boyce JC, etal.
A review of the use of health status
No. 20 measures in economic evaluation.
By Brazier J, Deverill M, Green C, No. 19
Primary total hip replacement surgery:
a systematic review of outcomes Harper R, Booth A. What role for statins? A review and
and modelling of cost-effectiveness economic model.
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Factors that limit the quality, number
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Volume 3, 1999 trials.
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haemoglobinopathy screening in the A review by Prescott RJ, Counsell CE,
UK: review and economic analysis. Gillespie WJ, Grant AM, Russell IT,
No. 1 By Zeuner D, Ades AE, Karnon J, Kiauka S, etal.
Informed decision making: an Brown J, Dezateux C, Anionwu EN.
annotated bibliography and systematic No. 21
review. No. 12 Antimicrobial prophylaxis in total hip
By Bekker H, Thornton JG, Assessing the quality of reports of replacement: a systematic review.
Airey CM, Connelly JB, Hewison J, randomised trials: implications for the
conduct of meta-analyses. By Glenny AM, Song F.
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No. 2 Jones A, etal. Health promoting schools and health
Handling uncertainty when performing promotion in schools: two systematic
economic evaluation of healthcare No. 13 reviews.
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A review by Briggs AH, Gray AM. new healthcare technologies. Stewart-Brown S, Sowden A.
By Robert G, Stevens A, Gabbay J.
No. 3 No. 23
No. 14
The role of expectancies in the placebo A systematic review of the role of Economic evaluation of a primary
effect and their use in the delivery of human papillomavirus testing within a care-based education programme for
health care: a systematic review. cervical screening programme. patients with osteoarthritis of the knee.
By Crow R, Gage H, Hampson S, By Cuzick J, Sasieni P, Davies P, A review by Lord J, Victor C,
110 Hart J, Kimber A, Thomas H. Adams J, Normand C, Frater A, etal. Littlejohns P, Ross FM, Axford JS.
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Volume 4, 2000 No. 11 No. 21


Cost and outcome implications of the Systematic reviews of wound care
organisation of vascular services. management: (3) antimicrobial agents
No. 1 By Michaels J, Brazier J, for chronic wounds; (4) diabetic foot
Palfreyman S, Shackley P, Slack R. ulceration.
The estimation of marginal time
preference in a UK-wide sample By OMeara S, Cullum N, Majid M,
(TEMPUS) project. No. 12 Sheldon T.
A review by Cairns JA, Monitoring blood glucose control in
diabetes mellitus: a systematic review. No. 22
van der Pol MM.
By Coster S, Gulliford MC, Seed PT, Using routine data to complement
Powrie JK, Swaminathan R. and enhance the results of randomised
No. 2
controlled trials.
Geriatric rehabilitation following By Lewsey JD, Leyland AH, Murray
fractures in older people: a systematic No. 13
The effectiveness of domiciliary GD, Boddy FA.
review.
By Cameron I, Crotty M, Currie C, health visiting: a systematic review of
international studies and a selective No. 23
Finnegan T, Gillespie L, Gillespie W, Coronary artery stents in the treatment
etal. review of the British literature.
By Elkan R, Kendrick D, Hewitt M, of ischaemic heart disease: a rapid and
Robinson JJA, Tolley K, Blair M, etal. systematic review.
No. 3 By Meads C, Cummins C, Jolly K,
Screening for sickle cell disease and Stevens A, Burls A, Hyde C.
thalassaemia: a systematic review with No. 14
supplementary research. The determinants of screening uptake
and interventions for increasing No. 24
By Davies SC, Cronin E, Gill M, Outcome measures for adult critical
Greengross P, Hickman M, Normand C. uptake: a systematic review.
care: a systematic review.
By Jepson R, Clegg A, Forbes C,
Lewis R, Sowden A, Kleijnen J. By Hayes JA, Black NA, Jenkinson C,
No. 4 Young JD, Rowan KM, Daly K, etal.
Community provision of hearing aids
and related audiology services. No. 15
No. 25
A review by Reeves DJ, Alborz A, The effectiveness and cost-effectiveness
of prophylactic removal of wisdom A systematic review to evaluate the
Hickson FS, Bamford JM. effectiveness of interventions to
teeth.
promote the initiation of breastfeeding.
A rapid review by Song F, OMeara S,
No. 5 By Fairbank L, OMeara S,
Wilson P, Golder S, Kleijnen J.
False-negative results in screening Renfrew MJ, Woolridge M, Sowden AJ,
programmes: systematic review of Lister-Sharp D.
No. 16
impact and implications.
Ultrasound screening in pregnancy: No. 26
By Petticrew MP, Sowden AJ,
a systematic review of the clinical
Lister-Sharp D, Wright K. Implantable cardioverter defibrillators:
effectiveness, cost-effectiveness and
arrhythmias. A rapid and systematic
womens views.
No. 6 review.
By Bricker L, Garcia J, Henderson J, By Parkes J, Bryant J, Milne R.
Costs and benefits of community Mugford M, Neilson J, Roberts T, etal.
postnatal support workers: a
randomised controlled trial. No. 27
No. 17
By Morrell CJ, Spiby H, Stewart P, Treatments for fatigue in multiple
A rapid and systematic review of the sclerosis: a rapid and systematic review.
Walters S, Morgan A.
effectiveness and cost-effectiveness of By Braas P, Jordan R, Fry-Smith A,
the taxanes used in the treatment of Burls A, Hyde C.
No. 7 advanced breast and ovarian cancer.
Implantable contraceptives (subdermal By Lister-Sharp D, McDonagh MS,
implants and hormonally impregnated No. 28
Khan KS, Kleijnen J.
intrauterine systems) versus other Early asthma prophylaxis, natural
forms of reversible contraceptives: two history, skeletal development and
No. 18 economy (EASE): a pilot randomised
systematic reviews to assess relative
Liquid-based cytology in cervical controlled trial.
effectiveness, acceptability, tolerability
screening: a rapid and systematic By Baxter-Jones ADG, Helms PJ,
and cost-effectiveness.
review. Russell G, Grant A, Ross S, Cairns JA,
By French RS, Cowan FM,
By Payne N, Chilcott J, McGoogan E. etal.
Mansour DJA, Morris S, Procter T,
Hughes D, etal.
No. 19 No. 29
No. 8 Randomised controlled trial of non- Screening for hypercholesterolaemia
directive counselling, cognitive versus case finding for familial
An introduction to statistical methods
behaviour therapy and usual general hypercholesterolaemia: a systematic
for health technology assessment.
practitioner care in the management of review and cost-effectiveness analysis.
A review by White SJ, Ashby D, depression as well as mixed anxiety and
Brown PJ. By Marks D, Wonderling
depression in primary care. D, Thorogood M, Lambert H,
By King M, Sibbald B, Ward E, Humphries SE, Neil HAW.
No. 9 Bower P, Lloyd M, Gabbay M, etal.
Disease-modifying drugs for multiple No. 30
sclerosis: a rapid and systematic review. No. 20 A rapid and systematic review of
By Clegg A, Bryant J, Milne R. Routine referral for radiography of the clinical effectiveness and cost-
patients presenting with low back pain: effectiveness of glycoprotein IIb/
No. 10 is patients outcome influenced by GPs IIIa antagonists in the medical
Publication and related biases. referral for plain radiography? management of unstable angina.
A review by Song F, Eastwood AJ, By Kerry S, Hilton S, Patel S, By McDonagh MS, Bachmann LM,
Gilbody S, Duley L, Sutton AJ. Dundas D, Rink E, Lord J. Golder S, Kleijnen J, ter Riet G. 111

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Health Technology Assessment reports published to date

No. 31 Volume 5, 2001 No. 11


A randomised controlled trial Effectiveness of autologous chondrocyte
of prehospital intravenous fluid transplantation for hyaline cartilage
replacement therapy in serious trauma. No. 1 defects in knees: a rapid and systematic
By Turner J, Nicholl J, Webber L, review.
Clinical and cost-effectiveness
Cox H, Dixon S, Yates D. of donepezil, rivastigmine and By Jobanputra P, Parry D, Fry-Smith
galantamine for Alzheimers disease: a A, Burls A.
No. 32 rapid and systematic review.
No. 12
Intrathecal pumps for giving opioids in By Clegg A, Bryant J, Nicholson T,
McIntyre L, De Broe S, Gerard K, etal. Statistical assessment of the learning
chronic pain: a systematic review. curves of health technologies.
By Williams JE, Louw G, By Ramsay CR, Grant AM, Wallace
Towlerton G. No. 2
SA, Garthwaite PH, Monk AF, Russell IT.
The clinical effectiveness and cost-
No. 33 effectiveness of riluzole for motor
No. 13
neurone disease: a rapid and systematic
Combination therapy (interferon The effectiveness and cost-effectiveness
review.
alfa and ribavirin) in the treatment of temozolomide for the treatment of
of chronic hepatitis C: a rapid and By Stewart A, Sandercock J, Bryan S,
recurrent malignant glioma: a rapid
systematic review. Hyde C, Barton PM, Fry-Smith A, etal.
and systematic review.
By Shepherd J, Waugh N, By Dinnes J, Cave C, Huang S,
No. 3 Major K, Milne R.
Hewitson P.
Equity and the economic evaluation of
healthcare. No. 14
No. 34
By Sassi F, Archard L, Le Grand J. A rapid and systematic review of
A systematic review of comparisons of
effect sizes derived from randomised the clinical effectiveness and cost-
No. 4 effectiveness of debriding agents in
and non-randomised studies.
Quality-of-life measures in chronic treating surgical wounds healing by
By MacLehose RR, Reeves BC, diseases of childhood. secondary intention.
Harvey IM, Sheldon TA, Russell IT,
By Eiser C, Morse R. By Lewis R, Whiting P, ter Riet G,
Black AMS.
OMeara S, Glanville J.
No. 5
No. 35 No. 15
Eliciting public preferences for
Intravascular ultrasound-guided healthcare: a systematic review of Home treatment for mental health
interventions in coronary artery techniques. problems: a systematic review.
disease: a systematic literature review, By Burns T, Knapp M, Catty J,
By Ryan M, Scott DA, Reeves C, Bate
with decision-analytic modelling, of Healey A, Henderson J, Watt H, etal.
A, van Teijlingen ER, Russell EM, etal.
outcomes and cost-effectiveness.
By Berry E, Kelly S, Hutton J, No. 16
No. 6
Lindsay HSJ, Blaxill JM, Evans JA, etal. How to develop cost-conscious
General health status measures for
people with cognitive impairment: guidelines.
No. 36 learning disability and acquired brain By Eccles M, Mason J.
A randomised controlled trial to injury.
evaluate the effectiveness and cost- By Riemsma RP, Forbes CA, No. 17
effectiveness of counselling patients Glanville JM, Eastwood AJ, Kleijnen J. The role of specialist nurses in multiple
with chronic depression. sclerosis: a rapid and systematic review.
By Simpson S, Corney R, No. 7 By De Broe S, Christopher F,
Fitzgerald P, Beecham J. An assessment of screening strategies Waugh N.
for fragile X syndrome in the UK.
No. 37 No. 18
By Pembrey ME, Barnicoat AJ,
Systematic review of treatments for Carmichael B, Bobrow M, Turner G. A rapid and systematic review
atopic eczema. of the clinical effectiveness and
cost-effectiveness of orlistat in the
By Hoare C, Li Wan Po A, No. 8
management of obesity.
Williams H. Issues in methodological research: By OMeara S, Riemsma R,
perspectives from researchers and Shirran L, Mather L, ter Riet G.
No. 38 commissioners.
Bayesian methods in health technology By Lilford RJ, Richardson A, Stevens No. 19
assessment: a review. A, Fitzpatrick R, Edwards S, Rock F, etal.
The clinical effectiveness and cost-
By Spiegelhalter DJ, Myles JP, effectiveness of pioglitazone for
Jones DR, Abrams KR. No. 9 type 2 diabetes mellitus: a rapid and
Systematic reviews of wound systematic review.
No. 39 care management: (5) beds; By Chilcott J, Wight J, Lloyd Jones
(6) compression; (7) laser therapy, M, Tappenden P.
The management of dyspepsia: a therapeutic ultrasound, electrotherapy
systematic review. and electromagnetic therapy. No. 20
By Delaney B, Moayyedi P, Deeks J, By Cullum N, Nelson EA,
Innes M, Soo S, Barton P, etal. Extended scope of nursing practice:
Flemming K, Sheldon T. a multicentre randomised controlled
trial of appropriately trained nurses
No. 40 No. 10 and preregistration house officers in
A systematic review of treatments for Effects of educational and psychosocial preoperative assessment in elective
severe psoriasis. interventions for adolescents with general surgery.
By Griffiths CEM, Clark CM, diabetes mellitus: a systematic review. By Kinley H, Czoski-Murray C,
Chalmers RJG, Li Wan Po A, By Hampson SE, Skinner TC, Hart J, George S, McCabe C, Primrose J,
112 Williams HC. Storey L, Gage H, Foxcroft D, etal. Reilly C, etal.
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 21 No. 31 No. 4


Systematic reviews of the effectiveness Design and use of questionnaires: a A systematic review of discharge
of day care for people with severe review of best practice applicable to arrangements for older people.
mental disorders: (1) Acute day hospital surveys of health service staff and By Parker SG, Peet SM, McPherson
versus admission; (2) Vocational patients. A, Cannaby AM, Baker R, Wilson A, etal.
rehabilitation; (3) Day hospital versus By McColl E, Jacoby A, Thomas L,
outpatient care. Soutter J, Bamford C, Steen N, etal. No. 5
By Marshall M, Crowther R, The clinical effectiveness and cost-
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Kluiter H, etal. in the routine management of chronic
A rapid and systematic review of
asthma in older children: a systematic
No. 22 the clinical effectiveness and cost-
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The measurement and monitoring of effectiveness of paclitaxel, docetaxel,
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surgical adverse events. Lim J, Smith S.
small-cell lung cancer.
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Krukowski ZH. By Clegg A, Scott DA, Sidhu M,
No. 6
Hewitson P, Waugh N.
The clinical effectiveness and cost-
No. 23 effectiveness of sibutramine in the
Action research: a systematic review and No. 33 management of obesity: a technology
guidance for assessment. Subgroup analyses in randomised assessment.
By Waterman H, Tillen D, Dickson R, controlled trials: quantifying the risks By OMeara S, Riemsma R, Shirran
de Koning K. of false-positives and false-negatives. L, Mather L, ter Riet G.
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No. 24 Mulheran PA, Egger M, Davey Smith G. No. 7
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the clinical effectiveness and cost- No. 34 resonance angiography for carotid
effectiveness of gemcitabine for the artery stenosis and peripheral vascular
treatment of pancreatic cancer. Depot antipsychotic medication
in the treatment of patients with disease: a systematic review.
By Ward S, Morris E, Bansback N, By Berry E, Kelly S, Westwood ME,
schizophrenia: (1) Meta-review; (2)
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Patient and nurse attitudes.
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A rapid and systematic review of the No. 8
evidence for the clinical effectiveness No. 35
Promoting physical activity in South
and cost-effectiveness of irinotecan, A systematic review of controlled Asian Muslim women through exercise
oxaliplatin and raltitrexed for the trials of the effectiveness and cost- on prescription.
treatment of advanced colorectal effectiveness of brief psychological
By Carroll B, Ali N, Azam N.
cancer. treatments for depression.
By Lloyd Jones M, Hummel S, By Churchill R, Hunot V, Corney R, No. 9
Bansback N, Orr B, Seymour M. Knapp M, McGuire H, Tylee A, etal. Zanamivir for the treatment of
No. 26 influenza in adults: a systematic review
No. 36 and economic evaluation.
Comparison of the effectiveness of
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inhaler devices in asthma and chronic
surveillance. Preston C, Bryan S, Jefferson T, etal.
obstructive airways disease: a systematic
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epidemiology of multiple sclerosis:
No. 27 implications for resource allocation and
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resonance imaging for investigation of By Richards RG, Sampson FC,
the knee joint. Beard SM, Tappenden P.
By Bryan S, Weatherburn G, Bungay No. 1
H, Hatrick C, Salas C, Parry D, etal. A study of the methods used to select No. 11
review criteria for clinical audit. Screening for gestational diabetes:
No. 28 By Hearnshaw H, Harker R, a systematic review and economic
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the clinical effectiveness and cost- By Scott DA, Loveman E, McIntyre
effectiveness of topotecan for ovarian No. 2 L, Waugh N.
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B cell chronic lymphocytic leukaemia: a
Duffy S, ter Riet G. technology assessment. The clinical effectiveness and cost-
effectiveness of surgery for people with
By Hyde C, Wake B, Bryan S, Barton morbid obesity: a systematic review and
No. 29
P, Fry-Smith A, Davenport C, etal. economic evaluation.
Superseded by a report published in a
later volume. By Clegg AJ, Colquitt J, Sidhu MK,
No. 3 Royle P, Loveman E, Walker A.
No. 30 Rituximab as third-line treatment for
The role of radiography in primary refractory or recurrent Stage III or IV No. 13
care patients with low back pain of at follicular non-Hodgkins lymphoma: The clinical effectiveness of
least 6 weeks duration: a randomised a systematic review and economic trastuzumab for breast cancer: a
(unblinded) controlled trial. evaluation. systematic review.
By Kendrick D, Fielding K, Bentley By Wake B, Hyde C, Bryan S, Barton By Lewis R, Bagnall A-M, Forbes C,
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Health Technology Assessment reports published to date

No. 14 No. 23 No. 32


The clinical effectiveness and cost- A systematic review and economic The measurement of satisfaction with
effectiveness of vinorelbine for breast evaluation of pegylated liposomal healthcare: implications for practice
cancer: a systematic review and doxorubicin hydrochloride for ovarian from a systematic review of the
economic evaluation. cancer. literature.
By Lewis R, Bagnall A-M, King S, By Forbes C, Wilby J, Richardson G, By Crow R, Gage H, Hampson S,
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No. 15 No. 24 No. 33


A systematic review of the effectiveness A systematic review of the effectiveness The effectiveness and cost-effectiveness
and cost-effectiveness of metal-on- of interventions based on a stages-of- of imatinib in chronic myeloid
metal hip resurfacing arthroplasty for change approach to promote individual leukaemia: a systematic review.
treatment of hip disease. behaviour change. By Garside R, Round A, Dalziel K,
By Vale L, Wyness L, McCormack K, By Riemsma RP, Pattenden J, Bridle Stein K, Royle R.
McKenzie L, Brazzelli M, Stearns SC. C, Sowden AJ, Mather L, Watt IS, etal.
No. 34
No. 16 No. 25 A comparative study of hypertonic
A systematic review update of the saline, daily and alternate-day rhDNase
The clinical effectiveness and cost-
clinical effectiveness and cost- in children with cystic fibrosis.
effectiveness of bupropion and nicotine
replacement therapy for smoking effectiveness of glycoprotein IIb/IIIa By Suri R, Wallis C, Bush A,
cessation: a systematic review and antagonists. Thompson S, Normand C, Flather M,
economic evaluation. By Robinson M, Ginnelly L, Sculpher etal.
By Woolacott NF, Jones L, Forbes CA, M, Jones L, Riemsma R, Palmer S, etal.
No. 35
Mather LC, Sowden AJ, Song FJ, etal.
No. 26 A systematic review of the costs and
A systematic review of the effectiveness, effectiveness of different models of
No. 17 paediatric home care.
A systematic review of effectiveness cost-effectiveness and barriers to
implementation of thrombolytic and By Parker G, Bhakta P, Lovett CA,
and economic evaluation of new drug Paisley S, Olsen R, Turner D, etal.
treatments for juvenile idiopathic neuroprotective therapy for acute
arthritis: etanercept. ischaemic stroke in the NHS.
By Cummins C, Connock M, By Sandercock P, Berge E, Dennis M,
Fry-Smith A, Burls A. Forbes J, Hand P, Kwan J, etal. Volume 7, 2003
No. 27
No. 18
A randomised controlled crossover trial No. 1
Clinical effectiveness and cost-
of nurse practitioner versus doctor- How important are comprehensive
effectiveness of growth hormone in
led outpatient care in a bronchiectasis literature searches and the assessment
children: a systematic review and
clinic. of trial quality in systematic reviews?
economic evaluation.
By Caine N, Sharples LD, Empirical study.
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Clinical effectiveness and cost- No. 2
Clinical effectiveness and cost Systematic review of the effectiveness
effectiveness of growth hormone consequences of selective serotonin
in adults in relation to impact on and cost-effectiveness, and economic
reuptake inhibitors in the treatment of evaluation, of home versus hospital or
quality of life: a systematic review and sex offenders.
economic evaluation. satellite unit haemodialysis for people
By Adi Y, Ashcroft D, Browne K, with end-stage renal failure.
By Bryant J, Loveman E, Chase D, Beech A, Fry-Smith A, Hyde C.
Mihaylova B, Cave C, Gerard K, etal. By Mowatt G, Vale L, Perez J, Wyness
L, Fraser C, MacLeod A, etal.
No. 29
No. 20 Treatment of established osteoporosis: No. 3
Clinical medication review by a a systematic review and costutility Systematic review and economic
pharmacist of patients on repeat analysis. evaluation of the effectiveness of
prescriptions in general practice: a By Kanis JA, Brazier JE, Stevenson infliximab for the treatment of Crohns
randomised controlled trial. M, Calvert NW, Lloyd Jones M. disease.
By Zermansky AG, Petty DR, Raynor By Clark W, Raftery J, Barton P,
DK, Lowe CJ, Freementle N, Vail A. No. 30 Song F, Fry-Smith A, Burls A.
Which anaesthetic agents are cost-
No. 21 effective in day surgery? Literature No. 4
The effectiveness of infliximab and review, national survey of practice and A review of the clinical effectiveness
etanercept for the treatment of randomised controlled trial. and cost-effectiveness of routine anti-D
rheumatoid arthritis: a systematic By Elliott RA, Payne K, Moore JK, prophylaxis for pregnant women who
review and economic evaluation. Davies LM, Harper NJN, St Leger AS, are rhesus negative.
By Jobanputra P, Barton P, Bryan S, etal. By Chilcott J, Lloyd Jones M, Wight
Burls A. J, Forman K, Wray J, Beverley C, etal.
No. 31
No. 22 Screening for hepatitis C among No. 5
A systematic review and economic injecting drug users and in Systematic review and evaluation of the
evaluation of computerised cognitive genitourinary medicine clinics: use of tumour markers in paediatric
behaviour therapy for depression and systematic reviews of effectiveness, oncology: Ewings sarcoma and
anxiety. modelling study and national survey of neuroblastoma.
By Kaltenthaler E, Shackley P, current practice. By Riley RD, Burchill SA,
Stevens K, Beverley C, Parry G, By Stein K, Dalziel K, Walker A, Abrams KR, Heney D, Lambert PC,
114 Chilcott J. McIntyre L, Jenkins B, Horne J, etal. Jones DR, etal.
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 6 No. 15 No. 25


The cost-effectiveness of screening for Early thrombolysis for the treatment The clinical and cost-effectiveness of
Helicobacter pylori to reduce mortality of acute myocardial infarction: a pulsatile machine perfusion versus cold
and morbidity from gastric cancer and systematic review and economic storage of kidneys for transplantation
peptic ulcer disease: a discrete-event evaluation. retrieved from heart-beating and non-
simulation model. heart-beating donors.
By Boland A, Dundar Y, Bagust A,
By Roderick P, Davies R, Raftery J, Haycox A, Hill R, Mujica Mota R, etal. By Wight J, Chilcott J, Holmes M,
Crabbe D, Pearce R, Bhandari P, etal. Brewer N.

No. 7 No. 16
No. 26
The clinical effectiveness and cost- Screening for fragile X syndrome: a Can randomised trials rely on existing
effectiveness of routine dental checks: literature review and modelling. electronic data? A feasibility study to
a systematic review and economic By Song FJ, Barton P, Sleightholme explore the value of routine data in
evaluation. V, Yao GL, Fry-Smith A. health technology assessment.
By Davenport C, Elley K, Salas By Williams JG, Cheung WY,
C, Taylor-Weetman CL, Fry-Smith A, No. 17 Cohen DR, Hutchings HA, Longo MF,
Bryan S, etal. Russell IT.
Systematic review of endoscopic sinus
surgery for nasal polyps.
No. 8 No. 27
A multicentre randomised controlled By Dalziel K, Stein K, Round A,
Garside R, Royle P. Evaluating non-randomised
trial assessing the costs and benefits intervention studies.
of using structured information and By Deeks JJ, Dinnes J, DAmico R,
analysis of womens preferences in the No. 18 Sowden AJ, Sakarovitch C, Song F, etal.
management of menorrhagia. Towards efficient guidelines: how to
By Kennedy ADM, Sculpher MJ, monitor guideline use in primary care. No. 28
Coulter A, Dwyer N, Rees M, Horsley S,
By Hutchinson A, McIntosh A, A randomised controlled trial to assess
etal.
Cox S, Gilbert C. the impact of a package comprising a
patient-orientated, evidence-based self-
No. 9
No. 19 help guidebook and patient-centred
Clinical effectiveness and costutility consultations on disease management
of photodynamic therapy for wet Effectiveness and cost-effectiveness
and satisfaction in inflammatory bowel
age-related macular degeneration: of acute hospital-based spinal cord
disease.
a systematic review and economic injuries services: systematic review.
By Kennedy A, Nelson E, Reeves D,
evaluation. By Bagnall A-M, Jones L, Richardson Richardson G, Roberts C, Robinson A,
By Meads C, Salas C, Roberts T, G, Duffy S, Riemsma R. etal.
Moore D, Fry-Smith A, Hyde C.
No. 20 No. 29
No. 10
Prioritisation of health technology The effectiveness of diagnostic tests for
Evaluation of molecular tests for
assessment. The PATHS model: the assessment of shoulder pain due
prenatal diagnosis of chromosome
methods and case studies. to soft tissue disorders: a systematic
abnormalities.
By Townsend J, Buxton M, review.
By Grimshaw GM, Szczepura A,
Hultn M, MacDonald F, Nevin NC, Harper G. By Dinnes J, Loveman E, McIntyre L,
Sutton F, etal. Waugh N.
No. 21
No. 11 No. 30
Systematic review of the clinical
First and second trimester antenatal effectiveness and cost-effectiveness of The value of digital imaging in diabetic
screening for Downs syndrome: tension-free vaginal tape for treatment retinopathy.
the results of the Serum, Urine and of urinary stress incontinence. By Sharp PF, Olson J, Strachan F,
Ultrasound Screening Study (SURUSS). Hipwell J, Ludbrook A, ODonnell M,
By Cody J, Wyness L, Wallace S, etal.
By Wald NJ, Rodeck C, Hackshaw Glazener C, Kilonzo M, Stearns S, etal.
AK, Walters J, Chitty L, Mackinson AM.
No. 31
No. 22 Lowering blood pressure to prevent
No. 12
The effectiveness and cost-effectiveness The clinical and cost-effectiveness of myocardial infarction and stroke: a new
of ultrasound locating devices for patient education models for diabetes: preventive strategy.
central venous access: a systematic a systematic review and economic By Law M, Wald N, Morris J.
review and economic evaluation. evaluation.
By Calvert N, Hind D, McWilliams By Loveman E, Cave C, Green C, No. 32
RG, Thomas SM, Beverley C, Royle P, Dunn N, Waugh N. Clinical and cost-effectiveness of
Davidson A. capecitabine and tegafur with uracil for
No. 23 the treatment of metastatic colorectal
No. 13 The role of modelling in prioritising cancer: systematic review and economic
A systematic review of atypical and planning clinical trials. evaluation.
antipsychotics in schizophrenia. By Ward S, Kaltenthaler E, Cowan J,
By Chilcott J, Brennan A, Booth A,
By Bagnall A-M, Jones L, Lewis R, Brewer N.
Karnon J, Tappenden P.
Ginnelly L, Glanville J, Torgerson D,
etal. No. 33
No. 24 Clinical and cost-effectiveness of new
No. 14 Costbenefit evaluation of routine and emerging technologies for early
Prostate Testing for Cancer and influenza immunisation in people localised prostate cancer: a systematic
Treatment (ProtecT) feasibility study. 6574 years of age. review.
By Donovan J, Hamdy F, Neal D, By Allsup S, Gosney M, Haycox A, By Hummel S, Paisley S, Morgan A,
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Health Technology Assessment reports published to date

No. 34 Volume 8, 2004 No. 10


Literature searching for clinical and A systematic review and economic
cost-effectiveness studies used in health evaluation of magnetic resonance
technology assessment reports carried cholangiopancreatography compared
No. 1
out for the National Institute for with diagnostic endoscopic retrograde
What is the best imaging strategy for cholangiopancreatography.
Clinical Excellence appraisal system. acute stroke? By Kaltenthaler E, Bravo Vergel Y,
By Royle P, Waugh N. By Wardlaw JM, Keir SL, Seymour J, Chilcott J, Thomas S, Blakeborough T,
Lewis S, Sandercock PAG, Dennis MS, Walters SJ, etal.
No. 35 etal.
Systematic review and economic No. 11
decision modelling for the prevention No. 2 The use of modelling to evaluate
and treatment of influenza A and B. Systematic review and modelling of the new drugs for patients with a chronic
By Turner D, Wailoo A, Nicholson K, investigation of acute and chronic chest condition: the case of antibodies
Cooper N, Sutton A, Abrams K. pain presenting in primary care. against tumour necrosis factor in
By Mant J, McManus RJ, Oakes RAL, rheumatoid arthritis.
Delaney BC, Barton PM, Deeks JJ, etal. By Barton P, Jobanputra P, Wilson J,
No. 36 Bryan S, Burls A.
A randomised controlled trial
to evaluate the clinical and cost- No. 3
No. 12
effectiveness of Hickman line insertions The effectiveness and cost-effectiveness Clinical effectiveness and cost-
in adult cancer patients by nurses. of microwave and thermal balloon effectiveness of neonatal screening
By Boland A, Haycox A, Bagust A, endometrial ablation for heavy for inborn errors of metabolism using
Fitzsimmons L. menstrual bleeding: a systematic review tandem mass spectrometry: a systematic
and economic modelling. review.
By Garside R, Stein K, Wyatt K, By Pandor A, Eastham J, Beverley C,
No. 37
Round A, Price A. Chilcott J, Paisley S.
Redesigning postnatal care: a
randomised controlled trial of protocol- No. 4 No. 13
based midwifery-led care focused Clinical effectiveness and cost-
A systematic review of the role of
on individual womens physical and effectiveness of pioglitazone and
bisphosphonates in metastatic disease.
psychological health needs. rosiglitazone in the treatment of type
By Ross JR, Saunders Y,
By MacArthur C, Winter HR, 2 diabetes: a systematic review and
Edmonds PM, Patel S, Wonderling D,
Bick DE, Lilford RJ, Lancashire RJ, economic evaluation.
Normand C, etal.
Knowles H, etal. By Czoski-Murray C, Warren E,
Chilcott J, Beverley C, Psyllaki MA,
No. 5 Cowan J.
No. 38
Systematic review of the clinical
Estimating implied rates of discount in effectiveness and cost-effectiveness No. 14
healthcare decision-making. of capecitabine (Xeloda) for locally Routine examination of the newborn:
By West RR, McNabb R, Thompson advanced and/or metastatic breast the EMREN study. Evaluation of an
AGH, Sheldon TA, Grimley Evans J. cancer. extension of the midwife role including
By Jones L, Hawkins N, Westwood M, a randomised controlled trial of
No. 39 Wright K, Richardson G, Riemsma R. appropriately trained midwives and
Systematic review of isolation policies paediatric senior house officers.
in the hospital management of No. 6 By Townsend J, Wolke D, Hayes J,
methicillin-resistant Staphylococcus Effectiveness and efficiency of guideline Dav S, Rogers C, Bloomfield L, etal.
aureus: a review of the literature dissemination and implementation
with epidemiological and economic strategies. No. 15
modelling. By Grimshaw JM, Thomas RE, Involving consumers in research and
MacLennan G, Fraser C, Ramsay CR, development agenda setting for the
By Cooper BS, Stone SP, Kibbler CC, NHS: developing an evidence-based
Cookson BD, Roberts JA, Medley GF, Vale L, etal.
approach.
etal.
By Oliver S, Clarke-Jones L, Rees R,
No. 7 Milne R, Buchanan P, Gabbay J, etal.
No. 40 Clinical effectiveness and costs of the
Treatments for spasticity and pain in Sugarbaker procedure for the treatment No. 16
multiple sclerosis: a systematic review. of pseudomyxoma peritonei. A multi-centre randomised controlled
By Beard S, Hunn A, Wight J. By Bryant J, Clegg AJ, Sidhu MK, trial of minimally invasive direct
Brodin H, Royle P, Davidson P. coronary bypass grafting versus
percutaneous transluminal coronary
No. 41 angioplasty with stenting for proximal
No. 8
The inclusion of reports of randomised Psychological treatment for insomnia stenosis of the left anterior descending
trials published in languages other than in the regulation of long-term hypnotic coronary artery.
English in systematic reviews. drug use. By Reeves BC, Angelini GD, Bryan
By Moher D, Pham B, Lawson ML, AJ, Taylor FC, Cripps T, Spyt TJ, etal.
By Morgan K, Dixon S, Mathers N,
Klassen TP. Thompson J, Tomeny M.
No. 17
Does early magnetic resonance imaging
No. 42 No. 9 influence management or improve
The impact of screening on future Improving the evaluation of outcome in patients referred to
health-promoting behaviours and therapeutic interventions in multiple secondary care with low back pain? A
health beliefs: a systematic review. sclerosis: development of a patient- pragmatic randomised controlled trial.
By Bankhead CR, Brett J, Bukach C, based measure of outcome. By Gilbert FJ, Grant AM, Gillan
Webster P, Stewart-Brown S, Munafo M, By Hobart JC, Riazi A, Lamping DL, MGC, Vale L, Scott NW, Campbell MK,
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DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 18 No. 27 No. 36


The clinical and cost-effectiveness Methods for expected value of Review of guidelines for good practice
of anakinra for the treatment of information analysis in complex health in decision-analytic modelling in health
rheumatoid arthritis in adults: a economic models: developments on technology assessment.
systematic review and economic the health economics of interferon- By Philips Z, Ginnelly L, Sculpher M,
analysis. and glatiramer acetate for multiple Claxton K, Golder S, Riemsma R, etal.
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Burls A. By Tappenden P, Chilcott JB, No. 37
Eggington S, Oakley J, McCabe C. Rituximab (MabThera) for aggressive
non-Hodgkins lymphoma: systematic
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A rapid and systematic review and Effectiveness and cost-effectiveness By Knight C, Hind D, Brewer N,
economic evaluation of the clinical of imatinib for first-line treatment Abbott V.
and cost-effectiveness of newer drugs of chronic myeloid leukaemia in
for treatment of mania associated with chronic phase: a systematic review and No. 38
bipolar affective disorder. economic analysis. Clinical effectiveness and cost-
By Bridle C, Palmer S, Bagnall A-M, By Dalziel K, Round A, Stein K, effectiveness of clopidogrel and
Darba J, Duffy S, Sculpher M, etal. Garside R, Price A. modified-release dipyridamole in the
secondary prevention of occlusive
No. 20 No. 29 vascular events: a systematic review and
Liquid-based cytology in cervical VenUS I: a randomised controlled trial economic evaluation.
screening: an updated rapid and of two types of bandage for treating By Jones L, Griffin S, Palmer S, Main
systematic review and economic venous leg ulcers. C, Orton V, Sculpher M, etal.
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NA, Torgerson DJ, on behalf of the No. 39
By Karnon J, Peters J, Platt J,
VenUS Team. Pegylated interferon -2a and -2b
Chilcott J, McGoogan E, Brewer N.
in combination with ribavirin in the
No. 30 treatment of chronic hepatitis C:
No. 21 Systematic review of the effectiveness a systematic review and economic
Systematic review of the long-term and cost-effectiveness, and economic evaluation.
effects and economic consequences of evaluation, of myocardial perfusion By Shepherd J, Brodin H, Cave C,
treatments for obesity and implications scintigraphy for the diagnosis and Waugh N, Price A, Gabbay J.
for health improvement. management of angina and myocardial
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Poobalan A, Aucott L, Stearns SC, etal. By Mowatt G, Vale L, Brazzelli M, Clopidogrel used in combination with
Hernandez R, Murray A, Scott N, etal. aspirin compared with aspirin alone
No. 22 in the treatment of non-ST-segment-
No. 31 elevation acute coronary syndromes:
Autoantibody testing in children
A pilot study on the use of decision a systematic review and economic
with newly diagnosed type 1 diabetes
theory and value of information evaluation.
mellitus.
analysis as part of the NHS Health By Main C, Palmer S, Griffin S, Jones
By Dretzke J, Cummins C, Technology Assessment programme. L, Orton V, Sculpher M, etal.
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Provision, uptake and cost of cardiac
No. 23 No. 32 rehabilitation programmes: improving
Clinical effectiveness and cost- The Social Support and Family Health services to under-represented groups.
effectiveness of prehospital intravenous Study: a randomised controlled trial By Beswick AD, Rees K, Griebsch I,
fluids in trauma patients. and economic evaluation of two Taylor FC, Burke M, West RR, etal.
By Dretzke J, Sandercock J, Bayliss alternative forms of postnatal support
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inner-city areas. Involving South Asian patients in
By Wiggins M, Oakley A, Roberts I, clinical trials.
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systematic review and economic Psychosocial aspects of genetic No. 43
evaluation. screening of pregnant women and Clinical and cost-effectiveness of
By Dndar Y, Boland A, Strobl J, newborns: a systematic review. continuous subcutaneous insulin
Dodd S, Haycox A, Bagust A, etal. By Green JM, Hewison J, Bekker HL, infusion for diabetes.
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No. 25 Hartwell D, Waugh N.
Development and validation of No. 34
methods for assessing the quality of Evaluation of abnormal uterine No. 44
diagnostic accuracy studies. bleeding: comparison of three Identification and assessment of
By Whiting P, Rutjes AWS, Dinnes J, outpatient procedures within cohorts ongoing trials in health technology
Reitsma JB, Bossuyt PMM, Kleijnen J. defined by age and menopausal status. assessment reviews.
By Critchley HOD, Warner P, Lee AJ, By Song FJ, Fry-Smith A, Davenport
Brechin S, Guise J, Graham B. C, Bayliss S, Adi Y, Wilson JS, etal.
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EVALUATE hysterectomy trial: No. 35 No. 45
a multicentre randomised trial Coronary artery stents: a rapid Systematic review and economic
comparing abdominal, vaginal and systematic review and economic evaluation of a long-acting insulin
laparoscopic methods of hysterectomy. evaluation. analogue, insulin glargine
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Health Technology Assessment reports published to date

No. 46 No. 4 No. 13


Supplementation of a home-based Randomised evaluation of alternative Cervical screening programmes: can
exercise programme with a class- electrosurgical modalities to treat automation help? Evidence from
based programme for people bladder outflow obstruction in men systematic reviews, an economic
with osteoarthritis of the knees: a with benign prostatic hyperplasia. analysis and a simulation modelling
randomised controlled trial and health By Fowler C, McAllister W, Plail R, exercise applied to the UK.
economic analysis. Karim O, Yang Q. By Willis BH, Barton P, Pearmain P,
By McCarthy CJ, Mills PM, Pullen R, Bryan S, Hyde C.
Richardson G, Hawkins N, Roberts CR, No. 5
etal. No. 14
A pragmatic randomised controlled Laparoscopic surgery for inguinal
trial of the cost-effectiveness of hernia repair: systematic review of
No. 47 palliative therapies for patients with effectiveness and economic evaluation.
Clinical and cost-effectiveness of once- inoperable oesophageal cancer. By McCormack K, Wake B, Perez J,
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potency topical corticosteroids for Bond J, Griffin SM.
atopic eczema: a systematic review and
No. 15
economic evaluation. No. 6 Clinical effectiveness, tolerability and
By Green C, Colquitt JL, Kirby J, Impact of computer-aided detection cost-effectiveness of newer drugs for
Davidson P, Payne E. prompts on the sensitivity and epilepsy in adults: a systematic review
specificity of screening mammography. and economic evaluation.
No. 48 By Taylor P, Champness J, Given- By Wilby J, Kainth A, Hawkins N,
Acupuncture of chronic headache Wilson R, Johnston K, Potts H. Epstein D, McIntosh H, McDaid C, etal.
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By Vickers AJ, Rees RW, Zollman CE, A randomised controlled trial to
Issues in data monitoring and interim
McCarney R, Smith CM, Ellis N, etal. compare the cost-effectiveness of
analysis of trials.
tricyclic antidepressants, selective
By Grant AM, Altman DG, Babiker serotonin reuptake inhibitors and
No. 49
AB, Campbell MK, Clemens FJ, lofepramine.
Generalisability in economic evaluation Darbyshire JH, etal.
studies in healthcare: a review and case By Peveler R, Kendrick T, Buxton M,
studies. Longworth L, Baldwin D, Moore M, etal.
No. 8
By Sculpher MJ, Pang FS, Manca A,
Lay publics understanding of equipoise No. 17
Drummond MF, Golder S, Urdahl H,
and randomisation in randomised Clinical effectiveness and cost-
etal.
controlled trials. effectiveness of immediate angioplasty
By Robinson EJ, Kerr CEP, for acute myocardial infarction:
No. 50 systematic review and economic
Stevens AJ, Lilford RJ, Braunholtz DA,
Virtual outreach: a randomised Edwards SJ, etal. evaluation.
controlled trial and economic By Hartwell D, Colquitt J, Loveman
evaluation of joint teleconferenced E, Clegg AJ, Brodin H, Waugh N, etal.
No. 9
medical consultations.
Clinical and cost-effectiveness of
By Wallace P, Barber J, Clayton W, No. 18
electroconvulsive therapy for depressive
Currell R, Fleming K, Garner P, etal. A randomised controlled comparison of
illness, schizophrenia, catatonia
alternative strategies in stroke care.
and mania: systematic reviews and
By Kalra L, Evans A, Perez I,
economic modelling studies.
Volume 9, 2005 Knapp M, Swift C, Donaldson N.
By Greenhalgh J, Knight C, Hind D,
Beverley C, Walters S. No. 19
The investigation and analysis of
No. 1 No. 10 critical incidents and adverse events in
Randomised controlled multiple Measurement of health-related quality healthcare.
treatment comparison to provide a cost- of life for people with dementia: By Woloshynowych M, Rogers S,
effectiveness rationale for the selection development of a new instrument Taylor-Adams S, Vincent C.
of antimicrobial therapy in acne. (DEMQOL) and an evaluation of
By Ozolins M, Eady EA, Avery A, current methodology. No. 20
Cunliffe WJ, ONeill C, Simpson NB, By Smith SC, Lamping DL, Banerjee Potential use of routine databases in
etal. S, Harwood R, Foley B, Smith P, etal. health technology assessment.
By Raftery J, Roderick P, Stevens A.
No. 2 No. 11
Clinical effectiveness and cost- No. 21
Do the findings of case series studies
vary significantly according to effectiveness of drotrecogin alfa Clinical and cost-effectiveness of newer
methodological characteristics? (activated) (Xigris) for the treatment immunosuppressive regimens in renal
of severe sepsis in adults: a systematic transplantation: a systematic review and
By Dalziel K, Round A, Stein K, modelling study.
Garside R, Castelnuovo E, Payne L. review and economic evaluation.
By Woodroffe R, Yao GL, Meads C,
By Green C, Dinnes J, Takeda A,
Bayliss S, Ready A, Raftery J, etal.
No. 3 Shepherd J, Hartwell D, Cave C, etal.
Improving the referral process No. 22
for familial breast cancer genetic No. 12 A systematic review and economic
counselling: findings of three A methodological review of how evaluation of alendronate, etidronate,
randomised controlled trials of two heterogeneity has been examined in risedronate, raloxifene and teriparatide
interventions. systematic reviews of diagnostic test for the prevention and treatment of
By Wilson BJ, Torrance N, accuracy. postmenopausal osteoporosis.
Mollison J, Wordsworth S, Gray JR, By Dinnes J, Deeks J, Kirby J, By Stevenson M, Lloyd Jones M, De
118 Haites NE, etal. Roderick P. Nigris E, Brewer N, Davis S, Oakley J.
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No. 23 No. 32 No. 40


A systematic review to examine Longer term clinical and economic A randomised controlled trial and
the impact of psycho-educational benefits of offering acupuncture care to cost-effectiveness study of systematic
interventions on health outcomes patients with chronic low back pain. screening (targeted and total
and costs in adults and children with population screening) versus routine
difficult asthma. By Thomas KJ, MacPherson
practice for the detection of atrial
H, Ratcliffe J, Thorpe L, Brazier J,
By Smith JR, Mugford M, Holland fibrillation in people aged 65 and over.
Campbell M, etal.
R, Candy B, Noble MJ, Harrison BDW, The SAFE study.
etal. By Hobbs FDR, Fitzmaurice DA,
No. 33 Mant J, Murray E, Jowett S, Bryan S,
No. 24 Cost-effectiveness and safety of etal.
An evaluation of the costs, effectiveness epidural steroids in the management
and quality of renal replacement of sciatica. No. 41
therapy provision in renal satellite units By Price C, Arden N, Coglan L, Displaced intracapsular hip fractures
in England and Wales. Rogers P. in fit, older people: a randomised
By Roderick P, Nicholson T, Armitage comparison of reduction and fixation,
A, Mehta R, Mullee M, Gerard K, etal. No. 34 bipolar hemiarthroplasty and total hip
arthroplasty.
The British Rheumatoid Outcome
No. 25 By Keating JF, Grant A, Masson M,
Study Group (BROSG) randomised
Imatinib for the treatment of patients Scott NW, Forbes JF.
controlled trial to compare the
with unresectable and/or metastatic effectiveness and cost-effectiveness of
gastrointestinal stromal tumours: aggressive versus symptomatic therapy No. 42
systematic review and economic in established rheumatoid arthritis. Long-term outcome of cognitive
evaluation. behaviour therapy clinical trials in
By Symmons D, Tricker K, Roberts C,
By Wilson J, Connock M, Song F, Davies L, Dawes P, Scott DL. central Scotland.
Yao G, Fry-Smith A, Raftery J, etal. By Durham RC, Chambers JA,
Power KG, Sharp DM, Macdonald RR,
No. 35
No. 26 Major KA, etal.
Indirect comparisons of competing Conceptual framework and systematic
interventions. review of the effects of participants No. 43
and professionals preferences in
By Glenny AM, Altman DG, Song F, randomised controlled trials. The effectiveness and cost-effectiveness
Sakarovitch C, Deeks JJ, DAmico R, of dual-chamber pacemakers compared
etal. By King M, Nazareth I, Lampe F, with single-chamber pacemakers for
Bower P, Chandler M, Morou M, etal. bradycardia due to atrioventricular
No. 27 block or sick sinus syndrome: systematic
Cost-effectiveness of alternative No. 36 review and economic evaluation.
strategies for the initial medical The clinical and cost-effectiveness of By Castelnuovo E, Stein K, Pitt M,
management of non-ST elevation acute implantable cardioverter defibrillators: Garside R, Payne E.
coronary syndrome: systematic review a systematic review.
and decision-analytical modelling. No. 44
By Bryant J, Brodin H, Loveman E,
By Robinson M, Palmer S, Sculpher Payne E, Clegg A. Newborn screening for congenital heart
M, Philips Z, Ginnelly L, Bowens A, etal. defects: a systematic review and cost-
effectiveness analysis.
No. 37
No. 28 By Knowles R, Griebsch I,
Outcomes of electrically stimulated A trial of problem-solving by Dezateux C, Brown J, Bull C, Wren C.
gracilis neosphincter surgery. community mental health nurses for
anxiety, depression and life difficulties
By Tillin T, Chambers M, Feldman R. among general practice patients. The No. 45
CPN-GP study. The clinical and cost-effectiveness of
No. 29 left ventricular assist devices for end-
By Kendrick T, Simons L,
The effectiveness and cost-effectiveness stage heart failure: a systematic review
Mynors-Wallis L, Gray A, Lathlean J,
of pimecrolimus and tacrolimus for and economic evaluation.
Pickering R, etal.
atopic eczema: a systematic review and By Clegg AJ, Scott DA, Loveman E,
economic evaluation. Colquitt J, Hutchinson J, Royle P, etal.
No. 38
By Garside R, Stein K, Castelnuovo
E, Pitt M, Ashcroft D, Dimmock P, etal. The causes and effects of socio- No. 46
demographic exclusions from clinical
The effectiveness of the Heidelberg
No. 30 trials.
Retina Tomograph and laser diagnostic
Systematic review on urine albumin By Bartlett C, Doyal L, Ebrahim S, glaucoma scanning system (GDx) in
testing for early detection of diabetic Davey P, Bachmann M, Egger M, etal. detecting and monitoring glaucoma.
complications. By Kwartz AJ, Henson DB, Harper
By Newman DJ, Mattock MB, No. 39 RA, Spencer AF, McLeod D.
Dawnay ABS, Kerry S, McGuire A, Is hydrotherapy cost-effective?
Yaqoob M, etal. A randomised controlled trial of No. 47
combined hydrotherapy programmes Clinical and cost-effectiveness of
No. 31 compared with physiotherapy land autologous chondrocyte implantation
Randomised controlled trial of the cost- techniques in children with juvenile for cartilage defects in knee joints:
effectiveness of water-based therapy for idiopathic arthritis. systematic review and economic
lower limb osteoarthritis. By Epps H, Ginnelly L, Utley M, evaluation.
By Cochrane T, Davey RC, Southwood T, Gallivan S, Sculpher M, By Clar C, Cummins E, McIntyre L,
Matthes Edwards SM. etal. Thomas S, Lamb J, Bain L, etal. 119

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Health Technology Assessment reports published to date

No. 48 No. 6 No. 15


Systematic review of effectiveness of Systematic review and evaluation Measurement of the clinical and cost-
different treatments for childhood of methods of assessing urinary effectiveness of non-invasive diagnostic
retinoblastoma. incontinence. testing strategies for deep vein
By McDaid C, Hartley S, Bagnall By Martin JL, Williams KS, Abrams thrombosis.
A-M, Ritchie G, Light K, Riemsma R. KR, Turner DA, Sutton AJ, Chapple C,
By Goodacre S, Sampson F,
etal.
Stevenson M, Wailoo A, Sutton A,
No. 49 Thomas S, etal.
Towards evidence-based guidelines No. 7
for the prevention of venous The clinical effectiveness and cost-
effectiveness of newer drugs for No. 16
thromboembolism: systematic
reviews of mechanical methods, oral children with epilepsy. A systematic Systematic review of the effectiveness
anticoagulation, dextran and regional review. and cost-effectiveness of HealOzone
anaesthesia as thromboprophylaxis. By Connock M, Frew E, Evans B-W, for the treatment of occlusal pit/fissure
By Roderick P, Ferris G, Wilson K, Bryan S, Cummins C, Fry-Smith A, etal. caries and root caries.
Halls H, Jackson D, Collins R, etal. By Brazzelli M, McKenzie L, Fielding
No. 8 S, Fraser C, Clarkson J, Kilonzo M, etal.
No. 50 Surveillance of Barretts oesophagus:
The effectiveness and cost-effectiveness exploring the uncertainty through No. 17
of parent training/education systematic review, expert workshop and
economic modelling. Randomised controlled trials of
programmes for the treatment
conventional antipsychotic versus
of conduct disorder, including By Garside R, Pitt M, Somerville M,
new atypical drugs, and new atypical
oppositional defiant disorder, in Stein K, Price A, Gilbert N.
drugs versus clozapine, in people with
children.
schizophrenia responding poorly to, or
By Dretzke J, Frew E, Davenport C, No. 9 intolerant of, current drug treatment.
Barlow J, Stewart-Brown S, Sandercock J, Topotecan, pegylated liposomal
etal. doxorubicin hydrochloride and By Lewis SW, Davies L, Jones PB,
paclitaxel for second-line or subsequent Barnes TRE, Murray RM, Kerwin R,
treatment of advanced ovarian cancer: etal.

Volume 10, 2006 a systematic review and economic


evaluation. No. 18
By Main C, Bojke L, Griffin S, Diagnostic tests and algorithms used
Norman G, Barbieri M, Mather L, etal. in the investigation of haematuria:
No. 1 systematic reviews and economic
The clinical and cost-effectiveness of No. 10 evaluation.
donepezil, rivastigmine, galantamine Evaluation of molecular techniques
and memantine for Alzheimers By Rodgers M, Nixon J, Hempel S,
in prediction and diagnosis Aho T, Kelly J, Neal D, etal.
disease. of cytomegalovirus disease in
By Loveman E, Green C, Kirby J, immunocompromised patients.
Takeda A, Picot J, Payne E, etal. By Szczepura A, Westmoreland D, No. 19
Vinogradova Y, Fox J, Clark M. Cognitive behavioural therapy in
No. 2 addition to antispasmodic therapy for
FOOD: a multicentre randomised trial No. 11 irritable bowel syndrome in primary
evaluating feeding policies in patients Screening for thrombophilia in high- care: randomised controlled trial.
admitted to hospital with a recent risk situations: systematic review By Kennedy TM, Chalder T,
stroke. and cost-effectiveness analysis. The McCrone P, Darnley S, Knapp M,
By Dennis M, Lewis S, Cranswick G, Thrombosis: Risk and Economic Jones RH, etal.
Forbes J. Assessment of Thrombophilia
Screening (TREATS) study. No. 20
No. 3 By Wu O, Robertson L, Twaddle S,
Lowe GDO, Clark P, Greaves M, etal. A systematic review of the
The clinical effectiveness and cost-
clinical effectiveness and cost-
effectiveness of computed tomography
effectiveness of enzyme replacement
screening for lung cancer: systematic No. 12
therapies for Fabrys disease and
reviews. A series of systematic reviews to inform mucopolysaccharidosis type 1.
By Black C, Bagust A, Boland A, a decision analysis for sampling and
Walker S, McLeod C, De Verteuil R, etal. treating infected diabetic foot ulcers. By Connock M, Juarez-Garcia A,
By Nelson EA, OMeara S, Craig D, Frew E, Mans A, Dretzke J, Fry-Smith A,
No. 4 Iglesias C, Golder S, Dalton J, etal. etal.
A systematic review of the effectiveness
and cost-effectiveness of neuroimaging No. 13 No. 21
assessments used to visualise the seizure Randomised clinical trial, observational Health benefits of antiviral therapy for
focus in people with refractory epilepsy study and assessment of cost- mild chronic hepatitis C: randomised
being considered for surgery. effectiveness of the treatment of controlled trial and economic
By Whiting P, Gupta R, Burch J, varicose veins (REACTIV trial). evaluation.
Mujica Mota RE, Wright K, Marson A, By Michaels JA, Campbell WB, By Wright M, Grieve R, Roberts J,
etal. Brazier JE, MacIntyre JB, Palfreyman SJ, Main J, Thomas HC, on behalf of the
Ratcliffe J, etal. UK Mild Hepatitis C Trial Investigators.
No. 5
Comparison of conference abstracts No. 14
No. 22
and presentations with full-text articles The cost-effectiveness of screening for
in the health technology assessments of oral cancer in primary care. Pressure relieving support surfaces: a
rapidly evolving technologies. By Speight PM, Palmer S, Moles DR, randomised evaluation.
By Dundar Y, Dodd S, Dickson R, Downer MC, Smith DH, Henriksson M, By Nixon J, Nelson EA, Cranny G,
120 Walley T, Haycox A, Williamson PR. etal. Iglesias CP, Hawkins K, Cullum NA, etal.
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 23 No. 31 No. 40


A systematic review and economic Etanercept and infliximab for the What are the clinical outcome and cost-
model of the effectiveness and cost- treatment of psoriatic arthritis: a effectiveness of endoscopy undertaken
effectiveness of methylphenidate, systematic review and economic by nurses when compared with doctors?
dexamfetamine and atomoxetine evaluation. A Multi-Institution Nurse Endoscopy
for the treatment of attention deficit By Woolacott N, Bravo Vergel Y, Trial (MINuET).
hyperactivity disorder in children and Hawkins N, Kainth A, Khadjesari Z, By Williams J, Russell I, Durai D,
adolescents. Misso K, etal. Cheung W-Y, Farrin A, Bloor K, etal.
By King S, Griffin S, Hodges Z,
Weatherly H, Asseburg C, Richardson G, No. 32
The cost-effectiveness of testing for No. 41
etal.
hepatitis C in former injecting drug The clinical and cost-effectiveness of
users. oxaliplatin and capecitabine for the
No. 24
By Castelnuovo E, Thompson-Coon adjuvant treatment of colon cancer:
The clinical effectiveness and cost- systematic review and economic
effectiveness of enzyme replacement J, Pitt M, Cramp M, Siebert U, Price A,
etal. evaluation.
therapy for Gauchers disease: a
systematic review. By Pandor A, Eggington S, Paisley S,
No. 33 Tappenden P, Sutcliffe P.
By Connock M, Burls A, Frew E,
Fry-Smith A, Juarez-Garcia A, McCabe C, Computerised cognitive behaviour
etal. therapy for depression and anxiety No. 42
update: a systematic review and A systematic review of the effectiveness
economic evaluation. of adalimumab, etanercept and
No. 25
By Kaltenthaler E, Brazier J, infliximab for the treatment of
Effectiveness and cost-effectiveness De Nigris E, Tumur I, Ferriter M,
of salicylic acid and cryotherapy for rheumatoid arthritis in adults and
Beverley C, etal. an economic evaluation of their cost-
cutaneous warts. An economic decision
model. effectiveness.
No. 34
By Thomas KS, Keogh-Brown MR, By Chen Y-F, Jobanputra P, Barton P,
Cost-effectiveness of using prognostic
Chalmers JR, Fordham RJ, Holland RC, Jowett S, Bryan S, Clark W, etal.
information to select women with breast
Armstrong SJ, etal. cancer for adjuvant systemic therapy.
By Williams C, Brunskill S, Altman D, No. 43
No. 26 Briggs A, Campbell H, Clarke M, etal. Telemedicine in dermatology: a
A systematic literature review of the randomised controlled trial.
effectiveness of non-pharmacological No. 35 By Bowns IR, Collins K, Walters SJ,
interventions to prevent wandering in Psychological therapies including McDonagh AJG.
dementia and evaluation of the ethical dialectical behaviour therapy for
implications and acceptability of their borderline personality disorder: a No. 44
use. systematic review and preliminary
By Robinson L, Hutchings D, Corner Cost-effectiveness of cell salvage and
economic evaluation.
L, Beyer F, Dickinson H, Vanoli A, etal. alternative methods of minimising
By Brazier J, Tumur I, Holmes M,
perioperative allogeneic blood
Ferriter M, Parry G, Dent-Brown K, etal.
transfusion: a systematic review and
No. 27
economic model.
A review of the evidence on the effects No. 36
and costs of implantable cardioverter Clinical effectiveness and cost- By Davies L, Brown TJ, Haynes S,
defibrillator therapy in different effectiveness of tests for the diagnosis Payne K, Elliott RA, McCollum C.
patient groups, and modelling of cost- and investigation of urinary tract
effectiveness and costutility for these infection in children: a systematic No. 45
groups in a UK context. review and economic model. Clinical effectiveness and cost-
By Buxton M, Caine N, Chase D, By Whiting P, Westwood M, Bojke L, effectiveness of laparoscopic surgery
Connelly D, Grace A, Jackson C, etal. Palmer S, Richardson G, Cooper J, etal. for colorectal cancer: systematic reviews
and economic evaluation.
No. 28 No. 37 By Murray A, Lourenco T, de Verteuil
Adefovir dipivoxil and pegylated Cognitive behavioural therapy R, Hernandez R, Fraser C, McKinley A,
interferon alfa-2a for the treatment of in chronic fatigue syndrome: a etal.
chronic hepatitis B: a systematic review randomised controlled trial of an
and economic evaluation. outpatient group programme.
No. 46
By ODowd H, Gladwell P, Rogers
By Shepherd J, Jones J, Takeda A, Etanercept and efalizumab for the
CA, Hollinghurst S, Gregory A.
Davidson P, Price A. treatment of psoriasis: a systematic
No. 38 review.
No. 29 By Woolacott N, Hawkins N,
A comparison of the cost-effectiveness
An evaluation of the clinical and cost- of five strategies for the prevention Mason A, Kainth A, Khadjesari Z, Bravo
effectiveness of pulmonary artery of nonsteroidal anti-inflammatory Vergel Y, etal.
catheters in patient management in drug-induced gastrointestinal toxicity:
intensive care: a systematic review and a a systematic review with economic No. 47
randomised controlled trial. modelling. Systematic reviews of clinical decision
By Harvey S, Stevens K, Harrison D, By Brown TJ, Hooper L, Elliott RA, tools for acute abdominal pain.
Young D, Brampton W, McCabe C, etal. Payne K, Webb R, Roberts C, etal. By Liu JLY, Wyatt JC, Deeks JJ,
No. 30 Clamp S, Keen J, Verde P, etal.
No. 39
Accurate, practical and cost-effective The effectiveness and cost-effectiveness
assessment of carotid stenosis in the of computed tomography screening No. 48
UK. for coronary artery disease: systematic Evaluation of the ventricular assist
By Wardlaw JM, Chappell FM, review. device programme in the UK.
Stevenson M, De Nigris E, Thomas S, By Waugh N, Black C, Walker S, By Sharples L, Buxton M, Caine N,
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Health Technology Assessment reports published to date

No. 49 No. 7 No. 16


A systematic review and economic Glucocorticoid-induced osteoporosis: Additional therapy for young
model of the clinical and cost- a systematic review and costutility children with spastic cerebral palsy: a
effectiveness of immunosuppressive analysis. randomised controlled trial.
therapy for renal transplantation in By Kanis JA, Stevenson M,
children. McCloskey EV, Davis S, Lloyd-Jones M. By Weindling AM, Cunningham CC,
Glenn SM, Edwards RT, Reeves DJ.
By Yao G, Albon E, Adi Y, Milford D,
Bayliss S, Ready A, etal. No. 8
Epidemiological, social, diagnostic and No. 17
economic evaluation of population
No. 50 screening for genital chlamydial Screening for type 2 diabetes: literature
Amniocentesis results: investigation of infection. review and economic modelling.
anxiety. The ARIA trial. By Low N, McCarthy A, Macleod J, By Waugh N, Scotland G, McNamee
By Hewison J, Nixon J, Fountain J, Salisbury C, Campbell R, Roberts TE, P, Gillett M, Brennan A, Goyder E, etal.
Cocks K, Jones C, Mason G, etal. etal.
No. 18
No. 9
Methadone and buprenorphine for the The effectiveness and cost-effectiveness
Volume 11, 2007 management of opioid dependence: of cinacalcet for secondary
a systematic review and economic hyperparathyroidism in end-stage renal
evaluation. disease patients on dialysis: a systematic
By Connock M, Juarez-Garcia A, review and economic evaluation.
No. 1
Jowett S, Frew E, Liu Z, Taylor RJ, etal. By Garside R, Pitt M, Anderson R,
Pemetrexed disodium for the treatment
of malignant pleural mesothelioma: Mealing S, Roome C, Snaith A, etal.
a systematic review and economic No. 10
evaluation. Exercise Evaluation Randomised
No. 19
Trial (EXERT): a randomised trial
By Dundar Y, Bagust A, Dickson R, comparing GP referral for leisure The clinical effectiveness and cost-
Dodd S, Green J, Haycox A, etal. centre-based exercise, community-based effectiveness of gemcitabine for
walking and advice only. metastatic breast cancer: a systematic
No. 2 By Isaacs AJ, Critchley JA, See Tai review and economic evaluation.
A systematic review and economic S, Buckingham K, Westley D, Harridge By Takeda AL, Jones J, Loveman E,
model of the clinical effectiveness SDR, etal. Tan SC, Clegg AJ.
and cost-effectiveness of docetaxel
in combination with prednisone or No. 11
prednisolone for the treatment of Interferon alfa (pegylated and non- No. 20
hormone-refractory metastatic prostate pegylated) and ribavirin for the A systematic review of duplex
cancer. treatment of mild chronic hepatitis ultrasound, magnetic resonance
By Collins R, Fenwick E, Trowman R, C: a systematic review and economic angiography and computed
Perard R, Norman G, Light K, etal. evaluation. tomography angiography for
By Shepherd J, Jones J, Hartwell D, the diagnosis and assessment of
Davidson P, Price A, Waugh N. symptomatic, lower limb peripheral
No. 3
arterial disease.
A systematic review of rapid diagnostic No. 12
tests for the detection of tuberculosis By Collins R, Cranny G, Burch J,
Systematic review and economic
infection. Aguiar-Ibez R, Craig D, Wright K,
evaluation of bevacizumab and
etal.
By Dinnes J, Deeks J, Kunst H, cetuximab for the treatment of
Gibson A, Cummins E, Waugh N, etal. metastatic colorectal cancer.
By Tappenden P, Jones R, Paisley S, No. 21
No. 4 Carroll C. The clinical effectiveness and cost-
The clinical effectiveness and cost- effectiveness of treatments for children
effectiveness of strontium ranelate for No. 13 with idiopathic steroid-resistant
the prevention of osteoporotic fragility A systematic review and economic nephrotic syndrome: a systematic
fractures in postmenopausal women. evaluation of epoetin alfa, epoetin review.
beta and darbepoetin alfa in anaemia
By Stevenson M, Davis S, Lloyd-Jones associated with cancer, especially that By Colquitt JL, Kirby J, Green C,
M, Beverley C. attributable to cancer treatment. Cooper K, Trompeter RS.
By Wilson J, Yao GL, Raftery J,
No. 5 Bohlius J, Brunskill S, Sandercock J, No. 22
A systematic review of quantitative and etal.
A systematic review of the routine
qualitative research on the role and monitoring of growth in children of
effectiveness of written information No. 14 primary school age to identify growth-
available to patients about individual A systematic review and economic related conditions.
medicines. evaluation of statins for the prevention
of coronary events. By Fayter D, Nixon J, Hartley S,
By Raynor DK, Blenkinsopp
By Ward S, Lloyd Jones M, Pandor A, Rithalia A, Butler G, Rudolf M, etal.
A, Knapp P, Grime J, Nicolson DJ,
Pollock K, etal. Holmes M, Ara R, Ryan A, etal.
No. 23
No. 15
No. 6 Systematic review of the effectiveness of
A systematic review of the effectiveness
Oral naltrexone as a treatment for and cost-effectiveness of different preventing and treating Staphylococcus
relapse prevention in formerly opioid- models of community-based respite aureus carriage in reducing peritoneal
dependent drug users: a systematic care for frail older people and their catheter-related infections.
review and economic evaluation. carers. By McCormack K, Rabindranath K,
By Adi Y, Juarez-Garcia A, Wang D, By Mason A, Weatherly H, Spilsbury Kilonzo M, Vale L, Fraser C, McIntyre L,
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DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 24 No. 33 No. 41


The clinical effectiveness and cost The clinical effectiveness and cost- The clinical effectiveness and cost-
of repetitive transcranial magnetic effectiveness of inhaled insulin in effectiveness of screening for open
stimulation versus electroconvulsive diabetes mellitus: a systematic review angle glaucoma: a systematic review
therapy in severe depression: a and economic evaluation. and economic evaluation.
multicentre pragmatic randomised By Burr JM, Mowatt G, Hernndez
By Black C, Cummins E, Royle P,
controlled trial and economic analysis. R, Siddiqui MAR, Cook J, Lourenco T,
Philip S, Waugh N.
By McLoughlin DM, Mogg A, Eranti etal.
S, Pluck G, Purvis R, Edwards D, etal.
No. 34
No. 25 No. 42
Surveillance of cirrhosis for
A randomised controlled trial and hepatocellular carcinoma: systematic Acceptability, benefit and costs of early
economic evaluation of direct versus review and economic analysis. screening for hearing disability: a study
indirect and individual versus group of potential screening tests and models.
By Thompson Coon J, Rogers G,
modes of speech and language therapy Hewson P, Wright D, Anderson R, By Davis A, Smith P, Ferguson M,
for children with primary language Cramp M, etal. Stephens D, Gianopoulos I.
impairment.
By Boyle J, McCartney E, Forbes J, No. 43
OHare A. No. 35
Contamination in trials of educational
The Birmingham Rehabilitation
interventions.
No. 26 Uptake Maximisation Study (BRUM).
Hormonal therapies for early breast Homebased compared with hospital- By Keogh-Brown MR, Bachmann
cancer: systematic review and economic based cardiac rehabilitation in a multi- MO, Shepstone L, Hewitt C, Howe A,
evaluation. ethnic population: cost-effectiveness Ramsay CR, etal.
By Hind D, Ward S, De Nigris E, and patient adherence.
Simpson E, Carroll C, Wyld L. By Jolly K, Taylor R, Lip GYH, No. 44
Greenfield S, Raftery J, Mant J, etal. Overview of the clinical effectiveness of
No. 27 positron emission tomography imaging
Cardioprotection against the toxic No. 36 in selected cancers.
effects of anthracyclines given to By Facey K, Bradbury I, Laking G,
children with cancer: a systematic A systematic review of the clinical,
Payne E.
review. public health and cost-effectiveness of
By Bryant J, Picot J, Levitt G, rapid diagnostic tests for the detection
and identification of bacterial intestinal No. 45
Sullivan I, Baxter L, Clegg A.
pathogens in faeces and food. The effectiveness and cost-effectiveness
By Abubakar I, Irvine L, Aldus CF, of carmustine implants and
No. 28
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Adalimumab, etanercept and infliximab
newly diagnosed high-grade glioma:
for the treatment of ankylosing
a systematic review and economic
spondylitis: a systematic review and No. 37 evaluation.
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By McLeod C, Bagust A, Boland A, By Garside R, Pitt M, Anderson R,
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cost-effectiveness of cardiac
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No. 30 resynchronisation (biventricular pacing)
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Clinical effectiveness and cost- for heart failure: systematic review and
By Connock M, Stevens C, Fry-Smith economic model.
effectiveness of bone morphogenetic A, Jowett S, Fitzmaurice D, Moore D,
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By Garrison KR, Donell S, Ryder J,
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A randomised controlled trial of and cost-effectiveness of interventions participation study. The STEPS study.
postoperative radiotherapy following for preventing relapse in people with
By Campbell MK, Snowdon C,
breast-conserving surgery in a bipolar disorder.
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Cost-effectiveness of functional
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and cost-effectiveness of the school early breast cancer: systematic review disease: a randomised controlled trial.
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Health Technology Assessment reports published to date

No. 50 No. 5 No. 14


Evaluation of diagnostic tests when A multi-centre retrospective cohort A randomised controlled trial of
there is no gold standard. A review of study comparing the efficacy, safety cognitive behaviour therapy in
methods. and cost-effectiveness of hysterectomy adolescents with major depression
By Rutjes AWS, Reitsma and uterine artery embolisation for treated by selective serotonin reuptake
JB, Coomarasamy A, Khan KS, the treatment of symptomatic uterine inhibitors. The ADAPT trial.
Bossuyt PMM. fibroids. The HOPEFUL study. By Goodyer IM, Dubicka B, Wilkinson
By Hirst A, Dutton S, Wu O, Briggs A, P, Kelvin R, Roberts C, Byford S, etal.
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No. 51
Systematic reviews of the clinical No. 15
No. 6 The use of irinotecan, oxaliplatin
effectiveness and cost-effectiveness of
proton pump inhibitors in acute upper Methods of prediction and prevention and raltitrexed for the treatment of
gastrointestinal bleeding. of pre-eclampsia: systematic reviews of advanced colorectal cancer: systematic
accuracy and effectiveness literature review and economic evaluation.
By Leontiadis GI, Sreedharan A, with economic modelling.
Dorward S, Barton P, Delaney B, Howden By Hind D, Tappenden P, Tumur I,
By Meads CA, Cnossen JS, Meher S, Eggington E, Sutcliffe P, Ryan A.
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A review and critique of modelling in Ranibizumab and pegaptanib for
The use of economic evaluations in the treatment of age-related macular
prioritising and designing screening NHS decision-making: a review and
programmes. degeneration: a systematic review and
empirical investigation. economic evaluation.
By Karnon J, Goyder E, Tappenden P, By Williams I, McIver S, Moore D,
McPhie S, Towers I, Brazier J, etal. By Colquitt JL, Jones J, Tan SC,
Bryan S.
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NHS Health Technology Assessment
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Programme.
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By Hanney S, Buxton M, Green C, tomography angiography as an
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alternative to invasive coronary
A, Weatherly H, Fox D, Golder S, etal.
angiography in the investigation of
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No. 9
Volume 12, 2008 By Mowatt G, Cummins E, Waugh N,
The clinical effectiveness of diabetes Walker S, Cook J, Jia X, etal.
education models for Type 2 diabetes: a
systematic review.
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No. 1 By Loveman E, Frampton GK,
Clegg AJ. Structural neuroimaging in psychosis:
A systematic review and economic
a systematic review and economic
model of switching from
evaluation.
nonglycopeptide to glycopeptide No. 10
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of the comparative effectiveness of
Cut down to quit with nicotine different inhaled corticosteroids and
replacement therapies in smoking No. 11
Cyclooxygenase-2 selective non- their usage with long-acting beta2
cessation: a systematic review of agonists for the treatment of chronic
effectiveness and economic analysis. steroidal anti-inflammatory drugs
(etodolac, meloxicam, celecoxib, asthma in adults and children aged
By Wang D, Connock M, Barton P, 12 years and over.
rofecoxib, etoricoxib, valdecoxib and
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lumiracoxib) for osteoarthritis and
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of strategies for reducing fracture risk Bryan S, Fry-Smith A, Harris G, etal. No. 20
in children with juvenile idiopathic Systematic review and economic analysis
arthritis with additional data on long- No. 12 of the comparative effectiveness of
term risk of fracture and cost of disease The clinical effectiveness and cost- different inhaled corticosteroids and
management. effectiveness of central venous catheters their usage with long-acting beta2
By Thornton J, Ashcroft D, ONeill T, treated with anti-infective agents in agonists for the treatment of chronic
Elliott R, Adams J, Roberts C, etal. preventing bloodstream infections: asthma in children under the age of
a systematic review and economic 12 years.
No. 4 evaluation. By Main C, Shepherd J, Anderson R,
Does befriending by trained lay workers By Hockenhull JC, Dwan K, Boland Rogers G, Thompson-Coon J, Liu Z, etal.
improve psychological well-being and A, Smith G, Bagust A, Dundar Y, etal.
quality of life for carers of people No. 21
with dementia, and at what cost? A No. 13 Ezetimibe for the treatment of
randomised controlled trial. Stepped treatment of older adults on hypercholesterolaemia: a systematic
By Charlesworth G, Shepstone L, laxatives. The STOOL trial. review and economic evaluation.
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DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 22 No. 31 No. 3


Topical or oral ibuprofen for chronic The effectiveness and cost-effectivness Surgical procedures and non-surgical
knee pain in older people. The TOIB of minimal access surgery amongst devices for the management of non-
study. people with gastro-oesophageal reflux apnoeic snoring: a systematic review of
By Underwood M, Ashby D, Carnes disease a UK collaborative study. The clinical effects and associated treatment
D, Castelnuovo E, Cross P, Harding G, reflux trial. costs.
etal. By Main C, Liu Z, Welch K, Weiner G,
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Continuous positive airway pressure
secondary care. The MiSTIC trial. Time to full publication of studies of
devices for the treatment of obstructive
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sleep apnoeahypopnoea syndrome: a
Smith H, Little P, Kinley H, etal. and the potential for publication bias: a
systematic review and economic analysis.
short systematic review.
By McDaid C, Griffin S, Weatherly H,
No. 24 By Takeda A, Loveman E, Harris P, Dure K, van der Burgt M, van Hout S,
A review and critical appraisal Hartwell D, Welch K. Akers J, et al.
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a systematic review and economic Curative catheter ablation in atrial The harmful health effects of recreational
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effectiveness and cost-effectiveness and
No. 35 Systematic review of the clinical
economic modelling of minimal incision
effectiveness and cost-effectiveness
total hip replacement approaches in Systematic review and economic
of oesophageal Doppler monitoring
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in critically ill and high-risk surgical
the hip. utility of surgical treatments for men
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incontinence: a comparative evaluation with chronic anaemia: a systematic review and economic evaluation.
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Health Technology Assessment reports published to date

No. 12 No. 21 No. 29


Improving the evaluation of therapeutic Neuroleptics in the treatment of Sensitivity analysis in economic
interventions in multiple sclerosis: the aggressive challenging behaviour for evaluation: an audit of NICE current
role of new psychometric methods. people with intellectual disabilities: practice and a review of its use and
By Hobart J, Cano S. a randomised controlled trial value in decision-making.
(NACHBID). By Andronis L, Barton P, Bryan S.
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R, Knapp M, Dickens S, Bouras N, et al. Suppl. 1
Treatment of severe ankle sprain: a
pragmatic randomised controlled trial Trastuzumab for the treatment of
comparing the clinical effectiveness No. 22 primary breast cancer in HER2-positive
and cost-effectiveness of three types of Randomised controlled trial to women: a single technology appraisal.
mechanical ankle support with tubular determine the clinical effectiveness By Ward S, Pilgrim H, Hind D.
bandage. The CAST trial. and cost-effectiveness of selective
serotonin reuptake inhibitors plus Docetaxel for the adjuvant treatment
By Cooke MW, Marsh JL, Clark M,
supportive care, versus supportive care of early node-positive breast cancer: a
Nakash R, Jarvis RM, Hutton JL, et al.,
alone, for mild to moderate depression single technology appraisal.
on behalf of the CAST trial group.
with somatic symptoms in primary By Chilcott J, Lloyd Jones M,
care: the THREAD (THREshold for Wilkinson A.
No. 14 AntiDepressant response) study.
Non-occupational postexposure By Kendrick T, Chatwin J, Dowrick C, The use of paclitaxel in the
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Blood glucose self-monitoring in type 2 for hereditary haemochromatosis in
Rituximab for the first-line treatment
diabetes: a randomised controlled trial. at-risk populations: a systematic review
of stage III/IV follicular non-Hodgkins
By Farmer AJ, Wade AN, French DP, and economic evaluation.
lymphoma.
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By Dundar Y, Bagust A, Hounsome J,
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No. 16
How far does screening women for No. 24 Bortezomib for the treatment of
domestic (partner) violence in different Enhanced external counterpulsation multiple myeloma patients.
health-care settings meet criteria for for the treatment of stable angina and By Green C, Bryant J, Takeda A,
a screening programme? Systematic heart failure: a systematic review and Cooper K, Clegg A, Smith A, et al.
reviews of nine UK National Screening economic analysis.
Committee criteria. By McKenna C, McDaid C, Suekarran Fludarabine phosphate for the first-
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Spinal cord stimulation for chronic tool for primary care management of
Erlotinib for the treatment of relapsed
pain of neuropathic or ischaemic patients with abnormal liver function
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evaluation. Hockenhull J, Dundar Y, Proudlove C,
cohort study and decision analysis
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JF, Ryder S, Roderick P, Sullivan F, et al. treatment of locally advanced squamous
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The role of magnetic resonance imaging No. 26
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A systematic review of presumed White S, Erhorn S, Brent S, et al.
acoustic neuroma: a systematic review consent systems for deceased organ
of clinical and cost-effectiveness and donation. Infliximab for the treatment of adults
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and validation, randomised trial, C, Montgomery AA, Fletcher M, trial.
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and qualitative study. Dixon S, Walters S, Paley G, et al.
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A randomised controlled trial to
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No. 20 monitoring devices with conventional durations of clopidogrel in patients
Systematic review of respite care in the monitoring in the management of with non-ST-segment elevation acute
frail elderly. insulin-treated diabetes mellitus coronary syndromes: a systematic review
By Shaw C, McNamara R, Abrams K, (MITRE). and value of information analysis.
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DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 32 No. 40 Adalimumab for the treatment of


Systematic review and individual patient Breastfeeding promotion for infants in psoriasis.
data meta-analysis of diagnosis of heart neonatal units: a systematic review and By Turner D, Picot J, Cooper K,
failure, with modelling of implications economic analysis. Loveman E.
of different diagnostic strategies in By Renfrew MJ, Craig D, Dyson L, Dabigatran etexilate for the prevention
primary care. McCormick F, Rice S, King SE, et al. of venous thromboembolism in patients
By Mant J, Doust J, Roalfe A, Barton undergoing elective hip and knee
P, Cowie MR, Glasziou P, et al. No. 41 surgery: a single technology appraisal.
The clinical effectiveness and cost- By Holmes M, Carroll C,
No. 33 effectiveness of bariatric (weight loss) Papaioannou D.
surgery for obesity: a systematic review and
A multicentre randomised controlled
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By Picot J, Jones J, Colquitt JL, of chronic immune or idiopathic
airway pressure and non-invasive
Gospodarevskaya E, Loveman E, Baxter thrombocytopenic purpura: a single
positive pressure ventilation in the early
L, et al. technology appraisal.
treatment of patients presenting to the
emergency department with severe By Mowatt G, Boachie C, Crowther
acute cardiogenic pulmonary oedema: No. 42 M, Fraser C, Hernndez R, Jia X, et al.
the 3CPO trial. Rapid testing for group B streptococcus Sunitinib for the treatment of
By Gray AJ, Goodacre S, Newby during labour: a test accuracy study with gastrointestinal stromal tumours: a
DE, Masson MA, Sampson F, Dixon evaluation of acceptability and cost- critique of the submission from Pfizer.
S, et al., on behalf of the 3CPO study effectiveness. By Bond M, Hoyle M, Moxham T,
investigators. By Daniels J, Gray J, Pattison H, Napier M, Anderson R.
Roberts T, Edwards E, Milner P, et al.
No. 34 No. 45
Early high-dose lipid-lowering therapy No. 43 Vitamin K to prevent fractures in older
to avoid cardiac events: a systematic Screening to prevent spontaneous women: systematic review and economic
review and economic evaluation. preterm birth: systematic reviews of evaluation.
accuracy and effectiveness literature By Stevenson M, Lloyd-Jones M,
By Ara R, Pandor A, Stevens J, Rees
with economic modelling. Papaioannou D.
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Adefovir dipivoxil and pegylated No. 44 treatment of essential hypertension: a
interferon alpha for the treatment systematic review.
The effectiveness and cost-effectiveness
of chronic hepatitis B: an updated By Greenhalgh J, Dickson R,
of cochlear implants for severe to
systematic review and economic Dundar Y.
profound deafness in children and
evaluation.
adults: a systematic review and
By Jones J, Shepherd J, Baxter L, economic model. No. 47
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By Bond M, Mealing S, Anderson R,
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Elston J, Weiner G, Taylor RS, et al.
the early treatment of Bells palsy: the
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Methods to identify postnatal Gemcitabine for the treatment of PT, Morrison JM, Smith BH, McKinstry
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Alteplase for the treatment of acute By Hyde C, Bryan S, Juarez-Garcia A,
children with persistent bilateral otitis
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media with effusion in primary care.
appraisal.
By Williamson I, Benge S, Barton S, Rimonabant for the treatment of
By Lloyd Jones M, Holmes M.
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Rituximab for the treatment of By Burch J, McKenna C, Palmer S,
No. 38 rheumatoid arthritis. Norman G, Glanville J, Sculpher M, et al.
The effectiveness and cost-effectiveness By Bagust A, Boland A, Hockenhull
Telbivudine for the treatment of chronic
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By Parker SG, Oliver P, Pennington By Boland A, Bagust A, Hockenhull J, single technology appraisal.
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Health Technology Assessment reports published to date

Rivaroxaban for the prevention of No. 54 Volume 14, 2010


venous thromboembolism: a single Randomised controlled trial of the use
technology appraisal. of three dressing preparations in the
By Stevenson M, Scope A, Holmes M, management of chronic ulceration of No. 1
Rees A, Kaltenthaler E. the foot in diabetes.
Multicentre randomised controlled
By Jeffcoate WJ, Price PE, Phillips CJ,
Cetuximab for the treatment of trial examining the cost-effectiveness of
Game FL, Mudge E, Davies S, et al.
recurrent and/or metastatic squamous contrast-enhanced high field magnetic
cell carcinoma of the head and neck. resonance imaging in women with
No. 55 primary breast cancer scheduled for
By Greenhalgh J, Bagust A, Boland A, VenUS II: a randomised controlled trial wide local excision (COMICE).
Fleeman N, McLeod C, Dundar Y, et al. of larval therapy in the management of By Turnbull LW, Brown SR, Olivier C,
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appraisal. MO, Bland JM, Cullum N, Dowson C,
No. 2
et al.
By Pandor A, Fitzgerald P, Stevenson Bevacizumab, sorafenib tosylate,
M, Papaioannou D. sunitinib and temsirolimus for renal
No. 56
cell carcinoma: a systematic review and
Ustekinumab for the treatment of A prospective randomised controlled economic evaluation.
moderate to severe psoriasis. trial and economic modelling of
antimicrobial silver dressings versus By Thompson Coon J, Hoyle M,
By Gospodarevskaya E, Picot J, Green C, Liu Z, Welch K, Moxham T,
Cooper K, Loveman E, Takeda A. non-adherent control dressings for
venous leg ulcers: the VULCAN trial. et al.

No. 48 By Michaels JA, Campbell WB,


King BM, MacIntyre J, Palfreyman SJ, No. 3
Endovascular stents for abdominal The clinical effectiveness and cost-
Shackley P, et al.
aortic aneurysms: a systematic review effectiveness of testing for cytochrome
and economic model. P450 polymorphisms in patients
No. 57
By Chambers D, Epstein D, Walker S, with schizophrenia treated with
Communication of carrier status
Fayter D, Paton F, Wright K, et al. antipsychotics: a systematic review and
information following universal
newborn screening for sickle cell economic evaluation.
No. 49 disorders and cystic fibrosis: qualitative By Fleeman N, McLeod C, Bagust A,
Clinical and cost-effectiveness of study of experience and practice. Beale S, Boland A, Dundar Y, et al.
epoprostenol, iloprost, bosentan, By Kai J, Ulph F, Cullinan T,
sitaxentan and sildenafil for pulmonary Qureshi N. No. 4
arterial hypertension within their Systematic review of the clinical
licensed indications: a systematic review effectiveness and cost-effectiveness of
No. 58
and economic evaluation. photodynamic diagnosis and urine
Antiviral drugs for the treatment of
By Chen Y-F, Jowett S, Barton P, influenza: a systematic review and biomarkers (FISH, ImmunoCyt,
Malottki K, Hyde C, Gibbs JSR, et al. economic evaluation. NMP22) and cytology for the detection
By Burch J, Paulden M, Conti S, Stock and follow-up of bladder cancer.
No. 50 C, Corbett M, Welton NJ, et al. By Mowatt G, Zhu S, Kilonzo M,
Cessation of attention deficit Boachie C, Fraser C, Griffiths TRL, et al.
hyperactivity disorder drugs No. 59
in the young (CADDY) a No. 5
Development of a toolkit and glossary
pharmacoepidemiological and Effectiveness and cost-effectiveness of
to aid in the adaptation of health
qualitative study. arthroscopic lavage in the treatment
technology assessment (HTA) reports
By Wong ICK, Asherson P, Bilbow A, for use in different contexts. of osteoarthritis of the knee: a mixed
Clifford S, Coghill D, DeSoysa R, et al. By Chase D, Rosten C, Turner S, methods study of the feasibility of
Hicks N, Milne R. conducting a surgical placebo-controlled
No. 51 trial (the KORAL study).
ARTISTIC: a randomised trial of No. 60 By Campbell MK, Skea ZC,
human papillomavirus (HPV) testing in Colour vision testing for diabetic Sutherland AG, Cuthbertson BH,
primary cervical screening. retinopathy: a systematic review of Entwistle VA, McDonald AM, et al.
By Kitchener HC, Almonte M, diagnostic accuracy and economic
Gilham C, Dowie R, Stoykova B, Sargent evaluation. No. 6
A, et al. By Rodgers M, Hodges R, Hawkins A randomised 22 trial of community
J, Hollingworth W, Duffy S, McKibbin versus hospital pulmonary rehabilitation
No. 52 M, et al. for chronic obstructive pulmonary
The clinical effectiveness of glucosamine disease followed by telephone or
and chondroitin supplements in slowing No. 61 conventional follow-up.
or arresting progression of osteoarthritis Systematic review of the effectiveness By Waterhouse JC, Walters SJ,
of the knee: a systematic review and and cost-effectiveness of weight Oluboyede Y, Lawson RA.
economic evaluation. management schemes for the under
By Black C, Clar C, Henderson R, fives: a short report. No. 7
MacEachern C, McNamee P, Quayyum By Bond M, Wyatt K, Lloyd J, Welch The effectiveness and cost-effectiveness
Z, et al. K, Taylor R. of behavioural interventions for the
prevention of sexually transmitted
No. 53 No. 62 infections in young people aged 1319:
Randomised preference trial of medical Are adverse effects incorporated in a systematic review and economic
versus surgical termination of pregnancy economic models? An initial review of evaluation.
less than 14 weeks gestation (TOPS). current practice. By Shepherd J, Kavanagh J, Picot J,
By Robson SC, Kelly T, Howel D, By Craig D, McDaid C, Fonseca T, Cooper K, Harden A, Barnett-Page E,
128 Deverill M, Hewison J, Lie MLS, et al. Stock C, Duffy S, Woolacott N. et al.
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

No. 8 No. 16 No. 24


Dissemination and publication of Randomised controlled trials for policy A systematic review and economic
research findings: an updated review of interventions: a review of reviews and evaluation of the clinical effectiveness
related biases. meta-regression. and cost-effectiveness of aldosterone
By Song F, Parekh S, Hooper L, Loke By Oliver S, Bagnall AM, Thomas J, antagonists for postmyocardial
YK, Ryder J, Sutton AJ, et al. Shepherd J, Sowden A, White I, et al. infarction heart failure.
By McKenna C, Burch J, Suekarran S,
No. 17 Walker S, Bakhai A, Witte K, et al.
No. 9
Paracetamol and selective and
The effectiveness and cost-effectiveness No. 25
non-selective non-steroidal anti-
of biomarkers for the prioritisation Avoiding and identifying errors in
inflammatory drugs (NSAIDs) for the
of patients awaiting coronary health technology assessment models:
reduction of morphine-related side
revascularisation: a systematic review qualitative study and methodological
effects after major surgery: a systematic
and decision model. review.
review.
By Hemingway H, Henriksson By McDaid C, Maund E, Rice S, By Chilcott JB, Tappenden P, Rawdin
M, Chen R, Damant J, Fitzpatrick N, Wright K, Jenkins B, Woolacott N. A, Johnson M, Kaltenthaler E, Paisley S,
Abrams K, et al. et al.
No. 18
No. 10 A systematic review of outcome No. 26
Comparison of case note review measures used in forensic mental health BoTULS: a multicentre randomised
methods for evaluating quality and research with consensus panel opinion. controlled trial to evaluate the clinical
safety in health care. By Fitzpatrick R, Chambers J, Burns effectiveness and cost-effectiveness of
By Hutchinson A, Coster JE, Cooper T, Doll H, Fazel S, Jenkinson C, et al. treating upper limb spasticity due to
KL, McIntosh A, Walters SJ, Bath PA, stroke with botulinum toxin type A.
et al. No. 19 By Shaw L, Rodgers H, Price C, van
The clinical effectiveness and cost- Wijck F, Shackley P, Steen N, et al., on
effectiveness of topotecan for small cell behalf of the BoTULS investigators.
No. 11
Clinical effectiveness and cost- lung cancer: a systematic review and
economic evaluation. No. 27
effectiveness of continuous
By Loveman E, Jones J, Hartwell D, Weighting and valuing quality-adjusted
subcutaneous insulin infusion for
Bird A, Harris P, Welch K, et al. life-years using stated preference
diabetes: systematic review and
methods: preliminary results from the
economic evaluation.
Social Value of a QALY Project.
By Cummins E, Royle P, Snaith A, No. 20
By Baker R, Bateman I, Donaldson C,
Greene A, Robertson L, McIntyre L, et al. Antenatal screening for
Jones-Lee M, Lancsar E, Loomes G, et al.
haemoglobinopathies in primary care:
No. 12 a cohort study and cluster randomised
trial to inform a simulation model. The Suppl. 1
Self-monitoring of blood glucose in type Screening for Haemoglobinopathies in Cetuximab for the first-line treatment of
2 diabetes: systematic review. First Trimester (SHIFT) trial. metastatic colorectal cancer.
By Clar C, Barnard K, Cummins E, By Dormandy E, Bryan S, Gulliford By Meads C, Round J, Tubeuf S,
Royle P, Waugh N. MC, Roberts T, Ades T, Calnan M, et al. Moore D, Pennant M, Bayliss S.

Infliximab for the treatment of acute


No. 13 No. 21 exacerbations of ulcerative colitis.
North of England and Scotland Study of Early referral strategies for By Bryan S, Andronis L, Hyde C,
Tonsillectomy and Adeno-tonsillectomy management of people with markers of Connock M, Fry-Smith A, Wang D.
in Children (NESSTAC): a pragmatic renal disease: a systematic review of the
randomised controlled trial with a evidence of clinical effectiveness, cost- Sorafenib for the treatment of advanced
parallel non-randomised preference effectiveness and economic analysis. hepatocellular carcinoma.
study. By Black C, Sharma P, Scotland G, By Connock M, Round J, Bayliss S,
By Lock C, Wilson J, Steen N, Eccles McCullough K, McGurn D, Robertson Tubeuf S, Greenheld W, Moore D.
M, Mason H, Carrie S, et al. L, et al.
Tenofovir disoproxil fumarate for
No. 22 the treatment of chronic hepatitis B
No. 14
A randomised controlled trial of infection.
Multicentre randomised controlled trial By Jones J, Colquitt J, Shepherd J,
cognitive behaviour therapy and
of the clinical and cost-effectiveness of Harris P, Cooper K.
motivational interviewing for people
a bypass-surgery-first versus a balloon-
with Type 1 diabetes mellitus with
angioplasty-first revascularisation Prasugrel for the treatment of acute
persistent sub-optimal glycaemic
strategy for severe limb ischaemia due coronary artery syndromes with
control: A Diabetes and Psychological
to infrainguinal disease. The Bypass percutaneous coronary intervention.
Therapies (ADaPT) study.
versus Angioplasty in Severe Ischaemia By Greenhalgh J, Bagust A, Boland
of the Leg (BASIL) trial. By Ismail K, Maissi E, Thomas S,
Chalder T, Schmidt U, Bartlett J, et al. A, Saborido CM, Fleeman N, McLeod
By Bradbury AW, Adam DJ, Bell J, C, et al.
Forbes JF, Fowkes FGR, Gillespie I, et al.
No. 23 Alitretinoin for the treatment of severe
A randomised controlled equivalence chronic hand eczema.
No. 15 trial to determine the effectiveness By Paulden M, Rodgers M, Griffin S,
A randomised controlled multicentre and costutility of manual chest Slack R, Duffy S, Ingram JR, et al.
trial of treatments for adolescent physiotherapy techniques in the
anorexia nervosa including assessment management of exacerbations of Pemetrexed for the first-line treatment
of cost-effectiveness and patient chronic obstructive pulmonary disease of locally advanced or metastatic non-
acceptability the TOuCAN trial. (MATREX). small cell lung cancer.
By Gowers SG, Clark AF, Roberts C, By Cross J, Elender F, Barton G, By Fleeman N, Bagust A, McLeod C,
Byford S, Barrett B, Griffiths A, et al. Clark A, Shepstone L, Blyth A, et al. Greenhalgh J, Boland A, Dundar Y, et al. 129

2010 Queens Printer and Controller of HMSO. All rights reserved.


Health Technology Assessment reports published to date

Topotecan for the treatment of No. 34 No. 38


recurrent and stage IVB carcinoma of Exploring the needs, concerns and Towards single embryo transfer?
the cervix. behaviours of people with existing Modelling clinical outcomes of potential
By Paton F, Paulden M, Saramago P, respiratory conditions in relation to the treatment choices using multiple data
Manca A, Misso K, Palmer S, et al. H1N1 swine influenza pandemic: a sources: predictive models and patient
multicentre survey and qualitative study. perspectives.
Trabectedin for the treatment of By Caress A-L, Duxbury P, Woodcock By Roberts SA, McGowan L, Hirst
advanced metastatic soft tissue sarcoma. A, Luker KA, Ward D, Campbell M, et al. WM, Brison DR, Vail A, Lieberman BA.
By Simpson EL, Rafia R, Stevenson
MD, Papaioannou D. Influenza A/H1N1v in pregnancy: an No. 39
Azacitidine for the treatment of investigation of the characteristics and Sugammadex for the reversal of muscle
myelodysplastic syndrome, chronic management of affected women and the relaxation in general anaesthesia:
myelomonocytic leukaemia and acute relationship to pregnancy outcomes for a systematic review and economic
myeloid leukaemia. mother and infant. assessment.
By Edlin R, Connock M, Tubeuf S, By Yates L, Pierce M, Stephens S, Mill By Chambers D, Paulden M, Paton F,
Round J, Fry-Smith A, Hyde C, et al. AC, Spark P, Kurinczuk JJ, et al. Heirs M, Duffy S, Craig D, et al.

No. 28 The impact of communications about No. 40


The safety and effectiveness of swine flu (influenza A H1N1v) on public Systematic review and economic
different methods of earwax removal: responses to the outbreak: results from modelling of the effectiveness and cost-
a systematic review and economic 36 national telephone surveys in the effectiveness of non-surgical treatments
evaluation. UK. for women with stress urinary
By Clegg AJ, Loveman E, By Rubin GJ, Potts HWW, Michie S. incontinence.
Gospodarevskaya E, Harris P, Bird A, By Imamura M, Abrams P, Bain C,
Bryant J, et al. The impact of illness and the impact Buckley B, Cardozo L, Cody J, et al.
of school closure on social contact
No. 29 patterns. No. 41
Systematic review of the clinical By Eames KTD, Tilston NL, White PJ, A multicentred randomised controlled
effectiveness and cost-effectiveness Adams E, Edmunds WJ. trial of a primary care-based cognitive
of rapid point-of-care tests for the behavioural programme for low back
detection of genital chlamydia infection Vaccine effectiveness in pandemic pain. The Back Skills Training (BeST)
in women and men. influenza primary care reporting trial.
By Hislop J, Quayyum Z, Flett G, (VIPER): an observational study to By Lamb SE, Lall R, Hansen Z,
Boachie C, Fraser C, Mowatt G. assess the effectiveness of the pandemic Castelnuovo E, Withers EJ, Nichols V,
influenza A (H1N1)v vaccine. et al.
No. 30 By Simpson CR, Ritchie LD,
School-linked sexual health services for Robertson C, Sheikh A, McMenamin J. No. 42
young people (SSHYP): a survey and Recombinant human growth hormone
systematic review concerning current Physical interventions to interrupt or for the treatment of growth disorders
models, effectiveness, cost-effectiveness reduce the spread of respiratory viruses: in children: a systematic review and
and research opportunities. a Cochrane review. economic evaluation.
By Owen J, Carroll C, Cooke J, By Jefferson T, Del Mar C, Dooley L, By Takeda A, Cooper K,
Formby E, Hayter M, Hirst J, et al. Ferroni E, Al-Ansary LA, Bawazeer GA, Bird A, Baxter L, Frampton GK,
et al. Gospodarevskaya E, et al.
No. 31
Systematic review and cost-effectiveness No. 35 No. 43
evaluation of pill-in-the-pocket strategy Randomised controlled trial and A pragmatic randomisedcontrolled
for paroxysmal atrial fibrillation parallel economic evaluation of trial to compare antidepressants with
compared to episodic in-hospital conventional ventilatory support versus a community-based psychosocial
treatment or continuous antiarrhythmic extracorporeal membrane oxygenation intervention for thetreatment of
drug therapy. for severe adult respiratory failure women with postnatal depression: the
By Martin Saborido C, Hockenhull J, (CESAR). RESPOND trial.
Bagust A, Boland A, Dickson R, Todd D. By Peek GJ, Elbourne D, Mugford M, By Sharp DJ, Chew-Graham C, Tylee
Tiruvoipati R, Wilson A, Allen E, et al. A, Lewis G, Howard L, Anderson I, et al.
No. 32
Chemoprevention of colorectal cancer: No. 36
systematic review and economic Newer agents for blood glucose control
evaluation. in type 2 diabetes: systematic review and
By Cooper K, Squires H, Carroll C, economic evaluation.
Papaioannou D, Booth A, Logan RF, et al. By Waugh N, Cummins E, Royle P,
Clar C, Marien M, Richter B, et al.
No. 33
Cross-trimester repeated measures No. 37
testing for Downs syndrome screening: Barretts oesophagus and cancers of the
an assessment. biliary tract, brain, head and neck, lung,
By Wright D, Bradbury I, Malone F, oesophagus and skin.
DAlton M, Summers A, Huang T, et al. By Fayter D, Corbett M, Heirs M, Fox
D, Eastwood A.

130
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

Health Technology Assessment


programme
Director, Deputy Director,
Professor Tom Walley, Professor Jon Nicholl,
Director, NIHR HTA Director, Medical Care Research
programme, Professor of Unit, University of Sheffield
Clinical Pharmacology,
University of Liverpool

Prioritisation Strategy Group


Members
Chair, Dr Andrew Cook, Professor Paul Glasziou, Ms Lynn Kerridge,
Professor Tom Walley, Consultant Advisor, NETSCC, Professor of Evidence-Based Chief Executive Officer,
Director, NIHR HTA HTA Medicine, University of Oxford NETSCC and NETSCC, HTA
programme, Professor of
Clinical Pharmacology, Dr Peter Davidson, Dr Nick Hicks, Professor Ruairidh Milne,
University of Liverpool Director of NETSCC, Health Consultant Adviser, NETSCC, Director of NETSCC External
Technology Assessment HTA Relations
Deputy Chair,
Professor Jon Nicholl, Professor Robin E Ferner, Dr Edmund Jessop, Ms Kay Pattison,
Director, Medical Care Research Consultant Physician and Medical Adviser, National Senior NIHR Programme
Unit, University of Sheffield Director, West Midlands Centre Specialist, National Manager, Department of
for Adverse Drug Reactions, Commissioning Group (NCG), Health
Dr Bob Coates, City Hospital NHS Trust, Department of Health, London
Consultant Advisor, NETSCC, Birmingham Ms Pamela Young,
HTA Specialist Programme Manager,
NETSCC, HTA

HTA Commissioning Board


Members
Programme Director, Professor Deborah Ashby, Professor Freddie Hamdy, Professor Ian Roberts,
Professor Tom Walley, Professor of Medical Statistics, Professor of Urology, Professor of Epidemiology &
Director, NIHR HTA Queen Mary, University of University of Sheffield Public Health, London School
programme, Professor of London of Hygiene and Tropical
Clinical Pharmacology, Professor Allan House, Medicine
University of Liverpool Professor John Cairns, Professor of Liaison Psychiatry,
Professor of Health Economics, University of Leeds Professor Mark Sculpher,
Chairs, London School of Hygiene and Professor of Health Economics,
Professor Sallie Lamb, Tropical Medicine Dr Martin J Landray, University of York
Director, Warwick Clinical Trials Reader in Epidemiology,
Unit Professor Peter Croft, Honorary Consultant Physician, Professor Helen Smith,
Director of Primary Care Clinical Trial Service Unit, Professor of Primary Care,
Professor Hywel Williams, Sciences Research Centre, Keele University of Oxford University of Brighton
Director, Nottingham Clinical University
Trials Unit Professor Stuart Logan, Professor Kate Thomas,
Professor Nicky Cullum, Director of Health & Social Professor of Complementary &
Deputy Chair, Director of Centre for Evidence- Care Research, The Peninsula Alternative Medicine Research,
Dr Andrew Farmer, Based Nursing, University of Medical School, Universities of University of Leeds
Senior Lecturer in General York Exeter and Plymouth
Practice, Department of Professor David John
Primary Health Care, Professor Jenny Donovan, Dr Rafael Perera, Torgerson,
University of Oxford Professor of Social Medicine, Lecturer in Medical Statisitics, Director of York Trials Unit,
University of Bristol Department of Primary Health University of York
Professor Ann Ashburn, Care, University of Oxford
Professor of Rehabilitation Professor Steve Halligan,
and Head of Research, Professor of Gastrointestinal
Southampton General Hospital Radiology, University College
Hospital, London

Observers
Ms Kay Pattison, Dr Morven Roberts,
Section Head, NHS R&D Clinical Trials Manager,
Programme, Department of Medical Research Council
Health
131

2010 Queens Printer and Controller of HMSO. All rights reserved.


Health Technology Assessment programme

Diagnostic Technologies and Screening Panel


Members
Chair, Dr Dianne Baralle, Professor Anthony Robert Mrs Una Rennard,
Professor Paul Glasziou, Consultant & Senior Lecturer Kendrick, Service User Representative
Professor of Evidence-Based in Clinical Genetics, Human Professor of Primary
Medicine, University of Oxford Genetics Division & Wessex Medical Care, University of Ms Jane Smith,
Clinical Genetics Service, Southampton Consultant Ultrasound
Deputy Chair, Southampton, University of Practitioner, Ultrasound
Dr David Elliman, Southampton Dr Susanne M Ludgate, Department, Leeds Teaching
Consultant Paediatrician and Director, Medical Devices Hospital NHS Trust, Leeds
Honorary Senior Lecturer, Dr Stephanie Dancer, Agency, London
Great Ormond Street Hospital, Consultant Microbiologist, Dr W Stuart A Smellie,
London Hairmyres Hospital, East Dr Anne Mackie, Consultant, Bishop Auckland
Kilbride Director of Programmes, UK General Hospital
Professor Judith E Adams, National Screening Committee
Consultant Radiologist, Dr Ron Gray, Professor Lindsay Wilson
Manchester Royal Infirmary, Consultant, National Perinatal Dr David Mathew Turnbull,
Central Manchester & Epidemiology Unit, Institute of Service User Representative Scientific Director of the
Manchester Childrens Health Sciences, University of Centre for Magnetic Resonance
Dr Michael Millar, Lead Investigations and YCR
University Hospitals NHS Oxford Consultant in Microbiology,
Trust, and Professor of Professor of Radiology, Hull
Professor Paul D Griffiths, Department of Pathology & Royal Infirmary
Diagnostic Radiology, Imaging Microbiology, Barts and The
Science and Biomedical Professor of Radiology,
Academic Unit of Radiology, London NHS Trust, Royal Dr Alan J Williams,
Engineering, Cancer & London Hospital Consultant in General
Imaging Sciences, University of University of Sheffield
Medicine, Department of
Manchester Mr Martin Hooper, Mr Stephen Pilling, Thoracic Medicine, The Royal
Service User Representative Director, Centre for Outcomes, Bournemouth Hospital
Mr A S Arunkalaivanan, Research & Effectiveness,
Honorary Senior Lecturer, University College London
University of Birmingham and
Consultant Urogynaecologist
and Obstetrician, City Hospital

Observers
Dr Tim Elliott, Dr Catherine Moody, Dr Ursula Wells,
Team Leader, Cancer Programme Manager, Principal Research Officer,
Screening, Department of Neuroscience and Mental Department of Health
Health Health Board

Disease Prevention Panel


Members
Chair, Dr Elizabeth Fellow-Smith, Dr Chris McCall, Professor Ian Roberts,
Dr Edmund Jessop, Medical Director, West London General Practitioner, The Professor of Epidemiology and
Medical Adviser, National Mental Health Trust, Middlesex Hadleigh Practice, Corfe Public Health, London School
Specialist Commissioning Mullen, Dorset of Hygiene & Tropical Medicine
Advisory Group (NSCAG), Dr Colin Greaves
Department of Health Senior Research Fellow, Miss Nicky Mullany, Professor Carol Tannahill,
Peninsular Medical School Service User Representative Glasgow Centre for Population
Deputy Chair, (Primary Care) Health
Professor Margaret Dr Julie Mytton,
Thorogood, Dr John Jackson, Locum Consultant in Public Mrs Jean Thurston,
Professor of Epidemiology, General Practitioner, Parkway Health Medicine, Bristol Service User Representative
University of Warwick Medical Medical Centre, Newcastle Primary Care Trust
upon Tyne Professor David Weller,
School, Coventry Professor Irwin Nazareth, Head, School of Clinical
Dr Robert Cook Dr Russell Jago, Professor of Primary Care Science and Community
Clinical Programmes Director, Senior Lecturer in Exercise, and Director, Department of Health, University of
Bazian Ltd, London Nutrition and Health, Centre Primary Care and Population Edinburgh
for Sport, Exercise and Health, Sciences, University College
University of Bristol London

Observers
Ms Christine McGuire, Ms Kay Pattison Dr Caroline Stone,
Research & Development, Senior NIHR Programme Programme Manager, Medical
Department of Health Manager, Department of Research Council
Health

132

Current and past membership details of all HTA programme committees are available from the HTA website (www.hta.ac.uk)
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

External Devices and Physical Therapies Panel


Members

Chair, Dr Dawn Carnes, Dr Peter Martin, Dr Pippa Tyrrell,


Dr John Pounsford, Senior Research Fellow, Barts Consultant Neurologist, Stroke Medicine, Senior
Consultant Physician North and the London School of Addenbrookes Hospital, Lecturer/Consultant Stroke
Bristol NHS Trust, Bristol Medicine and Dentistry, Cambridge Physician, Salford Royal
London Foundation Hospitals Trust,
Deputy Chair, Dr Lorraine Pinnigton, Salford
Professor E Andrea Nelson, Dr Emma Clark, Associate Professor in
Reader in Wound Healing and Clinician Scientist Fellow Rehabilitation, University of Dr Sarah Tyson,
Director of Research, University & Cons. Rheumatologist, Nottingham, Nottingham Senior Research Fellow &
of Leeds, Leeds University of Bristol, Bristol Associate Head of School,
Dr Kate Radford, University of Salford, Salford
Professor Bipin Bhakta Mrs Anthea De Barton-Watson, Division of Rehabilitation and
Charterhouse Professor in Service User Representative Ageing, School of Community Dr Nefyn Williams,
Rehabilitation Medicine, Health Sciences. University of Clinical Senior Lecturer, Cardiff
University of Leeds, Leeds Professor Christopher Griffiths, Nottingham, Nottingham University, Cardiff
Professor of Primary Care,
Mrs Penny Calder Barts and the London School Mr Jim Reece,
Service User Representative of Medicine and Dentistry, Service User Representative
London
Professor Paul Carding, Professor Maria Stokes,
Professor of Voice Pathology, Dr Shaheen Hamdy, Professor of
Newcastle Hospital NHS Trust, Clinical Senior Lecturer Neuromusculoskeletal
Newcastle and Consultant Physician, Rehabilitation, University of
University of Manchester, Southampton, Southampton
Manchester

Observers
Dr Phillip Leech, Ms Kay Pattison Dr Morven Roberts, Dr Ursula Wells
Principal Medical Officer for Senior NIHR Programme Clinical Trials Manager, MRC, PRP, DH, London
Primary Care, Department of Manager, Department of London
Health , London Health

Interventional Procedures Panel


Members
Chair, Mr Seamus Eckford, Dr Nadim Malik, Dr Ashish Paul,
Professor Jonathan Michaels, Consultant in Obstetrics & Consultant Cardiologist/ Medical Director, Bedfordshire
Consultant Surgeon & Gynaecology, North Devon Honorary Lecturer, University PCT
Honorary Clinical Lecturer, District Hospital of Manchester
University of Sheffield Dr Sarah Purdy,
Professor David Taggart, Mr Hisham Mehanna, Consultant Senior Lecturer,
Mr David P Britt, Consultant Cardiothoracic Consultant & Honorary University of Bristol
Service User Representative, Surgeon, John Radcliffe Associate Professor, University
Cheshire Hospital Hospitals Coventry & Mr Michael Thomas,
Warwickshire NHS Trust Consultant Colorectal Surgeon,
Mr Sankaran Dr Matthew Hatton, Bristol Royal Infirmary
ChandraSekharan, Consultant in Clinical Dr Jane Montgomery,
Consultant Surgeon, Colchester Oncology, Sheffield Teaching Consultant in Anaesthetics and Professor Yit Chiun Yang,
Hospital University NHS Hospital Foundation Trust Critical Care, South Devon Consultant Ophthalmologist,
Foundation Trust Healthcare NHS Foundation Royal Wolverhampton Hospitals
Dr John Holden, Trust NHS Trust
Professor Nicholas Clarke, General Practitioner, Garswood
Consultant Orthopaedic Surgery, Wigan Dr Simon Padley, Mrs Isabel Boyer,
Surgeon, Southampton Consultant Radiologist, Chelsea Service User Representative,
University Hospitals NHS Trust & Westminster Hospital London

133

2010 Queens Printer and Controller of HMSO. All rights reserved.


Health Technology Assessment programme

Pharmaceuticals Panel
Members
Chair, Dr Peter Elton, Dr Dyfrig Hughes, Dr Martin Shelly,
Professor Imti Choonara, Director of Public Health, Reader in Pharmacoeconomics General Practitioner, Leeds,
Professor in Child Health, Bury Primary Care Trust and Deputy Director, Centre and Associate Director, NHS
University of Nottingham for Economics and Policy in Clinical Governance Support
Professor Robin Ferner, Health, IMSCaR, Bangor Team, Leicester
Deputy Chair, Consultant Physician and University
Dr Lesley Wise, Director, West Midlands Centre Dr Gillian Shepherd,
Unit Manager, for Adverse Drug Reactions, Dr Yoon K Loke, Director, Health and Clinical
Pharmacoepidemiology City Hospital NHS Trust, Senior Lecturer in Clinical Excellence, Merck Serono Ltd
Research Unit, VRMM, Birmingham Pharmacology, University of
Medicines & Healthcare East Anglia Mrs Katrina Simister,
Products Regulatory Agency Dr Ben Goldacre, Assistant Director New
Research Fellow, Division of Professor Femi Oyebode, Medicines, National Prescribing
Mrs Nicola Carey, Psychological Medicine and Consultant Psychiatrist Centre, Liverpool
Senior Research Fellow, Psychiatry, Kings College and Head of Department,
School of Health and Social London University of Birmingham Mr David Symes,
Care, The University of Service User Representative
Reading Dr Bill Gutteridge, Dr Andrew Prentice,
Medical Adviser, London Senior Lecturer and Consultant
Mr John Chapman, Strategic Health Authority Obstetrician and Gynaecologist,
Service User Representative The Rosie Hospital, University
of Cambridge

Observers
Ms Kay Pattison Mr Simon Reeve, Dr Heike Weber, Dr Ursula Wells,
Senior NIHR Programme Head of Clinical and Cost- Programme Manager, Principal Research Officer,
Manager, Department of Effectiveness, Medicines, Medical Research Council Department of Health
Health Pharmacy and Industry Group,
Department of Health

Psychological and Community Therapies Panel


Members
Chair, Dr Steve Cunningham, Ms Mary Nettle, Dr Howard Ring,
Professor Scott Weich, Consultant Respiratory Mental Health User Consultant, Consultant & University
Professor of Psychiatry, Paediatrician, Lothian Health Gloucestershire Lecturer in Psychiatry,
University of Warwick Board University of Cambridge
Professor John Potter,
Professor Jane Barlow, Dr Anne Hesketh, Professor of Ageing and Stroke Dr Karen Roberts,
Professor of Public Health in Senior Clinical Lecturer in Medicine, University of East Nurse/Consultant, Dunston Hill
the Early Years, Health Sciences Speech and Language Therapy, Anglia Hospital, Tyne and Wear
Research Institute, Warwick University of Manchester
Medical School Dr Greta Rait, Dr Karim Saad,
Dr Yann Lefeuvre, Senior Clinical Lecturer and Consultant in Old Age
Dr Sabyasachi Bhaumik, GP Partner, Burrage Road General Practitioner, University Psychiatry, Coventry &
Consultant Psychiatrist, Surgery, London College London Warwickshire Partnership Trust
Leicestershire Partnership NHS
Trust Dr Jeremy J Murphy, Dr Paul Ramchandani, Dr Alastair Sutcliffe,
Consultant Physician & Senior Research Fellow/Cons. Senior Lecturer, University
Mrs Val Carlill, Cardiologist, County Durham & Child Psychiatrist, University of College London
Service User Representative, Darlington Foundation Trust Oxford
Gloucestershire Dr Simon Wright,
Mr John Needham, GP Partner, Walkden Medical
Service User, Buckingmashire Centre, Manchester

Observers
Ms Kay Pattison Dr Morven Roberts, Professor Tom Walley, Dr Ursula Wells,
Senior NIHR Programme Clinical Trials Manager, MRC, HTA Programme Director, Policy Research Programme,
Manager, Department of London Liverpool DH, London
Health

134

Current and past membership details of all HTA programme committees are available from the HTA website (www.hta.ac.uk)
DOI: 10.3310/hta14440 Health Technology Assessment 2010;Vol. 14: No. 44

Expert Advisory Network


Members
Professor Douglas Altman, Mr Jonothan Earnshaw, Professor Allen Hutchinson, Professor Miranda Mugford,
Professor of Statistics in Consultant Vascular Surgeon, Director of Public Health and Professor of Health Economics
Medicine, Centre for Statistics Gloucestershire Royal Hospital, Deputy Dean of ScHARR, and Group Co-ordinator,
in Medicine, University of Gloucester University of Sheffield University of East Anglia
Oxford
Professor Martin Eccles, Professor Peter Jones, Professor Jim Neilson,
Professor John Bond, Professor of Clinical Professor of Psychiatry, Head of School of Reproductive
Professor of Social Gerontology Effectiveness, Centre for Health University of Cambridge, & Developmental Medicine
& Health Services Research, Services Research, University of Cambridge and Professor of Obstetrics
University of Newcastle upon Newcastle upon Tyne and Gynaecology, University of
Tyne Professor Stan Kaye, Liverpool
Professor Pam Enderby, Cancer Research UK Professor
Professor Andrew Bradbury, Dean of Faculty of Medicine, of Medical Oncology, Royal Mrs Julietta Patnick,
Professor of Vascular Surgery, Institute of General Practice Marsden Hospital and Institute National Co-ordinator, NHS
Solihull Hospital, Birmingham and Primary Care, University of of Cancer Research, Surrey Cancer Screening Programmes,
Sheffield Sheffield
Mr Shaun Brogan, Dr Duncan Keeley,
Chief Executive, Ridgeway Professor Gene Feder, General Practitioner (Dr Burch Professor Robert Peveler,
Primary Care Group, Aylesbury Professor of Primary Care & Ptnrs), The Health Centre, Professor of Liaison Psychiatry,
Research & Development, Thame Royal South Hants Hospital,
Mrs Stella Burnside OBE, Centre for Health Sciences, Southampton
Chief Executive, Regulation Barts and The London School Dr Donna Lamping,
and Improvement Authority, of Medicine and Dentistry Research Degrees Programme Professor Chris Price,
Belfast Director and Reader in Director of Clinical Research,
Mr Leonard R Fenwick, Psychology, Health Services Bayer Diagnostics Europe,
Ms Tracy Bury, Chief Executive, Freeman Research Unit, London School Stoke Poges
Project Manager, World Hospital, Newcastle upon Tyne of Hygiene and Tropical
Confederation for Physical Medicine, London Professor William Rosenberg,
Therapy, London Mrs Gillian Fletcher, Professor of Hepatology
Antenatal Teacher and Tutor Mr George Levvy, and Consultant Physician,
Professor Iain T Cameron, and President, National Chief Executive, Motor University of Southampton
Professor of Obstetrics and Childbirth Trust, Henfield Neurone Disease Association,
Gynaecology and Head of the Northampton Professor Peter Sandercock,
School of Medicine, University Professor Jayne Franklyn, Professor of Medical Neurology,
of Southampton Professor of Medicine, Professor James Lindesay, Department of Clinical
University of Birmingham Professor of Psychiatry for the Neurosciences, University of
Dr Christine Clark, Elderly, University of Leicester Edinburgh
Medical Writer and Consultant Mr Tam Fry,
Pharmacist, Rossendale Honorary Chairman, Child Professor Julian Little, Dr Susan Schonfield,
Growth Foundation, London Professor of Human Genome Consultant in Public Health,
Professor Collette Clifford, Epidemiology, University of Hillingdon Primary Care Trust,
Professor of Nursing and Professor Fiona Gilbert, Ottawa Middlesex
Head of Research, The Consultant Radiologist and
Medical School, University of NCRN Member, University of Professor Alistaire McGuire, Dr Eamonn Sheridan,
Birmingham Aberdeen Professor of Health Economics, Consultant in Clinical Genetics,
London School of Economics St Jamess University Hospital,
Professor Barry Cookson, Professor Paul Gregg, Leeds
Director, Laboratory of Hospital Professor of Orthopaedic Professor Rajan Madhok,
Infection, Public Health Surgical Science, South Tees Medical Director and Director Dr Margaret Somerville,
Laboratory Service, London Hospital NHS Trust of Public Health, Directorate Director of Public Health
of Clinical Strategy & Public Learning, Peninsula Medical
Dr Carl Counsell, Bec Hanley, Health, North & East Yorkshire School, University of Plymouth
Clinical Senior Lecturer in Co-director, TwoCan Associates, & Northern Lincolnshire
Neurology, University of West Sussex Health Authority, York Professor Sarah Stewart-Brown,
Aberdeen Professor of Public Health,
Dr Maryann L Hardy, Professor Alexander Markham, Division of Health in the
Professor Howard Cuckle, Senior Lecturer, University of Director, Molecular Medicine Community, University of
Professor of Reproductive Bradford Unit, St Jamess University Warwick, Coventry
Epidemiology, Department Hospital, Leeds
of Paediatrics, Obstetrics & Mrs Sharon Hart, Professor Ala Szczepura,
Gynaecology, University of Healthcare Management Dr Peter Moore, Professor of Health Service
Leeds Consultant, Reading Freelance Science Writer, Research, Centre for Health
Ashtead Services Studies, University of
Dr Katherine Darton, Professor Robert E Hawkins,
Warwick, Coventry
Information Unit, MIND The CRC Professor and Director Dr Andrew Mortimore,
Mental Health Charity, London of Medical Oncology, Christie Public Health Director, Mrs Joan Webster,
CRC Research Centre, Southampton City Primary Consumer Member, Southern
Professor Carol Dezateux, Christie Hospital NHS Trust, Care Trust Derbyshire Community Health
Professor of Paediatric Manchester Council
Epidemiology, Institute of Child Dr Sue Moss,
Health, London Professor Richard Hobbs, Associate Director, Cancer Professor Martin Whittle,
Head of Department of Primary Screening Evaluation Unit, Clinical Co-director, National
Mr John Dunning, Care & General Practice, Institute of Cancer Research, Co-ordinating Centre for
Consultant Cardiothoracic University of Birmingham Sutton Womens and Childrens
Surgeon, Papworth Hospital Health, Lymington
NHS Trust, Cambridge Professor Alan Horwich,
Dean and Section Chairman,
The Institute of Cancer
Research, London

135

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