InnovAiT: The RCGP Journal for Associates in Training

http://ino.sagepub.com/ Non-Pharmacological Treatments for Depression in Primary Care: An Overview

Chantal Simon and Alys Cole-King InnovAiT 2011 4: 265 DOI: 10.1093/innovait/inr032 The online version of this article can be found at: http://ino.sagepub.com/content/4/5/265

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InnovAiT, Vol. 4, No. 5, pp. 265271, 2011

doi:10.1093/innovait/inr032 Advance access publication 5 April 2011

Non-pharmacological treatments for depression in primary care: an overview

etween 2 and 3% of the UK population experience depression in any year; a further 9% experience mixed anxiety and depression . The net costs of antidepressant medication in England alone in 2009 were just under 300 million. This article discusses the range of non-pharmacological treatments available to patients with depression and their use.
The GP curriculum and non-pharmacological treatments for depression with taking antidepressant drugs. Alternatively, they may be wary about drug interactions between antidepressant medication and medication for other conditions. As a result, patients often prefer psychological treatments to medication (Prins et al., 2008). However, despite national guidance recommending nonpharmacological treatment for depression, the volume of antidepressant prescribing has increased dramatically in developed countries over the past 20 years (Hollinghurst et al., 2005). This is partly as a result of increased detection of depression but also because of changes in the way that antidepressants are used with patients tending to be on higher doses for longer periods of time (Moore et al., 2009). Therefore, much of this apparent increased usage may be derived from repeat rather than new prescriptions. There is also some indication that poor availability of the non-pharmacological treatments recommended in current guidelines may influence the use of medication (Morrison et al., 2008). The Mental Health Foundation (2010) found that 75% of GPs have prescribed antidepressants to patients with recurrent depression believing that an alternative approach might have been more appropriate, 67% because there was a waiting list for the suitable alternative treatment and 57% because they did not have sufficient access to other suitable treatments. Moreover, GPs may perceive that it takes more consultation time to engage the patient in non-pharmacological self-help

Curriculum statement 13: Care of people with mental health problems requires GPs to be able to describe interventions and national guidelines relevant to mental health problems, including depression. It also requires GPs to be able to present individuals suffering from mental health problems with choices about intervention for their condition and understand that this ability to choose improves the effectiveness of the intervention.
The assessment of depression is described in detail in another article in this special issue of InnovAiT. The National Institute for Health and Clinical Excellence (NICE) recommends a stepped approach to treatment (Fig. 1) for depression, including the use of non-pharmacological treatments both alone and in combination with antidepressant drugs (NICE, 2009). The Scottish Intercollegiate Guidelines Network (SIGN) has produced a guideline overviewing the nonpharmacological management of depression in adults (SIGN, 2010). Many people with depression regard antidepressants as harmful or addictive and thus do not want to take them. They may have had bad experiences with antidepressant side effects in the past or found antidepressant drugs ineffective. They may be worried about the stigma associated

The Author 2011. Published by Oxford University Press on behalf of the RCGP. All rights reserved. For permissions please e-mail: journals.permissions@oup.com
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Figure 1.Stepped treatment of depression. Adapted from Depression: the treatment and management of depression in adults (NICE, 2009).

methods or refer for psychological therapy than to provide a prescription. Since the advent of the Improving Access to Psychological Therapies (IAPT) programme in England (Department of Health, 2008) and similar programmes in other parts of the UK, there is now increased accessibility to psychological therapies for patients being treated for depression in primary care. People who present themselves or are referred to an IAPT service are assessed by a member of the psychological therapies team and then offered treatment in primary care or another community setting. By April 2011, IAPT services were available to patients in around 60% of the UK, and the aim is to achieve 100% by April 2015. This article reviews the types of non-pharmacological therapies available for patients with depression in the UK and the evidence base that underpins them. The choice of whether to prescribe antidepressants and/or to refer for psychological therapies is an individual decision for each patient and depends on many factors including: OO Severity of depression (those with more severe depression require antidepressant medication) OO Underlying aetiology of the depression OO Presence of a co-morbid physical condition making antidepressant use problematic OO Past history of depression in that patient OO Previous response to treatment such as antidepressants and/or psychological therapies (including problems with treatment and side effects) OO Patient preference OO Local availability

The doctorpatient relationship

When treating patients with mental health problems, it is essential to establish an empathic constructive relationship with your patient. This enables effective communication and serves as the basis for any subsequent therapeutic relationship. Although not always possible in todays primary care settings, ideally there should also be continuity of care through follow-up, allowing the doctor to continue to build on that relationship. An ongoing therapeutic alliance between doctor and patient has a positive effect in the treatment of depression. Meta-analysis shows that a good therapeutic alliance results in better outcomes (Martin et al., 2000). Three elements of this relationship are thought to be important (Bordin, 1979): OO Agreement on treatment OO Agreement about the goals of treatment OO The bond between doctor and patient Furthermore, within a therapeutic relationship, increasing hopefulness, resilience and reasons for living have even been shown to reduce suicide rates (McLean et al., 2008). Health care professionals who are empathic and compassionate encourage increased disclosure by the patients about concerns, symptoms and behaviour and are ultimately more effective in delivering care (Larson and Yao, 2005).

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Active monitoring
NICE (2009) recommends an option of active monitoring for patients with mild depression who do not want intervention or those with subthreshold depression who request intervention. This is based on the premise that the symptoms of a proportion of people with mild depression may simply improve on their own without any intervention. Active monitoring involves: OO Discussing the presenting problems and the concerns that the patient has OO Providing information about depression OO Arranging a further assessment, usually within 2 weeks initially OO Making contact if the patient misses an appointment

Exercise
For their Cochrane review, Mead et al. (2009) combined data from 25 trials of exercise therapy for depression. They found that exercise did improve symptoms of depression but did not draw any conclusions about the most effective type of exercise. However, there is a larger evidence base for aerobic exercise (such as walking or swimming) than for anaerobic exercise (such as weights). Exercise probably needs to be continued in the longer term for benefits on mood to be maintained. NICE (2009) recommends exercise as a treatment option for patients of all ages with a diagnosis of depression. They suggest a structured and supervised exercise programme. Such programmes are frequently available to GPs through exercise prescriptions to local sports, health and leisure facilities. However, although many patients enjoy exercise prescription schemes and benefit from them enormously, these schemes are not ideal for all patients. In some areas, there are long waits for initial assessment. Participants often have to pay a joining fee and/or a fee per session, which may be preclusive for some patients. Types of exercise offered may be limited and this can prevent some patients with other illnesses or disabilities from participating. Lastly, many exercise prescription schemes limit the times at which patients can attend, frequently to off-peak times when people who are working cannot go. If your patient cannot or does not want to attend a formal exercise scheme, do not dismiss exercise as a treatment option. Recommend building up to 30 minutes of moderate activity at least three and preferably five times per week. Patients are more likely to exercise on a regular and ongoing basis if it is built into their usual routine (for example, cycling to work).

Information provision
Patients with depression may feel isolated and alone. Provision of information is very important to help patients to understand their condition and educate them about strategies that they might be able to use to help themselves. Ideally, support verbal information with written information that the patient can read at home. National Health Service (NHS) Tyne and Wear produce a very readable information leaflet that can be downloaded and given to patients in the surgery (Box 1). Web-based information can also be very helpful for those with Internet access. However, some Internet sites provide unhelpful and conflicting information, so it is important to point patients towards reputable sites (Box 1).

Box 1. Useful sources of information for patients who have depression and their families Information and self-help leaflets NHS Tyne and Wear. Depression: an information leaflet. Accessed via ww.ntw.nhs.uk/pic/leaflets/Depression% 20A4%202010.pdf Royal College of Psychiatrists. Depression. Accessed via ww.rcpsych.ac.uk/mentalhealthinformation/mental healthproblems/depression/depression.aspx Support organizations Depression Alliance. Telephone: 0845 123 2320; website: www.depressionalliance.org Depression UK. Telephone: 0870 774 4320; website: www.depressionuk.org Saneline (England). Telephone: 0845 767 8000 (111 p.m. daily); website: www.sane.org.uk Breathing Space (Scotland). Telephone: 0800 83 85 87; website: www.breathingspacescotland.co.uk C.A.L.L. Mental health helpline (Wales). Telephone: 0800 132 737; website: www.callhelpline.org.uk Samaritans (24 hour emotional support). Telephone: 08457 909 090; website: www.samaritans.org.uk

Other lifestyle measures

All patients should be advised to cut down or stop smoking and eat a healthy diet regardless of a diagnosis of depression. Apart from exercise, there is very little evidence to support specific lifestyle measures in the treatment of depression. However, alcohol and substance abuse are causative factors for depression and risk of suicide is higher in these groups. Therefore, it seems sensible to advise patients to cut back on excessive alcohol consumption and avoid illicit drugs. Any factors that can encourage emotional resilience and self-efficacy will help patients to deal with their depression. It is often crucial for patients to gain the support and understanding of their families, partners and spouses. The role of the GP may be to help facilitate such increased understanding and support. SIGN (2010) recommends that patients should be encouraged to maintain social networks and personally meaningful activities.

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The concept of social connectedness is very important. A recent meta-analysis and systematic review of non-directive emotional support provided through befriending interventions found a modest but significant reduction in depressive symptoms in the short and long term (Mead et al., 2010).

Work
The issue of work can be difficult. If the patient is unable to perform usual work duties because of depression, then it is reasonable to provide a sickness certificate. However, long absences from a job can make getting back to work harder. Therefore, wherever possible restrict duration of sick notes to weeks rather than months. The social support of work colleagues and structured routine of the working day may actually help some patients with depression and fits with the concept of social connectedness. Introduction of the new fit note in 2010 with the option of asking employers to amend workers duties, reduce their hours or provide additional support has enabled many patients suffering from depression to remain working and has also made it considerably easier for patients to return to work following a period of absence resulting from depression.

Figure 2. Simple problem-solving strategy to use in the GP surgery.

Sleep
Advice on sleep is another recommendation in both SIGN (2010) and NICE (2009) guidance. NICE recommends: OO Establishing regular sleep times OO Avoiding excess eating, smoking, drinking and alcohol before bed (and no caffeine after 3 p.m.) OO Creating a proper environment for sleep OO Taking regular physical exercise if possible

Computerized cognitive behavioural therapy

In 2004, a randomized controlled trial comparing the Moodgym [an online interactive cognitive behavioural therapy (CBT) course] with a written psychoeducation course found that both were effective at reducing symptoms of depression (Christensen et al., 2004 ). Subsequently, a Health Technology Assessment of 10 studies appraising the efficacy of computerized CBT (CCBT) reported a consistent reduction in symptoms of depression in patients treated with CCBT across the studies (Kaltenthaler et al., 2006). In particular, the Beating the Blues package was identified as effective. Commonly used CCBT packages are listed in Box 2. For patients who are not computer literate, self-help books based on CBT techniques are available as an alternative (Box 2).

Problem solving
Problem-solving therapy (PST) can be an effective tool to use in the GP surgery (Mynors-Wallis et al., 2000). It works on the basis that symptoms of depression develop as a result of psychosocial problems that the patient has. A simple model of PST that can be used in the GP surgery is summarized in Fig. 2. Initially, the patient is asked to identify and clarify his or her problems. In our experience, this can be a useful exercise in itself as it helps the patient to focus on the issues that are important. From this problem list, an achievable list of goals is identified. It is important to limit the number of goals to no more than two or three at any time. The next step is to discuss possible solutions to achieve the identified goals and decide on an option for each to take forward. The patient then goes away and implements that solution, reporting back to you at the next review, when the whole process is repeated. At review, new goals can be negotiated and/or new solutions to existing goals can be formulated as needed. Metaanalysis of PST for depression has found that it is more effective than control interventions (Cuijpers et al., 2007a ).

Box 2. CCBT packages and self-help books Free online interactive CCBT Living Life to the Full. Website: www.livinglifetothefull. com OO The Mood Gym and e-Couch. Website: www. moodgym.anu.edu.au/welcome
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Other computerized CBT Beating the Blues. A fee is payable but some Primary Care Trusts have purchased this programme for use by patients free-of-charge in GP surgeries. Website: www.beatingtheblues.co.uk

Self-help books Gilbert, P. Overcoming depression (2000) Constable and Robinson ISBN: 1841191256 OO Burns, D. Feeling good: the new mood therapy (2000) Harper Collins ISBN: 1847081517
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Counselling

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Traditionally, counselling is the form of non-pharmacological therapy that the most GPs have had access to for their patients with depression. However, although many practices do still have access to counsellors, there is little evidence of beneficial effects or cost-effectiveness of counselling (NICE, 2009; SIGN, 2010) and it has fallen out of favour. Usually, the key element in counselling is reflective listening to encourage patients to think about and try to resolve their own difficulties. It does not involve giving advice. It is important to note that there is no formal registration requirement in the UK for counsellors or psychotherapists. The General Medical Council advises that GPs should only refer to practitioners who are members of a recognized regulatory body and thus subject to ethical and disciplinary codes. If there is a specific identifiable cause for the patients depression, counselling directed at the cause may be helpful. Examples of these specialist counselling services are listed in Box 3.

The patients availabilitymany patients in full-time employment are unable to give up time from work to attend for psychological therapy sessions

Guided self-help
Guided self-help is based on a cognitive or behavioural therapy approach. It makes use of books or other printed materials designed specifically for the purposes of guided self-help. Crucially, use of this material is supervised by a trained facilitator who introduces, monitors and then reviews the outcome of each treatment. Usually, there is minimal contact with the facilitator (no more than 3 hours in total). Guided self-help is often available via local psychological therapy services. In some areas, patients may self-refer. NICE (2009) reviewed 16 studies investigating the effectiveness of guided self-help. Overall, they showed that it has a beneficial effect in people with mild or subthreshold depression.

Cognitive behavioural therapy

When depressed, patients tend to focus on negative views. These might be relating to themselves, the future and/or the world around them. In CBT, the therapist works with the patient so that the patient learns to recognize negative or unhelpful thinking patterns. These are often unconscious and automatic. By enabling the patient to be more aware of this and teaching ways that the patient can gently challenge such cognitive errors, more helpful thinking styles can result. Patients must then practise re-evaluating their thoughts, and associated behaviours, before further review. There is a considerable body of evidence to show that CBT is acceptable to patients, more effective than control interventions, and at least as effective as drug treatment (Churchill et al., 2001; Cuijpers et al., 2006 ; Pinquart et al., 2006 ). Furthermore, CBT may be more effective than pharmacological therapies longer term (Hensley et al., 2004 ). Individual CBT is more effective than group CBT, with better reduction in symptom control and fewer symptoms at follow-up.

Box 3. Examples of specialist counselling services. Relationship breakdown counselling is available through organizations such as RELATE (website: www. relate.org.uk) Bereavementcounselling is available via organizations such as CRUSE (Telephone: 0870 167 1677; website: www. crusebereavementcare.org.uk) Debt counselling is available from the Citizens Advice Bureau, National Debtline (Telephone: 0808 808 4000) or the Consumer Credit Counselling Service Debtremedy website (www.cccs.co.uk)

Psychological therapies
Except for patients with dysthymia, a recent meta-analysis concluded that psychological therapies are as effective as pharmacological therapies for the treatment of depression (Cuijpers et al., 2008). There is currently insufficient evidence to recommend one form of psychological therapy over another. Psychological therapies, apart from CCBT, are available by GP and/or self-referral to local psychological therapy services. When deciding whether to refer for psychological therapies, it is important to consider: OO The patients preferences OO The patients previous response to any psychological therapies already tried OO The patients motivationit takes considerable commitment to participate fully in psychological therapies and see them through. Such therapies are unlikely to be successful if the patient does not turn up to appointments

Mindfulness-based cognitive therapy

Mindful-based cognitive therapy is a skills training programme specifically designed to enable patients to learn skills that prevent the recurrence of depression. It is an 8-week group programme aimed at patients who have had three or more relapses of their depression, with four further follow-up sessions in the year following therapy. The programme aims to teach patients to become more aware of the bodily sensations, thoughts and feelings associated with depressive relapse and to react to them in a constructive way to prevent depression returning. A systematic review has shown that this type of therapy reduces relapse by over 50% over the first year after treatment. However, it does not seem to be effective in patients who have suffered fewer than three relapses (Coelho et al., 2007 ).

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Behavioural activation
Behavioural activation is a time-limited psychological intervention. Therapist and patient work together with the aim of identifying effects that the patients behaviour might have on symptoms, mood and problems. Then they address any problematic behaviours. Techniques may include reducing avoidance, activity scheduling, graded exposure and initiating positively reinforced behaviours. Two meta-analyses have found that behavioural activation is effective in reducing symptoms of depression, particularly in older adults (Cuijpers et al., 2006, 2007b ).
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Other strategies to use in the GP surgery include lifestyle recommendations, exercise, simple problemsolving techniques and CCBT More specialist psychological therapies that are effective for those with more severe depression or for whom simple home- or surgery-based techniques have not worked, include guided self-help, individual CBT, mindful-based cognitive therapy, behavioural activation and IPT.

Interpersonal therapy
Interpersonal therapy (IPT) concentrates on the difficulties that arise in maintaining relationships with others. It focuses on current, not past relationships, and works on the premise that if interpersonal conflicts are resolved, both relationships and mood will be improved. IPT may be an individual or group therapy. Systematic reviews have shown that IPT, CBT and antidepressant medication are all equally effective (Casacalenda et al., 2002 ; de Mello et al., 2005). This type of therapy is most useful for patients who can identify that they have relationship difficulties.

REFERENCES AND FURTHER INFORMATION

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Complementary therapies
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Many patients seek alternative and complementary therapies for their depression, such as hypnotherapy or acupuncture. There are a wide range of such therapies available, usually accessed privately by patients. Currently, there is insufficient evidence of effectiveness to recommend any complementary non-pharmacological therapy for the treatment of depression (SIGN, 2010).

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Conclusions
In the past, GPs have had poor access to psychological or talking therapies for their patients suffering from depression. They had little choice but to prescribe antidepressants if treatment was needed. However, psychological therapies are now becoming more available in the UK. They are an effective and realistic treatment alternative, or adjunct to drug therapy, for many patients with depression seen in general practice.
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Key points
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Psychological therapies for depression are recommended by NICE both alone as treatment for mild to moderate depression and in combination with drug therapy for patients with more severe depression Psychological therapies are becoming more available within the NHS through the IAPT scheme In the GP surgery, empathic patient-centred care is important backed up by good information provision; for patients with mild or subthreshold depression, an active monitoring approach without any specific treatment can be effective

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Bordin, E.S. The generalizability of the psychoanalytic concept of the working alliance. Psychotherapy: Theory, Research and Practice (1979) 16: p. 25260 Casacalenda, N., Perry, J.C., Looper, K. Remission in major depressive disorder: a comparison of pharmacotherapy, psychotherapy, and control conditions. American Journal of Psychiatry (2002) 159 (8): p. 135460 Christensen, H., Griffiths, K.M., Jorm, A.F. Delivering interventions for depression by using the internet: randomised controlled trial. British Medical Journal (2004) 328 (7434): p. 2659 Churchill, R., Hunot, V., Corney, R. et al. A systematic review of controlled trials of the effectiveness and cost-effectiveness of brief psychological treatments for depression. Health Technology Assessment (2001) 5 (35): p. 1173. Accessed viawww.hta.ac.uk/fullmono /mon535.pdf [date last accessed 30.1.2011] Coelho, H.F., Canter, P.H., Ernst, E. Mindfulness-based cognitive therapy: evaluating current evidence and informing future research. Journal of Consulting and Clinical Psychology (2007) 75 (6): p. 10005 Cuijpers, P., van Straten, A., Smit, F. Psychological treatment of late-life depression: a meta-analysis of randomized controlled trials. International Journal of Geriatric Psychiatry (2006) 21 (12): p. 113949 Cuijpers, P., van Straten, A., Warmerdam, L. Behavioral activation treatments of depression: a meta-analysis. Clinical Psychology Review (2007a) 27 (3): p. 31826 Cuijpers, P., van Straten, A., Warmerdam, L. Problem solving therapies for depression: a meta-analysis. European Psychiatry (2007b) 22 (1): p. 915 Cuijpers, P., van Straten, A., van Oppen, P. et al. Are psychological and pharmacologic interventions equally effective in the treatment of adult depressive disorders? A meta-analysis of comparative studies. Journal of Clinical Psychiatry (2008) 9: p. 167585 de Mello, M.F., de Jesus Mari, J., Bacaltchuk, J., Verdeli, H., Neugebauer, R. A systematic review of research findings on the efficacy of interpersonal therapy for depressive disorders. European Archives of Psychiatry and Clinical Neurosciences (2005) 255 (2): p. 7582

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Department of Health. Improving access to psychological therapies implementation plan: national guidelines for regional delivery (2008) Accessed via www.dh .gov.uk/en/Publicationsandstatistics/Publications /PublicationsPolicyAndGuidance/DH_083150 [date last accessed 30.1.2011] Hensley, P.L., Nadiga, D., Uhlenhuth, E.H. Long-term effectiveness of cognitive therapy in major depressive disorder. Depression and Anxiety (2004) 20 (1): p. 17 Hollinghurst, S., Kessler, D., Peters, T.J., Gunnell, D. Opportunity cost of antidepressant prescribing in England: analysis of routine data. British Medical Journal (2005) 330 (7505): p. 9991000 House of Commons. Written answers 19.7 (2010) Accessed via http://services.parliament.uk/hansard| /Commons/ByDate/20100719/writtenanswers /part016.html [date last accessed 20.1.2011] Kaltenthaler, E., Brazier, J., De Nigris, E. et al. Computerised cognitive behaviour therapy for depression and anxiety update: a systematic review and economic evaluation. Health Technology Assessment (2006) 10 (33): p. 1168. Accessed via www.hta.ac.uk/pdfexecs /summ1033.pdf [date last accessed 30.1.2011] Larson, E.B., Yao, Y. Clinical empathy as emotional labour in the patient-physician relationship. Journal of the American Medical Association (2005) 293: p. 11006 Martin, D.J., Garske, J.P., Davis, M.K. Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of Consulting and Clinical Psychology (2000) 68: p. 43850 McLean, J., Maxwell, M., Platt, S., Harris, F., Jepson, R. Risk and protective factors for suicide and suicidal behaviour: a literature review (2008) Accessed via www .scotland.gov.uk/Publications/2008/11/28141444 /0 [date last accessed 8.2.2011] Mead, G.E., Morley, W., Campbell, P., Greig, C.A., McMurdo, M., Lawlor, D.A. Exercise for depression. Cochrane Database of Systematic Reviews (2009) Issue 3. Art. No.: CD004366. DOI: 10.1002/14651858. CD004366.pub4 Mead, N., Lester, H., Chew-Graham, C., Gask, L. Effects of befriending on depressive symptoms and distress: systematic review and meta-analysis. British Journal of Psychiatry (2010) 196: p. 96101

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Mental Health Foundation. Be mindful report (2010) Moore, M., Yuen, H., Dunn, N., Mullee, M., Maskell, J., Kendrick, T. Explaining the rise in antidepressant prescribing: a descriptive study using the general practice research database. British Medical Journal (2009) 339: p. b3999 Morrison, J., Anderson, M-J., Sutton, M. et al. Factors influencing variation in prescribing of antidepressants by general practice in Scotland. British Journal of General Practice (2008) 59 (559): p. e2531 Mynors-Wallis, L.M., Gath, D.H., Day, A., Baker, F. Randomised controlled trial of problem solving treatment, antidepressant medication, and combined treatment for major depression in primary care. British Medical Journal (2000) 320 (7226): p. 2630 NHS Information Centre. Adult psychiatric morbidity in England, 2007 (2009) Accessed via www.ic.nhs.uk /webfiles/publications/mental%20health/other% 20mental%20health%20publications/Adult% 20psychiatric%20morbidity%2007/APMS%2007% 20(FINAL)%20Standard.pdf [date last accessed 20.1.2011] NICE. Depression: the treatment and management of depression in adults (2009) Accessed via www.nice .org.uk/nicemedia/live/12329/45888/45888.pdf [date last accessed 16.1.2011] Pinquart, M., Duberstein, P.R., Lyness, J.M. Treatments for later-life depressive conditions: a meta-analytic comparison of pharmacotherapy and psychotherapy. American Journal of Psychiatry (2006) 163 (9): p. 1493501 Prins, M.A., Verhaak, P.F.M., Bensing, J.M., van der Meer, K. Health beliefs and perceived need for mental health care of anxiety and depression: the patients perspective explored. Clinical Psychology Review (2008) 28: p. 103858 RCGP Curriculum statement 13: Care of people with mental health problems. Accessed via www.rcgpcurriculum.org.uk/PDF/curr_13_Mental _Health.pdf [date last accessed 16.1.2011] SIGN. Guideline number 114: non-pharmaceutical management of depression in adults: a national clinical guideline. (2010) Accessed via www.sign.ac.uk/pdf /sign114.pdf [date last accessed 30.1.2011]

Dr Chantal Simon Executive Editor, InnovAiT E-mail: chantal.simon@oup.com Dr Alys Cole-King Consultant Liaison Psychiatrist, Betsi Cadwaladr University Local Health Board, Glan Clwyd Hospital, St Asaph and Open Minds Alliance Community Interest Company, London

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