Trajectories of change in anxiety severity and impairment during and after treatment with evidence-based treatment for multiple anxiety disorders in primary care

Latent classes of symptom trajectories during partial hospitalization for major depressive disorder and generalized anxiety disorder

BACKGROUND

A variety of treatments have been empirically validated in the treatment of major depressive disorder and generalized anxiety disorder. Researchers commonly evaluate symptom change during treatment using single model curves, however, modeling multiple curves simultaneously allows for the identification of subgroups of patients that progress through treatment on distinct paths.

METHODS

Latent growth mixture modeling was used to identify and characterize distinct classes of symptom trajectories among two samples of patients with either MDD or GAD receiving treatment in a daily partial hospital program.

RESULTS

Four depression symptom trajectories were identified in the MDD sample, and three anxiety symptom trajectories were identified in the GAD sample. Both samples shared symptom trajectory classes of responders, rapid responders, and minimal responders, while the MDD sample demonstrated an additional class of early rapid responders. In both samples, low symptom severity at baseline was associated with membership in the responder class, though few other patterns emerged in baseline characteristics predicting trajectory class membership. At treatment discharge, those in the minimal responder class reported poorer outcomes on every clinical measure. Patients within each class reported similar scores at discharge as compared to each other class, indicating that class membership affects clinical measures beyond symptom severity.

LIMITATIONS

Patient demographic characteristics were relatively homogeneous. Group-based trajectory modeling inherently involves some degree of uncertainty regarding the number and shape of trajectories.

CONCLUSIONS

Identifying symptom trajectories can provide information regarding how patients are likely to progress through treatment, and thus inform clinicians when a patient deviates from expected progress.

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

BACKGROUND

In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC).

METHODS

Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7).

OUTCOMES

change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation.

RESULTS

Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment.

CONCLUSION

As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.

Early childhood growth trajectories in a Medicaid population

BACKGROUND

Evidence on the role of early growth trajectories and later obesity risk is primarily based on privately insured or universally insured samples.

OBJECTIVES

We aimed to characterize and determine factors associated with early growth trajectories and estimate associations with overweight/obesity risk in a Medicaid-insured and uninsured cohort.

METHODS

Infants seen at a large pediatric academic centre in 2010-2016 were included. Weight and length/height measurements were converted to age and sex-specific BMI z-scores (BMIz) based on the World Health Organization (WHO) Growth Standards. Group-based trajectories were modelled using BMIz created groups. Logistic and log-binomial regression models estimated associations between membership in trajectories and maternal/child factors and overweight or obesity at 36, 48, and 60 months, separately. Analyses were performed between 2019 and 2021.

RESULTS

The best-fitting model identified five BMIz trajectories among 30 189 children and 310 113 clinical encounters; two trajectories showed rapid rise in BMIz. Lower maternal education, pre-pregnancy maternal overweight/obese status, and maternal smoking were positively associated with both rapid-rising BMIz trajectories. Children in either of the two rapid-rising trajectories were 3.00 (95% CI: 2.85, 3.25), 2.97 (95% CI: 2.77, 3.18) and 2.76 (95% CI: 2.53, 3.01) times more likely to have overweight or obesity at 36, 48, and 60 months, respectively compared to children in the stable trajectory groups.

CONCLUSIONS

Among Medicaid insured and uninsured children, several maternal and child characteristics were associated with early rapid-rise in BMIz. Clinical monitoring of early rapidly rising BMI may be important to address modifiable risk factors for obesity in families from low-income households.

Psychometric evaluation of a caregiver-report adaptation of the Overall Anxiety Severity and Impairment Scale (OASIS) for use with youth populations

Background Despite progress in youth anxiety assessment, there is need for a measure that is simultaneously (a) free, (b) brief, (c) focused broadly on anxiety and avoidance severity, frequency, and interference, and (d) concerned with the past week. The adult overall anxiety severity and impairment scale (OASIS) was adapted to yield a caregiver-report of past week youth anxiety and interference (OASIS-Y). Methods In a sample of diverse youth seeking anxiety services (N = 132; 67% racial/ethnic minority) and their caregivers, analyses examined the OASIS-Y factor structure, internal consistency, and convergent and divergent validity. Hierarchical linear modeling in a participant subset examined OASIS-Y sensitivity to treatment-related change. Results OASIS-Y internal consistency was high and confirmatory factor analysis supported a single-factor structure similar to that found in adults. OASIS-Y convergent validity was supported by a medium-sized association with an established, commercially available measure of youth anxiety, and divergent validity was supported by the absence of unique associations with measures of youth attention and externalizing problems. In a sample subset, session-by-session OASIS-Y scores significantly declined across treatment, and declined at a steeper rate among treatment "responders" versus "non-responders," providing evidence of OASIS-Y sensitivity to treatment-related change. Limitations This study focused on a clinical sample and cannot speak to OASIS-Y performance in community settings. Shared method-variance may have also influenced findings. Conclusions This study offers the first psychometric evaluation of the OASIS-Y, and underscores the promising clinical utility of the measure for assessing past week youth anxiety and impairment and for supporting routine outcome monitoring.

Mindful Emotion Awareness Facilitates Engagement with Exposure Therapy: An Idiographic Exploration Using Single Case Experimental Design

Exposure therapy works through inhibitory learning, whereby patients are exposed to stimuli that elicit anxiety in order to establish safety associations. Mindful emotion awareness, or nonjudgmental and present-focused attention toward emotions, may facilitate engagement in exposures, which may in turn enhance therapeutic outcome. This study utilizes a single-case experimental design (n = 6) to investigate the effect of mindful emotion awareness training on the use of avoidant strategies during exposures, distress during exposures, overall mindfulness, experiential avoidance, and symptom reduction in a sample of participants with social anxiety disorder. Data were analyzed using a combination of visual inspection and quantitative effect size metrics commonly applied in single-case experimental designs. To further investigate the relationship between distress and avoidant strategy use, contemporaneous and cross-lagged correlations were run. Results highlight individual differences in responses to mindful emotion awareness training and exposure exercises. Given these individual differences, repeated assessment and monitoring over the course of treatment may help clinicians most effectively identify treatment skills that will be most helpful for individual patients.

Trajectories of changes in distress in counseling center clients: a replication study

Objective: Latent growth mixture modeling (LGMM) and latent class growth analysis (LCGA) are methods of identifying subgroups of individuals with similar trajectories during the course of psychotherapy. Due to inconsistent methodology, previous LGMM/LCGA psychotherapy research has led to inconsistent findings. The purpose of this study was to contribute to our understanding of individual differences in change trajectories during psychotherapy using LGMM/LCGA by attempting to replicate a previous study by Owen et al. (2015. Trajectories of change in psychotherapy. Journal of Clinical Psychology, 71(9), 817-827). Method: This study used LGMM/LCGA to model trajectories of change in a sample of 2538 psychotherapy clients at a university student counseling center. This was a secondary analysis of naturalistically-collected outcome data using The Behavioral Health Measure. Results: LGMM models did not converge. A 2-class LCGA model was selected based on fit statistics and parsimony. One class was labeled as Slow and Steady Change Before Plateau, whereas the other was labeled as Early Rapid Change Before Plateau. We also extended these findings by considering variables associated with class membership. Conclusions: These classes followed similar trajectories to two of the classes identified by Owen et al. These results indicate that latent trajectory modeling may lead to replicable findings. Furthermore, these results have implications for managing expectations about change in psychotherapy.

Typical symptom change patterns and their predictors in patients with social anxiety disorder: A latent class analysis

OBJECTIVES

The use of trajectories and analysis of change patterns is a promising way toward better differentiation of subgroups in psychotherapy studies. Research on change patterns in social anxiety disorder (SAD) are still rare, although SAD is one of the most common mental disorders. In a secondary analysis of data from the SOPHO-NET-trial (ISRCTN53517394) this study aimed to investigate change patterns and their predictors in a sample of SAD patients.

METHODS

Patients with SAD (N = 357) were randomly assigned to cognitive-behavioral or psychodynamic therapy. The Liebowitz Social Anxiety Scale (LSAS) was assessed at 1^st session (pre), 8th session, 15th session and at the end of treatment (post). We used latent state variables and latent class analysis for the classification of change patterns and logistic regression for the identification of different predictors.

RESULTS

Analyses revealed three typical patterns: (i.) responders with a high initial impairment (N = 57), (ii.) responders with a moderate initial impairment (N = 225), and (iii.) patients with a high initial impairment and no remission (N = 75). Among other significant predicators, patient´s attachment anxiety and therapeutic alliance at session eight contributed to the prediction of change patterns.

DISCUSSION

Psychotherapy of SAD should consider patient's attachment and focus on the establishment of a solid therapeutic alliance in an early therapy stage.

Early Life Poly-Victimization and Differential Development of Anxiety as Risk Factors for the Continuity of Substance Dependence in Adulthood

Background: Abuse of psychoactive substances may lead to physical and/or physiological dependence on said substances. While a great deal of research has focused on risk factors predicting onset, there has been little research focused on risk factors influencing continued dependence on substances in adulthood following onset early in life. Purpose/Objectives: The present study examined poly-victimization and developmental patterns of anxiety as predictors of continued substance dependence problems. Methods: The Pathways to Desistance data were used in the present study. A subset of this sample was used in analyses comprising 261 juvenile offenders who reported lifetime drug and/or alcohol dependence at baseline. Firth logistic regression was used to estimate the impact that covariates had on the odds that individuals in this subsample had continued substance dependence in adulthood. Results: Results indicated that increased poly-victimization score pertaining to direct victimization at baseline was associated with increased odds of continued substance dependence problems in adulthood. Further, presentation of high and chronic anxiety symptomatology during adolescence was associated with increased risk for continued dependence. Conclusions/Importance: Drug dependent adolescents who demonstrate chronic anxiety and/or have experienced polyvictimization are at-risk for continuity of dependent in adulthood. Youth should be screened for these issues and targeted with treatment.

The pattern of symptom change during prolonged exposure therapy and present-centered therapy for PTSD in active duty military personnel

BACKGROUND

Few studies have investigated the patterns of posttraumatic stress disorder (PTSD) symptom change in prolonged exposure (PE) therapy. In this study, we aimed to understand the patterns of PTSD symptom change in both PE and present-centered therapy (PCT).

METHODS

Participants were active duty military personnel (N = 326, 89.3% male, 61.2% white, 32.5 years old) randomized to spaced-PE (S-PE; 10 sessions over 8 weeks), PCT (10 sessions over 8 weeks), or massed-PE (M-PE; 10 sessions over 2 weeks). Using latent profile analysis, we determined the optimal number of PTSD symptom change classes over time and analyzed whether baseline and follow-up variables were associated with class membership.

RESULTS

Five classes, namely rapid responder (7-17%), steep linear responder (14-22%), gradual responder (30-34%), non-responder (27-33%), and symptom exacerbation (7-13%) classes, characterized each treatment. No baseline clinical characteristics predicted class membership for S-PE and M-PE; in PCT, more negative baseline trauma cognitions predicted membership in the non-responder v. gradual responder class. Class membership was robustly associated with PTSD, trauma cognitions, and depression up to 6 months after treatment for both S-PE and M-PE but not for PCT.

CONCLUSIONS

Distinct profiles of treatment response emerged that were similar across interventions. By and large, no baseline variables predicted responder class. Responder status was a strong predictor of future symptom severity for PE, whereas response to PCT was not as strongly associated with future symptoms.

PATTERNS OF CHANGE IN RESPONSE TO PROLONGED EXPOSURE: IMPLICATIONS FOR TREATMENT OUTCOME

BACKGROUND

Assessment of response to Prolonged Exposure (PE) suggests some patients may experience discontinuous change involving sudden symptom reductions and/or temporary exacerbations. The current study looked to (1) isolate profiles of PE response among treatment-seeking veterans and (2) identify factors associated with unique patterns of change.

METHODS

Archival records were examined for veterans receiving PE through a specialty Veterans Affairs Medical Center (VAMC) clinic (N = 109). Latent profile analysis was used to extract response trajectories defined by change in weekly PTSD Checklist (PCL) scores. Associations with provider status (staff vs. intern), setting (in-person vs. telehealth), initial severity (PTSD; depression), and eventual treatment gains were examined.

RESULTS

Three profiles were observed. Rapid Responders (18.3%) evidenced sharp reductions at Week 2 and again between Weeks 5 and 6. Linear Responders (40.4%) demonstrated gradual reductions throughout the 10-week assessment window. Delayed Responder (41.3%) scores were relatively stable over the evaluation period although final session outcomes indicated reliable change (PCLΔ > 10) in 40% of patients. Profiles were similar with respect to provider status, treatment setting, and initial symptom severity. Rapid Responders evidenced lower final session scores relative to Linear (g = 1.13) and Delayed (g = 1.85) groups, with Linear Responders reporting lower end scores than Delayed Responders (g = 1.02).

CONCLUSIONS

Anticipating patterns of recovery and their association with therapeutic outcome is of immense clinical value. Sudden gains emerged as a strong predictor of enhanced response. Data also suggest potential benefits of extending standard intervention for patients who fail to demonstrate an immediate response to PE.

Predicting Response Trajectories during Cognitive-Behavioural Therapy for Panic Disorder: No Association with the BDNF Gene or Childhood Maltreatment

BACKGROUND

Anxiety disorders are highly prevalent and result in low quality of life and a high social and economic cost. The efficacy of cognitive-behavioural therapy (CBT) for anxiety disorders is well established, but a substantial proportion of patients do not respond to this treatment. Understanding which genetic and environmental factors are responsible for this differential response to treatment is a key step towards "personalized medicine". Based on previous research, our objective was to test whether the BDNF Val66Met polymorphism and/or childhood maltreatment are associated with response trajectories during exposure-based CBT for panic disorder (PD).

METHOD

We used Growth Mixture Modeling to identify latent classes of change (response trajectories) in patients with PD (N = 97) who underwent group manualized exposure-based CBT. We conducted logistic regression to investigate the effect on these trajectories of the BDNF Val66Met polymorphism and two different types of childhood maltreatment, abuse and neglect.

RESULTS

We identified two response trajectories ("high response" and "low response"), and found that they were not significantly associated with either the genetic (BDNF Val66Met polymorphism) or childhood trauma-related variables of interest, nor with an interaction between these variables.

CONCLUSIONS

We found no evidence to support an effect of the BDNF gene or childhood trauma-related variables on CBT outcome in PD. Future studies in this field may benefit from looking at other genotypes or using different (e.g. whole-genome) approaches.

Mindfulness-Based Exposure Strategies as a Transdiagnostic Mechanism of Change: An Exploratory Alternating Treatment Design

The present study explored whether distress reduction in response to strong negative emotions, a putative transdiagnostic mechanism of action, is facilitated by mindfulness strategies. Seven patients (mean age=31.14years, SD=12.28, range 19-48 years, 43% female, 86% Caucasian) with heterogeneous anxiety disorders (i.e., panic disorder with or without agoraphobia, social anxiety, generalized anxiety) were assigned a randomized order of weeklong blocks utilizing either mindfulness- or avoidance-based strategies while ascending a 6-week emotion exposure hierarchy. Participants completed three exposures per block and provided distress and avoidance use ratings following each exposure. Anxiety severity, distress aversion, and distraction/suppression tendencies were also assessed at baseline and the conclusion of each block. Visual, descriptive, and effect size results showing exposures utilizing mindfulness were associated with higher overall distress levels, compared with those utilizing avoidance. Within blocks, the majority of participants exhibited declining distress levels when employing mindfulness strategies, as opposed to more static distress levels in the avoidance condition. Systematic changes in anxiety severity, distress aversion, and distraction/suppression were not observed. These results suggest mindfulness strategies may be effective in facilitating emotion exposure; however, a minimum dosage may be necessary to overcome initial distress elevation. Potential transdiagnostic change mechanisms and clinical implications are discussed.

Predictors of anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial

Few studies have examined anxiety recurrence after symptom remission in the primary care setting. We examined anxiety recurrence in the Coordinated Anxiety Learning and Management (CALM) trial. From 2006 to 2009, CALM randomized adults with anxiety disorders (generalized anxiety disorder, panic disorder, social anxiety disorder, and post-traumatic stress disorder) in primary care clinics to usual care (UC) or a collaborative care (CC) intervention of pharmacotherapy and/or cognitive behavioral therapy. We examined 274 patients who met criteria for anxiety remission (Brief Symptom Inventory for anxiety and somatization (BSI-12) < 6) after 6 months of randomized treatment and completed a follow-up of 18 months. Logistic regression and receiver operating characteristics (ROC) were used to identify predictors of anxiety recurrence (BSI-12 ≥ 6 and 50% increase from 6-month ratings) during the year following remission. Recurrence was lower in CC (29%) compared to UC (41%) (p = 0.04). Patients with comorbid depression or lower self-perceived socioeconomic status particularly benefited (in terms of reduced recurrence) if assigned to CC instead of UC. In the multivariable logistic regression model, smoking, being single, Anxiety Sensitivity Index score, functional impairment at month 6 due to residual anxiety (measured with the Sheehan Disability Scale), and treatment with benzodiazepines were associated with subsequent anxiety recurrence. ROC identified prognostic subgroups based on the risk of recurrence. Our study was exploratory, and our findings require replication. Future studies should also examine the effectiveness of relapse prevention programs in patients at highest risk for recurrence.