Treatment preference, engagement, and clinical improvement in pharmacotherapy versus psychotherapy for depression

Parenteral versus enteral fluids for infants hospitalized with bronchiolitis: The PREFER shared decision-making prospective observational study protocol

INTRODUCTION

Incorporating shared decision-making (SDM) with children and families in hospitals was a top priority identified by patients, caregivers, and clinicians. Bronchiolitis, a common and costly reason for hospitalization in children, is an exemplar condition to study SDM in hospitals. Internationally, clinical practice guidelines differ when recommending intravenous (IV or parenteral) or nasogastric (NG or enteral) fluids for hospitalized infants with bronchiolitis who are unsafe to be fed orally. While evidence indicates that either IV or NG fluids are safe and effective, parent involvement in SDM in selecting IV or NG fluids is unknown. Our aim is to generate knowledge of SDM with parents in choosing between IV or NG fluids and the benefits and harms of these two treatment options for hospitalized children with bronchiolitis.

METHOD

This is a multicenter, prospective, observational study, including children aged <12 months admitted to hospital with bronchiolitis requiring supplemental IV or NG fluids. The primary outcome will evaluate the extent of SDM in choosing IV versus NG fluids using the validated CollaboRATE tool. Secondary outcomes include the proportion of parents provided a choice of IV versus NG fluids; parent knowledge of fluid therapy; rate of fluids; length of hospital stay; and complications.

DISCUSSION

This study will evaluate the extent of SDM in hospitalized infants with bronchiolitis who require IV or NG fluids and will evaluate both patient-centered and clinical outcomes that are relevant to clinical practice.

Psychosocial factors associated with treatment preference in mental health

BACKGROUND

Studies examining the effects of incorporating patients' preferences into treatment outcomes highlight their impact on crucial aspects such as reduced dropout rates and enhanced effectiveness. Recognizing individuals' rights to participate in decisions about their treatments underscores the importance of studying treatment preferences and the factors influencing these choices.

AIM

This study aims to identify treatment preferences (psychological, pharmacological, or combined) among a sample of patients and to discern the psychosocial and clinical factors influencing these preferences.

METHODS

A total of 2,133 individuals receiving care at a community mental health unit completed assessments on anxious-depressive symptoms, social and occupational adjustment, and their treatment preference. Data analysis was conducted using SPSS, with descriptive statistics, Chi-square tests, and one-way ANOVA applied.

RESULTS

Preferences for treatments were distributed as follows: Combined (49.8%), psychological (33%), and pharmacological (10.6%). Factors such as diagnosis, severity of depressive and anxious symptoms, and functional impact were related to treatment preference with a moderate effect size. Meanwhile, various sociodemographic factors correlated with the selected treatment, though with a weak effect size.

CONCLUSIONS

There is a pronounced preference for combined treatments. The significance of psychological treatments is evident, as four out of five participants favored them in their choices. Addressing these preferences calls for an exploration within the broader context of prescription freedom in mental health.

The Effects of Patient Preference on Clinical Outcome, Satisfaction and Adherence Within the Treatment of Anxiety and Depression: A Meta-Analysis

BACKGROUND

Taking patient preference into consideration has received increased attention in the last decades. We conducted a meta-analysis to estimate the effects of patient preference on clinical outcome, satisfaction and adherence regarding treatment of depression and anxiety.

METHODS

Pubmed, Embase, PsycINFO and Scopus were searched for (cluster) randomized controlled trials. Twenty-six randomized controlled clinical trials were included, comprising 3670 participants, examining the effect of patient preference regarding treatment of anxiety and depression on clinical outcome, satisfaction and/or adherence.

RESULTS

No effect of patient preference was found on clinical outcome [d = 0.06, 95% CI = (-0.03, 0.15), p = 0.16, n = 23 studies]. A small effect of patient preference was found on treatment satisfaction [d = 0.33, 95% CI = (0.08, 0.59), p = 0.01, n = 6 studies] and on treatment adherence [OR = 1.55, 95% CI = (1.28, 1.87), p < 0.001, n = 22 studies].

LIMITATIONS

Patient preference is a heterogeneous concept, future studies should strive to equalize operationalization of preference. Subgroup analyses within this study should be interpreted with caution because the amount of studies per analysed subgroup was generally low. Most studies included in this meta-analysis focused on patients with depression. The small number of studies (n = 6) on satisfaction, prevents us from drawing firm conclusions.

CONCLUSIONS

While this meta-analysis did not find a positive effect of considering patient preference on clinical outcome, it was associated with slightly better treatment satisfaction and adherence. Accommodating preference of patients with anxiety and depression can improve treatment.

TRIAL REGISTRATION

PROSPERO: CRD42020172556.

Individuals fearing positivity do not perceive positive affect treatments as strong fits: A novel experimental finding and replication

BACKGROUND AND OBJECTIVES

Positive affect treatments, which hold great promise to connect with those who are otherwise resistant to depression treatments, attempt to upregulate positive emotions. These treatments have potential advantages over standard therapies because they target cross-diagnostic core symptoms (e.g., anhedonia) that may respond better to interventions aimed at increased positivity. However, the extent to which these treatments are a perceived fit by individuals for whom they were developed (i.e., individuals who are afraid of, avoid, or experience less positivity) is unclear.

METHODS

We conducted two independent studies utilizing a cross-sectional, experimental design to examine perceived treatment fit. Participants (Study 1: N = 416; Study 2: N = 321) read counterbalanced treatment descriptions of (1) positive affect treatment and (2) psychodynamic psychotherapy and answered questions regarding perceived treatment fit, effectiveness, and preference of the two treatments.

RESULTS

Our findings suggest that individuals fearful of happiness perceived a prospective depression treatment specifically targeting positivity as a poorer fit, demonstrating an opposite pattern to the overall samples' treatment preference in both studies. Thus, as predicted by Reward Devaluation Theory, those fearing positivity exhibited avoidance behaviors for treatments that are to an extent designed, and might otherwise be most effective, for them.

LIMITATIONS

The current study utilized a college student sample.

CONCLUSION

These empirical findings may ultimately inform psychoeducation of why positive affect treatments, which are in direct contrast with clients' preferences, may be the very treatments they need the most.

The impact of treatment preferences: A narrative review

Attending to treatment preferences is an element of person-centred care, reported as beneficial in improving treatment adherence, satisfaction, and outcome, in practice. The results of preference trials were inconsistent in supporting these benefits in intervention evaluation research. Informed by the conceptualisation of treatment preferences positing their indirect impact on outcomes, this narrative review aimed to summarise the evidence on the effects of preferences on enrolment; withdrawal or attrition; engagement, enactment, and satisfaction with treatment; and outcomes. The search yielded 72 studies (57 primary trials and 15 reviews). The results of vote counting indicated that (1) offering participants the opportunity to choose treatment enhances enrolment (reported in 87.5% of studies), and (2) providing treatments that match participants' preferences reduces attrition (48%); enhances engagement (67%), enactment (50%) and satisfaction with (43%) treatment; and improves outcomes (35%). The results are attributed to conceptual and methodological issues including less-than-optimal assessment of treatment preferences, which contributes to ill-identified preferences, accounting for withdrawal, low enactment, and limited satisfaction with treatment. These treatment processes, in turn, mediate the impact of treatment preferences on outcomes. It is important to refine and standardise the methods for assessing preferences and to examine their indirect impact (mediated by treatment processes) on outcomes in future preference trials to validly identify their benefits.

Women want male partner engagement in antenatal care services: A qualitative study of pregnant women from rural South Africa

INTRODUCTION

Evidence strongly shows that a supportive, involved male partner facilitates maternal HIV testing during pregnancy, increases maternal antiretroviral (ART) adherence and increases HIV-free infant survival. Partner engagement in antenatal care (ANC) is influential; however, the most effective strategy to engage male partners is currently unknown. Engaging pregnant women to understand whether male partner involvement is welcome in ANC, what this involvement entails and how best to invite their partner is an important first step in determining how best to engage male partners.

METHODS

We interviewed 36 pregnant women receiving ANC services at a district hospital in rural Mpumalanga, South Africa to assess the strengths and weaknesses of their current relationship, the type of partner support they receive, whether they would like their male partner to be involved in their ANC, and how best to invite their male partner to their appointments. We conducted a thematic analysis of the qualitative interviews using MAXQDA software.

RESULTS

Financial, emotional, and physical support were noted as important aspects of support currently provided by male partners, with most pregnant women wanting their partners to engage in ANC services during pregnancy. Preferred engagement strategies included participation in couple-based HIV testing and counseling, regular ANC appointment attendance, and delivery room presence. Women who reported a positive relationship with her partner were more likely to prefer inviting their partner without health facility assistance, while those who reported challenges in their relationship preferred assistance through a letter or community health worker. Pregnant women perceived regular business hours (due to their partner being employed and unable to take off work) and having a partner involved in multiple relationships as barriers in getting their partner to attend ANC services.

DISCUSSION

Rural South African women, even those in unsatisfactory relationships want their male partners to attend their ANC visits and birth. To make this possible, health facilities will have to tailor male partner engagement outreach strategies to the preferences and needs of the pregnant woman.

Use of Mobile Apps & Stepped-Care Model for Treating Depression in Primary Care

Stepped-care (SC) models have been adopted in primary care settings as a method for treating mental health conditions within primary care. In a SC model, a patient's symptoms are assessed, and an intervention is prescribed that matches the severity of symptoms. Thus, the SC model offers a variety of steps and levels of treatment that range from low to high intensity. Progression in treatment is monitored on a weekly basis and patients are stepped up or down in level of care depending on their clinical response to the intervention.

The development and internal evaluation of a predictive model to identify for whom Mindfulness-Based Cognitive Therapy (MBCT) offers superior relapse prevention for recurrent depression versus maintenance antidepressant medication

Depression is highly recurrent, even following successful pharmacological and/or psychological intervention. We aimed to develop clinical prediction models to inform adults with recurrent depression choosing between antidepressant medication (ADM) maintenance or switching to Mindfulness-Based Cognitive Therapy (MBCT). Using data from the PREVENT trial (N=424), we constructed prognostic models using elastic net regression that combined demographic, clinical and psychological factors to predict relapse at 24 months under ADM or MBCT. Only the ADM model (discrimination performance: AUC=.68) predicted relapse better than baseline depression severity (AUC=.54; one-tailed DeLong's test: z=2.8, p=.003). Individuals with the poorest ADM prognoses who switched to MBCT had better outcomes compared to those who maintained ADM (48% vs. 70% relapse, respectively; superior survival times [z=-2.7, p=.008]). For individuals with moderate-to-good ADM prognosis, both treatments resulted in similar likelihood of relapse. If replicated, the results suggest that predictive modeling can inform clinical decision-making around relapse prevention in recurrent depression.

A systematic meta-review of patient-level predictors of psychological therapy outcome in major depressive disorder

BACKGROUND

Psychological therapies are effective for treating major depressive disorder, but current clinical guidelines do not provide guidance on the personalization of treatment choice. Established predictors of psychotherapy treatment response could help inform machine learning models aimed at predicting individual patient responses to different therapy options. Here we sought to comprehensively identify known predictors.

METHODS

EMBASE, Medline, PubMed, PsycINFO were searched for systematic reviews with or without meta-analysis published until June 2020 to identify individual patient-level predictors of response to psychological treatments. 3113 abstracts were identified and 300 articles assessed. We qualitatively synthesized our findings by predictor category (sociodemographic; symptom profile; social support; personality features; affective, cognitive, and behavioural; comorbidities; neuroimaging; genetics) and treatment type. We used the AMSTAR 2 to evaluate the quality of included reviews.

RESULTS

Following screening and full-text assessment, 27 systematic reviews including 12 meta-analyses were eligible for inclusion. 74 predictors emerged for various psychological treatments, primarily cognitive behavioural therapy, interpersonal therapy, and mindfulness-based cognitive therapy.

LIMITATIONS

A paucity of studies examining predictors of psychological treatment outcome, as well as methodological heterogeneities and publication biases limit the strength of the identified predictors.

CONCLUSIONS

The synthesized predictors could be used to supplement clinical decision-making in selecting psychological therapies based on individual patient characteristics. These predictors could also be used as a priori input features for machine learning models aimed at predicting a given patient's likelihood of response to different treatment options for depression, and may contribute toward the development of patient-specific treatment recommendations in clinical guidelines.

Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration

BACKGROUND

Physician responsiveness to patient preferences for depression treatment may improve treatment adherence and clinical outcomes.

OBJECTIVE

To examine associations of patient treatment preferences with types of depression treatment received and treatment adherence among Veterans initiating depression treatment.

DESIGN

Patient self-report surveys at treatment initiation linked to medical records.

SETTING

Veterans Health Administration (VA) clinics nationally, 2018-2020.

PARTICIPANTS

A total of 2582 patients (76.7% male, mean age 48.7 years, 62.3% Non-Hispanic White) MAIN MEASURES: Patient self-reported preferences for medication and psychotherapy on 0-10 self-anchoring visual analog scales (0="completely unwilling"; 10="completely willing"). Treatment receipt and adherence (refilling medications; attending 3+ psychotherapy sessions) over 3 months. Logistic regression models controlled for socio-demographics and geographic variables.

KEY RESULTS

More patients reported strong preferences (10/10) for psychotherapy than medication (51.2% versus 36.7%, McNemar χ²₁=175.3, p<0.001). A total of 32.1% of patients who preferred (7-10/10) medication and 21.8% who preferred psychotherapy did not receive these treatments. Patients who strongly preferred medication were substantially more likely to receive medication than those who had strong negative preferences (odds ratios [OR]=17.5; 95% confidence interval [CI]=12.5-24.5). Compared with patients who had strong negative psychotherapy preferences, those with strong psychotherapy preferences were about twice as likely to receive psychotherapy (OR=1.9; 95% CI=1.0-3.5). Patients who strongly preferred psychotherapy were more likely to adhere to psychotherapy than those with strong negative preferences (OR=3.3; 95% CI=1.4-7.4). Treatment preferences were not associated with medication or combined treatment adherence. Patients in primary care settings had lower odds of receiving (but not adhering to) psychotherapy than patients in specialty mental health settings. Depression severity was not associated with treatment receipt or adherence.

CONCLUSIONS

Mismatches between treatment preferences and treatment type received were common and associated with worse treatment adherence for psychotherapy. Future research could examine ways to decrease mismatch between patient preferences and treatments received and potential effects on patient outcomes.

A Randomized Preference Trial Comparing Cognitive-Behavioral Therapy and Yoga for the Treatment of Late-Life Worry: Examination of Impact on Depression, Generalized Anxiety, Fatigue, Pain, Social Participation, and Physical Function

Background

Depression, generalized anxiety, fatigue, diminished physical function, reduced social participation, and pain are common for many older adults and negatively impact quality of life. The purpose of the overall trial was to compare the effects of cognitive-behavioral therapy (CBT) and yoga on late-life worry, anxiety, and sleep; and examine preference and selection effects on these outcomes.

Objective

The present analyses compared effects of the 2 interventions on additional outcomes (depressive symptoms, generalized anxiety symptoms, fatigue, pain interference/intensity, physical function, social participation); and examined whether there are preference and selection effects for these treatments.

Methods

A randomized preference trial of CBT and yoga was conducted in adults ≥60 years who scored ≥26 on the Penn State Worry Questionnaire-Abbreviated (PSWQ-A), recruited from outpatient medical clinics, mailings, and advertisements. Cognitive-behavioral therapy consisted of 10 weekly telephone sessions. Yoga consisted of 20 bi-weekly group yoga classes. Participants were randomized to(1): a randomized controlled trial (RCT) of CBT or yoga (n = 250); or (2) a preference trial in which they selected their treatment (CBT or yoga; n = 250). Outcomes were measured at baseline and post-intervention.

Results

Within the RCT, there were significant between-group differences for both pain interference and intensity. The pain interference score improved more for the CBT group compared with the yoga group [intervention effect of (mean (95% CI) = 2.5 (.5, 4.6), P = .02]. For the pain intensity score, the intervention effect also favored CBT over yoga [.7 (.2, 1.3), P < .01]. Depressive symptoms, generalized anxiety, and fatigue showed clinically meaningful within-group changes in both groups. There were no changes in or difference between physical function or social participation for either group. No preference or selection effects were found.

Conclusion

Both CBT and yoga may be useful for older adults for improving psychological symptoms and fatigue. Cognitive-behavioral therapy may offer even greater benefit than yoga for decreasing pain.

The impact of mental health support for the chronically ill on hospital utilisation: Evidence from the UK

Individuals with common mental disorders (CMDs) such as depression and anxiety frequently have co-occurring long-term physical health conditions (LTCs) and this co-occurrence is associated with higher hospital utilisation. Psychological treatment for CMDs may reduce healthcare utilisation through better management of the LTC, but there is little previous research. We examined the impact of psychological treatment delivered under the nationwide Improving Access to Psychological Therapies (IAPT) programme in England on hospital utilisation 12-months after the end of IAPT treatment. We examined three types of hospital utilisation: Inpatient treatment, Outpatient treatment and Emergency Room attendance. We examined individuals with Chronic Obstructive Pulmonary Disease (COPD) (n = 816), Diabetes (n = 2813) or Cardiovascular Disease (CVD) (n = 4115) who received psychological treatment between April 2014 and March 2016. IAPT episode data was linked to hospital utilisation data which went up to March 2017. Changes in the probability of hospital utilisation were compared to a matched control sample for each LTC. Individuals in the control sample received IAPT treatment between April 2017 and March 2018. Compared to the control sample, the treated sample had significant reductions in the probability of all three types of hospital utilisation, for all three LTCs 12-months after the end of IAPT treatment. Reductions in utilisation of Emergency Room, Outpatient and non-elective Inpatient treatment were also observed immediately following the end of psychological treatment, and 6-months after, for individuals with diabetes and CVD, compared to the matched sample. These findings suggest that psychological interventions for CMDs delivered to individuals with co-occurring long-term chronic conditions may reduce the probability of utilisation of hospital services. Our results support the roll-out of psychological treatment aimed at individuals who have co-occurring CMDs and long-term chronic conditions.

Profiles of Parents' Preferences for Delivery Formats and Program Features of Parenting Interventions

Parents are the targeted consumers of parenting interventions but a small body of research has examined parental preferences for program characteristics to incorporate them in the adaptation and implementation of such programs. Furthermore, the relationship between parents' preferences for program characteristics and their cognitions and behaviours has not yet been explored. This study aimed to identify profiles of parental preferences for delivery formats and program features of parenting interventions. Data from 6949 participants from the International Parenting Survey was analysed. Two-step cluster analyses were conducted to determine clusters of delivery formats and program features of parenting interventions. Preferences for delivery formats showed two clusters, a face-to-face cluster and a media-based cluster. In terms of program features, two clusters were also obtained, a personalised cluster and logistic cluster. While these clusters differed in some demographics, parents' report of child emotional and behavioural problems and parent factors were the key differentiating variables.

Effectiveness of a Guided Web-Based Intervention to Reduce Depressive Symptoms before Outpatient Psychotherapy: A Pragmatic Randomized Controlled Trial

INTRODUCTION

Psychotherapy is a first-line treatment for depression. However, capacities are limited, leading to long waiting times for outpatient psychotherapy in health care systems. Web-based interventions (WBI) could help to bridge this treatment gap.

OBJECTIVE

This study investigates the effectiveness of a guided cognitive-behavioral WBI in depressive patients seeking face-to-face psychotherapy.

METHODS

A 2-arm randomized controlled trial was conducted. Depressive patients (n = 136) recruited from the waiting lists of outpatient clinics were randomly assigned to an intervention group (IG; treatment as usual [TAU] + immediate access to WBI) or a control group (CG; TAU + access to WBI after follow-up). Depressive symptoms and secondary outcomes were assessed at baseline, 7 weeks, and 5 months after randomization.

RESULTS

Mixed-model analyses revealed a significant group × time interaction effect on depressive symptoms (F2, 121.5 = 3.91; p < 0.05). Between-group effect sizes were d = 0.55 at 7 weeks and d = 0.52 at 5 months. The IG was superior regarding psychological symptoms and mental health quality of life but not on physical health quality of life, attitudes, motivation for psychotherapy, or subjective need and uptake of psychotherapy.

CONCLUSIONS

Patients waiting for face-to-face psychotherapy can benefit from a WBI when compared to TAU. Despite the reduction of depressive symptoms in the IG, the uptake of subsequent psychotherapy was still high in both groups. The effects remained stable at the 5-month follow-up. However, this study could not determine the proportion of specific intervention effects vs. nonspecific effects, such as positive outcome expectations or attention. Future research should focus on the long-term effects and cost-effectiveness of WBI before psychotherapy.

Women's Preferences for Body Image Programming: A Qualitative Study to Inform Future Programs Targeting Women Diagnosed With Breast Cancer

Purpose: This paper describes women's opinions of the attributes of the ideal body image program to inform the design, development, and implementation of future programs for those diagnosed with breast cancer. Methods: Deductive-inductive content analysis of semi-structured interviews with 26 women diagnosed with breast cancer (mean age = 55.96 years; mean time since diagnosis = 2.79 years) was performed. Findings: Participants' opinions regarding the ideal body image program are summarized into five themes, mapping the where (community-based, hospital-based, or online), when (across the cancer continuum or at specific points), how (peer-led programs, professional help, events, presentations/workshops, resources, support groups), what (self-care, counseling and education for one self, education for others, support for addressing sexuality/sexual health concerns, and concealing treatment-related changes), and who (team approach or delivered by women, health professionals, make-up artists). Conclusion: This study provides useful data on what women believe are the attributes of the ideal body image program, which can contribute to efforts aimed at developing and delivering body image programs for women diagnosed with breast cancer that prioritize their needs and preferences.

Addressing anhedonia to increase depression treatment engagement

Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.

Preferences for research design and treatment of comorbid depression among patients with an opioid use disorder: A cross-sectional discrete choice experiment

BACKGROUND

Up to 74 % of people with an opioid use disorder (OUD) will experience depression in their lifetime. Understanding and addressing the concept of preference for depression treatments and clinical trial designs may serve as an important milestone in enhancing treatment and research outcomes. Our goal is to evaluate preferences for depression treatments and clinical trial designs among individuals with an OUD and comorbid depression.

METHODS

We evaluated preferences for depression treatments and clinical trial designs using an online cross-sectional survey including a best-best discrete choice experiment. We recruited 165 participants from opioid agonist treatment clinics and community-based services in Calgary, Charlottetown, Edmonton, Halifax, Montreal, Ottawa, Quebec City, St. John's and Trois-Rivières, Canada.

RESULTS

Psychotherapy was the most accepted (80.0 %; CI: 73.9-86.1 %) and preferred (31.5 %; CI: 24.4-38.6 %) treatment. However, there was a high variability in acceptability and preferences of depression treatments. Significant predictors of choice for depression treatments were administration mode depending on session duration (p < 0.001), access mode (p < 0.001) and treatment duration (p < 0.001). Significant predictors of choice for clinical trial designs were allocation type (p = 0.008) and monetary compensation (p = 0.033). Participants preferred participating in research compared to non-participation (p < 0.001).

CONCLUSIONS

Accessibility and diversity of depression interventions, including psychotherapy, need to be enhanced in addiction services to ensure that all patients can receive their preferred treatment. Ensuring proper monetary compensation and comparing an intervention of interest with an active treatment might increase participation of depressed OUD patients in future clinical research initiative.

Which Trauma Treatment Suits me? Identification of Patients' Treatment Preferences for Posttraumatic Stress Disorder (PTSD)

Several psychotherapy treatments exist for posttraumatic stress disorder. This study examines the treatment preferences of treatment-seeking traumatized adults in Germany and investigates the reasons for their treatment choices. Preferences for prolonged exposure, cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing (EMDR), psychodynamic psychotherapy and stabilization were assessed via an online survey. Reasons for preferences were analyzed by means of thematic coding by two independent rates. 104 traumatized adults completed the survey. Prolonged exposure and CBT were each preferred by nearly 30%, and EMDR and psychodynamic psychotherapy were preferred by nearly 20%. Stabilization was significantly less preferred than all other options, by only 4%. Significantly higher proportions of patients were disinclined to choose EMDR and stabilization. Patients who preferred psychodynamic psychotherapy were significantly older than those who preferred CBT. Reasons underlying preferences included the perceived treatment mechanisms and treatment efficacy. Traumatized patients vary in their treatment preferences. Preference assessments may help clinicians comprehensively address patients' individual needs and thus improve therapy outcomes.

Does treatment preference affect outcome in a randomized trial of a mindfulness intervention versus cognitive behaviour therapy for social anxiety disorder?

Research suggests that treatment preference may affect outcome of randomized clinical trials, but few studies have assessed treatment preference in trials comparing different types of psychosocial interventions. This study used secondary data analysis to evaluate the impact of treatment preference in a randomized trial of a mindfulness-based intervention adapted for social anxiety disorder (MBI-SAD) versus cognitive behaviour group therapy (CBGT). Ninety-seven participants who met DSM-5 criteria for SAD were randomized. Prior to randomization, twice as many participants expressed a preference for the MBI-SAD over CBGT. However, being allocated or not to one's preferred treatment had no impact on treatment response. Additionally, with the exception of perception of treatment credibility, treatment matching had no impact on treatment-related variables, including treatment initiation, session attendance, homework compliance, satisfaction with treatment and perception that treatment met expectations. In sum, despite the greater preference for the mindfulness intervention in this sample of participants with SAD, we found little evidence of preference effects on our study outcomes. Findings should be viewed as preliminary and require replication.

Predictors of preference for cognitive-behavioral therapy (CBT) and yoga interventions among older adults

The purpose of this study was to examine factors that influence a person's choice of cognitive-behavioral therapy (CBT) or yoga, the stability of these preferences, and the impact of preference on engagement and process measures. We conducted a randomized preference trial of CBT and yoga in 500 adults ≥60 years with symptoms of worry. Participants reported their intervention preference, strength of preference, and factors impacting preference. Engagement in the intervention (session completion and dropout rates) was assessed. Process measures included satisfaction with the intervention, therapeutic alliance, and intervention expectancy. Neither intervention preference (48% and 52% chose CBT and yoga, respectively) nor strength of preference differed significantly between the two preference trial groups. Intervention expectancies at baseline among those in the preference trial were approximately 4.5 units (40-point scale) higher for their preferred intervention (p < .0001 within each group). A principal component analysis of factors influencing preference identified three constructs. Using logistic regression, components focused on attitudes about CBT or yoga were predictive of ultimate preference (odds ratio = 11.5, 95% C.I.6.3-21.0 per 1SD difference in component 1 for choosing CBT; odds ratio = 7.8, 95% CI4.3-13.9 per 1SD difference in component 2 for choosing yoga). There were no significant differences between the randomized and preference trials on intervention adherence, completion of assessments, intervention satisfaction, or working alliance. Receiving a preferred treatment had no significant effects on intervention outcomes through participant engagement or process measures. When options are limited, providers may have confidence in offering the most readily available non-pharmacological treatments.

Mental Health Screening Needs and Preference in Treatment Types and Providers in African American and Asian American Older Adults

Older African Americans and Asian Americans in the U.S. underuse mental health services, despite their vulnerability to diverse mental health problems. This study examined their perspectives on the importance of various mental health problems, mental health treatment, and provider type preference. A total of 243 participants residing in Philadelphia were recruited through community-based organizations. Chi-square, ANOVA, and logistic regression were conducted to examine ethnic differences in demographic characteristics, mental health screening needs, and treatment preferences. African Americans were more likely to endorse the screening needs for depression (AOR: 3.77; 95% CI: 1.19–11.93, p < 0.05) and less likely to endorse the screening needs for suicide (AOR: 0.24; 95% CI: 0.08–0.76, p < 0.05) compared to Asian Americans. For treatment preferences, African Americans were more likely to seek help from primary care physicians (AOR: 8.26; 95% CI: 1.71–32.86, p < 0.01) and less likely to prefer medication as a treatment option (AOR: 0.36; 95% CI: 0.09–0.79, p < 0.05) than Asian Americans. African Americans and Asian Americans prioritized mental health screening needs differently and had different treatment preferences, indicating that matching community needs and preferences regarding mental health services is critical to improve mental service utilization rates in the targeted populations.

Efficacy of hypnotherapy compared to cognitive behavioral therapy for mild to moderate depression - Results of a randomized controlled rater-blind clinical trial

BACKGROUND

Methodologically well-designed RCTs concerning the efficacy of Hypnotherapy in the treatment of Major Depression are lacking. The aim of this study was to determine whether Hypnotherapy (HT) is not inferior to Cognitive Behavioral Therapy (CBT), the gold-standard psychotherapy, in the percentage reduction of depressive symptoms, assessed in mild to moderate Major Depression (MD).

METHODS

This study reports the main results of a monocentric two-armed randomized-controlled rater-blind clinical trial. A total of 152 patients with MD were randomized to either CBT or HT receiving outpatient individual psychotherapy with 16 to 20 sessions for the duration of six months. The primary outcome was the mean percentage improvement in depressive symptoms assessed with the Montgomery-Asberg Depression Rating Scale (MADRS) before and after treatment.

RESULTS

The difference in the mean percentage symptom reduction between HT and CBT was 2.8 (95% CI=-9.85 to 15.44) in the Intention-to-treat sample and 4.0 (95% CI=-9.27 to 17.27) in the Per Protocol sample (N=134). Concerning the pre-specified non-inferiority margin of -16.4, both results confirm the non-inferiority of HT to CBT. The results for the follow-ups six and twelve months after the end of the treatment support the primary results.

LIMITATIONS

For ethical reasons the trial did not include a control group without treatment; therefore we can only indirectly conclude that both treatment conditions are effective.

CONCLUSION

This is the first study to demonstrate that HT was not inferior to CBT in MD, while employing rigorous methodological standards.

Factors Influencing Preference for Intervention in a Comparative Effectiveness Trial of Mindfulness-Based Cancer Recovery and Tai Chi/Qigong in Cancer Survivors

Introduction: An important gap between randomized efficacy research and real-world implementation of complementary therapies is the role of patient preferences in influencing engagement and outcome. Several studies have highlighted the benefits of patient preference on health outcomes, but few have investigated the factors associated with preference for interventions, which may be critical to assure the success of program implementation. The current study sought to explore the factors associated with patient preference in an ongoing randomized preference-based trial of Mindfulness-Based Cancer Recovery (MBCR) versus Tai Chi/qigong (TCQ) (the Mindfulness and Tai Chi/qigong in Cancer Health [MATCH] study). Materials and Methods: A multi-method study design was used. A subsample of participants were purposely selected from the ongoing MATCH study to have representation from both intervention arms and from both men and women across different age groups. Open-ended, semi-structured qualitative interviews were conducted to explore the factors influencing initial patient preference. Interviews were transcribed verbatim and analyzed by using inductive thematic analysis. The treatment acceptability and preference measure was administered to determine patients' ratings of acceptability and credibility of both preferred and nonpreferred interventions. Results: A total of 13 participants were interviewed prior to program attendance, with 8 (62%) preferring TCQ and 5 (38%) choosing MBCR. Major themes related to patients' preference for intervention included: (1) expectations about the preferred intervention; (2) knowledge of the intervention; (3) past experiences with the intervention; and (4) self-efficacy. Participants' mean treatment acceptability scores were higher for their preferred program than their nonpreferred program. Conclusion: Understanding the factors that influence cancer survivors' preference for mind-body interventions can augment health care providers' knowledge of the barriers and facilitators for successful implementation of interventions in clinical settings, as well as help patients make informed treatment decisions and improve satisfaction and outcomes. Clinical trial registration no.: NCT03641222.

Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

INTRODUCTION

The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice.

METHODS

Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days.

RESULTS

Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68).

DISCUSSION

By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

The Impact of Matching to Psychotherapy Preference on Engagement in a Randomized Controlled Trial for Patients With Advanced Cancer

Objective: This study examined whether patients who were randomly assigned to their preferred therapy arm had stronger engagement with their treatment than those who were randomly assigned to a non-preferred therapy arm. Method: Data were drawn from a RCT comparing Individual Meaning-Centered Psychotherapy (IMCP), with Individual Supportive Psychotherapy (ISP), in patients with advanced cancer. Treatment engagement was operationalized as patients' perceptions of the therapeutic alliance with their therapist and therapy sessions attended. Two 2 by 2 Analysis of Variance (ANOVA) models were used, with treatment preference (IMCP vs. ISP) and treatment assignment (IMCP vs. ISP) as the independent variables and working alliance and number of sessions attended as outcome variables. Results: Patients who preferred and were assigned to IMCP reported a significantly stronger alliance than those who preferred IMCP but were assigned to ISP. Conclusions: The findings from this study have broader implications for research on psychotherapy beyond the appeal of IMCP in advanced cancer patients. Patients who prefer a novel psychotherapy that they cannot engage in elsewhere, but receive the standard treatment may experience weaker alliance than patients who prefer the standard but receive the novel therapy. Trial registration: Clinicaltrial.gov ID: NCT01323309.

Twelve-Week Yoga vs. Aerobic Cycling Initiation in Sedentary Healthy Subjects: A Behavioral and Multiparametric Interventional PET/MR Study

Interventional yoga studies with an active control group remain scarce and are important to clarify the underlying neurobiology. We conducted an interventional study in healthy controls using simultaneous positron emission tomography/magnetic resonance (PET/MR) imaging and psychometric scales. Thirty healthy, female volunteers (28.4 ± 8.4 years) participated and were randomly assigned to a 12-week yoga or indoor cycling intervention. Before and after the intervention, [¹⁸F]FDG and [¹¹C]UCB-J PET was performed on a simultaneous GE Signa PET/MR with volumetric imaging. Psychometric scales were evaluated on affect, mindfulness, stress, worrying, self-compassion, and interoceptive awareness. Yoga subjects scored higher on interoceptive awareness compared to baseline (p < 0.001). Cognitive (P = 0.009) and overall cognitive functioning (P = 0.01) improved after the yoga intervention compared to the cycling group. We did not observe significant differences in glucose metabolism, synaptic density, or gray matter (GM) volume. The indoor cycling group did not show changes in psychometric variables, but significant increases in relative glucose metabolism were observed in the parahippocampal/fusiform gyrus and cerebellum (P < 0.001). In conclusion, 12 weeks of yoga practice has significant effects on interoceptive awareness and perceived cognitive function in starters. Longer interventions and/or higher frequency of yoga practice may be needed to detect cerebral metabolic and/or morphologic effects on the macroscopic level.

Acceptance and Commitment Therapy for Major Depressive Disorder: Insights into a New Generation of Face-to-Face Treatment and Digital Self-Help Approaches

Major depressive disorder (MDD) represents a key contributor to the global burden of mental illness given its relatively high lifetime prevalence, frequent comorbidity, and disability rates. Evidence-based treatment options for depression include pharmacotherapy and psychotherapy, such as cognitive behavioral therapy (CBT). Beyond traditional CBT, over 15 years ago, Hayes proclaimed a new generation of contextualistic and process-orientated so-called third wave of CBT interventions, including acceptance and commitment therapy (ACT). Using mindfulness and acceptance as well as commitment and behavior change processes, the transdiagnostic ACT approach aims to increase psychological flexibility as universal mechanism of behavior change and to build a value-driven orientation in life. ACT for MDD can be provided as either stand-alone individual, group, or self-help formats (e.g., apps) or combined with other approaches like behavioral activation. To date, a steadily growing empirical support from outcome and process research suggests the efficacy of ACT, which appears to work specifically through the six proposed core processes involved in psychological flexibility, such as defusion. In view of an ongoing interest of clinicians in "third-wave" CBTs and the important role of clients' preferences in providing therapy choices that work, the purpose of this chapter is to give a brief overview on the application of ACT in the treatment of MDD in adults.

REM density is associated with treatment response in major depression: Antidepressant pharmacotherapy vs. psychotherapy

Major depression is one of the most common psychiatric illnesses. Interestingly, a few studies have indicated the existence of depression subgroups, which respond differently to the available treatment options. Previously, sleep abnormalities have been suggested to indicate amenability to different treatment regimens. Thereby, especially REM-sleep parameters seem to play a prominent role, and REM-sleep dysregulation has been repeatedly discussed as a potential endophenotype of depression. With that said, estimating therapy outcome in order to choose the best line of treatment is of utmost importance to patients suffering from depression. The present study looks deeper into these clues by investigating the capability of polysomnographic sleep parameters to predict treatment response in depressed patients to either pharmacotherapy or psychotherapy. Moderately to severely depressed patients (n = 38) were randomly assigned to either psychotherapy (i.e. interpersonal psychotherapy) or pharmacotherapy (i.e., monotherapy with selective serotonin reuptake inhibitors, SSRI, or selective serotonin noradrenalin reuptake inhibitors, SSNRI). Prior to treatment, all patients underwent polysomnography in the sleep laboratory. After treatment, responders and non-responders of both treatment groups were compared regarding their baseline sleep parameters. Higher baseline REM density, i.e. the amount of rapid eye movements during REM sleep, predicted better response to antidepressant pharmacotherapy. In the psychotherapy group, the effect seemed reversed but was not statistically significant. No other sleep parameter predicted treatment response. Our findings support the notion that REM-sleep dysregulation is indeed indicative of a distinct endophenotype of depression and that pharmacotherapy with SSRI/SSNRI might be superior to psychotherapy in these patients.

An exploration of the relationships between patient application of CBT skills and therapeutic outcomes during a two-week CBT treatment

The application of Cognitive Behavioural Therapy (CBT) skills are believed to be a mechanism of therapeutic change in treatment. Research has shown that the application of CBT skills affects outcomes, however, the way these relationships may change during treatment has not been explored. In this study, a naturalistic observational approach is used to examine the relationships between patients' wellbeing, symptoms, and the application of CBT skills throughout treatment. It is hypothesized that the application of CBT skills would lead to an increase in patients reported wellbeing, and a decrease in symptoms. Additionally, it was hypothesized that the application of CBT skills affects wellbeing and symptoms at different points in therapy. A sample of 584 patients in a two-week CBT treatment completed session-to-session measures of wellbeing, symptoms, and their application of CBT skills. Results of an autoregressive cross-lagged path analysis indicated that in the early stages of treatment the application of CBT skills predicted patient wellbeing but not symptoms. At the later stages of therapy, the application of CBT skills predicted both patient wellbeing and symptoms. At no point in treatment did patient wellbeing or symptoms predict the later application of CBT skills. Implications and future directions for research are discussed.

Understanding the Role of Past Health Care Discrimination in Help-Seeking and Shared Decision-Making for Depression Treatment Preferences

As a part of a larger, mixed-methods research study, we conducted semi-structured interviews with 21 adults with depressive symptoms to understand the role that past health care discrimination plays in shaping help-seeking for depression treatment and receiving preferred treatment modalities. We recruited to achieve heterogeneity of racial/ethnic backgrounds and history of health care discrimination in our participant sample. Participants were Hispanic/Latino (n = 4), non-Hispanic/Latino Black (n = 8), or non-Hispanic/Latino White (n = 9). Twelve reported health care discrimination due to race/ethnicity, language, perceived social class, and/or mental health diagnosis. Health care discrimination exacerbated barriers to initiating and continuing depression treatment among patients from diverse backgrounds or with stigmatized mental health conditions. Treatment preferences emerged as fluid and shaped by shared decisions made within a trustworthy patient-provider relationship. However, patients who had experienced health care discrimination faced greater challenges to forming trusting relationships with providers and thus engaging in shared decision-making processes.

Preferences of people with type 2 diabetes for telemedical lifestyle programmes in Germany: protocol of a discrete choice experiment

INTRODUCTION

Telemedical lifestyle programmes for people with type 2 diabetes mellitus (T2DM) provide an opportunity to develop a healthier lifestyle and consequently to improve health outcomes. When implementing new programmes into standard care, considering patients' preferences may increase the success of the participants. This study aims to examine the preferences of people with T2DM with respect to telemedical lifestyle programmes, to analyse whether these preferences predict programme success and to explore the changes that may occur during a telemedical lifestyle intervention.

METHODS AND ANALYSIS

We outline the protocol of the development and assessment of a discrete choice experiment (DCE) to examine patient preferences in a telemedical lifestyle programme with regard to the functions of the online portal, communication, responsibilities, group activities and time requirements. To develop the design of the DCE, we conducted pilot work involving healthcare experts and in particular people with T2DM using cognitive pretesting. The final DCE is being implemented within a randomised controlled trial for investigating whether participation in a telemedical lifestyle intervention programme sustainably improves the HbA1c values in 850 members of a large German statutory health insurance with T2DM. Preferences are being assessed before and after participants complete the programme. The DCE data will be analysed using regression and latent class analyses.

ETHICS AND DISSEMINATION

The DCE study has been approved by the ethics committee of the medical faculty of the Heinrich Heine University Duesseldorf, registration number 2018-242-ProspDEuA, registered on 6 December 2018. The TeLIPro trial is registered at the US National Library of Medicine, registration number NCT03675919, registered on 15 September 2018. We aim to disseminate our results in peer-reviewed journals, at national and international conferences and among interested patient groups and the public.

Association of Patient Treatment Preference With Dropout and Clinical Outcomes in Adult Psychosocial Mental Health Interventions: A Systematic Review and Meta-analysis

IMPORTANCE

Receiving a preferred treatment has previously been associated with lower dropout rates and better clinical outcomes, but this scenario has not been investigated specifically for psychosocial interventions for patients with a mental health diagnosis.

OBJECTIVE

To assess the association of patient treatment preference with dropout and clinical outcomes in adult psychosocial mental health interventions via a systematic review and meta-analysis.

DATA SOURCES

The Cochrane Library, Embase, PubMed, PsychINFO, Scopus, Web of Science, Nice HDAS (Healthcare Databases Advanced Search), Google Scholar, BASE (Bielefeld Academic Search Engine), Semantic Scholar, and OpenGrey were searched from inception to July 20, 2018, and updated on June 10, 2019.

STUDY SELECTION

Studies were eligible if they (1) were a randomized clinical trial; (2) involved participants older than 18 years; (3) involved participants with mental health diagnoses; (4) reported data from a group of participants who received their preferred treatment and a group who received their nonpreferred treatment or who were not given a choice; and (5) offered at least 1 psychosocial intervention.

DATA EXTRACTION AND SYNTHESIS

Two researchers extracted study data for attendance, dropout, and clinical outcomes independently. Both assessed the risk of bias according to the Cochrane tool. Data were pooled using random-effects meta-analyses.

MAIN OUTCOMES AND MEASURES

The following 7 outcomes were examined: attendance, dropout, therapeutic alliance, depression and anxiety outcomes, global outcomes, treatment satisfaction, and remission.

RESULTS

A total of 7341 articles were identified, with 34 eligible for inclusion. Twenty-nine articles were included in the meta-analyses comprising 5294 participants. Receiving a preferred psychosocial mental health treatment had a medium positive association with dropout rates (relative risk, 0.62; 0.48-0.80; P < .001; I2 = 44.6%) and therapeutic alliance (Cohen d = 0.48; 0.15-0.82; P = .01; I2 = 20.4%). There was no evidence of a significant association with other outcomes.

CONCLUSIONS AND RELEVANCE

This is the first review, to our knowledge, examining the association of receiving a preferred psychosocial mental health treatment with both engagement and outcomes for patients with a mental health diagnosis. Patients with mental health diagnoses who received their preferred treatment demonstrated a lower dropout rate from treatment and higher therapeutic alliance scores. These findings underline the need to accommodate patient preference in mental health services to maximize treatment uptake and reduce financial costs of premature dropout and disengagement.

Shared decision-making in mental and behavioural health interventions

Elements of shared decision-making (ie, collaboration, patient preferences, and working alliance) have long been discussed and studied in the field of clinical psychology; however, research indicates that shared decision-making is not typically used in clinical practice. Instead, clinicians often rely on a paternalistic approach. In this article, we provide a narrative review of the existing research supporting shared decision-making for mental and behavioural health concerns, we discuss several barriers that impede its use in actual clinical practice, and we provide recommendations for increasing shared decision-making when working with patients.

Effect of Treatment Preference in Randomized Controlled Trials: Systematic Review of the Literature and Meta-Analysis

BACKGROUND

A significant limitation of the traditional randomized controlled trials is that strong preferences for (or against) one treatment may influence outcomes and/or willingness to receive treatment. Several trial designs incorporating patient preference have been introduced to examine the effect of treatment preference separately from the effects of individual interventions. In the current study, we summarized results from studies using doubly randomized preference trial (DRPT) or fully randomized preference trial (FRPT) designs and examined the effect of treatment preference on clinical outcomes.

METHODS

The current systematic review and meta-analysis was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies using DRPT or FRPT design were identified using electronic databases, including PubMed, Cochrane Library, EMBASE, and Google Scholar between January 1989 and November 2018. All studies included in this meta-analysis were examined to determine the extent to which giving patients their preferred treatment option influenced clinical outcomes. The following data were extracted from included studies: study characteristics, sample size, study duration, follow-up, patient characteristics, and clinical outcomes. We further appraised risk of bias for the included studies using the Cochrane Collaboration's risk of bias tool.

RESULTS

The search identified 374 potentially relevant articles, of which 27 clinical trials utilized a DRPT or FRPT design and were included in the final analysis. Overall, patients who were allocated to their preferred treatment intervention were more likely to achieve better clinical outcomes [effect size (ES) = 0.18, 95% confidence interval (CI) 0.10-0.26]. Subgroup analysis also found that mental health as well as pain and functional disorders moderated the preference effect (ES = 0.23, 95% CI 0.11-0.36, and ES = 0.09, 95% CI 0.03-0.15, respectively).

CONCLUSIONS

Matching patients to preferred interventions has previously been shown to promote outcomes such as satisfaction and treatment adherence. Our analysis of current evidence showed that allowing patients to choose their preferred treatment resulted in better clinical outcomes in mental health and pain than giving them a treatment that is not preferred. These results underline the importance of incorporating patient preference when making treatment decisions.

Multi-institutional trial of non-operative management and surgery for uncomplicated appendicitis in children: Design and rationale

Traditionally, children presenting with appendicitis are referred for urgent appendectomy. Recent improvements in the quality and availability of diagnostic imaging allow for better pre-operative characterization of appendicitis, including severity of inflammation; size of the appendix; and presence of extra-luminal inflammation, phlegmon, or abscess. These imaging advances, in conjunction with the availability of broad spectrum oral antibiotics, allow for the identification of a subset of patients with uncomplicated appendicitis that can be successfully treated with antibiotics alone. Recent studies demonstrated that antibiotics alone are a safe and efficacious treatment alternative for patents with uncomplicated appendicitis. The objective of this study is to perform a multi-institutional trial to examine the effectiveness of non-operative management of uncomplicated pediatric appendicitis across a group of large children's hospitals. A prospective patient choice design was chosen to compare non-operative management to surgery in order to assess effectiveness in a broad population representative of clinical practice in which non-operative management is offered as an alternative to surgery. The risks and benefits of each treatment are very different and a "successful" treatment depends on which risks and benefits are most important to each patient and his/her family. The patient-choice design allows for alignment of preferences with treatment. Patients meeting eligibility criteria are offered a choice of non-operative management or appendectomy. Primary outcomes include determining the success rate of non-operative management and comparing differences in disability days, and secondarily, complication rates, quality of life, and healthcare satisfaction, between patients choosing non-operative management and those choosing appendectomy.

Moderators of Cognitive Therapy and Bright Light Therapy Effects on Depressive Symptoms in Patients with Breast Cancer

BACKGROUND

Cognitive therapy (CT) and bright light therapy (BLT) have been found to be effective to treat depressive symptoms in breast cancer patients. No study has investigated the baseline patients' characteristics that are associated with better outcomes with CT vs. BLT in this population. This study aimed to assess, in breast cancer patients, the moderating role of eight clinical variables on the effects of CT and BLT on depressive symptoms.

METHODS

This is a secondary analysis of a randomized controlled trial conducted in 59 women who received an 8-week CT or BLT and completed questionnaires evaluating depression and possible moderating variables.

RESULTS

Patients benefited more from BLT when they had no prior history of major depressive disorder, higher depression scores on the Hospital Anxiety and Depression Scale (HADS-D) at baseline, a greater initial preference for BLT, and when they received BLT during spring or summer. Patients benefited more from CT when they had a lower initial preference for receiving CT, higher depression scores on the HADS-D, and seasonal depressive symptoms.

CONCLUSIONS

Although replication is needed, findings of this study suggest the existence of different profiles of patients more likely to benefit from CT and BLT.

TRIAL REGISTRATION

NCT01637103 https://clinicaltrials.gov/ct2/show/NCT01637103.

The Impact of Integrating Physical Health into a Brief CBT Approach for Medically Ill Veterans

The current study explored the use and preliminary outcomes of physical health treatment elements integrated into a traditional brief cognitive behavioral therapy (bCBT) approach for medically ill veterans with depression and/or anxiety. Data were collected as part of a pragmatic randomized trial examining patient outcomes of bCBT versus an enhanced usual care condition. bCBT was delivered to participants by Veterans Health Administration (VA) mental health providers in the primary care setting. Using a skill-based approach, providers and participants selected modules from a list of intervention strategies. Modules included Taking Control of Your Physical Health, Using Thoughts to Improve Wellness, Increasing Pleasant Activities, and Learning How to Relax. Skill module use and impact on treatment completion and clinical outcomes were explored for participants randomized to bCBT who received at least one skill module (n = 127). Utilization data showed that participants and providers most commonly selected the physical health module for the first skill session. Receiving the "physical health" and "thoughts" modules earlier in treatment were associated with a higher likelihood of treatment completion (defined as four or more sessions). Preliminary outcome data suggest that the physical health skill module was equally effective or superior to other bCBT skill modules. Results suggest that incorporating physical health elements with a bCBT approach hold the potential to positively impact treatment engagement/completion and may result in improved outcomes for medically ill patient populations.

Racial And Ethnic Differences In The Attainment Of Behavioral Health Quality Measures In Medicare Advantage Plans

As the Medicare population becomes more diverse and its demand for behavioral health care grows, a better understanding of racial/ethnic disparities in the quality of behavioral health care is crucial. Medicare Advantage (MA) plans are accountable through the public reporting of quality performance on measures, including the Healthcare Effectiveness Data and Information Set (HEDIS). We examined HEDIS data on eight MA behavioral health care quality measures, using mixed-effects logistic regressions to distinguish racial/ethnic differences within and between MA health plans. We found that performance differed across racial/ethnic groups by more than 10 percentage points on most quality measures. Significant within-plan disparities were found in twenty of twenty-four comparisons of racial/ethnic minority groups with whites. Within-plan disparities varied widely across plans, with performance being equivalent across racial/ethnic groups in some plans and widely divergent in others. Unlike other types of medical care, in behavioral health within-plan quality disparities are prominent in MA plans, which suggests a role for stratified reporting by racial/ethnic group.

Evidenced-Based Treatment of Posttraumatic Stress Disorder: An Updated Review of Validated Psychotherapeutic and Pharmacological Approaches

LEARNING OBJECTIVES

After participating in this activity, learners should be better able to:• Evaluate psychotherapeutic and pharmacologic approaches to treating patients with posttraumatic stress disorder.

ABSTRACT

A strong evidence base exists for psychological and pharmacological interventions for the treatment of posttraumatic stress disorder (PTSD). The published literature investigating the effectiveness of these treatments in reducing the symptoms and impairments associated with PTSD has expanded substantially in recent years. This review provides a concise overview of the empirical literature examining these treatment approaches. Evidence-based, trauma-focused therapies are recommended as first-line interventions, with the most support for cognitive- and exposure-based approaches. Prolonged exposure and cognitive processing therapy are the two most cited and rigorously investigated. Various other evidence-supported protocols are discussed. Pharmacotherapies can be used when evidence-based psychotherapies are not available or are ineffective, or on the basis of patient preference. Pharmacotherapy with the most support for PTSD includes selective serotonin reuptake inhibitors and serotonin-norepinephrine reuptake inhibitors. Evidence supports the implementation of these interventions across genders, populations, and settings. Given that little research directly compares the effectiveness of different PTSD interventions and their mechanisms of action, it remains uncertain how to best select and tailor treatments to optimize individual outcomes. Future directions and novel, ongoing research are discussed.

Management of perinatal depression with non-drug interventions

Perinatal depression is a common disorder that has been associated with serious risks to mother and child. Recently, screening for depression in pregnant and postpartum women has increased, as has the development of new psychotherapy and non-drug treatment modalities. Matching patients to treatments can be challenging, and although research into personalized treatment of major depression in the general population has increased, no published guidelines focus on personalized treatment approaches to perinatal depression. In particular, guidelines on non-drug treatments are lacking. This review summarizes the evidence on personalized non-drug treatment of perinatal depression, how to incorporate patients' preferences, novel treatments under investigation, and the potential role of biomarkers in matching patients to treatment. The review provides recommendations for future research in personalized care of perinatal depression.

Preference for in-person psychotherapy versus digital psychotherapy options for depression: survey of adults in the U.S

Several barriers complicate access to psychotherapy for depression, including time commitment, location of services, and stigma. Digital treatment has the potential to address these barriers, yet long term use of digital psychotherapy is poor. This paper presents data from a mixed-methods, online survey to document concerns patients with depression face when given the choice of in-person psychotherapy and digital psychotherapy. Participants were 164 adults living in the United States who had previously used or considered psychotherapy for depression. Rural-dwelling and racial/ethnic minority (Native American, African American, and Spanish-speaking) respondents were purposively sampled. Participants were asked their preferences for and opinions about four treatment modalities: self-guided digital, peer-supported digital, expert-guided digital, or in-person psychotherapy. Less than half (44.5%) of participants preferred in-person psychotherapy, 25.6% preferred self-guided digital treatment, 19.7% preferred expert-guided digital treatment, and 8.5% peer-supported digital treatment. Principal themes extracted from qualitative analysis centered on the efficacy of digital treatment, access to digital treatment, concerns about peer-supported care, confidentiality and privacy concerns, preference for in-person treatment, skepticism about self-guided therapy, and the impact of social anxiety on the use of video-chat based care. Future development of digital psychotherapy will need to address concerns regarding efficacy, privacy, data security, and methods to enhance motivation to use these treatments.

The transportability of Memory Specificity Training (MeST): adapting an intervention derived from experimental psychology to routine clinical practices

Background

Accumulating evidence shows that a cognitive factor associated with a worsening of depressive symptoms amongst people with and without diagnoses of depression – reduced Autobiographical Memory (rAMS) – can be ameliorated by a group cognitive training protocol referred to as Memory Specificity Training (MeST). When transporting interventions such as MeST from research to routine clinical practices (RCPs), modifications are inevitable, with potentially a decrease in effectiveness, so called voltage drop. We examined the transportability of MeST to RCPs as an add-on to treatment as usual with depressed in- and out- patients.

Methods

We examined whether 1) MeST was adaptable to local needs of RCPs by implementing MeST in a joint decision-making process in seven Belgian RCPs 2) without losing its effect on rAMS. The effectiveness of MeST was measured by pre- and post- intervention measurements of memory specificity.

Results

Adaptations were made to the MeST protocol to optimize the fit with RCPs. Local needs of RCPs were met by dismantling MeST into different subparts. By dismantling it in this way, we were able to address several challenges raised by clinicians. In particular, multidisciplinary teams could divide the workload across different team members and, for the open version of MeST, the intervention could be offered continuously with tailored dosing per patient. Both closed and open versions of MeST, with or without peripheral components, and delivered by health professionals with different backgrounds, resulted in a significant increase in memory specificity for depressed in- and out- patients in RCPs.

Conclusions

MeST is shown to be a transportable and adaptable add-on intervention which effectively maintains its core mechanism when delivered in RCPs.

Trial registration

ISRCTN registry, IDISRCTN10144349, registered on January 22, 2019. Retrospectively registered.

Electronic supplementary material

The online version of this article (10.1186/s40359-019-0279-y) contains supplementary material, which is available to authorized users.

Diagnostic accuracy and treatment approach to depression in primary care: predictive factors

OBJECTIVE

The study assessed the predictive factors of diagnostic accuracy and treatment approach (antidepressants versus active monitoring) for depression in primary care.

METHODS

This is a cross-sectional study that uses information from a naturalistic prospective controlled trial performed in Barcelona (Spain) enrolling newly diagnosed patients with mild to moderate depression by GPs. Treatment approach was based on clinical judgement. Diagnosis was later assessed according to DSM-IV criteria using Structured Clinical Interview for DSM-IV Axis I Disorders (SCID-I) interview by an external researcher. Patients (sociodemographic, psychiatric diagnosis, severity of depression and anxiety, health-related quality of life, disability, beliefs about medication and illness and comorbidities) and GP factors associated with diagnostic accuracy and treatment approach were assessed using multilevel logistic regression. Variables with missing data were imputed through multiple imputations.

RESULTS

Two hundred sixty-three patients were recruited by 53 GPs. Mean age was 51 years (SD = 15). Thirty percent met DSM-IV criteria for major depression. Mean depression symptomatology was moderate-severe. Using multivariate analyses, patients' beliefs about medicines were the only variable associated with the antidepressant approach. Specialization in general medicine and being a resident tutor were associated with a more accurate diagnosis.

CONCLUSIONS

Clinical depression diagnosis by GPs was not always associated with a formal diagnosis through a SCID-I. GPs' training background was central to an adequate depression diagnosis. Patients' beliefs in medication were the only factor associated with treatment approach. More resources should be allocated to improving the diagnosis of depression.

Does Giving Parents Their Choice of Interventions for Child Behavior Problems Improve Child Outcomes?

Empowering consumers to be active decision-makers in their own care is a core tenet of personalized, or precision medicine. Nonetheless, there is a dearth of research on intervention preferences in families seeking interventions for a child with behavior problems. Specifically, the evidence is inconclusive as to whether providing parents with choice of intervention improves child/youth outcomes (i.e., reduces externalizing problems). In this study, 129 families presenting to community mental health clinics for child conduct problems were enrolled in a doubly randomized preference study and initially randomized to choice or no-choice conditions. Families assigned to the choice condition were offered their choice of intervention from among three different formats of the Parent Management Training-Oregon Model/PMTO (group, individual clinic, home based) and services-as-usual (child-focused therapy). Those assigned to the no-choice condition were again randomized, to one of the four intervention conditions. Intent-to-treat analyses revealed partial support for the effect of parental choice on child intervention outcomes. Assignment to the choice condition predicted teacher-reported improved child hyperactivity/inattention outcomes at 6 months post-treatment completion. No main effect of choice on parent reported child outcomes was found. Moderation analyses indicated that among parents who selected PMTO, teacher report of hyperactivity/inattention was significantly improved compared with parents selecting SAU, and compared with those assigned to PMTO within the no-choice condition. Contrary to hypotheses, teacher report of hyperactivity/inattention was also significantly improved for families assigned to SAU within the no-choice condition, indicating that within the no-choice condition, SAU outperformed the parenting interventions. Implications for prevention research are discussed.

Treatment selection and treatment initialization in guideline-based stepped and collaborative care for depression

In order to optimize patient allocation, guidelines recommend stepped and collaborative care models (SCM) including low-intensity treatments. The aim of this study is to investigate the implementation of guideline-adherent treatments in a SCM for depression in routine care. We analyzed care provider documentation data of n = 569 patients treated within a SCM. Rates of guideline-adherent treatment selections and initializations as well as accordance between selected and initialized treatment were evaluated for patients with mild, moderate and severe depression. Guideline-adherent treatment selection and initialization was highest for mild depression (91% resp. 85%). For moderate depression, guideline-adherent treatments were selected in 68% and applied in 54% of cases. Guideline adherence was lowest for severe depression (59% resp. 19%). In a multiple mixed logistic regression model a significant interaction between guideline adherence in treatment selection/initialization and severity degree was found. The differences between treatment selection and initialization were significant for moderate (OR: 1.8 [95% CI: 1.30 to 2.59; p = 0.0006]) and severe depression (OR: 6.9; [95% CI: 4.24 to 11.25; p < .0001] but not for mild depression (OR = 1.8, [95%-CI: 0.68 to 4.56; p = 0.2426]). Accordance between selected and initialized treatment was highest for mild and lowest for severe depression. We conclude that SCMs potentially improve care for mild depression and guideline adherence of treatment selections. Guideline adherence of treatment initialization and accordance between treatment selection and initialization varies with depression severity. Deficits in treating severe depression adequately may be more a problem of failed treatment initializations than of inadequate treatment selections.

Primary care patient beliefs and help-seeking preferences regarding depression in China

Patient beliefs about depression and its treatment in primary care clinics in China influence the delivery of care. Our objective was to investigate primary care patients' beliefs about depression and its treatment as well as help-seeking preferences regarding depression in China to aid in the development and promotion of interventions that are acceptable to patients with depression. 100 primary care nurses used the Public Knowledge and Beliefs Survey Package (PKBSP) to assess patients in the primary care clinic waiting rooms. Of the 2639 patients, 15.5% were depressed. Patients with higher education level were less likely to be depressed. Differences in beliefs were significantly associated with age, education level and depression status, but no significant differences were found on gender. Help-seeking preferences were also significantly associated with age, education level and depression status. Patients screened with PHQ-9 positive depression were less willing to endorse "take antidepressants" and "consult a non-medical practitioner" than non-depressed patients. However, they were more willing to endorse "consult a psychotherapist". Patient beliefs about depression and its treatment highlight a need for modification of current paradigms, practices, and approaches to improve the acceptability of depression care provision. Efforts to increase collaboration between primary care physicians and mental health professionals are needed.