Predictors of response to CBT and IPT for depression; the contribution of therapy process

Predictors of Response to Cognitive Behavioral Therapy in Patients With Tinnitus

Importance

Clinical guidelines recommend cognitive behavioral therapy (CBT) as a treatment for tinnitus. However, patient response to CBT is variable, and currently, there are no known predictors of response to CBT treatment for tinnitus.

Objective

To identify the clinical predictors of patient response to CBT for treatment of tinnitus.

Design, Setting, and Participants

This was a secondary cohort analysis of a single-arm clinical study including adults with chronic bothersome tinnitus recruited from Washington University School of Medicine in St Louis (Missouri) from September 2019 to February 2023. Participants completed an 8-week group CBT program with a licensed clinical psychologist. Each week consisted of 2.5 hours of CBT, amounting to 20 hours of total CBT participation, primarily delivered through a virtual platform. Conjunctive consolidation was used to create a predictive classification system for response to CBT based on tinnitus bother and anxiety levels.

Main Outcome and Measure

Response to CBT was predefined as a 13-point or greater decrease in the Tinnitus Functional Index (TFI) survey score.

Results

The study sample included 88 adult patients (median [IQR] age, 59 [49-66] years; 47 [53%] females and 41 [47%] males) with chronic bothersome tinnitus, of whom 53 (60%) had at least 13-point decrease in TFI and were considered to be responders. In univariable and multivariable logistic regression analyses, high to moderate anxiety level and severe tinnitus bother were associated with treatment response (adjusted odds ratio: anxiety, 3.33; 95% CI, 0.90-12.30; tinnitus bother, 12.08; 95% CI, 1.48-98.35). The clinical stratification system showed good predictive and discriminative ability (χ2 for linear trend = 20.0; C statistic = 0.75; 95% CI, 0.65-0.85).

Conclusions and Relevance

The findings of this study show that assessment of bother and anxiety levels in patients with tinnitus may be useful for identifying those who are more likely to respond to CBT. Before incorporation into clinical practice, future research should externally validate this finding in a separate population.

The Use of Text Messaging as an Adjunct to Internet-Based Cognitive Behavioral Therapy for Major Depressive Disorder in Youth: Secondary Analysis

BACKGROUND

As an established treatment for major depressive disorder (MDD), cognitive behavioral therapy (CBT) is now implemented and assessed in internet-based formats that, when combined with smartphone apps, enable secure text messaging. As an adjunct to such internet-based CBT (ICBT) approaches, text messaging has been associated with increased adherence and therapeutic alliance.

OBJECTIVE

This study analyzed data from the intervention arm of a randomized control trial evaluating 24-week ICBT for MDD (intervention arm) against standard-care psychiatry (waitlist control). The aim of this secondary analysis was to assess MDD symptom improvement in relation to the frequency and content of text messages sent by ICBT participants to Navigator-Coaches during randomized control trial participation. Higher text frequency in general and in 3 conceptual categories (appreciating alliance, alliance building disclosures, and agreement confirmation) was hypothesized to predict larger MDD symptom improvement.

METHODS

Participants were young adults (18-30 years) from the Centre for Addiction and Mental Health. The frequencies of categorized texts from 20 ICBT completers were analyzed with respect to MDD symptom improvement using linear regression models. Texts were coded by 2 independent coders and categorized using content analysis. MDD symptoms were measured using the Beck Depression Inventory-II (BDI-II).

RESULTS

Participants sent an average of 136 text messages. Analyses indicated that BDI-II improvement was negatively associated with text messaging frequency in general (β=-0.029, 95% CI -0.11 to 0.048) and in each of the 3 categories: appreciating alliance (β=-0.096, 95% CI -0.80 to 0.61), alliance building disclosures (β=-0.098, 95% CI -0.28 to 0.084), and agreement confirmation (β=-0.076, 95% CI -0.40 to 0.25). Altogether, the effect of text messaging on BDI-II improvement was uniformly negative across statistical models. More text messaging appeared associated with less MDD symptom improvement.

CONCLUSIONS

The hypothesized positive associations between conceptually categorized text messages and MDD symptom improvement were not supported in this study. Instead, more text messaging appeared to indicate less treatment benefit. Future studies with larger samples are needed to discern the optimal use of text messaging in ICBT approaches using adjunctive modes of communication.

TRIAL REGISTRATION

Clinical Trials.gov NCT03406052; https://www.clinicaltrials.gov/ct2/show/NCT03406052.

Contribution of socio-demographic and clinical characteristics to predict initial referrals to psychosocial interventions in patients with serious mental illness

AIMS

Psychosocial rehabilitation (PSR) is at the core of psychiatric recovery. There is a paucity of evidence regarding how the needs and characteristics of patients guide clinical decisions to refer to PSR interventions. Here, we used explainable machine learning methods to determine how socio-demographic and clinical characteristics contribute to initial referrals to PSR interventions in patients with serious mental illness.

METHODS

Data were extracted from the French network of rehabilitation centres, REHABase, collected between years 2016 and 2022 and analysed between February and September 2022. Participants presented with serious mental illnesses, including schizophrenia spectrum disorders, bipolar disorders, autism spectrum disorders, depressive disorders, anxiety disorders and personality disorders. Information from 37 socio-demographic and clinical variables was extracted at baseline and used as potential predictors. Several machine learning models were tested to predict initial referrals to four PSR interventions: cognitive behavioural therapy (CBT), cognitive remediation (CR), psychoeducation (PE) and vocational training (VT). Explanatory power of predictors was determined using the artificial intelligence-based SHAP (SHapley Additive exPlanations) method from the best performing algorithm.

RESULTS

Data from a total of 1146 patients were included (mean age, 33.2 years [range, 16-72 years]; 366 [39.2%] women). A random forest algorithm demonstrated the best predictive performance, with a moderate or average predictive accuracy [micro-averaged area under the receiver operating curve from 'external' cross-validation: 0.672]. SHAP dependence plots demonstrated insightful associations between socio-demographic and clinical predictors and referrals to PSR programmes. For instance, patients with psychotic disorders were more likely to be referred to PE and CR, while those with non-psychotic disorders were more likely to be referred to CBT and VT. Likewise, patients with social dysfunctions and lack of educational attainment were more likely to be referred to CR and VT, while those with better functioning and education were more likely to be referred to CBT and PE.

CONCLUSIONS

A combination of socio-demographic and clinical features was not sufficient to accurately predict initial referrals to four PSR programmes among a French network of rehabilitation centres. Referrals to PSR interventions may also involve service- and clinician-level factors. Considering socio-demographic and clinical predictors revealed disparities in referrals with respect to diagnoses, current clinical and psychological issues, functioning and education.

Comparing Online and On-Site Cognitive Behavior Therapy in Major Depressive Disorder: Protocol for a Noninferiority Randomized Controlled Trial

Background

The incidence of mental health disorders in Canada is increasing with costs of CAD $51 billion (US $40 billion) per year. Depression is the most prevalent cause of disability while cognitive behavioral therapy (CBT) is the best validated behavioral depression treatment. CBT, when combined with mindfulness meditation (CBT-M), has strong evidence for increased efficacy. While randomized controlled trials (RCTs) have demonstrated online CBT-M efficacy, comparisons with in-office delivery are lacking.

Objective

The aim of this research is to assess whether online group CBT-M (with standard psychiatric care) is non-inferior in efficacy and more cost-effective than office-based, on-site group CBT-M at post-intervention and 6-months follow-up in major depressive disorder. The study will also assess whether digitally recorded data (ie, online workbooks completed, Fitbit step count, and online text messages) predict depression symptom reduction in online participants.

Methods

This single-center, two-arm, noninferiority RCT employs assessor-blinded and self-report outcomes and economic evaluation. The research site is the Centre for Addiction and Mental Health (Toronto), a research-based psychiatry institution where participants will be identified from service wait lists and through contacts with other Toronto clinics. Inclusion criteria are as follows: (1) aged 18-60 years, any ethnicity; (2) Beck Depression Inventory-II (BDI-II) of mild severity (score ≥14) with no upper severity limit; (3) Mini-International Neuropsychiatric Interview-confirmed, psychiatric major depressive disorder diagnosis; (4) fluent in English. All patients are diagnosed by staff psychiatrists. Exclusion criteria are as follows: (1) receipt of weekly structured psychotherapy; (2) observation of Diagnostic and Statistical Manual of Mental Disorders (5th Edition) criteria for severe alcohol or substance use disorder (in past 3 months), borderline personality disorder, schizophrenia (or other primary psychotic disorder), bipolar disorder, or obsessive-compulsive disorder; (3) clinically significant suicidal ideation (imminent intent or attempted suicide in the past 6 months); and (4) treatment-resistant depression. All participants receive standard psychiatric care, experimental participants receive online group CBT-M, and controls receive standard care in-office group CBT-M. The online group program (in collaboration with NexJ Health, Inc) combines smartphone and computer-accessed workbooks with mental health phone counselling (16 hours in 16 weeks) that coordinates software interactions (eg, secure text messaging and Fitbit-tracked walking). The primary outcome is BDI-II, and secondary outcomes are anxiety (Beck Anxiety Inventory), depression (ie, Quick Inventory of Depressive Symptomatology and 17-item Hamilton Depression Rating Scale), mindfulness (Five-Facet Mindfulness Questionnaire), quality of life (European Quality of Life Five Dimension), and pain (Brief Pain Inventory).

Results

Based on prior studies with the BDI-II and 80% power to reject an inferiority hypothesis with a 1-sided type I error rate of 5%, a sample of 78 per group is adequate to detect small-to-medium–effect sizes.

Conclusions

This study assesses online CBT-M efficacy and noninferiority in relation to in-person CBT, and the cost-effectiveness of both interventions.

Trial Registration

ClinicalTrials.gov NCT04825535; https://www.clinicaltrials.gov/ct2/show/NCT04825535

International Registered Report Identifier (IRRID)

DERR1-10.2196/29726

Evidence of validity of the revised Helping Alliance Questionnaire based on the internal structure in a Brazilian clinical sample

The revised Helping Alliance Questionnaire (HAq-II) is among the most used instruments that measure therapeutic alliance. Despite its use in research, this instrument is not validated for the Brazilian population. The aim of this study was to explore the evidence of validity of the HAq-II based on the internal structure in a sample of Brazilian psychiatric patients. An ambulatory convenience sample of 204 patients with major depressive disorder (MDD) and 81 patients with obsessive-compulsive disorder (OCD) was randomized between two different types of treatment. The HAq-II was completed by patients (patient version) and by 33 therapists who performed the interventions (therapist version) between the second and third sessions. We used confirmatory factor analysis (CFA) to investigate two models: (1) a one-dimensional therapeutic alliance model and (2) a two-dimensional model considering the factors 'positive alliance' and 'negative alliance'. The internal consistency of the HAq-II was measured by Cronbach's alpha. To investigate discriminant validity, we used the t-test for independent samples, ANOVA and Pearson's correlation coefficient. The analysis showed that the best model of the instrument was one-dimensional. Cronbach's alpha for both versions displayed values above 0.89. The Brazilian version of the HAq-II presented properties similar to those found in the original version. However, studies related to the one-dimensional model with other samples are necessary.

Genetic influences on treatment-seeking for common mental health problems in the UK biobank

The majority of those who experience clinical anxiety and/or depressive symptoms in the population do not receive treatment. Studies investigating inequalities in treatment outcomes rarely consider that individuals respond differently to their experience of the environment. Much of our environment is under genetic influence, via our behaviour, whereby individuals actively select their experiences. If genes influence who seeks and receives treatment, selection bias will confound genomic studies of treatment response. Furthermore, if some individuals are at high genetic risk of needing but not commencing treatment, then greater efforts could be made to engage them. The role of common genetic variation on four lifetime treatment-seeking behaviours (treatment-seeking, treatment-receipt, self-help, self-medication with alcohol/drugs) was examined in participants of the UK Biobank (sample size range: 48,106 - 75,322). Treatment-related behaviours were only modestly heritable in these data. Nonetheless, genetic correlations reveal substantial genetic overlap between lifetime treatment-related behaviours and psychiatric disorders, symptoms and behavioural traits. To our knowledge, this is the first study to examine genetic influences on treatment-related behaviours. Further work is required to determine whether genetic factors could be used alongside clinical, social and demographic factors to identify at risk groups and inform strategies which target early intervention.

A genome-wide association meta-analysis of prognostic outcomes following cognitive behavioural therapy in individuals with anxiety and depressive disorders

Major depressive disorder and the anxiety disorders are highly prevalent, disabling and moderately heritable. Depression and anxiety are also highly comorbid and have a strong genetic correlation (rg ≈ 1). Cognitive behavioural therapy is a leading evidence-based treatment but has variable outcomes. Currently, there are no strong predictors of outcome. Therapygenetics research aims to identify genetic predictors of prognosis following therapy. We performed genome-wide association meta-analyses of symptoms following cognitive behavioural therapy in adults with anxiety disorders (n = 972), adults with major depressive disorder (n = 832) and children with anxiety disorders (n = 920; meta-analysis n = 2724). We estimated the variance in therapy outcomes that could be explained by common genetic variants (h2SNP) and polygenic scoring was used to examine genetic associations between therapy outcomes and psychopathology, personality and learning. No single nucleotide polymorphisms were strongly associated with treatment outcomes. No significant estimate of h2SNP could be obtained, suggesting the heritability of therapy outcome is smaller than our analysis was powered to detect. Polygenic scoring failed to detect genetic overlap between therapy outcome and psychopathology, personality or learning. This study is the largest therapygenetics study to date. Results are consistent with previous, similarly powered genome-wide association studies of complex traits.

The relationship between the therapeutic alliance and clinical outcomes in cognitive behaviour therapy for adults with depression: A meta-analytic review

Research consistently provides evidence for the relationship between the therapeutic alliance (TA) and outcome across various therapies and presenting problems. Depression is considered the leading cause of disability worldwide, and there is substantial evidence for the efficacy for Cognitive Behaviour Therapy (CBT) in its treatment. At present, there is lack of clarity specifically about the relationship between the TA and outcome in CBT for depression. The present review is the first meta-analytic review to explore this relationship and also considering moderators. Within a random-effects model, an overall mean effect size of r = 0.26 (95% CI [.19-.32]) was found, indicating that the TA was moderately related to outcome in CBT for depression. The mean TA-outcome correlation is consistent with existing meta-analysis that looked across a broad range of presenting problems and psychological therapies. A secondary exploratory analysis of moderators suggested the TA-outcome relationship varied according to the TA rater, where the relationship was weaker for therapist raters compared with clients and observer raters. Additionally, the results indicated that the TA-outcome relationship marginally increased over the course of CBT treatment. The results of the meta-analysis are discussed in reference to the wider body of research, methodological limitations, clinical implications, and future directions for research.

Standardization of health outcomes assessment for depression and anxiety: recommendations from the ICHOM Depression and Anxiety Working Group

Purpose

National initiatives, such as the UK Improving Access to Psychological Therapies program (IAPT), demonstrate the feasibility of conducting empirical mental health assessments on a large scale, and similar initiatives exist in other countries. However, there is a lack of international consensus on which outcome domains are most salient to monitor treatment progress and how they should be measured. The aim of this project was to propose (1) an essential set of outcome domains relevant across countries and cultures, (2) a set of easily accessible patient-reported instruments, and (3) a psychometric approach to make scores from different instruments comparable.

Methods

Twenty-four experts, including ten health outcomes researchers, ten clinical experts from all continents, two patient advocates, and two ICHOM coordinators worked for seven months in a consensus building exercise to develop recommendations based on existing evidence using a structured consensus-driven modified Delphi technique.

Results

The group proposes to combine an assessment of potential outcome predictors at baseline (47 items: demographics, functional, clinical status, etc.), with repeated assessments of disease-specific symptoms during the treatment process (19 items: symptoms, side effects, etc.), and a comprehensive annual assessment of broader treatment outcomes (45 items: remission, absenteeism, etc.). Further, it is suggested reporting disease-specific symptoms for depression and anxiety on a standardized metric to increase comparability with other legacy instruments. All recommended instruments are provided online (www.ichom.org).

Conclusion

An international standard of health outcomes assessment has the potential to improve clinical decision making, enhance health care for the benefit of patients, and facilitate scientific knowledge.

Electronic supplementary material

The online version of this article (doi:10.1007/s11136-017-1659-5) contains supplementary material, which is available to authorized users.