A pragmatic, unblinded randomised controlled trial comparing an occupational therapy-led lifestyle approach and routine GP care for panic disorder treatment in primary care

Exercise and health-related quality of life and work-related outcomes in primary care patients with anxiety disorders - A randomized controlled study

BACKGROUND

Exercise interventions show promise in the treatment of anxiety disorders, but effects on health-related quality of life (HR-QoL), work ability, and sick leave are little studied. We investigated these outcomes in a 12-week randomized controlled trial with a 1-year follow-up.

METHODS

Patients aged 18-65 (n = 222) with anxiety disorders from primary care centers in Gothenburg were randomized to a control group or one of two 12-week exercise intervention groups (low-intensity, [LI] and moderate/high-intensity, [HI]); 148 were evaluated at 12-weeks and 113 completed the 1-year follow-up. The EuroQol 5D (EQ5D; index and the visual analogue scale [VAS]), work ability score (WAS), presenteeism, and self-reported sick leave were assessed at baseline, 12 weeks, and 1 year. Improvements were defined by binary cut-offs for each scale. Binary logistic regression with odds ratios (OR) and 95 % confidence intervals (CI) were reported.

RESULTS

There were improved scores for EQ5D and WAS in the HI group compared to controls after 12 weeks (EQ5D index: 4.74 [1.91-11.7], EQ5D-VAS 4.00, [1.65-9.72], WAS 3.41 [1.24-7.37]) and 1 year (EQ5D index: 3.05 [1.05-8.81], EQ5D-VAS 3.20 [1.16-8.84], WAS 5.50 [1.85-16.3]). Post-hoc analysis showed higher ORs in participants on antidepressants (n = 75) (12-week EQ5D index: OR 9.95 [2.85-34.8]) and significant improvements in EQ5D scores for both intervention groups after 1 year. There were no between-group differences for presenteeism or sick leave.

LIMITATIONS

Discontinuation was high, mostly early after randomization (n = 74), as is common for anxiety interventions.

CONCLUSIONS

HI Exercise improves HR-QoL and work ability in anxiety patients, especially when combined with antidepressants.

Occupational therapy services in primary care: a scoping review

AIM

To examine and describe the current evidence about occupational therapy services in primary care.

BACKGROUND

Interprofessional primary care teams have been introduced to support the changing demographics and provide more comprehensive and coordinated care. Occupational therapists have the opportunity to play an important role in this expanding area of practice. To do so, occupational therapists must develop roles built on evidence and a clear understanding of the care delivery context.

METHODS

A scoping review was conducted based on the scientific and grey literature. Studies that described or examined the occupational therapy role with clients (individuals, groups, communities, populations) of all ages, conditions or occupational issues in a primary care context and that presented or referred to an occupational therapist working in a primary care setting were included. Studies were excluded if they were not in English or French. The Canadian Model of Occupational Performance and Engagement was used to chart the data.

FINDINGS

129 articles were identified, with 62 non-research and 67 research-focussed articles. A total of 268 assessments and 868 interventions were identified. The top interventions offered by occupational therapists were referring to/advocating for/coordinating/linking to and navigating community services (n = 36 articles), chronic disease management (n = 34 articles)/self-management education (n = 28 articles), health promotion (n = 30 articles) and falls prevention (n = 27 articles). The predominant focus in the literature is on adult and older adult populations.

Lifestyle medicine for anxiety symptoms: A meta-analysis of randomized controlled trials

BACKGROUND

Lifestyle medicine (LM) is gaining increasing attention as a treatment option for anxiety, but the current state of evidence has not yet been systematically examined.

METHODS

Six electronic databases were systematically searched from inception to February 2022. Randomized controlled trials (RCTs) comparing the effects of multicomponent LM interventions on anxiety symptoms with either care-as-usual, waitlist, no intervention, or attention control group on anxiety symptoms were identified.

RESULTS

A total of 53 RCTs with 18,894 participants were included for qualitative synthesis, in which 45 RCTs with data available were included for meta-analysis. Multicomponent LM intervention was significantly more effective than the control groups in reducing anxiety symptoms at immediate posttreatment (d = 0.19, p < .001) and at short-term follow-up (d = 0.29, p < .001). However, no significant difference at medium-term was found (p = .14), whereas more studies are needed to study the long-term effects. The subgroup analyses suggested that baseline anxiety symptoms was a significant moderator, suggesting that those with moderate level of baseline anxiety symptoms appeared to have greater improvements (d = 0.66, p < .05).

LIMITATIONS

Minimal anxiety symptoms at baseline contributed to the floor effect and influenced the degree of improvement. The included RCTs had a high risk of bias in general with potential publication bias detected.

CONCLUSION

The findings of this meta-analysis provided support for the positive effects of multicomponent LM interventions for anxiety symptoms. Future research is needed to determine the long-term effects of multicimponent LM and the optimal baseline anxiety severity.

The effectiveness of occupational therapy for mental health disorders in primary care: A systematic review

Introduction

Occupational therapy (OT) has a rich history of integrating physical and mental health care services, however, there is a limited evidence base regarding the effectiveness of OT interventions for mental health disorders in primary care.

Methods

A comprehensive systematic review was conducted from database inception through 31 January 2021. Eligible studies had to include: (1) an intervention that involved an occupational therapist in design and/or implementation; (2) a quantitative outcome assessing symptoms related to a mental health disorder; (3) a comparison group; and (4) primary care or community dwelling patients and/or primary care clinical settings.

Results

The researchers identified five studies and there was heterogeneity in the OT interventions. There were no significant differences between intervention and control groups in depression symptoms at different time intervals. Several trials employed interventions that involved interprofessional team members, including OTs, to provide training in specific strategies that promoted functioning. Other studies utilized only OTs within the intervention arm. OT interventions demonstrated no significant difference in anxiety in one study, however, another indicated a reduction in symptoms. The overall risk of bias was considered low in three studies and unclear in two studies.

Conclusion

There is limited evidence demonstrating the impact of OT interventions in primary care settings on quantitative outcomes measuring symptoms related to a mental health disorder. Given the heterogeneity of interventions and variation in reported findings, there is need for further pragmatic trials in this area.

Physical exercise as an add-on treatment to cognitive behavioural therapy for anxiety: a systematic review

BACKGROUND

Cognitive behavioural therapy (CBT) is currently the treatment of choice for most anxiety disorders. Yet, with recovery rates of approximately 50%, many patients fail to achieve complete remission. This has led to increased efforts to enhance treatment efficacy. Physical exercise (PE) has in recent years been advocated as means to augment the effects of CBT for anxiety disorders. PE appears to reduce anxiety through other mechanisms than CBT, some of which might also have the potential to augment the effects of psychological treatment.

AIMS

The current review aimed to summarize and discuss the current research status on CBT augmented with PE for anxiety.

METHOD

A systematic literature search was conducted in the databases PsychInfo, Medline and Web of Science to evaluate the potential augmentative effect of combining PE with CBT for anxiety disorders. These effects were intended to be evaluated in a meta-analysis, but findings from the few and diverse studies were better summarized in a systematic review.

RESULTS

Eight articles were included in this review, of which two had no control group, while six had from two to four experimental arms. Six of the studies concluded in favour of benefits of add-on PE, while two studies found no added benefits of the combined interventions.

CONCLUSIONS

The combination of PE and CBT appears feasible. Add-on PE seems to be more beneficial for clinical populations, when administered regularly several times per week, across several weeks. Future studies should investigate further how and for whom to best combine PE and CBT.

Establishing an occupational therapy assessment clinic in a public mental health service: A pragmatic mixed methods evaluation of feasibility, utilisation, and impact

INTRODUCTION

Employment of occupational therapists in generic roles in public mental health services (PMHSs) constrains capacity to undertake discipline-specific activity meaning consumers may be unable to access valuable occupational therapy assessments and interventions that could promote recovery. Establishing a dedicated occupational therapy clinic has been identified as one way of improving care provided and outcomes for organisations, therapists, and consumers. To inform such developments, this paper reports evaluation of feasibility, acceptability, and sustainability of a pilot clinic established within a PMHS.

METHODS

An observational evaluation was used combining quantitative and qualitative data collected from service documents, clinic records, and in semi-structured interviews with 42 stakeholders. Quantitative data were used to describe referrals and flow through the clinic. Framework analysis of qualitative data examined the process and outcomes of referrals and enabled understanding of acceptability, perceived impact and areas for improvement.

RESULTS

Substantial ground work, particularly stakeholder engagement, and redistribution of resources enabled establishment and successful operation of an assessment clinic for 12 months. Assessments were completed for 68% of the 100 accepted referrals, with the remainder in process or unable to be completed. Stakeholders agreed that the clinic enabled clinicians' timely access to specialist assessment, improving care for consumers. Occupational therapists valued the opportunity to deploy and develop discipline-specific skills and when there was some impact on work flow of occupational therapists' 'home teams', team managers judged the investment worthwhile. Strong leadership by the discipline lead and support from team managers who enabled allocation of occupational therapists to the clinic were critical to success.

CONCLUSION

An occupational therapy assessment clinic can be established and operate successfully within a public mental health setting. Redistribution of resources supported increased efficiency and consumer access to specialist interventions that support their recovery.

Exercise in the treatment of clinical anxiety in general practice - a systematic review and meta-analysis

BACKGROUND

Anxiety disorders are common, yet treatment options in general practice are often limited to medication or CBT. There is a lack of evidence for the effectiveness of exercise in the treatment of anxiety in patients who present to general practice and also about the intensity of exercise required to lead to improvement. The aim of this systematic review was to assess the use of exercise versus waiting list control groups in the treatment of anxiety and also to assess the benefit of high intensity exercise vs low intensity exercise. Long term follow up scores were also analysed. We included patients who met diagnostic criteria for anxiety disorders or had clinically raised anxiety levels on a validated rating scale and performed a subgroup analysis of the outcomes between the two groups. The intervention was any aerobic exercise programme carried out for at least two weeks, or exercise carried out at high intensity for at least two weeks. The comparison groups were either a waiting list control group or low intensity exercise.

METHOD

Systematic review of randomised controlled trials. Three databases were searched; CENTRAL, Medline and Embase. Outcome assessment was based on validated anxiety rating scales. The quality of the studies was appraised according to the Cochrane Risk of Bias tool. Effect sizes were calculated using the standardised mean difference.

RESULTS

Fifteen studies were identified with a total of 675 patients. Nine trials had participants with diagnosed anxiety disorders and six trials had participants with raised anxiety on a validated rating scale. Aerobic exercise was effective in the treatment of raised anxiety compared to waiting list control groups (effect size - 0.41, 95% CI = - 0.70 to - 0.12). High intensity exercise programmes showed greater effects than low intensity programmes. There was no significant difference in outcomes between groups of patients with diagnosed anxiety disorders and patients who had raised anxiety on a rating scale. Conclusions were limited by the small number of studies and wide variation in the delivery of exercise interventions.

CONCLUSION

Exercise programmes are a viable treatment option for the treatment of anxiety. High intensity exercise regimens were found to be more effective than low intensity regimens. The results have implications for the use of exercise schemes in General Practice.

Clinical Effectiveness of Occupational Therapy in Mental Health: A Meta-Analysis

OBJECTIVE

The purpose of this study was to estimate the effectiveness of theory-based occupational therapy interventions in improving occupational performance and well-being among people with a mental health diagnosis.

METHOD

The meta-analysis included 11 randomized controlled trials with a total of 520 adult participants with a mental health diagnosis. Outcomes were occupational performance, well-being, or both. We conducted meta-analyses using Comprehensive Meta-Analysis software (Version 3.0) with occupational performance and well-being as the dependent variables.

RESULTS

Results indicated a medium effect of intervention on improving occupational performance (mean Hedge's g = 0.50, Z = 4.05, p < .001) and a small effect on well-being (mean Hedge's g = 0.46, Z = 4.96, p < .001).

CONCLUSION

Theory-based occupational therapy interventions may be effective in improving occupational performance and well-being among people with a mental health diagnosis and should be an integral part of rehabilitation services in mental health.

Exercise as Treatment for Anxiety: Systematic Review and Analysis

BACKGROUND

Exercise has been shown to reduce symptoms of anxiety, but few studies have studied exercise in individuals preselected because of their high anxiety.

PURPOSE

The objective of this study is to review and critically evaluate studies of exercise training in adults with either high levels of anxiety or an anxiety disorder.

METHODS

We conducted a systematic review of randomized clinical trials (RCTs) in which anxious adults were randomized to an exercise or nonexercise control condition. Data were extracted concerning anxiety outcomes and study design. Existing meta-analyses were also reviewed.

RESULTS

Evidence from 12 RCTs suggested benefits of exercise, for select groups, similar to established treatments and greater than placebo. However, most studies had significant methodological limitations, including small sample sizes, concurrent therapies, and inadequate assessment of adherence and fitness levels.

CONCLUSIONS

Exercise may be a useful treatment for anxiety, but lack of data from rigorous, methodologically sound RCTs precludes any definitive conclusions about its effectiveness.

Lifestyle Behaviours Add to the Armoury of Treatment Options for Panic Disorder: An Evidence-Based Reasoning

This article presents an evidence-based reasoning, focusing on evidence of an Occupational Therapy input to lifestyle behaviour influences on panic disorder that also provides potentially broader application across other mental health problems (MHP). The article begins from the premise that we are all different. It then follows through a sequence of questions, examining incrementally how MHPs are experienced and classified. It analyses the impact of individual sensitivity at different levels of analysis, from genetic and epigenetic individuality, through neurotransmitter and body system sensitivity. Examples are given demonstrating the evidence base behind the logical sequence of investigation. The paper considers the evidence of how everyday routine lifestyle behaviour impacts on occupational function at all levels, and how these behaviours link to individual sensitivity to influence the level of exposure required to elicit symptomatic responses. Occupational Therapists can help patients by adequately assessing individual sensitivity, and through promoting understanding and a sense of control over their own symptoms. It concludes that present clinical guidelines should be expanded to incorporate knowledge of individual sensitivities to environmental exposures and lifestyle behaviours at an early stage.

The Elizabeth Casson Memorial Lecture 2012: The Effectiveness, Impact and Legacy of Occupational Therapy

The Elizabeth Casson Memorial Lecture 2012, given on 13 June at the 36th Annual Conference and Exhibition of the College of Occupational Therapists, held at the Scottish Exhibition and Conference Centre, Glasgow.

Routine general practice care for panic disorder within the lifestyle approach to managing panic study

Routine general practice (GP) care is rarely comprehensively described in clinical trials. This paper examines routine GP care within the lifestyle approach to managing panic (LAMP) study. The aim of this paper is to describe/discuss routine GP care for panic disorder (PD) patients within both study arms in the LAMP study. An unblinded pragmatic randomised controlled trial in 15 East of England GP practices (2 primary care trusts). Participants met Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition criteria for PD with/without agoraphobia. Follow-up measures recorded at 20 weeks/10 months following randomisation. Control arm, unrestricted routine GP care (practice appointments, referrals and prescriptions). Trial arm, occupational therapy-led lifestyle treatment comprising lifestyle review of fluid intake, diet pattern, exercise, caffeine, alcohol and nicotine. Primary outcome measure: beck anxiety inventory. At baseline, participants attended 2–3 times more GP appointments than population average, reducing at 10 months to 1.6 times population average for routine GP care and 0.97 population average for lifestyle arm. At 10 months, 33% fewer referrals (6 referrals; 0 mental health) than at baseline (9 referrals; 2 mental health) were made for lifestyle arm patients compared with 42% increase (from 12 referrals; 8 mental health at baseline to 17 referrals; 7 mental health) in GP care arm. Selective serotonin reuptake inhibitors were prescribed most often. Benzodiazepines and beta-blockers were prescribed more often than tricyclic against current clinical guidelines. In conclusion, we found that PD patients at baseline were high healthcare resource users. Treatment in both study arms reduced resource use. Routine GP care requires further review for this patient group.

Cost-effectiveness analysis of an occupational therapy-led lifestyle approach and routine general practitioner's care for panic disorder

OBJECTIVE

To assess the cost-effectiveness of an occupational therapy-led lifestyle approach to treating panic disorder in primary care compared with routine general practitioner's (GP) care. The burden of mental health disorders is considerable. Cost-effective interventions are necessary to alleviate some of these burdens. Habitual lifestyle behaviours influence mood, although to date mainly single lifestyle factor trials have been conducted to examine the effects on anxiety.

METHODS

An economic evaluation was conducted alongside an unblinded pragmatic randomised controlled trial with assessment at 5 and 10 months. Costs and consequences, as measured by the Beck anxiety inventory (BAI) and quality adjusted life years (QALYs), were compared using incremental cost-effectiveness ratios (ICERs).

RESULTS

The occupational therapy-led lifestyle intervention was more costly than routine GP care at both 5 and 10 months. Significant outcome improvements were evident at 5 months when using the BAI, although these were not maintained at 10 months. Small differences in mean QALYs were found. The estimated ICER was 36 pounds per BAI improvement for 5 months and 39 pounds for 10 months, and 18,905 pounds per QALY gained for 5 months and 8,283 pounds for 10 months.

CONCLUSIONS

If the maximum willingness to pay per additional QALY is 30,000 pounds, then there is an 86% chance that a lifestyle intervention may be considered to be value-for-money over 10 months.

Patterns of caffeine consumption in psychiatric patients. An Italian study

PURPOSE

The aim of the present study was to explore and compare the caffeine intake, intoxication, withdrawal and dependence prevalence in Italian psychiatric patients and healthy subjects.

MATERIALS AND METHODS

Three hundred and sixty-nine out- and inpatients, suffering from different psychiatric disorders, and 104 healthy subjects were included in the study. They were assessed by the SCID and by a structured interview for caffeine intoxication and withdrawal and for substance dependence applied to caffeine use.

RESULTS

Patients and healthy subjects did not differ in terms of current caffeine intake (mg/day, mean+/-SD: 281+/-325 vs. 288+/-148, respectively), while the maximum lifetime intake of caffeine was significantly higher in the first group (mg/day, mean SD: 630+/-549 vs. 504+/-344, respectively; F=4.897, p=.03) where it was significantly related to the CGI severity item scores (rho=.107; p=.04). In both patients and healthy subjects, a lower age was related to a higher current caffeine intake, while both current and maximum lifetime caffeine intake in the healthy subjects were significantly higher in men than in women. The patients suffering from eating disorders reported higher current caffeine intake than those with anxiety or mood disorders. The prevalence of dependence and intoxication was significantly higher in the patients than in the healthy subjects, without inter-group differences. Healthy subjects showed a trend towards a higher prevalence of withdrawal.

CONCLUSIONS

Our study highlights the need that a more accurate attention should be paid to the caffeine use which seems to be strongly, although generically, related to different psychiatric disorders.

On-site mental health workers delivering psychological therapy and psychosocial interventions to patients in primary care: effects on the professional practice of primary care providers

BACKGROUND

Mental health problems are common in primary care and mental health workers (MHWs) are increasingly working in this setting delivering psychological therapy and psychosocial interventions to patients. In addition to treating patients directly, the introduction of on-site MHWs represents an organisational change that may lead to changes in the clinical behaviour of primary care providers (PCPs).

OBJECTIVES

To assess the effects of on-site MHWs delivering psychological therapy and psychosocial interventions in primary care on the clinical behaviour of primary care providers (PCPs).

SEARCH STRATEGY

The following sources were searched in 1998: the Cochrane Effective Practice and Organisation of Care Group Specialised Register, the Cochrane Controlled Trials Register, MEDLINE, EMBASE, PsycINFO, CounselLit, NPCRDC skill-mix in primary care bibliography, and reference lists of articles. Additional searches were conducted in February 2007 using the following sources: MEDLINE, EMBASE, PsycINFO, CINAHL, and Cochrane Central Register of Clinical Trials (CENTRAL) (The Cochrane Library).

SELECTION CRITERIA

Randomised trials, controlled before and after studies, and interrupted time series analyses of MHWs working alongside PCPs in primary care settings. The outcomes included objective measures of PCP behaviours such as consultation rates, prescribing, and referral.

DATA COLLECTION AND ANALYSIS

Two review authors independently extracted data and assessed study quality.

MAIN RESULTS

Forty-two studies were included in the review. There was evidence that MHWs caused significant reductions in PCP consultations (standardised mean difference -0.17, 95% CI -0.30 to -0.05), psychotropic prescribing (relative risk 0.67, 95% CI 0.56 to 0.79), prescribing costs (standardised mean difference -0.22, 95% CI -0.38 to -0.07), and rates of mental health referral (relative risk 0.13, 95% CI 0.09 to 0.20) for the patients they were seeing. In controlled before and after studies, the addition of MHWs to a practice did not affect prescribing behaviour towards the wider practice population and there was no consistent pattern to the impact on referrals in the wider patient population.

AUTHORS' CONCLUSIONS

This review provides some evidence that MHWs working in primary care to deliver psychological therapy and psychosocial interventions cause a significant reduction in PCP behaviours such as consultations, prescribing, and referrals to specialist care. However, the changes are modest in magnitude, inconsistent, do not generalise to the wider patient population, and their clinical or economic significance is unclear.

Influences of lifestyle and general practice (GP) care on the symptom profile of people with panic disorder

Current treatment guidelines for anxiety disorders, including panic disorder (PD), recommend either medication or cognitive behavioural therapy (CBT). There is currently a call through the Layard Report for significant investment to increase the availability of CBT resources. However, there are reported limitations to both medication and CBT in the treatment of anxiety, and it appears prudent to consider additional methods of treatment that may offer effective interventions. One such intervention is based around the evidence of altered sensitivity within a number of physiological body systems in anxiety patients (particularly those with PD), all of which are influenced in their function by habitual lifestyle behaviours. A randomised controlled trial compared a 16‐week occupational therapy‐led lifestyle intervention and routine general practice (GP) care for PD. At 20 weeks, 14 symptoms with ‘moderate’ to ‘very severe’ ratings were assessed in 36 GP and 31 lifestyle‐intervention patients. Composite symptom profiles, similar at baseline, were produced. The GP intervention produced modest improvements in most symptoms. The lifestyle intervention overall produced greater symptomatic relief (Wilcoxon signed ranks test, P= 0.008). The physiological and cognitive symptom profile also changed more with lifestyle intervention. Occupational therapists have developed their interventions based on their understanding of everyday occupation. Habitual lifestyle behaviours are characterised as being recurrent elements of everyday occupation and are, therefore, legitimate targets for occupational therapy interventions. They provide a vehicle through which to encourage patients to regain understanding and control of their own anxiety symptoms.

Recent Advances in the Understanding and Treatment of Anxiety Disorders

Anxiety disorders usually are chronic or recurrent disorders characterized by stress sensitivity and a fluctuating course. Both psychopharmacologic and cognitive-behavioral treatments are well-established, evidence-based treatments for panic disorder, social anxiety disorder, generalized anxiety disorder, and obsessive-compulsive disorder. Exposure-based behavioral treatment is well established as evidence-based treatment for specific phobias. Primary care physicians can make a significant impact on patients' lives by identifying and educating about anxiety disorders, directing patients to appropriate self-help resources, choosing evidence-based drug treatment when indicated, and making referrals for specialist care.