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Holzer KJ, Bartosiak KA, Calfee RP, Hammill CW, Haroutounian S, Kozower BD, Cordner TA, Lenard EM, Freedland KE, Tellor Pennington BR, Wolfe RC, Miller JP, Politi MC, Zhang Y, Yingling MD, Baumann AA, Kannampallil T, Schweiger JA, McKinnon SL, Avidan MS, Lenze EJ, Abraham J. Perioperative mental health intervention for depression and anxiety symptoms in older adults study protocol: design and methods for three linked randomised controlled trials. BMJ Open 2024; 14:e082656. [PMID: 38569683 PMCID: PMC11146368 DOI: 10.1136/bmjopen-2023-082656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Accepted: 03/18/2024] [Indexed: 04/05/2024] Open
Abstract
INTRODUCTION Preoperative anxiety and depression symptoms among older surgical patients are associated with poor postoperative outcomes, yet evidence-based interventions for anxiety and depression have not been applied within this setting. We present a protocol for randomised controlled trials (RCTs) in three surgical cohorts: cardiac, oncological and orthopaedic, investigating whether a perioperative mental health intervention, with psychological and pharmacological components, reduces perioperative symptoms of depression and anxiety in older surgical patients. METHODS AND ANALYSIS Adults ≥60 years undergoing cardiac, orthopaedic or oncological surgery will be enrolled in one of three-linked type 1 hybrid effectiveness/implementation RCTs that will be conducted in tandem with similar methods. In each trial, 100 participants will be randomised to a remotely delivered perioperative behavioural treatment incorporating principles of behavioural activation, compassion and care coordination, and medication optimisation, or enhanced usual care with mental health-related resources for this population. The primary outcome is change in depression and anxiety symptoms assessed with the Patient Health Questionnaire-Anxiety Depression Scale from baseline to 3 months post surgery. Other outcomes include quality of life, delirium, length of stay, falls, rehospitalisation, pain and implementation outcomes, including study and intervention reach, acceptability, feasibility and appropriateness, and patient experience with the intervention. ETHICS AND DISSEMINATION The trials have received ethics approval from the Washington University School of Medicine Institutional Review Board. Informed consent is required for participation in the trials. The results will be submitted for publication in peer-reviewed journals, presented at clinical research conferences and disseminated via the Center for Perioperative Mental Health website. TRIAL REGISTRATION NUMBERS NCT05575128, NCT05685511, NCT05697835, pre-results.
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Affiliation(s)
- Katherine J Holzer
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kimberly A Bartosiak
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ryan P Calfee
- Department of Orthopaedics, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Chet W Hammill
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Simon Haroutounian
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Benjamin D Kozower
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Theresa A Cordner
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Emily M Lenard
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Kenneth E Freedland
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Bethany R Tellor Pennington
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Rachel C Wolfe
- Department of Pharmacy, Barnes-Jewish Hospital, St Louis, Missouri, USA
| | - J Philip Miller
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Mary C Politi
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Yi Zhang
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael D Yingling
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Ana A Baumann
- Department of Surgery, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Thomas Kannampallil
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
| | - Julia A Schweiger
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Sherry L McKinnon
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Michael S Avidan
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Eric J Lenze
- Department of Psychiatry, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
| | - Joanna Abraham
- Department of Anesthesiology, Washington University School of Medicine in Saint Louis, St Louis, Missouri, USA
- Institute for Informatics, Data Science and Biostatistics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri, USA
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Swirsky ES, Boyd AD, Gu C, Burke LA, Doorenbos AZ, Ezenwa MO, Knisely MR, Leigh JW, Li H, Mandernach MW, Molokie RE, Patil CL, Steffen AD, Shah N, deMartelly VA, Staman KL, Schlaeger JM. Monitoring and responding to signals of suicidal ideation in pragmatic clinical trials: Lessons from the GRACE trial for Chronic Sickle Cell Disease Pain. Contemp Clin Trials Commun 2023; 36:101218. [PMID: 37842321 PMCID: PMC10569945 DOI: 10.1016/j.conctc.2023.101218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 09/11/2023] [Accepted: 10/01/2023] [Indexed: 10/17/2023] Open
Abstract
Sickle cell disease (SCD) is a hemoglobin disorder and the most common genetic disorder that affects 100,000 Americans and millions worldwide. Adults living with SCD have pain so severe that it often requires opioids to keep it in control. Depression is a major global public health concern associated with an increased risk in chronic medical disorders, including in adults living with sickle cell disease (SCD). A strong relationship exists between suicidal ideation, suicide attempts, and depression. Researchers enrolling adults living with SCD in pragmatic clinical trials are obligated to design their methods to deliberately monitor and respond to symptoms related to depression and suicidal ideation. This will offer increased protection for their participants and help clinical investigators meet their fiduciary duties. This article presents a review of this sociotechnical milieu that highlights, analyzes, and offers recommendations to address ethical considerations in the development of protocols, procedures, and monitoring activities related to suicidality in depressed patients in a pragmatic clinical trial.
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Affiliation(s)
| | | | - Carol Gu
- University of Illinois Chicago, Chicago, IL, USA
| | | | | | | | | | | | - Hongjin Li
- University of Illinois Chicago, Chicago, IL, USA
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Landrum KR, Akiba CF, Pence BW, Akello H, Chikalimba H, Dussault JM, Hosseinipour MC, Kanzoole K, Kulisewa K, Malava JK, Udedi M, Zimba CC, Gaynes BN. Assessing suicidality during the SARS-CoV-2 pandemic: Lessons learned from adaptation and implementation of a telephone-based suicide risk assessment and response protocol in Malawi. PLoS One 2023; 18:e0281711. [PMID: 36930620 PMCID: PMC10022777 DOI: 10.1371/journal.pone.0281711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 01/26/2023] [Indexed: 03/18/2023] Open
Abstract
The SARS-CoV-2 pandemic led to the rapid transition of many research studies from in-person to telephone follow-up globally. For mental health research in low-income settings, tele-follow-up raises unique safety concerns due to the potential of identifying suicide risk in participants who cannot be immediately referred to in-person care. We developed and iteratively adapted a telephone-delivered protocol designed to follow a positive suicide risk assessment (SRA) screening. We describe the development and implementation of this SRA protocol during follow-up of a cohort of adults with depression in Malawi enrolled in the Sub-Saharan Africa Regional Partnership for Mental Health Capacity Building (SHARP) randomized control trial during the COVID-19 era. We assess protocol feasibility and performance, describe challenges and lessons learned during protocol development, and discuss how this protocol may function as a model for use in other settings. Transition from in-person to telephone SRAs was feasible and identified participants with suicidal ideation (SI). Follow-up protocol monitoring indicated a 100% resolution rate of SI in cases following the SRA during this period, indicating that this was an effective strategy for monitoring SI virtually. Over 2% of participants monitored by phone screened positive for SI in the first six months of protocol implementation. Most were passive risk (73%). There were no suicides or suicide attempts during the study period. Barriers to implementation included use of a contact person for participants without personal phones, intermittent network problems, and pre-paid phone plans delaying follow-up. Delays in follow-up due to challenges with reaching contact persons, intermittent network problems, and pre-paid phone plans should be considered in future adaptations. Future directions include validation studies for use of this protocol in its existing context. This protocol was successful at identifying suicide risk levels and providing research assistants and participants with structured follow-up and referral plans. The protocol can serve as a model for virtual SRA development and is currently being adapted for use in other contexts.
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Affiliation(s)
- Kelsey R. Landrum
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Christopher F. Akiba
- Department of Health Behavior, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Brian W. Pence
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | | | - Josée M. Dussault
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | - Mina C. Hosseinipour
- University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
| | | | - Kazione Kulisewa
- Department of Psychiatry and Mental Health, Kamuzu University of Health, Blantyre, Malawi
| | | | - Michael Udedi
- Noncommunicable Disease and Mental Health Unit, Malawi Ministry of Health, Lilongwe, Malawi
| | | | - Bradley N. Gaynes
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
- Department of Psychiatry, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, United States of America
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Brandl L, van Velsen L, Brodbeck J, Jacinto S, Hofs D, Heylen D. Developing an eMental health monitoring module for older mourners using fuzzy cognitive maps. Digit Health 2023; 9:20552076231183549. [PMID: 37361430 PMCID: PMC10286164 DOI: 10.1177/20552076231183549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 06/05/2023] [Indexed: 06/28/2023] Open
Abstract
Objective Effective internet interventions often combine online self-help with regular professional guidance. In the absence of regularly scheduled contact with a professional, the internet intervention should refer users to professional human care if their condition deteriorates. The current article presents a monitoring module to recommend proactively seeking offline support in an eMental health service to aid older mourners. Method The module consists of two components: a user profile that collects relevant information about the user from the application, enabling the second component, a fuzzy cognitive map (FCM) decision-making algorithm that detects risk situations and to recommend the user to seek offline support, whenever advisable. In this article, we show how we configured the FCM with the help of eight clinical psychologists and we investigate the utility of the resulting decision tool using four fictitious scenarios. Results The current FCM algorithm succeeds in detecting unambiguous risk situations, as well as unambiguously safe situations, but it has more difficulty classifying borderline cases correctly. Based on recommendations from the participants and an analysis of the algorithm's erroneous classifications, we propose how the current FCM algorithm can be further improved. Conclusion The configuration of FCMs does not necessarily demand large amounts of privacy-sensitive data and their decisions are scrutable. Thus, they hold great potential for automatic decision-making algorithms in mental eHealth. Nevertheless, we conclude that there is a need for clear guidelines and best practices for developing FCMs, specifically for eMental health.
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Affiliation(s)
- Lena Brandl
- Roessingh Research and Development, eHealth group, Enschede, The Netherlands
- Department of Human Media Interaction, University of Twente, Enschede, The Netherlands
| | - Lex van Velsen
- Roessingh Research and Development, eHealth group, Enschede, The Netherlands
| | - Jeannette Brodbeck
- FHNW School of Social Work, Institute for Consulting, Coaching and Social Management, Olten, Switzerland
- Institute for Psychology, University of Bern, Bern, Switzerland
| | - Sofia Jacinto
- FHNW School of Social Work, Institute for Consulting, Coaching and Social Management, Olten, Switzerland
- Institute for Psychology, University of Bern, Bern, Switzerland
| | - Dennis Hofs
- Roessingh Research and Development, eHealth group, Enschede, The Netherlands
| | - Dirk Heylen
- Department of Human Media Interaction, University of Twente, Enschede, The Netherlands
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Rollman BL, Anderson AM, Rothenberger SD, Abebe KZ, Ramani R, Muldoon MF, Jakicic JM, Herbeck Belnap B, Karp JF. Efficacy of Blended Collaborative Care for Patients With Heart Failure and Comorbid Depression: A Randomized Clinical Trial. JAMA Intern Med 2021; 181:1369-1380. [PMID: 34459842 PMCID: PMC8406216 DOI: 10.1001/jamainternmed.2021.4978] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Depression is often comorbid in patients with heart failure (HF) and is associated with worse clinical outcomes. However, depression generally goes unrecognized and untreated in this population. OBJECTIVE To determine whether a blended collaborative care program for treating both HF and depression can improve clinical outcomes more than collaborative care for HF only and physicians' usual care (UC). DESIGN, SETTING, AND PARTICIPANTS This 3-arm, single-blind, randomized effectiveness trial recruited 756 participants with HF with reduced left ventricular ejection fraction (<45%) from 8 university-based and community hospitals in southwestern Pennsylvania between March 2014 and October 2017 and observed them until November 2018. Participants included 629 who screened positive for depression during hospitalization and 2 weeks postdischarge and 127 randomly sampled participants without depression to facilitate further comparisons. Key analyses were performed November 2018 to March 2019. INTERVENTIONS Separate physician-supervised nurse teams provided either 12 months of collaborative care for HF and depression ("blended" care) or collaborative care for HF only (enhanced UC [eUC]). MAIN OUTCOMES AND MEASURES The primary outcome was mental health-related quality of life (mHRQOL) as measured by the Mental Component Summary of the 12-item Short Form Health Survey (MCS-12). Secondary outcomes included mood, physical function, HF pharmacotherapy use, rehospitalizations, and mortality. RESULTS Of the 756 participants (mean [SD] age, 64.0 [13.0] years; 425 [56%] male), those with depression reported worse mHRQOL, mood, and physical function but were otherwise similar to those without depression (eg, mean left ventricular ejection fraction, 28%). At 12 months, blended care participants reported a 4.47-point improvement on the MCS-12 vs UC (95% CI, 1.65 to 7.28; P = .002), but similar scores as the eUC arm (1.12; 95% CI, -1.15 to 3.40; P = .33). Blended care participants also reported better mood than UC participants (Patient-Reported Outcomes Measurement Information System-Depression effect size, 0.47; 95% CI, 0.28 to 0.67) and eUC participants (0.24; 95% CI, 0.07 to 0.41), but physical function, HF pharmacotherapy use, rehospitalizations, and mortality were similar by both baseline depression and randomization status. CONCLUSIONS AND RELEVANCE In this randomized clinical trial of patients with HF and depression, telephone-delivered blended collaborative care produced modest improvements in mHRQOL, the primary outcome, on the MCS-12 vs UC but not eUC. Although blended care did not differentially affect rehospitalization and mortality, it improved mood better than eUC and UC and thus may enable organized health care systems to provide effective first-line depression care to medically complex patients. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02044211.
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Affiliation(s)
- Bruce L Rollman
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Behavioral Health, Media and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Amy M Anderson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Behavioral Health, Media and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Scott D Rothenberger
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kaleab Z Abebe
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Research on Health Care Data Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ravi Ramani
- Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Matthew F Muldoon
- Heart and Vascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - John M Jakicic
- Healthy Lifestyle Institute & Physical Activity and Weight Management Research Center, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Bea Herbeck Belnap
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Center for Behavioral Health, Media and Technology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.,Now with Department of Psychiatry, University of Arizona College of Medicine, Tucson
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Stevens K, Thambinathan V, Hollenberg E, Inglis F, Johnson A, Levinson A, Salman S, Cardinale L, Lo B, Shi J, Wiljer D, Korczak DJ, Cleverley K. Core components and strategies for suicide and risk management protocols in mental health research: a scoping review. BMC Psychiatry 2021; 21:13. [PMID: 33413192 PMCID: PMC7792084 DOI: 10.1186/s12888-020-03005-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 12/07/2020] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Suicide and risk management protocols in mental health research aim to ensure patient safety, provide vital information on how to assess suicidal ideation, manage risk, and respond to unexpected and expected situations. However, there is a lack of literature that identifies specific components and strategies to include in suicide and risk management protocols (SRMPs) for mental health research. The goal of this scoping review was to review academic and grey literature to determine core components and associated strategies, which can be used to inform SRMPs in mental health research. METHODS AND ANALYSIS The methodological framework outlined by Arksey and O'Malley was used for this scoping review. The search strategy, conducted by a medical librarian, was multidisciplinary and included seven databases. Two reviewers independently assessed eligibility criteria in each document and used a standardized charting form to extract relevant data. The extracted data were then examined using qualitative content analysis. Specifically, summative content analysis was used to identify the core components and strategies used in SRMPs. The data synthesis process was iterative. RESULTS This review included 36 documents, specifically 22 peer-reviewed articles and 14 documents from the grey literature. Five core components of SRMPs emerged from the reviewed literature including: training; educational resources for research staff; educational resources for research participants; risk assessment and management strategies; and clinical and research oversight. Potentials strategies for risk mitigation within each of the core components are outlined. CONCLUSIONS The five core components and associated strategies for inclusion in SRMPs will assist mental health researchers in conducting research safely and rigorously. Findings can inform the development of SRMPs and how to tailor them across various research contexts.
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Affiliation(s)
- Katye Stevens
- The Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Vivetha Thambinathan
- The Western Centre for Public Health and Family Medicine, Western University, London, Ontario, Canada
| | - Elisa Hollenberg
- Office of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Fiona Inglis
- Library Services, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Humber Libraries, Humber College, Toronto, Ontario, Canada
| | - Andrew Johnson
- Office of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Andrea Levinson
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Soha Salman
- Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Leah Cardinale
- Lawrence S. Bloomberg Faculty of Nursing and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada
| | - Brian Lo
- Office of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Information Management Group, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - Jenny Shi
- Office of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
| | - David Wiljer
- Office of Education, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Centre for Excellence in Economic Analysis Research, St. Michael's Hospital, Toronto, Ontario, Canada
- Education, Technology and Innovation, UHN Digital, University Health Network, Toronto, Ontario, Canada
| | - Daphne J Korczak
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Kristin Cleverley
- The Margaret and Wallace McCain Centre for Child, Youth and Family Mental Health, Centre for Addiction and Mental Health, Toronto, Ontario, Canada.
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
- Lawrence S. Bloomberg Faculty of Nursing and Department of Psychiatry, University of Toronto, Toronto, Ontario, Canada.
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Belnap BH, Anderson A, Abebe KZ, Ramani R, Muldoon MF, Karp JF, Rollman BL. Blended Collaborative Care to Treat Heart Failure and Comorbid Depression: Rationale and Study Design of the Hopeful Heart Trial. Psychosom Med 2020; 81:495-505. [PMID: 31083056 PMCID: PMC6602832 DOI: 10.1097/psy.0000000000000706] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Despite numerous improvements in care, morbidity from heart failure (HF) has remained essentially unchanged in recent years. One potential reason is that depression, which is comorbid in approximately 40% of hospitalized HF patients and associated with adverse HF outcomes, often goes unrecognized and untreated. The Hopeful Heart Trial is the first study to evaluate whether a widely generalizable telephone-delivered collaborative care program for treating depression in HF patients improves clinical outcomes. METHODS The Hopeful Heart Trial aimed to enroll 750 patients with reduced ejection fraction (HFrEF) (ejection fraction ≤ 45%) including the following: (A) 625 patients who screened positive for depression both during their hospitalization (Patient Health Questionnaire [PHQ-2]) and two weeks following discharge (PHQ-9 ≥ 10); and (B) 125 non-depressed control patients (PHQ-2(-)/PHQ-9 < 5). We randomized depressed patients to either their primary care physician's "usual care" (UC) or to one of two nurse-delivered 12-month collaborative care programs for (a) depression and HFrEF ("blended") or (b) HrEFF alone (enhanced UC). Our co-primary hypotheses will test whether "blended" care can improve mental health-related quality of life versus UC and versus enhanced UC, respectively, on the Mental Component Summary of the Short-Form 12 Health Survey. Secondary hypotheses will evaluate the effectiveness of our interventions on mood, functional status, hospital readmissions, deaths, provision of evidence-based care for HFrEF, and treatment costs. RESULTS Not applicable. CONCLUSIONS The Hopeful Heart Trial will determine whether "blended" collaborative care for depression and HFrEF is more effective at improving patient-relevant outcomes than collaborative care for HFrEF alone or doctors' UC for HFrEF. TRIAL REGISTRATION ClinicalTrials.gov identifier NCT02044211.
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Affiliation(s)
- Bea Herbeck Belnap
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Department of Psychosomatic Medicine and Psychotherapy, University of Göttingen Medical Center, Göttingen, Germany
| | - Amy Anderson
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Kaleab Z. Abebe
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Center for Clinical Trials & Data Coordination, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Ravi Ramani
- Cardiovascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Mathew F. Muldoon
- Cardiovascular Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Jordan F. Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Bruce L. Rollman
- Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
- Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA
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Busby DR, King CA, Brent D, Grupp-Phelan J, Gould M, Page K, Casper TC. Adolescents' Engagement with Crisis Hotline Risk-management Services: A Report from the Emergency Department Screen for Teen Suicide Risk (ED-STARS) Study. Suicide Life Threat Behav 2020; 50:72-82. [PMID: 31152463 PMCID: PMC8788931 DOI: 10.1111/sltb.12558] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 05/06/2019] [Indexed: 11/29/2022]
Abstract
OBJECTIVE This study examines the feasibility of a risk-management protocol for adolescent research participants at risk for suicide that relies on engagement with telephone crisis counselors. The study also examines whether engagement is moderated by adolescent demographics and clinical characteristics. METHOD Participants were 234 adolescents (83% female; 63% White) ages 12-18 (M = 15.3 years) drawn from the national study, Emergency Department Screen for Teens at Risk for Suicide (ED-STARS) Study One sample of adolescents randomized for 3-month telephone follow-up (n = 2,850). This study's sample was comprised of adolescents who completed the follow-up (69% retention), met study risk criteria, and were transferred to a crisis hotline for risk management. Engagement with a counselor was assessed by successful call connection, call duration, and information sharing. RESULTS Ninety-four percent of calls resulted in a successful call transfer, and the majority of youth (84%) shared information with counselor about one or more coping strategies. Average call length was 12.6 min (SD = 9.9). Engagement did not vary by gender, race, age, ethnicity, or clinical characteristics. CONCLUSIONS Adolescents' engagement with telephone risk-management services was strong, suggesting that this strategy can address safety. Further, findings suggest telephone risk-management services effectively engage youth across demographic and clinical subgroups.
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Affiliation(s)
| | | | | | | | | | - Kent Page
- University of Utah School of Medicine
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Development and psychometric properties of the "Suicidality: Treatment Occurring in Paediatrics (STOP) Risk and Resilience Factors Scales" in adolescents. Eur Child Adolesc Psychiatry 2020; 29:153-165. [PMID: 31054125 PMCID: PMC7024696 DOI: 10.1007/s00787-019-01328-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2018] [Accepted: 04/01/2019] [Indexed: 11/25/2022]
Abstract
Suicidality in the child and adolescent population is a major public health concern. There is, however, a lack of developmentally sensitive valid and reliable instruments that can capture data on risk, and clinical and psychosocial mediators of suicidality in young people. In this study, we aimed to develop and assess the validity of instruments evaluating the psychosocial risk and protective factors for suicidal behaviours in the adolescent population. In Phase 1, based on a systematic literature review of suicidality, focus groups, and expert panel advice, the risk factors and protective factors (resilience factors) were identified and the adolescent, parent, and clinician versions of the STOP-Suicidality Risk Factors Scale (STOP-SRiFS) and the Resilience Factors Scale (STOP-SReFS) were developed. Phase 2 involved instrument validation and comprised of two samples (Sample 1 and 2). Sample 1 consisted of 87 adolescents, their parents/carers, and clinicians from the various participating centres, and Sample 2 consisted of three sub-samples: adolescents (n = 259) who completed STOP-SRiFS and/or the STOP-SReFS scales, parents (n = 213) who completed one or both of the scales, and the clinicians who completed the scales (n = 254). The STOP-SRiFS demonstrated a good construct validity-the Cronbach Alpha for the adolescent (α = 0.864), parent (α = 0.842), and clinician (α = 0.722) versions of the scale. Test-retest reliability, inter-rater reliability, and content validity were good for all three versions of the STOP-SRiFS. The sub-scales generated using Exploratory Factor Analysis (EFA) were the (1) anxiety and depression risk, (2) substance misuse risk, (3) interpersonal risk, (4) chronic risk, and (5) risk due to life events. For the STOP-SRiFS, statistically significant correlations were found between the Columbia-Suicide Severity Rating Scale (C-SSRS) total score and the adolescent, parent, and clinical versions of the STOP-SRiFS sub-scale scores. The STOP-SRiFS showed good psychometric properties. This study demonstrated a good construct validity for the STOP-SReFS-the Cronbach Alpha for the three versions were good (adolescent: α = 0.775; parent: α = 0.808; α = clinician: 0.808). EFA for the adolescent version of the STOP-SReFS, which consists of 9 resilience factors domains, generated two factors (1) interpersonal resilience and (2) cognitive resilience. The STOP-SReFS Cognitive Resilience sub-scale for the adolescent was negatively correlated (r = - 0.275) with the C-SSRS total score, showing that there was lower suicidality in those with greater Cognitive Resilience. The STOP-SReFS Interpersonal resilience sub-scale correlations were all negative, but none of them were significantly different to the C-SSRS total scores for either the adolescent, parent, or clinician versions of the scales. This is not surprising, because the items in this sub-scale capture a much larger time-scale, compared to the C-SSRS rating period. The STOP-SReFS showed good psychometric properties. The STOP-SRiFS and STOP-SReFS are instruments that can be used in future studies about suicidality in children and adolescents.
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Cristancho P, Lenard E, Lenze EJ, Miller JP, Brown PJ, Roose SP, Montes-Garcia C, Blumberger DM, Mulsant BH, Lavretsky H, Rollman BL, Reynolds CF, Karp JF. Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM): Study Design and Treatment Characteristics of the First 396 Participants Randomized. Am J Geriatr Psychiatry 2019; 27:1138-1152. [PMID: 31147244 DOI: 10.1016/j.jagp.2019.04.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2018] [Revised: 04/16/2019] [Accepted: 04/17/2019] [Indexed: 10/27/2022]
Abstract
OBJECTIVE Evidence from clinical trials comparing effectiveness and safety of pharmacological strategies in older adults unresponsive to first-line antidepressants is limited. The study, Optimizing Outcomes of Treatment-Resistant Depression in Older Adults (OPTIMUM), tests three hypotheses concerning pharmacotherapy strategies for treatment-resistant late-life depression: 1) augmentation strategies will provide greater improvement than switching monotherapies; 2) augmentation strategies will have lower tolerability and more safety concerns than switching monotherapies; and 3) age will moderate the effectiveness and safety differences between treatment strategies. The authors describe the methodology, processes for stakeholder engagement, challenges, and lessons learned in the early phases of OPTIMUM. METHODS This pragmatic randomized clinical trial located in five North American regions will enroll 1,500 participants aged 60 years and older unresponsive to two or more antidepressant trials. The authors evaluate two strategies (medication augmentation versus switch) using four medications (aripiprazole, bupropion, lithium, and nortriptyline) via a stepwise, prespecified protocol. Primary outcomes include: 1) symptom remission (Montgomery Asberg Depression scale ≤10); 2) psychological well-being, comprising positive affect, general life satisfaction, and purpose; and 3) safety (rates of serious adverse events and prevalence of falls and fall-related injuries). RESULTS To date, 396 participants have been randomized. The authors report on four challenges: 1) engagement and recruitment; 2) increasing polypharmacy in older adults, resulting in potentially hazardous scenarios; 3) reporting adverse events and procedure standardization across sites; and 4) dissemination of results. CONCLUSION Solutions to these challenges, including early inclusion of stake holders, will inform future pragmatic studies in older adults with depression.
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Affiliation(s)
- Pilar Cristancho
- Department of Psychiatry (PC, EL, EJL), Healthy Mind Lab, School of Medicine, Washington University in St. Louis, St. Louis.
| | - Emily Lenard
- Department of Psychiatry (PC, EL, EJL), Healthy Mind Lab, School of Medicine, Washington University in St. Louis, St. Louis
| | - Eric J Lenze
- Department of Psychiatry (PC, EL, EJL), Healthy Mind Lab, School of Medicine, Washington University in St. Louis, St. Louis
| | - J Philip Miller
- the Division of Biostatistics (JPM), School of Medicine, Washington University in St. Louis, St. Louis
| | - Patrick J Brown
- the Department of Geriatric Psychiatry (PJB, SPR, CMG), Program on Healthy Aging and Late Life Brain Disorders, New York State Psychiatric Institute, Columbia University Medical Center, New York
| | - Steven P Roose
- the Department of Geriatric Psychiatry (PJB, SPR, CMG), Program on Healthy Aging and Late Life Brain Disorders, New York State Psychiatric Institute, Columbia University Medical Center, New York
| | - Carolina Montes-Garcia
- the Department of Geriatric Psychiatry (PJB, SPR, CMG), Program on Healthy Aging and Late Life Brain Disorders, New York State Psychiatric Institute, Columbia University Medical Center, New York
| | - Daniel M Blumberger
- the Centre for Addiction and Mental Health and Department of Psychiatry (DMB, BHM), University of Toronto, Toronto
| | - Benoit H Mulsant
- the Centre for Addiction and Mental Health and Department of Psychiatry (DMB, BHM), University of Toronto, Toronto
| | - Helen Lavretsky
- the Semel Institute for Neuroscience and Human Behavior (HL), University of California, Los Angeles
| | - Bruce L Rollman
- the Department of Medicine and Center for Behavioral Health and Smart Technology (BLR), University of Pittsburgh School of Medicine, Pittsburgh
| | - Charles F Reynolds
- the Department of Psychiatry (CFR, JFK), University of Pittsburgh School of Medicine, Pittsburgh
| | - Jordan F Karp
- the Department of Psychiatry (CFR, JFK), University of Pittsburgh School of Medicine, Pittsburgh
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Tielman ML, Neerincx MA, Pagliari C, Rizzo A, Brinkman WP. Considering patient safety in autonomous e-mental health systems - detecting risk situations and referring patients back to human care. BMC Med Inform Decis Mak 2019; 19:47. [PMID: 30885190 PMCID: PMC6421702 DOI: 10.1186/s12911-019-0796-x] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2018] [Accepted: 03/07/2019] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Digital health interventions can fill gaps in mental healthcare provision. However, autonomous e-mental health (AEMH) systems also present challenges for effective risk management. To balance autonomy and safety, AEMH systems need to detect risk situations and act on these appropriately. One option is sending automatic alerts to carers, but such 'auto-referral' could lead to missed cases or false alerts. Requiring users to actively self-refer offers an alternative, but this can also be risky as it relies on their motivation to do so. This study set out with two objectives. Firstly, to develop guidelines for risk detection and auto-referral systems. Secondly, to understand how persuasive techniques, mediated by a virtual agent, can facilitate self-referral. METHODS In a formative phase, interviews with experts, alongside a literature review, were used to develop a risk detection protocol. Two referral protocols were developed - one involving auto-referral, the other motivating users to self-refer. This latter was tested via crowd-sourcing (n = 160). Participants were asked to imagine they had sleeping problems with differing severity and user stance on seeking help. They then chatted with a virtual agent, who either directly facilitated referral, tried to persuade the user, or accepted that they did not want help. After the conversation, participants rated their intention to self-refer, to chat with the agent again, and their feeling of being heard by the agent. RESULTS Whether the virtual agent facilitated, persuaded or accepted, influenced all of these measures. Users who were initially negative or doubtful about self-referral could be persuaded. For users who were initially positive about seeking human care, this persuasion did not affect their intentions, indicating that a simply facilitating referral without persuasion was sufficient. CONCLUSION This paper presents a protocol that elucidates the steps and decisions involved in risk detection, something that is relevant for all types of AEMH systems. In the case of self-referral, our study shows that a virtual agent can increase users' intention to self-refer. Moreover, the strategy of the agent influenced the intentions of the user afterwards. This highlights the importance of a personalised approach to promote the user's access to appropriate care.
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Affiliation(s)
- Myrthe L. Tielman
- Department of Interactive Intelligence, Delft University of Technology, van Mourik Broekmanweg 6, 2628 XE Delft, The Netherlands
| | - Mark A. Neerincx
- Department of Interactive Intelligence, Delft University of Technology, van Mourik Broekmanweg 6, 2628 XE Delft, The Netherlands
- TNO Perceptual and Cognitive Systems, Soesterberg, The Netherlands
| | | | - Albert Rizzo
- USC Institute of Creative Technologies, Playa Vista, California USA
| | - Willem-Paul Brinkman
- Department of Interactive Intelligence, Delft University of Technology, van Mourik Broekmanweg 6, 2628 XE Delft, The Netherlands
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Bryan CJ, May AM, Rozek DC, Williams SR, Clemans TA, Mintz J, Leeson B, Burch TS. Use of crisis management interventions among suicidal patients: Results of a randomized controlled trial. Depress Anxiety 2018; 35:619-628. [PMID: 29748993 DOI: 10.1002/da.22753] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2017] [Revised: 03/01/2018] [Accepted: 03/08/2018] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Previous research supports the efficacy of the crisis response plan (CRP) for the reduction of suicidal behaviors as compared to treatment as usual (TAU). Patient perspectives and use of the CRP, and their relationship to later suicidal thoughts, remain unknown. METHODS A secondary analysis of a randomized clinical trial comparing a standard CRP (S-CRP), a CRP enhanced with reasons for living (E-CRP), and TAU in a sample of 97 active-duty U.S. Army personnel was conducted. Participants were asked about their use, perceptions, and recall of each intervention. Generalized estimating equations were used to test the conditional effects of intervention use, perceptions, and recall on severity of suicide ideation during follow-up. RESULTS Across all treatment groups, over 80% of participants retained their written CRP up to 6 months later, but less than 25% had the written plan in their physical possession at the time of each assessment. Participants in S-CRP and E-CRP were more likely to recall self-management strategies and sources of social support. Participants in TAU were more likely to recall use of professional healthcare services and crisis management services. All three interventions were rated as highly useful. More frequent use of the E-CRP and recall of its components were associated with significantly reduced suicide ideation as compared to TAU. CONCLUSIONS Both CRPs have high acceptability ratings. The effect of both CRPs on reduced suicide ideation is associated with patient recall of components. More frequent use of the E-CRP is associated with larger reductions in suicide ideation.
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Affiliation(s)
- Craig J Bryan
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT, USA
| | - Alexis M May
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT, USA
| | - David C Rozek
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT, USA
| | - Sean R Williams
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT, USA
| | - Tracy A Clemans
- National Center for Veterans Studies, University of Utah, Salt Lake City, UT, USA
| | - Jim Mintz
- Health Science Center, University of Texas, San Antonio, TX, USA
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Schulberg HC. My Odyssey Through the Changing World of Mental Health. Am J Geriatr Psychiatry 2018; 26:257-263. [PMID: 29198429 DOI: 10.1016/j.jagp.2017.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 10/09/2017] [Indexed: 11/15/2022]
Affiliation(s)
- Herbert C Schulberg
- Professor Emeritus of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA; Clinical Professor Emeritus of Psychology in Psychiatry, Weill Cornell Medicine, New York, NY.
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Rollman BL, Herbeck Belnap B, Abebe KZ, Spring MB, Rotondi AJ, Rothenberger SD, Karp JF. Effectiveness of Online Collaborative Care for Treating Mood and Anxiety Disorders in Primary Care: A Randomized Clinical Trial. JAMA Psychiatry 2018; 75:56-64. [PMID: 29117275 PMCID: PMC5833533 DOI: 10.1001/jamapsychiatry.2017.3379] [Citation(s) in RCA: 77] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
IMPORTANCE Collaborative care for depression and anxiety is superior to usual care from primary care physicians for these conditions; however, challenges limit its provision in routine practice and at scale. Advances in technology may overcome these barriers but have yet to be tested. OBJECTIVE To examine the effectiveness of combining an internet support group (ISG) with an online computerized cognitive behavioral therapy (CCBT) provided via a collaborative care program for treating depression and anxiety vs CCBT alone and whether providing CCBT in this manner is more effective than usual care. DESIGN, SETTING, AND PARTICIPANTS In this 3-arm randomized clinical trial with blinded outcome assessments, primary care physicians from 26 primary care practices in Pittsburgh, Pennsylvania, referred 2884 patients aged 18 to 75 years in response to an electronic medical record prompt from August 2012 to September 2014. Overall, 704 patients (24.4%) met all eligibility criteria and were randomized to CCBT alone (n = 301), CCBT+ISG (n = 302), or usual care (n = 101). Intent-to-treat analyses were conducted November 2015 to January 2017. INTERVENTIONS Six months of guided access to an 8-session CCBT program provided by care managers who informed primary care physicians of their patients' progress and promoted patient engagement with our online programs. MAIN OUTCOMES AND MEASURES Mental health-related quality of life (12-Item Short-Form Health Survey Mental Health Composite Scale) and depression and anxiety symptoms (Patient-Reported Outcomes Measurement Information System) at 6-month follow-up, with treatment durability assessed 6 months later. RESULTS Of the 704 randomized patients, 562 patients (79.8%) were female, and the mean (SD) age was 42.7 (14.3) years. A total of 604 patients (85.8%) completed our primary 6-month outcome assessment. At 6-month assessment, 254 of 301 patients (84.4%) receiving CCBT alone started the program (mean [SD] sessions completed, 5.4 [2.8]), and 228 of 302 patients (75.5%) in the CCBT+ISG cohort logged into the ISG at least once, of whom 141 (61.8%) provided 1 or more comments or posts (mean, 10.5; median [range], 3 [1-306]). Patients receiving CCBT+ISG reported similar 6-month improvements in mental health-related quality of life, mood, and anxiety symptoms compared with patients receiving CCBT alone. However, compared with patients receiving usual care, patients in the CCBT alone cohort reported significant 6-month effect size improvements in mood (effect size, 0.31; 95% CI, 0.09-0.53) and anxiety (effect size, 0.26; 95% CI, 0.05-0.48) that persisted 6 months later, and completing more CCBT sessions produced greater effect size improvements in mental health-related quality of life and symptoms. CONCLUSIONS AND RELEVANCE While providing moderated access to an ISG provided no additional benefit over guided CCBT at improving mental health-related quality of life, mood, and anxiety symptoms, guided CCBT alone is more effective than usual care for these conditions. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01482806.
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Affiliation(s)
- Bruce L. Rollman
- Division of General Internal Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Behavioral Health and Smart Technology,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Bea Herbeck Belnap
- Division of General Internal Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Behavioral Health and Smart Technology,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Kaleab Z. Abebe
- Division of General Internal Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Clinical Trials and Data Coordination,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Michael B. Spring
- School of Information Science and Technology,
University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Armando J. Rotondi
- Center for Behavioral Health and Smart Technology,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,School of Information Science and Technology,
University of Pittsburgh, Pittsburgh, Pennsylvania,Mental Illness Research, Education, and Clinical
Center, VA Pittsburgh Health Care System, Department of Veterans Affairs, Pittsburgh,
Pennsylvania
| | - Scott D. Rothenberger
- Division of General Internal Medicine, University of
Pittsburgh School of Medicine, Pittsburgh, Pennsylvania,Center for Clinical Trials and Data Coordination,
University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Jordan F. Karp
- Department of Psychiatry, University of Pittsburgh
School of Medicine, Pittsburgh, Pennsylvania
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Cavanagh K, Herbeck Belnap B, Rothenberger SD, Abebe KZ, Rollman BL. My care manager, my computer therapy and me: The relationship triangle in computerized cognitive behavioural therapy. Internet Interv 2017; 11:11-19. [PMID: 30135755 PMCID: PMC6084903 DOI: 10.1016/j.invent.2017.10.005] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Revised: 09/25/2017] [Accepted: 10/28/2017] [Indexed: 11/19/2022] Open
Abstract
UNLABELLED Previous research has reported mixed findings regarding the relationship between therapeutic alliance, engagement and outcomes in e-mental health. This study aims to overcome some of the methodological limitations of previous research and extend our understanding of alliance-outcome relationships in e-mental health by exploring the nature of the relationship triangle between the patient, their care manager and their computerized cognitive behavioural therapy (CCBT) program, accessed with or without an Internet Support Group (ISG). Positive patient-rated alliance with both their care manager and the CCBT program itself was found and these were significantly associated with measures of engagement and clinical outcome. The magnitude of this association was moderate, and within the range of that reported for traditional face-to-face psychotherapies in recent meta-analyses. Limitations of the study, including the reliance on completer data and a cross-sectional design, and directions for future research are presented. Our findings suggest that both the training and supervision of support staff and the optimization of CCBT interventions themselves to enhance alliance and experience may lead to improved engagement and outcomes. TRIAL REGISTRATION Clinicaltrials.gov Identifier: NCT01482806https://www.clinicaltrials.gov/ct2/show/NCT01482806?term=rollman&rank=4.
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Affiliation(s)
- Kate Cavanagh
- University of Sussex, School of Psychology, East Sussex, United Kingdom
- Corresponding author at: School of Psychology, University of Sussex, Falmer, East Sussex BN1 9QH, United Kingdom.
| | - Bea Herbeck Belnap
- Division of General Internal Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Scott D. Rothenberger
- Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, United States
| | - Kaleab Z. Abebe
- Division of General Internal Medicine, Center for Clinical Trials & Data Coordination, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Bruce L. Rollman
- Division of General Internal Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
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Rollman BL, Belnap BH, Mazumdar S, Abebe KZ, Karp JF, Lenze EJ, Schulberg HC. Telephone-Delivered Stepped Collaborative Care for Treating Anxiety in Primary Care: A Randomized Controlled Trial. J Gen Intern Med 2017; 32:245-255. [PMID: 27714649 PMCID: PMC5330997 DOI: 10.1007/s11606-016-3873-1] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/12/2016] [Revised: 08/22/2016] [Accepted: 09/13/2016] [Indexed: 01/08/2023]
Abstract
BACKGROUND Collaborative care for depression is more effective in improving treatment outcomes than primary care physicians' (PCPs) usual care (UC). However, few trials of collaborative care have targeted anxiety. OBJECTIVE To examine the impact and 12-month durability of a centralized, telephone-delivered, stepped collaborative care intervention (CC) for treating anxiety disorders across a network of primary care practices. DESIGN Randomized controlled trial with blinded outcome assessments. PARTICIPANTS A total of 329 patients aged 18-64 referred by their PCPs in response to an electronic medical record (EMR) prompt. They include 250 highly anxious patients randomized to either CC or to UC, and 79 moderately anxious patients who were triaged to a watchful waiting (WW) cohort and later randomized if their conditions clinically deteriorated. INTERVENTION Twelve months of telephone-delivered CC involving non-mental health professionals who provided patients with basic psycho-education, assessed preferences for guideline-based pharmacotherapy, monitored treatment responses, and informed PCPs of their patients' care preferences and progress via the EMR. MAIN MEASURES Mental health-related quality of life ([HRQoL]; SF-36 MCS); secondary outcomes: anxiety (Hamilton Anxiety Rating Scale [SIGH-A], Panic Disorder Severity Scale) and mood (PHQ-9). KEY RESULTS At 12-month follow-up, highly anxious patients randomized to CC reported improved mental HRQoL (effect size [ES]: 0.38 [95 % CI: 0.13-0.63]; P = 0.003), anxiety (SIGH-A ES: 0.30 [0.05-0.55]; P = 0.02), and mood (ES: 0.45 [0.19-0.71] P = 0.001) versus UC. These improvements were sustained for 12 months among African-Americans (ES: 0.70-1.14) and men (ES: 0.43-0.93). Of the 79 WW patients, 29 % met severity criteria for randomization, and regardless of treatment assignment, WW patients reported fewer anxiety and mood symptoms and better mental HRQoL over the full 24-month follow-up period than highly anxious patients who were randomized at baseline. CONCLUSIONS Telephone-delivered, centralized, stepped CC improves mental HRQoL, anxiety and mood symptoms. These improvements were durable and particularly evident among those most anxious at baseline, and among African-Americans and men.
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Affiliation(s)
- Bruce L Rollman
- Division of General Internal Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Suite 600, 230 McKee Place, Pittsburgh, PA, 15213-2582, USA.
| | - Bea Herbeck Belnap
- Division of General Internal Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Suite 600, 230 McKee Place, Pittsburgh, PA, 15213-2582, USA
| | - Sati Mazumdar
- Department of Biostatistics, University of Pittsburgh Graduate School of Public Health, Pittsburgh, PA, USA
| | - Kaleab Z Abebe
- Division of General Internal Medicine, Center for Behavioral Health and Smart Technology, University of Pittsburgh School of Medicine, Suite 600, 230 McKee Place, Pittsburgh, PA, 15213-2582, USA
| | - Jordan F Karp
- Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.,Geriatric Research, Education & Clinical Center, VA Pittsburgh Healthcare System, Pittsburgh, PA, USA
| | - Eric J Lenze
- Healthy Mind Lab, Department of Psychiatry, Washington University School of Medicine, St. Louis, MO, USA
| | - Herbert C Schulberg
- Department of Psychiatry, Weill Cornell Medical College, White Plains, NY, USA
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