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Khan I, Taylor SJC, Robinson C, Moschopoulou E, McCrone P, Bourke L, Thaha M, Bhui K, Rosario D, Ridge D, Donovan S, Korszun A, Little P, Morgan A, Quentin O, Roylance R, White P, Chalder T. Study protocol for a pragmatic randomised controlled trial of comparing enhanced acceptance and commitment therapy plus (+) added to usual aftercare versus usual aftercare only, in patients living with or beyond cancer: SUrvivors' Rehabilitation Evaluation after CANcer (SURECAN) trial. Trials 2024; 25:228. [PMID: 38566197 PMCID: PMC10985882 DOI: 10.1186/s13063-024-08062-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 03/18/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Two million people in the UK are living with or beyond cancer and a third of them report poor quality of life (QoL) due to problems such as fatigue, fear of cancer recurrence, and concerns about returning to work. We aimed to develop and evaluate an intervention based on acceptance and commitment therapy (ACT), suited to address the concerns of cancer survivors and in improving their QoL. We also recognise the importance of exercise and vocational activity on QoL and therefore will integrate options for physical activity and return to work/vocational support, thus ACT Plus (+). METHODS We will conduct a multi-centre, pragmatic, theory driven, randomised controlled trial. We will assess whether ACT+ including usual aftercare (intervention) is more effective and cost-effective than usual aftercare alone (control). The primary outcome is QoL of participants living with or beyond cancer measured using the Functional Assessment of Cancer Therapy: General scale (FACT-G) at 52 weeks. We will recruit 344 participants identified from secondary care sites who have completed hospital-based treatment for cancer with curative intent, with low QoL (determined by the FACT-G) and randomise with an allocation ratio of 1:1 to the intervention or control. The intervention (ACT+) will be delivered by NHS Talking Therapies, specialist services, and cancer charities. The intervention consists of up to eight sessions at weekly or fortnightly intervals using different modalities of delivery to suit individual needs, i.e. face-to-face sessions, over the phone or skype. DISCUSSION To date, there have been no robust trials reporting both clinical and cost-effectiveness of an ACT based intervention for people with low QoL after curative cancer treatment in the UK. We will provide high quality evidence of the effectiveness and cost-effectiveness of adding ACT+ to usual aftercare provided by the NHS. If shown to be effective and cost-effective then commissioners, providers and cancer charities will know how to improve QoL in cancer survivors and their families. TRIAL REGISTRATION ISRCTN: ISRCTN67900293 . Registered on 09 December 2019. All items from the World Health Organization Trial Registration Data Set for this protocol can be found in Additional file 2 Table S1.
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Affiliation(s)
- Imran Khan
- Barts and the London Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Stephanie J C Taylor
- Barts and the London Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK.
| | - Clare Robinson
- Barts and the London Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Elisavet Moschopoulou
- Barts and the London Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Paul McCrone
- Institute for Lifecourse Development, University of Greenwich, London, UK
| | - Liam Bourke
- Dept. Allied Health Professionals, Sheffield Hallam University, Sheffield, UK
| | - Mohamed Thaha
- Blizard Institute, Queen Mary University of London, London, UK
| | - Kamaldeep Bhui
- Nuffield Department of Primary Care Health Sciences, Wadham College, University of Oxford, Oxford, UK
| | - Derek Rosario
- The Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Damien Ridge
- School of Social Sciences, University of Westminster, New Cavendish St, London, UK
| | - Sheila Donovan
- Barts and the London Centre for Primary Care, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Ania Korszun
- The Barts and the London Unit for Psychological Medicine, Centre for Psychiatry and Mental Health, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Paul Little
- Primary Care Research Centre, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Adrienne Morgan
- Independent Cancer Patient's Voice (ICPV), 17 Woodbridge Street, London, UK
| | - Olivier Quentin
- Barts and the London Pragmatic Clinical Trials Unit, Centre for Evaluation and Methods, Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Rebecca Roylance
- University College London Hospitals NHS Foundation Trust, London, UK
| | - Peter White
- The Academic Urology Unit, University of Sheffield, Sheffield, UK
| | - Trudie Chalder
- Institute of Psychiatry, Psychology & Neuroscience (IoPPN), King's College London, DeCrespigny Park, London, UK
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Hayward M, Berry K, Bremner S, Cavanagh K, Dodgson G, Fowler D, Gage H, Greenwood K, Hazell C, Bibby-Jones AM, Robertson S, Touray M, Dailey N, Strauss C. Increasing access to CBT for psychosis patients: study protocol for a randomised controlled trial evaluating brief, targeted CBT for distressing voices delivered by assistant psychologists (GiVE3). Trials 2023; 24:588. [PMID: 37715255 PMCID: PMC10503006 DOI: 10.1186/s13063-023-07611-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/28/2023] [Indexed: 09/17/2023] Open
Abstract
BACKGROUND The National Institute for Health and Care Excellence (NICE) recommends that cognitive behaviour therapy (CBT) is offered to all patients with a psychosis diagnosis. However, only a minority of psychosis patients in England and Wales are offered CBT. This is attributable, in part, to the resource-intensive nature of CBT. One response to this problem has been the development of CBT in brief formats that are targeted at a single symptom and are deliverable by briefly trained therapists. We have developed Guided self-help CBT (the GiVE intervention) as a brief form of CBT for distressing voices and reported evidence for the feasibility of a randomised controlled trial (RCT) when the intervention was delivered by briefly trained therapists (assistant psychologists). This study will investigate the clinical and cost-effectiveness of the GiVE intervention when delivered by assistant psychologists following a brief training. METHODS This study is a pragmatic, two-arm, parallel group, superiority RCT comparing the GiVE intervention (delivered by assistant psychologists) and treatment as usual to treatment as usual alone, recruiting across three sites, using 1:1 allocation and blind post-treatment and follow-up assessments. A nested qualitative study will develop a model for implementation. DISCUSSION If the GiVE intervention is found to be effective when delivered by assistant psychologists, this intervention could significantly contribute to increasing access to evidence-based psychological interventions for psychosis patients. Furthermore, implementation across secondary care services within the UK's National Health Service may pave the way for other symptom-specific and less resource-intensive CBT-informed interventions for psychosis patients to be developed and evaluated. TRIAL REGISTRATION Current Controlled Trials ISRCTN registration number: 12748453. Registered on 28 September 2022.
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Affiliation(s)
- Mark Hayward
- School of Psychology, University of Sussex, Brighton, BN1 9RH, UK.
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, BN3 7HZ, UK.
| | - Katherine Berry
- Faculty of Biology, University of Manchester, Medicine & Health, Manchester, M13 9PL, UK
| | - Stephen Bremner
- Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9RH, UK
| | - Kate Cavanagh
- School of Psychology, University of Sussex, Brighton, BN1 9RH, UK
| | - Guy Dodgson
- Department of Psychology, University of Durham, Durham, DH1 3LE, UK
| | - David Fowler
- School of Psychology, University of Sussex, Brighton, BN1 9RH, UK
| | - Heather Gage
- School of Biosciences & Medicine, University of Surrey, Guildford, GU2 7XH, UK
| | | | - Cassie Hazell
- School of Psychology, University of Surrey, Guildford, GU2 7HX, UK
| | - Anna-Marie Bibby-Jones
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, BN3 7HZ, UK
| | - Sam Robertson
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, BN3 7HZ, UK
| | - Morro Touray
- School of Biosciences & Medicine, University of Surrey, Guildford, GU2 7XH, UK
| | - Natalie Dailey
- Brighton & Sussex Medical School, University of Sussex, Brighton, BN1 9RH, UK
| | - Clara Strauss
- School of Psychology, University of Sussex, Brighton, BN1 9RH, UK
- Research and Development Department, Sussex Partnership NHS Foundation Trust, Hove, BN3 7HZ, UK
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Graboyes EM, Maurer S, Balliet W, Li H, Williams AM, Osazuwa-Peters N, Yan F, Padgett L, Rush A, Ruggiero KJ, Sterba KR. Efficacy of a Brief Tele-Cognitive Behavioral Treatment vs Attention Control for Head and Neck Cancer Survivors With Body Image Distress: A Pilot Randomized Clinical Trial. JAMA Otolaryngol Head Neck Surg 2023; 149:54-62. [PMID: 36454561 PMCID: PMC9716435 DOI: 10.1001/jamaoto.2022.3700] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Accepted: 10/01/2022] [Indexed: 12/05/2022]
Abstract
Importance Although 1 in 4 head and neck cancer (HNC) survivors experience clinically significant body image distress (BID), a psychosocial morbidity that adversely affects quality of life, effective interventions for these patients are lacking. Objective To evaluate the acceptability and preliminary efficacy of BRIGHT (Building a Renewed ImaGe after Head and neck cancer Treatment), a brief tele-cognitive behavioral therapy, at reducing BID among HNC survivors. Design, Setting, and Participants This parallel-group pilot randomized clinical trial recruited adult HNC survivors with BID between August 13, 2020, and December 9, 2021, from the Medical University of South Carolina HNC clinic during a routine survivorship encounter. Data were analyzed from May 3 to June 16, 2022. Interventions BRIGHT consisted of 5 weekly psychologist-led video tele-cognitive behavioral therapy sessions. Attention control (AC) consisted of dose- and delivery-matched survivorship education. Main Outcomes and Measures Change in HNC-related BID was assessed using IMAGE-HN (Inventory to Measure and Assess imaGe disturbancE-Head and Neck), a validated patient-reported outcome (score range, 0-84, with higher scores indicating greater HNC-related BID). Clinical response rate was measured as the proportion of patients with a clinically meaningful change in IMAGE-HN scores. Results Of the 44 HNC survivors with BID allocated to BRIGHT (n = 20) or AC (n = 24), the median (range) age was 63 (41-80) years, and 27 patients (61%) were female. Patients rated BRIGHT's acceptability highly (all metrics had a mean rating of ≥4.5/5), and 19 of 20 patients (95%) receiving BRIGHT were likely or highly likely to recommend it to other HNC survivors with BID. BRIGHT decreased HNC-related BID from baseline to 1 month postintervention relative to AC (mean model-based difference in change in IMAGE-HN score, -7.9 points; 90% CI, -15.9 to 0.0 points) and from baseline to 3 months postintervention relative to AC (mean model-based difference in change in IMAGE-HN score, -17.1 points; 90% CI, -25.6 to -8.6 points). At 3 months postintervention, the clinical response rate of BRIGHT was 6.6-fold higher than AC (model-based odds ratio, 6.6; 90% CI, 2.0-21.8). The improvement in HNC-related BID for BRIGHT vs AC at 3 months was clinically significant, and the effect size was large (Cohen d, -0.9; 90% CI, -1.4 to -0.4). Conclusions and Relevance In this pilot randomized clinical trial, BRIGHT was acceptable, may result in a clinically meaningful improvement in HNC-related BID, and showed a high clinical response rate. These promising preliminary data support conducting a large efficacy trial to establish BRIGHT as the first evidence-based treatment for HNC survivors with BID. Trial Registration ClinicalTrials.gov Identifier: NCT03831100.
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Affiliation(s)
- Evan M. Graboyes
- Department of Otolaryngology–Head and Neck Surgery, College of Medicine, Medical University of South Carolina, Charleston
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston
| | - Stacey Maurer
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston
| | - Wendy Balliet
- Department of Psychiatry and Behavioral Sciences, College of Medicine, Medical University of South Carolina, Charleston
| | - Hong Li
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston
| | - Amy M. Williams
- Department of Family Medicine, Henry Ford Health, Detroit, Michigan
| | - Nosayaba Osazuwa-Peters
- Department of Head and Neck Surgery & Communication Sciences, Duke University School of Medicine, Durham, North Carolina
| | - Flora Yan
- Department of Otolaryngology–Head and Neck Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania
| | - Lynne Padgett
- Office of Research and Development, US Department of Veteran Affairs, Washington, DC
| | - Angie Rush
- Head and Neck Cancer Alliance, Charleston, South Carolina
| | | | - Katherine R. Sterba
- Department of Public Health Sciences, College of Medicine, Medical University of South Carolina, Charleston
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Winkler CD, Koval P, Phillips LJ, Felmingham KL. Does prediction error during exposure relate to clinical outcomes in cognitive behavior therapy for social anxiety disorder? A study protocol. Front Psychiatry 2022; 13:1000686. [PMID: 37082515 PMCID: PMC10111196 DOI: 10.3389/fpsyt.2022.1000686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 11/08/2022] [Indexed: 11/25/2022] Open
Abstract
Facing your fears, or exposure therapy, is an effective psychological intervention for anxiety disorders that is often thought to work through fear extinction learning. Fear extinction learning is a type of associative learning where fear reduces through repeated encounters with a feared situation or stimulus in the absence of aversive outcomes. Laboratory research suggests fear extinction learning is driven by threat prediction errors, defined as when fearful predictions do not eventuate. Threat prediction error and its relationship to exposure therapy outcomes haven't been studied enough in actual therapy settings. It remains unclear whether prediction error and extinction learning are central mechanisms of exposure therapy. We are conducting a longitudinal and observational study of how threat prediction error during exposure in social anxiety disorder (SAD) treatment relates to session-by-session symptom change and treatment outcome in addition to exposure surprise and learning outcome. We aim to recruit 65 adults with a primary diagnosis of SAD through an outpatient psychology clinic. Participants will receive 12 sessions of individual manualized cognitive behavioral therapy (CBT), adapted from an efficacious group protocol, that includes graded exposure. Exposure processes, including self-report measures of anxiety, threat prediction, threat outcomes, surprise, and learning outcome, will be measured with smartphone-based event-contingent ecological momentary assessments (EMAs) of all behavioral experiments completed during treatment. Clinical outcomes include self-reported social anxiety symptoms and social threat appraisals, at each session, post and 3-months after treatment. Prediction error will be operationalized as the mismatch between the threat prediction and threat outcome. The joint effect of threat prediction and threat outcome on session-by-session symptom change, treatment outcome, exposure surprise, and learning outcome will be explored using multilevel modeling. The present study will help determine whether threat prediction error during exposures in SAD treatment is related to theoretically implied clinical outcomes. This would contribute to the larger research aim of clarifying exposure therapy mechanisms.
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Affiliation(s)
- Christopher D. Winkler
- Melbourne School of Psychological Sciences, University of Melbourne, Melbourne, VIC, Australia
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Fritz JM, Del Fiol G, Gibson B, Wetter DW, Solis V, Bennett E, Thackeray A, Goode A, Lundberg K, Romero A, Ford I, Stevens L, Siaperas T, Morales J, Yack M, Greene T. BeatPain Utah: study protocol for a pragmatic randomised trial examining telehealth strategies to provide non-pharmacologic pain care for persons with chronic low back pain receiving care in federally qualified health centers. BMJ Open 2022; 12:e067732. [PMID: 36351735 PMCID: PMC9664275 DOI: 10.1136/bmjopen-2022-067732] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Although evidence-based guidelines recommend non-pharmacologic treatments as first-line care for chronic low back pain (LBP), uptake has been limited, particularly in rural, low-income and ethnically diverse communities. The BeatPain study will evaluate the implementation and compare the effectiveness of two strategies to provide non-pharmacologic treatment for chronic LBP. The study will use telehealth to overcome access barriers for persons receiving care in federally qualified health centres (FQHCs) in the state of Utah. METHODS AND ANALYSIS BeatPain Utah is a pragmatic randomised clinical trial with a hybrid type I design investigating different strategies to provide non-pharmacologic care for adults with chronic LBP seen in Utah FQHCs. The intervention strategies include a brief pain consult (BPC) and telehealth physical therapy (PT) component provided using either an adaptive or sequenced delivery strategy across two 12-week treatment phases. Interventions are provided via telehealth by centrally located physical therapists. The sequenced delivery strategy provides the BPC, followed by telehealth PT in the first 12 weeks for all patients. The adaptive strategy uses a stepped care approach and provides the BPC in the first 12 weeks and telehealth PT to patients who are non-responders to the BPC component. We will recruit 500 English-speaking or Spanish-speaking participants who will be individually randomised with 1:1 allocation. The primary outcome is the Pain, Enjoyment and General Activity measure of pain impact with secondary outcomes including the additional pain assessment domains specified by the National Institutes (NIH) of Health Helping to End Addiction Long Initiative and implementation measures. Analyses of primary and secondary measures of effectiveness will be performed under longitudinal mixed effect models across assessments at baseline, and at 12, 26 and 52 weeks follow-ups. ETHICS AND DISSEMINATION Ethics approval for the study was obtained from the University of Utah Institutional Review Board. On completion, study data will be made available in compliance with NIH data sharing policies. TRIAL REGISTRATION NUMBER NCT04923334.
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Affiliation(s)
- Julie M Fritz
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Guilherme Del Fiol
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Bryan Gibson
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - David W Wetter
- Population Sciences, Huntsman Cancer Institute, Salt Lake City, Utah, USA
| | - Victor Solis
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Emily Bennett
- Association for Utah Community Health, Salt Lake City, Utah, USA
| | - Anne Thackeray
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Adam Goode
- Orthopedic Surgery and Population Health Sciences, Duke University, Durham, North Carolina, USA
| | - Kelly Lundberg
- Department of Psychiatry, University of Utah, Salt Lake City, Utah, USA
| | - Adrianna Romero
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Isaac Ford
- Department of Physical Therapy & Athletic Training, The University of Utah, Salt Lake City, Utah, USA
| | - Leticia Stevens
- Department of Biomedical Informatics, University of Utah, Salt Lake City, Utah, USA
| | - Tracey Siaperas
- Association for Utah Community Health, Salt Lake City, Utah, USA
| | - Jennyfer Morales
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah, USA
| | - Melissa Yack
- Center for Health Outcomes and Population Equity - Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah, USA
| | - Tom Greene
- Division of Epidemiology, University of Utah, Salt Lake City, Utah, USA
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Hayes D, Henderson C, Bakolis I, Lawrence V, Elliott RA, Ronaldson A, Richards G, Repper J, Bates P, Brewin J, Meddings S, Winship G, Bishop S, Emsley R, Elton D, McNaughton R, Whitley R, Smelson D, Stepanian K, McPhilbin M, Dunnett D, Hunter-Brown H, Yeo C, Jebara T, Slade M. Recovery Colleges Characterisation and Testing in England (RECOLLECT): rationale and protocol. BMC Psychiatry 2022; 22:627. [PMID: 36153488 PMCID: PMC9509550 DOI: 10.1186/s12888-022-04253-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 09/11/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recovery Colleges are a relatively recent initiative within mental health services. The first opened in 2009 in London and since then numbers have grown. They are based on principles of personal recovery in mental health, co-production between people with lived experience of mental health problems and professionals, and adult learning. Student eligibility criteria vary, but all serve people who use mental health services, with empirical evidence of benefit. Previously we developed a Recovery College fidelity measure and a preliminary change model identifying the mechanisms of action and outcomes for this group, which we refer to as service user students. The Recovery Colleges Characterisation and Testing (RECOLLECT) study is a five-year (2020-2025) programme of research in England. The aim of RECOLLECT is to determine Recovery Colleges' effectiveness and cost-effectiveness, and identify organisational influences on fidelity and improvements in mental health outcomes. METHODS: RECOLLECT comprises i) a national survey of Recovery Colleges, ii) a prospective cohort study to establish the relationship between fidelity, mechanisms of action and psychosocial outcomes, iii) a prospective cohort study to investigate effectiveness and cost-effectiveness, iv) a retrospective cohort study to determine the relationship between Recovery College use and outcomes and mental health service use, and v) organisational case studies to establish the contextual and organisational factors influencing fidelity and outcomes. The programme has been developed with input from individuals who have lived experience of mental health problems. A Lived Experience Advisory Panel will provide input into all stages of the research. DISCUSSION RECOLLECT will provide the first rigorous evidence on the effectiveness and cost effectiveness of Recovery Colleges in England, to inform their prioritising, commissioning, and running. The validated RECOLLECT multilevel change model will confirm the active components of Recovery Colleges. The fidelity measure and evidence about the fidelity-outcome relationship will provide an empirically-based approach to develop Recovery Colleges, to maximise benefits for students. Findings will be disseminated through the study website (researchintorecovery.com/recollect) and via national and international Recovery College networks to maximise impact, and will shape policy on how Recovery Colleges can help those with mental health problems lead empowered, meaningful and fulfilling lives.
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Affiliation(s)
- Daniel Hayes
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Claire Henderson
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK.
- South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK.
| | - Ioannis Bakolis
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
- Department of Biostatistics and Health Informatics, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Vanessa Lawrence
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Rachel A Elliott
- Manchester Centre for Health Economics, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Amy Ronaldson
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Gabrielle Richards
- South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
| | - Julie Repper
- ImROC-Implementing Recovery for Organisational Change, Nottinghamshire Healthcare NHS Foundation Trust, Duncan Macmillan House, Porchester Road, Mapperley, Nottingham, NG3 6AA, UK
| | - Peter Bates
- Peter Bates Associates, 96 Burlington Road, Nottingham, NG5 2GS, UK
| | - John Brewin
- Nottingham Healthcare NHS Foundation Trust, Duncan MacMillan House, Porchester Rd, Mapperley, Nottingham, NG3 6AA, UK
| | - Sara Meddings
- ImROC-Implementing Recovery for Organisational Change, Nottinghamshire Healthcare NHS Foundation Trust, Duncan Macmillan House, Porchester Road, Mapperley, Nottingham, NG3 6AA, UK
| | - Gary Winship
- University of Nottingham School of Education, Nottingham, NG8 1BB, UK
| | - Simon Bishop
- Nottingham University Business School, Nottingham, NG8 1BB, UK
| | - Richard Emsley
- Department of Biostatistics and Health Informatics, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Daniel Elton
- RECOLLECT Lived Experience Advisory Panel, Nottingham, UK
| | | | - Rob Whitley
- Department of Psychiatry, Douglas Research Centre, McGill University, 6875 LaSalle Boulevard, Montreal, Quebec, H4H 1R3, Canada
| | - David Smelson
- Department of Psychiatry, University of Massachusetts Medical School, 55 Lake Avenue, North Worcester, Massachusetts, 01655, USA
| | - Katy Stepanian
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Merly McPhilbin
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, NG7 2TU, UK
| | - Danielle Dunnett
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Holly Hunter-Brown
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Caroline Yeo
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, NG7 2TU, UK
| | - Tesnime Jebara
- Health Service and Population Research Department, David Goldberg Centre, King's College London Institute of Psychiatry, Psychology and Neuroscience, De Crespigny Park, London, SE5 8AF, UK
| | - Mike Slade
- School of Health Sciences, Institute of Mental Health, University of Nottingham, Nottingham, NG7 2TU, UK
- Nord University, Postboks 474, 7801, Namsos, Norway
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A parallel randomised controlled trial of the Hypoglycaemia Awareness Restoration Programme for adults with type 1 diabetes and problematic hypoglycaemia despite optimised self-care (HARPdoc). Nat Commun 2022; 13:2229. [PMID: 35484106 PMCID: PMC9050729 DOI: 10.1038/s41467-022-29488-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/18/2022] [Indexed: 02/02/2023] Open
Abstract
Impaired awareness of hypoglycaemia (IAH) is a major risk for severe hypoglycaemia in insulin treatment of type 1 diabetes (T1D). To explore the hypothesis that unhelpful health beliefs create barriers to regaining awareness, we conducted a multi-centre, randomised, parallel, two-arm trial (ClinicalTrials.gov NCT02940873) in adults with T1D and treatment-resistant IAH and severe hypoglycaemia, with blinded analysis of 12-month recall of severe hypoglycaemia at 12 and/or 24 months the primary outcome. Secondary outcomes included cognitive and emotional measures. Adults with T1D, IAH and severe hypoglycaemia despite structured education in insulin adjustment, +/- diabetes technologies, were randomised to the "Hypoglycaemia Awareness Restoration Programme despite optimised self-care" (HARPdoc, n = 49), a psychoeducation programme uniquely focussing on changing cognitive barriers to avoiding hypoglycaemia, or the evidence-based "Blood Glucose Awareness Training" (BGAT, n = 50), both delivered over six weeks. Median [IQR] severe hypoglycaemia at baseline was 5[2-12] per patient/year, 1[0-5] at 12 months and 0[0-2] at 24 months, with no superiority for HARPdoc (HARPdoc vs BGAT incident rate ratios [95% CI] 1.25[0.51, 3.09], p = 0.62 and 1.26[0.48, 3.35], p = 0.64 respectively), nor for changes in hypoglycaemia awareness scores or fear. Compared to BGAT, HARPdoc significantly reduced endorsement of unhelpful cognitions (Estimated Mean Difference for Attitudes to Awareness scores at 24 months, -2.07 [-3.37,-0.560], p = 0.01) and reduced scores for diabetes distress (-6.70[-12.50,-0.89], p = 0.02); depression (-1.86[-3.30, -0.43], p = 0.01) and anxiety (-1.89[-3.32, -0.47], p = 0.01). Despite positive impact on cognitive barriers around hypoglycaemia avoidance and on diabetes-related and general emotional distress scores, HARPdoc was not more effective than BGAT at reducing severe hypoglycaemia.
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Neukel C, Bermpohl F, Kaess M, Taubner S, Boedeker K, Williams K, Dempfle A, Herpertz SC. Understanding and breaking the intergenerational cycle of abuse in families enrolled in routine mental health services: study protocol for a randomized controlled trial and two non-interventional trials investigating mechanisms of change within the UBICA II consortium. Trials 2021; 22:749. [PMID: 34711261 PMCID: PMC8555002 DOI: 10.1186/s13063-021-05653-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 09/24/2021] [Indexed: 11/10/2022] Open
Abstract
Background Parents’ mental illness (MI) and parental history of early life maltreatment (ELM) are known to be significant risk factors for poor parenting while poor parenting is a crucial mediator of the intergenerational continuity of child maltreatment. Hence, maltreatment prevention programs for families with an MI parent, which pay particular attention to experiences of ELM in the parent, are urgently needed. Parental mentalizing was previously found to mediate successful parenting. Interventions aimed at improving the parental mentalizing capacity reduced maltreatment risk in parents. The aim of the present study is to investigate the effectiveness of a mentalization-based parenting-counseling in acutely mentally ill parents currently treated at a psychiatric hospital. Methods Mentalization-based parenting-counseling (MB-PC) vs. enhanced standard clinical care (SCC+) will be administered in a cluster-randomized-controlled trial (RCT). Patients treated at psychiatric hospitals with children between 1.5 and 15 years will be included in the trial. MB-PC will be administered as a 12-h combined individual and group program enriched by social counseling (over a course of 5 weeks) as add-on to standard clinical care, while the control condition will be standard clinical care plus a 90-min psychoeducation workshop on positive parenting. Primary efficacy endpoint is self-reported parenting practices at follow-up. Embedded within the RCT will be two sub-studies investigating social cognition and dyadic synchrony as biobehavioral mechanisms of change. Discussion The main goal of the present study is to investigate ways to break the intergenerational continuity of maltreatment by assessing the benefits of a prevention program which aims at improving parenting in vulnerable mothers and fathers. MB-PC is a short, low-cost intervention which can be delivered by nurses and social workers and is applicable to MI patients with children with a broad range of diagnoses. If it is shown to be effective, it can be directly implemented into standard psychiatric hospital care thereby providing help to prevent child maltreatment. Trial registration German Clinical Trials Register DRKS00017398. Registered on 5 July 2019
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Affiliation(s)
- C Neukel
- Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany.
| | - F Bermpohl
- Department of Psychiatry and Psychotherapy, Berlin Institute of Health, Charité Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität Zu Berlin, Campus Charité Mitte, Berlin, Germany, Berlin, Germany
| | - M Kaess
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany.,University Hospital of Child and Adolescent Psychiatry and Psychotherapy, University of Bern, Bern, Switzerland
| | - S Taubner
- Department of Psychosocial Prevention, University Hospital of Heidelberg, Heidelberg, Germany
| | - K Boedeker
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health (BIH), Campus Virchow-Klinikum, Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, Berlin, Germany
| | - K Williams
- Department of Child and Adolescent Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany
| | - A Dempfle
- Institute of Medical Informatics and Statistics, University Hospital Schleswig-Holstein, Campus Kiel, Kiel, Germany
| | - S C Herpertz
- Department of General Psychiatry, Center for Psychosocial Medicine, Heidelberg University, Heidelberg, Germany
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9
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Goldstein LH, Robinson EJ, Pilecka I, Perdue I, Mosweu I, Read J, Jordan H, Wilkinson M, Rawlings G, Feehan SJ, Callaghan H, Day E, Purnell J, Baldellou Lopez M, Brockington A, Burness C, Poole NA, Eastwood C, Moore M, Mellers JD, Stone J, Carson A, Medford N, Reuber M, McCrone P, Murray J, Richardson MP, Landau S, Chalder T. Cognitive-behavioural therapy compared with standardised medical care for adults with dissociative non-epileptic seizures: the CODES RCT. Health Technol Assess 2021; 25:1-144. [PMID: 34196269 DOI: 10.3310/hta25430] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Dissociative (non-epileptic) seizures are potentially treatable by psychotherapeutic interventions; however, the evidence for this is limited. OBJECTIVES To evaluate the clinical effectiveness and cost-effectiveness of dissociative seizure-specific cognitive-behavioural therapy for adults with dissociative seizures. DESIGN This was a pragmatic, multicentre, parallel-arm, mixed-methods randomised controlled trial. SETTING This took place in 27 UK-based neurology/epilepsy services, 17 liaison psychiatry/neuropsychiatry services and 18 cognitive-behavioural therapy services. PARTICIPANTS Adults with dissociative seizures in the previous 8 weeks and no epileptic seizures in the previous year and meeting other eligibility criteria were recruited to a screening phase from neurology/epilepsy services between October 2014 and February 2017. After psychiatric assessment around 3 months later, eligible and interested participants were randomised between January 2015 and May 2017. INTERVENTIONS Standardised medical care consisted of input from neurologists and psychiatrists who were given guidance regarding diagnosis delivery and management; they provided patients with information booklets. The intervention consisted of 12 dissociative seizure-specific cognitive-behavioural therapy 1-hour sessions (plus one booster session) that were delivered by trained therapists, in addition to standardised medical care. MAIN OUTCOME MEASURES The primary outcome was monthly seizure frequency at 12 months post randomisation. The secondary outcomes were aspects of seizure occurrence, quality of life, mood, anxiety, distress, symptoms, psychosocial functioning, clinical global change, satisfaction with treatment, quality-adjusted life-years, costs and cost-effectiveness. RESULTS In total, 698 patients were screened and 368 were randomised (standardised medical care alone, n = 182; and cognitive-behavioural therapy plus standardised medical care, n = 186). Primary outcome data were obtained for 85% of participants. An intention-to-treat analysis with multivariate imputation by chained equations revealed no significant between-group difference in dissociative seizure frequency at 12 months [standardised medical care: median of seven dissociative seizures (interquartile range 1-35 dissociative seizures); cognitive-behavioural therapy and standardised medical care: median of four dissociative seizures (interquartile range 0-20 dissociative seizures); incidence rate ratio 0.78, 95% confidence interval 0.56 to 1.09; p = 0.144]. Of the 16 secondary outcomes analysed, nine were significantly better in the arm receiving cognitive-behavioural therapy at a p-value < 0.05, including the following at a p-value ≤ 0.001: the longest dissociative seizure-free period in months 7-12 inclusive post randomisation (incidence rate ratio 1.64, 95% confidence interval 1.22 to 2.20; p = 0.001); better psychosocial functioning (Work and Social Adjustment Scale, standardised treatment effect -0.39, 95% confidence interval -0.61 to -0.18; p < 0.001); greater self-rated and clinician-rated clinical improvement (self-rated: standardised treatment effect 0.39, 95% confidence interval 0.16 to 0.62; p = 0.001; clinician rated: standardised treatment effect 0.37, 95% confidence interval 0.17 to 0.57; p < 0.001); and satisfaction with treatment (standardised treatment effect 0.50, 95% confidence interval 0.27 to 0.73; p < 0.001). Rates of adverse events were similar across arms. Cognitive-behavioural therapy plus standardised medical care produced 0.0152 more quality-adjusted life-years (95% confidence interval -0.0106 to 0.0392 quality-adjusted life-years) than standardised medical care alone. The incremental cost-effectiveness ratio (cost per quality-adjusted life-year) for cognitive-behavioural therapy plus standardised medical care versus standardised medical care alone based on the EuroQol-5 Dimensions, five-level version, and imputed data was £120,658. In sensitivity analyses, incremental cost-effectiveness ratios ranged between £85,724 and £206,067. Qualitative and quantitative process evaluations highlighted useful study components, the importance of clinical experience in treating patients with dissociative seizures and potential benefits of our multidisciplinary care pathway. LIMITATIONS Unlike outcome assessors, participants and clinicians were not blinded to the interventions. CONCLUSIONS There was no significant additional benefit of dissociative seizure-specific cognitive-behavioural therapy in reducing dissociative seizure frequency, and cost-effectiveness over standardised medical care was low. However, this large, adequately powered, multicentre randomised controlled trial highlights benefits of adjunctive dissociative seizure-specific cognitive-behavioural therapy for several clinical outcomes, with no evidence of greater harm from dissociative seizure-specific cognitive-behavioural therapy. FUTURE WORK Examination of moderators and mediators of outcome. TRIAL REGISTRATION Current Controlled Trials ISRCTN05681227 and ClinicalTrials.gov NCT02325544. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 43. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emily J Robinson
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Izabela Pilecka
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iain Perdue
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Iris Mosweu
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Julie Read
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Harriet Jordan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Matthew Wilkinson
- Canterbury Christ Church University, Salamons Institute for Applied Psychology, Tunbridge Wells, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Gregg Rawlings
- School of Clinical Psychology, University of Sheffield, Sheffield, UK
| | - Sarah J Feehan
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Hannah Callaghan
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Elana Day
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - James Purnell
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Maria Baldellou Lopez
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Alice Brockington
- Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Norman A Poole
- Department of Neuropsychiatry, St George's Hospital, South West London and St George's NHS Mental Health NHS Trust, London, UK
| | - Carole Eastwood
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Michele Moore
- Centre for Social Justice and Global Responsibility, School of Law and Social Sciences, London South Bank University, London, UK
| | | | - Jon Stone
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Alan Carson
- Department of Clinical Neuroscience, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Nick Medford
- South London and Maudsley NHS Foundation Trust, London, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Paul McCrone
- King's Health Economics, King's College London, Institute of Psychiatry, Psychology and Neuroscience, London, UK
| | - Joanna Murray
- Department of Health Services & Population Research, Institute of Psychiatry,Psychology and Neuroscience, King's College London, London, UK
| | - Mark P Richardson
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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10
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Slesnick N, Chavez L, Bunger A, Famelia R, Ford J, Feng X, Higgins S, Holowacz E, Jaderlund S, Luthy E, Mallory A, Martin J, Walsh L, Yilmazer T, Kelleher K. Housing, opportunities, motivation and engagement (HOME) for homeless youth at-risk for opioid use disorder: study protocol for a randomized controlled trial. Addict Sci Clin Pract 2021; 16:30. [PMID: 33980315 PMCID: PMC8115873 DOI: 10.1186/s13722-021-00237-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 04/23/2021] [Indexed: 01/18/2023] Open
Abstract
Background Homeless youth experience high rates of substance use disorders, exposures to violence, mental and physical health conditions, and mortality. They have been particularly affected by the opioid crisis. However, no study to date has used a randomized controlled design to test preventive interventions of opioid and other drug use among this vulnerable population. Resolution of youth homelessness through housing and supportive services including prevention services, often referred to as “Housing First,” has great potential to reduce the likelihood for the development of an opioid use disorder as well as other problem behaviors associated with living on the streets. Housing First has been tested through randomized trials among homeless adults with mental health and substance use disorders, but has not been empirically tested for opioid prevention among homeless youth. Methods Homeless youth will be recruited from a drop-in shelter site frequented by disconnected youth; they will be screened for eligibility, including current homelessness, age 18–24 years, and not currently meeting criteria for opioid use disorder (OUD). In a controlled trial, 240 youth will then be randomized to one of two conditions, (1) housing + opioid and related risk prevention services, or (2) opioid and related risk prevention services alone. This project utilizes existing efficacious models of prevention to address opioid-related risks, including motivational interviewing, strengths-based outreach and advocacy, and an HIV risk preventive intervention. Follow-up will be conducted at 3, 6, 9 and 12-months post-baseline. The economic cost of each intervention will be determined to support implementation decisions with other providers and their funders. Discussion This study will provide essential information for researchers and providers on the efficacy of housing + opioid and related risk prevention services in an RCT for effects on opioid use and mechanisms underlying change. Because youth experiencing homelessness are at increased risk for a variety of adverse outcomes, the proposed intervention may produce substantial health care benefits to the youths and society at large. Trial registration ClinicalTrials.gov, NCT04135703, Registered October 13, 2019, https://clinicaltrials.gov/ct2/show/NCT04135703?term=NCT04135703&draw=2&rank=1#contacts
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Affiliation(s)
- Natasha Slesnick
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA.
| | - Laura Chavez
- Center for Innovation in Pediatric Practice, The Abigail Wexner Research Institute At Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Alicia Bunger
- College of Social Work, The Ohio State University, 1947 N. College Road, Columbus, OH, 43210, USA
| | - Ruri Famelia
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Jodi Ford
- College of Nursing, The Ohio State University, 1585 Neil Avenue, Columbus, OH, 43210, USA
| | - Xin Feng
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Sarah Higgins
- Center for Innovation in Pediatric Practice, The Abigail Wexner Research Institute At Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Eugene Holowacz
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Soren Jaderlund
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Ellison Luthy
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Allen Mallory
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Jared Martin
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Laura Walsh
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Tansel Yilmazer
- Department of Human Sciences, College of Education and Human Ecology, The Ohio State University, 1787 Neil Ave, Columbus, OH, 43210, USA
| | - Kelly Kelleher
- Center for Innovation in Pediatric Practice, The Abigail Wexner Research Institute At Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
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11
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Kelcey B, Xie Y, Spybrook J, Dong N. Power and Sample Size Determination for Multilevel Mediation in Three-Level Cluster-Randomized Trials. MULTIVARIATE BEHAVIORAL RESEARCH 2021; 56:496-513. [PMID: 32293929 DOI: 10.1080/00273171.2020.1738910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
Mediation analyses supply a principal lens to probe the pathways through which a treatment acts upon an outcome because they can dismantle and test the core components of treatments and test how these components function as a coordinated system or theory of action. Experimental evaluation of mediation effects in addition to total effects has become increasingly common but literature has developed only limited guidance on how to plan mediation studies with multi-tiered hierarchical or clustered structures. In this study, we provide methods for computing the power to detect mediation effects in three-level cluster-randomized designs that examine individual- (level one), intermediate- (level two) or cluster-level (level three) mediators. We assess the methods using a simulation and provide examples of a three-level clinic-randomized study (individuals nested within therapists nested within clinics) probing an individual-, intermediate- or cluster-level mediator using the R package PowerUpR and its Shiny application.
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Affiliation(s)
- Ben Kelcey
- College of Education, Criminal Justice, Human Services and Information Technology, University of Cincinnati
| | - Yanli Xie
- College of Education, Criminal Justice, Human Services and Information Technology, University of Cincinnati
| | - Jessaca Spybrook
- College of Education, Criminal Justice, Human Services and Information Technology, Western Michigan University
| | - Nianbo Dong
- College of Education, University of North Carolina Chapel Hill
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12
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Lyon AR, Pullmann MD, Dorsey S, Levin C, Gaias LM, Brewer SK, Larson M, Corbin CM, Davis C, Muse I, Joshi M, Reyes R, Jungbluth NJ, Barrett R, Hong D, Gomez MD, Cook CR. Protocol for a hybrid type 2 cluster randomized trial of trauma-focused cognitive behavioral therapy and a pragmatic individual-level implementation strategy. Implement Sci 2021; 16:3. [PMID: 33413511 PMCID: PMC7788537 DOI: 10.1186/s13012-020-01064-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 11/26/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND More than two-thirds of youth experience trauma during childhood, and up to 1 in 5 of these youth develops posttraumatic stress symptoms that significantly impair their functioning. Although trauma-focused cognitive behavior therapy (TF-CBT) has a strong evidence base, it is rarely adopted, delivered with adequate fidelity, or evaluated in the most common setting where youth access mental health services-schools. Given that individual behavior change is ultimately required for successful implementation, even when organizational factors are firmly in place, focusing on individual-level processes represents a potentially parsimonious approach. Beliefs and Attitudes for Successful Implementation in Schools (BASIS) is a pragmatic, motivationally focused multifaceted strategy that augments training and consultation and is designed to target precise mechanisms of behavior change to produce enhanced implementation and youth clinical outcomes. This study protocol describes a hybrid type 2 effectiveness-implementation trial designed to concurrently evaluate the main effects, mediators, and moderators of both the BASIS implementation strategy on implementation outcomes and TF-CBT on youth mental health outcomes. METHODS Using a cluster randomized controlled design, this trial will assign school-based mental health (SMH) clinicians and schools to one of three study arms: (a) enhanced treatment-as-usual (TAU), (b) attention control plus TF-CBT, or (c) BASIS+TF-CBT. With a proposed sample of 120 SMH clinicians who will each recruit 4-6 youth with a history of trauma (480 children), this project will gather data across 12 different time points to address two project aims. Aim 1 will evaluate, relative to an enhanced TAU condition, the effects of TF-CBT on identified mechanisms of change, youth mental health outcomes, and intervention costs and cost-effectiveness. Aim 2 will compare the effects of BASIS against an attention control plus TF-CBT condition on theoretical mechanisms of clinician behavior change and implementation outcomes, as well as examine costs and cost-effectiveness. DISCUSSION This study will generate critical knowledge about the effectiveness and cost-effectiveness of BASIS-a pragmatic, theory-driven, and generalizable implementation strategy designed to enhance motivation-to increase the yield of evidence-based practice training and consultation, as well as the effectiveness of TF-CBT in a novel service setting. TRIAL REGISTRATION ClinicalTrials.gov registration number NCT04451161 . Registered on June 30, 2020.
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Affiliation(s)
- Aaron R Lyon
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA.
| | - Michael D Pullmann
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Shannon Dorsey
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Carol Levin
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Larissa M Gaias
- Department of Psychology, University of Massachusetts, Lowell, 850 Broadway St, Lowell, MA, 01854, USA
| | - Stephanie K Brewer
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Madeline Larson
- University of Minnesota, 250 Education Sciences Building, 56 East River Road, Minneapolis, MN, 55455, USA
| | - Catherine M Corbin
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Chayna Davis
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Ian Muse
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Mahima Joshi
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - Rosemary Reyes
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | | | - Rachel Barrett
- University of Washington, 6200 NE 74th Street, Suite 100, Seattle, WA, 98115, USA
| | - David Hong
- Washburn Training Institute, 1100 Glenwood Ave, Minneapolis, MN, 55405, USA
| | - Michael D Gomez
- Psychological Sciences, Texas Tech University, 2700 18th Street, Lubbock, TX, 79410, USA
| | - Clayton R Cook
- University of Minnesota, 250 Education Sciences Building, 56 East River Road, Minneapolis, MN, 55455, USA
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13
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Millner UC, Brandt D, Chan L, Jette A, Marfeo E, Ni P, Rasch E, Rogers ES. Exploring Counselor‐Client Agreement on Clients’ Work Capacity in Established and Consultative Dyads. JOURNAL OF EMPLOYMENT COUNSELING 2020. [DOI: 10.1002/joec.12148] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
| | - Diane Brandt
- Rehabilitation Medicine Department National Institutes of Health (NIH)
| | - Leighton Chan
- Rehabilitation Medicine Department National Institutes of Health (NIH)
| | - Alan Jette
- School of Public Health Boston University
| | | | | | - Elizabeth Rasch
- Rehabilitation Medicine Department National Institutes of Health (NIH)
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14
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Everitt H, Landau S, Little P, Bishop FL, O'Reilly G, Sibelli A, Holland R, Hughes S, Windgassen S, McCrone P, Goldsmith K, Coleman N, Logan R, Chalder T, Moss-Morris R. Therapist telephone-delivered CBT and web-based CBT compared with treatment as usual in refractory irritable bowel syndrome: the ACTIB three-arm RCT. Health Technol Assess 2020; 23:1-154. [PMID: 31042143 DOI: 10.3310/hta23170] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Irritable bowel syndrome (IBS) affects 10-22% of people in the UK. Abdominal pain, bloating and altered bowel habits affect quality of life and can lead to time off work. Current treatment relies on a positive diagnosis, reassurance, lifestyle advice and drug therapies, but many people suffer ongoing symptoms. Cognitive-behavioural therapy (CBT) is recommended in guidelines for patients with ongoing symptoms but its availability is limited. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of therapist telephone-delivered CBT (TCBT) and web-based CBT (WCBT) with minimal therapist support compared with treatment as usual (TAU) in refractory IBS. DESIGN This was a three-arm randomised controlled trial. SETTING This trial took place in UK primary and secondary care. PARTICIPANTS Adults with refractory IBS (clinically significant symptoms for 12 months despite first-line therapies) were recruited from 74 general practices and three gastroenterology centres from May 2014 to March 2016. INTERVENTIONS TCBT - patient CBT self-management manual, six 60-minute telephone sessions over 9 weeks and two 60-minute booster sessions at 4 and 8 months (8 hours' therapist time). WCBT - interactive, tailored web-based CBT, three 30-minute telephone sessions over 9 weeks and two 30-minute boosters at 4 and 8 months (2.5 hours' therapist time). MAIN OUTCOME MEASURES Primary outcomes - IBS symptom severity score (IBS SSS) and Work and Social Adjustment Scale (WSAS) at 12 months. Cost-effectiveness [quality-adjusted life-years (QALYs) and health-care costs]. RESULTS In total, 558 out of 1452 patients (38.4%) screened for eligibility were recruited - 186 were randomised to TCBT, 185 were randomised to WCBT and 187 were randomised to TAU. The mean baseline Irritable Bowel Syndrome Symptom Severity Score (IBS SSS) was 265.0. An intention-to-treat analysis with multiple imputation was carried out at 12 months; IBS SSS were 61.6 points lower in the TCBT arm [95% confidence interval (CI) 89.5 to 33.8; p < 0.001] and 35.2 points lower in the WCBT arm (95% CI 57.8 to 12.6; p = 0.002) than in the TAU arm (IBS SSS of 205.6). The mean WSAS score at 12 months was 10.8 in the TAU arm, 3.5 points lower in the TCBT arm (95% CI 5.1 to 1.9; p < 0.001) and 3.0 points lower in the WCBT arm (95% CI 4.6 to 1.3; p = 0.001). For the secondary outcomes, the Subject's Global Assessment showed an improvement in symptoms at 12 months (responders) in 84.8% of the TCBT arm compared with 41.7% of the TAU arm [odds ratio (OR) 6.1, 95% CI 2.5 to 15.0; p < 0.001] and 75.0% of the WCBT arm (OR 3.6, 95% CI 2.0 to 6.3; p < 0.001). Patient enablement was 78.3% (responders) for TCBT, 23.5% for TAU (OR 9.3, 95% CI 4.5 to 19.3; p < 0.001) and 54.8% for WCBT (OR 3.5, 95% CI 2.0 to 5.9; p < 0.001). Adverse events were similar between the trial arms. The incremental cost-effectiveness ratio (ICER) (QALY) for TCBT versus TAU was £22,284 and for WCBT versus TAU was £7724. Cost-effectiveness reduced after imputation for missing values. Qualitative findings highlighted that, in the CBT arms, there was increased capacity to cope with symptoms, negative emotions and challenges of daily life. Therapist input was important in supporting WCBT. CONCLUSIONS In this large, rigorously conducted RCT, both CBT arms showed significant improvements in IBS outcomes compared with TAU. WCBT had lower costs per QALY than TCBT. Sustained improvements in IBS symptoms are possible at an acceptable cost. Suggested future research work is longer-term follow-up and research to translate these findings into usual clinical practice. FUTURE WORK Longer-term follow-up and research to translate these findings into usual clinical practice is needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN44427879. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 23, No. 17. See the NIHR Journals Library website for further project information. The University of Southampton sponsored this study. Funding was received from the NIHR HTA Board and the NIHR Clinical Research Network and support was received from the NIHR Clinical Research Network.
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Affiliation(s)
- Hazel Everitt
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sabine Landau
- Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Felicity L Bishop
- Centre for Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Gillian O'Reilly
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Alice Sibelli
- Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Rachel Holland
- Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Stephanie Hughes
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sula Windgassen
- Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Kim Goldsmith
- Biostatistics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Nicholas Coleman
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Robert Logan
- Department of Gastroenterology, King's College Hospital, London, UK
| | - Trudie Chalder
- Academic Department of Psychological Medicine, King's College London, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
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15
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Ehlers A, Wild J, Warnock-Parkes E, Grey N, Murray H, Kerr A, Rozental A, Beierl ET, Tsiachristas A, Perera-Salazar R, Andersson G, Clark DM. A randomised controlled trial of therapist-assisted online psychological therapies for posttraumatic stress disorder (STOP-PTSD): trial protocol. Trials 2020; 21:355. [PMID: 32326954 PMCID: PMC7181498 DOI: 10.1186/s13063-020-4176-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2019] [Accepted: 02/17/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Over the last few decades, effective psychological treatments for posttraumatic stress disorder (PTSD) have been developed, but many patients are currently unable to access these treatments. There is initial evidence that therapist-assisted internet-based psychological treatments are effective for PTSD and may help increase access, but it remains unclear which of these treatments work best and are most acceptable to patients. This randomised controlled trial will compare a trauma-focussed and a nontrauma-focussed therapist-assisted cognitive behavioural Internet treatment for PTSD: Internet-delivered cognitive therapy for PTSD (iCT-PTSD) and internet-delivered stress management therapy (iStress-PTSD). METHODS/DESIGN The study is a single-blind, randomised controlled trial comparing iCT-PTSD, iStress-PTSD and a 13-week wait-list condition, with an embedded process study. Assessors of treatment outcome will be blinded to trial arm. Two hundred and seventeen participants who meet DSM-5 criteria for PTSD will be randomly allocated by a computer programme to iCT-PTSD, iStress-PTSD or wait-list at a 3:3:1 ratio. The primary assessment point is at 13 weeks, and further assessments are taken at 6, 26, 39 and 65 weeks. The primary outcome measure is the severity of PTSD symptoms as measured by the PTSD Checklist for DSM-5 (PCL-5). Secondary measures of PTSD symptoms are the Clinician Administered PTSD Scale for DSM-5 (CAPS-5) and the Impact of Event Scale-Revised (IES-R). Other symptoms and well-being will be assessed with the Patient Health Questionnaire (PHQ-9), Generalised Anxiety Disorder Scale (GAD-7), WHO (Five) Well-Being Index, Work and Social Adjustment Scale (WSAS), Endicott Quality of Life Scale (QoL), and Insomnia Sleep Index (ISI). Health economics analyses will consider quality of life, productivity, health resource utilisation, employment status and state benefits, and treatment delivery costs. Process analyses will investigate candidate mediators and moderators of outcome. Patient experience will be assessed by interview and questionnaire. DISCUSSION This study will be the first to compare the efficacy of a trauma-focussed and nontrauma-focussed therapist-assisted online cognitive behavioural treatment for people with posttraumatic stress disorder. TRIAL REGISTRATION ISRCTN16806208. Registered prospectively on 5 January 2018.
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Affiliation(s)
- Anke Ehlers
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK.
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK.
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, SE5 8AF, UK.
- South London and Maudsley NHS Foundation Trust, London, SE5 8AZ, UK.
| | - Jennifer Wild
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
| | - Emma Warnock-Parkes
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, SE5 8AZ, UK
| | - Nick Grey
- Sussex Partnership NHS Foundation Trust, Aldrington House, 35 New Church Road, Hove, BN3 4AG, UK
| | - Hannah Murray
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
| | - Alice Kerr
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, SE5 8AZ, UK
| | - Alexander Rozental
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, 113 64, Stockholm, Sweden
| | - Esther T Beierl
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
| | - Apostolos Tsiachristas
- Nuffield Department of Population Health, University of Oxford, Richard Doll Building, Old Road Campus, Oxford, OX3 7LF, UK
| | - Rafael Perera-Salazar
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, University of Oxford, Woodstock Road, Oxford, OX2 6GG, UK
| | - Gerhard Andersson
- Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Institutet, Norra Stationsgatan 69, 113 64, Stockholm, Sweden
- Department of Behavioural Sciences and Learning, Linköping University, 581 83, Linköping, Sweden
| | - David M Clark
- Department of Experimental Psychology, University of Oxford, Paradise Square, Oxford, OX1 1TW, UK
- Oxford Health NHS Foundation Trust, Oxford, OX3 7JX, UK
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill, London, SE5 8AF, UK
- South London and Maudsley NHS Foundation Trust, London, SE5 8AZ, UK
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16
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Kelcey B, Bai F, Xie Y. Statistical power in partially nested designs probing multilevel mediation. Psychother Res 2020; 30:1061-1074. [PMID: 32036780 DOI: 10.1080/10503307.2020.1717012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Abstract
Objective: Analysis of the intermediate behaviors and mechanisms through which innovative therapies come to shape outcomes is a critical objective in many areas of psychotherapy research because it supports the iterative exploration, development and refinement of theories and therapies. Despite widespread interest in the intermediate behaviors and mechanisms that convey treatment effects, there is limited guidance on how to effectively and efficiently design studies to detect such mediated effects in the types of partially nested designs that commonly arise in psychotherapy research. In this study, we develop statistical power formulas to identify requisite sample sizes and guide the planning of studies probing mediation under two- and three-level partially nested designs. Method: We investigate multilevel mediation in partially nested structures and models for two- and three-level designs. Results: Well-powered studies probing mediation using partially nested designs will typically require moderate to large sample sizes or moderate to large effects. Discussion: We implement these formulas in the R package PowerUpR and a simple Shiny web application (https://poweruprshiny.shinyapps.io/PartiallyNestedMediationPower/) and demonstrate their use to plan studies using partially nested designs.
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Affiliation(s)
- Ben Kelcey
- College of Education, Criminal Justice, Human Services and Information Technology, University of Cincinnati, Cincinnati, OH, USA
| | - Fangxing Bai
- College of Education, Criminal Justice, Human Services and Information Technology, University of Cincinnati, Cincinnati, OH, USA
| | - Yanli Xie
- College of Education, Criminal Justice, Human Services and Information Technology, University of Cincinnati, Cincinnati, OH, USA
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17
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Everitt HA, Landau S, O’Reilly G, Sibelli A, Hughes S, Windgassen S, Holland R, Little P, McCrone P, Bishop F, Goldsmith K, Coleman N, Logan R, Chalder T, Moss-Morris R. Assessing telephone-delivered cognitive-behavioural therapy (CBT) and web-delivered CBT versus treatment as usual in irritable bowel syndrome (ACTIB): a multicentre randomised trial. Gut 2019; 68:1613-1623. [PMID: 30971419 PMCID: PMC6709776 DOI: 10.1136/gutjnl-2018-317805] [Citation(s) in RCA: 46] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2018] [Revised: 01/31/2019] [Accepted: 02/22/2019] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To evaluate the clinical effectiveness of two modes of cognitive-behavioural therapy (CBT) for IBS compared with treatment as usual (TAU) in refractory IBS. DESIGN A three-arm randomised controlled trial assessing telephone-delivered CBT (TCBT), web-based CBT (WCBT) with minimal therapist support, and TAU. Blinding participants and therapists was not possible. Chief investigator, assessors and statisticians were blinded. Participants were adults with refractory IBS (clinically significant symptoms for ≥12 months despite first-line therapies), recruited by letter and opportunistically from 74 general practices and three gastroenterology centres in London and South of England between May 2014 to March 2016. Co-primary outcomes were IBS Symptom Severity Score (IBS-SSS) and Work and Social Adjustment Scale (WSAS) at 12 months. RESULTS 558/1452 (38.4%) patients screened for eligibility were randomised: 76% female: 91% white: mean age 43 years. (391/558) 70.1% completed 12 months of follow-up. Primary outcomes: Compared with TAU (IBS-SSS 205.6 at 12 months), IBS-SSS was 61.6 (95% CI 33.8 to 89.5) points lower (p<0.001) in TCBT and 35.2 (95% CI 12.6 to 57.8) points lower (p=0.002) in WCBT at 12 months. Compared with TAU (WSAS score 10.8 at 12 months) WSAS was 3.5 (95% CI 1.9 to 5.1) points lower (p<0.001) in TCBT and 3.0 (95% CI 1.3 to 4.6) points lower (p=0.001) in WCBT. All secondary outcomes showed significantly greater improvement (p≤0.002) in CBT arms compared with TAU. There were no serious adverse reactions to treatment. CONCLUSION Both CBT interventions were superior to TAU up to 12 months of follow-up. TRIAL REGISTRATION NUMBER ISRCTN44427879.
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Affiliation(s)
- Hazel Anne Everitt
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sabine Landau
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Gilly O’Reilly
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Alice Sibelli
- Department of Psychology, Institue of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Stephanie Hughes
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sula Windgassen
- Department of Psychology, Institue of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Rachel Holland
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Paul McCrone
- Department of Health Services and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Felicity Bishop
- Department of Psychology, University of Southampton, Southampton, UK
| | - Kimberley Goldsmith
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Nicholas Coleman
- Department of Gastroenterology, University Hospital Southampton, Southampton, UK
| | - Robert Logan
- Department of Gastroenterology, King’s College Hospital, London, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
| | - Rona Moss-Morris
- Department of Psychology, Institue of Psychiatry, Psychology and Neuroscience, King’s College, London, UK
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18
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Amiel SA, Choudhary P, Jacob P, Smith EL, De Zoysa N, Gonder-Frederick L, Kendall M, Heller S, Brooks A, Toschi E, Kariyawasam D, Potts L, Healy A, Rogers H, Sevdalis N, Stadler M, Qayyum M, Bakolis I, Goldsmith K. Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc): protocol for a group randomised controlled trial of a novel intervention addressing cognitions. BMJ Open 2019; 9:e030356. [PMID: 31209097 PMCID: PMC6588968 DOI: 10.1136/bmjopen-2019-030356] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2019] [Revised: 04/10/2019] [Accepted: 04/12/2019] [Indexed: 12/21/2022] Open
Abstract
INTRODUCTION Severe hypoglycaemia (SH), when blood glucose falls too low to support brain function, is the most feared acute complication of insulin therapy for type 1 diabetes mellitus (T1DM). 10% of people with T1DM contribute nearly 70% of all episodes, with impaired awareness of hypoglycaemia (IAH) a major risk factor. People with IAH may be refractory to conventional approaches to reduce SH, with evidence for cognitive barriers to hypoglycaemia avoidance. This paper describes the protocol for the Hypoglycaemia Awareness Restoration Programme for People with Type 1 Diabetes and Problematic Hypoglycaemia Persisting Despite Optimised Self-care (HARPdoc) study, a trial to assess the impact on hypoglycaemia experience of a novel intervention that addresses cognitive barriers to hypoglycaemia avoidance, compared with an existing control intervention, recommended by the National Institute of Health and Care Excellence. METHODS AND ANALYSIS A randomised parallel two-arm trial of two group therapies: HARPdoc versus Blood Glucose Awareness Training, among 96 adults with T1DM and problematic hypoglycaemia, despite attendance at education with or without technology use, in four centres providing specialist T1DM services. The primary outcome will be the SH rate at 12 and/or 24 months after randomisation to either course. Secondary outcomes include rates of SH requiring parenteral therapy, involving unconsciousness or needing emergency services; hypoglycaemia awareness status, overall diabetes control and quality of life measures. An implementation study to evaluate how the interventions are delivered and how implementation impacts on clinical effectiveness is planned as a parallel study, with its own protocol. ETHICS AND DISSEMINATION The protocol was approved by the London Dulwich Research Ethics Committee, the Health Research Authority, National Health Service R&D and the Institutional Review Board of the Joslin Diabetes Center in the USA. Study findings will be disseminated to study participants and through peer-reviewed publications and conference presentations, including user groups. TRIAL REGISTRATION NUMBER NCY02940873; Pre-results.
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Affiliation(s)
- Stephanie A Amiel
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
- Department of Diabetes, King's College Hospital NHS Foundation Trust, London, UK
| | - Pratik Choudhary
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Peter Jacob
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Emma Lauretta Smith
- Department of Diabetes, King's College Hospital NHS Foundation Trust, London, UK
| | - Nicole De Zoysa
- Department of Diabetes, King's College Hospital NHS Foundation Trust, London, UK
| | - Linda Gonder-Frederick
- Department of Psychiatry and Behavioral Sciences, University of Virginia, Charlottesville, Virginia, USA
| | - Mike Kendall
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Simon Heller
- School of Medicine and Biomedical Sciences, University of Sheffield Faculty of Medicine Dentistry and Health, Sheffield, UK
| | - Augustin Brooks
- Bournemouth Diabetes and Endocrine Centre, Royal Bournemouth Hospital, Bournemouth, UK
| | - Elena Toschi
- Joslin Diabetes Center, Harvard University, Cambridge, Massachusetts, USA
| | - Dulmini Kariyawasam
- Department of Diabetes, Guy's and Saint Thomas' Hospitals NHS Trust, London, UK
| | - Laura Potts
- Department of Biostatistics, Department of Health Services and Population Research, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Andy Healy
- Department of Biostatistics, Department of Health Services and Population Research, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Helen Rogers
- Department of Diabetes, King's College Hospital NHS Foundation Trust, London, UK
| | - Nick Sevdalis
- Centre for Implementation Science, Health Sciences and Population Research Department, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Marietta Stadler
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Mustabshira Qayyum
- Diabetes Department, Denmark Hill Campus, King's College London Faculty of Life Sciences and Medicine, London, UK
| | - Ioannis Bakolis
- Department of Biostatistics, Department of Health Services and Population Research, Institute of Psychiatry Psychology and Neuroscience, London, UK
| | - Kimberley Goldsmith
- Department of Biostatistics, Department of Health Services and Population Research, Institute of Psychiatry Psychology and Neuroscience, London, UK
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19
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Candlish J, Teare MD, Dimairo M, Flight L, Mandefield L, Walters SJ. Appropriate statistical methods for analysing partially nested randomised controlled trials with continuous outcomes: a simulation study. BMC Med Res Methodol 2018; 18:105. [PMID: 30314463 PMCID: PMC6186141 DOI: 10.1186/s12874-018-0559-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 09/18/2018] [Indexed: 11/12/2022] Open
Abstract
Background In individually randomised trials we might expect interventions delivered in groups or by care providers to result in clustering of outcomes for participants treated in the same group or by the same care provider. In partially nested randomised controlled trials (pnRCTs) this clustering only occurs in one trial arm, commonly the intervention arm. It is important to measure and account for between-cluster variability in trial design and analysis. We compare analysis approaches for pnRCTs with continuous outcomes, investigating the impact on statistical inference of cluster sizes, coding of the non-clustered arm, intracluster correlation coefficient (ICCs), and differential variance between intervention and control arm, and provide recommendations for analysis. Methods We performed a simulation study assessing the performance of six analysis approaches for a two-arm pnRCT with a continuous outcome. These include: linear regression model; fully clustered mixed-effects model with singleton clusters in control arm; fully clustered mixed-effects model with one large cluster in control arm; fully clustered mixed-effects model with pseudo clusters in control arm; partially nested homoscedastic mixed effects model, and partially nested heteroscedastic mixed effects model. We varied the cluster size, number of clusters, ICC, and individual variance between the two trial arms. Results All models provided unbiased intervention effect estimates. In the partially nested mixed-effects models, methods for classifying the non-clustered control arm had negligible impact. Failure to account for even small ICCs resulted in inflated Type I error rates and over-coverage of confidence intervals. Fully clustered mixed effects models provided poor control of the Type I error rates and biased ICC estimates. The heteroscedastic partially nested mixed-effects model maintained relatively good control of Type I error rates, unbiased ICC estimation, and did not noticeably reduce power even with homoscedastic individual variances across arms. Conclusions In general, we recommend the use of a heteroscedastic partially nested mixed-effects model, which models the clustering in only one arm, for continuous outcomes similar to those generated under the scenarios of our simulations study. However, with few clusters (3–6), small cluster sizes (5–10), and small ICC (≤0.05) this model underestimates Type I error rates and there is no optimal model. Electronic supplementary material The online version of this article (10.1186/s12874-018-0559-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jane Candlish
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK.
| | - M Dawn Teare
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Munyaradzi Dimairo
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Laura Flight
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Laura Mandefield
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
| | - Stephen J Walters
- School of Health and Related Research (ScHARR), University of Sheffield, 30 Regent Street, S1 4DA, Sheffield, UK
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20
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Sideridis GD, Tsaousis I, Al-Sadaawi A. Assessing Construct Validity in Math Achievement: An Application of Multilevel Structural Equation Modeling (MSEM). Front Psychol 2018; 9:1451. [PMID: 30233437 PMCID: PMC6134196 DOI: 10.3389/fpsyg.2018.01451] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Accepted: 07/24/2018] [Indexed: 11/13/2022] Open
Abstract
The purpose of the present study was to model math achievement at both the person and university levels of the analyses in order to understand the optimal factor structure of math competency. Data involved 2,881 students who took a national mathematics examination as part of their entry at the university public system in Saudi Arabia. Four factors from the National math examination comprised the math achievement measure, namely, numbers and operations, algebra and analysis, geometry and measurement, and, statistics and probabilities. Data were analyzed using the aggregate method and by use of Multilevel Structural Equation Modeling (MSEM). Results indicated that both a unidimensional and a 4-factor correlated model fitted the data equally well using aggregate data, where for reasons of parsimony the unidimensional model was the preferred choice with these data. When modeling data including clustering, results pointed to alternative factor structures at the person and university levels. Thus, a unidimensional model provided the best fit at the University level, whereas a four-factor correlated model was most descriptive for person level data. The optimal simple structure was evaluated using the Ryu and West (2009) methodology for partially saturating the MSEM model and also met criteria for discriminant validation as described in Gorsuch (1983). Furthermore, a university level variable, namely the year of establishment, pointed to the superiority of older institutions with regard to math achievement. It is concluded that ignoring a multilevel structure in the data may result in erroneous conclusions with regard to the optimal factor structure and the tests of structural models following that.
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Affiliation(s)
- Georgios D Sideridis
- Harvard Medical School, Boston Children's Hospital, Boston, MA, United States.,Department of Primary Education, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Abdullah Al-Sadaawi
- Department of Psychology, King Saud University, Riyadh, Saudi Arabia.,National Center for Assessment in Higher Education, Riyadh, Saudi Arabia
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21
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Stigsdotter UK, Corazon SS, Sidenius U, Nyed PK, Larsen HB, Fjorback LO. Efficacy of nature-based therapy for individuals with stress-related illnesses: randomised controlled trial. Br J Psychiatry 2018; 213:404-411. [PMID: 29793558 DOI: 10.1192/bjp.2018.2] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Stress-related illnesses are a major threat to public health, and there is increasing demand for validated treatments.AimsTo test the efficacy of nature-based therapy (NBT) for patients with stress-related illnesses. METHOD Randomised controlled trial (ClinicalTrials.gov ID NCT01849718) comparing Nacadia® NBT (NNBT) with the cognitive-behavioural therapy known as Specialised Treatment for Severe Bodily Distress Syndromes (STreSS). In total, 84 participants were randomly allocated to one of the two treatments. The primary outcome measure was the mean aggregate score on the Psychological General Well-Being Index (PGWBI). RESULTS Both treatments resulted in a significant increase in the PGWBI (primary outcome) and a decrease in burnout (the Shirom-Melamed Burnout Questionnaire, secondary outcome), which were both sustained 12 months later. No significant difference in efficacy was found between NNBT and STreSS for primary outcome and secondary outcomes. CONCLUSIONS The study showed no statistical evidence of a difference between NNBT and STreSS for treating patients with stress-related illnesses.Declaration of interestNone.
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Affiliation(s)
- Ulrika Karlsson Stigsdotter
- Department of Geosciences and Natural Resource Management,Faculty of Social Sciences,University of Copenhagen,Denmark
| | - Sus Sola Corazon
- Department of Geosciences and Natural Resource Management,Faculty of Social Sciences,University of Copenhagen,Denmark
| | - Ulrik Sidenius
- Department of Geosciences and Natural Resource Management,Faculty of Social Sciences,University of Copenhagen,Denmark
| | - Patrik Karlsson Nyed
- Department of Geosciences and Natural Resource Management,Faculty of Social Sciences,University of Copenhagen,Denmark
| | - Helmer Bøving Larsen
- Department of Psychology,Faculty of Social Sciences,University of Copenhagen,Denmark
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Richards DA, Rhodes S, Ekers D, McMillan D, Taylor RS, Byford S, Barrett B, Finning K, Ganguli P, Warren F, Farrand P, Gilbody S, Kuyken W, O'Mahen H, Watkins E, Wright K, Reed N, Fletcher E, Hollon SD, Moore L, Backhouse A, Farrow C, Garry J, Kemp D, Plummer F, Warner F, Woodhouse R. Cost and Outcome of BehaviouRal Activation (COBRA): a randomised controlled trial of behavioural activation versus cognitive-behavioural therapy for depression. Health Technol Assess 2018; 21:1-366. [PMID: 28857042 DOI: 10.3310/hta21460] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression is a common, debilitating and costly disorder. The best-evidenced psychological therapy - cognitive-behavioural therapy (CBT) - is complex and costly. A simpler therapy, behavioural activation (BA), may be an effective alternative. OBJECTIVES To determine the clinical effectiveness and cost-effectiveness of BA compared with CBT for depressed adults at 12 and 18 months' follow-up, and to investigate the processes of treatments. DESIGN Randomised controlled, non-inferiority trial stratified by depression severity, antidepressant use and recruitment site, with embedded process evaluation; and randomisation by remote computer-generated allocation. SETTING Three community mental health services in England. PARTICIPANTS Adults aged ≥ 18 years with major depressive disorder (MDD) recruited from primary care and psychological therapy services. INTERVENTIONS BA delivered by NHS junior mental health workers (MHWs); CBT by NHS psychological therapists. OUTCOMES Primary: depression severity (as measured via the Patient Health Questionnaire-9; PHQ-9) at 12 months. Secondary: MDD status; number of depression-free days; anxiety (as measured via the Generalised Anxiety Disorder-7); health-related quality of life (as measured via the Short Form questionnaire-36 items) at 6, 12 and 18 months; and PHQ-9 at 6 and 18 months, all collected by assessors blinded to treatment allocation. Non-inferiority margin was 1.9 PHQ-9 points. We undertook intention-to-treat (ITT) and per protocol (PP) analyses. We explored cost-effectiveness by collecting direct treatment and other health- and social-care costs and calculating quality-adjusted life-years (QALYs) using the EuroQol-5 Dimensions, three-level version, at 18 months. RESULTS We recruited 440 participants (BA, n = 221; CBT, n = 219); 175 (79%) BA and 189 (86%) CBT participants provided ITT data and 135 (61%) BA and 151 (69%) CBT participants provided PP data. At 12 months we found that BA was non-inferior to CBT {ITT: CBT 8.4 PHQ-9 points [standard deviation (SD) 7.5 PHQ-9 points], BA 8.4 PHQ-9 points (SD 7.0 PHQ-9 points), mean difference 0.1 PHQ-9 points, 95% confidence interval (CI) -1.3 to 1.5 PHQ-9 points, p = 0.89; PP: CBT 7.9 PHQ-9 points (SD 7.3 PHQ-9 points), BA 7.8 PHQ-9 points (SD 6.5 PHQ-9 points), mean difference 0.0 PHQ-9 points, 95% CI -1.5 to 1.6 PHQ-9 points, p = 0.99}. We found no differences in secondary outcomes. We found a significant difference in mean intervention costs (BA, £975; CBT, £1235; p < 0.001), but no differences in non-intervention (hospital, community health, social care and medication costs) or total (non-intervention plus intervention) costs. Costs were lower and QALY outcomes better in the BA group, generating an incremental cost-effectiveness ratio of -£6865. The probability of BA being cost-effective compared with CBT was almost 80% at the National Institute for Health and Care Excellence's preferred willingness-to-pay threshold of £20,000-30,000 per QALY. There were no trial-related adverse events. LIMITATIONS In this pragmatic trial many depressed participants in both groups were also taking antidepressant medication, although most had been doing so for a considerable time before entering the trial. Around one-third of participants chose not to complete a PP dose of treatment, a finding common in both psychotherapy trials and routine practice. CONCLUSIONS We found that BA is as effective as CBT, more cost-effective and can be delivered by MHWs with no professional training in psychological therapies. FUTURE WORK Settings and countries with a paucity of professionally qualified psychological therapists, might choose to investigate the delivery of effective psychological therapy for depression without the need to develop an extensive and costly professional infrastructure. TRIAL REGISTRATION Current Controlled Trials ISRCTN27473954. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 46. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- David A Richards
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Shelley Rhodes
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - David Ekers
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Dean McMillan
- Department of Health Sciences, University of York, York, UK
| | - Rod S Taylor
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Sarah Byford
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Barbara Barrett
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Katie Finning
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Poushali Ganguli
- Institute of Psychiatry, Psychology & Neuroscience, Kings College London, London, UK
| | - Fiona Warren
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Paul Farrand
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Simon Gilbody
- Department of Health Sciences, University of York, York, UK
| | - Willem Kuyken
- Oxford Mindfulness Centre, Department of Psychiatry, University of Oxford, Oxford, UK
| | - Heather O'Mahen
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Ed Watkins
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Kim Wright
- Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Nigel Reed
- Lived Experience Group, care of Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Exeter, UK
| | - Emily Fletcher
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Steven D Hollon
- Department of Psychology, Vanderbilt University, Nashville, TN, USA
| | - Lucy Moore
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Amy Backhouse
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Claire Farrow
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Julie Garry
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
| | - Deborah Kemp
- Psychological Therapy, Tees, Esk & Wear Valleys NHS Foundation Trust, County Durham, UK
| | - Faye Plummer
- Academic Unit of Elderly Care and Rehabilitation, Leeds Institute of Health Sciences, Bradford Royal Infirmary, Bradford, UK
| | - Faith Warner
- University of Exeter Medical School, St Luke's Campus, Exeter, UK
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Moerbeek M. Cost-efficient designs for three-arm trials with treatment delivered by health professionals: Sample sizes for a combination of nested and crossed designs. Clin Trials 2018; 15:169-177. [PMID: 29316807 PMCID: PMC5894817 DOI: 10.1177/1740774517750622] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background This article studies the design of trials that compare three treatment conditions that are delivered by two types of health professionals. The one type of health professional delivers one treatment, and the other type delivers two treatments, hence, this design is a combination of a nested and crossed design. As each health professional treats multiple patients, the data have a nested structure. This nested structure has thus far been ignored in the design of such trials, which may result in an underestimate of the required sample size. In the design stage, the sample sizes should be determined such that a desired power is achieved for each of the three pairwise comparisons, while keeping costs or sample size at a minimum. Methods The statistical model that relates outcome to treatment condition and explicitly takes the nested data structure into account is presented. Mathematical expressions that relate sample size to power are derived for each of the three pairwise comparisons on the basis of this model. The cost-efficient design achieves sufficient power for each pairwise comparison at lowest costs. Alternatively, one may minimize the total number of patients. The sample sizes are found numerically and an Internet application is available for this purpose. The design is also compared to a nested design in which each health professional delivers just one treatment. Results Mathematical expressions show that this design is more efficient than the nested design. For each pairwise comparison, power increases with the number of health professionals and the number of patients per health professional. The methodology of finding a cost-efficient design is illustrated using a trial that compares treatments for social phobia. The optimal sample sizes reflect the costs for training and supervising psychologists and psychiatrists, and the patient-level costs in the three treatment conditions. Conclusion This article provides the methodology for designing trials that compare three treatment conditions while taking the nesting of patients within health professionals into account. As such, it helps to avoid underpowered trials. To use the methodology, a priori estimates of the total outcome variances and intraclass correlation coefficients must be obtained from experts' opinions or findings in the literature.
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Affiliation(s)
- Mirjam Moerbeek
- Department of Methodology and Statistics, Utrecht University, Utrecht, The Netherlands
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24
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Daughters SB, Magidson JF, Anand D, Seitz-Brown C, Chen Y, Baker S. The effect of a behavioral activation treatment for substance use on post-treatment abstinence: a randomized controlled trial. Addiction 2018; 113:535-544. [PMID: 28963853 PMCID: PMC5807178 DOI: 10.1111/add.14049] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 04/12/2017] [Accepted: 09/27/2017] [Indexed: 12/23/2022]
Abstract
AIMS To compare outcomes for a behavioral activation group treatment for substance use [life enhancement treatment for substance use (LETS ACT)] versus a time and group size-matched control condition delivered in a residential treatment setting. DESIGN Single-site two-arm parallel-group randomized clinical trial with follow-up assessment at 3, 6 and 12 months post-treatment. SETTING Residential substance use treatment facility in the United States. PARTICIPANTS Participants were 263 adults [mean age 42.7 (11.8); 29.5% female; 95.4% African American; 73.2% court mandated] whose insurance dictated 30-day (65.9%) or 90-day (34.1%) treatment duration. INTERVENTION AND COMPARATOR LETS ACT (n = 142) is a treatment developed originally for depression and modified for substance use. It teaches participants to increase positively reinforcing value-driven activities in order to counter depression and relapse. The control group [supportive counseling (SC); n = 121] received time and group size-matched supportive counseling. Treatment was delivered in five or eight 1-hour sessions depending on patient length of stay. MEASUREMENTS Percentage abstinent at follow-up, percentage of substance use days among those reporting use, depressive symptoms [Beck Depression Inventory (BDI)] and adverse consequences of drug use [Short Inventory of Problems-Alcohol and Drug (SIP-AD)]. FINDINGS LETS ACT had significantly higher abstinence rates at 3 months [odds ratio (OR) = 2.2, 95% confidence interval (CI) = 1.3-3.7], 6 months (OR = 2.6, 95% CI= 1.3-5.0) and 12 months (OR = 2.9, 95% CI = 1.3-6.1) post-treatment compared with SC. LETS ACT participants reported significantly fewer adverse consequences from substance use at 12 months post-treatment [B = 4.50, standard error (SE) = 2.17, 95% CI = 0.22-8.78]. Treatment condition had no effect on percentage substance use days among those who resumed use or on change in depressive symptoms; the latter decreased over time only in those who remained abstinent after residential treatment irrespective of condition (B = 0.43, SE = 0.11, 95% confidence interval = 0.22-0.65). CONCLUSIONS A behavioral activation group treatment for substance use (LETS ACT) appears to increase the likelihood of abstinence and reduce adverse consequences from substance use up to 12 months post-treatment.
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Affiliation(s)
- Stacey B. Daughters
- University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Chapel Hill, NC, USA
| | | | - Deepika Anand
- University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Chapel Hill, NC, USA
| | - C.J. Seitz-Brown
- University of Maryland, College Park, Department of Psychology, College Park, MD, USA
| | - Yun Chen
- University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Chapel Hill, NC, USA
| | - Sydney Baker
- University of North Carolina at Chapel Hill, Department of Psychology and Neuroscience, Chapel Hill, NC, USA
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25
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Abstract
Psychotherapy meta-analyses sometimes generate heterogeneous results, partially due to key methodological characteristics which vary between studies (e.g., psychotherapy conditions are contrasted with structurally different control conditions). Examining these potential moderator variables can help explain heterogeneous results within and between psychotherapy meta-analyses. The present manuscript provides an overview of moderators that are highly relevant to test the generalizability of effects across psychotherapy trials. These moderators mainly fall into one of the following groups: (a) structural equivalence of interventions, (b) preferences/allegiances, (c) therapist effects, and (d) sample representativeness. Individual moderators include: Bona fide psychotherapy, proximity to psychological interventions, psychotherapy orientation, pre-training of therapists, supervision, caseload of therapists, dosage, homework, patient preferences, researcher and therapist allegiance, therapist effects in nested designs, aspects of sample representativeness, multiple outcomes, and time of assessment. Our analysis of 15 psychotherapy meta-analyses published in 2016 suggests that the structural equivalence of psychotherapeutic conditions, patient and therapist preferences/allegiances, therapist effects and nested data structures as well as sample representativeness were often neglected and little-discussed as potential moderators. The manuscript describes further conceptual and methodological challenges when conducting moderator analyses such as the categorization of psychological treatments and the importance of interrater coding. We encourage meta-analysts to consider moderators which have previously shown utility in explaining heterogeneous results in the psychotherapy literature. Clinical or methodological significance of this article: Relevant moderator variables help explain heterogeneous results in psychotherapy meta-analyses. Though these variables are often overlooked, they should be regularly incorporated in meta-analyses.
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Affiliation(s)
- Glen I Spielmans
- a Department of Psychology , Metropolitan State University , Saint Paul , MN , USA.,b Department of Counseling Psychology , University of Wisconsin , Madison , WI , USA
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26
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Rogers ES, Millner UC, Brandt D, Chan L, Jette A, Marfeo E, Ni P, Rasch E. Concordance of assessments of clients' mental and behavioral health with in vivo assessment of work performance. Work 2018; 61:11-20. [PMID: 30223409 PMCID: PMC10009694 DOI: 10.3233/wor-182776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Assessing functioning and disability among individuals with mental and behavioral health disorders has historically relied on deriving accurate psychiatric diagnoses and assessing symptoms. However, growing empirical evidence suggests that this approach is inadequate to determine real world performance, particularly with respect to work. OBJECTIVE We examined a performance-based approach to the assessment of work functioning and its relationship to mental and behavioral health status. METHODS A cross-sectional study was conducted at two mental health programs. Trained employment providers conducted performance-based assessments of work function and ratings of mental and behavioral health while study participants self-reported their mental/behavioral health functioning. We hypothesized that participant and provider ratings of mental/behavioral health would be moderately correlated with performance-based assessments of work function. RESULTS We found no significant correlation between participants' self-report of their mental and behavioral health and performance-based assessments of work. Employment providers' ratings of participants' mental/behavioral health were moderately correlated with performance-based measures of work. Finally, we found low concordance between employment providers and study participants' with respect to ratings of their mental/behavioral health. CONCLUSIONS Contrary to our hypotheses, ratings of mental/behavioral health were only moderately correlated with performance-based measures of work. Results confirm earlier research suggesting that it is difficult to predict work performance from participants' self-reports of their mental/behavioral health alone. Performance-based assessments of work capacity as well as ratings of mental and behavioral health may both be needed for a more complete and complimentary picture of the ability of individuals with mental and behavioral health disorders to function in the work place.
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Affiliation(s)
- E Sally Rogers
- Center for Psychiatric Rehabilitation, Sargent College, Boston University, Boston, MA, USA
| | - Uma Chandrika Millner
- Center for Psychiatric Rehabilitation, Sargent College, Boston University, Boston, MA, USA
| | - Diane Brandt
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Leighton Chan
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD, USA
| | - Alan Jette
- Health and Disability Research Institute, School of Public Health, Boston University, Boston, MA, USA
| | - Elizabeth Marfeo
- Department of Occupational Therapy, Tufts University, Medford, MA, USA
| | - Pengsheng Ni
- Health and Disability Research Institute, School of Public Health, Boston University, Boston, MA, USA
| | - Elizabeth Rasch
- Department of Rehabilitation Medicine, National Institutes of Health, Bethesda, MD, USA
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27
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Alegana VA, Wright J, Bosco C, Okiro EA, Atkinson PM, Snow RW, Tatem AJ, Noor AM. Malaria prevalence metrics in low- and middle-income countries: an assessment of precision in nationally-representative surveys. Malar J 2017; 16:475. [PMID: 29162099 PMCID: PMC5697056 DOI: 10.1186/s12936-017-2127-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 11/16/2017] [Indexed: 12/28/2022] Open
Abstract
Background One pillar to monitoring progress towards the Sustainable Development Goals is the investment in high quality data to strengthen the scientific basis for decision-making. At present, nationally-representative surveys are the main source of data for establishing a scientific evidence base, monitoring, and evaluation of health metrics. However, little is known about the optimal precisions of various population-level health and development indicators that remains unquantified in nationally-representative household surveys. Here, a retrospective analysis of the precision of prevalence from these surveys was conducted. Methods Using malaria indicators, data were assembled in nine sub-Saharan African countries with at least two nationally-representative surveys. A Bayesian statistical model was used to estimate between- and within-cluster variability for fever and malaria prevalence, and insecticide-treated bed nets (ITNs) use in children under the age of 5 years. The intra-class correlation coefficient was estimated along with the optimal sample size for each indicator with associated uncertainty. Findings Results suggest that the estimated sample sizes for the current nationally-representative surveys increases with declining malaria prevalence. Comparison between the actual sample size and the modelled estimate showed a requirement to increase the sample size for parasite prevalence by up to 77.7% (95% Bayesian credible intervals 74.7–79.4) for the 2015 Kenya MIS (estimated sample size of children 0–4 years 7218 [7099–7288]), and 54.1% [50.1–56.5] for the 2014–2015 Rwanda DHS (12,220 [11,950–12,410]). Conclusion This study highlights the importance of defining indicator-relevant sample sizes to achieve the required precision in the current national surveys. While expanding the current surveys would need additional investment, the study highlights the need for improved approaches to cost effective sampling. Electronic supplementary material The online version of this article (10.1186/s12936-017-2127-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Victor A Alegana
- Geography and Environment, University of Southampton, Southampton, UK. .,Flowminder Foundation, Stockholm, Sweden.
| | - Jim Wright
- Geography and Environment, University of Southampton, Southampton, UK
| | - Claudio Bosco
- Geography and Environment, University of Southampton, Southampton, UK.,Flowminder Foundation, Stockholm, Sweden
| | - Emelda A Okiro
- Population Health Theme, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya
| | - Peter M Atkinson
- Geography and Environment, University of Southampton, Southampton, UK.,Faculty of Science and Technology, Lancaster University, Lancaster, UK.,School of Geography, Archaeology and Palaeoecology, Queen's University Belfast, Belfast, BT7 1NN, Northern Ireland, UK
| | - Robert W Snow
- Population Health Theme, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK
| | - Andrew J Tatem
- Geography and Environment, University of Southampton, Southampton, UK.,Flowminder Foundation, Stockholm, Sweden
| | - Abdisalan M Noor
- Population Health Theme, Kenya Medical Research Institute-Wellcome Trust Research Programme, Nairobi, Kenya.,Centre for Tropical Medicine and Global Health, Nuffield Department of Clinical Medicine, University of Oxford, Oxford, OX3 7LJ, UK.,World Health Organization, Geneva, Switzerland
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Sun QW, Wang CDC, Jiang GR. Culture-Based Emotional Working Models of Attachment, Western-Based Attachment, and Psychosocial Functioning of Chinese Young Adults. ACTA ACUST UNITED AC 2017. [DOI: 10.1037/ipp0000075] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The aim of these 2 studies is to address the applicability of adult attachment theory to Chinese populations. Guided by the emic principle, the first study used a bottom-up, locally normed approach to develop a culture-based adult attachment scale, named Feelings in Significant Relationships Scale (FSRS) that focused on the emotional components of internal working models (IWMs) experienced by Chinese individuals. Results of Study 1 provided initial evidence for the preliminary psychometric properties of the FSRS. Study 2 examined the unique and joint effects of the emotional components of IWMs, Western-based adult attachment, and parental attachment on 3 psychosocial variables: depression, loneliness, and interpersonal problems. Results indicated that parental and adult attachment variables significantly predicted all 3 dependent variables reported by Chinese participants. In addition, the FSRS was found to predict a significant amount of variance in all dependent variables above and beyond what was accounted for by the existing attachment scales. An important implication of the findings is that the inclusion of the emotional components of IWMs, as measured by the emic-based FSRS, provides a more comprehensive understanding of attachment impacts on Chinese adults’ psychosocial functioning.
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Affiliation(s)
- Qi-Wu Sun
- School of Psychology, Central China Normal University
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29
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Robinson EJ, Goldstein LH, McCrone P, Perdue I, Chalder T, Mellers JDC, Richardson MP, Murray J, Reuber M, Medford N, Stone J, Carson A, Landau S. COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES): statistical and economic analysis plan for a randomised controlled trial. Trials 2017; 18:258. [PMID: 28587649 PMCID: PMC5461767 DOI: 10.1186/s13063-017-2006-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2016] [Accepted: 05/20/2017] [Indexed: 01/15/2023] Open
Abstract
Background Dissociative seizures (DSs), also called psychogenic non-epileptic seizures, are a distressing and disabling problem for many patients in neurological settings with high and often unnecessary economic costs. The COgnitive behavioural therapy versus standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES) trial is an evaluation of a specifically tailored psychological intervention with the aims of reducing seizure frequency and severity and improving psychological well-being in adults with DS. The aim of this paper is to report in detail the quantitative and economic analysis plan for the CODES trial, as agreed by the trial steering committee. Methods The CODES trial is a multicentre, pragmatic, parallel group, randomised controlled trial performed to evaluate the clinical effectiveness and cost-effectiveness of 13 sessions of cognitive behavioural therapy (CBT) plus standardised medical care (SMC) compared with SMC alone for adult outpatients with DS. Discussion The objectives and design of the trial are summarised, and the aims and procedures of the planned analyses are illustrated. The proposed analysis plan addresses statistical considerations such as maintaining blinding, monitoring adherence with the protocol, describing aspects of treatment and dealing with missing data. The formal analysis approach for the primary and secondary outcomes is described, as are the descriptive statistics that will be reported. This paper provides transparency to the planned inferential analyses for the CODES trial prior to the extraction of outcome data. It also provides an update to the previously published trial protocol and guidance to those conducting similar trials. Trial registration ISRCTN registry ISRCTN05681227 (registered on 5 March 2014); ClinicalTrials.gov NCT02325544 (registered on 15 December 2014).
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Affiliation(s)
- Emily J Robinson
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK.
| | - Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - Paul McCrone
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - Iain Perdue
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - Trudie Chalder
- Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - John D C Mellers
- Department of Neuropsychiatry, Maudsley Hospital, South London and Maudsley NHS Foundation Trust, Denmark Hill Campus, London, SE5 8AZ, UK
| | - Mark P Richardson
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - Joanna Murray
- Department of Health Service and Population Research, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
| | - Markus Reuber
- Academic Neurology Unit, Royal Hallamshire Hospital, University of Sheffield, Glossop Road, Sheffield, S10 2JF, UK
| | - Nick Medford
- The Lishman Unit, South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK
| | - Jon Stone
- Department of Clinical Neurosciences, Western General Hospital, University of Edinburgh, Edinburgh, EX4 2XU, UK
| | - Alan Carson
- Centre for Clinical Brain Sciences, Western General Hospital, University of Edinburgh, Edinburgh, EX4 2XU, UK
| | - Sabine Landau
- Department of Biostatistics & Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King's College London, Denmark Hill Campus, London, SE5 8AF, UK
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Nyström MBT, Stenling A, Sjöström E, Neely G, Lindner P, Hassmén P, Andersson G, Martell C, Carlbring P. Behavioral activation versus physical activity via the internet: A randomized controlled trial. J Affect Disord 2017; 215:85-93. [PMID: 28319696 DOI: 10.1016/j.jad.2017.03.018] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2016] [Revised: 02/06/2017] [Accepted: 03/05/2017] [Indexed: 01/09/2023]
Abstract
BACKGROUND A major problem today is that only about fifty percent of those affected by depression seeks help. One way to reach more sufferers would be by offering easily accessible internet based treatments. The purpose of this study was to compare/evaluate four therapist supported internet administered treatments. METHOD/RESULTS Two hundred eighty six participants were included. The treatment period lasted twelve weeks, consisting of the following treatments: 1) physical activity without treatment rational, 2) physical activity with treatment rational, 3) behavioral activation without treatment rational and 4) behavioral activation with treatment rational. All groups (including a control-group) showed a significant decrease in depressive symptoms. When the treatment groups were pooled and compared to the control group, there were significant differences from pretest to posttest (Hedges gav treatment =1.01, control group =0.47). This held true also when each of the four treatment groups was compared to the control group, with one exception: Physical activity without treatment rationale. LIMITATIONS The differences between how many modules the participants completed could indicate that there are other factors than the treatments that caused the symptom reduction, however, the dose-response analysis did not detect any significant differences on account of modules completed. CONCLUSIONS The results support the positive effects of internet administered treatments for depression, and highlights the importance of psychoeducation, which tends to affect both the treatment outcome and the probability of remaining in treatment. These aspects need to be considered when developing and conducting new treatments for depression, since they would increase the likelihood of positive treatment outcomes.
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Affiliation(s)
- Markus B T Nyström
- Umeå University, Department of Psychology, Umeå University, SE-901 87 Umeå, Sweden.
| | - Andreas Stenling
- Umeå University, Department of Psychology, Umeå University, SE-901 87 Umeå, Sweden
| | - Emma Sjöström
- Umeå University, Department of Psychology, Umeå University, SE-901 87 Umeå, Sweden
| | - Gregory Neely
- Umeå University, Department of Psychology, Umeå University, SE-901 87 Umeå, Sweden
| | | | - Peter Hassmén
- Umeå University, Department of Psychology, Umeå University, SE-901 87 Umeå, Sweden; School of Health and Human Sciences, Southern Cross University, Australia
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | | | - Per Carlbring
- Department of Psychology, Stockholm University, Sweden
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31
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The relationship between clients’ personality traits, working alliance and therapy outcome in a training context. CURRENT ISSUES IN PERSONALITY PSYCHOLOGY 2017. [DOI: 10.5114/cipp.2017.65244] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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Walwyn R, Roberts C. Meta-analysis of standardised mean differences from randomised trials with treatment-related clustering associated with care providers. Stat Med 2016; 36:1043-1067. [DOI: 10.1002/sim.7186] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 10/10/2016] [Accepted: 11/09/2016] [Indexed: 01/21/2023]
Affiliation(s)
- Rebecca Walwyn
- Leeds Institute for Clinical Trials Research; University of Leeds; Leeds U.K
| | - Chris Roberts
- Biostatistics Group; University of Manchester; Manchester U.K
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Heng ML, Chua YK, Pek HK, Krishnasamy P, Kong PW. A novel method of measuring passive quasi-stiffness in the first metatarsophalangeal joint. J Foot Ankle Res 2016; 9:41. [PMID: 27800027 PMCID: PMC5080733 DOI: 10.1186/s13047-016-0173-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Accepted: 10/19/2016] [Indexed: 11/26/2022] Open
Abstract
Background First metatarsophalangeal joint (MTPJ) mobility is commonly assessed by its angular displacement (joint angle) or subjectively rated as ‘hypermobile’, ‘normal’ or ‘stiff’ by a clinician. Neither of these methods is ideal because displacement alone does not take into account the force required to displace the joint and subjective evaluation is not always reliable. This study presented a novel method to determine the passive quasi-stiffness of the first MTPJ. The reliability of the proposed method was also assessed. The first MTPJ passive quasi-stiffness of 13 healthy subjects were measured at two occasions, 7 days apart, by two testers (experienced and inexperienced). A tactile pressure sensing system was used to measure the force applied to dorsiflex the first toe by the testers. The torque (in Nmm) about the first MTPJ was calculated as the applied force (in N) multiplied by a moment arm (in mm), where moment arm was the length of the first proximal phalanx. A video camera recorded the motion of the first MTPJ, simultaneously with force measurements, to determine the joint angular displacement (in degrees) using the Dartfish software. The quasi-stiffness (in Nmm/degrees) was calculated as the slope of a graph where torque was plotted against first MTPJ angular displacement. Descriptive statistics of the first MTPJ quasi-stiffness were calculated. Intra-rater and inter-rater reliability were assessed using Bland and Altman plot, intraclass correlation coefficients (ICC), and standard error of measurement (SEM). Results First MTPJ quasi-stiffness of the subjects ranged widely from 0.66 to 53.4 Nmm/degrees. Intra-rater reliability for experienced tester was moderate (Session 1: 14.9 ± 14.6 Nmm/degrees, Session 2: 14.2 ± 8.5 Nmm/degrees, ICC = .568, SEM = 7.71 Nmm/degrees). Inter-rater reliability between experienced (12.6 ± 8.4 Nmm/degrees) and non-experienced (19.9 ± 9.2 Nmm/degrees) testers was poor (ICC = -.447, SEM = 11.29 Nmm/degrees). Conclusions First MTPJ passive quasi-stiffness can be quantified from torque and angular displacement measurements using simple equipment in a clinical setting. The tester’s experience affected the consistency in joint quasi-stiffness measurements. Electronic supplementary material The online version of this article (doi:10.1186/s13047-016-0173-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marabelle L Heng
- Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, 1 Nanyang Walk, Singapore, 637616 Singapore ; Podiatry Department, Singapore General Hospital, Diabetes & Metabolism Centre, 17 Third Hospital Avenue, Singapore, 168752 Singapore
| | - Yaohui K Chua
- Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, 1 Nanyang Walk, Singapore, 637616 Singapore
| | - Hong K Pek
- Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, 1 Nanyang Walk, Singapore, 637616 Singapore
| | - Priathashini Krishnasamy
- Sports Medicine and Surgery Clinic, Tan Tock Seng Hospital, Medical Centre 2, 11 Jalan Tan Tock Seng, Singapore, 308433 Singapore
| | - Pui W Kong
- Physical Education and Sports Science Academic Group, National Institute of Education, Nanyang Technological University, 1 Nanyang Walk, Singapore, 637616 Singapore
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Abstract
Some experimental designs involve clustering within only one treatment group. Such designs may involve group tutoring, therapy administered by multiple therapists, or interventions administered by clinics for the treatment group, whereas the control group receives no treatment. In such cases, the data analysis often proceeds as if there were no clustering within the treatment group. A consequence is that the actual significance level of the treatment effects is larger (i.e., actual p values are larger) than nominal. Additionally, biases will be introduced in estimates of the effect sizes and their variances, leading to inflated effects and underestimated variances when clustering in the treatment group is not taken into account. These consequences of clustering can seriously compromise the interpretation of study results. This article shows how information on the intraclass correlation can be used to obtain a correction for biases in the effect sizes and their variances, and also to obtain an adjustment to the significance test for the effects of clustering.
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Imel ZE, Sheng E, Baldwin SA, Atkins DC. Removing very low-performing therapists: A simulation of performance-based retention in psychotherapy. ACTA ACUST UNITED AC 2016; 52:329-36. [PMID: 26301424 DOI: 10.1037/pst0000023] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Therapists can impact the likelihood a given patient will benefit from psychotherapy. However, therapists are rarely held accountable for their patients' outcomes. As a result, low-performing providers likely continue to practice alongside providers with high response rates. In the current study, we conducted a Monte Carlo simulation to illustrate a thought experiment-what happens to patient outcomes if therapists with the worst outcomes were removed from practice? We drew initial samples of 50 therapists from 3 simulated populations of 1,000 therapists with a mean patient response rate of 50% and different effect sizes for therapist variability in outcomes. We simulated 30 patient outcomes for each therapist, with outcome defined as response to treatment versus no response. We removed therapists with response rates in the bottom 5% and replaced them with a random sample of therapists from the population. Over 10 years, the difference in responses between the lowest and highest performing therapists was substantial (between 697 and 997 additional responses to treatment). After repeatedly removing the lowest performing providers 40 times (simulating a 10-year time span), response rates increased substantially. The cumulative number of patient responses (i.e., summing the total number of responses across 10 years) increased by 4,266, 6,404, and 9,307 when therapists accounted for 5%, 10%, or 20% of the patient outcome variance, respectively. These findings indicate that performance-based retention of therapists could improve the quality of psychotherapy in health systems by improving the average response rate and decreasing the probability that a patient will be treated by a therapist who consistently has poor outcomes.
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Affiliation(s)
| | - Elisa Sheng
- Department of Biostatistics, University of Washington
| | | | - David C Atkins
- Department of Psychiatry and Behavioral Sciences, University of Washington
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Mcclintock AS, Stiles WB, Himawan L, Anderson T, Barkham M, Hardy GE. An investigation of client mood in the initial and final sessions of cognitive-behavioral therapy and psychodynamic-interpersonal therapy. Psychother Res 2016; 26:377-85. [DOI: 10.1080/10503307.2015.1034796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Moyers TB, Houck J, Rice SL, Longabaugh R, Miller WR. Therapist empathy, combined behavioral intervention, and alcohol outcomes in the COMBINE research project. J Consult Clin Psychol 2016; 84:221-9. [PMID: 26795938 DOI: 10.1037/ccp0000074] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Common factors such as therapist empathy play an important role in treatment for addictive behaviors. The present study was a secondary analysis designed to evaluate the relation between therapist empathy and alcohol treatment outcomes in data from a large, multisite, randomized controlled trial. METHOD Audio-recorded psychotherapy sessions for 38 therapists and 700 clients had been randomly selected for fidelity coding from the combined behavioral intervention condition of Project COMBINE. Sessions were evaluated by objective raters for both specific content (coping with craving, building social skills, and managing negative mood) and relational components (empathy level of the therapist). Multilevel modeling with clients nested within therapists evaluated drinks per week at the end of treatment. RESULTS Approximately 11% of the variance in drinking was accounted for by therapists. A within-therapist effect of empathy was detected (B = -0.381, SE = 0.103, p < .001); more empathy than usual was associated with subsequent decreased drinking. The Social and Recreational Counseling module (B = -0.412, SE = 0.124, p < .001), Coping with Cravings and Urges module (B = -0.362, SE = 0.134, p < .01), and the Mood Management module (B = -0.403, SE = 0.138, p < .01) were also associated with decreased drinking. No between-therapist effect was detected, and the Empathy × Module Content interactions were not significant. CONCLUSIONS The results of the study appear consistent with the hypothesis that skills building and therapist empathy are independent contributions to the overall benefit derived from the combined behavioral intervention.
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Affiliation(s)
| | - Jon Houck
- Center on Alcoholism, Substance Abuse and Addictions, University of New Mexico
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Lutz W, Rubel J, Schiefele AK, Zimmermann D, Böhnke JR, Wittmann WW. Feedback and therapist effects in the context of treatment outcome and treatment length. Psychother Res 2015. [DOI: 10.1080/10503307.2015.1053553] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Everitt H, Landau S, Little P, Bishop FL, McCrone P, O'Reilly G, Coleman N, Logan R, Chalder T, Moss-Morris R. Assessing Cognitive behavioural Therapy in Irritable Bowel (ACTIB): protocol for a randomised controlled trial of clinical-effectiveness and cost-effectiveness of therapist delivered cognitive behavioural therapy and web-based self-management in irritable bowel syndrome in adults. BMJ Open 2015; 5:e008622. [PMID: 26179651 PMCID: PMC4513538 DOI: 10.1136/bmjopen-2015-008622] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION Irritable bowel syndrome (IBS) affects 10-22% of the UK population, with England's annual National Health Service (NHS) costs amounting to more than £200 million. Abdominal pain, bloating and altered bowel habit affect quality of life, social functioning and time off work. Current treatment relies on a positive diagnosis, reassurance, lifestyle advice and drug therapies, but many people suffer ongoing symptoms. Cognitive behaviour therapy (CBT) and self-management can be helpful, but availability is limited. METHODS AND ANALYSIS To determine the clinical- and cost-effectiveness of therapist delivered cognitive behavioural therapy (TCBT) and web-based CBT self-management (WBCBT) in IBS, 495 participants with refractory IBS will be randomised to TCBT plus treatment as usual (TAU); WBCBT plus TAU; or TAU alone. The two CBT programmes have similar content. However, TCBT consists of six, 60 min telephone CBT sessions with a therapist over 9 weeks, at home, and two 'booster' 1 hour follow-up phone calls at 4 and 8 months (8 h therapist contact time). WBCBT consists of access to a previously developed and piloted WBCBT management programme (Regul8) and three 30 min therapist telephone sessions over 9 weeks, at home, and two 'booster' 30 min follow-up phone calls at 4 and 8 months (2½ h therapist contact time). Clinical effectiveness will be assessed by examining the difference between arms in the IBS Symptom Severity Score (IBS SSS) and Work and Social Adjustment Scale (WASAS) at 12 months from randomisation. Cost-effectiveness will combine measures of resource use with the IBS SSS at 12 months and quality-adjusted life years. ETHICS AND DISSEMINATION This trial has full ethical approval. It will be disseminated via peer reviewed publications and conference presentations. The results will enable clinicians, patients and health service planners to make informed decisions regarding the management of IBS with CBT. TRIAL REGISTRATION NUMBER ISRCTN44427879.
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Affiliation(s)
- Hazel Everitt
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Sabine Landau
- Department of Biostatistics, Institute of Psychiatry, Psychology and Neurosciences, Psychology and Neuroscience Kings College, London, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Felicity L Bishop
- Centre for Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Paul McCrone
- Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
| | - Gilly O'Reilly
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Nicholas Coleman
- Department of Gastroenterology, Southampton University Hospital, Southampton, UK
| | - Robert Logan
- Department of Gastroenterology, Kings College Hospital, London, UK
| | - Trudie Chalder
- Academic Department of Psychological Medicine, Kings College, London, UK
| | - Rona Moss-Morris
- Health Psychology Section, Institute of Psychiatry, Psychology and Neuroscience, Kings College, London, UK
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Goldstein LH, Mellers JDC, Landau S, Stone J, Carson A, Medford N, Reuber M, Richardson M, McCrone P, Murray J, Chalder T. COgnitive behavioural therapy vs standardised medical care for adults with Dissociative non-Epileptic Seizures (CODES): a multicentre randomised controlled trial protocol. BMC Neurol 2015; 15:98. [PMID: 26111700 PMCID: PMC4482314 DOI: 10.1186/s12883-015-0350-0] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 06/07/2015] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The evidence base for the effectiveness of psychological interventions for patients with dissociative non-epileptic seizures (DS) is currently extremely limited, although data from two small pilot randomised controlled trials (RCTs), including from our group, suggest that Cognitive Behavioural Therapy (CBT) may be effective in reducing DS occurrence and may improve aspects of psychological status and psychosocial functioning. METHODS/DESIGN The study is a multicentre, pragmatic parallel group RCT to evaluate the clinical and cost-effectiveness of specifically-tailored CBT plus standardised medical care (SMC) vs SMC alone in reducing DS frequency and improving psychological and health-related outcomes. In the initial screening phase, patients with DS will receive their diagnosis from a neurologist/epilepsy specialist. If patients are eligible and interested following the provision of study information and a booklet about DS, they will consent to provide demographic information and fortnightly data about their seizures, and agree to see a psychiatrist three months later. We aim to recruit ~500 patients to this screening stage. After a review three months later by a psychiatrist, those patients who have continued to have DS in the previous eight weeks and who meet further eligibility criteria will be told about the trial comparing CBT + SMC vs SMC alone. If they are interested in participating, they will be given a further booklet on DS and study information. A research worker will see them to obtain their informed consent to take part in the RCT. We aim to randomise 298 people (149 to each arm). In addition to a baseline assessment, data will be collected at 6 and 12 months post randomisation. Our primary outcome is monthly seizure frequency in the preceding month. Secondary outcomes include seizure severity, measures of seizure freedom and reduction, psychological distress and psychosocial functioning, quality of life, health service use, cost effectiveness and adverse events. We will include a nested qualitative study to evaluate participants' views of the intervention and factors that acted as facilitators and barriers to participation. DISCUSSION This study will be the first adequately powered evaluation of CBT for this patient group and offers the potential to provide an evidence base for treating this patient group. TRIAL REGISTRATION Current Controlled Trials ISRCTN05681227 ClinicalTrials.gov NCT02325544.
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Affiliation(s)
- Laura H Goldstein
- Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King's College London, De Crespigny Park, London, SE5 8AF, UK.
| | - John D C Mellers
- South London and Maudsley NHS Foundation Trust, Denmark Hill, London, SE5 8AZ, UK.
| | - Sabine Landau
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Biostatistics, De Crespigny Park, London, SE5 8AF, UK.
| | - Jon Stone
- Department of Clinical Neurosciences, Western General Hospital, Edinburgh, EH4 2XU, UK.
| | - Alan Carson
- Department of Rehabilitation Medicine and Department of Clinical Neurosciences, Royal Edinburgh Hospital, Morningside Terrace, Edinburgh EH10 5HF, and University of Edinburgh, Edinburgh, UK.
| | - Nick Medford
- Clinical Imaging Sciences Centre, Brighton and Sussex Medical School, Falmer, Brighton, BN1 9RR, UK.
| | - Markus Reuber
- Academic Neurology Unit, University of Sheffield, Royal Hallamshire Hospital, Glossop Road, Sheffield, S10 2JF, UK.
| | - Mark Richardson
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Basic and Clinical Neuroscience, De Crespigny Park, London, SE5 8AF, UK.
| | - Paul McCrone
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Health Service and Population Research, De Crespigny Park, London, SE5 8AF, UK.
| | - Joanna Murray
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Health Service and Population Research, De Crespigny Park, London, SE5 8AF, UK.
| | - Trudie Chalder
- King's College London, Institute of Psychiatry, Psychology and Neuroscience, Department of Psychological Medicine, De Crespigny Park, London, SE5 8AF, UK.
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Hutchins SS, Brown C, Mayberry R, Sollecito W. Value of a small control group for estimating intervention effectiveness: results from simulations of immunization effectiveness studies. J Comp Eff Res 2015; 4:227-238. [PMID: 25959743 DOI: 10.2217/cer.15.11] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
AIM To improve evidence for public health practice, the conduct of effectiveness studies by practitioners is needed and may be stimulated if knowledge that smaller than usual samples may provide the same reliability of intervention effect size as larger samples. MATERIALS & METHODS We examined reliability of intervention effect using computerized simulations of 2000 hypothetical immunization effectiveness studies from an actual study population and by small (30 and 60) and larger (100 and 200) control groups compared with an intervention group of 200 participants. RESULTS & CONCLUSION Across simulated studies, the mean intervention effect (14%) and effect sizes were equivalent regardless of control group size and equal to the actual study effect. These results are relevant for similarly designed and executed studies and indicate that studies with smaller control groups can generate valid and accurate evidence for effective public health practice in communities.
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Affiliation(s)
- Sonja S Hutchins
- Office of Minority Health & Health Equity, Centers for Disease Control & Prevention, 1600 Clifton Road, Atlanta, GA 30333, USA
| | - Cedric Brown
- National Center for Immunization & Respiratory Diseases, Centers for Disease Control & Prevention, GA, USA
| | - Robert Mayberry
- Department of Community Health & Preventive Medicine, Morehouse School of Medicine, Atlanta, GA, USA
| | - William Sollecito
- Public Health Leadership Program, University of North Carolina Gillings School of Global Public Health, NC, USA
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42
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Rozental A, Forsell E, Svensson A, Forsström D, Andersson G, Carlbring P. Psychometric evaluation of the Swedish version of the pure procrastination scale, the irrational procrastination scale, and the susceptibility to temptation scale in a clinical population. BMC Psychol 2014; 2:54. [PMID: 25566392 PMCID: PMC4269972 DOI: 10.1186/s40359-014-0054-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2014] [Accepted: 11/24/2014] [Indexed: 11/22/2022] Open
Abstract
Background Procrastination is a prevalent self-regulatory failure associated with stress and anxiety, decreased well-being, and poorer performance in school as well as work. One-fifth of the adult population and half of the student population describe themselves as chronic and severe procrastinators. However, despite the fact that it can become a debilitating condition, valid and reliable self-report measures for assessing the occurrence and severity of procrastination are lacking, particularly for use in a clinical context. The current study explored the usefulness of the Swedish version of three Internet-administered self-report measures for evaluating procrastination; the Pure Procrastination Scale, the Irrational Procrastination Scale, and the Susceptibility to Temptation Scale, all having good psychometric properties in English. Methods In total, 710 participants were recruited for a clinical trial of Internet-based cognitive behavior therapy for procrastination. All of the participants completed the scales as well as self-report measures of depression, anxiety, and quality of life. Principal Component Analysis was performed to assess the factor validity of the scales, and internal consistency and correlations between the scales were also determined. Intraclass Correlation Coefficient, Minimal Detectable Change, and Standard Error of Measurement were calculated for the Irrational Procrastination Scale. Results The Swedish version of the scales have a similar factor structure as the English version, generated good internal consistencies, with Cronbach’s α ranging between .76 to .87, and were moderately to highly intercorrelated. The Irrational Procrastination Scale had an Intraclass Correlation Coefficient of .83, indicating excellent reliability. Furthermore, Standard Error of Measurement was 1.61, and Minimal Detectable Change was 4.47, suggesting that a change of almost five points on the scale is necessary to determine a reliable change in self-reported procrastination severity. Conclusions The current study revealed that the Pure Procrastination Scale, the Irrational Procrastination Scale, and the Susceptibility to Temptation Scale are both valid and reliable from a psychometric perspective, and that they might be used for assessing the occurrence and severity of procrastination via the Internet. Trial registration The current study is part of a clinical trial assessing the efficacy of Internet-based cognitive behavior therapy for procrastination, and was registered 04/22/2013 on ClinicalTrials.gov (NCT01842945).
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Affiliation(s)
- Alexander Rozental
- Division of Clinical Psychology, Department of Psychology, Stockholm University, Frescati Hagväg 8, SE-106 91 Stockholm, Sweden
| | - Erik Forsell
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - Andreas Svensson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden
| | - David Forsström
- Division of Clinical Psychology, Department of Psychology, Stockholm University, Frescati Hagväg 8, SE-106 91 Stockholm, Sweden
| | - Gerhard Andersson
- Department of Behavioural Sciences and Learning, Linköping University, Linköping, Sweden ; Department of Clinical Neuroscience, Division of Psychiatry, Karolinska Institutet, Stockholm, Sweden
| | - Per Carlbring
- Division of Clinical Psychology, Department of Psychology, Stockholm University, Frescati Hagväg 8, SE-106 91 Stockholm, Sweden
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Walwyn R, Roberts C. Meta-analysis of absolute mean differences from randomised trials with treatment-related clustering associated with care providers. Stat Med 2014; 34:966-83. [PMID: 25446577 DOI: 10.1002/sim.6379] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2014] [Revised: 11/03/2014] [Accepted: 11/06/2014] [Indexed: 11/10/2022]
Abstract
Nesting of patients within care providers in trials of physical and talking therapies creates an additional level within the design. The statistical implications of this are analogous to those of cluster randomised trials, except that the clustering effect may interact with treatment and can be restricted to one or more of the arms. The statistical model that is recommended at the trial level includes a random effect for the care provider but allows the provider and patient level variances to differ across arms. Evidence suggests that, while potentially important, such within-trial clustering effects have rarely been taken into account in trials and do not appear to have been considered in meta-analyses of these trials. This paper describes summary measures and individual-patient-data methods for meta-analysing absolute mean differences from randomised trials with two-level nested clustering effects, contrasting fixed and random effects meta-analysis models. It extends methods for incorporating trials with unequal variances and homogeneous clustering to allow for between-arm and between-trial heterogeneity in intra-class correlation coefficient estimates. The work is motivated by a meta-analysis of trials of counselling in primary care, where the control is no counselling and the outcome is the Beck Depression Inventory. Assuming equal counsellor intra-class correlation coefficients across trials, the recommended random-effects heteroscedastic model gave a pooled absolute mean difference of -2.53 (95% CI -5.33 to 0.27) using summary measures and -2.51 (95% CI -5.35 to 0.33) with the individual-patient-data. Pooled estimates were consistently below a minimally important clinical difference of four to five points on the Beck Depression Inventory.
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Affiliation(s)
- Rebecca Walwyn
- Leeds Institute for Clinical Trials Research, University of Leeds, Leeds LS2 9JT, U.K
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44
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Schöttke H, Trame L, Sembill A. Relevance of therapy goals in outpatient cognitive-behavioral and psychodynamic psychotherapy. Psychother Res 2014; 24:711-23. [DOI: 10.1080/10503307.2014.881578] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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45
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Rhodes S, Richards DA, Ekers D, McMillan D, Byford S, Farrand PA, Gilbody S, Hollon SD, Kuyken W, Martell C, O’Mahen HA, O’Neill E, Reed N, Taylor RS, Watkins ER, Wright KA. Cost and outcome of behavioural activation versus cognitive behaviour therapy for depression (COBRA): study protocol for a randomised controlled trial. Trials 2014; 15:29. [PMID: 24447460 PMCID: PMC3903024 DOI: 10.1186/1745-6215-15-29] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/08/2014] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Cognitive behaviour therapy (CBT) is an effective treatment for depression. However, CBT is a complex therapy that requires highly trained and qualified practitioners, and its scalability is therefore limited by the costs of training and employing sufficient therapists to meet demand. Behavioural activation (BA) is a psychological treatment for depression that may be an effective alternative to CBT and, because it is simpler, might also be delivered by less highly trained and specialised mental health workers. METHODS/DESIGN COBRA is a two-arm, non-inferiority, patient-level randomised controlled trial, including clinical, economic, and process evaluations comparing CBT delivered by highly trained professional therapists to BA delivered by junior professional or para-professional mental health workers to establish whether the clinical effectiveness of BA is non-inferior to CBT and if BA is cost effective compared to CBT. Four hundred and forty patients with major depressive disorder will be recruited through screening in primary care. We will analyse for non-inferiority in per-protocol and intention-to-treat populations. Our primary outcome will be severity of depression symptoms (Patient Health Questionnaire-9) at 12 months follow-up. Secondary outcomes will be clinically significant change and severity of depression at 18 months, and anxiety (General Anxiety Disorder-7 questionnaire) and health-related quality of life (Short-Form Health Survey-36) at 12 and 18 months. Our economic evaluation will take the United Kingdom National Health Service/Personal Social Services perspective to include costs of the interventions, health and social care services used, plus productivity losses. Cost-effectiveness will explored in terms of quality-adjusted life years using the EuroQol-5D measure of health-related quality of life. DISCUSSION The clinical and economic outcomes of this trial will provide the evidence to help policy makers, clinicians and guideline developers decide on the merits of including BA as a first-line treatment of depression. TRIAL REGISTRATION Current Controlled Trials ISRCTN27473954.
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Affiliation(s)
- Shelley Rhodes
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2 LU, UK
| | - David A Richards
- University of Exeter Medical School, St Luke’s Campus, Exeter EX1 2 LU, UK
| | - David Ekers
- Durham University/Tees Esk and Wear Valleys NHS Foundation Trust, Wolfson Research Institute for Health and Wellbeing, Durham University, Queen’s Campus, University Boulevard, Stockton on Tees, Durham TS17 6BH, UK
| | - Dean McMillan
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Sarah Byford
- Institute of Psychiatry, Kings College London, De Crespigny Park, London SE5 8AF, UK
| | - Paul A Farrand
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Simon Gilbody
- Department of Health Sciences, Seebohm Rowntree Building, University of York, Heslington, York YO10 5DD, UK
| | - Steven D Hollon
- Department of Psychology, 306 Wilson Hall, 21st Avenue South, Vanderbilt University, 2301 Vanderbilt Place, Nashville, TN 37240-7817, USA
| | - Willem Kuyken
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Christopher Martell
- Department of Psychology, University of Wisconsin, Milwaukee, P.O. Box 413, Milwaukee WI 53201, USA
| | - Heather A O’Mahen
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Emer O’Neill
- Depression Alliance, 20 Great Dover Street, London SE1 4LX, UK
| | - Nigel Reed
- Lived Experience Group, c/o School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Rod S Taylor
- University of Exeter Medical School, The Veysey Building, Salmon Pool Lane, Exeter EX2 4SG, UK
| | - Ed R Watkins
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
| | - Kim A Wright
- School of Psychology, Sir Henry Wellcome Building for Mood Disorders Research, University of Exeter, Streatham Campus, Exeter EX4 4QG, UK
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Mitchell MM, Bradshaw CP. Examining classroom influences on student perceptions of school climate: The role of classroom management and exclusionary discipline strategies. J Sch Psychol 2013; 51:599-610. [DOI: 10.1016/j.jsp.2013.05.005] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2012] [Revised: 05/09/2013] [Accepted: 05/13/2013] [Indexed: 11/28/2022]
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Ehlers A, Grey N, Wild J, Stott R, Liness S, Deale A, Handley R, Albert I, Cullen D, Hackmann A, Manley J, McManus F, Brady F, Salkovskis P, Clark DM. Implementation of cognitive therapy for PTSD in routine clinical care: effectiveness and moderators of outcome in a consecutive sample. Behav Res Ther 2013; 51:742-52. [PMID: 24076408 PMCID: PMC3897916 DOI: 10.1016/j.brat.2013.08.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2013] [Revised: 07/26/2013] [Accepted: 08/26/2013] [Indexed: 11/28/2022]
Abstract
Objective Trauma-focused psychological treatments are recommended as first-line treatments for Posttraumatic Stress Disorder (PTSD), but clinicians may be concerned that the good outcomes observed in randomized controlled trials (RCTs) may not generalize to the wide range of traumas and presentations seen in clinical practice. This study investigated whether Cognitive Therapy for PTSD (CT-PTSD) can be effectively implemented into a UK National Health Service Outpatient Clinic serving a defined ethnically mixed urban catchment area. Method A consecutive sample of 330 patients with PTSD (age 17–83) following a wide range of traumas were treated by 34 therapists, who received training and supervision in CT-PTSD. Pre and post treatment data (PTSD symptoms, anxiety, depression) were collected for all patients, including dropouts. Hierarchical linear modeling investigated candidate moderators of outcome and therapist effects. Results CT-PTSD was well tolerated and led to very large improvement in PTSD symptoms, depression and anxiety. The majority of patients showed reliable improvement/clinically significant change: intent-to-treat: 78.8%/57.3%; completer: 84.5%/65.1%. Dropouts and unreliable attenders had worse outcome. Statistically reliable symptom exacerbation with treatment was observed in only 1.2% of patients. Treatment gains were maintained during follow-up (M = 280 days, n = 220). Few of the selection criteria used in some RCTs, demographic, diagnostic and trauma characteristics moderated treatment outcome, and only social problems and needing treatment for multiple traumas showed unique moderation effects. There were no random effects of therapist on symptom improvement, but therapists who were inexperienced in CT-PTSD had more dropouts than those with greater experience. Conclusions The results support the effectiveness of CT-PTSD and suggest that trauma-focused cognitive behavior therapy can be successfully implemented in routine clinical services treating patients with a wide range of traumas. Cognitive Therapy for PTSD can be effectively implemented in routine clinical care. The intent-to-treat analysis showed very large treatment effects. Patients found the treatment acceptable, and the majority showed clinically significant change. Few patient characteristics moderated treatment outcome. Inexperienced therapists had more dropouts.
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Affiliation(s)
- Anke Ehlers
- Department of Experimental Psychology, University of Oxford, South Parks Road, Oxford OX1 3UD, UK; Oxford Cognitive Health Clinical Research Facility, UK; National Institute for Health Research (NIHR) Mental Health Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London, UK.
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Roberts C, Walwyn R. Design and analysis of non-pharmacological treatment trials with multiple therapists per patient. Stat Med 2012; 32:81-98. [PMID: 22865729 DOI: 10.1002/sim.5521] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Revised: 05/22/2012] [Accepted: 06/18/2012] [Indexed: 11/06/2022]
Abstract
In trials of physical and talking therapies, nesting of patients within therapists has statistical implications analogous to those of cluster randomised trials. Nevertheless, the clustering effect may be more complex, as it interacts with treatment. For some therapies, individual patients may receive care from multiple therapists of the same type, so that patients are no longer strictly nested within therapists, creating a 'multiple-membership' relationship between patients and therapists. This paper considers methods of analysis and sample size estimation for trials with multiple-membership clustering effects. It is motivated by a trial of a psychotherapy for the treatment of adolescent depression with cognitive behavioural therapy. We tested methods and issues in a Monte Carlo simulation study, simulating trials with multiple membership. Results demonstrate satisfactory performance in terms of convergence and give estimates of the intra-cluster correlation coefficient and empirical test size similar to a simple hierarchical design. We derive formulae for sample size and power for multiple-membership trial designs. We then compare estimates of power from this formula with empirical power derived from the simulation study. Finally, we show that we can easily extend formulae for sample size and power to allow consideration of power and sample size for certain types of more complex interventions. These include situations where therapists of different types deliver separate components of the intervention, creating a cross-classified relationship, or where several therapists deliver a group-administered treatment, creating further levels.
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Therapist Behaviours in Internet-Delivered Cognitive Behaviour Therapy: Analyses of E-Mail Correspondence in the Treatment of Generalized Anxiety Disorder. Behav Cogn Psychother 2012; 41:280-9. [DOI: 10.1017/s1352465812000240] [Citation(s) in RCA: 107] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: Internet-delivered cognitive behaviour therapy (iCBT) has been found to be an effective way to disseminate psychological treatment, and support given by a therapist seems to be important in order to achieve good outcomes. Little is known about what the therapists actually do when they provide support in iCBT and whether their behaviour influences treatment outcome. Aims: This study addressed the content of therapist e-mails in guided iCBT for generalized anxiety disorder. Method: We examined 490 e-mails from three therapists providing support to 44 patients who participated in a controlled trial on iCBT for generalized anxiety disorder. Results: Through content analysis of the written correspondence, eight distinguishable therapist behaviours were derived: deadline flexibility, task reinforcement, alliance bolstering, task prompting, psychoeducation, self-disclosure, self-efficacy shaping, and empathetic utterances. We found that task reinforcement, task prompting, self-efficacy shaping and empathetic utterances correlated with module completion. Deadline flexibility was negatively associated with outcome and task reinforcement positively correlated with changes on the Penn State Worry Questionnaire. Conclusions: Different types of therapist behaviours can be identified in iCBT, and though many of these behaviours are correlated to each other, different behaviours have an impact on change in symptoms and module completion.
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