Predicting post-treatment symptom severity for adults receiving psychological therapy in routine care for generalised anxiety disorder: a machine learning approach

Approximately half of generalised anxiety disorder (GAD) patients do not recover from first-line treatments, and no validated prediction models exist to inform individuals or clinicians of potential treatment benefits. This study aimed to develop and validate an accurate and explainable prediction model of post-treatment GAD symptom severity. Data from adults receiving treatment for GAD in eight Improving Access to Psychological Therapies (IAPT) services (n=15,859) were separated into training, validation and holdout datasets. Thirteen machine learning algorithms were compared using 10-fold cross-validation, against two simple clinically relevant comparison models. The best-performing model was tested on the holdout dataset and model-specific explainability measures identified the most important predictors. A Bayesian Additive Regression Trees model out-performed all comparison models (MSE=16.54 [95 % CI=15.58; 17.51]; MAE=3.19; R²=0.33, including a single predictor linear regression model: MSE=20.70 [95 % CI=19.58; 21.82]; MAE=3.94; R²=0.14). The five most important predictors were: PHQ-9 anhedonia, GAD-7 annoyance/irritability, restlessness and fear items, then the referral-assessment waiting time. The best-performing model accurately predicted post-treatment GAD symptom severity using only pre-treatment data, outperforming comparison models that approximated clinical judgement and remaining within the GAD-7 error of measurement and minimal clinically important differences. This model could inform treatment decision-making and provide desired information to clinicians and patients receiving treatment for GAD.

Demographic and clinical characteristics associated with anxiety and depressive symptom outcomes in users of a digital mental health intervention incorporating a relational agent

BACKGROUND

Digital mental health interventions (DMHIs) may reduce treatment access issues for those experiencing depressive and/or anxiety symptoms. DMHIs that incorporate relational agents may offer unique ways to engage and respond to users and to potentially help reduce provider burden. This study tested Woebot for Mood & Anxiety (W-MA-02), a DMHI that employs Woebot, a relational agent that incorporates elements of several evidence-based psychotherapies, among those with baseline clinical levels of depressive or anxiety symptoms. Changes in self-reported depressive and anxiety symptoms over 8 weeks were measured, along with the association between each of these outcomes and demographic and clinical characteristics.

METHODS

This exploratory, single-arm, 8-week study of 256 adults yielded non-mutually exclusive subsamples with either clinical levels of depressive or anxiety symptoms at baseline. Week 8 Patient Health Questionnaire-8 (PHQ-8) changes were measured in the depressive subsample (PHQ-8 ≥ 10). Week 8 Generalized Anxiety Disorder-7 (GAD-7) changes were measured in the anxiety subsample (GAD-7 ≥ 10). Demographic and clinical characteristics were examined in association with symptom changes via bivariate and multiple regression models adjusted for W-MA-02 utilization. Characteristics included age, sex at birth, race/ethnicity, marital status, education, sexual orientation, employment status, health insurance, baseline levels of depressive and anxiety symptoms, and concurrent psychotherapeutic or psychotropic medication treatments during the study.

RESULTS

Both the depressive and anxiety subsamples were predominantly female, educated, non-Hispanic white, and averaged 38 and 37 years of age, respectively. The depressive subsample had significant reductions in depressive symptoms at Week 8 (mean change =-7.28, SD = 5.91, Cohen's d = -1.23, p < 0.01); the anxiety subsample had significant reductions in anxiety symptoms at Week 8 (mean change = -7.45, SD = 5.99, Cohen's d = -1.24, p < 0.01). No significant associations were found between sex at birth, age, employment status, educational background and Week 8 symptom changes. Significant associations between depressive and anxiety symptom outcomes and sexual orientation, marital status, concurrent mental health treatment, and baseline symptom severity were found.

CONCLUSIONS

The present study suggests early promise for W-MA-02 as an intervention for depression and/or anxiety symptoms. Although exploratory in nature, this study revealed potential user characteristics associated with outcomes that can be investigated in future studies.

TRIAL REGISTRATION

This study was retrospectively registered on ClinicalTrials.gov (#NCT05672745) on January 5th, 2023.

Enhancing patient experience assessment with psychological care in severe mental disorders: A study of the PREMIUM program

Incorporating the experiences of patients with severe mental disorders (SMD) into clinical practice offers valuable insights for optimizing psychological care's effectiveness with more patient-centered and personalized interventions. The study aimed to develop a patient-reported experience measure regarding psychological care (PREMIUM-PSY) using adaptive testing and investigate its association with quality of life. In a multicenter study involving 443 patients with SMD, PREMIUM-PSY demonstrated both validity and efficiency (6-item average). Positive patient experiences were associated with enhanced mental and physical quality of life (β = 3.15[2.17;4.12], p < 0.001 and β = 1.18[0.04;2.32], p = 0.042), suggesting PREMIUM-PSY's potential for optimizing psychological care outcomes.

The effect of Oxytocin administration on patient-therapist alliance congruence: Results from a randomized controlled trial

OBJECTIVES

The effects of oxytocin (OT) administration on psychotherapeutic processes have thus far been elusive. This study explored the effect of OT administration on patient-therapist congruence of the working alliance.

METHOD

Inpatients with mental disorders (N = 87) participating in a randomized controlled trial received OT (n = 44) or placebo (n = 43) intranasally twice a day, for four weeks. Patients and therapists rated the alliance after each session.

RESULTS

Oxytocin significantly moderated the level of agreement (b = -0.56, SE = 0.25, t = -2.30, p = 0.02), such that patients receiving OT demonstrated lower discrepancy (b = -0.73, p < 0.001) than did those receiving placebo (b = -1.30, p < 0.001). On the other hand, the mutual covariance of patient-therapist ratings across sessions was positive and significant for patients receiving placebo (b = 0.26, p = 0.01) but not for patients in the OT group (b = -0.06, p = .56).

CONCLUSION

Oxytocin can reduce discrepancies of patient-therapist perceptions of the alliance, although additional studies are needed to explore OT's effect on alliance development over time. As alliance congruence is associated with therapy outcomes, such intervention may lead to enhancement of therapeutic gains.

Who benefits from brief motivational intervention among young adults presenting to the emergency department with alcohol intoxication: A latent-class moderation analysis

BACKGROUND

Research has not identified which patients optimally benefit from brief Motivational Interviewing (bMI) for heavy drinking when delivered to young adults in the Emergency Department (ED).

METHODS

We conducted secondary analyses of data from a randomized controlled trial in which 344 young adults (18-35 years) presenting to the ED with alcohol intoxication received either bMI or Brief Advice (BA, control group). We used Latent Class Analysis to derive participants' profiles from baseline characteristics (i.e., sex, age, severity of alcohol use disorder, attribution of ED admission to alcohol use, importance, and confidence to change, cognitive discrepancy, anxiety, depression, and trait reactance). We then conducted a moderation analysis to assess the number of heavy drinking days at short-term (1-month) and long-term (12-month) follow-up using negative binomial regressions with interactions between the intervention and derived classes.

RESULTS

Fit statistics indicated that a 4-class solution best fit the data. Class 3 (high severity, importance and discrepancy, and low confidence and anxiety) benefitted more from bMI than BA at short- and long-term follow-up than Class 1 (younger; lowest severity, importance, discrepancy, reactance, anxiety and depression, and highest confidence). Class 2 (older; highest severity, importance, discrepancy, reactance, anxiety and depression, and lowest confidence) also benefitted more from bMI than BA than did Class 1 at short-term follow-up. In these significant contrasts, Class 1 benefitted more from BA than bMI. There were no significant interactions involving Class 4 (more likely to be women; low severity; high levels of anxiety, depression, and reactance).

CONCLUSIONS

This study identified the patient profiles that benefitted more from bMI than BA among nontreatment-seeking young adults who present intoxicated to the ED. The findings have implications for intervention design and argue for the importance of research aimed at developing intervention content tailored to patient profiles.

Moderators of the cost-effectiveness of transdiagnostic CBT for anxiety disorders over an 8-month time horizon using a net-benefit regression framework

BACKGROUND

Access to evidence-based psychological treatment is a concern in many parts of the globe due to government-level financial constraints and patient-level barriers. Transdiagnostic cognitive behavioural therapy (tCBT) is an effective treatment approach that uses a single protocol for anxiety disorders which could enhance the dissemination of evidence-based psychotherapy. In a context of limited resources, the study of treatment moderators can allow to identify subgroups for which the cost-effectiveness of an intervention differs, information that could impact decision-making. So far, there has been no economic evaluation of tCBT for different subpopulations. The objectives of this study, using the net-benefit regression framework, were to explore clinical and sociodemographic factors as potential moderators of the cost-effectiveness of tCBT compared to treatment-as-usual (TAU).

METHODS

This is a secondary data analysis of a pragmatic randomized controlled trial opposing tCBT added to TAU (n = 117) to TAU only (n = 114). Data on costs from the health system and the limited societal perspectives, as well as anxiety-free days, an effectiveness measure based on the Beck Anxiety Inventory, were collected over an 8-month time horizon and used to derive individual net-benefits. The net-benefit regression framework was used to assess moderators of the cost-effectiveness of tCBT + TAU as opposed to TAU alone. Variables of sociodemographic and clinical nature were assessed.

RESULTS

Results showed that the number of comorbid anxiety disorders significantly moderated the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective.

CONCLUSIONS

The number of comorbid anxiety disorders was identified as a moderator affecting the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. More research is needed to strengthen the case of tCBT from an economic standpoint for large-scale dissemination.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT02811458, 23/06/2016.

Examining differential responses to the Take Care of Me trial: A latent class and moderation analysis

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Take Care of Me participants fell into three classes varying in risk.

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The low-risk class had the lowest pre-treatment symptom severity.

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The high-risk group had the highest symptom severity and executive dysfunction.

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Moderate risk individuals experienced the greatest benefits of the program.

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Future interventions may be tailored based on risk to maximize efficacy.

Given prevalent alcohol misuse-emotional comorbidities among young adults, we developed an internet-based integrated treatment called Take Care of Me. Although the treatment had an impact on several secondary outcomes, effects were not observed for the primary outcome. Therefore, the goal of the current study was to examine heterogeneity in treatment responses. The initial RCT randomized participants to either a treatment or psychoeducational control condition. We conducted an exploratory latent class analysis to distinguish individuals based on pre-treatment risk and then used moderated regressions to examine differential treatment responses based on class membership. We found evidence for three distinct groups. Most participants fell in the “low severity” group (n = 123), followed by the “moderate severity” group (n = 57) who had a higher likelihood of endorsing a previous mental health diagnosis and treatment and higher symptom severity than the low group. The “high severity” group (n = 42) endorsed a family history of alcoholism, and the highest symptom severity and executive dysfunction. Moderated regressions revealed significant class differences in treatment responses. In the treatment condition, high severity (relative to low) participants reported higher alcohol consumption and hazardous drinking and lower quality of life at follow-up, whereas moderate severity (relative to low) individuals had lower alcohol consumption at follow-up, and lower hazardous drinking at end-of-treatment. No class differences were found for participants in the control group. Higher risk individuals in the treatment condition had poorer responses to the program. Tailoring interventions to severity may be important to examine in future research.

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Co-Occurring Obsessive-Compulsive Disorder and Compulsive Sexual Behavior: Clinical Features and Psychiatric Comorbidities

Obsessive-compulsive disorder (OCD) commonly co-occurs with other psychiatric conditions. Though research is limited, there is preliminary evidence that OCD also co-occurs with compulsive sexual behavior (CSB). Yet, few studies have investigated the demographic, clinical, and psychiatric comorbidities associated with co-occurring OCD and CSB. To address this gap, the current study aimed to evaluate rates of co-occurring OCD and CSB, identify demographic and clinical factors associated with comorbid OCD and CSB, and assess associated psychiatric comorbidity. Participants (N = 950) were patients of a large multisite treatment for OCD. Standardized self-report measures were used to assess demographic and clinical characteristics such as anxiety, depression, and severity and dimensions of OCD. Semi-structured interviews including the SCID were used to assess psychiatric comorbidities. A total of 36 (3.8%) of participants met the criteria for CSB. Binary logistic regression analysis revealed that males were significantly more likely to present with CSB than females and CSB was associated with greater psychiatric comorbidity, particularly impulse control disorders. These findings suggest that individuals with co-occurring OCD and CSB may have more complex treatment needs, and more tailored interventions may be necessary.

Determinants of patient-reported outcome trajectories and symptomatic recovery in Improving Access to Psychological Therapies (IAPT) services

BACKGROUND

Despite evidence for the general effectiveness of psychological therapies, there exists substantial heterogeneity in patient outcomes. We aimed to identify factors associated with baseline severity of depression and anxiety symptoms, rate of symptomatic change over the course of therapy, and symptomatic recovery in a primary mental health care setting.

METHODS

Using data from a service evaluation involving 35 527 patients in England's psychological and wellbeing [Improving Access to Psychological Therapies (IAPT)] services, we applied latent growth models to explore which routinely-collected sociodemographic, clinical, and therapeutic variables were associated with baseline symptom severity and rate of symptomatic change. We used a multilevel logit model to determine variables associated with symptomatic recovery.

RESULTS

Being female, younger, more functionally impaired, and more socioeconomically disadvantaged was associated with higher baseline severity of both depression and anxiety symptoms. Being older, less functionally impaired, and having more severe baseline symptomatology was associated with more rapid improvement of both depression and anxiety symptoms (male gender and greater socioeconomic disadvantage were further associated with rate of change for depression only). Therapy intensity and appointment frequency seemed to have no correlation with rate of symptomatic improvement. Patients with lower baseline symptom severity, less functional impairment, and older age had a greater likelihood of achieving symptomatic recovery (as defined by IAPT criteria).

CONCLUSIONS

We must continue to investigate how best to tailor psychotherapeutic interventions to fit patients' needs. Patients who begin therapy with more severe depression and/or anxiety symptoms and poorer functioning merit special attention, as these characteristics may negatively impact recovery.

The impact of comorbid spinal pain in depression on work participation and clinical remission following brief or short psychotherapy. Secondary analysis of a randomized controlled trial with two-year follow-up

Objectives

This explorative study analyses the influence of baseline comorbid long-lasting spinal pain (CSP) on improvement of long term work participation and clinical remission of mental health illness following either brief coping-focussed or short-term psychotherapy for depression. Whether type of treatment modifies outcome with or without CSP is also analysed.

Design

A secondary post hoc subgroup analysis of a pragmatic randomised controlled trial.

Interventions

Brief or standard short psychotherapy.

Methods

Based on baseline assessment, the sample was subdivided into a subgroup with and a subgroup without CSP. Work participation and clinical remission of depression and anxiety were assessed as treatment outcome at two-year follow-up. Simple and multivariate logistic regression analyses, across the intervention arms, were applied to evaluate the impact of CSP on treatment outcome. Selected baseline variables were considered as potential confounders and included as variates if relevant. The modifying effect of CSP on treatment outcome was evaluated by including intervention modality as an interaction term.

Main results

Among the 236 participants with depressive symptoms, 83 participants (35%) were identified with CSP. In simple logistic regression analysis, CSP reduced improvements on both work participation and clinical remission rate. In the multivariate analysis however, the impact of CSP on work participation and on clinical remission were not significant after adjusting for confounding variables. Reduction of work participation was mainly explained by the higher age of the CSP participants and the reduced clinical remission by the additional co-occurrence of anxiety symptoms at baseline. The occurrence of CSP at baseline did not modify long term outcome of brief compared to short psychotherapy.

Conclusions

CSP at baseline reduced work participation and worsened remission of mental health symptoms two-year following psychotherapy. Older age and more severe baseline anxiety are associated to reduced effectiveness. Type of psychotherapy received did not contribute to differences.

Professionals' understanding of their responsibilities in the collaboration with family caregivers of older persons with mental health problems in Norway

Research has highlighted the importance of health and social care professionals' collaboration with family caregivers. In the field of mental healthcare, involvement of family members is perceived as beneficial to the recovery process of the care recipient. Furthermore, family care-giving is an essential part of elderly care. It is well documented that family members need support to prevent negative consequences of care-giving. Nevertheless, involvement of and support for family caregivers have not developed into a common practice, and research has identified professional barriers to collaboration with family caregivers in several areas. The aim of this study was to explore professionals' experiences of collaboration with family caregivers of older persons with mental health problems, and how they understood their responsibility towards families. We conducted three focus group interviews with 18 health and social care professionals working in community-based services, in three rural municipalities in Western Norway. The thematic analysis by Braun and Clarke guided the analysis. The findings in relation to the professionals' role and responsibility towards family caregivers are presented in three themes: family caregivers - a resource that needs support; a responsibility with unclear boundaries; and balancing different needs. Professionals recognised family caregivers' need for support and acknowledged the importance of family relationships. However, they experienced dilemmas in performing their dual responsibility of caring for the older care recipient as well as the family member, which they described as having unclear guidelines. They also experienced that they had insufficient knowledge to take on this responsibility. We argue that the exercising of discretion is essential for the professionals' responsibility, and that clarification of their responsibility is needed. We recommend a stronger focus in education on developing competence in the family perspective. Furthermore, the apportionment of professionals' responsibility needs to be formalised, especially when several services are involved in providing care.

Mental health outcomes in patients with a long-term condition: analysis of an Improving Access to Psychological Therapies service

BACKGROUND

Having a long-term condition (LTC) significantly affects mental health. UK policy requires effective mental health provisions for patients with an LTC, generally provided by Improving Access to Psychological Therapies (IAPT) services. National IAPT data suggest that patients with an LTC typically demonstrate poorer outcomes compared with patients without an LTC. However, exploration of confounding factors and different outcome variables is limited.

AIMS

To establish the association of LTC status with demographic and clinical factors, and clinical mental health outcomes.

METHOD

Anonymised patient-level data from a London IAPT service during January 2019 to October 2020 were used in this cohort study, to compare differences between LTC and non-LTC groups on sociodemographic and clinical variables. Binary logistic and multiple linear regression models were constructed for binary outcome variables (recovery and reliable improvement) and continuous outcomes (distress and functioning), respectively.

RESULTS

Patients with an LTC were more likely to be female; older; from a Black, mixed or other ethnic background; and have greater social deprivation. Across the four clinical outcomes (recovery, reliable improvement, final psychological distress and final functioning), having an LTC significantly predicted poorer outcomes even after controlling for sociodemographic and clinical baseline variables. For three outcome variables, greater social deprivation and being discharged during the COVID-19 pandemic also predicted poorer clinical outcomes.

CONCLUSIONS

LTC status has a negative effect on mental health outcomes in IAPT services, independent of associated variables such as severity of baseline mental health symptoms, ethnicity and social deprivation. Effective psychological treatment for patients with an LTC remains an unresolved priority.

Patients' self-perceived strengths increase during treatment and predict outcome in outpatient cognitive behavioral therapy

OBJECTIVE

Modern conceptualizations suggest the independence of positive and negative mental health constructs. Research of positive constructs in psychotherapy is scarce. This study analyzed the development of patients' strengths during psychotherapy and whether pre-therapy strengths incrementally predict treatment outcome.

METHODS

Two hundred and two patients (56.44% female, mean age = 42.49) treated by 54 therapists underwent cognitive behavioral therapy. Patients' strengths in different contexts as well as psychopathology, interpersonal problems, and self-esteem were assessed at the beginning and end of therapy.

RESULTS

Strengths increased in the contexts of everyday life (EvdayS; d = 0.44, p < 0.001) and current problems (ProbS; d = 0.70, p < 0.001). Strengths in the context of previous crises that were managed successfully (CrisesS) did not change. However, baseline scores of CrisesS were a significant incremental predictor of all outcomes.

CONCLUSION

A differentiated assessment of positive constructs is useful for outcome prediction and the implementation of strength-based interventions.

Longitudinal experiences and risk factors for common mental health problems and suicidal behaviours among female sex workers in Nairobi, Kenya

BACKGROUND

Female sex workers (FSWs) are at high risk of mental health problems and suicide risk. Few longitudinal studies have examined risk factors for poor mental health among FSWs.

METHODS

Maisha Fiti is a longitudinal study among FSWs randomly selected from Sex Worker Outreach Programme clinics across Nairobi. Behavioural-biological survey data were collected at baseline (n = 1003, June-December 2019), midline (n = 366) (Jan-March 2020) and endline (n = 877) (June 2020-Jan 2021). Women reporting mental health problems were offered counselling services. Multivariable mixed logistic regression models were used to examine factors associated with mental health problems and suicidal behaviours.

RESULTS

There was a decline in the proportion of women reporting any mental health problem (depression and/or anxiety and/or PTSD) (baseline: 29.9%, midline: 13.3%, endline: 11.8%). There was strong evidence that any mental health problem was associated with recent hunger (aOR 1.99; 95% CI 1.37-2.88) and recent violence from non-intimate partners (2.23; 95% CI 1.55-3.19). Recent suicidal behaviour prevalence was similar across survey rounds (baseline: 10.2%; midline: 10.2%; endline: 10.4%), and was associated with recent violence from non-intimate partners (aOR 1.96; 95% CI 1.31-2.95), recent hunger (aOR 1.69; 95% CI 1.15-2.47) and having an additional employment to sex work (aOR 1.50; 95% CI 1.00-2.23).

CONCLUSIONS

Our study found a decline in mental health problems but high levels of persistent suicidal behaviours among FSWs. Syndemic risk factors including food insecurity and violence were longitudinally associated with mental health problems and recent suicidal behaviours. There is a need for accessible mental health services for FSWs, alongside structural interventions addressing poverty and violence.

The level of formal support received by people with severe mental illness living in supported accommodation and participation: A systematic review

AIM

The review aimed to identify and explore the association of level of support received by people with severe mental illness in supported accommodation and participation.

METHOD

The authors conducted a systematic search in MEDLINE, PsychINFO, PsychARTICLES, CINAHL Plus and ASSIA. Searches were restricted to articles published in English and participants aged 18 years and over with severe mental illness. Articles were included based on level of support received in mental health supported accommodation, classified according to the Simple Taxonomy for Supported Accommodation, and three factors of participation: social participation, daily living functioning and personal empowerment. Studies of in-patient settings and nursing homes were excluded. The review protocol is registered on PROSPERO (registration number: CRD42019161808).

RESULTS

Six articles were included in the review from USA, Australia, Sweden and Taiwan. Factors of participation for people living in accommodation with moderate support and accommodation with high support were explored. Data indicated an association between level of support and participation showing that people living in accommodation with moderate support had increased participation compared to people living in accommodation with high support.

CONCLUSION

This review identified an association between level of formal support and participation. People with SMI living in accommodation with medium support participated in more community occupations, more activities and had a higher level of personal empowerment than people living in accommodation with high support.

Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees

BACKGROUND

Older adults commonly experience depression and anxiety, yet are under-represented in psychological treatment services. There is uncertainty about the outcomes from psychological therapies for older adults relative to working-age adults. This study explored: pre-treatment differences between older and working-age patients with depression or anxiety disorders; whether outcomes from psychological therapy differ between groups controlling for pre-treatment clinical severity, functioning, and socio-demographics; and whether the impact of a long-term health condition (LTC) on outcome differs by age.

METHODS

Data on >100,000 patients treated with psychological therapies in eight Improving Access to Psychological Therapies services were analyzed. We compared pre-treatment characteristics and therapy outcomes for older (≥65 years) and working-age (18-64 years) patients, and investigated associations between age and outcomes.

RESULTS

Older adults had less severe clinical presentations pre-treatment. In adjusted models older adults were more likely to reliably recover (OR=1.33(95%CI=1.24-1.43)), reliably improve (OR=1.34(95%CI =1.24-1.45)), and attrition was less likely (OR=0.48(95%CI =0.43-0.53)). Effects were more pronounced in patients with anxiety disorders compared to depression. Having an LTC was associated with a much lower likelihood of reliable recovery for working-age patients but had only a modest effect for older adults.

LIMITATIONS

There are potential selection biases affecting the characteristics of older people attending these services. Residual confounding cannot be ruled out due to limits on data available.

CONCLUSIONS

Older adults experienced better outcomes from psychological treatments than working-age adults. Given the deleterious effects if mental health conditions go untreated, increasing access to psychological therapies for older people should be an international priority.

Moderators and predictors of treatment outcome in transdiagnostic group cognitive-behavioral therapy for primary care patients with emotional disorders

OBJECTIVE

Transdiagnostic group cognitive behavior therapy (TD-GCBT) has shown to be efficacious in the treatment of emotional disorders in primary care. However, little is known about possible moderators or predictors of treatment outcome. We aimed to explore the potential predictors and moderators of outcome in a large multicentre randomized controlled trial comparing TD-GCBT plus treatment as usual (TAU) to TAU alone.

METHOD

Putative demographic and baseline clinical variables were examined using the PROCESS macro as potential predictors/moderators of depressive and anxiety symptoms at posttreatment and 1-year follow-up.

RESULTS

Analyses were based on a study completer sample of 1061 participants randomized to TD-CBT + TAU (n = 527) or TAU alone (n = 534), with 631 participants assessed at the posttreatment evaluation and 388 at the 1-year follow-up. Individuals working or with a partner among sociodemographic variables, and higher baseline comorbidities and more severity of symptoms among clinical variables obtained more benefits from adding TDCBT to TAU. Those taking medication before treatment obtained less benefits from the TD-GCBT than those without prescribed antidepressant medications, after controlling for baseline severity of symptoms. Overall, the moderating effect of clinical (but not sociodemographic) variables remained at 1-year follow-up.

CONCLUSION

Findings support largely the generalization of the TD-GCBT for emotional disorders in primary care to a variety of sociodemographic and clinical groups. However, TD-GCBT seems to work to a greater extent for those individuals with a more severe clinical profile. Providing TD-GCBT before prescribing antidepressant medication and while people are still working may enhance the effects of adding this psychological treatment to TAU in primary care.

A community health volunteer delivered problem-solving therapy mobile application based on the Friendship Bench 'Inuka Coaching' in Kenya: A pilot cohort study

BACKGROUND

Sub-Saharan Africa (SSA) has the largest care gap for common mental disorders (CMDs) globally, heralding the use of cost-cutting approaches such as task-shifting and digital technologies as viable approaches for expanding the mental health workforce. This study aims to evaluate the effectiveness of a problem-solving therapy (PST) intervention that is delivered by community health volunteers (CHVs) through a mobile application called 'Inuka coaching' in Kenya.

METHODS

A pilot prospective cohort study recruited participants from 18 health centres in Kenya. People who self-screened were eligible if they scored 8 or higher on the Self-Reporting Questionnaire-20 (SRQ-20), were aged 18 years or older, conversant in written and spoken English, and familiar with the use of smart mobile devices. The intervention consisted of four PST mobile application chat-sessions delivered by CHVs. CMD measures were administered at baseline, 4-weeks (post-treatment), and at 3-months follow-up assessment.

RESULTS

In all, 80 participants consented to the study, of which 60 participants (female, n = 38; male, n = 22) completed their 4-week assessments, and 52 participants completed their 3-month follow-up assessment. The results showed a significant improvement over time on the Self-Reporting Questionnaire-20 (SRQ-20). Higher-range income, not reporting suicidal ideation, being aged over 30 years, and being male were associated with higher CMD symptom reduction.

CONCLUSION

To our knowledge, this report is the first to pilot a PST intervention that is delivered by CHVs through a locally developed mobile application in Kenya, to which clinically meaningful improvements were found. However, a randomised-controlled trial is required to robustly evaluate this intervention.

An Internet-Delivered Cognitive Behavioral Therapy for Depression and Anxiety Among Clients Referred and Funded by Insurance Companies Compared With Those Who Are Publicly Funded: Longitudinal Observational Study

BACKGROUND

Anxiety and depression are leading causes of disability but are often undertreated. Internet-delivered cognitive behavioral therapy (ICBT) improves access to treatment by overcoming barriers to obtaining care. ICBT has been found to be efficacious in research trials and routine care, but there is limited research of ICBT when it is recommended and funded by insurance companies for clients on or recently in receipt of disability benefits or accommodations.

OBJECTIVE

The aim of this study was to examine ICBT engagement, treatment satisfaction, and effectiveness among individuals involved with 2 insurance companies. The 2 samples were benchmarked against published outcomes from a publicly funded (PF) ICBT clinic.

METHODS

Individuals who were on or recently in receipt of disability benefits and were either insurance company (IC) employees (n=21) or IC plan members (n=19) were referred to ICBT funded by the respective insurance companies. Outcomes were benchmarked against outcomes of ICBT obtained in a PF ICBT clinic, with clients in the clinic divided into those who reported no involvement with insurance companies (n=414) and those who were on short-term disability (n=44). All clients received the same 8-week, therapist-assisted, transdiagnostic ICBT course targeting anxiety and depression. Engagement was assessed using completion rates, log-ins, and emails exchanged. Treatment satisfaction was assessed posttreatment. Depression, anxiety, and disability measures were administered pretreatment, posttreatment, and at 3 months.

RESULTS

All samples showed high levels of ICBT engagement and treatment satisfaction. IC employees experienced significant improvement at posttreatment (depression d=0.77; anxiety d=1.13; and disability d=0.91) with outcomes maintained at 3 months. IC plan members, who notably had greater pretreatment disability than the other samples, experienced significant moderate effects at posttreatment (depression d=0.58; anxiety d=0.54; and disability d=0.60), but gains were not maintained at 3 months. Effect sizes at posttreatment in both IC samples were significantly smaller than in the PF sample who reported no insurance benefits (depression d=1.14 and anxiety d=1.30) and the PF sample who reported having short-term disability benefits (depression d=0.95 and anxiety d=1.07). No difference was seen in effect sizes among IC employees and the PF samples on disability. However, IC plan members experienced significantly smaller effects on disability d=0.60) compared with the PF sample with no disability benefits d=0.90) and those on short-term disability benefits d=0.94).

CONCLUSIONS

Many clients referred and funded by insurance companies were engaged with ICBT and found it acceptable and effective. Results, however, were not maintained among those with very high levels of pretreatment disability. Small sample sizes in the IC groups are a limitation. Directions for research related to ICBT funded by insurance companies have been described.