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Newman-Taylor K, Bentall R. Cognitive behavioural therapy for psychosis: The end of the line or time for a new approach? Psychol Psychother 2024; 97:4-18. [PMID: 37804105 DOI: 10.1111/papt.12498] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 08/28/2023] [Accepted: 09/05/2023] [Indexed: 10/08/2023]
Abstract
PURPOSE Following its introduction in the early 1990s, cognitive behavioural therapy for psychosis (CBTp) has been evaluated in a large number of clinical trials and is now established as a recommended treatment in the UK National Health Service and elsewhere in the world. Meta-analyses, however, indicate modest effects compared to treatment as usual or comparison therapies such as supportive counselling. Here, we seek to identify factors impacting the effectiveness of CBTp, and avenues for future psychotherapy research that may improve outcomes. METHOD We outline two recent umbrella reviews and discuss factors likely to impact the effectiveness of CBTp. RESULTS Modest effect sizes from meta-analyses mask heterogeneous outcomes, with some people benefiting and others possibly being harmed by therapy. Common factors such as the therapeutic alliance play an important role in determining outcomes but have been largely neglected by CBTp researchers. There is also the promise of improving outcomes by identifying and targeting the psychological mechanisms that either maintain psychotic symptoms (e.g. worry) or are causally implicated (e.g. trauma). CONCLUSIONS It is unlikely that everyone with psychosis will be equally responsive to the same therapeutic protocols. We need a new, personalised psychotherapy approach to CBTp research and practice, and can learn from research for anxiety and depression examining predictors of therapeutic response to inform treatment decisions. Precision psychological therapies informed by a combination of individual characteristics, common factors and a focus on specific mechanisms will require new research strategies and are likely to lead to improved outcomes for people with psychosis.
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Affiliation(s)
- Katherine Newman-Taylor
- Psychology Department, University of Southampton, Southampton, UK
- Psychology Department, Southern Health NHS Foundation Trust, Southampton, UK
| | - Richard Bentall
- Psychology Department, University of Sheffield, Sheffield, UK
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Morse AK, Sercombe J, Askovic M, Fisher A, Marel C, Chatterton ML, Kay-Lambkin F, Barrett E, Sunderland M, Harvey L, Peach N, Teesson M, Mills KL. Systematic review of the efficacy, effectiveness, and cost-effectiveness of stepped-care interventions for the prevention and treatment of problematic substance use. J Subst Abuse Treat 2023; 144:108928. [PMID: 36370469 DOI: 10.1016/j.jsat.2022.108928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 09/15/2022] [Accepted: 10/30/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Stepped-care is a commonly recommended and implemented care model across health care domains, including substance use. Despite their presumed efficient allocation of treatment resources, a current and robust evidence synthesis is needed on the efficacy, effectiveness and cost-effectiveness of stepped-care for substance use. METHODS This systematic review analyzed articles describing evaluations of stepped-care models that measured the use of acutely psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in participants over 18 years old. The analysis investigated model and participant characteristics associated with treatment outcomes. RESULTS The study team conducted a search of five databases of literature (PsychINFO, MEDLINE, Embase, Cochrane Library and Scopus) published between January 1, 2010, and November 1, 2020. The search yielded 1051 unique articles, 19 of which were included in the analysis. The studies had considerable variability in sample sizes (n = 18-2310), time to follow-up (4.5 months to 3 years), and retention rates (35.1-100 %). Studies examined outcomes for either alcohol alone (n = 9), alcohol and other drug use (n = 9), or drug use alone (n = 1). Most studies (n = 13;) were rated as good quality. Three (15.8 %) were rated as fair and three (15.8 %) were rated as poor quality. The evidence regarding the efficacy, effectiveness and cost-effectiveness of stepped-care approaches is limited, but four of seven studies found that adaptive-care interventions delivered in the context of other systemic interventions produced greater benefit than control conditions in relation to at least one alcohol-related outcome. We have insufficient evidence to determine whether the modes or intensity of interventions included in the models, or decision rules used to step people up or down to differing levels of care, have an impact on outcome. CONCLUSION Heterogeneity between studies with regard to model and evaluation design limited the degree to which the analysis could draw robust conclusions. Sample recruitment and statistical power are particular challenges, and the field needs more innovative evaluation designs to assess the efficacy, effectiveness, and cost-effectiveness of stepped-care models.
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Affiliation(s)
- Ashleigh K Morse
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Jayden Sercombe
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Mina Askovic
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Alana Fisher
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Christina Marel
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Mary-Lou Chatterton
- Deakin Health Economics, Institute for Health Transformation, School of Health and Social Development, Faculty of Health, Deakin University, Geelong Waterfront Campus, Locked Bag 20001, Geelong, VIC 3220, Australia
| | - Frances Kay-Lambkin
- School of Medicine and Public Health, Faculty of Medicine and Health, The University of Newcastle Callaghan NSW 2308, Australia
| | - Emma Barrett
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Matthew Sunderland
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Logan Harvey
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Natalie Peach
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Maree Teesson
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia
| | - Katherine L Mills
- The Matilda Centre for Research in Mental Health and Substance Use, University of Sydney, Level 6 Jane Foss Russell Building, Camperdown, NSW 2006, Australia.
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Tsoi EWS, Mak WWS, Ho CYY, Yeung GTY. TourHeart—An Online Stratified Stepped Care Mental Health Platform: Qualitative Evaluation from Multiple Stakeholders’ Perspectives (Preprint). JMIR Hum Factors 2021; 9:e35057. [PMID: 35560109 PMCID: PMC9143776 DOI: 10.2196/35057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Revised: 03/08/2022] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Background TourHeart, a web-based stratified stepped care mental health platform, is a one-stop solution that integrates psychoeducation and other well-being promotional tools for mental health promotion and mental illness prevention and evidence-based, low-intensity psychological interventions for the treatment of people with anxiety and depressive symptoms. Instead of focusing only on symptom reduction, the platform aims to be person-centered and recovery-oriented, and continual feedback from stakeholders is sought. Understanding the perspectives of users and service providers enables platform developers to fine-tune both the design and content of the services for enhanced service personalization and personal recovery. Objective This qualitative study evaluated a web-based mental health platform by incorporating the perspectives of both users and service providers who administered the platform and provided coaching services. The platform included both web-based and offline services targeting adults along the mental health spectrum based on the two-continua model of mental health and mental illness. Methods Interview questions were designed based on the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework (RE-AIM). Views on offline services, the design of the web-based platform, user experience, and the contents of the platform were explored using semistructured interviews. A total of 27 service users and 22 service providers were recruited using purposive criterion sampling. A hybrid thematic analysis was performed to identify salient aspects of users’ and providers’ experiences with and views of the platform. Results Totally, 3 broad themes (namely, the quality of the platform, drivers for platform use, and coaching services) emerged from the interview data that highlighted users’ views of and experiences with the web-based platform. The platform’s general esthetics, operations, and contents were found to be critical features and drivers for continued use. Although coaching services were indispensable, participants preferred the autonomy and anonymity associated with web-based mental health services. Conclusions This study highlights the importance of web-based mental health services being easy to navigate and understand, being user-centric, and providing adequate guidance in self-help. It also confirms existing design standards and recommendations and suggests that more rigorous, iterative user experience research and robust evaluation should be conducted in the future adaptation of web-based stratified stepped care services, so that they can be more personalized and better promote personal recovery.
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Affiliation(s)
- Emily W S Tsoi
- Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, China (Hong Kong)
| | - Winnie W S Mak
- Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, China (Hong Kong)
| | - Connie Y Y Ho
- Department of Psychology, The Chinese University of Hong Kong, Shatin, NT, China (Hong Kong)
| | - Gladys T Y Yeung
- New Life Psychiatric Rehabilitation Association, Kowloon, China (Hong Kong)
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Jiang MYW, Kandris E, El-Masry Y, Drobny J, St. Clare T, Chen JTH. Effectiveness of transdiagnostic group cognitive-behavioural therapy for anxiety disorders in a naturalistic clinical setting. CLIN PSYCHOL-UK 2021. [DOI: 10.1080/13284207.2021.1913048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Affiliation(s)
- Michelle Y. W. Jiang
- Anxiety Treatment and Research Unit, Western Sydney Local Health District, Sydney, Australia
| | - Evelyn Kandris
- Anxiety Treatment and Research Unit, Western Sydney Local Health District, Sydney, Australia
| | - Yasmeen El-Masry
- Anxiety Treatment and Research Unit, Western Sydney Local Health District, Sydney, Australia
| | - Juliette Drobny
- Discipline of Psychiatry, University of Sydney, Sydney, Australia
| | - Tamsen St. Clare
- Anxiety Treatment and Research Unit, Western Sydney Local Health District, Sydney, Australia
| | - Jessamine T. H. Chen
- Centre for Emotional Health, Department of Psychology, Macquarie University, Sydney, Australia
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Linardon J, Messer M, Lee S, Rosato J. Perspectives of e-health interventions for treating and preventing eating disorders: descriptive study of perceived advantages and barriers, help-seeking intentions, and preferred functionality. Eat Weight Disord 2021; 26:1097-1109. [PMID: 32959274 DOI: 10.1007/s40519-020-01005-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 08/31/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Digital interventions that consider end-user needs, preferences, and concerns may address suboptimal rates of e-health uptake, usage, and engagement. We explored target-user perspectives of e-health treatment and prevention programs for eating disorders (EDs), with a focus on investigating (1) perceived advantages and barriers of e-health; (2) help-seeking intentions; and (3) preferences for different digital functionality, device types, and content-delivery formats. METHODS Survey data were analysed from 722 community-based participants. Participants were categorized into one of four groups based on symptom presentation and severity, ranging from low risk to probable bulimia nervosa or binge-eating disorder. RESULTS e-health advantages that received the highest endorsement (~ 84%) were "always there in times of need" and "travel not required". e-health barriers that received the highest endorsement (~ 50%) were concerns about data privacy and the accuracy of content presented. Nearly three-quarters reported an intention to use an e-health platform for preventing or treating EDs. Preference ratings were highest for programs to be available on all digital devices (relative to restricting the program to one type of device) and for content to be presented via graphics and video tutorials (rather than audio-based). e-health functionality that received highest preference ratings (~ 80%) were added clinician support, tailored feedback, strategies to change unhelpful ED thoughts, screening scales to assess symptoms, ED psychoeducation, and just-in-time intervention prompts. Preference and intention ratings were strikingly similar across all subgroups. CONCLUSION Findings may inform the development and design of e-health platforms that meet the needs of people at different stages of an ED. LEVEL OF EVIDENCE Level V, cross-sectional descriptive study.
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Affiliation(s)
- Jake Linardon
- School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia.
| | - Mariel Messer
- School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia
| | - Sohee Lee
- Faculty of Health and Environmental Science, Auckland University of Technology, Private Bag 92006, Auckland, 1142, New Zealand
| | - John Rosato
- School of Psychology, Deakin University, 1 Gheringhap Street, Geelong, VIC, 3220, Australia
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Translating evidence-based psychological interventions for older adults with depression and anxiety into public and private mental health settings using a stepped care framework: Study protocol. Contemp Clin Trials 2021; 104:106360. [PMID: 33766760 DOI: 10.1016/j.cct.2021.106360] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2020] [Revised: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 11/23/2022]
Abstract
BACKGROUND With expected increases in the number of older adults worldwide, the delivery of stepped psychological care for depression and anxiety in older populations may improve both treatment and allocative efficiency for individual patients and the health system. DESIGN A multisite pragmatic randomised controlled trial evaluating the clinical and cost-effectiveness of a stepped care model of care for treating depression and anxiety among older adults compared to treatment as usual (TAU) will be conducted. Eligible participants (n = 666) with clinically interfering anxiety and/or depression symptoms will be recruited from and treated within six Australian mental health services. The intervention group will complete a low intensity cognitive behavioural therapy (CBT) program: Internet-delivered or using a work-at-home book with brief therapist calls (STEP 1). Following STEP 1 a higher intensity face-to-face CBT (STEP 2) will then be offered if needed. Intention-to-treat analyses will be used to examine changes in primary outcomes (e.g. clinician-rated symptom severity changes) and secondary outcomes (e.g. self-reported symptoms severity, health related quality of life and service utilisation costs). An economic evaluation will be conducted using a cost-utility analysis to derive the incremental cost-effectiveness ratio for the stepped care intervention. DISCUSSION This study will demonstrate the relative clinical and economic benefits of stepped care model of psychological care for older adults experiencing anxiety and/or depression compared to TAU. The evaluation of the intervention within existing mental health services means that results will have significant implications for the translation of evidence-based interventions in older adult services across urban and rural settings. TRAIL REGISTRATION Prospectively registered on anzctr.org.au (ACTRN12619000219189) and isrctn.com (ISRCTN37503850).
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van Krugten FCW, van der Feltz-Cornelis CM, Boeschoten MA, van Broeckhuysen-Kloth SAM, van Eck van der Sluijs JF, van Ee E, van Es SM, Schoorl M, Tak LM, Brouwer WBF, Hakkaart-van Roijen L. Development and psychometric evaluation of the Transdiagnostic Decision Tool: matched care for patients with a mental disorder in need of highly specialised care. BJPsych Open 2020; 6:e93. [PMID: 38058113 PMCID: PMC7488321 DOI: 10.1192/bjo.2020.74] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Revised: 07/14/2020] [Accepted: 07/20/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Early identification of patients with mental health problems in need of highly specialised care could enhance the timely provision of appropriate care and improve the clinical and cost-effectiveness of treatment strategies. Recent research on the development and psychometric evaluation of diagnosis-specific decision-support algorithms suggested that the treatment allocation of patients to highly specialised mental healthcare settings may be guided by a core set of transdiagnostic patient factors. AIMS To develop and psychometrically evaluate a transdiagnostic decision tool to facilitate the uniform assessment of highly specialised mental healthcare need in heterogeneous patient groups. METHOD The Transdiagnostic Decision Tool was developed based on an analysis of transdiagnostic items of earlier developed diagnosis-specific decision tools. The Transdiagnostic Decision Tool was psychometrically evaluated in 505 patients with a somatic symptom disorder or post-traumatic stress disorder. Feasibility, interrater reliability, convergent validity and criterion validity were assessed. In order to evaluate convergent validity, the five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) and the ICEpop CAPability measure for Adults (ICECAP-A) were administered. RESULTS The six-item clinician-administered Transdiagnostic Decision Tool demonstrated excellent feasibility and acceptable interrater reliability. Spearman's rank correlations between the Transdiagnostic Decision Tool and ICECAP-A (-0.335), EQ-5D-5L index (-0.386) and EQ-5D-visual analogue scale (-0.348) supported convergent validity. The area under the curve was 0.81 and a cut-off value of ≥3 was found to represent the optimal cut-off value. CONCLUSIONS The Transdiagnostic Decision Tool demonstrated solid psychometric properties and showed promise as a measure for the early detection of patients in need of highly specialised mental healthcare.
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Affiliation(s)
| | | | | | | | - Jonna F. van Eck van der Sluijs
- Clinical Centre of Excellence for Body, Mind and Health, GGz Breburg; and Tranzo Department, Tilburg University, the Netherlands
| | - Elisa van Ee
- Centre for Psychotrauma, Reinier van Arkel Group, the Netherlands
| | - Saskia M. van Es
- Department of Psychopathology, PsyQ Amsterdam, Parnassia Groep, the Netherlands
| | - Maartje Schoorl
- Institute of Psychology, Leiden University; and Department of Psychotrauma, PsyQ Haaglanden, Parnassia Groep, the Netherlands
| | - Lineke M. Tak
- Interdisciplinary Center Psychopathology and Emotion Regulation, University Medical Center Groningen; and Dimence, Institute for Mental Health Care, the Netherlands
| | - Werner B. F. Brouwer
- Erasmus School of Health Policy & Management, Erasmus University Rotterdam, the Netherlands
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Lervik LV, Knapstad M, Smith ORF. Process evaluation of Prompt Mental Health Care (PMHC): the Norwegian version of Improving Access to Psychological Therapies. BMC Health Serv Res 2020; 20:437. [PMID: 32430000 PMCID: PMC7236093 DOI: 10.1186/s12913-020-05311-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 05/08/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Prompt Mental Health Care (PMHC) is the Norwegian adaptation of Improving Access to Psychological Therapies (IAPT). Thus far, evaluations of PMHC have mostly focused on the effectiveness, rather than on contextual and implementation processes. Therefore, the objective of this study was to do a process evaluation and examine: 1) To what extent do the services follow guidelines provided by the Norwegian Directorate of Health (NDH), 2) what the therapists experienced as important barriers and facilitators in implementing the service, and 3) client treatment satisfaction and its associations with baseline variables. METHOD The present study uses data from 526 clients who received PMHC treatment in the municipalities of Sandnes and Kristiansand. The therapists completed questionnaires about each client's course of treatment. We conducted semi-structured interviews with the therapists and analysed them using thematic analysis. Data from client questionnaires were used to report descriptive sample statistics including symptom severity and treatment satisfaction. Linear regression was adopted to examine the associations between client treatment satisfaction and baseline characteristics. RESULTS Several aspects of PMHC were implemented in line with the guidelines provided by NDH. Importantly, both services reached out to the intended target group, and could further be characterized as low-threshold with relatively short waiting times (median waiting time between initial contact and treatment start was 27 days, IQR 18-39), no waiting lists, and frequent use of self-referral (33.3%). From the client perspective, results indicated a high degree of treatment satisfaction (Mean = 3.93 (SD = .71, range 1-5)), and this was true across demographic characteristics and symptom severity at baseline (all p > .05). Most notable challenges that came forward were; the low provision of guided self-help (received by only 1.0% of clients), the lack of focus on work participation (low to some degree of focus in 70.8% among sick-listed clients), the collaboration with other services (no collaboration in 85.3% of the clients), and some aspects regarding future development of the service. CONCLUSION Both sites managed to implement key aspects of PMHC in line with the guidelines, but further development of the program is warranted. Discussion of challenges and future recommendations are presented.
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Affiliation(s)
- Linn Vathne Lervik
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015, Bergen, Norway.
| | - Marit Knapstad
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015, Bergen, Norway.,Faculty of Psychology, Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Otto Robert Frans Smith
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015, Bergen, Norway
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Webb CA, Cohen ZD, Beard C, Forgeard M, Peckham AD, Björgvinsson T. Personalized prognostic prediction of treatment outcome for depressed patients in a naturalistic psychiatric hospital setting: A comparison of machine learning approaches. J Consult Clin Psychol 2020; 88:25-38. [PMID: 31841022 DOI: 10.1037/ccp0000451] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Research on predictors of treatment outcome in depression has largely derived from randomized clinical trials involving strict standardization of treatments, stringent patient exclusion criteria, and careful selection and supervision of study clinicians. The extent to which findings from such studies generalize to naturalistic psychiatric settings is unclear. This study sought to predict depression outcomes for patients seeking treatment within an intensive psychiatric hospital setting and while comparing the performance of a range of machine learning approaches. METHOD Depressed patients (N = 484; ages 18-72; 89% White) receiving treatment within a psychiatric partial hospital program delivering pharmacotherapy and cognitive behavioral therapy were split into a training sample and holdout sample. First, within the training sample, 51 pretreatment variables were submitted to 13 machine learning algorithms to predict, via cross-validation, posttreatment Patient Health Questionnaire-9 depression scores. Second, the best performing modeling approach (lowest mean squared error; MSE) from the training sample was selected to predict outcome in the holdout sample. RESULTS The best performing model in the training sample was elastic net regularization (ENR; MSE = 20.49, R2 = .28), which had comparable performance in the holdout sample (MSE = 11.26; R2 = .38). There were 14 pretreatment variables that predicted outcome. To demonstrate the translation of an ENR model to personalized prediction of treatment outcome, a patient-specific prognosis calculator is presented. CONCLUSIONS Informed by pretreatment patient characteristics, such predictive models could be used to communicate prognosis to clinicians and to guide treatment planning. Identified predictors of poor prognosis may suggest important targets for intervention. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
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Affiliation(s)
- Christian A Webb
- Department of Psychiatry, Harvard Medical School/McLean Hospital
| | - Zachary D Cohen
- Department of Psychology, University of California, Los Angeles
| | - Courtney Beard
- Department of Psychiatry, Harvard Medical School/McLean Hospital
| | - Marie Forgeard
- Department of Clinical Psychology, William James College
| | - Andrew D Peckham
- Department of Psychiatry, Harvard Medical School/McLean Hospital
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Boyd L, Baker E, Reilly J. Impact of a progressive stepped care approach in an improving access to psychological therapies service: An observational study. PLoS One 2019; 14:e0214715. [PMID: 30964883 PMCID: PMC6456251 DOI: 10.1371/journal.pone.0214715] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Accepted: 03/19/2019] [Indexed: 12/03/2022] Open
Abstract
England's national Improving Access to Psychological Therapies (IAPT) programme advocates stepped care as its organizational delivery of psychological therapies to common mental health problems. There is limited evidence regarding the efficacy of stepped care as a service delivery model, heterogeneity of definition and differences in model implementation in both research and routine practice, hence outcome comparison in terms of effectiveness of model is difficult. Despite sound evidence of the efficacy of low intensity interventions there appears to be a perpetuation of the notion that severity and complexity should only be treated by a high intensity intervention through the continuation of a stratified care model. Yet no psychotherapy treatment is found to be more superior to another, and not enough is known about what works for whom to aid the matching of treatment decision. In the absence of understanding precise treatment factors optimal for recovery, it may be useful to better understand the impact of a service delivery model, and whether different models achieve different outcomes. This study aims to contribute to the discussion regarding the stepped care definition and delivery, and explores the impact on clinical outcomes where different types of stepped care have been implemented within the same service. An observational cohort study analysed retrospective data (n = 16,723) over a 4 year period, in a single IAPT service, where delivery changed from one type of stepped care model to another. We compared the outcomes of treatment completers with a stratified care model and a progression care model. We also explored the assumption that patients who score severe on psychological measures, and therefore are potentially complex, would achieve better outcomes in a stratified model. Outcomes in each model type were compared, alongside baseline factor variables. A significant association was observed between a recovery outcome and model type, with patients 1.5 times more likely to recover in the progression delivery model. The potential implications are that with a progression stepped care model of service delivery, more patients can be treated with a lower intensity intervention, even with initial severe presentations, ensuring that only those that need high intensity CBT or equivalent are stepped up. This could provide services with an effective clinical model that is efficient and potentially more cost effective.
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Affiliation(s)
- Lisa Boyd
- Tees Esk and Wear Valleys NHS Foundation Trust, Durham, England
| | - Emma Baker
- Tees Esk and Wear Valleys NHS Foundation Trust, Durham, England
| | - Joe Reilly
- Tees Esk and Wear Valleys NHS Foundation Trust, Durham, England
- University of York, York, England
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Hollon SD, Cohen ZD, Singla DR, Andrews PW. Recent Developments in the Treatment of Depression. Behav Ther 2019; 50:257-269. [PMID: 30824244 DOI: 10.1016/j.beth.2019.01.002] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2018] [Revised: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 01/22/2023]
Abstract
The cognitive and behavioral interventions can be as efficacious as antidepressant medications and more enduring, but some patients will be more likely to respond to one than the other. Recent work has focused on developing sophisticated selection algorithms using machine-learning approaches that answer the question, "What works best for whom?" Moreover, the vast majority of people suffering from depression reside in low- and middle-income countries where access to either psychotherapy or medications is virtually nonexistent. Great strides have been made in training nonspecialist providers (known as task sharing) to overcome this gap. Finally, recent work growing out of evolutionary psychology suggests that antidepressant medications may suppress symptoms at the expense of prolonging the underlying episode so as to increase the risk of relapse whenever someone tries to stop. We address each of these developments and their cumulative implications.
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Heddaeus D, Dirmaier J, Daubmann A, Grochtdreis T, König HH, Löwe B, Maehder K, Porzelt S, Rosenkranz M, Schäfer I, Scherer M, Schulte B, von dem Knesebeck O, Wegscheider K, Weigel A, Werner S, Zimmermann T, Härter M. [Clinical trial of a stepped and collaborative care model for mental illnesses and comorbidities in the Hamburg Network for Health Services Research]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2019; 62:205-213. [PMID: 30607447 DOI: 10.1007/s00103-018-2865-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Healthcare for mental disorders is a big challenge for the German healthcare system. In cases of comorbid mental diseases, patients suffer from an especially high burden of disease. So far, innovative care models for collaborative and stepped care have only been investigated with respect to their effectiveness for single mental disorders.The project "Collaborative and Stepped Care in Mental Health by Overcoming Treatment Sector Barriers" (COMET), which is being carried out by the Hamburg Network for Health Services Research (HAM-NET) from 2017 until 2020, examines an innovative, guideline-based healthcare model for the improvement of healthcare for patients with mental illnesses and their potential comorbidities. In this article this new stepped and collaborative care model for patients in primary care that integrates general practitioners, psychiatrists, psychotherapists, and hospitals is presented. For the implementation and facilitation of the model, guideline-based treatment pathways, a tablet-based computer program for screening, diagnostic and guideline-based treatment recommendations, as well as a web-based transferal platform were developed.The results of this project on the effectiveness and efficacy of the model can help determine if the model can be implemented in routine healthcare. This could represent a major step towards more integrated and cross-sectoral healthcare for patients with mental illnesses.
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Affiliation(s)
- Daniela Heddaeus
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Jörg Dirmaier
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland
| | - Anne Daubmann
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas Grochtdreis
- Institut für Gesundheitsökonomie und Versorgungsforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Hans-Helmut König
- Institut für Gesundheitsökonomie und Versorgungsforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Bernd Löwe
- Institut und Poliklinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Kerstin Maehder
- Institut und Poliklinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Sarah Porzelt
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Moritz Rosenkranz
- Zentrum für interdisziplinäre Suchtforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Ingo Schäfer
- Zentrum für interdisziplinäre Suchtforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Martin Scherer
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Bernd Schulte
- Zentrum für interdisziplinäre Suchtforschung, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Olaf von dem Knesebeck
- Institut für Medizinische Soziologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Karl Wegscheider
- Institut für Medizinische Biometrie und Epidemiologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Angelika Weigel
- Institut und Poliklinik für Psychosomatische Medizin und Psychotherapie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Silke Werner
- Institut für Medizinische Soziologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Thomas Zimmermann
- Institut und Poliklinik für Allgemeinmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Martin Härter
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Deutschland.
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Magaard JL, Liebherz S, Melchior H, Engels A, König HH, Kriston L, Schulz H, Jahed J, Brütt AL, Reber KC, Härter M. Collaborative mental health care program versus a general practitioner program and usual care for treatment of patients with mental or neurological disorders in Germany: protocol of a multiperspective evaluation study. BMC Psychiatry 2018; 18:347. [PMID: 30359248 PMCID: PMC6202836 DOI: 10.1186/s12888-018-1914-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2018] [Accepted: 09/27/2018] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND German statutory health insurances are pursuing the goal of improving treatment of chronically ill people by promoting networks of health care providers and supporting treatments that reflect the current medical knowledge. The so-called PNP program is a collaborative care program developed by a German statutory health insurance, which defines specific rules on psychiatric, neurological, psychosomatic, and psychotherapeutic treatment. It aims to strengthen provision of guideline-based outpatient treatment and collaboration between different health care providers. It includes the general practitioners' program, which aims to strengthen the coordinating role of GPs. This study aims to evaluate the PNP program. METHODS To evaluate the effectiveness of the PNP program, we will conduct a prospective non-randomized controlled trial with primary data comparing patients enrolled in the PNP program and in the general practitioner program (intervention group) to patients enrolled only in the general practitioner program and patients who receive usual care (control groups). To evaluate costs and level of detail of diagnoses in care of patients with PNP program, we will use routinely collected secondary administrative health data in a retrospective quasi-experimental design. Patients who are at least 18 years old, insured by the statutory health insurance AOK, and on sick leave due to one of the mental or neurological diagnoses (affective, anxiety, somatoform or adjustment disorders, alcohol use disorders, schizophrenia, multiple sclerosis) will be included. We will collect data at baseline and at 12-months follow-up. Health-related quality of life (primary data) and direct costs (secondary data) caused by outpatient and inpatient service utilization and medication will be the primary outcomes. We will analyze data using (generalized) linear mixed models and exploratory analyses. We will use entropy balancing to control for possible differences between the groups. We will use an exploratory sequential design including qualitative and descriptive statistical analyses to assess the structure and process quality of the PNP program among health care providers. DISCUSSION The results will help to develop a comprehensive picture of collaborative care programs for mental and neurological health care from the perspective of patients, health care providers, and health insurance companies. TRIAL REGISTRATION German Clinical Trial Register DRKS00013114.
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Affiliation(s)
- Julia Luise Magaard
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
| | - Sarah Liebherz
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
| | - Hanne Melchior
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
| | - Alexander Engels
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Levente Kriston
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
| | - Holger Schulz
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
| | | | - Anna Levke Brütt
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
- Department for Health Services Research, Faculty of Medicine and Health Sciences, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
| | - Katrin Christiane Reber
- Department of Health Economics and Health Services Research, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Martin Härter
- Department of Medical Psychology, Center for Psychosocial Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, Building W26, 20246 Hamburg, Germany
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Knapstad M, Nordgreen T, Smith ORF. Prompt mental health care, the Norwegian version of IAPT: clinical outcomes and predictors of change in a multicenter cohort study. BMC Psychiatry 2018; 18:260. [PMID: 30115041 PMCID: PMC6097447 DOI: 10.1186/s12888-018-1838-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 08/07/2018] [Indexed: 11/05/2022] Open
Abstract
BACKGROUND Prompt mental health care (PMHC) is a Norwegian initiative, inspired by the English 'Improving Access to Psychological Therapy' (IAPT), aimed to provide low-threshold access to primary care treatment for persons with symptoms of anxiety and depression. The objectives of the present study are to describe the PMHC service, to examine changes in symptoms of anxiety and depression following treatment and to identify predictors of change, using data from the 12 first pilot sites. METHODS A prospective cohort design was used. All participants were asked to complete questionnaires at baseline, before each treatment session and at the end of treatment. Effect sizes (ES) for pre-post changes and recovery rates were calculated based on the Patient Health Questionnaire and the Generalized Anxiety Disorder scale. Multiple imputation (MI) was used in order to handle missing data. We examined predictors through latent difference score models and reported the contribution of each predictor level in terms of ES. RESULTS In total, N = 2512 clients received treatment at PMHC between October 2014 and December 2016, whereof 61% consented to participate. The changes from pre- to post-treatment were large for symptoms of both depression (ES = 1.1) and anxiety (ES = 1.0), with an MI-based reliable recovery rate of 58%. The reliable recovery rate comparable to IAPT based on last-observation-carried-forward was 48%. The strongest predictors for less improvement were having immigrant background (ES change depression - 0.27, ES change anxiety - 0.26), being out of work at baseline (ES change depression - 0.18, ES change anxiety - 0.35), taking antidepressants (ES change anxiety - 0.36) and reporting bullying as cause of problems (ES change depression - 0.29). Taking sleep medication did on the other hand predict more improvement (ES change depression 0.23, ES change anxiety 0.45). CONCLUSIONS Results in terms of clinical outcomes were promising, compared to both the IAPT pilots and other benchmark samples. Though all groups of clients showed substantial improvements, having immigrant background, being out of work, taking antidepressant medication and reporting bullying as cause stood out as predictors of poorer treatment response. Altogether, PMHC was successfully implemented in Norway. Areas for improvement of the service are discussed.
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Affiliation(s)
- Marit Knapstad
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5018, Bergen, Norway. .,Department of Clinical Psychology, University of Bergen, Bergen, Norway.
| | - Tine Nordgreen
- 0000 0004 1936 7443grid.7914.bDepartment of Clinical Psychology, University of Bergen, Bergen, Norway ,0000 0000 9753 1393grid.412008.fDivision of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Otto R. F. Smith
- 0000 0001 1541 4204grid.418193.6Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5018 Bergen, Norway
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Härter M, Watzke B, Daubmann A, Wegscheider K, König HH, Brettschneider C, Liebherz S, Heddaeus D, Steinmann M. Guideline-based stepped and collaborative care for patients with depression in a cluster-randomised trial. Sci Rep 2018; 8:9389. [PMID: 29925893 PMCID: PMC6010425 DOI: 10.1038/s41598-018-27470-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/30/2018] [Indexed: 01/22/2023] Open
Abstract
Guidelines recommend stepped and collaborative care models (SCM) for depression. We aimed to evaluate the effectiveness of a complex guideline-based SCM for depressed patients. German primary care units were cluster-randomised into intervention (IG) or control group (CG) (3:1 ratio). Adult routine care patients with PHQ-9 ≥ 5 points could participate and received SCM in IG and treatment as usual (TAU) in CG. Primary outcome was change in PHQ-9 from baseline to 12 months (hypothesis: greater reduction in IG). A linear mixed model was calculated with group as fixed effect and practice as random effect, controlling for baseline PHQ-9 (intention-to-treat). 36 primary care units were randomised to IG and 13 to CG. 36 psychotherapists, 6 psychiatrists and 7 clinics participated in SCM. 737 patients were included (IG: n = 569 vs. CG: n = 168); data were available for 60% (IG) and 64% (CG) after 12 months. IG showed 2.4 points greater reduction [95% confidence interval (CI): -3.4 to -1.5, p < 0.001; Cohen's d = 0.45] (adjusted PHQ-9 mean change). Odds of response [odds ratio: 2.8; 95% CI: 1.6 to 4.7] and remission [odds ratio: 3.2; 95% CI: 1.58 to 6.26] were higher in IG. Guideline-based SCM can improve depression care.
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Affiliation(s)
- Martin Härter
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Birgit Watzke
- Clinical Psychology and Psychotherapy Research, Institute of Psychology, University of Zurich, Binzmühlestrasse 14/16, CH-8050, Zurich, Switzerland
| | - Anne Daubmann
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karl Wegscheider
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans-Helmut König
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christian Brettschneider
- Department of Health Economics and Health Services Research, Hamburg Center for Health Economics, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Sarah Liebherz
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Daniela Heddaeus
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Maya Steinmann
- Department of Medical Psychology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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16
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Affiliation(s)
- Zachary D. Cohen
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
| | - Robert J. DeRubeis
- Department of Psychology, University of Pennsylvania, Philadelphia, Pennsylvania 19104, USA
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17
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van Krugten FCW, Goorden M, van Balkom AJLM, Spijker J, Brouwer WBF, Hakkaart‐van Roijen L. Indicators to facilitate the early identification of patients with major depressive disorder in need of highly specialized care: A concept mapping study. Depress Anxiety 2018; 35:346-352. [PMID: 29575387 PMCID: PMC6282616 DOI: 10.1002/da.22741] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2017] [Revised: 02/01/2018] [Accepted: 02/09/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Early identification of the subgroup of patients with major depressive disorder (MDD) in need of highly specialized care could enhance personalized intervention. This, in turn, may reduce the number of treatment steps needed to achieve and sustain an adequate treatment response. The aim of this study was to identify patient-related indicators that could facilitate the early identification of the subgroup of patients with MDD in need of highly specialized care. METHODS Initial patient indicators were derived from a systematic review. Subsequently, a structured conceptualization methodology known as concept mapping was employed to complement the initial list of indicators by clinical expertise and develop a consensus-based conceptual framework. Subject-matter experts were invited to participate in the subsequent steps (brainstorming, sorting, and rating) of the concept mapping process. A final concept map solution was generated using nonmetric multidimensional scaling and agglomerative hierarchical cluster analyses. RESULTS In total, 67 subject-matter experts participated in the concept mapping process. The final concept map revealed the following 10 major clusters of indicators: 1-depression severity, 2-onset and (treatment) course, 3-comorbid personality disorder, 4-comorbid substance use disorder, 5-other psychiatric comorbidity, 6-somatic comorbidity, 7-maladaptive coping, 8-childhood trauma, 9-social factors, and 10-psychosocial dysfunction. CONCLUSIONS The study findings highlight the need for a comprehensive assessment of patient indicators in determining the need for highly specialized care, and suggest that the treatment allocation of patients with MDD to highly specialized mental healthcare settings should be guided by the assessment of clinical and nonclinical patient factors.
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Affiliation(s)
- F. C. W. van Krugten
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - M. Goorden
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - A. J. L. M. van Balkom
- Department of PsychiatryVU University Medical CenterAmsterdamThe Netherlands,GGZ inGeestAmsterdamThe Netherlands
| | - J. Spijker
- Behavioural Science InstituteRadboud University Medical CenterNijmegenThe Netherlands,Pro Persona Mental Health CareNijmegenThe Netherlands
| | - W. B. F. Brouwer
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamThe Netherlands
| | - L. Hakkaart‐van Roijen
- Erasmus School of Health Policy & ManagementErasmus University RotterdamRotterdamThe Netherlands
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A prognostic index (PI) as a moderator of outcomes in the treatment of depression: A proof of concept combining multiple variables to inform risk-stratified stepped care models. J Affect Disord 2017; 213:78-85. [PMID: 28199892 DOI: 10.1016/j.jad.2017.02.010] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 01/29/2017] [Accepted: 02/06/2017] [Indexed: 11/20/2022]
Abstract
BACKGROUND Prognostic indices (PIs) combining variables to predict future depression risk may help guide the selection of treatments that differ in intensity. We develop a PI and show its promise in guiding treatment decisions between treatment as usual (TAU), treatment starting with a low-intensity treatment (brief therapy (BT)), or treatment starting with a high-intensity treatment intervention (cognitive-behavioral therapy (CBT)). METHODS We utilized data from depressed patients (N=622) who participated in a randomized comparison of TAU, BT, and CBT in which no statistically significant differences in the primary outcomes emerged between the three treatments. We developed a PI by predicting depression risk at follow-up using a LASSO-style bootstrap variable selection procedure. We then examined between-treatment differences in outcome as a function of the PI. RESULTS Unemployment, depression severity, hostility, sleep problems, and lower positive emotionality at baseline predicted a lower likelihood of recovery across treatments. The PI incorporating these variables produced a fair classification accuracy (c=0.73). Among patients with a high PI (75% percent of the sample), recovery rates were high and did not differ between treatments (79-86%). Among the patients with the poorest prognosis, recovery rates were substantially higher in the CBT condition (60%) than in TAU (39%) or BT (44%). LIMITATIONS No information on additional treatment sought. Prospective tests needed. CONCLUSION Replicable PIs may aid treatment selection and help streamline stepped models of care. Differences between treatments for depression that differ in intensity may only emerge for patients with the poorest prognosis.
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van Orden M, Leone S, Haffmans J, Spinhoven P, Hoencamp E. Prediction of Mental Health Services Use One Year After Regular Referral to Specialized Care Versus Referral to Stepped Collaborative Care. Community Ment Health J 2017; 53:316-323. [PMID: 27430954 PMCID: PMC5337236 DOI: 10.1007/s10597-016-0046-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/11/2016] [Indexed: 11/19/2022]
Abstract
Referral to collaborative mental health care within the primary care setting is a service concept that has shown to be as effective as direct referral to specialized mental health care for patients with common mental disorders. Additionally it is more efficient in terms of lower mental health services use. This post-hoc analysis examines if treatment intensity during 1-year of follow-up can be predicted prospectively by baseline characteristics. With multilevel multivariate regression analyses baseline characteristics were examined as potential predictors of visit counts. Results showed that only the enabling factors service concept and referral delay for treatment had a significant association with mental health visit counts, when outcome was dichotomized in five or more visits. Inclusion of the outcome variable as a count variable confirmed the predictive value of service concept and referral delay, but added marital status as a significant predictor. Overall, enabling factors (service concept and referral delay) seem to be important and dominant predictors of mental health services use.
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Affiliation(s)
- Mirjam van Orden
- Parnassia Groep, Parnassia Academie, Kiwistraat 32, 2552 DH, The Hague, The Netherlands.
| | - Stephanie Leone
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
| | - Judith Haffmans
- Medical Chronobiology, PsyQ, The Hague, The Netherlands.,Faculty of Social and Behavioral Sciences, Leiden University, Leiden, The Netherlands
| | - Philip Spinhoven
- Faculty of Social and Behavioral Sciences, Leiden University, Leiden, The Netherlands
| | - Erik Hoencamp
- Faculty of Social and Behavioral Sciences, Leiden University, Leiden, The Netherlands.,Indigo Zorgservice, Parnassia Groep, The Hague, The Netherlands
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Abstract
Martinsen and Raglin provide a persuasive, evidence-based rationale for lifestyle approaches to the management of anxiety, depressive disorders, and their comorbidities. Yet, their review prompts discussion of the complexities navigating this terrain, including barriers to the identification and management of these common psychological problems in medical settings, the potential of these disorders to complicate health care, and challenges to the implementation of lifestyle interventions for depression and anxiety-related concerns.
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Affiliation(s)
- Lisa Terre
- Department of Psychlology, University of Missouri-Kansas City,
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Henriksson S, Anclair M, Hiltunen AJ. Effectiveness of cognitive behavioral therapy on health-related quality of life: An evaluation of therapies provided by trainee therapists. Scand J Psychol 2016; 57:215-22. [PMID: 27119256 DOI: 10.1111/sjop.12291] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2015] [Accepted: 03/07/2016] [Indexed: 11/27/2022]
Abstract
The present study was carried out to examine the treatment effect of cognitive behavioral therapy provided by trainee therapists at a university clinic, focusing on health-related quality of life (HRQOL) optimism and symptoms. The study was conducted through a repeated measures design and included a treatment group (n = 21), which received cognitive behavioral therapy for an average of 10.7 therapy sessions and a control group (n = 14), that was put on a wait list for 8.6 weeks on average. After treatment, the treatment group improved significantly concerning general health (p = 0.028) and optimism (p = 0.027). In addition, clients improved in several areas within mental health and displayed some reduction in anxiety symptoms. Concurrently, the results also indicated some improvement within the control group, which may have been caused by the initial therapeutic contact, expectancy effects or spontaneous remission. The study concluded that cognitive behavioral therapy provided by trainee therapists may have a positive effect on areas within HRQOL and optimism.
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Affiliation(s)
- Sophie Henriksson
- Department of Social and Psychological Studies, Section of Psychology, Karlstad University, Sweden
| | - Malin Anclair
- Department of Social and Psychological Studies, Section of Psychology, Karlstad University, Sweden
| | - Arto J Hiltunen
- Department of Social and Psychological Studies, Section of Psychology, Karlstad University, Sweden
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22
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Meuldijk D, Carlier I, van Vliet I, van Veen T, Wolterbeek R, van Hemert A, Zitman F. The clinical effectiveness of concise cognitive behavioral therapy with or without pharmacotherapy for depressive and anxiety disorders; a pragmatic randomized controlled equivalence trial in clinical practice. Contemp Clin Trials 2016; 47:131-8. [DOI: 10.1016/j.cct.2015.12.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 12/29/2015] [Accepted: 12/31/2015] [Indexed: 12/28/2022]
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23
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Härter M, Heddaeus D, Steinmann M, Schreiber R, Brettschneider C, König HH, Watzke B. [Collaborative and stepped care for depression: Development of a model project within the Hamburg Network for Mental Health (psychenet.de)]. Bundesgesundheitsblatt Gesundheitsforschung Gesundheitsschutz 2016; 58:420-9. [PMID: 25698121 DOI: 10.1007/s00103-015-2124-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Depression is one of the most widespread mental disorders in Germany and causes a great suffering and involves high costs. Guidelines recommend stepped and interdisciplinary collaborative care models for the treatment of depression. OBJECTIVES Stepped and collaborative care models are described regarding their efficacy and cost-effectiveness. A current model project within the Hamburg Network for Mental Health exemplifies how guideline-based stepped diagnostics and treatment incorporating innovative low-intensity interventions are implemented by a large network of health care professionals and clinics. MATERIALS AND METHODS An accompanying evaluation using a cluster randomized controlled design assesses depressive symptom reduction and cost-effectiveness for patients treated within "Health Network Depression" ("Gesundheitsnetz Depression", a subproject of psychenet.de) compared with patients treated in routine care. RESULTS Over 90 partners from inpatient and outpatient treatment have been successfully involved in recruiting over 600 patients within the stepped care model. Communication in the network was greatly facilitated by the use of an innovative online tool for the supply and reservation of treatment capacities. The participating professionals profit from the improved infrastructure and the implementation of advanced training and quality circle work. CONCLUSIONS New treatment models can greatly improve the treatment of depression owing to their explicit reference to guidelines, the establishment of algorithms for diagnostics and treatment, the integration of practices and clinics, in addition to the implementation of low-intensity treatment alternatives. These models could promote the development of a disease management program for depression.
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Affiliation(s)
- Martin Härter
- Institut und Poliklinik für Medizinische Psychologie, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland,
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Boerema AM, Cuijpers P, Beekman ATF, Hellenthal A, Voorrips L, van Straten A. Is duration of psychological treatment for depression related to return into treatment? Soc Psychiatry Psychiatr Epidemiol 2016; 51:1495-1507. [PMID: 27448572 PMCID: PMC5101270 DOI: 10.1007/s00127-016-1267-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2015] [Accepted: 07/15/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE There is increasing pressure on mental health providers to reduce the duration of treatments, while retaining level of quality and effectiveness. The risk is that the population is underserved and therefore needs new treatment episodes. The primary aim of this study was to investigate whether duration of treatment and return into mental health care were related. METHODS This study examined Dutch patients with an initial treatment episode in 2009 or 2010 in specialized mental health settings for depressive disorder (N = 85,754). Follow-up data about treatment episodes were available up until 2013. The data set included demographic (age, gender), and clinical factors (comorbidity with other DSM-IV Axis; scores on the 'Global Assessment of Functioning'). Cox regression analyses were used to assess whether duration of treatment and relapse into mental health care were related. RESULTS The majority of patients did not return into mental health care (86 %). Patients with a shorter duration of treatment (5-250 min; 251-500 min and 751-1000 min) were slightly more likely to return (reference group: >1000 min) (HR 1.19 95 % CI 1.13-1.26; HR 1.11 95 % CI 1.06-1.17; HR 1.18 95 % CI 1.11-1.25), adjusted for demographic and clinical variables. CONCLUSIONS The results suggest that a longer duration of treatment may prevent return into mental health care in some groups. However, because of the design of the study, no causal inference can be drawn. Further research, preferably in a RCT, is needed to determine whether the trend towards lower intensity treatments is associated with repeated mental health care use.
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Affiliation(s)
- A M Boerema
- Department of Clinical Neuro and Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
- EMGO+ Institute for Health Care and Research, VU University Medical Centre, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands.
| | - P Cuijpers
- Department of Clinical Neuro and Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
- EMGO+ Institute for Health Care and Research, VU University Medical Centre, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - A T F Beekman
- EMGO+ Institute for Health Care and Research, VU University Medical Centre, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
- Department of Psychiatry, VU University Medical Centre, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
| | - A Hellenthal
- Statistics Netherlands (CBS), Henri Faasdreef 312, 2492 JP, The Hague, The Netherlands
| | - L Voorrips
- Statistics Netherlands (CBS), Henri Faasdreef 312, 2492 JP, The Hague, The Netherlands
| | - A van Straten
- Department of Clinical Neuro and Developmental Psychology, Section Clinical Psychology, Faculty of Behavioural and Movement Sciences, Vrije Universiteit Amsterdam, van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands
- EMGO+ Institute for Health Care and Research, VU University Medical Centre, van der Boechorststraat 7, 1081 BT, Amsterdam, The Netherlands
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The clinical effectiveness of stepped care systems for depression in working age adults: a systematic review. J Affect Disord 2015; 170:119-30. [PMID: 25240141 DOI: 10.1016/j.jad.2014.08.030] [Citation(s) in RCA: 58] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2014] [Revised: 07/13/2014] [Accepted: 08/19/2014] [Indexed: 12/22/2022]
Abstract
BACKGROUND Stepped care service delivery models involve treatments that become increasingly intense through successive steps, with patients re-assigned via pre-defined decision criteria. This article reviews the clinical effectiveness of stepped care systems for depression in working age adults. METHODS Systematic literature review of quantitative clinical outcome evidence comprising 14 controlled and uncontrolled studies meeting specified criteria. Principal outcomes were (a) recovery rates, defined as patients no longer meeting clinical cut-off criteria for the specific outcome measure and (b) treatment response rates, defined as a 50% decrease in outcome measure score. RESULTS Stepped care systems had recovery rates ranging predominantly between 40% and 60% and response rates approximating 60%. Studies comparing stepped care with usual/enhanced usual care tended to find significant differences favouring stepped care. The median recovery odds ratio was 1.31 (interquartile intervals of 1.05 and 1.66; k=7 studies). The median comparative Cohen's d effect size estimate was 0.41 (interquartile intervals 0.25 and 0.45; k=5 studies). LIMITATIONS The inclusion of uncontrolled studies could be seen as reducing the overall quality of evidence and a meta-analysis was not included due to limitations with the available data. CONCLUSIONS Evidence suggested that stepped care interventions for depression are at least as effective as usual care. However, the clinical and organisational superiority of stepped care is yet to be scientifically verified. Differential benefits of stepped care may ultimately depend on service quality. Further research investigating and comparing the specific components and configurations of stepped care interventions are indicated.
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Health-related quality of life and productivity losses in patients with depression and anxiety disorders. J Occup Environ Med 2014; 56:420-4. [PMID: 24709765 DOI: 10.1097/jom.0000000000000112] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To assess the explanatory power of disease severity and health-related quality of life (HRQOL) on absenteeism and presenteeism in a working population suffering from depression and/or anxiety disorders. METHODS We used data of a large, multicenter, randomized trial (n = 644). Pearson chi-squared tests, analysis of variance, and multinomial logistic regression analyses were performed to explore associations of the type of the disorder and HRQOL with different types of productivity losses. Multivariate regression analyses were performed to assess associations with the duration of absenteeism. RESULTS The type of the disorder, disease severity, and HRQOL were associated with different types of productivity losses. Health-related quality of life and age were significantly associated with the duration of absenteeism. CONCLUSIONS Our findings indicate that HRQOL may significantly explain the type of productivity loss as well as the duration of absenteeism.
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Mild to severe social fears: ranking types of feared social situations using item response theory. J Anxiety Disord 2014; 28:471-9. [PMID: 24873885 DOI: 10.1016/j.janxdis.2014.05.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2014] [Revised: 05/02/2014] [Accepted: 05/07/2014] [Indexed: 11/21/2022]
Abstract
Social anxiety disorder is one of the most common mental disorders, and is associated with long term impairment, distress and vulnerability to secondary disorders. Certain types of social fears are more common than others, with public speaking fears typically the most prevalent in epidemiological surveys. The distinction between performance- and interaction-based fears has been the focus of long-standing debate in the literature, with evidence performance-based fears may reflect more mild presentations of social anxiety. This study aims to explicitly test whether different types of social fears differ in underlying social anxiety severity using item response theory techniques. Different types of social fears were assessed using items from three different structured diagnostic interviews in four different epidemiological surveys in the United States (n=2261, n=5411) and Australia (n=1845, n=1497); and ranked using 2-parameter logistic item response theory models. Overall, patterns of underlying severity indicated by different fears were consistent across the four samples with items functioning across a range of social anxiety. Public performance fears and speaking at meetings/classes indicated the lowest levels of social anxiety, with increasing severity indicated by situations such as being assertive or attending parties. Fears of using public bathrooms or eating, drinking or writing in public reflected the highest levels of social anxiety. Understanding differences in the underlying severity of different types of social fears has important implications for the underlying structure of social anxiety, and may also enhance the delivery of social anxiety treatment at a population level.
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Gidding LG, Spigt MG, Dinant GJ. Stepped collaborative depression care: primary care results before and after implementation of a stepped collaborative depression programme. Fam Pract 2014; 31:180-92. [PMID: 24277384 DOI: 10.1093/fampra/cmt072] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Numerous intensive research projects to assess the effects of stepped collaborative care (SCC) for depressed patients have been reported in primary care, yet it is unclear how SCC is sustained in usual care. OBJECTIVE To assess how SCC for depression is actually being used and how it performs in usual primary care by studying medical data that are routinely collected in family practice, outside the research setting. METHODS Retrospective before and after comparison of electronic medical records (EMR) regarding the implementation of an SCC depression programme in a large primary care organization from 2003 to 2012. Depression care parameters included prevalences, minimal interventions, Beck Depression Inventory-2 (BDI-2), antidepressants, referrals to psychologists and psychiatrists and primary health care consumption. RESULTS After programme implementation, differentiation between levels of depression severity increased, more patients were treated with minimal interventions and more patients were monitored with BDI-2. These effects occurred in both nonseverely and severely depressed patients, although they were larger for patients registered as nonseverely depressed. Antidepressant prescription rates and referral rates seemed not to have been influenced by the SCC programme. Health care consumption of the depressed patients increased significantly. CONCLUSIONS The depression care parameters changed to a different extent and at a different pace than after previous implementation initiatives. Future research should identify whether SCC uptake in primary care is best enhanced by intensive external guidance or by making care providers themselves responsible for the implementation. Analyses of EMR can be valuable in monitoring the implementation effects, especially after research projects are completed.
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Affiliation(s)
- Luc G Gidding
- Department of Family Medicine, Maastricht University/CAPHRI School for Public Health and Primary Care, Maastricht, The Netherlands
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Service Use, Drop-Out Rate and Clinical Outcomes: A Comparison Between High and Low Intensity Treatments in an IAPT Service. Behav Cogn Psychother 2014; 42:747-59. [DOI: 10.1017/s1352465813000544] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Background: The IAPT services provide high and low intensity psychological treatments for adults suffering from depression and anxiety disorders using a stepped care model. The latest national evaluation study reported an average recovery rate of 42%. However, this figure varied widely between services, with better outcomes associated with higher “step-up” rates between low and high intensity treatments. Aims: This study aimed to compare the two intensity groups in an IAPT service in Suffolk. Method: This study adopted a between groups design. A sample of 100 service users was randomly selected from the data collected from an IAPT service in Suffolk between May 2008 and February 2011. The treatment outcomes, drop-out rate, and other characteristics were compared between those who received high and low intensity treatments. Results: The high intensity group received, on average, more sessions and contact time. They received more CBT sessions and less guided self-help. There were no group differences in terms of the drop-out and appointment cancellation rates. Analyses on clinical outcomes suggested no group difference but demonstrated an overall recovery rate of 52.6% and significant reduction in both depression and anxiety symptoms. Conclusions: Despite methodological limitations, this study concludes that the service as a whole achieved above-average clinical outcomes. Further research building upon the current study in unpacking the relative strengths and weaknesses for the high and low intensity treatments would be beneficial for service delivery.
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Miller CJ, Grogan-Kaylor A, Perron BE, Kilbourne AM, Woltmann E, Bauer MS. Collaborative chronic care models for mental health conditions: cumulative meta-analysis and metaregression to guide future research and implementation. Med Care 2013; 51:922-30. [PMID: 23938600 PMCID: PMC3800198 DOI: 10.1097/mlr.0b013e3182a3e4c4] [Citation(s) in RCA: 88] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Prior meta-analysis indicates that collaborative chronic care models (CCMs) improve mental and physical health outcomes for individuals with mental disorders. This study aimed to investigate the stability of evidence over time and identify patient and intervention factors associated with CCM effects to facilitate implementation and sustainability of CCMs in clinical practice. METHODS We reviewed 53 CCM trials that analyzed depression, mental quality of life (QOL), or physical QOL outcomes. Cumulative meta-analysis and metaregression were supplemented by descriptive investigations across and within trials. RESULTS Most trials targeted depression in the primary care setting, and cumulative meta-analysis indicated that effect sizes favoring CCM quickly achieved significance for depression outcomes, and more recently achieved significance for mental and physical QOL. Four of 6 CCM elements (patient self-management support, clinical information systems, system redesign, and provider decision support) were common among reviewed trials, whereas 2 elements (health care organization support and linkages to community resources) were rare. No single CCM element was statistically associated with the success of the model. Similarly, metaregression did not identify specific factors associated with CCM effectiveness. Nonetheless, results within individual trials suggest that increased illness severity predicts CCM outcomes. CONCLUSIONS Significant CCM trials have been derived primarily from 4 original CCM elements. Nonetheless, implementing and sustaining this established model will require health care organization support. Although CCMs have typically been tested as population-based interventions, evidence supports stepped care application to more severely ill individuals. Future priorities include developing implementation strategies to support adoption and sustainability of the model in clinical settings while maximizing fit of this multicomponent framework to local contextual factors.
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Affiliation(s)
- Christopher J Miller
- *Center for Healthcare Organization and Implementation Research, VA Boston Healthcare System †Department of Psychiatry, Harvard Medical School, Boston, MA ‡School of Social Work, University of Michigan §VA Ann Arbor Center for Clinical Management Research ∥Department of Psychiatry, University of Michigan Medical School, Ann Arbor, MI ¶The Brown School, Washington University, St Louis, MO
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Affiliation(s)
- David J. Kupfer
- University of Pittsburgh Medical Center and Western Psychiatric Institute and Clinic, Pittsburgh, Pennsylvania 15213;
| | - Emily A. Kuhl
- Division of Research and American Psychiatric Institute for Research and Education, American Psychiatric Association, Arlington, Virginia 22209;
| | - Lawson Wulsin
- University of Cincinnati College of Medicine, Cincinnati, Ohio 45267;
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Meuldijk D, Carlier IVE, van Vliet IM, van den Akker-Marle ME, Zitman FG. A randomized controlled trial of the efficacy and cost-effectiveness of a brief intensified cognitive behavioral therapy and/or pharmacotherapy for mood and anxiety disorders: design and methods. Contemp Clin Trials 2012; 33:983-92. [PMID: 22588010 DOI: 10.1016/j.cct.2012.05.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2012] [Revised: 03/30/2012] [Accepted: 05/01/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND Anxiety and mood disorders involve a high disease burden and are associated with high economic costs. A stepped-care approach intervention and abbreviated diagnostic method are assumed to increase effectiveness and efficiency of the mental healthcare and are expected to reduce economic costs. METHODS Presented are the rationale, design, and methods of a two-armed randomized controlled trial comparing 'treatment as usual' (TAU) with a brief intensified cognitive behavioral therapy (CBT) and/or pharmacotherapy. Eligible participants (N=500) of five Dutch outpatient Mental Healthcare Centers are randomly assigned to either TAU or to the experimental condition (brief CBT and/or pharmacotherapy). Data on patients' progress and clinical effectiveness of treatment are assessed at baseline, post-treatment (3 months after baseline), and at 6 and 12 months post-treatment by Routine Outcome Monitoring (ROM). Cost analysis is performed on the obtained data. DISCUSSION Since few studies have investigated both the clinical and cost effectiveness of a stepped-care approach intervention and a shortened diagnostic ROM method in both anxiety and/or mood disorders within secondary mental health care, the results of this study might contribute to the improvement of (cost)-effective treatment options and diagnostic methods for these disorders.
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Affiliation(s)
- Denise Meuldijk
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
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Richards DA. Stepped care: a method to deliver increased access to psychological therapies. CANADIAN JOURNAL OF PSYCHIATRY. REVUE CANADIENNE DE PSYCHIATRIE 2012; 57:210-5. [PMID: 22480585 DOI: 10.1177/070674371205700403] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE To introduce stepped care as a method of organizing the delivery of treatments, and to consider the factors necessary for implementation. METHOD Stepped care is described within the context of strategies such as collaborative care that aim to increase access to mental health care through the improved coordination of care between primary and specialist mental health services. Results from the implementation of stepped care in the United Kingdom and elsewhere are used to highlight the factors required for introducing stepped care into routine services. Issues to address when implementing high-volume services for common mental health problems are derived from this experience. RESULTS Stepped care sits within the continuum of organizational systems, from situations where responsibility rests almost entirely with primary care clinicians to systems where all patients are managed by specialists for the entire duration of their treatment. Its core principles of delivering low-burden treatments first, followed by careful patient progress monitoring to step patients up to more intensive treatment, are easy to articulate but lead to considerable implementation diversity when services attempt to work in this manner. Services need to ensure they have specific staff competency training, including skills in delivering evidence-based treatments, access to telephony, and smart patient management informatics systems. CONCLUSIONS Stepped care can provide the delivery system for supported self-management. To be successful, health systems need high levels of clinical outcome data and appropriately trained workers. Further attention is required to ensure equity of access and to reduce patient attrition in these systems.
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Affiliation(s)
- David A Richards
- Mood Disorders Centre, College of Life and Environmental Sciences, University of Exeter, Exeter, England.
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Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Stepped care treatment for depression and anxiety in primary care. a randomized controlled trial. Trials 2011; 12:171. [PMID: 21736720 PMCID: PMC3152524 DOI: 10.1186/1745-6215-12-171] [Citation(s) in RCA: 55] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Accepted: 07/07/2011] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Depressive and anxiety disorders are common in general practice but not always treated adequately. Introducing stepped care might improve this. In this randomized trial we examined the effectiveness of such a stepped care model. METHODS The study population consisted of primary care attendees aged 18-65 years with minor or major DSM-IV depressive and/or anxiety disorders, recruited through screening. We randomized 120 patients to either stepped care or care as usual. The stepped care program consisted of (1) watchful waiting, (2) guided self-help, (3) short face-to-face problem solving treatment and (4) pharmacotherapy and/or specialized mental health care. Patients were assessed at baseline and after 8, 16 and 24 weeks. RESULTS Symptoms of depression and anxiety decreased significantly over time for both groups. However, there was no statistically significant difference between the two groups (IDS: P = 0.35 and HADS: P = 0.64). The largest, but not significant, effect (d = -0.21) was found for anxiety on T3. In both groups approximately 48% of the patients were recovered from their DSM-IV diagnosis at the final 6 months assessment. CONCLUSIONS In summary we could not demonstrate that stepped care for depression and anxiety in general practice was more effective than care as usual. Possible reasons are discussed. TRIAL REGISTRATION Current Controlled Trails: ISRCTN17831610.
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Affiliation(s)
- Wike Seekles
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands.
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Gask L, Khanna T. Ways of working at the interface between primary and specialist mental healthcare. Br J Psychiatry 2011; 198:3-5, sup 1. [PMID: 21200068 DOI: 10.1192/bjp.bp.109.075382] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Ways of working at the interface between primary and specialist care are considered with discussion of the limits of available evidence and the potential for a new role for psychiatrists in providing supervision and consultation in novel models of care.
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Seekles W, van Straten A, Beekman A, van Marwijk H, Cuijpers P. Stepped care for depression and anxiety: from primary care to specialized mental health care: a randomised controlled trial testing the effectiveness of a stepped care program among primary care patients with mood or anxiety disorders. BMC Health Serv Res 2009; 9:90. [PMID: 19500346 PMCID: PMC2700097 DOI: 10.1186/1472-6963-9-90] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2009] [Accepted: 06/05/2009] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mood and anxiety disorders are highly prevalent and have a large impact on the lives of the affected individuals. Therefore, optimal treatment of these disorders is highly important. In this study we will examine the effectiveness of a stepped care program for primary care patients with mood and anxiety disorders. A stepped care program is characterized by different treatment steps that are arranged in order of increasing intensity. METHODS This study is a randomised controlled trial with two conditions: stepped care and care as usual, whereby the latter forms the control group. The stepped care program consists of four evidence based interventions: (1) Watchful waiting, (2) Guided self-help, (3) Problem Solving Treatment and (4) Medication and/or specialized mental health care. The study population consists of primary care attendees aged 18-65 years. Screeners are sent to all patients of the participating general practitioners. Individuals with a Diagnostic and Statistical Manual of mental disorders (DSM) diagnosis of major depression, dysthymia, panic disorder (with or without agoraphobia), generalized anxiety disorder, or social phobia are included as well as individuals with minor depression and anxiety disorders. Primary focus is the reduction of depressive and anxiety symptoms. Both conditions are monitored at 8, 16 and 24 weeks. DISCUSSION This study evaluates the effectiveness of a stepped care program for patients with depressive and anxiety disorder. If effective, a stepped care program can form a worthwhile alternative for care as usual. Strengths and limitations of this study are discussed. TRIAL REGISTRATION Current Controlled Trails: ISRCTN17831610.
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Affiliation(s)
- Wike Seekles
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
- EMGO institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Annemieke van Straten
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
- EMGO institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Aartjan Beekman
- Department of Psychiatry, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Harm van Marwijk
- Department of General Practice, VU University Medical Centre, Amsterdam, The Netherlands
- EMGO institute, VU University Medical Centre, Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, VU University, Amsterdam, The Netherlands
- EMGO institute, VU University Medical Centre, Amsterdam, The Netherlands
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Abstract
Self-help approaches can be relevant for individuals with sexual difficulties who cannot visit a therapist yet have sufficient coping skills and motivation to adhere to the advice and prescriptions included in the self-help method. Self-help can facilitate the transfer of treatment gains to the unassisted situation at home and thus reduce generalization difficulties from therapist setting to the home setting. They may prevent the development of client's codependency on therapist support and can help boost the client's sense of self-efficacy. Several self-help approaches were found to be efficacious, both statistically and clinically, in the treatment of several types of sexual dysfunction. The outcome is qualified by problem type, client characteristics, and delivery format of the self-help. The methods that are offered vary from cookbook-like protocols, which need to be followed in a stepwise and strict fashion, to strategies requiring the user to self-adapt a general problem-solving method to his or her personal situation, thereby enabling the individual to become his or her own therapist.
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Affiliation(s)
- Jacques van Lankveld
- Department of Clinical Psychological Science, Maastricht University, Maastricht, The Netherlands.
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Meeuwissen JAC, van der Feltz-Cornelis CM, van Marwijk HWJ, Rijnders PBM, Donker MCH. A stepped care programme for depression management: an uncontrolled pre-post study in primary and secondary care in The Netherlands. Int J Integr Care 2008; 8:e05. [PMID: 18317562 PMCID: PMC2254490 DOI: 10.5334/ijic.228] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2007] [Revised: 11/20/2007] [Accepted: 11/23/2007] [Indexed: 11/20/2022] Open
Abstract
INTRODUCTION Stepped care strategies are potentially effective to organise integrated care but unknown is whether they function well in practice. This paper evaluates the implementation of a stepped care programme for depression in primary care and secondary care. THEORY AND METHODS We developed a stepped care algorithm for diagnostics and treatment of depression, supported by a liaison-consultation function. In a 2(1/2) year study with pre-post design in a pilot region, adherence to the protocol was assessed by interviewing 28 caregivers of 235 patients with mild, moderate, or severe major depression. Consultation and referral patterns between primary and secondary care were analysed. RESULTS Adherence of general practitioners and consultant caregivers to the stepped care protocol proved to be 96%. The percentage of patients referred for depression to secondary care decreased significantly from 26% to 21% (p=0.0180). In the post-period more patients received treatment in primary care and requests for consultation became more concordant with the stepped care protocol. CONCLUSIONS Implementation of a stepped care programme is feasible in a primary and secondary care setting and is associated with less referrals. DISCUSSION Further research on all subsequent treatment steps in a standardised stepped care protocol is needed.
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Affiliation(s)
- Jolanda A C Meeuwissen
- Trimbos Institute, Netherlands Institute of Mental Health and Addiction, Utrecht, The Netherlands
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Abstract
PURPOSE OF REVIEW Depression treatment guidelines typically recommend cognitive behavioral therapy and/or interpersonal therapy for the acute treatment of mild-moderate depression. However, several new developments support an expanded role for psychotherapy in depression treatment. This article summarizes recent psychotherapy efficacy studies across the depression treatment continuum and the effectiveness of psychosocial interventions in community settings. RECENT FINDINGS New psychotherapies in the acute treatment of mild-moderate depression include emotion-focused therapy, self-system therapy, cognitive control training and positive psychotherapy. Furthermore, emerging evidence supports the use of psychotherapy for moderate-severe and treatment-resistant depression and for recurrent depression with a seasonal pattern. An important area of growth is the development and evaluation of continuation/maintenance treatments based on cognitive behavioral therapy and interpersonal therapy to reduce depressive relapse risk in recurrent and chronic depression. Finally, there is evidence supporting the effectiveness of stepped care, chronic disease management and collaborative care models in community settings. SUMMARY Emerging evidence supports an expanded role for the use of psychosocial interventions as acute and continuation/maintenance treatments for unipolar depression. Although further research is required to replicate these findings, a remaining challenge is to increase the availability of these treatments to the mental health consumer.
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Driessen E, Van HL, Schoevers RA, Cuijpers P, van Aalst G, Don FJ, Hendriksen M, Kool S, Molenaar PJ, Peen J, Dekker JJM. Cognitive Behavioral Therapy versus Short Psychodynamic Supportive Psychotherapy in the outpatient treatment of depression: a randomized controlled trial. BMC Psychiatry 2007; 7:58. [PMID: 17963493 PMCID: PMC2174932 DOI: 10.1186/1471-244x-7-58] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2007] [Accepted: 10/26/2007] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Previous research has shown that Short Psychodynamic Supportive Psychotherapy (SPSP) is an effective alternative to pharmacotherapy and combined treatment (SPSP and pharmacotherapy) in the treatment of depressed outpatients. The question remains, however, how Short Psychodynamic Supportive Psychotherapy compares with other established psychotherapy methods. The present study compares Short Psychodynamic Supportive Psychotherapy to the evidence-based Cognitive Behavioral Therapy in terms of acceptability, feasibility, and efficacy in the outpatient treatment of depression. Moreover, this study aims to identify clinical predictors that can distinguish patients who may benefit from either of these treatments in particular. This article outlines the study protocol. The results of the study, which is being currently carried out, will be presented as soon as they are available. METHODS/DESIGN Adult outpatients with a main diagnosis of major depressive disorder or depressive disorder not otherwise specified according to DSM-IV criteria and mild to severe depressive symptoms (Hamilton Depression Rating Scale score > or = 14) are randomly allocated to Short Psychodynamic Supportive Psychotherapy or Cognitive Behavioral Therapy. Both treatments are individual psychotherapies consisting of 16 sessions within 22 weeks. Assessments take place at baseline (week 0), during the treatment period (week 5 and 10) and at treatment termination (week 22). In addition, a follow-up assessment takes place one year after treatment start (week 52). Primary outcome measures are the number of patients refusing treatment (acceptability); the number of patients terminating treatment prematurely (feasibility); and the severity of depressive symptoms (efficacy) according to an independent rater, the clinician and the patient. Secondary outcome measures include general psychopathology, general psychotherapy outcome, pain, health-related quality of life, and cost-effectiveness. Clinical predictors of treatment outcome include demographic variables, psychiatric symptoms, cognitive and psychological patient characteristics and the quality of the therapeutic relationship. DISCUSSION This study evaluates Short Psychodynamic Supportive Psychotherapy as a treatment for depressed outpatients by comparing it to the established evidence-based treatment Cognitive Behavioral Therapy. Specific strengths of this study include its strong external validity and the clinical relevance of its research aims. Limitations of the study are discussed. TRIAL REGISTRATION Current Controlled Trails ISRCTN31263312.
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Affiliation(s)
- Ellen Driessen
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Henricus L Van
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Robert A Schoevers
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Pim Cuijpers
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Gerda van Aalst
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Frank J Don
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Mariëlle Hendriksen
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Simone Kool
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Pieter J Molenaar
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
| | - Jaap Peen
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
| | - Jack JM Dekker
- Depression Research Group, JellinekMentrum Mental Health Care, Overschiestraat 65, 1062 XD Amsterdam, The Netherlands
- Department of Clinical Psychology, VU University Amsterdam, Van der Boechorststraat 1, 1081 BT Amsterdam, The Netherlands
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van Straten A, Cuijpers P, van Zuuren FJ, Smits N, Donker M. Personality traits and health-related quality of life in patients with mood and anxiety disorders. Qual Life Res 2006; 16:1-8. [PMID: 17033892 PMCID: PMC2778691 DOI: 10.1007/s11136-006-9124-x] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2005] [Accepted: 09/01/2006] [Indexed: 01/22/2023]
Abstract
Background Health-related quality of life (HRQL) is an accepted outcome measure in patients with mood and anxiety disorders. Yet, surprisingly little attention has been paid to the determinants. In this paper we test the hypothesis that it is associated with personality traits while controlling for mental disorders. Methods A large sample of outpatients (n=640) with mood and anxiety disorders was studied. The empirically supported five factor model of normal personality traits was assessed using the NEO-FFI and includes: neuroticism, extraversion, openness to experience, agreeableness, and conscientiousness. Mental disorders were assessed with the CIDI, and HRQL with the SF-36. Results Regression analyses revealed that the NEO-FFI scores, with the exception of conscientiousness, were significantly associated with SF-36 subscales and summary scores, independently from the mental disorders. The percentage of explained variance due to the personality traits was highest for the subscales Vitality (10.0%), Mental Health (13.3%) and the Mental Health Summary Score (9.5%). Furthermore, specific personality traits were related to specific SF-36 subscales. Conclusions A low HRQL of patients with mood or anxiety disorders is not only determined by the disease or the current health but is also shaped by personality traits that are relatively stable throughout an individual’s life time.
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Affiliation(s)
- Annemieke van Straten
- Department of Clinical Psychology, Faculty FPP, Vrije Universiteit, Van der Boechorststraat 1, 1081 BT, Amsterdam, The Netherlands.
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