Making Evidence-Based Psychotherapy More Accessible in Canada

Artificial Intelligence-Based Co-Facilitator (AICF) for Detecting and Monitoring Group Cohesion Outcomes in Web-Based Cancer Support Groups: Single-Arm Trial Study

BACKGROUND

Commonly offered as supportive care, therapist-led online support groups (OSGs) are a cost-effective way to provide support to individuals affected by cancer. One important indicator of a successful OSG session is group cohesion; however, monitoring group cohesion can be challenging due to the lack of nonverbal cues and in-person interactions in text-based OSGs. The Artificial Intelligence-based Co-Facilitator (AICF) was designed to contextually identify therapeutic outcomes from conversations and produce real-time analytics.

OBJECTIVE

The aim of this study was to develop a method to train and evaluate AICF's capacity to monitor group cohesion.

METHODS

AICF used a text classification approach to extract the mentions of group cohesion within conversations. A sample of data was annotated by human scorers, which was used as the training data to build the classification model. The annotations were further supported by finding contextually similar group cohesion expressions using word embedding models as well. AICF performance was also compared against the natural language processing software Linguistic Inquiry Word Count (LIWC).

RESULTS

AICF was trained on 80,000 messages obtained from Cancer Chat Canada. We tested AICF on 34,048 messages. Human experts scored 6797 (20%) of the messages to evaluate the ability of AICF to classify group cohesion. Results showed that machine learning algorithms combined with human input could detect group cohesion, a clinically meaningful indicator of effective OSGs. After retraining with human input, AICF reached an F1-score of 0.82. AICF performed slightly better at identifying group cohesion compared to LIWC.

CONCLUSIONS

AICF has the potential to assist therapists by detecting discord in the group amenable to real-time intervention. Overall, AICF presents a unique opportunity to strengthen patient-centered care in web-based settings by attending to individual needs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.2196/21453.

Impact of a publicly-funded pharmacare program policy on benzodiazepine dispensing among children and youth: a population-based natural experiment

BACKGROUND

In January 2018, the Government of Ontario, Canada, initiated a universal pharmacare program (OHIP+) for all individuals aged 24 years and younger. In April 2019, the program was amended to cover only children and youth without private insurance. Because benzodiazepines are commonly prescribed to children and youth despite their potential hazards, we examined whether changes in publicly-funded drug coverage influenced benzodiazepine dispensing trends in this demographic.

METHODS

We conducted a population-based natural experiment study of benzodiazepine dispensing to children and youth in Ontario between January 2013 and March 2020. We used interventional autoregressive integrated moving average models to estimate the impact of OHIP + and its subsequent modification on these trends.

RESULTS

The implementation of OHIP + was associated with an immediate increase in the monthly rate of benzodiazepine dispensing of 12.9 individuals per 100,000 population (95% confidence interval [CI]; 7.5 to 18.3 per 100,000). Benzodiazepine dispensing rates rose from 214.2 to 241.5 per 100,000 from December 2017 to March 2019, a 12.8% (95% CI 9.6-16.0%) increase. In stratified analyses, increases were most pronounced among females, children and youth living in the lowest income neighbourhoods and individuals aged 20 to 24. The April 2019 modification to OHIP + was not associated with changes in monthly benzodiazepine dispensing trends (0.39 individuals per 100,000; 95% CI -1.3 to 2.1 per 100,000). However, rates remained elevated relative to the period preceding OHIP + implementation.

CONCLUSIONS

Implementation of a publicly-funded pharmacare program resulted in more children and youth being prescribed benzodiazepines.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data

BACKGROUND

This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone.

METHODS

This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included.

RESULTS

Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness.

CONCLUSIONS

From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

E-Mental Health Services in Canada: Can They Close the Access Gap?

With significant unmet needs for mental healthcare in Canada, there is a growing interest in e-mental health (e-MH) services to meet gaps in access. While the policy window appears to be open, it is unclear how best to implement e-MH services due to health system barriers that create unmet needs in the first place. We explore the financing, organization and delivery of Canadian mental health services and discuss the promise of e-MH services for alleviating access barriers, highlighting increased policy attention during the COVID-19 pandemic. We consider how evidence-based e-MH services have successfully scaled in other publicly funded healthcare systems and note potential issues in the Canadian context.

Providing Care Beyond Therapy Sessions With a Natural Language Processing-Based Recommender System That Identifies Cancer Patients Who Experience Psychosocial Challenges and Provides Self-care Support: Pilot Study

BACKGROUND

The negative psychosocial impacts of cancer diagnoses and treatments are well documented. Virtual care has become an essential mode of care delivery during the COVID-19 pandemic, and online support groups (OSGs) have been shown to improve accessibility to psychosocial and supportive care. de Souza Institute offers CancerChatCanada, a therapist-led OSG service where sessions are monitored by an artificial intelligence-based co-facilitator (AICF). The AICF is equipped with a recommender system that uses natural language processing to tailor online resources to patients according to their psychosocial needs.

OBJECTIVE

We aimed to outline the development protocol and evaluate the AICF on its precision and recall in recommending resources to cancer OSG members.

METHODS

Human input informed the design and evaluation of the AICF on its ability to (1) appropriately identify keywords indicating a psychosocial concern and (2) recommend the most appropriate online resource to the OSG member expressing each concern. Three rounds of human evaluation and algorithm improvement were performed iteratively.

RESULTS

We evaluated 7190 outputs and achieved a precision of 0.797, a recall of 0.981, and an F1 score of 0.880 by the third round of evaluation. Resources were recommended to 48 patients, and 25 (52%) accessed at least one resource. Of those who accessed the resources, 19 (75%) found them useful.

CONCLUSIONS

The preliminary findings suggest that the AICF can help provide tailored support for cancer OSG members with high precision, recall, and satisfaction. The AICF has undergone rigorous human evaluation, and the results provide much-needed evidence, while outlining potential strengths and weaknesses for future applications in supportive care.

The Impact of Aerobic Exercise on Mood Symptoms in Trauma-Exposed Young Adults: A Pilot Study

Introduction

Physical activity has beneficial effects on mood in both healthy and clinical populations. Emerging literature suggests that physical activity may benefit psychological symptoms, such as depressive mood, in those with post-traumatic stress disorder (PTSD). It is estimated that 76% of Canadians have experienced a traumatic event during their lifetime (Van Ameringen et al., 2008). Thus, there is a large proportion of the population that does not meet criteria for PTSD but may still suffer from trauma-related symptoms such as depression and require support for their mental health. The current pilot study aimed to evaluate the impact of an aerobic exercise intervention on mood symptoms in trauma-exposed young adults.

Methods

Twenty-five low active young adults with subclinical trauma symptoms but no current or past diagnosis of PTSD were recruited. Participants were randomly assigned to participate in an 8-week exercise intervention group or a waitlist control group. Mood symptoms were assessed before and after the intervention. In addition, measures of aerobic fitness, trauma symptoms, emotion regulation, and trait mindfulness were assessed at both time points.

Results

The exercise intervention was effective at inducing the expected improvements in aerobic fitness. Overall, the exercise group had a significantly greater decrease in mood symptoms across the intervention compared to the waitlist control group.

Conclusion

The current pilot study is the first to evaluate the impact of aerobic exercise on mood in trauma-exposed young adults. An 8-week intervention significantly reduced mood symptoms in exercisers relative to waitlist controls. Our results are consistent with previous research indicating that physical activity reduced depressive symptoms in those with PTSD (Rosenbaum et al., 2015b). Importantly, we extend these findings to individuals with subclinical or undiagnosed PTSD symptoms, where exercise may be an effective intervention to improve mood and manage or prevent further decline in mental health in those at risk of developing PTSD.

Association between psychotropic prescriptions and the total amount of psychotropics ingested during an intentional overdose: A single-center retrospective study

Aim

To investigate the association between psychotropic prescriptions and the total amount of psychotropics ingested during a subsequent intentional overdose and to examine factors related to the number of psychotropic prescriptions.

Methods

The initial sample comprised 69 patients who were admitted to the emergency department of a general hospital in Japan following an intentional overdose via psychotropic medications. We performed retrospective hierarchical multiple regression analysis with the total amount of psychotropics ingested at the overdose as a dependent variable and factors related to deliberate self‐harm or overdose identified in previous studies as independent variables. We compared two models, one that did not (Step 1) and one that did (Step 2) include the number of different prescribed psychotropic medications as an independent variable in the analysis.

Results

Forty‐seven patients were eligible for the analysis. The number of different prescribed psychotropic medications was associated with the total amount of psychotropics ingested at the overdose in Step 2 (β = 0.40, P = .01). There was a trend toward an association between the past number of deliberate self‐harm events and the total amount of psychotropics ingested at the overdose in Step 1 (β = 0.30, P = .05), but this trend was weakened in Step 2 (β = 0.15, P = .33).

Conclusion

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

The number of different prescribed psychotropics appeared to influence the risk of subsequent intentional overdose through increasing the total amount of psychotropics ingested. Cumulative psychotropic prescriptions, particularly those delivered after deliberate self‐harm, might be indirectly related to this risk.

Natural Language Processing-Based Virtual Cofacilitator for Online Cancer Support Groups: Protocol for an Algorithm Development and Validation Study

BACKGROUND

Cancer and its treatment can significantly impact the short- and long-term psychological well-being of patients and families. Emotional distress and depressive symptomatology are often associated with poor treatment adherence, reduced quality of life, and higher mortality. Cancer support groups, especially those led by health care professionals, provide a safe place for participants to discuss fear, normalize stress reactions, share solidarity, and learn about effective strategies to build resilience and enhance coping. However, in-person support groups may not always be accessible to individuals; geographic distance is one of the barriers for access, and compromised physical condition (eg, fatigue, pain) is another. Emerging evidence supports the effectiveness of online support groups in reducing access barriers. Text-based and professional-led online support groups have been offered by Cancer Chat Canada. Participants join the group discussion using text in real time. However, therapist leaders report some challenges leading text-based online support groups in the absence of visual cues, particularly in tracking participant distress. With multiple participants typing at the same time, the nuances of the text messages or red flags for distress can sometimes be missed. Recent advances in artificial intelligence such as deep learning-based natural language processing offer potential solutions. This technology can be used to analyze online support group text data to track participants' expressed emotional distress, including fear, sadness, and hopelessness. Artificial intelligence allows session activities to be monitored in real time and alerts the therapist to participant disengagement.

OBJECTIVE

We aim to develop and evaluate an artificial intelligence-based cofacilitator prototype to track and monitor online support group participants' distress through real-time analysis of text-based messages posted during synchronous sessions.

METHODS

An artificial intelligence-based cofacilitator will be developed to identify participants who are at-risk for increased emotional distress and track participant engagement and in-session group cohesion levels, providing real-time alerts for therapist to follow-up; generate postsession participant profiles that contain discussion content keywords and emotion profiles for each session; and automatically suggest tailored resources to participants according to their needs. The study is designed to be conducted in 4 phases consisting of (1) development based on a subset of data and an existing natural language processing framework, (2) performance evaluation using human scoring, (3) beta testing, and (4) user experience evaluation.

RESULTS

This study received ethics approval in August 2019. Phase 1, development of an artificial intelligence-based cofacilitator, was completed in January 2020. As of December 2020, phase 2 is underway. The study is expected to be completed by September 2021.

CONCLUSIONS

An artificial intelligence-based cofacilitator offers a promising new mode of delivery of person-centered online support groups tailored to individual needs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/21453.

Access to psychotherapy for patients with personality disorders

The best evidence for effective treatment of personality disorder supports the use of specialized forms of psychotherapy. However, these forms of treatment are generally unavailable in health care systems. This may be partly due to the expense of routinely offering long-term therapies. There is evidence that psychotherapy for personality disorder is cost-effective. One way to address this problem is to treat most patients more briefly. © 2020 John Wiley & Sons, Ltd.

Impact of Pharmacist-Led Cognitive Behavioural Therapy for Chronic Insomnia

Background

Chronic insomnia is a common medical condition that negatively impacts quality of life and daytime function. Access to the first-line treatment for insomnia, cognitive behavioural therapy (CBT-i), is limited. Pharmacists are well positioned to provide this service, but evidence regarding pharmacist delivered CBT-i is sparse. The aim of this study was to evaluate the effectiveness of CBT-i delivered by pharmacists practicing in an outpatient clinic setting.

Methods

This study was a retrospective chart audit of adult patients with chronic insomnia who received CBT-i from a pharmacist at one of two outpatient clinics in Canada. The primary endpoints were the differences between patient self-reported sleep diary parameters and utilization of hypnotic medications before and after CBT-i was delivered. The differences in patient reported sleep parameters were compared using Wilcoxon Signed Rank test and paired samples t-test and changes in hypnotic utilization was compared using McNemar Chi-square test.

Results

183 patients were referred for CBT-i and attended an initial appointment with a pharmacist. Of these, 105 did not receive the CBT-i. This resulted in 78 patients who met the inclusion criteria. Changes in sleep diary parameters were all statistically significantly improved after patients received CBT-i, except for total sleep time. Hypnotic medication use was also reduced. At baseline, 71.8% (n=56/78) of patients were taking one or more hypnotic medications compared to 52.6% (n=41/78) after CBT-i (p=0.0003).

Discussion

The results of this study provide preliminary evidence that pharmacists working in an outpatient clinic setting may be able to effectively deliver CBT-i for patients with chronic insomnia. The external validity of these results is limited by the observational study design and the inclusion of pharmacists practicing in outpatient clinics, which is not the setting where most pharmacists currently practice.

Conclusion

This observational study found improvements in sleep quality and efficiency, as well as, a reduction in hypnotic medication use, in patients who received CBT-i from pharmacists practicing in an outpatient clinic setting. Future randomized, controlled trials should evaluate the impact of CBT-i in a larger sample of patients, provided by pharmacists practicing in both outpatient clinics and community pharmacies.

Does Introducing Public Funding for Allied Health Psychotherapy Lead to Reductions in Private Insurance Claims? Lessons for Canada from the Australian Experience

OBJECTIVE

Provincial and territorial governments are considering how best to improve access to psychotherapy from the current patchwork of programmes. To achieve the best value for money, new funding needs to reach a wider population rather than simply replacing services funded through insurance benefits. We considered lessons for Canada from the relative uptake of private insurance and public funding for allied health psychotherapy in Australia.

METHOD

We analysed published administrative claims data from 2003-2004 to 2014-2015 on Australian privately insured psychologist services, publicly insured psychotherapy under the 'Better Access' initiative, and public grant funding for psychotherapy through the 'Access to Allied Psychological Services' programme. Utilisation was compared to the prevalence of mental disorders and treatment rates in the 2007 National Survey of Mental Health and Wellbeing.

RESULTS

The introduction of public funding for psychotherapy led to a 52.1% reduction in private insurance claims. Costs per session were more than double under private insurance and likely contributed to individuals with private coverage choosing to instead access public programmes. However, despite substantial community unmet need, we estimate just 0.4% of the population made private insurance claims in the 2006-2007 period. By contrast, from its introduction, growth in the utilisation of Better Access quickly dwarfed other programmes and led to significantly increased community access to treatment.

CONCLUSIONS

Although insurance in Canada is sponsored by employers, psychology claims also appear surprisingly low, and unmet need similarly high. Careful consideration will be needed in designing publicly funded psychotherapy programmes to prepare for the high demand while minimizing reductions in private insurance claims.

Efficacy, tolerability, and cognitive effects of deep transcranial magnetic stimulation for late-life depression: a prospective randomized controlled trial

Late-life depression (LLD) is a growing worldwide problem due to demographic changes, with limited treatment options due to high rates of pharmacotherapy adverse effects, accessibility of psychotherapy, and tolerability of electroconvulsive therapy. Novel neuromodulation techniques, such as repetitive transcranial magnetic stimulation (rTMS), may overcome these limitations. The objective of this study is to determine the efficacy, tolerability, and cognitive effects of high-dose deep rTMS in LLD. In this study we randomized older adults between 60 and 85 years old with major depressive disorder (MDD) to sham or active deep rTMS (H1 coil, 6012 pulses, 18 Hz, 120% of resting motor threshold) delivered over the dorsolateral and ventrolateral prefrontal cortex 5 days per week over 4 weeks. Our primary outcome was remission of depression in an intention-to-treat analysis. We also assessed change in cognitive functioning with rTMS treatment and tolerability based on adverse effects. Fifty-two participants were randomized to active (n = 25) or sham H1 coil (n = 27). Remission rate was significantly higher with active than sham rTMS (40.0% vs 14.8%) with a number needed to treat of 4.0 (95% CI: 2.1-56.5). There was no change on any measure of executive function and no serious adverse events. Adverse effect profiles were similar between active and sham rTMS, except for reports of pain being significantly more common in the active condition (16.0% vs 0%). High-dose deep rTMS appears to be safe, well tolerated, and efficacious in the treatment of LLD.

Prevalence of psychological distress: How do Australia and Canada compare?

OBJECTIVE

To compare equivalent population-level mental health indicators in Canada and Australia, and articulate recommendations to support equitable mental health services. These are two somewhat similar resource-rich countries characterized by extensive non-metropolitan and rural regions as well as significant areas of socioeconomic deprivation.

METHODS

A cross-national epidemiology and equity study: primary outcome was Kessler Psychological Distress Scale (K10) in recent national surveys. A secondary outcome was mental disorders rate since these surveys were 5-years apart.

RESULTS

Elevated distress, defined by K10 scores (0-40 range) of 12 and over, affected 11.1% Australians and 12.0% Canadians. Elevated distress in both countries affected more people in the lowest income quintile (21-27%) compared to the richest (6%). In the lowest income quintile, 1-in-4 Australians and 1-in-5 Canadians reported elevated distress - twice the national average in both countries. Australians in the lowest income quintile (over 5 million people) have a significantly higher risk by over a 5% for elevated distress compared to their low-income Canadian counterparts. After adjusting for effects of age and gender, the relative odds in the lowest quintile compared to richest was 6.4 for Australians and 3.5 for Canadians, which remained significantly different thus confirming greater inequity in Australia. Mental disorders affected approximately 1-in-10 people in both countries.

CONCLUSIONS

This adds to the mental health prevalence monitoring in these two countries by supporting an overall prevalence of elevated distress in approximately 1-in-10 people. It supports large-scale public health interventions that target elevated distress in people with low incomes to order to achieve the biggest impact, and, to reduce the greater inequity in mental health indicators in Australians, policy-makers should consider eliminating gap-fees as they are illegal in Canada. As encouraged by World Health Organization, we highlight the importance of such population-level studies so that cross-national results can be reliably compared.