Baseline Psychological Treatment Reduces the Effect of Coaching in a Randomised Trial of a Depression Self-Care Intervention

Self-care interventions to assist family physicians with mental health care of older patients during the COVID-19 pandemic: Feasibility, acceptability, and outcomes of a pilot randomized controlled trial

BACKGROUND

The COVID-19 pandemic has required family physicians to rapidly address increasing mental health problems with limited resources. Vulnerable home-based seniors with chronic physical conditions and commonly undermanaged symptoms of anxiety and depression were recruited in this pilot study to compare two brief self-care intervention strategies for the management of symptoms of depression and/or anxiety.

METHODS

We conducted a pilot RCT to compare two tele-health strategies to address mental health symptoms either with 1) validated CBT self-care tools plus up to three telephone calls from a trained lay coach vs. 2) the CBT self-guided tools alone. The interventions were abbreviated from those previously trialed by our team, to enable their completion in 2 months. Objectives were to assess the feasibility of delivering the interventions during a pandemic (recruitment and retention); and assess the comparative acceptability of the interventions across the two groups (satisfaction and tool use); and estimate preliminary comparative effectiveness of the interventions on severity of depression and anxiety symptoms. Because we were interested in whether the interventions were acceptable to a wide range of older adults, no mental health screening for eligibility was performed.

RESULTS

90 eligible patients were randomized. 93% of study completers consulted the self-care tools and 84% of those in the coached arm received at least some coaching support. Satisfaction scores were high among participants in both groups. No difference in depression and anxiety outcomes between the coached and non-coached participants was observed, but coaching was found to have a significant effect on participants' use and perceived helpfulness of the tools.

CONCLUSION

Both interventions were feasible and acceptable to patients. Trained lay coaching increased patients' engagement with the tools. Self-care tools offer a low cost and acceptable remote activity that can be targeted to those with immediate needs. While effectiveness results were inconclusive, this may be due to the lack of eligibility screening for mental health symptoms, abbreviated toolkit, and fewer coaching sessions than those used in our previous effective interventions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT0460937.

Adaptation and outcomes of a lay-guided mental health self-care model: Results of six trials

OBJECTIVE

To synthesize results of six controlled trials of self-care interventions for depression and/or anxiety, focusing on five trials in which lay guidance was compared to self-directed use of the same self-care tools.

METHODS

The trials were conducted in Canada in different target populations. Self-care tools were adapted to each population. Guidance was provided in 3-15 calls over a period of 6-26 weeks. Depression and/or anxiety were assessed at follow-up (6-26 weeks). Pooled analyses used a meta-analytic approach. Engagement with the self-care tools was compared using the standardized difference or Cohen's d effect size.

RESULTS

In studies with homogeneous outcomes (three for depression, four for anxiety), the pooled effect sizes of guidance vs. self-directed use of the self-care tools were 0.36 (95% CI 0.10, 0.62, N = 235) for depression and 0.21 (95% CI -0.03, 0.44, N = 285) for anxiety. Guidance consistently led to greater engagement with the tools.

CONCLUSIONS

The intervention model is a potentially sustainable and accessible alternative to professionally guided self-care for people with mild-moderate depression. Factors which may have limited implementation success include: co-interventions, reduced number of guide calls (3 vs 6 or more), and delivery to dyads (patient-caregiver).

Trained lay coaches and self-care cognitive-behavioral tools improve depression outcomes

OBJECTIVES

Identify the key effective components of a depression self-care intervention.

METHODS

Secondary analysis of data from 3 studies that demonstrated effectiveness of a similar depression self-care intervention (n = 275): 2 studies among patients with chronic physical conditions and 1 among cancer survivors. The studies used similar tools, and telephone-based lay coaching. Depression remission and reduction at 6 months were assessed with either PHQ-9 (chronic condition cohorts) or CES-D (cancer survivor cohort). Multiple logistic regression was used to analyze data when the interaction p-value with cohort was < 0.10.

RESULTS

The 3 coached cohorts achieved better depression outcomes than usual care. The combination of coaching and joint use of 2 tools based on cognitive-behavioral therapy (CBT) was associated with depression remission and reduction among chronic condition cohorts but not among cancer survivors. Neither the number nor the length of coach calls were associated with outcomes in pooled data.

CONCLUSIONS

Trained lay coaching and use of CBT-based self-care tools were associated with improved depression outcomes in patients with chronic conditions but not among cancer survivors.

PRACTICE IMPLICATIONS

Trained lay coaching and CBT tools are key components of depression self-care interventions. Further research is needed on the effective components in cancer survivors.

CanDirect: Effectiveness of a Telephone-Supported Depression Self-Care Intervention for Cancer Survivors

PURPOSE

Depression in post-treatment cancer survivors is common and can impair quality of life. CanDirect is a novel, telephone-delivered depression self-care intervention for cancer survivors. We conducted a randomized controlled superiority trial to compare CanDirect with usual care (UC) in this population.

METHODS

Participants completing cancer treatment within the past 10 years who had mild-moderate depressive symptoms with or without major depression were recruited from clinical and community settings in Quebec and Ontario. Permuted block random assignment allocated participants to CanDirect plus UC or to UC alone. Assessments of depression severity (Center for Epidemiological Studies-Depression scale [CES-D]; primary outcome) and secondary outcomes health-related quality of life (Short Form Survey-12 mental and physical component summaries), anxiety symptoms (Hospital Anxiety and Depression Scale), activation (Patient Activation Measure), depression diagnosis (Structured Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders-IV), and health services (self-report) were conducted at baseline, as well as 3 and 6 months (primary time point). Analyses of outcomes were adjusted for covariates using linear regression and missing data by inverse probability weighting.

RESULTS

Participants recruited between September 2016 and October 2018 were randomly assigned to CanDirect (n = 121) or UC (n = 124). Among 245 participants randomly assigned, 218 (89.0%) completed the primary outcome at 6 months. CanDirect participants reported less severe depressive symptoms on the CES-D than UC participants at 6 months, adjusted effect size (ES) 0.61 (95% CI, 0.33 to 0.88). CanDirect participants also had significantly greater quality of life, lower anxiety, more activation, and lower rates of depression diagnoses, compared with UC. Exploratory analysis suggested that sex was a modifier of the primary outcome (interaction term P value = .03); the intervention was less effective in men (ES, 0.12; 95% CI, -0.45 to 0.69).

CONCLUSION

The findings suggest that CanDirect is an effective method of managing mild-moderate depression symptoms in cancer survivors.

Self-management across chronic diseases: Targeting education and support needs

OBJECTIVES

Among Canadian adults with chronic disease: 1) to identify groups that differ in self-management task frequency and self-efficacy; 2) to compare group characteristics and preferences for self-management support.

METHODS

Using data from an online survey, cluster analysis was used to identify groups that differed in self-management task frequency and self-efficacy. Multivariable regression was used to explore relationships with patient characteristics and preferences.

RESULTS

Cluster analysis (n = 247) revealed three groups:Vulnerable Self-Managers (n = 55), with the highest task frequency and lowest self-efficacy; Confident Self-Managers (n = 73), with the lowest task frequency and highest self-efficacy; and Moderate Needs Self-Managers (n = 119), with intermediate task frequency and self-efficacy. Vulnerable Self-Managers, when compared with the Confident group, were more often: on illness-related employment disability or unemployed; less well educated; diagnosed with emotional problems or hypertension, and had greater multimorbidity. They participated less often in self-management programs, and differed in support preferences.

CONCLUSIONS

Knowing the characteristics of vulnerable self-managers can help in targeting those in greater need for self-management support that matches their preferences.

PRACTICE IMPLICATIONS

Different approaches are needed to support self-management in the vulnerable population.

Computer-Aided Telephone Support for Primary Care Patients with Common Mental Health Conditions: Randomized Controlled Trial

BACKGROUND

Depression, anxiety, and at-risk drinking are highly prevalent in primary care settings. Many jurisdictions experience geographical barriers to accessing mental health services, necessitating the development and validation of alternative models of care delivery. Existing evidence supports the acceptability and effectiveness of providing mental health care by telephone.

OBJECTIVE

This analysis assesses patient's acceptability of computer-aided telephone support delivered by lay providers to primary care patients with depression, anxiety, or at-risk drinking.

METHODS

The Primary care Assessment and Research of a Telephone intervention for Neuropsychiatric conditions with Education and Resources study is a randomized controlled trial comparing a computer-aided telephone-based intervention to usual care enhanced by periodic assessments in adult primary care patients referred for the treatment of depression, anxiety, or at-risk drinking; no part of the study involves in-person contact. For this analysis, the following data were obtained: reasons provided for declining consent; reasons provided for withdrawing from the study; study retention rate; and a thematic analysis of a satisfaction survey upon study completion.

RESULTS

During the consent process, 17.1% (114/667) patients referred to the study declined to participate and 57.0% of them (65/114) attributed their refusal to research-related factors (ie, randomization and time commitment); a further 16.7% (19/114) declined owing to the telephone delivery of the intervention. Among the 377 participants who were randomized to the 1-year intervention, the overall retention rate was 82.8% (312/377). Almost no participants who withdrew from the study identified the telephone components of the study as their reason for withdrawal. Analysis of a qualitative satisfaction survey revealed that 97% (38/39) of comments related to the telephone components were positive with key reported positive attributes being accessibility, convenience, and privacy.

CONCLUSIONS

Our results suggest that a computer-aided telephone support is highly acceptable to primary care patients with depression, anxiety, or at-risk drinking. In particular, these patients appreciate its accessibility, flexibility, and privacy.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02345122; https://clinicaltrials.gov/ct2/show/NCT02345122 (Archived by WebCite at http://www.webcitation.org/73R9Q2cle).

La gestion de la dépression chez les aînés et leurs aidants naturels : résultats d’un programme de recherche au Québec

La dépression est un problème répandu, sérieux, et souvent chronique chez les aînés, qui sont souvent atteints de maladies physiques chroniques, et affecte de façon négative leurs traitements et leurs soins. Malheureusement, le taux de détection et de suivi adéquat de la dépression est faible dans cette population. Au cours des deux dernières décennies, notre équipe a mené une série d’études pour mieux comprendre et améliorer la gestion de la dépression chez les aînés. Nous présentons une revue narrative et synthèse de 25 articles qui incluent : 4 revues systématiques, 10 études observationnelles, 9 essais d’interventions, et 2 conférences de consensus. Nous proposons en conclusion nos recommandations pour 1) la détection de la dépression dans les soins de santé primaires ; 2) les soins collaboratifs de la dépression ; 3) des interventions d’autogestion de la dépression ; 4) le rôle des aidants naturels dans les interventions d’autogestion de la dépression.