Evaluation of reliable improvement rates in depression and anxiety at the end of treatment in adolescents

Online arts and culture for mental health in young people: a qualitative interview study

OBJECTIVES

This study aimed to understand young people's perception of the potential utility of arts and culture, focusing on online access, for supporting their mental health.

DESIGN

A qualitative interview study.

SETTING

Online.

PARTICIPANTS

Participants were selected by purposeful sampling from an online survey of arts and culture for mental health and well-being.

METHOD

Individual semi-structured interviews were conducted from 30 July 2020 to 9 September 2020. Rich interview data were analysed using reflexive thematic analysis.

RESULTS

Thirteen participants aged 18-24 who were socio-demographically diverse and varied in their use of online arts and culture (OAC) and in their level of psychological distress were interviewed. Six themes, 'Characteristics of other activities', 'Online engagement', 'Human connection', 'Mechanisms of impact', 'Mental health outcomes' and 'Engagement optimisation', were identified along with subthemes. Participants identified that online engagement had some advantages over in-person engagement and benefits were greater with familiarity and regular use. Participants described that human connection was the feature of OAC most likely to benefit mental health and emphasised the importance of representation. Mechanisms included improving perspective, reflection, learning, escapism, creativity, exploration and discovery. Outcomes were described as the disruption of negative thought patterns, lifting of mood and increased feelings of calm and proactivity.

CONCLUSIONS

This study demonstrates that young people have a critical level of insight and understanding regarding their mental health and ways in which it might be improved. These findings can be used to optimise the mental health benefits of OAC in an engaging and acceptable way for young people. These methodologies could be applied to other types of community resources for mental health.

Measuring goal progress using the goal-based outcome measure in Jigsaw - A primary care youth mental health service

BACKGROUND

Jigsaw is a primary care youth mental health service designed to increase access to and utilisation of mental health supports for 12- to 25-year-olds. Effectiveness in community youth mental health services is typically assessed using standardised instruments. The aim of this study was to examine the effectiveness of Jigsaw's brief intervention model of support using an idiographic tool, the goal-based outcome (GBO) measure. The study also aimed to explore the type of goals set by young people engaging with this service.

METHOD

The study sample consisted of a secondary dataset of 4839 young people aged 12-25 years (63.5% female, 36.5% male) who engaged with one of Jigsaw's 13 brief intervention services. Overall, 7366 goals set using the GBO were examined. Inductive thematic analysis was conducted to examine the type of goals set by young people, and inferential analyses were used to examine statistical and reliable changes in goal progress.

RESULTS

The goals young people set focused on developing coping mechanisms and personal growth and managing interpersonal difficulties. Mean scores for progress towards goals improved significantly from pre- to postintervention. The reliable change index (RCI) indicated that change greater than 2.82 points represents reliable change on the GBO, with 78.6% of young people showing reliable improvement. Demographic characteristics did not impact goal progress.

CONCLUSION

These findings suggest Jigsaw's brief intervention model of support is effective in assisting young people reach their goals and that the GBO is a suitable measure for young people attending a community-based youth mental health service.

Online Support and Intervention (OSI) for child anxiety: a case series within routine clinical practice

BACKGROUND

Online treatments for child anxiety offer a potentially cost-effective and non-stigmatizing means to widen access to evidence-based treatments and meet the increasing demand on services; however, uptake in routine clinical practice remains a challenge. This study conducted an initial evaluation of the clinical effectiveness, feasibility and acceptability of OSI (Online Support and Intervention for child anxiety) within clinical practice. OSI is a co-designed online therapist-supported, parent-led CBT treatment for pre-adolescent children with anxiety problems.

METHOD

This case series was part of routine service evaluation in a clinic in England where families were offered OSI to treat a primary anxiety difficulty among 7- to 12-year-old children; 24 families were offered OSI, and 23 took it up. Measures of anxiety symptomatology, functional impairment and progress towards therapeutic goals were taken at pre-treatment, post-treatment and 4-week follow-up. Treatment satisfaction and engagement were also measured throughout the intervention.

RESULTS

Mean anxiety symptoms significantly improved to below the clinical cut-off post-treatment, with further reduction at follow-up. Functional impairment also significantly improved and significant progress was made towards treatment goals. The majority of children showed reliable change in anxiety symptoms and reliable recovery by follow-up, and were discharged without needing further treatment for anxiety. Uptake, adherence and engagement in OSI were excellent, and parents reported high levels of satisfaction with the treatment.

CONCLUSIONS

We have provided initial evidence that OSI is feasible, acceptable to families, and appears to be associated with good outcomes within routine clinical practice.

Understanding the illness representations of young people with anxiety and depression: A qualitative study

BACKGROUND

Many young people with anxiety or depression drop out of treatment early, and/or leave treatment without showing measurably improved symptom levels. To enhance treatment engagement and effectiveness, it is critical to better understand how young people's perceptions of the symptoms, causes, consequences, treatability, and course of their anxiety and depression influence engagement.

AIM

This study aimed to provide a qualitative account of illness perceptions among youth with anxiety and depression by applying the Common Sense Model of Self-Regulation (CSM), which was developed in physical health contexts.

METHODS

Semi-structured interviews were conducted with 26 young people (aged 16-24, 73% female) with a history of anxiety and/or depression. Interviews were analysed using a combination of theory- and data-driven analysis techniques, consisting primarily of deductive thematic analysis.

RESULTS

The five themes broadly mapped onto the dimensions of the CSM, suggesting parallels in how mental and physical health problems are perceived. Anxiety and depression were viewed as non-linear, relapsing and remitting, but lifelong conditions, with a fluctuating and complex path to recovery and coping. Youth described pervasive negative impacts on their lives, but also described some positive aspects.

IMPLICATIONS

Better understanding of young people's illness beliefs has the potential to open a range of intervention possibilities by prioritizing young people's illness perceptions over the clinician's understanding and the supposed objective condition severity and trajectory. Although this study supported a common structure of illness beliefs, the content of these beliefs was idiosyncratic and specific to anxiety and depression, suggesting the need to develop a valid tool to measure illness perceptions in this group.

PRACTITIONER POINTS

Our findings suggest that illness perceptions are complex, highly idiosyncratic, and specific to youth anxiety and depression. Given the complexity of these beliefs and the known association with important treatment- and health-related outcomes, it is important that clinical formulation incorporates young people's illness belief models, including their perceptions of symptoms, cause, timeline to recovery, consequences, and personal and treatment control. To increase help-seeking, treatment engagement and adaptive coping strategies, therapy should work to a shared understanding of illness beliefs. Increasing congruence between the belief models of young people, families, and clinicians may serve to improve treatment benefits and address the unmet mental health needs of young people.

Cumulative risk exposure and emotional symptoms among early adolescent girls

Background

From early adolescence, girls and women report the highest rates of emotional symptoms, and there is evidence of increased prevalence in recent years. We investigate risk factors and cumulative risk exposure (CRE) in relation to emotional symptoms among early adolescent girls.

Methods

We used secondary data analysis, drawing on data capturing demographic information and self-reported emotional symptoms from 8327 girls aged 11–12 years from the 2017 baseline data collection phase of the HeadStart evaluation. We used structural equation modelling to identify risk factors in relation to self-reported emotional symptoms, and collated this into a CRE index to investigate associations between CRE and emotional symptoms.

Results

Four risk factors were found to have a statistically significant relationship with emotional symptoms among early adolescent girls: low academic attainment, special educational needs, low family income, and caregiving responsibilities. CRE was positively associated with emotional symptoms, with a small effect size.

Conclusions

Results identify risk factors (outlined above) that are associated with emotional symptoms among early adolescent girls, and highlight that early adolescent girls experiencing a greater number of risk factors in their lives are likely to also experience greater emotional distress. Findings highlight the need for identification and targeted mental health intervention (e.g., individual or group counselling, approaches targeting specific symptoms), for those facing greater risk and/or with emergent symptoms.

A Systematic Review and Lived-Experience Panel Analysis of Hopefulness in Youth Depression Treatment

Hopefulness is arguably of central importance to the recovery of youth with major or complex youth depression, yet it is unclear how hopefulness can best be enhanced in treatment. A narrative synthesis of published and grey literature was combined with new insights from a youth lived-experience panel (N = 15), focusing on to what extent and how specific psychological therapies and standard mental health care scaffold hopefulness as applied to depression among 14-25-year-olds. Thirty-one studies of variable quality were included in this review; thirteen were qualitative, thirteen quantitative, and five used mixed methods. Hopefulness is an important active ingredient of psychotherapies and standard mental health care in youth depression. Evidence suggests talking and activity therapies have moderate to large effects on hopefulness and that hopefulness can be enhanced in standard mental health care. However, varying intervention effects suggest a marked degree of uncertainty. Hopefulness is best scaffolded by a positive relational environment in which there is support for identifying and pursuing personally valued goals and engaging in meaningful activity. Animated (https://www.youtube.com/watch?v=o4690PdTGec) and graphical summaries (https://doi.org/10.13140/RG.2.2.27024.84487) are available.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40894-021-00167-0.

How to manage endings in unsuccessful therapy: A qualitative comparison of youth and clinician perspectives

Background: Approximately half of those who access child and adolescent mental health services do not show measurable improvement in symptoms. This study aimed to provide practice recommendations for managing treatment endings, particularly when outcomes have not improved. Method: Semi-structured interviews were carried out with 26 young people with a history of anxiety and/or depression along with 7 roundtable sessions with 52 mental health clinicians. Data were analyzed using Framework Analysis. Results: A common experience for young people when outcomes did not improve was a poor experience of the treatment ending, which often resulted in setbacks in their mental health and feelings of loss and abandonment. Clinicians agreed that ending was hard for young people and reported that they found managing ending hard on a personal and professional level. This was compounded by unrealistically high public expectations about the impact of therapy on outcomes and trying to strike a balance between fostering hope and managing expectations, within a context of inflexible service structures and resource constraint. Implications: Recommendations include establishing expectations from the outset and a shared understanding of what outcomes matter most to the young person. This can be achieved through communicating honestly about likely outcomes, while also providing hope.

Assessing recovery in treatment as usual provided by community child and adolescent mental health services

BACKGROUND

Despite the importance of routinely assessing the outcomes of everyday practice, few studies have reported outcome metrics for child and adolescent mental health services (CAMHS).

AIMS

Our aim is to investigate reliable change and recovery rates for treatment as usual, provided by one community CAMHS over two time periods.

METHOD

We prospectively audited accepted consecutive referrals from November 2017 to January 2018, and April to September 2019. Cases with paired outcomes were identified, and reliable change and recovery rates were calculated.

RESULTS

Baseline outcome data were obtained for 672 (78.2%) and 744 (77.5%) young people in 2018 and 2019, respectively. Of eligible participants, 174 (59.2%) and 155 (45.7%) completed at least one follow-up outcome measure in 2018 and 2019, respectively. Pre- and post-test scores on the Revised Child Anxiety and Depression Scale (RCADS) and Strengths and Difficulties Questionnaire (SDQ) showed a reduction in symptoms. Total RCADS scores showed 21-25% of participants reliably improved, with 44-49% showing reliable improvement on one or more subscale. On the SDQ, 11 (15.5%) and 19 (25.3%) participants reported reliable improvement on at least one subscale in 2018 and 2019, respectively. Reliable recovery rates ranged from 48 to 51% for youth-completed and 40 to 42% for parent-completed RCADS.

CONCLUSIONS

Half of young people receiving treatment as usual from CAMHS reliably improved on at least one routine outcome measure subscale, improvement rates comparable with adult psychological therapies services. Our findings indicate that reliable change and recovery on subscale rather than total scores may be a better indication of outcomes.

Neurobiological evidence of longer-term physical activity interventions on mental health outcomes and cognition in young people: A systematic review of randomised controlled trials

OBJECTIVE

To investigate putative neurobiological mechanisms that link longer-term physical activity interventions to mental health and cognitive outcomes using randomised controlled trials in children, adolescents and young adults.

DATA SOURCES

A range of medical and psychological science electronic databases were searched (MEDLINE, EMBASE, Scopus, Web of Science, PsychINFO).

REVIEW METHODS

Original research studies were selected, data were extracted and quality was appraised.

RESULTS

Sixteen primary papers were included, ranging from healthy and community samples to subclinical and clinical populations across a variety of age ranges and using different neurobiological measures (e.g. magnetic resonance imaging, electroencephalography, cortisol, brain-derived neurotropic factor).

DISCUSSION

The majority of studies report improvement in mental health and cognition outcomes following longer-term physical activity interventions which coincide with neurobiological alterations, especially neuroimaging alterations in activation and electrophysiological parameters in frontal areas. Future research should include measures of pre-existing fitness and target those who would benefit the most from this type of intervention (e.g. those with a lower level of fitness and at risk for or with mental health problems).

Editorial: Promoting Quality Psychotherapy: It Is Not the Process but the Outcome That Matters!

The article published in this issue of the Journal by Bear et al.¹ is the first to use meta-analytic procedures to try to understand the value of psychotherapy for pediatric anxiety and depression as usually delivered in the community. The authors scoured the literature for psychotherapy clinical trials that used treatment as usual as a control group or observational studies of treatment in mental health settings, then applied meta-analytic approaches to get a better idea of what treatment as usual outcomes were and by extension what to expect from psychotherapy as usually delivered. The study findings suggest that psychotherapy as practiced in the community even in high-quality settings does not provide consistently good outcomes. In this editorial, we will review the results of this study and discuss trends in psychotherapy research and practice that could improve the outcomes for patients and families.

Systematic Review and Meta-analysis: Outcomes of Routine Specialist Mental Health Care for Young People With Depression and/or Anxiety

OBJECTIVE

Depression and anxiety are the most prevalent mental health problems in youth, yet almost nothing is known about what outcomes are to be expected at the individual level following routine treatment. This paper sets out to address this gap by undertaking a systematic review of outcomes following treatment as usual (TAU) with a particular focus on individual-level outcomes.

METHOD

MEDLINE, Embase and PsycInfo were searched for articles published between 1980 and January 2019 that assessed TAU outcomes for youth depression and anxiety accessing specialist mental health care. Meta-analysis considered change at both group-level pre-post effect size (ES) and individual-level recovery, reliable change, and reliable recovery. Temporal analysis considered stability of primary and secondary outcomes over time. Subgroup analysis considered the moderating effect of informant; presenting problem; study design; study year; mean age of youth; use of medication; intervention dosage and type of treatment offered on outcomes. A protocol was preregistered on PROSPERO (CRD42017063914).

RESULTS

Initial screening of 6,350 publications resulted in 38 that met the inclusion criteria, and that were subsequently included in meta-analyses. This resulted in a final full pooled sample of 11,739 young people (61% of whom were female, mean age 13.8 years). The pre-post ES (Hedges' g) at first/final outcome (13/26 weeks) was -0.74/-0.87. The individual-level change on measures of self-report was 38% reliable improvement, 44% no reliable change, and 6% reliable deterioration. Outcomes varied according to moderators, informant, problem type and dosage.

CONCLUSION

Poor data quantity and quality are limitations, but this is the first study that indicates likely rates of reliable improvement for those accessing TAU. We propose the need for improved reporting of both individual-level metrics and details of TAU to enable greater understanding of likely current outcomes from routine care for youths with depression and anxiety in order to allow the potential for further improvement of impact.

Predicting mental health improvement and deterioration in a large community sample of 11- to 13-year-olds

Of children with mental health problems who access specialist help, 50% show reliable improvement on self-report measures at case closure and 10% reliable deterioration. To contextualise these figures it is necessary to consider rates of improvement for those in the general population. This study examined rates of reliable improvement/deterioration for children in a school sample over time. N = 9074 children (mean age 12; 52% female; 79% white) from 118 secondary schools across England provided self-report mental health (SDQ), quality of life and demographic data (age, ethnicity and free school meals (FSM) at baseline and 1 year and self-report data on access to mental health support at 1 year). Multinomial logistic regressions and classification trees were used to analyse the data. Of 2270 (25%) scoring above threshold for mental health problems at outset, 27% reliably improved and 9% reliably deteriorated at 1-year follow up. Of 6804 (75%) scoring below threshold, 4% reliably improved and 12% reliably deteriorated. Greater emotional difficulties at outset were associated with greater rates of reliable improvement for both groups (above threshold group: OR = 1.89, p < 0.001, 95% CI [1.64, 2.17], below threshold group: OR = 2.23, p < 0.001, 95% CI [1.93, 2.57]). For those above threshold, higher baseline quality of life was associated with greater likelihood of reliable improvement (OR = 1.28, p < 0.001, 95% CI [1.13, 1.46]), whilst being in receipt of FSM was associated with reduced likelihood of reliable improvement (OR = 0.68, p < 0.01, 95% CI [0.53, 0.88]). For the group below threshold, being female was associated with increased likelihood of reliable deterioration (OR = 1.20, p < 0.025, 95% CI [1.00, 1.42]), whereas being from a non-white ethnic background was associated with decreased likelihood of reliable deterioration (OR = 0.66, p < 0.001, 95% CI [0.54, 0.80]). For those above threshold, almost one in three children showed reliable improvement at 1 year. The extent of emotional difficulties at outset showed the highest associations with rates of reliable improvement.

Trajectories of change of youth depressive symptoms in routine care: shape, predictors, and service-use implications

Depression is one of the main reasons for youth accessing mental health services, yet we know little about how symptoms change once youth are in routine care. This study used multilevel modeling to examine the average trajectory of change and the factors associated with change in depressive symptoms in a large sample of youth seen in routine mental health care services in England. Participants were 2336 youth aged 8-18 (mean age 14.52; 77% females; 88% white ethnic background) who tracked depressive symptoms over a period of up to 32 weeks while in contact with mental health services. Explanatory variables were age, gender, whether the case was closed, total length of contact with services, and baseline severity in depression scores. Faster rates of improvement were found in older adolescents, males, those with shorter time in contact with services, closed cases, and those with more severe symptoms at baseline. This study demonstrates that when youth self-report their depressive symptoms during psychotherapy, symptoms decrease in a linear trajectory. Attention should be paid to younger people, females, and those with lower than average baseline scores, as their symptoms decrease at a slower pace compared to others.

'I Just Stopped Going': A Mixed Methods Investigation Into Types of Therapy Dropout in Adolescents With Depression

What does it mean to 'drop out' of therapy? Many definitions of 'dropout' have been proposed, but the most widely accepted is the client ending treatment without agreement of their therapist. However, this is in some ways an external criterion that does not take into account the client's experience of therapy, or reasons for ending it prematurely. This study aimed to identify whether there were more meaningful categories of dropout than the existing dropout definition, and to test whether this refined categorization of dropout was associated with clinical outcomes. This mixed-methods study used a subset of data from the IMPACT trial, which investigated psychological therapies for adolescent depression. Adolescents were randomly allocated to a treatment arm (Brief Psychosocial Intervention; Cognitive-Behavioral Therapy; Short-Term Psychoanalytic Psychotherapy). The sample for this study comprised 99 adolescents, aged 11-17 years. Thirty-two were classified as having dropped out of treatment and participated in post-therapy qualitative interviews about their experiences of therapy. For 26 dropout cases, the therapist was also interviewed. Sixty-seven cases classified as having completed treatment were included to compare their outcomes to dropout cases. Interview data for dropout cases were analyzed using ideal type analysis. Three types of dropout were constructed: 'dissatisfied' dropout, 'got-what-they-needed' dropout, and 'troubled' dropout. 'Dissatisfied' dropouts reported stopping therapy because they did not find it helpful. 'Got-what-they-needed' dropouts reported stopping therapy because they felt they had benefitted from therapy. 'Troubled' dropouts reported stopping therapy because of a lack of stability in their lives. The findings indicate the importance of including the perspective of clients in definitions of drop out, as otherwise there is a risk that the heterogeneity of 'dropout' cases may mask more meaningful distinctions. Clinicians should be aware of the range of issues experienced by adolescents in treatment that lead to disengagement. Our typology of dropout may provide a framework for clinical decision-making in managing different types of disengagement from treatment.

Strategies not accompanied by a mental health professional to address anxiety and depression in children and young people: a scoping review of range and a systematic review of effectiveness

This Review reports on a scoping review followed by a systematic review to consider interventions designed to address or manage depression or anxiety in children and young people up to the age of 25 years without the need to involve mental health professionals. The scoping review identified 132 approaches, 103 of which referred to children or young people (younger than 25 years). These approaches included social interaction, engagement with nature, relaxation, distraction, sensory stimulation, physical activity, altering perceptions, engaging in hobbies, self-expression, and exploration. A systematic review of effectiveness studies from the literature identified in the scoping review found only 38 studies on seven types of intervention that met the inclusion criteria. 16 studies were based on cognitive or behavioural principles (15 on digital interventions and one on bibliotherapy), ten focused on physical exercise, five on light therapy, three on dietary supplements, two on massage therapy, one on online peer support, and one on contact with a dog. Most studies focused on adolescents or young adults. Evidence suggested that light therapy could be effective for season depression and that digital interventions based on attention bias modification are ineffective for anxiety. Mixed evidence was available on the effectiveness of computerised cognitive behavioural therapy for depression and anxiety, and of physical exercise for depression. All other studies had insufficient certainty to obtain even tentative conclusions about effectiveness. These results highlight the disparity between the extensive range of approaches identified in the scoping review and the restricted number and focus found in the systematic review of effectiveness of these approaches. We call for an expanded research agenda that brings evaluation rigour to a wide range of self or community approaches.