Twelve Months Post-treatment Results From the Norwegian Version of Improving Access to Psychological Therapies

Do the effects of internet-delivered cognitive-behavioral therapy (i-CBT) last after a year and beyond? A meta-analysis of 154 randomized controlled trials (RCTs)

Although the short-term efficacy of internet-delivered cognitive-behavioral therapy (i-CBT) is well-established, its long-term efficacy remains understudied. Robust variance estimation meta-analysis was thus conducted across guided and self-guided i-CBT, synthesizing data from 154 randomized controlled trials (N = 45,335) with ≥ 12-month follow-ups. For binary outcomes, guided (52.3% vs. 38.6%; log-risk ratio [LOG-RR] = 1.15 95% confidence interval [1.04, 1.26]) yielded higher remission, reliable improvement, and response rates, and lower suboptimal treatment outcome rates (9.3% vs. 10.8%; LOG-RR = 0.63 [0.45, 0.80]) than treatment-as-usual, active controls, and waitlists at ≥12 months. Insufficient studies precluded testing the efficacy between self-guided i-CBT and controls for binary outcomes. For baseline-to-12-month dimensional outcomes, guided i-CBT produced greater reductions in anxiety, depressive, post-traumatic stress disorder (PTSD) symptoms, and repetitive negative thinking (Hedge's g = -1.86 to -0.31), and self-guided i-CBT yielded stronger reductions in depressive symptoms (g = -0.51) than all controls. For outcome scores aggregated at ≥ 12-month follow-ups, guided i-CBT alleviated anxiety, depression, distress, insomnia, PTSD symptoms, role impairment, emotion regulation, and quality of life (g = -0.31 to 0.26), and self-guided i-CBT yielded lower anxiety and depressive symptoms (g = -0.16 to -0.09) than all controls. No significant differences in efficacy emerged between guided and self-guided i-CBT when sufficient studies existed for a meta-analysis. There was no evidence for publication bias. Long-term efficacy was similar to short-term efficacy for most outcomes. Implementing scalable i-CBTs should entail transparency about their long-term benefits and drawbacks.

Messenger Use and Video Calls as Correlates of Depressive and Anxiety Symptoms: Results From the Corona Health App Study of German Adults During the COVID-19 Pandemic

BACKGROUND

Specialized studies have shown that smartphone-based social interaction data are predictors of depressive and anxiety symptoms. Moreover, at times during the COVID-19 pandemic, social interaction took place primarily remotely. To appropriately test these objective data for their added value for epidemiological research during the pandemic, it is necessary to include established predictors.

OBJECTIVE

Using a comprehensive model, we investigated the extent to which smartphone-based social interaction data contribute to the prediction of depressive and anxiety symptoms, while also taking into account well-established predictors and relevant pandemic-specific factors.

METHODS

We developed the Corona Health App and obtained participation from 490 Android smartphone users who agreed to allow us to collect smartphone-based social interaction data between July 2020 and February 2021. Using a cross-sectional design, we automatically collected data concerning average app use in terms of the categories video calls and telephony, messenger use, social media use, and SMS text messaging use, as well as pandemic-specific predictors and sociodemographic covariates. We statistically predicted depressive and anxiety symptoms using elastic net regression. To exclude overfitting, we used 10-fold cross-validation.

RESULTS

The amount of variance explained (R2) was 0.61 for the prediction of depressive symptoms and 0.57 for the prediction of anxiety symptoms. Of the smartphone-based social interaction data included, only messenger use proved to be a significant negative predictor of depressive and anxiety symptoms. Video calls were negative predictors only for depressive symptoms, and SMS text messaging use was a negative predictor only for anxiety symptoms.

CONCLUSIONS

The results show the relevance of smartphone-based social interaction data in predicting depressive and anxiety symptoms. However, even taken together in the context of a comprehensive model with well-established predictors, the data only add a small amount of value.

Long-term outcomes at 24- and 36-month follow-up in the intervention arm of the randomized controlled trial of Prompt Mental Health Care

BACKGROUND

Whether long-term symptom improvement is maintained after treatment in services such as the Norwegian Prompt Mental Health Care (PMHC) and the English Improving Access to Psychological Therapies is not yet known. In this prospective study, we investigate whether improvements observed at 6-month follow-up are maintained at 24- and 36-month follow-up among clients who received PMHC.

METHOD

Data from the treatment arm of the randomized controlled trial of PMHC were used (n = 459). The main outcomes were (reliable) recovery rate and symptoms of depression (PHQ-9) and anxiety (GAD-7). Primary outcome data at 24- and 36-months follow-up were available for 47% and 39% of participants, respectively. Secondary outcomes were work participation, functional status, health-related quality of life, and positive mental well-being. Sensitivity analyses with regard to missing data assumptions were conducted for the primary continuous outcomes.

RESULTS

Improvements were maintained at 24- and 36-month follow-up for symptoms of depression and anxiety, (reliable) recovery rate, and health-related quality of life. Small linear improvements since 6-month follow-up were observed for work participation, functional status, and positive mental well-being. Sensitivity analyses did not substantially alter the findings for symptoms of depression and anxiety mentioned above.

CONCLUSIONS

Our findings support the long-term effectiveness of PMHC, but results should be interpreted with caution due to lacking follow-up data at 24- and 36-month in the control group, and substantial attrition.

Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial

BACKGROUND

In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC).

METHODS

Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7).

OUTCOMES

change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation.

RESULTS

Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment.

CONCLUSION

As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.

Social anxiety and agoraphobia symptoms effectively treated by Prompt Mental Health Care versus TAU at 6- and 12-month follow-up: Secondary analysis from a randomized controlled trial

BACKGROUND

Prompt Mental Health Care (PMHC, Norwegian adaption of Improving Access to Psychological Therapies) has shown effects on symptoms of anxiety and depression compared to treatment as usual (TAU). In this secondary analysis, we examine the effectiveness of PMHC among clients presenting with symptoms of social anxiety disorder (SAD) and/or agoraphobia on core symptoms at 6- and 12-month follow-up.

METHODS

Randomized controlled trial in two PMHC sites (70:30 ratio PMHC:TAU). Of participants, 61.3% (n = 472) scored at caseness for SAD and 47.7% (n = 367) for agoraphobia (40% both). Effects on SAD avoidance and physiological discomfort (SPIN-9), SAD cognitions (ATQ-SA), agoraphobic avoidance (MIA-8), and agoraphobic cognitions (ATQ-AP) were examined in piecewise growth models.

RESULTS

The PMHC group showed substantially greater symptom reduction than the TAU group for all outcomes: At 6-month follow-up, the between-group effect sizes were d -0.60 (95% CI: -0.94 to -0.26) for SPIN-9, -0.45 (95% CI: -0.70 to -0.20) for ATQ-SA, -0.50 (95% CI: -0.87 to -0.13) for MIA-8, and -0.61 (95% CI: -0.92 to -0.31) for ATQ-AP. All effects were sustained at similar level at a 12-month follow-up.

CONCLUSION

PMHC effectively alleviated SAD and agoraphobia symptoms, and individuals struggling with such symptoms constituted a large proportion of clients. Although results should be interpreted with caution due to risk of attrition bias, they lend further support for a scale-up of PMHC and similar initiatives. Individuals struggling with SAD and/or agoraphobia stood out as relatively high burdened, whereas only one of five had sought help the last 12 months, underscoring the need for the PMHC service.

Process evaluation of Prompt Mental Health Care (PMHC): the Norwegian version of Improving Access to Psychological Therapies

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.

Prompt Mental Health Care (PMHC): work participation and functional status at 12 months post-treatment

BACKGROUND

Anxiety and depression are associated with substantial functional impairment. Prompt Mental Health Care (PMHC), the Norwegian adaptation of IAPT is currently piloted across Norway, as a means to improve access to evidence-based care for adults with anxiety disorders (including subthreshold cases) and minor to moderate depression. The aims of the current paper were to examine the change in work status and functional status from pre- to post-treatment and 12 months post-treatment among clients at the first 12 PMHC pilot sites, and whether degree of change differed across sociodemographic characteristics.

METHODS

A prospective cohort design was used, including working age clients receiving treatment between October 2014 and December 2016 (n = 1446, participation rate = 61%). Work status and functional status were self-reported, the latter by the Work and Social Adjustment Scale (WSAS). Changes in work status and WSAS score were examined through multilevel models based on maximum likelihood estimation. Likelihood ratio tests were performed to determine whether the interaction between time and the respective background variables were statistically significant.

RESULTS

A substantial increase in regular work participation was observed from pre- to post-treatment, which further had increased at 12 months post-treatment. The increase was driven by a corresponding reduction in proportion of clients working and receiving benefits (OR 0.38 [0.29-0.50] baseline to final treatment, OR = 0.19 [0.12-0.32] final treatment to 12-months post-treatment), while no statistically significant change was observed in proportion out of work. Large improvement (ES = - 0.89) in WSAS score was observed from pre- to post treatment. WSAS score at 12 months post-treatment remained at the post-treatment level.

CONCLUSIONS

Previous research has shown substantial symptom improvement among clients receiving treatment in PMHC. The current findings indicate that PMHC might also be able to aid adults struggling with mild to moderate anxiety and depression in returning to usual level of functioning. The degree to which the observed improvements are attributable to the treatment need nonetheless to be confirmed in a trial including a control group and with more complete follow-up data from registries.