Baseline Severity as a Moderator of the Waiting List-Controlled Association of Cognitive Behavioral Therapy With Symptom Change in Social Anxiety Disorder: A Systematic Review and Individual Patient Data Meta-analysis

Importance

Social anxiety disorder (SAD) can be adequately treated with cognitive behavioral therapy (CBT). However, there is a large gap in knowledge on factors associated with prognosis, and it is unclear whether symptom severity predicts response to CBT for SAD.

Objective

To examine baseline SAD symptom severity as a moderator of the association between CBT and symptom change in patients with SAD.

Data Sources

For this systematic review and individual patient data meta-analysis (IPDMA), PubMed, PsycInfo, Embase, and the Cochrane Library were searched from January 1, 1990, to January 13, 2023. Primary search topics were social anxiety disorder, cognitive behavior therapy, and randomized controlled trial.

Study Selection

Inclusion criteria were randomized clinical trials comparing CBT with being on a waiting list and using the Liebowitz Social Anxiety Scale (LSAS) in adults with a primary clinical diagnosis of SAD.

Data Extraction and Synthesis

Authors of included studies were approached to provide individual-level data. Data were extracted by pairs of authors following the Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline, and risk of bias was assessed using the Cochrane tool. An IPDMA was conducted using a 2-stage approach for the association of CBT with change in LSAS scores from baseline to posttreatment and for the interaction effect of baseline LSAS score by condition using random-effects models.

Main Outcomes and Measures

The main outcome was the baseline to posttreatment change in symptom severity measured by the LSAS.

Results

A total of 12 studies including 1246 patients with SAD (mean [SD] age, 35.3 [10.9] years; 738 [59.2%] female) were included in the meta-analysis. A waiting list-controlled association between CBT and pretreatment to posttreatment LSAS change was found (b = -20.3; 95% CI, -24.9 to -15.6; P < .001; Cohen d = -0.95; 95% CI, -1.16 to -0.73). Baseline LSAS scores moderated the differences between CBT and waiting list with respect to pretreatment to posttreatment symptom reductions (b = -0.22; 95% CI, -0.39 to -0.06; P = .009), indicating that individuals with severe symptoms had larger waiting list-controlled symptom reductions after CBT (Cohen d = -1.13 [95% CI, -1.39 to -0.88] for patients with very severe SAD; Cohen d = -0.54 [95% CI, -0.80 to -0.29] for patients with mild SAD).

Conclusions and Relevance

In this systematic review and IPDMA, higher baseline SAD symptom severity was associated with greater (absolute but not relative) symptom reductions after CBT in patients with SAD. The findings contribute to personalized care by suggesting that clinicians can confidently offer CBT to individuals with severe SAD symptoms.

Recurrence of anxiety disorders and its predictors in the general population

BACKGROUND

Anxiety disorders frequently recur in clinical populations, but the risk of recurrence of anxiety disorders is largely unknown in the general population. In this study, recurrence of anxiety and its predictors were studied in a large cohort of the adult general population.

METHODS

Baseline, 3-year and 6-year follow-up data were derived from the Netherlands Mental Health Survey and Incidence Study-2 (NEMESIS-2). Respondents (N = 468) who had been in remission for at least a year prior to baseline were included. Recurrence was assessed at 3 and 6 years after baseline, using the Composite International Diagnostic Interview version 3.0. Cumulative recurrence rates were estimated using the number of years since remission of the last anxiety disorder. Furthermore, Cox regression analyses were conducted to investigate predictors of recurrence, using a broad range of putative predictors.

RESULTS

The estimated cumulative recurrence rate was 2.1% at 1 year, 6.6% at 5 years, 10.6% at 10 years, and 16.2% at 20 years. Univariate regression analyses predicted a shorter time to recurrence for several variables, of which younger age at interview, parental psychopathology, neuroticism and a current depressive disorder remained significant in the, age and gender-adjusted, multivariable regression analysis.

CONCLUSIONS

Recurrence of anxiety disorders in the general population is common and the risk of recurrence extends over a lengthy period of time. In clinical practice, alertness to recurrence, monitoring of symptoms, and quick access to health care in case of recurrence are needed.

Acceptability, effectiveness and cost-effectiveness of blended cognitive-behavioural therapy (bCBT) versus face-to-face CBT (ftfCBT) for anxiety disorders in specialised mental health care: A 15-week randomised controlled trial with 1-year follow-up

BACKGROUND

Anxiety disorders are highly prevalent and cause substantial economic burden. Blended cognitive-behavioural therapy (bCBT), which integrates Internet-based CBT and face-to-face CBT (ftfCBT), is an attractive and potentially cost-saving treatment alternative to conventional CBT for patients with anxiety disorders in specialised mental health care. However, little is known about the effectiveness of bCBT in routine care. We examined the acceptability, effectiveness and cost-effectiveness of bCBT versus ftfCBT in outpatient specialised care to patients with panic disorder, social anxiety disorder and generalised anxiety disorder.

METHODS AND FINDINGS

Patients with anxiety disorders were randomised to bCBT (n = 52) or ftfCBT (n = 62). Acceptability of bCBT and ftfCBT were evaluated by assessing treatment preference, adherence, satisfaction and therapeutic alliance. Costs and effects were assessed at post-treatment and one-year follow-up. Primary outcome measure was the Beck Anxiety Inventory (BAI). Secondary outcomes were depressive symptoms, general psychopathology, work and social adjustment, quality of life and mastery. Incremental cost-effectiveness ratios (ICERs) were computed from societal and healthcare perspectives by calculating the incremental costs per incremental quality-adjusted life year (QALY). No significant differences between bCBT and ftfCBT were found on acceptability or effectiveness measures at post-treatment (Cohen's d between-group effect size on BAI = 0.15, 95% CI -0.30 to 0.60) or at one-year follow-up (d = -0.38, 95% CI -0.84 to 0.09). The modelled point estimates of societal costs (bCBT €10945, ftfCBT €10937) were higher and modelled point estimates of direct medical costs (bCBT €3748, ftfCBT €3841) were lower in bCBT. The acceptability curves showed that bCBT was expected to be a cost-effective intervention. Results should be carefully interpreted due to the small sample size.

CONCLUSIONS

bCBT appears an acceptable, clinically effective and potentially cost-saving alternative option for treating patients with anxiety disorders. Trials with larger samples are needed to further investigate cost-effectiveness.

TRIAL REGISTRATION

Netherlands Trial Register: NTR4912.

Does it blend? Exploring therapist fidelity in blended CBT for anxiety disorders

Blended cognitive-behavioural therapy (bCBT) combines face-to-face CBT (FtFCBT) and Internet-based CBT (iCBT) into one integrated treatment protocol, opening up new ways to deliver therapy, increase cost-effectiveness and resolve scarcity of therapist availability. When traditional therapy is transformed into a new format, there is a need to evaluate whether principles of the new protocol are consistently applied. This study aimed to explore therapist fidelity to bCBT protocols for anxiety disorders in specialised mental health care and to assess whether fidelity is related to patient characteristics. Adult patients (N = 44) received bCBT within a randomised controlled trial. Ratio of FtF to online sessions, session frequency and therapist adherence to instructions were assessed. Overall therapist fidelity with regard to ratio of blending, session frequency and instructions was high. Correlations were found between patients' share of online sessions and both session frequency (r = 0.373, p = .013), as well as patient computer experience (r = 0.314, p = .038). Adherence to instructions in FtF sessions was based on a subset of patients (n = 23) and should therefore be interpreted with caution. The blended approach was generally delivered as intended, indicating that the format is feasible in specialised mental health.

Comprehensive database and individual patient data meta-analysis of randomised controlled trials on psychotherapies reducing suicidal thoughts and behaviour: study protocol

INTRODUCTION

Psychotherapy may reduce suicidal thoughts and behaviour, but its effectiveness is not well examined. Furthermore, conventional meta-analyses are unable to test possible effects of moderators affecting this relationship. This protocol outlines the building of a comprehensive database of the literature in this research field. In addition, we will conduct an individual patient data meta-analysis (IPD-MA) to establish the effectiveness of psychotherapy in reducing suicidality, and to examine which factors moderate the efficacy of these interventions.

METHODS AND ANALYSIS

To build a comprehensive database, randomised controlled trials examining the effect of any psychotherapy targeting any psychiatric disorder on suicidal thoughts or behaviour will be identified by running a systematic search in PubMed, Embase, PsycINFO, Web of Science, Scopus and The Cochrane Central Register of Controlled Trials from data inception to 12 August 2019. For the IPD-MA, we will focus on adult outpatients with suicidal ideation or behaviour. In addition, as a comparison group we will focus on a control group (waiting-list, care as usual or placebo). A 1-stage IPD-MA will be used to determine the effectiveness of psychotherapy on suicidal ideation, suicide attempts and/or suicide deaths, and to investigate potential patient-related and intervention-related moderators. Subgroup and sensitivity analyses will be conducted to test the robustness of the findings. Additionally, a conventional MA will be conducted to determine the differences between studies that provided IPD and those that did not. IPD-MA may determine the effectiveness of psychotherapy in reducing suicidality and provide insights into the moderating factors influencing the efficacy of psychotherapy. Answering these questions will inform mental healthcare practitioners about optimal treatments for different groups of individuals with suicidal ideation and/or behaviour and consequently help to reduce suicide risk.

ETHICS AND DISSEMINATION

An ethical approval is not required for this study. The results will be published in a peer-review journal.

PROSPERO REGISTRATION NUMBER

CRD42020140573.

Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

Background

Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.

Objective

This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.

Methods

We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.

Results

We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.

Conclusions

iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients’ greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

A discrete-choice experiment to assess treatment modality preferences of patients with anxiety disorder

AIMS

The aim of this study was to elicit the preference of patients with an anxiety disorder regarding treatment modalities. Understanding patients' preferences could help optimize treatment uptake and adherence to therapeutic interventions.

MATERIALS AND METHODS

A discrete-choice experiment was used to elicit patients' preferences with regard to four treatment characteristics: waiting time until first treatment, intensity of treatment, face-to-face vs digital treatment, and group size. In 12 choice sets, participants were asked to choose between two treatment alternatives. A random parameters logit model was used to analyse the data.

RESULTS

A total of 126 participants, aged 18 years and older, currently or in the previous year in treatment for an anxiety disorder, completed the survey. Respondents preferred short (over long) waiting times, face-to-face (over digital) treatment, individual (over group) treatment and a treatment intensity of one session per week rather than two sessions per week or one session every two weeks. Waiting time and treatment intensity were substantially less important to patients than level of digitalization and group size. Heterogeneity in preference was significant for each attribute, and sub-group analyses revealed this was partly related to education level and age.

LIMITATIONS

The convenience sample over-represented the female and younger population, limiting generalizability. Limited information on background characteristics limited the possibilities to explore preference heterogeneity.

CONCLUSIONS

This study demonstrated how different treatment components for anxiety disorders affect patients' preferences for those treatments. There is significant variation in treatment preferences, even after accounting for age and education. Incorporating patients' preferences into treatment decisions could potentially lead to improved adherence of treatments for anxiety disorders.

Prediction of 6-yr symptom course trajectories of anxiety disorders by diagnostic, clinical and psychological variables

This study aimed to identify course trajectories of anxiety disorder using a data-driven method and to determine the incremental predictive value of clinical and psychological variables over and above diagnostic categories. 703 patients with DSM-IV panic disorder with or without agoraphobia, agoraphobia, social phobia, or generalized anxiety disorder were selected from a prospective cohort study. Latent Growth Mixture Modeling was conducted, based on symptoms of anxiety and avoidance as assessed with the Life Chart Interview covering a 6-year time period. In 44% of the participants symptoms of anxiety and avoidance improved, in 24% remained stable, in 25% slightly increased, and in 7% severely increased. Identified course trajectories were predicted by baseline DSM-IV anxiety categories, clinical variables (i.e., severity and duration and level of disability) and psychological predictors (i.e., neuroticism, extraversion, anxiety sensitivity, worry, and rumination). Clinical variables better predicted unfavorable course trajectories than psychological predictors, over and above diagnostic categories.

Cost-effectiveness of blended vs. face-to-face cognitive behavioural therapy for severe anxiety disorders: study protocol of a randomized controlled trial

BACKGROUND

Anxiety disorders are among the most prevalent psychiatric conditions, and are associated with poor quality of life and substantial economic burden. Cognitive behavioural therapy is an effective treatment to reduce anxiety symptoms, but is also costly and labour intensive. Cost-effectiveness could possibly be improved by delivering cognitive behavioural therapy in a blended format, where face-to-face sessions are partially replaced by online sessions. The aim of this trial is to determine the cost-effectiveness of blended cognitive behavioural therapy for adults with anxiety disorders, i.e. panic disorder, social phobia or generalized anxiety disorder, in specialized mental health care settings compared to face-to-face cognitive behavioural therapy. In this paper, we present the study protocol. It is hypothesized that blended cognitive behavioural therapy for anxiety disorders is clinically as effective as face-to-face cognitive behavioural therapy, but that intervention costs may be reduced. We thus hypothesize that blended cognitive behavioural therapy is more cost-effective than face-to-face cognitive behavioural therapy.

METHODS/DESIGN

In a randomised controlled equivalence trial 156 patients will be included (n = 78 in blended cognitive behavioural therapy, n = 78 in face-to-face cognitive behavioural therapy) based on a power of 0.80, calculated by using a formula to estimate the power of a cost-effectiveness analysis: [Formula: see text]. Measurements will take place at baseline, midway treatment (7 weeks), immediately after treatment (15 weeks) and 12-month follow-up. At baseline a diagnostic interview will be administered. Primary clinical outcomes are changes in anxiety symptom severity as measured with the Beck Anxiety Inventory. An incremental cost-effectiveness ratio will be calculated to obtain the costs per quality-adjusted life years (QALYs) measured by the EQ-5D (5-level version). Health-economic outcomes will be explored from a societal and health care perspective.

DISCUSSION

This trial will be one of the first to provide information on the cost-effectiveness of blended cognitive behavioural therapy for anxiety disorders in routine specialized mental health care settings, both from a societal and a health care perspective.

TRIAL REGISTRATION

Netherlands Trial Register NTR4912. Registered 13 November 2014.

Effectiveness of a tailored implementation programme to improve recognition, diagnosis and treatment of anxiety and depression in general practice: a cluster randomised controlled trial

BACKGROUND

Anxiety and depression are not always diagnosed and treated in primary care as has been recommended. A tailored implementation programme, which addresses key barriers for change by targeted interventions, may help to remedy this.

METHODS

The effectiveness of an individually tailored implementation programme, additional to standardised training and feedback on the recognition and treatment of patients with anxiety or depression in general practice, was examined in a cluster randomised controlled trial. Participants were 46 general practitioners (GPs) from 23 general practices (12 intervention, 11 control) and 444 patients aged 18 years or older (198 intervention, 246 control) who screened positive on the extended Kessler 10. In the control group, GPs received a 1-day training in guidelines for recognition and stepped treatment for anxiety and depression. Ten months after the training session, GPs received feedback on their performance over the preceding 6 months. In the intervention group, GPs received the same training and feedback as those in the control condition; in addition, they were offered support, tailored to perceived local barriers to change. The support was delivered in the format of peer group supervisions and personalised telephone consultations. Data were based on an audit of patient records and patient surveys at baseline and after 3 and 6 months.

RESULTS

The tailored implementation programme led to recognition of a higher proportion of patients presenting with anxiety and depression (42% versus 31%; odds ratio (OR) = 1.60; 95% CI: 1.01-2.53), more consultations after recognition (IRR = 1.78; 95% CI: 1.14-2.78) and did not lead to more prescription of antidepressants (OR = 1.07; 95% CI: 0.52-2.19) or referral to specialist mental health services (OR = 1.62; 95% CI: 0.72-3.64). Patients in the intervention group reported better accessibility of care (effect size (ES) = 0.4; p < 0.05) and provision of information and advice (ES = 0.5; p < 0.05).

CONCLUSIONS

A tailored implementation programme may enhance the recognition and treatment of patients with anxiety or depression. Further development and evaluation of the programme is warranted to determine its cost-effectiveness.

TRAIL REGISTRATION

Dutch Trial Register identifier NTR1912 .

Effectiveness of collaborative stepped care for anxiety disorders in primary care: a pragmatic cluster randomised controlled trial

BACKGROUND

Collaborative stepped care (CSC) may be an appropriate model to provide evidence-based treatment for anxiety disorders in primary care.

METHODS

In a cluster randomised controlled trial, the effectiveness of CSC compared to care as usual (CAU) for adults with panic disorder (PD) or generalised anxiety disorder (GAD) in primary care was evaluated. Thirty-one psychiatric nurses who provided their services to 43 primary care practices in the Netherlands were randomised to deliver CSC (16 psychiatric nurses, 23 practices) or CAU (15 psychiatric nurses, 20 practices). CSC was provided by the psychiatric nurses (care managers) in collaboration with the general practitioner and a consultant psychiatrist. The intervention consisted of 3 steps, namely guided self-help, cognitive behavioural therapy and antidepressants. Anxiety symptoms were measured with the Beck Anxiety Inventory (BAI) at baseline and after 3, 6, 9 and 12 months.

RESULTS

We recruited 180 patients with a DSM-IV diagnosis of PD or GAD, of whom 114 received CSC and 66 received usual primary care. On the BAI, CSC was superior to CAU [difference in gain scores from baseline to 3 months: -5.11, 95% confidence interval (CI) -8.28 to -1.94; 6 months: -4.65, 95% CI -7.93 to -1.38; 9 months: -5.67, 95% CI -8.97 to -2.36; 12 months: -6.84, 95% CI -10.13 to -3.55].

CONCLUSIONS

CSC, with guided self-help as a first step, was more effective than CAU for primary care patients with PD or GAD.

Cost utility analysis of a collaborative stepped care intervention for panic and generalized anxiety disorders in primary care

OBJECTIVE

Generalized anxiety and panic disorders are a burden on the society because they are costly and have a significant adverse effect on quality of life. The aim of this study was to evaluate the cost-utility of a collaborative stepped care intervention for panic disorder and generalized anxiety disorder in primary care compared to care as usual from a societal perspective.

METHODS

The design of the study was a two armed cluster randomized controlled trial. In total 43 primary care practices in the Netherlands participated in the study. Eventually, 180 patients were included (114 collaborative stepped care, 66 care as usual). Baseline measures and follow-up measures (3, 6, 9 and 12 months) were assessed using questionnaires. We applied the TiC-P, the SF-HQL and the EQ-5D respectively measuring health care utilization, production losses and health related quality of life.

RESULTS

The average annual direct medical costs in the collaborative stepped care group were 1854 Euro (95% C.I., 1726 to 1986) compared to €1503 (95% C.I., 1374 to 1664) in the care as usual group. The average quality of life years (QALYs) gained was 0.05 higher in the collaborative stepped care group, leading to an incremental cost effectiveness ratio (ICER) of 6965 Euro per QALY. Inclusion of the productivity costs, consequently reflecting the full societal costs, decreased the ratio even more.

CONCLUSION

The study showed that collaborative stepped care was a cost effective intervention for panic disorder and generalized anxiety disorder and was even dominant when a societal perspective was taken.

TRIAL REGISTRATION

trialregister.nl, Netherlands Trial Register NTR107.

Treatment inadequacy in primary and specialized care patients with depressive and/or anxiety disorders

All guidelines on major depressive disorder (MDD) and anxiety disorders recommend pharmacotherapy and/or psychological treatment for moderate to severe disease. The aim of this cross-sectional study was to investigate treatment inadequacy, both pharmacological and psychological, in a large naturalistic cohort of subjects with MDD and anxiety disorders from the Netherlands Study of Depression and Anxiety. All subjects with a current 6-month diagnosis were included (n=1662). Demographic data, clinical features and actual medication use were assessed in face-to-face interviews. In moderate to severe MDD, 43% of the subjects were not treated sufficiently with antidepressants or psychological treatment. In primary health care patients, this undertreatment was 70%. In moderate to severe anxiety disorders, 44% of the subjects were not treated sufficiently with antidepressants, benzodiazepines or psychological treatment. Among antidepressant users with moderate to severe MDD, 21% of the pharmacotherapy was inadequate with respect to drug choice, dose and every day use. Undertreatment and pharmacotherapeutic inadequacy are common in moderate to severe MDD and anxiety disorders. Both are more pronounced in primary care than in specialized care. This may be partly due to differences in disease recognition and help seeking behaviour.

Dopaminergic activity in Tourette syndrome and obsessive-compulsive disorder

Tourette syndrome (TS) and obsessive-compulsive disorder (OCD) both are neuropsychiatric disorders associated with abnormalities in dopamine neurotransmission. Aims of this study were to quantify striatal D2/3 receptor availability in TS and OCD, and to examine dopamine release and symptom severity changes in both disorders following amphetamine challenge. Changes in [(11)C]raclopride binding potential (BP(ND)) were assessed using positron emission tomography before and after administration of d-amphetamine (0.3 mg kg(-1)) in 12 TS patients without comorbid OCD, 12 OCD patients without comorbid tics, and 12 healthy controls. Main outcome measures were baseline striatal D2/3 receptor BP(ND) and change in BP(ND) following amphetamine as a measure of dopamine release. Voxel-based analysis revealed significantly decreased baseline [(11)C]raclopride BP(ND) in bilateral putamen of both patient groups vs. healthy controls, differences being more pronounced in the TS than in the OCD group. Changes in BP(ND) following amphetamine were not significantly different between groups. Following amphetamine administration, tic severity increased in the TS group, which correlated with BP(ND) changes in right ventral striatum. Symptom severity in the OCD group did not change significantly following amphetamine challenge and was not associated with changes in BP(ND). This study provides evidence for decreased striatal D2/3 receptor availability in TS and OCD, presumably reflecting higher endogenous dopamine levels in both disorders. In addition, it provides the first direct evidence that ventral striatal dopamine release is related to the pathophysiology of tics.

Systematic tailoring for the implementation of guideline recommendations for anxiety and depressive disorders in general practice: perceived usefulness of tailored interventions

BACKGROUND

The uptake of guideline recommendations in general practice can potentially be improved by designing implementation interventions that are tailored to prospectively identify barriers. However, there is insufficient evidence regarding the most effective and efficient approaches to tailoring. Our study provides an insight into the usefulness of tailored interventions to prospectively identified barriers affecting the uptake of guideline recommendations for anxiety and depressive disorders experienced by general practitioners (GPs) in their local context.

METHODS

A qualitative study was conducted, in which 23 GPs gave informed consent and 14 finally participated. To explore the barriers affecting the uptake of guideline recommendations, a face-to-face interview was conducted with each GP to generate a personalised list. In response to this list, interventions were tailored to remove the barriers experienced by the GPs. To examine the perceived usefulness of the tailored interventions, telephone interviews were conducted after one year and coded through thematic coding. The analysis was descriptive in nature.

RESULTS

The most frequently perceived barriers were: a lack of knowledge and skills, no agreement on guideline recommendations, negative outcome expectancy, low self-efficacy, no consensus with patients, and a lack of information about treatments provided by mental health professionals, together with waiting lists. The tailored interventions 'peer group supervision' and 'individualised telephone consultations' were perceived as useful by most GPs. Besides the tailored interventions, a perceived benefit of using a self-rating scale, measuring depressive and anxiety symptoms, and the idea of delivering better patient care, were supportive in the uptake of guideline recommendations.

CONCLUSIONS

Our findings suggest that tailoring interventions to prospectively identified barriers, affecting the uptake of guideline recommendations for anxiety and depressive disorders, as perceived by GPs, may enhance the implementation of these guideline recommendations.

A validation study of the Four-Dimensional Symptom Questionnaire (4DSQ) in insurance medicine

OBJECTIVE

This study aimed to evaluate the criterion validity and the diagnostic accuracy of the Four-Dimensional Symptom Questionnaire (4DSQ) regarding the identification of depressive and anxiety disorders in an insurance medicine setting.

PARTICIPANTS

Our sample consisted of 230 individuals who applied for a work disability benefit due to mental health problems.

METHODS

Depressive and anxiety disorders were assessed using the 4DSQ and the Composite International Diagnostic Interview (CIDI). Internal consistency was determined by calculating Cronbach's alpha values. Criterion validity was evaluated by regression techniques. A Receiver Operating Characteristic (ROC) analysis was performed to evaluate diagnostic accuracy.

RESULTS

Of the 230 participants 109 (47.4%) had a current DSM-IV depressive disorder and 146 (63.5%) an anxiety disorder. The 4DSQ scales showed an excellent internal consistency. The depression scale of the 4DSQ had specific sensitivity for major depressive disorder. The anxiety scale was also sensitive for the anxiety disorders. The area under the ROC curve (AUC) indicated good diagnostic accuracy of the 4DSQ for assessing depressive and/or anxiety disorders: AUC-value 0.81 for both depression and anxiety.

CONCLUSIONS

Although the 4DSQ shows good criterion validity and diagnostic accuracy with respect to depressive and anxiety disorders in applicants for a work disability benefit due to mental health problems, the feasibility of the 4DSQ as a screening measure for depressive and anxiety disorders is limited due to the high prevalence of depressive and anxiety disorders.

Late-life anxiety disorders: a review

Anxiety disorders are a major clinical problem in late life; estimated prevalence rates vary from 6% to 10%, and the disease impact is considerable and equal to that of depression. However, anxiety disorders often remain undetected and untreated in older adults. This discrepancy may be accounted for by a combination of patient variables (eg, a lack of help-seeking behavior and long duration of illness) and variables related to current clinical practice (eg, a lack of knowledge regarding late-life anxiety and ageism). Because anxiety disorders usually have an age at onset earlier in life, patients and mental health professionals may be inclined to attribute the anxiety and avoidance symptoms to personality factors instead of a treatable syndrome. Comorbidity with other psychiatric disorders, such as depressive disorder, may complicate the appropriate diagnosis. Identification may be further obscured because the phenomenology of anxiety disorders in older adults tends to differ from the phenomenology in younger adults. Randomized controlled trials have yielded support for the effectiveness of cognitive-behavioral therapy and serotonergic antidepressants. However, both treatments seem hampered by relatively high dropout rates, and the available data are based primarily on a relatively healthy, well-educated, and "young" older population. The dissemination of knowledge regarding late-life anxiety disorders is vital, as evidence-based treatments are available but are still rarely implemented.

Randomised controlled trial of tailored interventions to improve the management of anxiety and depressive disorders in primary care

BACKGROUND

Anxiety and depressive disorders are highly prevalent disorders and are mostly treated in primary care. The management of these disorders by general practitioners is not always consistent with prevailing guidelines because of a variety of factors. Designing implementation strategies tailored to prospectively identified barriers could lead to more guideline-recommended care. Although tailoring of implementation strategies is promoted in practice, little is known about the effect on improving the quality of care for the early recognition, diagnosis, and stepped care treatment allocation in patients with anxiety or depressive disorders in general practice. This study examines whether the tailored strategy supplemented with training and feedback is more effective than providing training and feedback alone.

METHODS

In this cluster randomised controlled trial, a total of 22 general practices will be assigned to one of two conditions: (1) training, feedback, and tailored interventions and (2) training and feedback. The primary outcome measure is the proportion of patients who have been recognised to have anxiety and/or depressive disorder. The secondary outcome measures in patients are severity of anxiety and depressive symptoms, level of functioning, expectation towards and experience with care, quality of life, and economic costs. Measures are taken after the start of the intervention at baseline and at three- and six-month follow-ups. Secondary outcome measures in general practitioners are adherence to guideline-recommended care in care that has been delivered, the proportion of antidepressant prescriptions, and number of referrals to specialised mental healthcare facilities. Data will be gathered from the electronic medical patient records from the patients included in the study. In a process evaluation, the identification of barriers to change and the relations between prospectively identified barriers and improvement interventions selected for use will be described, as well as the factors that influence the provision of guideline-recommended care.

DISCUSSION

It is hypothesised that the adherence to guideline recommendations will be improved by designing implementation interventions that are tailored to prospectively identified barriers in the local context of general practitioners. Currently, there is insufficient evidence on the most effective and efficient approaches to tailoring, including how barriers should be identified and how interventions should be selected to address the barriers.

TRIAL REGISTRATION

NTR1912.

Early intervention in panic: pragmatic randomised controlled trial

BACKGROUND

Many people suffer from subthreshold and mild panic disorder and are at risk of developing more severe panic disorder.

AIMS

This study (trial registration: ISRCTN33407455) was conducted to evaluate the effectiveness of an early group intervention based on cognitive-behavioural principles to reduce panic disorder symptomatology.

METHOD

Participants with subthreshold or mild panic disorder were recruited from the general population and randomised to the intervention (n = 109) or a waiting-list control group (n = 108). The course was offered by 17 community mental health centres.

RESULTS

In the early intervention group, 43/109 (39%) participants presented with a clinically significant change on the Panic Disorder Severity Scale-Self Report (PDSS-SR) v. 17/108 (16%) in the control group (odds ratio (OR) for favourable treatment response 3.49, 95% CI 1.77-6.88, P = 0.001). The course also had a positive effect on DSM-IV panic disorder status (OR = 1.96, 95% CI=1.05-3.66, P = 0.037). The PDSS-SR symptom reduction was also substantial (between-group standardised mean difference of 0.68). The effects were maintained at 6-month follow-up.

CONCLUSIONS

People presenting with subthreshold and mild panic disorder benefit from this brief intervention.

Preventing panic disorder: cost-effectiveness analysis alongside a pragmatic randomised trial

BACKGROUND

Panic disorder affects many people, is associated with a formidable disease burden, and imposes costs on society. The annual influx of new cases of panic disorder is substantial. From the public health perspective it may therefore be a sound policy to reduce the influx of new cases, to maintain the quality of life in many people, and to avoid the economic costs associated with the full-blown disorder. For this purpose, prevention is needed. Here we present the first economic evaluation of such an intervention.

METHODS

Randomised trial of 117 people with panic disorder symptoms not meeting the diagnostic criteria of DSM-IV panic disorder. The interventions were time-limited cognitive-behavioural therapy v care-as-usual. The central clinical endpoint was DSM-IV panic disorder-free survival over 3 months. Costs were calculated from the societal perspective. Using the bootstrap method, incremental cost-effectiveness ratios were obtained, placed in 95% confidence intervals, projected on the cost-effectiveness plane, and presented as acceptability curves.

RESULTS

The median incremental cost-effectiveness ratio is euro6,198 (95% CI 2,435 - 60,731) per PD-free survival gained, which has a likelihood of 75.2% of being more acceptable from a cost-effectiveness point of view than care-as-usual when a willingness-to-pay ceiling is assumed of euro10,000 per PD-free survival. The most significant cost driver was therapists' time. A sensitivity analysis indicated that cost-effectiveness improves when the number of therapist hours is reduced.

CONCLUSION

This is the first economic evaluation alongside a prevention trial in panic disorder. The small sample (n = 117) and the short time horizon of 3 months preclude firm conclusions, but our findings suggest that the intervention may be acceptable from a cost-effectiveness point of view, especially when therapist involvement can be kept minimal. Nevertheless, our results must await replication in a larger trial with longer follow-up times before we can confidently recommend implementation of the intervention on a broad scale. In the light of our findings and given the burden of panic disorder, such a new trial is well worth the effort.

Effects and feasibility of a preventive intervention in sub-threshold and mild panic disorder: Results of a pilot study

Background

Panic disorder (PD) is a serious DSM-IV axis I disorder affecting up to 3% of the adult population each year. It is associated with a large burden of disease and extensive economic costs. This study aims to examine the effects and feasibility of the 'Don't Panic' course, a preventive cognitive behavioural intervention in sub-threshold and mild PD. It also compares the effectiveness of two modifications of the course (8 vs. 12 sessions).

Methods

The method used was a quasi-experimental two-group pre-post design with a baseline measurement (T0) and two follow-up measurements. Follow-ups were at the end of the intervention (T1) and six months later (T2). Primary outcome measure was the Panic Disorder Severity Scale-Self Report. A total of 114 participants suffering from panic attacks (mean age 42 years; 78% female) entered the study.

Results

The course participants showed a significant effect on the outcome measures at follow-up. Large effect sizes were found on panic symptoms, on symptoms of agoraphobia and on mental health-related quality of life at T1 and T2. Overall, the course leaders and the participants evaluated the course positively. There were no significant differences in outcome measures between the short and the long version of the course.

Conclusion

The study suggests that people with sub-threshold PD and mild PD could benefit from this preventive intervention and that the intervention might be feasible. Furthermore, the short version could be as effective as the long version.

Early intervention in panic: randomized controlled trial and cost-effectiveness analysis

Background

Panic disorder (PD) is a common, severe and persistent mental disorder, associated with a high degree of distress and occupational and social disability. A substantial proportion of the population experiences subthreshold and mild PD and is at risk of developing a chronic PD. A promising intervention, aimed at preventing panic disorder onset and reducing panic symptoms, is the 'Don't Panic' course. It consists of eight sessions of two hours each. The purpose of this study is to evaluate the effectiveness of this early intervention – based on cognitive behavioural principles – on the reduction of panic disorder symptomatology. We predict that the experimental condition show superior clinical and economic outcomes relative to a waitlisted control group.

Methods/design

A pragmatic, pre-post, two-group, multi-site, randomized controlled trial of the intervention will be conducted with a naturalistic follow-up at six months in the intervention group. The participants are recruited from the general population and are randomized to the intervention or a waitlist control group. The intervention is offered by community mental health centres. Included are people over 18 years of age with subthreshold or mild panic disorder, defined as having symptoms of PD falling below the cut-off of 13 on the Panic Disorder Severity Scale-Self Report (PDSS-SR). Primary outcomes are panic disorder and panic symptoms. Secondary outcomes are symptoms of agoraphobia, anxiety, cognitive aspects of panic disorder, depressive symptoms, mastery, health-related quality of life, and cost-effectiveness. We will examine the following variables as potential mediators: cognitive aspects of panic disorder, symptoms of agoraphobia, anxiety and mastery. Potential moderating variables are: socio-demographic characteristics, panic disorder, agoraphobia, treatment credibility and mastery.

Discussion

This study was designed to evaluate the (cost) effectiveness of an early intervention based on cognitive behavioural principles. The strong external validity is one of the strengths of the study design.

Trial registration

Current Controlled Trials ISRCTN33407455.

Knowledge transfer and improvement of primary and ambulatory care for patients with anxiety

OBJECTIVE

To summarize current evidence on the effectiveness of different knowledge transfer and change interventions for improving primary and ambulatory anxiety care to provide guidance to professionals and policy-makers in mental health care.

METHOD

We searched electronic medical and psychological databases, conducted correspondence with authors, and checked reference lists. Studies examining the effectiveness of knowledge transfer and interventions targeted at improvement of the recognition or management of anxiety in primary and ambulatory health care settings were included. Methodological details and outcomes were independently extracted and checked by 2 reviewers. Where appropriate, data concerning the impact of interventions on symptoms of anxiety were pooled using metaanalytical procedures.

RESULTS

We identified 24 studies that met our inclusion criteria. Seven professional-directed interventions and 17 organizational interventions (including patient-oriented interventions) were identified. The methodological quality of studies was variable. Professional-directed interventions only impact the process and outcome of care when embedded in some sort of organizational intervention. Metaanalysis (n = 8 studies) showed no effect of diverse organizational interventions on patients' anxiety symptoms (effect size, -0.08; 95% confidence interval, -0.31 to 0.15; P = 0.50). Collaborative care interventions proved to be the most effective organizational intervention strategies. Six studies reported economic results: 4 studies showed that intervention had a high probability of being cost-effective.

CONCLUSIONS

Collaborative care seems to be very promising for improving primary and ambulatory care for anxiety. At the level of management and policy, the results of this review mandate the need to offer fair and reasonable reimbursement for collaborative care programs.

Economic costs of full-blown and subthreshold panic disorder

BACKGROUND

Data on the societal costs of mental disorders are necessary to inform health policies.

METHODS

This study assessed the costs of panic disorder and subthreshold panic disorder, compared these with costs of other mental disorders, and assessed the effects of (psychiatric and somatic) comorbidity and agoraphobia on the costs of panic. Using a large, population-based study in The Netherlands (n=5504), both medical and production costs were estimated from a societal perspective within a one-year timeframe.

RESULTS

Annual per capita costs of panic disorder were 10,269 euros, while subthreshold panic disorder generated 6384 euros. These costs were higher than those of the other mental disorders studied. About one quarter of the costs could be attributed to comorbidity. Agoraphobia was associated with higher costs.

LIMITATIONS

Methodological choices influence cost estimates. In the present study most of these will result in conservative cost estimates.

CONCLUSIONS

Panic thus causes substantial societal costs. Given the availability of effective treatment, treatment may not only benefit individual patients, but also have economic returns for society.

Predictors of relapse after discontinuation of long-term benzodiazepine use by minimal intervention: a 2-year follow-up study

BACKGROUND

Long-term results of minimal intervention strategies to cut down benzodiazepine use are not available.

OBJECTIVE

To evaluate the relapse rate over a two-year period and to search for predictors of relapse among patients who quit benzodiazepine use after receiving a discontinuation letter.

METHODS

Baseline assessment and prospective monitoring of the medical records of 109 patients who quit long-term benzodiazepine use after a minimal intervention strategy in general practice.

RESULTS

After 819 +/- 100 days of follow-up, 53 (49%) patients had remained completely abstinent. Two independent predictors of relapse were identified by Cox regression analysis: use of more than 10 mg diazepam equivalent (RR = 2.4 [1.2 - 4.7]) and poor general health perception (RR = 0.98 [0.97 - 0.99]).

CONCLUSION

Short-term success rates after a minimal intervention were maintained well during long-term follow-up. High-dose users have the highest risk of relapse.