Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial

IMPORTANCE

Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression.

OBJECTIVES

To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment.

DESIGN, SETTING, AND PARTICIPANTS

This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020.

INTERVENTIONS

CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded.

MAIN OUTCOMES AND MEASURES

The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8.

RESULTS

The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02700009.

Screening for trauma and behavioral health needs in child welfare: Practice implications for promoting placement stability

BACKGROUND

Although the child welfare field has initiated efforts to use standardized screening for trauma and behavioral health needs, research has rarely examined whether these screenings have influenced permanency outcomes.

OBJECTIVE

Using data from three states' federal demonstration projects, we examined whether receipt of trauma and behavioral health screening and results of screening were associated with placement stability (i.e., fewer placements). Our inquiry focused on whether similar patterns of statistical associations would be observed in three distinct state settings.

PARTICIPANTS AND SETTING

Samples comprised children in out-of-home care in three states newly implementing trauma and behavioral health screening. The states included a South Central state, New England state, and a Central Midwestern state.

RESULTS

In all three states, findings showed children who received screening had a higher number of placements (i.e., placement instability). Likewise, all three states found that children whose screening results indicated greater need, such as higher number of trauma symptoms or lower behavioral health functioning, were more likely to experience a higher number of placements (i.e., placement instability).

CONCLUSION

Despite differences in screening tools and state-specific approaches, findings suggest that early screenings may provide important information that could be used to identify children's needs, make appropriate service referrals, establish well-matched placements, and support resource parents and birth parents toward better permanency outcomes. Regardless of potential benefits of early screening, it may be underutilized in the field. Future research is needed to replicate these findings and continue to build an evidence base for trauma and behavioral health screening.

Changes in Couple Relationship Dynamics among Low-Income Parents in a Relationship Education Program Are Associated with Decreases in Their Children's Mental Health Symptoms

Witnessing intimate partner violence (IPV) among parents negatively impacts millions of children in the United States each year. Low-income families are disproportionately affected by IPV compared to middle- and high-income individuals, and are beginning to be the focus of IPV secondary prevention interventions, including relationship education programs. Despite these developments, few studies have examined changes in psychosocial functioning among children of parents participating in relationship education programs. The current study examined the extent to which changes in specific couple dynamics among individuals from low-income backgrounds participating in a couple relationship education program, Within My Reach, were associated with changes in child mental health symptoms. A second purpose of this paper is to examine whether changes in parent–child relationship quality mediates the association between changes in couple dynamics and changes in child mental health difficulties. Participants (n = 347) were parents who participated in Within My Reach as part of programming offered at a large community agency. Decreases in negative couple conflict behaviors, including conflict engagement, withdrawal and compliance, over the course of the program were linked to decreases in child mental health difficulties. In addition, increases in parent–child relationship quality partially mediated the associations between decreases in compliance, as well as increase in overall couple relationship quality, and decreases in child symptoms. Community-based couple relationship education programs for low-income families can potentially have multiple positive impacts throughout the family system, including for children.

Members' attendance rates and outcomes of relationship education groups: A consensus-dispersion analysis

Relationship education programs (REPs) are an effective way to enhance relationship communication, prevent relational distress, and increase relationship quality. Most REPs are delivered in a group format; however, there is little known about the influence of group processes on outcomes for these programs, such as group members' attendance. Therefore, the current study applied a dispersion-consensus model to test the impact of attendance at the member and group levels on group members' REP outcomes. In a sample of 558 lower income, primarily African American participants, we examined whether individual and group attendance rates influenced posttreatment communication patterns and relationship quality. Results indicated that an individual group member's attendance was significantly and positively related to their posttreatment relationship quality, although this relationship is complex. Specifically, this relationship was stronger in groups with higher levels of attendance as well as groups with more attendance variability. In addition, results indicated that group members reported better posttreatment relationship quality in groups with less variability in members' attendance. However, we found a significant interaction between attendance consensus and variability, and an individual group member's posttreatment relationship quality, suggesting that group members report higher levels of relationship quality in groups where the attendance of the group as a whole is lower yet more consistent. No significant relationships were found for group member's posttreatment communication patterns. Our findings suggest that the rate and variability in the group's attendance, as well as an individual group member's own attendance significantly impacts their posttreatment relationship quality in complex ways. (PsycINFO Database Record

Alliance and group cohesion in relationship education

Relationship education programs have been shown as an effective way to increase relationship functioning. There is less known about how process factors, such as alliance with the leader or group dynamics, affect outcomes in these interventions. We examined group cohesion and alliance with the leader in a relationship education program tailored for individuals. Specifically, we examined whether participants' ratings (n = 126) of the group cohesion and alliance with the leader were associated with changes in relationship adjustment, relationship confidence, and communication quality from pre- to postintervention. The results demonstrated that participants' perceptions of the cohesion among the members in their relationship education group, but not the leader-participant alliance, made a significant contribution to the changes in participants' relationship functioning. These results suggest that the group dynamics among the members in the group are important ingredients in relationship education. Implications for relationship programs are provided.

The impact of the within my reach relationship training on relationship skills and outcomes for low-income individuals

A federal grant was awarded to provide the Within My Reach healthy relationships curriculum to low-income, at-risk individuals involved with various social service agencies. The effectiveness of this curriculum was evaluated for 202 participants through measures of training and relationship outcomes pre-, immediately post- and 6 months posttraining. Participants experienced high levels of training satisfaction; significant increases in knowledge, communication/conflict resolution skills, and relationship quality; as well as a trend in the reduction of relationship violence. An important implication of this research is that MFTs may broaden their service delivery to at-risk individuals by collaborating with community agencies to adapt established relationship enhancement programs, evidence-based tools, and principles that complement traditional couples therapy.

Trajectory of parental hope when a child has difficult-to-treat cancer: a prospective qualitative study

OBJECTIVE

This prospective and longitudinal study was designed to further our understanding of parental hope when a child is being treated for a malignancy resistant to treatment over three time points during the first year after diagnosis using a qualitative approach to inquiry.

METHODS

We prospectively recruited parents of pediatric cancer patients with a poor prognosis who were treated in the Hematology/Oncology Program at a large children's hospital for this longitudinal grounded theory study. Parents were interviewed at three time points: within 3 months of the initial diagnosis, at 6 months, and at 9 months. Data collection and analysis took place concurrently using line-by-line coding. Constant comparison was used to examine relationships within and across codes and categories.

RESULTS

Two overarching categories defining hope as a positive inner source were found across time, but their frequency varied depending on how well the child was doing and disease progression: future-oriented hope and present-oriented hope. Under future-oriented hope, we identified the following: hope for a cure and treatment success, hope for the child's future, hope for a miracle, and hope for more quality time with child. Under present-oriented hope, we identified hope for day-to-day/moment-to-moment, hope for no pain and suffering, and hope for no complications.

CONCLUSIONS

For parents of children with a diagnosis of cancer with a poor prognosis, hope is an internal resource that can be present and future focused. These views fluctuated over time in response to changes in the child's well-being and disease progression.

Recruiting and retaining child welfare workers: is preparing social work students enough for sustained commitment to the field?

Graduates of specialized BSW child welfare education programs are more likely to be retained after two years of service in the agency, but many leave at the four year mark. Two studies explored possible reasons for departure at this time. The first study found that graduates of specialized child welfare programs were significantly more likely to engage in best practices in nine areas than workers from other fields. Thus, frustration with practice skill was ruled out as a cause. The second qualitative study found that poor supervision, lack of coworker support, and organizational stress among other variables prompted these high-functioning workers to leave the agency. Suggestions for innovative interventions to enhance retention at this critical juncture are included.