The Effectiveness of Psychological Interventions Delivered in Routine Practice: Systematic Review and Meta-analysis

Outcomes and experiences of DIALOG+ provided remotely for patients with anxiety disorders-A non-controlled pilot trial

BACKGROUND

Low-cost interventions in routine care are needed to reduce the burden of anxiety disorders. DIALOG+ is an evidence-based intervention specifically designed to make routine patient-clinician meetings in mental health care therapeutically effective. It has been shown to be beneficial in a range of studies, but so far not been tested in patients with a primary diagnosis of anxiety disorders.

METHODS

We conducted a non-controlled pilot trial in an out-patient service in Buenos Aires, Argentina. DIALOG+ was applied five times over a six-month period. Because of the pandemic all sessions had to be delivered remotely which had not been originally planned. At baseline and after the intervention, we assessed as outcome criteria subjective quality of life on the Manchester Short Assessment of Quality of Life, general symptoms on the Brief Psychiatric Rating Scale and the objective social situation on the Social Outcomes Index. Patient experiences were explored in semi-structured interviews.

RESULTS

Forty patients completed the study. All outcome criteria, quality of life (4.1±0.5 to 5.0±0.5; p<0.001), general symptoms (33.0±9.3 to 25.9±7.6; p<0.001) and the objective social situation (5.2±0.9 to 5.6±0.5; p=0.008) showed significant improvements. Patient reported largely positive experiences despite frequent technical problems with the online arrangements.

CONCLUSIONS

The findings suggest that DIALOG+ is feasible and beneficial for patients with anxiety disorders in routine care and that a remote delivery is a feasible realistic option for administering it. Future research should assess implementation methods and effectiveness in larger controlled trials and identify the effective mechanisms in DIALOG+.

TRIAL REGISTRATION

The trial was pre-registered (https://www.isrctn.com/ISRCTN38851969) on 16/12/2019.

Treatment and prevention of common mental health problems: comparisons of four low-intensity interventions in a community outpatient setting

Objective: Low-intensity interventions based on cognitive behavioral therapy are often used to scale up treatment volumes for common mental health problems. However, mode of delivery could have implications for outcomes. Methods: This was an observational study of adults seeking treatment in a naturalistic setting of outpatient community mental health services (N = 897). Depending on their problem description, patients were allocated to four different low-intensity interventions: group psychoeducation, group therapies, guided self-help, and one-to-one consultations. Pre-to posttreatment changes on the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and Work- and Social Adjustment Scale (WSAS) were estimated using linear mixed-effects models and propensity score weighted analyses. Results: The proportion of patients achieving clinically significant change (CSC), and time used to achieve CSC varied between interventions, with guided self-help showing the highest rates of CSC (53-66%, d = 0.62-1.04) and group psychoeducation being most time-effective intervention. For subclinical patients, guided self-help had the lowest rates of reliable deterioration (0-8%). Conclusion: Low-intensity interventions within routine community mental health care have acceptable outcomes. Mode of delivery appears to be important for rates of CSC, therapist time investment, and prevention of deterioration. Future studies should investigate which low-intensity interventions work for whom.

Psychiatric nurses' experiences implementing a model for constructive group therapy in mood disorders

BACKGROUND

 In South Africa, various treatment modalities from abroad have been implemented to treat patients with mood disorders. This article is based on a South African model that has been developed, implemented and evaluated for psychiatric nurses to use in facilitating constructive group therapy for patients with mood disorders.

OBJECTIVES

 This study aimed to describe psychiatric nurses' experiences in implementation of a model to facilitate constructive group therapy for patients with mood disorders.

METHOD

 A qualitative, exploratory, descriptive and contextual research design was used for this study. Participants were psychiatric nurses working in an inpatient unit for patients with mood disorders in a public psychiatric hospital.

RESULTS

 The study revealed that psychiatric nurses experienced the model as a supportive tool to facilitate constructive interaction among patients with mood disorders. The model was beneficial in creating a safe space for patients to share and deal with their challenges, promoting optimal functioning outside the hospital setting. The model's implementation also fostered improvement in psychiatric nurses' personal and professional skills.

CONCLUSION

 The model emphasised psychiatric nurses' importance in treating patients with mood disorders and ensuring positive patient experiences and outcomes.Contribution: This study contributes to the theory of clinical psychiatric nursing practice and the empowerment of psychiatric nurses, creating self-awareness related to working with patients with mood disorders.

The effect of comprehensive psychological interventions on the mental health of the community elderly

Objective

To observe the intervention effect of comprehensive psychological interventions on the mental health of the elderly population.

Methods

133 elderly aged 60 and above in two urban districts of Tianshui City from January 2020 to December 2020 were selected and divided into the intervention group (n=67) and the control group (n=66). The intervention group received comprehensive psychological interventions, with no intervention given to the control group. The anxiety rate, depression rate, loneliness rate and happiness rate of the two groups were collected and compared pre- and post-intervention. Self-Rating Anxiety Scale (SAS), Self-Rating Depression Scale (SDS), University of California, Los Angeles Loneliness Scale (UCLA) and Memorial University of Newfoundland Scale of Happiness (MUNSH) were used to compare the psychological status of the elderly pre- and post-intervention.

Results

Differences in the inter-group main effects and time-point main effects for SAS, SDS, UCLA, and MUNSH scores of the intervention group were significant (all p<0.05). The SAS, SDS, and UCLA scores of the intervention group were higher than those of the control group after intervention. Meanwhile, the SAS and SDS scores of the intervention group were lower than those of the control group after intervention (all p<0.05). Moreover, the MUNSH score of the intervention group was higher than that of the control group at 1-year follow-up post-intervention (p<0.05). Compared with pre-intervention values, the proportions of anxiety, depression loneliness, and happiness in the intervention group were improved at 1-year follow-up post-intervention (all P<0.05).

Conclusion

This study provides basis and important support for further investigations and the monitoring of health indicators in a population as fragile as the elderly. Targeted comprehensive psychological interventions can improve the negative emotions of community-dwelling elderly and maintain their physical and mental health. The "community-hospital linkage" mental health service model can improve the mental health status of community-dwelling elderly.

Real-World Effectiveness and Predictors of Nurse-Led Individual Cognitive Behavioral Therapy for Mental Disorders: An Updated Pragmatic Retrospective Cohort Study

The importance of nurses integrating effective psychological techniques into their clinical practice is widely recognized. Nevertheless, further evidence from real-world settings is needed to establish nurse-led cognitive behavioural therapy (CBT) as an effective approach in clinical practice. This study aimed to examine the clinical effectiveness and predictors of individual CBT for mental disorders delivered by nurses in various routine clinical settings. This pragmatic retrospective cohort study collected data from participants who received nurse-led individual CBT at four institutions from different prefectures in Japan between April 2015 and March 2023. During the study period, 280 clients were referred to nurses for CBT, 240 of whom received nurse-led individual CBT of at least one session. The common primary diagnoses among participants were major depressive disorder (33.8%), social phobia (12.9%), and obsessive-compulsive disorder (10.0%). Of these, 23 participants were ongoing cases at the end of the observation period, and 217 who had completed the course of therapy or discontinued/dropped out from the therapy were included in the analysis (173 completed and 44 discontinued/dropped out (i.e., dropout rate = 20.3%)). Based on the clinical significance definition (primary outcome), 62.4% of the participants who completed the therapy were judged to demonstrate positive clinical significance (recovered or improved), with only a few participants (6.9%) demonstrating deterioration. Significant improvements were observed before and after nurse-led individual CBT across all secondary outcomes, including depression and anxiety symptoms, health-related quality of life, and functional disability (all ps ≤ 0.001). Univariate logistic regression revealed that clients with higher baseline severity of depression and anxiety symptoms were less likely to achieve positive clinical significance following nurse-led individual CBT. The real-world evidence gained through this study will encourage frontline nurses and motivate institutional/organizational leaders and policymakers to employ nurse-led individual CBT, especially for depression and anxiety-related disorders.

Effectiveness of an add-on brief group behavioral activation treatment for depression in psychiatric care: a randomized clinical trial

Objective

Behavioral activation (BA) is an effective treatment for depression. We investigated the effectiveness of add-on group-format BA and peer support (PS) with treatment as usual (TAU) in a registered randomized clinical trial in psychiatric outpatient settings (ISRCTN10647845).

Methods

Adult outpatients (N = 140) with major depressive disorder (MDD) and Patient Health Questionnaire (PHQ-9) score ≥10 were randomized into a) group BA, consisting of eight 90-minute weekly group sessions plus TAU; b) group PS, including eight 90-minute weekly group sessions plus TAU; or c) TAU alone. The primary outcome was a within-individual change in PHQ-9 score between baseline and 8 weeks. Secondary outcomes were 1) response, 2) remission, and 3) functional impairment at 8 weeks, plus 4) change in PHQ-9 at 6 months.

Results

Of the randomized patients, 100 (71.4%) completed treatments, including 29/45 (64.4%) patients in the BA group, 39/49 (79.6%) in the PS group, and 32/46 (69.6%) in the TAU group. By 8 weeks, PHQ-9 scores declined most in the TAU group [BA -0.28 (95% CI -2.48, 1.92), PS -0.58 (-2.09, 0.94) vs. TAU -3.32 (-5.21, -1.44); group-difference test, p = 0.034]. The secondary outcomes in the BA or PS arms did not significantly differ from those in TAU. Videotaped sessions revealed marked variation in briefly trained therapists' adherence to the treatment manual.

Conclusions

In this randomized trial, the effectiveness of treatments with the added BA and PS groups did not exceed that of TAU alone. The preconditions in which brief BA or PS group interventions benefit outpatients with depression in psychiatric settings warrant critical investigation.

Long-term depressive symptom trajectories and related baseline characteristics in primary care patients: Analysis of the PsicAP clinical trial

BACKGROUND

There is heterogeneity in the long-term trajectories of depressive symptoms among patients. To date, there has been little effort to inform the long-term trajectory of symptom change and the factors associated with different trajectories. Such knowledge is key to treatment decision-making in primary care, where depression is a common reason for consultation. We aimed to identify distinct long-term trajectories of depressive symptoms and explore pre-treatment characteristics associated with them.

METHODS

A total of 483 patients from the PsicAP clinical trial were included. Growth mixture modeling was used to identify long-term distinct trajectories of depressive symptoms, and multinomial logistic regression models to explore associations between pre-treatment characteristics and trajectories.

RESULTS

Four trajectories were identified that best explained the observed response patterns: "recovery" (64.18%), "late recovery" (10.15%), "relapse" (13.67%), and "chronicity" (12%). There was a higher likelihood of following the recovery trajectory for patients who had received psychological treatment in addition to the treatment as usual. Chronicity was associated with higher depressive severity, comorbidity (generalized anxiety, panic, and somatic symptoms), taking antidepressants, higher emotional suppression, lower levels on life quality, and being older. Relapse was associated with higher depressive severity, somatic symptoms, and having basic education, and late recovery was associated with higher depressive severity, generalized anxiety symptoms, greater disability, and rumination.

CONCLUSIONS

There were different trajectories of depressive course and related prognostic factors among the patients. However, further research is needed before these findings can significantly influence care decisions.

Racial and Ethnic Disparities for Unmet Needs by Mental Health Condition: 2016 to 2021

OBJECTIVES

Racial and ethnic minority children receive less care and inferior care in the United States, but less is known about how these disparities vary by mental health conditions. We examined unmet mental health needs by condition types to identify potentially hidden racial and ethnic inequities.

METHODS

We used data from the nationally representative National Survey of Children's Health, from 2016 to 2021 (n = 172 107). Logistic regression analyses were applied to mental health conditions in aggregate and individually and adjusted for individual and household characteristics.

RESULTS

Relative to non-Hispanic white children with any mental health condition, non-Hispanic Black children had greater odds of unmet needs (adjusted odds ratio [aOR] = 1.56, 95% confidence interval [CI]: 1.18-2.05). Models disaggregated by specific mental health conditions revealed heterogeneous patterns. Specifically, relative to non-Hispanic white children, non-Hispanic Black children displayed elevated odds of unmet needs for behavioral problems (aOR = 1.41, 95% CI: 1.00-2.02), whereas Asian and Hispanic children displayed elevated odds for anxiety (aOR = 2.60, 95% CI: 1.20-4.29 and aOR = 1.41, 95% CI: 1.05-1.90, respectively).

CONCLUSIONS

Racial and ethnic minority children are disproportionately affected by unmet treatment needs. These disparities vary by individual mental health conditions and persist after controlling for socioeconomic characteristics. Results reveal clinically underserved racial and ethnic groups across different mental health conditions.

The status of psychodynamic psychotherapy as an empirically supported treatment for common mental disorders - an umbrella review based on updated criteria

To assess the current status of psychodynamic therapy (PDT) as an empirically supported treatment (EST), we carried out a pre-registered systematic umbrella review addressing the evidence for PDT in common mental disorders in adults, based on an updated model for ESTs. Following this model, we focused on meta-analyses of randomized controlled trials (RCTs) published in the past two years to assess efficacy. In addition, we reviewed the evidence on effectiveness, cost-effectiveness and mechanisms of change. Meta-analyses were evaluated by at least two raters using the proposed updated criteria, i.e. effect sizes, risk of bias, inconsistency, indirectness, imprecision, publication bias, treatment fidelity, and their quality as well as that of primary studies. To assess the quality of evidence we applied the GRADE system. A systematic search identified recent meta-analyses on the efficacy of PDT in depressive, anxiety, personality and somatic symptom disorders. High quality evidence in depressive and somatic symptom disorders and moderate quality evidence in anxiety and personality disorders showed that PDT is superior to (inactive and active) control conditions in reducing target symptoms with clinically meaningful effect sizes. Moderate quality evidence suggests that PDT is as efficacious as other active therapies in these disorders. The benefits of PDT outweigh its costs and harms. Furthermore, evidence was found for long-term effects, improving functioning, effectiveness, cost-effectiveness and mechanisms of change in the aforementioned disorders. Some limitations in specific research areas exist, such as risk of bias and imprecision, which are, however, comparable to those of other evidence-based psychotherapies. Thus, according to the updated EST model, PDT proved to be an empirically-supported treatment for common mental disorders. Of the three options for recommendation provided by the updated model (i.e., "very strong", "strong" or "weak"), the new EST criteria suggest that a strong recommendation for treating the aforementioned mental disorders with PDT is the most appropriate option. In conclusion, PDT represents an evidence-based psychotherapy. This is clinically important since no single therapeutic approach fits all psychiatric patients, as shown by the limited success rates across all evidence-based treatments.