Defining successful treatment outcome in depression using the PHQ-9: a comparison of methods

Feasibility and preliminary effects of an app-based physical activity intervention for individuals with depression (MoodMover): A protocol for a single-arm, pre-post intervention study

Depression is the leading cause of disability worldwide. Mobile app-based behavior change interventions that promote lifestyle physical activity (PA) may serve as viable alternatives or adjuncts to traditional treatments offering increased reach and accessibility. This protocol describes an experimental, pre-post single-arm trial to investigate the feasibility and preliminary effects of an app-based, 9-week PA intervention (MoodMover) designed for individuals with depression. MoodMover is co-designed with patients and a multidisciplinary research team using a no-code intervention development platform (Pathverse). This study will employ a single-arm pre-post trial with an optional 9-week follow-up, following the Obesity-Related Behavioral Intervention Trials (ORBIT) model. Thirty-six adults who self-report a clinical diagnosis of major depressive disorder or report at least mild depressive symptoms based on the Patient Health Questionnaire - 9 items (PHQ-9) will be recruited. The main outcomes of this study are the feasibility and acceptability of MoodMover, such as the recruitment strategy, assessments (e.g., PHQ-9), and user engagement. Preliminary effects will be assessed by evaluating changes in PA and depressive symptoms. Recruitment is expected to begin on November 1st, 2024, and end on May 1st, 2025. Trial results will be disseminated via publications in peer-reviewed journals and via presentations at academic conferences. This study fits within Phase IIa: Proof-of-concept and Phase IIb: Pilot and Preliminary Testing of the ORBIT model. The robust feasibility and acceptability measures, especially the user engagement data powered by Pathverse, will provide a comprehensive understanding of the MoodMover intervention's feasibility and potential effects. Results will inform potential progression to the next step of the ORBIT model-Phase IIc: Phase II Efficacy Trial-to test MoodMover in a more rigorous randomized controlled trial. This study has been registered at ClinicalTrials.gov (NCT06573125; https://clinicaltrials.gov/study/NCT06573125).

Mothers Time: A Cluster Randomized Controlled Trial of the Effects of a Community-Based Cognitive Behavioral Therapy Intervention on Postpartum Mental Health and Family Planning in Northwest Ethiopia

Depression and anxiety symptoms are associated with increased unmet need for family planning (FP) postpartum, yet solutions promoting the integration of mental health into FP service settings remain scarce. The aims of this study were to quantitatively examine the immediate and longer term effects of participation in a group-based cognitive behavioral therapy (CBT) intervention called Mothers Time on (1) symptoms of depression and anxiety, (2) the use of a modern family planning method, and (3) intermediate FP-related factors among postpartum women in Ethiopia. Building from lessons learned during a feasibility study, we implemented a cluster randomized controlled design, with structured interviews delivered before (baseline), immediately following (endline), and fourxst months after implementation of the intervention (follow-up). A total of 302 postpartum women were recruited from 10 health clusters in northwest Ethiopia. In comparison to control clusters where participants received standard of care, intervention clusters showed significantly greater reductions in symptoms for both depression and anxiety from baseline to follow-up. Modern FP use also increased significantly more in intervention clusters as compared to control clusters from baseline to follow-up. Results suggest that more holistic FP services that consider postpartum mental health can both reduce postpartum depression and anxiety and support women in fulfilling their reproductive intentions.

Explaining how a psychosocial intervention (PROACTIVE) based on behavioural activation improved outcomes of depression in older adults living in deprived regions of Brazil: The mediating roles of reduced loneliness and stepped care

BACKGROUND

The PROACTIVE trial was a task-shared, stepped and collaborative care, psychosocial intervention based on psychoeducation and behavioural activation in 715 participants (60-94 years; mean (SD) 68·6 (6.9) years; 74·1 % female), that was highly effective at improving recovery from depression among older adults in Brazil. Here we investigate mediators of the intervention's effectiveness.

METHODS

Causal mediation analysis using interventional indirect effects, simultaneously decomposed the total effect of PROACTIVE on recovery from depression (PHQ-9 < 10) into multiple indirect effects including: dose of intervention (numbers of sessions and activities completed); social support (Luben Social Network Scale); perceived loneliness (UCLA questionnaire); and additional sessions offered to participants who did not respond during the initial phase of the stepped care intervention.

RESULTS

Of the intervention's total effect (difference in probability of recovery from depression between the intervention and control arms 0·216 [bias-corrected 95 % CI: 0·149, 0·291]): 13 % was mediated through reduced loneliness (0·028 [0·013, 0·046]); and 25 % through attending additional sessions for participants who did not initially respond to the intervention (0·055 [0·007, 0·102]).

LIMITATIONS

Due to limitations in our sample size our study may lack power to detect some nuances such as interactions between different mediators.

CONCLUSIONS

Our findings emphasise the importance of a home-based intervention to improve depression outcomes where participants are encouraged to self-select activities to mitigate against loneliness. Importantly, our findings suggest that the intervention's stepped-care component offering additional sessions to participants who did not experience an early response shows promise in ensuring a sustained recovery from depression.

Effect of e-cigarettes for smoking cessation on depressive and anxiety symptoms: Secondary analysis of a randomized controlled trial

OBJECTIVE

This study aims to assess differences in depressive and anxiety symptoms at 6-month follow-up in a smoking cessation trial using e-cigarettes as quitting aids.

METHODS

We conducted a secondary analysis of the Swiss multicentre ESTxENDS smoking cessation randomized controlled trial (RCT) assessing differences in depressive (Patient Health Questionnaire-9, PHQ-9, range: 0-27) and anxiety symptoms (General Anxiety Disorder-7, GAD-7, range: 0-21) at 6-month follow-up comparing participants who received e-cigarettes to those who received smoking cessation counseling alone.

RESULTS

Of 1244 participants 913 completed the PHQ-9 and 884 the GAD-7 at 6-month follow-up. Mean PHQ-9 scores (SD) at 6 months for the intervention group were 3.7 (3.9), control group: 4.0 (4.2); mean GAD-7 scores (SD) at 6 months for the intervention group were 4.6 (4.3), control group: 4.6 (4.4). Multivariable analyses showed no evidence of a clinically relevant intervention effect on the PHQ-9 [coefficient - 0.101, 95 % CI -0.182 to -0.019, p = .016, corresponding to a 0.9 decrease of the original PHQ-9 score] and the GAD-7 scores [coefficient - 0.056, 95 % CI -0.135 to 0.022, p = .160] in the main adjusted models.

CONCLUSIONS

Among smokers who participated in the ESTxENDS smoking cessation trial, we found distribution of e-cigarettes for smoking cessation in addition to standard counseling compared to counseling alone had no clinically relevant effect on depressive or anxiety symptoms at 6-month follow-up.

TRIAL REGISTRATION

ClinicalTrials NCT03603340.

Statistical methods to adjust for the effects on intervention compliance in randomized clinical trials where precision treatment rules are being developed

BACKGROUND

Heterogeneity of treatment effects (HTEs) can occur because of either differential treatment compliance or differential treatment effectiveness. This distinction is important, as it has action implications, but it is unclear how to distinguish these two possibilities statistically in precision treatment analysis given that compliance is not observed until after randomization. We review available statistical methods and illustrate a recommended method in secondary analysis in a trial focused on HTE.

METHODS

The trial randomized n = 880 anxious and/or depressed university students to guided internet-delivered cognitive behavioral therapy (i-CBT) or treatment-as-usual (TAU) and evaluated joint remission. Previously reported analyses documented superiority of i-CBT but significant HTE. In the reanalysis reported here, we used baseline (i.e., pre-randomization) covariates to predict compliance among participants randomized to guided i-CBT, generated a cross-validated within-person expected compliance score based on this model in both intervention groups, and then used this expected composite score as a predictor in an expanded HTE analysis.

RESULTS

The significant intervention effect was limited to participants with high expected compliance. Residual HTE was nonsignificant.

CONCLUSIONS

Future psychotherapy HTE trials should routinely develop and include expected compliance composite scores to distinguish the effects of differential treatment compliance from the effects of differential treatment effectiveness.

Developing and validating the Sierra Leone perinatal psychological distress scale through an emic-etic approach

Background

Addressing perinatal psychological distress in Sierra Leone faces challenges due to the lack of culturally appropriate assessment tools, despite recent WHO recommendations for screening during the pre- and postpartum periods. While high-income countries use tools like the Edinburgh Postnatal Depression Scale or Patient Health Questionnaire-9 (PHQ-9), their cross-cultural validity and efficacy in developing countries are uncertain. The aim of this study was to address this gap by developing a functional assessment tool, culturally appropriate screening tool for perinatal psychological distress, and validate it with the PHQ-9.

Method

Following scale development guidelines, the study encompassed three phases: Item Development, Scale Development, and Scale Evaluation. Data from free listing interviews (n = 96), FGDs (n = 24), and cognitive interviews (n = 8) informed the development of the Sierra Leone Perinatal Psychological Distress Scale (SLPPDS) and a Function scale. Item reduction via exploratory factor analysis (n = 120) and validation (n = 140) were conducted in subsequent phases.

Result

Two screening instruments were developed: the 10-item SLPPDS and a 5-item Function scale assessing perinatal women's ability to perform daily tasks. Sensitivity/specificity values for the SLPPDS and PHQ-9 were 80.0/85.7 and 73.8/76.2 respectively. Internal consistency reliability was 0.88 for the SLPPDS and 0.81 for the PHQ-9. Confirmatory factor analysis supported a one-factor model with 54.9 % variance explained. ROC/cut-off points for SLPPDS and PHQ-9 were 0.90/0.81 and 8.0/7.0 respectively.

Conclusion

The PHQ-9 shows validity and reliability as a screening instrument, but the SLPPDS emerges as a potentially more salient alternative for assessing perinatal psychological distress in Sierra Leone. This implies the SLPDDS is particularly relevant, meaningful, and applicable to the specific cultural or community context it was designed for. It suggests that the tool effectively addresses the unique needs, perspectives, and experiences of the perinatal women, making it more likely to resonate with users and stakeholders. This relevance may enhance the tool's acceptance, usability, and overall impact in identifying and addressing perinatal mental health issues in Sierra Leone. These instruments could enable effective evaluation of perinatal mental health initiatives by government agencies, locals, and international NGOs.

Enhancing the effectiveness of CBT for patients with unipolar depression by integrating digital interventions into treatment: A pilot randomized controlled trial

OBJECTIVE

Blended cognitive behavioral therapy (bCBT) combines face-to-face therapy with digital elements, such as digital health apps. This pilot study aimed to explore the effectiveness and safety of a novel bCBT application for treating unipolar depression in adults combined with cognitive behavioral therapy (CBT) compared to CBT alone in routine care.

METHODS

Patients (N = 82) were randomly assigned to bCBT (n = 42) or CBT (n = 40) over 12 weeks. bCBT consisted of weekly CBT sessions accompanied by the elona therapy depression module (a bCBT application for unipolar depression) for use between sessions. Standard CBT consisted of weekly CBT sessions. Outcomes (6,12 weeks) were analyzed with linear mixed models.

RESULTS

Improvements in depressive symptoms (BDI-II, PHQ-9) were descriptively larger for the bCBT group. Yet, this difference did not reach statistical significance. bCBT was superior to standard CBT in secondary outcome measures of psychological health (d = .50) and generalized anxiety symptoms (d = -.45). In other secondary outcomes (BAI, PSWQ, GSE, WHOQOL-BREF), improvements were descriptively larger for bCBT compared to CBT.

CONCLUSION

This pilot study provided preliminary evidence that bCBT might be advantageous in comparison to CBT alone in the treatment of depression, but larger RCTs of the bCBT application are needed.

Treatment Readiness in Psychiatric Residential Care for Adolescents

There are many factors to consider when treating adolescents with psychiatric challenges, including whether they are willing and interested in participating in treatment. This study aimed to explore how treatment readiness impacts treatment experience for adolescents in psychiatric residential care who came into treatment with moderate to severe depression. All participants (N = 1,624; Mage = 15.58, SD = 1.46) were admitted to a large, multi-state psychiatric residential system between January 2020 and March 2022. Patients were 95.6% White, 99% non-Hispanic, and 64.7% identified as female. At intake, all patients were administered an assessment which includes the multi-dimensional Behavioral Health Screen (BHS) that assesses psychopathology and risk factors, a working alliance scale, depression, and well-being measures. Patients were also asked how they were admitted to the program, using a single item, multiple choice question as an informal treatment readiness measure, yielding three readiness groups: precontemplation, contemplation, or preparation. Regression analysis results indicated that patients' readiness level was associated with different baseline characteristics (e.g., age, gender, psychopathology symptoms, risk factors) and week 3 outcomes (e.g., decreased symptoms, well-being, alliance, satisfaction). The clinical implications, as well as limitations and future directions, will be discussed.

Investigating change in the ability to decentre and depressive symptomatology over the course of a six-month mindfulness-based intervention in patients with persistent depression

Mindfulness-based interventions (MBIs) for depression use regular mindfulness practice as a means of helping patients build skills that allow them to respond more adaptively to negative mood. Although effects of practice are assumed to accumulate over time, little is known about the trajectories of change in skills and symptoms beyond the duration of standard eight-week interventions. Forty-four patients with persistent depression were recruited to participate in a 6-month blended MBI and provided self-reports of depressive symptomatology and their ability to decenter, the core skill cultivated in MBIs, at baseline, mid-intervention and after the end of the intervention. Trajectories of change were analysed using latent change score modelling. Thirty-one participants (70 %) completed the intervention having engaged in 68.6 % of practices on average. Trajectories of change in decentering and depression were best described by a combination of a constant change component and a limiting factor indicating decreasing rates with higher previous gains. Bivariate analyses showed significant lagged change to change coupling linking earlier changes in decentering with later changes in symptoms. The findings suggest that decentering skills increase throughout longer periods of practice and drive changes in symptoms to move patients closer to recovery or remission.

Transforming the Effectiveness and Equity of a Psychological Therapy Service: A Case Study in the English NHS Talking Therapies Program

To work with a psychological therapies service to implement a recovery plan, as required by a government body, aimed at improving patient outcomes (effectiveness) and decreasing practitioner variability (equity). A case-study utilizing components of a learning health system, including nationally mandated patient outcome data, comprising three 18-month phases: (1) retrospective baseline; (2) improving patient outcomes (management-led); and (3) reducing practitioner variability (clinician-led). Primary analyses focused on 35 practitioners (NPR = 35) who were constant across the three phases and their patients in each phase (NPA = 930, 1226, 1217, respectively). Reliable improvement rates determined patient outcomes and multilevel modeling yielded practitioner effects. To test generalizability, results were compared to the whole practitioner sample for each phase: (1) NPR = 81, NPA = 1982; (2) NPR = 80, NPA = 2227; (3) NPR = 74, NPA = 2267. Ethical approval was granted by the Health Research Authority. Patient outcomes improved in successive phases for both the core and whole practitioner samples with the largest impact occurring in the management-led intervention. Practitioner variability decreased in successive phases in both the core and whole practitioner samples except in the management-led intervention of the whole sample. Compared with the management-led intervention, the practitioner-led intervention yielded a decrease in practitioner effect exceeding 60% in the core sample and approaching 50% in the whole sample. The implementation of multiple components of a learning health system can lead to improvements in both the effectiveness and equity of a psychological therapy service.

Development and validation of a prognostic model to predict relapse in adults with remitted depression in primary care: secondary analysis of pooled individual participant data from multiple studies

BACKGROUND

Relapse of depression is common and contributes to the overall associated morbidity and burden. We lack evidence-based tools to estimate an individual's risk of relapse after treatment in primary care, which may help us more effectively target relapse prevention.

OBJECTIVE

The objective was to develop and validate a prognostic model to predict risk of relapse of depression in primary care.

METHODS

Multilevel logistic regression models were developed, using individual participant data from seven primary care-based studies (n=1244), to predict relapse of depression. The model was internally validated using bootstrapping, and generalisability was explored using internal-external cross-validation.

FINDINGS

Residual depressive symptoms (OR: 1.13 (95% CI: 1.07 to 1.20), p<0.001) and baseline depression severity (OR: 1.07 (1.04 to 1.11), p<0.001) were associated with relapse. The validated model had low discrimination (C-statistic 0.60 (0.55-0.65)) and miscalibration concerns (calibration slope 0.81 (0.31-1.31)). On secondary analysis, being in a relationship was associated with reduced risk of relapse (OR: 0.43 (0.28-0.67), p<0.001); this remained statistically significant after correction for multiple significance testing.

CONCLUSIONS

We could not predict risk of depression relapse with sufficient accuracy in primary care data, using routinely recorded measures. Relationship status warrants further research to explore its role as a prognostic factor for relapse.

CLINICAL IMPLICATIONS

Until we can accurately stratify patients according to risk of relapse, a universal approach to relapse prevention may be most beneficial, either during acute-phase treatment or post remission. Where possible, this could be guided by the presence or absence of known prognostic factors (eg, residual depressive symptoms) and targeted towards these.

TRIAL REGISTRATION NUMBER

NCT04666662.

Economic Evaluation of Videoconference Group Acceptance and Commitment Therapy and Behavioral Activation Therapy for Depression Versus Usual Care Among Adults With Chronic Low Back Pain Plus Comorbid Depressive Symptoms

Chronic pain and depression are frequently comorbid conditions associated with significant health care and social costs. This study examined the cost-utility and cost-effectiveness of videoconference-based group forms of Acceptance and Commitment Therapy (ACT) and Behavioral Activation Therapy for Depression (BATD), as a complement to treatment-as-usual (TAU), for patients with chronic low back pain (CLBP) plus depressive symptoms, compared to TAU alone. A trial-based economic evaluation (n = 234) was conducted from a governmental and health care perspective with a time horizon of 12 months. Primary outcomes were the Brief Pain Inventory-Interference Scale (BPI-IS) and Quality Adjusted Life Year. Compared to TAU, ACT achieved a significant reduction in total costs (d = .47), and BATD achieved significant reductions in indirect (d = .61) and total costs (d = .63). Significant improvements in BPI-IS (d = .73 and d = .66, respectively) and Quality Adjusted Life Year scores (d = .46 and d = .28, respectively) were found in ACT and BATD compared to TAU. No significant differences in costs and outcomes were found between ACT and BATD. In the intention-to-treat analyses, from the governmental and health care perspective, no significant differences in cost reduction and incremental effects were identified in the comparison between ACT, BATD, and TAU. However, in the complete case analysis, significant incremental effects of ACT (∆BPI-IS = -1.57 and -1.39, respectively) and BATD (∆BPI-IS = -1.08 and -1.04, respectively) compared with TAU were observed. In the per-protocol analysis, only the significant incremental effects of ACT (∆BPI-IS = -1.68 and -1.43, respectively) compared to TAU were detected. In conclusion, ACT and BATD might be efficient options in the management of CLBP plus comorbid depression symptoms as compared to usual care. However, no clear difference was found in the comparison between the 2 active therapies regarding cost-effectiveness or cost-utility. PERSPECTIVE: The economic evaluation of psychological therapies for the management of complex conditions can be used in decision-making and resource allocation. This study provides evidence that ACT and BATD are more effective and involve a greater reduction in costs than usual care in the management of CLBP plus comorbid depressive symptoms. TRIAL NUMBER: NCT04140838.

Comparative effectiveness of remote digital gamified and group CBT skills training interventions for anxiety and depression among college students: Results of a three-arm randomised controlled trial

Digital interventions can enhance access to healthcare in under-resourced settings. However, guided digital interventions may be costly for low- and middle-income countries, despite their effectiveness. In this randomised control trial, we evaluated the effectiveness of two digital interventions designed to address this issue: (1) a Cognitive Behavioral Therapy Skills Training (CST) intervention that increased scalability by using remote online group administration; and (2) the SuperBetter gamified self-guided CBT skills training app, which uses other participants rather than paid staff as guides. The study was implemented among anxious and/or depressed South African undergraduates (n = 371) randomised with equal allocation to Remote Group CST, SuperBetter, or a MoodFlow mood monitoring control. Symptoms were assessed with the Generalized Anxiety Disorder-7 (GAD-7) and the Patient Health Questionnaire-9 (PHQ-9). Intention-to-treat analysis found effect sizes at the high end of prior digital intervention trials, including significantly higher adjusted risk differences (ARD; primary outcome) in joint anxiety/depression remission at 3-months and 6-months for Remote Group CST (ARD = 23.3-18.9%, p = 0.001-0.035) and SuperBetter (ARD = 12.7-22.2%, p = 0.047-0.006) than MoodFlow and mean combined PHQ-9/GAD-7 scores (secondary outcome) significantly lower for Remote Group CST and SuperBetter than MoodFlow. These results illustrate how innovative delivery methods can increase the scalability of standard one-on-one guided digital interventions. PREREGISTRATION INTERNATIONAL STANDARD RANDOMISED CONTROLLED TRIAL NUMBER (ISRTCN) SUBMISSION #: 47,089,643.

The Patient-Perceived Helpfulness of Measures Scale: Development and Validation of a Scale to Assess the Helpfulness of Using Measures in Psychological Treatment

In response to the increase in Routine Outcome Monitoring and Clinical Feedback, the Patient-Perceived Helpfulness of Measures Scale (ppHMS) was developed to assess the helpfulness-as perceived by patients-of using measures in psychological treatment. Study 1: The construct of patient-perceived helpfulness of measures was explored using thematic analysis with 15 patients. Six helpful and three unhelpful themes were identified and informed item development. Study 2: 28 items were formulated and rated by experts. Ten items were taken forward for psychometric shortening in a sample of 76 patients. Confirmatory factor analysis (CFA) led to an adequately fitting six-item model with excellent internal consistency, and convergence with the Delighted-Terrible single item of product satisfaction and a single item of measure helpfulness. Study 3: In a stratified online sample of 514 U.K. psychotherapy patients, a five-item model constituted the best fit. The final ppHMS had excellent internal consistency (McDonald's ω = .90), convergent validity with psychotherapy satisfaction (r = .5; p < .001), divergence from social desirability (r = .1), and metric and scalar invariance across measures. Study 4: Analyses were replicated and confirmed in a stratified U.S. sample (n = 602). The ppHMS is a reliable and valid scale that can be used to assess and compare patients' perceptions of the helpfulness of different measures as part of their psychological treatment.

Understanding heterogeneity, comorbidity, and variability in depression: Idiographic models and depression outcomes

This study uses time-intensive, item-level assessment to examine individual depressive and co-occurring symptom dynamics. Participants experiencing moderate-severe depression (N = 31) completed ecological momentary assessment (EMA) four times per day for 20 days (total observations = 2480). We estimated idiographic networks using MDD, anxiety, and ED items. ED items were most frequently included in individual networks relative to depression and anxiety items. We built ridge and logistic regression ensembles to explore how idiographic network centrality metrics performed at predicting between-subject depression outcomes (PHQ-9 change score and clinical deterioration, respectively) at 6-months follow-up. For predicting PHQ-9 change score, R2 ranged between 0.13 and 0.28. Models predicting clinical deterioration ranged from no better than chance to 80 % accuracy. This pilot study shows how co-occurring anxiety and ED symptoms may contribute to the maintenance of depressive symptoms. Future work should assess the predictive utility of psychological networks to develop understanding of how idiographic models may inform clinical decisions.

Depressive Symptoms in Caregivers of Hospice Cancer Patients

Objectives: Family members and close friends provide countless hours of care for patients enrolled in hospice care. They do so without pay, often sacrificing their own financial well-being and health in the process. This study asks 4 research questions: (1) What is the prevalence and severity of depressive symptoms among caregivers of hospice cancer patients? (2) What demographic and contextual factors (such as relationship with patient) are related to the severity of depressive symptoms among caregivers of hospice cancer patients? (3) Are caregiver quality of life and caregiver burden associated with depressive symptoms? and (4) Is baseline depression associated with change in depression over time? Methods: This was a secondary analysis of data collected in a cluster randomized controlled trial. Results: Thirty-five percent of caregivers reported depressive symptoms of moderate or greater severity. These depressive symptoms were found to increase depending on the relationship of the caregiver to the patient. Caregivers with higher reported burden and lower reported quality of life were also found to have higher depressive symptoms. Significance of Results: Hospice agencies are encouraged to assess caregiver depressive symptoms and have protocols in place to assist caregivers with high depressive symptoms.

Brief online negative affect focused functional imagery training (FIT) improves four-week drinking outcomes in hazardous student drinkers: A pilot randomised controlled trial replication in South Africa

Background

Previous study has shown that functional imagery training (FIT) to utilise positive mental imagery in response to negative affect could improve alcohol-related outcomes. The current study aimed to replicate whether this negative affect focused FIT would improve alcohol-related outcomes in hazardous student drinkers in South Africa at four-week follow-up.

Methods

50 hazardous student drinkers who reported drinking to cope with negative affect were randomised into two groups. The active group (n = 25) was trained online over two weeks to respond to personalised negative drinking triggers by retrieving a personalised adaptive strategy they might use to mitigate negative affect, whereas the control group (n = 25) received standard risk information about binge drinking. Outcome measures including alcohol consumption, drinking motives, anxiety and depression, self-efficacy and use of protective behavioural strategies were obtained at baseline and four-week follow-up.

Results

FIT effects were revealed by three significant group-by-timepoint interactions in a per-protocol analysis: there was a significant decrease in depressive symptoms, drinking to cope and drinking for social reasons from baseline to follow-up in the active group, but not the control group. No effects were observed on alcohol consumption, self-efficacy, protective behaviour strategies and anxiety.

Conclusions

Preliminary evidence supports that online negative affect focused FIT can improve depression as well as coping and social drinking motives in South African hazardous student drinkers who drank to cope, at four-week follow-up, suggesting that the principles of this FIT approach might be adapted and incorporated into a clinical intervention to test for efficacy in mitigating substance use problems.

Clinical effectiveness of patient-targeted feedback following depression screening in general practice (GET.FEEDBACK.GP): an investigator-initiated, prospective, multicentre, three-arm, observer-blinded, randomised controlled trial in Germany

BACKGROUND

Screening for depression in primary care alone is not sufficient to improve clinical outcomes. However, targeted feedback of the screening results to patients might result in beneficial effects. The GET.FEEDBACK.GP trial investigated whether targeted feedback of the depression screening result to patients, in addition to feedback to general practitioners (GPs), leads to greater reductions in depression severity than GP feedback alone or no feedback.

METHODS

The GET.FEEDBACK.GP trial was an investigator-initiated, multicentre, three-arm, observer-blinded, randomised controlled trial. Depression screening was conducted electronically using the Patient Health Questionnaire-9 (PHQ-9) in 64 GP practices across five regions in Germany while patients were waiting to see their GP. Currently undiagnosed patients (aged ≥18 years) who screened positive for depression (PHQ-9 score ≥10), were proficient in the German language, and had a personal consultation with a GP were randomly assigned (1:1:1) into a group that received no feedback on their depression screening result, a group in which only the GP received feedback, or a group in which both GP and patient received feedback. Randomisation was stratified by treating GP and PHQ-9 depression severity. Trial staff were masked to patient enrolment and study group allocation and GPs were masked to the feedback recieved by the patient. Written feedback, including the screening result and information on depression, was provided to the relevant groups before the consultation. The primary outcome was PHQ-9-measured depression severity at 6 months after randomisation. An intention-to-treat analysis was conducted for patients who had at least one follow-up visit. This study is registered at ClinicalTrials.gov (NCT03988985) and is complete.

FINDINGS

Between July 17, 2019, and Jan 31, 2022, 25 279 patients were approached for eligibility screening, 17 150 were excluded, and 8129 patients completed screening, of whom 1030 (12·7%) screened positive for depression. 344 patients were randomly assigned to receive no feedback, 344 were assigned to receive GP-targeted feedback, and 339 were assigned to receive GP-targeted plus patient-targeted feedback. 252 (73%) patients in the no feedback group, 252 (73%) in the GP-targeted feedback group, and 256 (76%) in the GP-targeted and patient-targeted feedback group were included in the analysis of the primary outcome at 6 months, which reflected a follow-up rate of 74%. Gender was reported as female by 637 (62·1%) of 1025 participants, male by 384 (37·5%), and diverse by four (0·4%). 169 (16%) of 1026 patients with available migration data had a migration background. Mean age was 39·5 years (SD 15·2). PHQ-9 scores improved for each group between baseline and 6 months by -4·15 (95% CI -4·99 to -3·30) in the no feedback group, -4·19 (-5·04 to -3·33) in the GP feedback group, and -4·91 (-5·76 to -4·07) in the GP plus patient feedback group, with no significant difference between the three groups (global p=0·13). The difference in PHQ-9 scores when comparing the GP plus patient feedback group with the no feedback group was -0·77 (-1·60 to 0·07, d=-0·16) and when comparing with the GP-only feedback group was -0·73 (-1·56 to 0·11, d=-0·15). No increase in suicidality was observed as an adverse event in either group.

INTERPRETATION

Providing targeted feedback to patients and GPs after depression screening does not significantly reduce depression severity compared with GP feedback alone or no feedback. Further research is required to investigate the potential specific effectiveness of depression screening with systematic feedback for selected subgroups.

FUNDING

German Innovation Fund.

TRANSLATION

For the German translation of the abstract see Supplementary Materials section.

Action recommendations review in community-based therapy and depression and anxiety outcomes: a machine learning approach

BACKGROUND

While the positive impact of homework completion on symptom alleviation is well-established, the pivotal role of therapists in reviewing these assignments has been under-investigated. This study examined therapists' practice of assigning and reviewing action recommendations in therapy sessions, and how it correlates with patients' depression and anxiety outcomes.

METHODS

We analyzed 2,444 therapy sessions from community-based behavioral health programs. Machine learning models and natural language processing techniques were deployed to discern action recommendations and their subsequent reviews. The extent of the review was quantified by measuring the proportion of session dialogues reviewing action recommendations, a metric we refer to as "review percentage". Using Generalized Estimating Equations modeling, we evaluated the correlation between this metric and changes in clients' depression and anxiety scores.

RESULTS

Our models achieved 76% precision in capturing action recommendations and 71.1% in reviewing them. Using these models, we found that therapists typically provided clients with one to eight action recommendations per session to engage in outside therapy. However, only half of the sessions included a review of previously assigned action recommendations. We identified a significant interaction between the initial depression score and the review percentage (p = 0.045). When adjusting for this relationship, the review percentage was positively and significantly associated with a reduction in depression score (p = 0.032). This suggests that more frequent review of action recommendations in therapy relates to greater improvement in depression symptoms. Further analyses highlighted this association for mild depression (p = 0.024), but not for anxiety or moderate to severe depression.

CONCLUSIONS

An observed positive association exists between therapists' review of previous sessions' action recommendations and improved treatment outcomes among clients with mild depression, highlighting the possible advantages of consistently revisiting therapeutic homework in real-world therapy settings. Results underscore the importance of developing effective strategies to help therapists maintain continuity between therapy sessions, potentially enhancing the impact of therapy.

Effectiveness-implementation hybrid trial of Spanish language, digital cognitive-behavioral therapy (dCBT) intervention for depression and anxiety - protocol for the SUPERA (SUpport from PEeRs to expand Access) study

BACKGROUND

Limited English Proficiency (LEP) Latinxs experience a longer duration of untreated depression and anxiety. LEP Latinxs have difficulty accessing mental healthcare due to insufficient Spanish-speaking behavioral/mental health clinicians to meet demand. These under-resourced healthcare systems are less likely to be the site for the implementation of innovations. Digital interventions can provide an effective option for overcoming these barriers; yet, when digital evidence-based treatments are available, uptake and engagement is often low. This manuscript presents the protocol for the SUPERA (SUpport from PEeRs to expand Access) study which will evaluate the implementation of an evidence-based, Spanish language, digital cognitive-behavioral therapy (dCBT) intervention (i.e., SilverCloud) in safety-net primary care clinics for LEP Latinx patients with depression or anxiety.

METHODS

We will conduct an effectiveness-implementation hybrid trial (Type 2) design comparing engagement and clinical outcomes in two modalities of dCBT delivery (peer-supported vs. unsupported). We will also compare provider-level outreach (using a clinic patient registry) versus inreach (traditional provider referral) to compare rates of initiation, completion, and cost. Participants will be 426 LEP Latinx adults ≥18 years of age, PHQ-9 ≥ 10 or GAD-7 ≥ 8, with access to the internet via smartphone, and not currently receiving individual psychotherapy. We will collect baseline, post-intervention (8 weeks), and follow up (3 months) data.

CONCLUSION

The long-term goal of this research is to aid in the implementation of digital mental health interventions that can be sustainably implemented in low-resourced settings, while reducing the reliance on professionals, overcoming workforce deficits, and increasing relevance for diverse populations.

Digitally managing depression: A fully remote randomised attention-placebo controlled trial

Background

Depression is a common and disabling condition. Digital apps may augment or facilitate care, particularly in under-served populations. We tested the efficacy of juli, a digital self-management app for depression in a fully remote randomised controlled trial.

Methods

A pragmatic randomised controlled trial that included participants aged > 18 who self-identified as having depression and scored > 5 on the Patient Health Questionnaire-8. Participants were randomly assigned (1:1) to receive juli for 8 weeks or a limited attention-placebo control app. Our primary outcome was the difference in Patient Health Questionnaire-8 scores at 8 weeks. Secondary outcomes were remission, minimal clinically important difference, worsening of depression, and health-related quality of life. Analyses were per-protocol (primary), and modified and full intention-to-treat (secondary). The trial was registered at ISRCTN (ISRCTN12329547).

Results

Between May 2021 and January 2023, we randomised 908 participants. 662 completed the week 2 outcome assessment and were included in the modified intention-to-treat analysis, and 456 completed the week 8 outcome assessments (per-protocol). In the per-protocol analysis, the juli group had a greater reduction in Patient Health Questionnaire-8 score (10.78, standard deviation 6.26) than the control group (11.88, standard deviation 5.73) by week 8 (baseline adjusted β-coefficient -0.94, 95% CI: -1.87 to -0.22, p = 0.045). Achieving remission and a minimal clinically important difference was more likely in the juli group at 8 weeks (adjusted odds ratios 2.22, 95% CI: 1.45-3.39, p < 0.001 and 1.56, 95% CI: 1.08-2.27, p = 0.018, respectively). There were no between-group differences in health-related quality of life or worsening of depression. Modified and full intention-to-treat analyses found similar results, but the primary outcome was non-significant.

Conclusion

The use of juli for 8 weeks resulted in a small reduction in symptoms of depression compared with an attention-placebo control. The juli app is a digital self-management tool that could increase the accessibility of evidence-based depression treatments.

Benchmarking secondary outcomes to posttraumatic stress disorder symptom change in response to cognitive processing and written exposure therapy for posttraumatic stress disorder

Posttraumatic stress disorder (PTSD) has high comorbidity with other psychiatric conditions, including depression, generalized anxiety, and suicidality. Evidence-based treatments (EBTs) for PTSD are effective at reducing PTSD symptoms. However, evidence on the impact of PTSD EBTs on comorbid conditions is mixed and often uses pre-post analyses, which disregards PTSD symptom response. This study replicated and extended prior work on benchmarking quality of life to PTSD symptom response to a broader range of secondary outcomes using a research-based metric of clinically meaningful PTSD symptom change. Ninety-five active duty military members seeking treatment for PTSD participated in a randomized noninferiority trial examining two cognitive behavioral therapies for PTSD: Written Exposure Therapy and Cognitive Processing Therapy. Participants completed clinician-administered and self-rating assessments at baseline and 10 weeks post-first treatment session and were classified as PTSD treatment responders or nonresponders. Data were analyzed using generalized linear mixed effects models with repeated measures with fixed effects of time and PTSD symptom response category. PTSD treatment responders experienced significant improvements in secondary outcomes; nonresponders demonstrated statistically significant, but not clinically meaningful, comorbid symptom change. Our findings provide evidence that successfully treating PTSD symptoms may also positively impact psychiatric comorbidity.

Assessing the Efficacy and Safety of a Digital Therapeutic for Symptoms of Depression in Adolescents: Protocol for a Randomized Controlled Trial

BACKGROUND

Depression is a serious, prevalent, recurrent, and undertreated disorder in adolescents. Low levels of treatment seeking and treatment adherence in this age group, combined with a growing national crisis in access to mental health care, have increased efforts to identify effective treatment alternatives for this demographic. Digital health interventions for mental illness can provide cost-effective, engaging, and accessible means of delivering psychotherapy to adolescents.

OBJECTIVE

This protocol describes a virtual randomized controlled trial designed to evaluate the efficacy and safety of a self-guided, mobile app-based implementation of behavioral activation therapy, SparkRx, for the adjunct treatment of symptoms of depression in adolescents.

METHODS

Participants are recruited directly through web-based and print advertisements. Following eligibility screening and consenting, participants are randomly assigned to a treatment arm (SparkRx) or a control arm (assessment-enhanced usual care) for 5 weeks. The primary efficacy outcome, total score on the 8-item Patient Health Questionnaire (PHQ-8), is assessed at the end of the 5-week intervention period. Additional participant-reported outcomes are assessed at baseline, the postintervention time point, and 1-month follow-up. The safety of the intervention is assessed by participant report (and legal guardian report, if the participant is younger than 18 years) and by patterns of symptom deterioration on the PHQ-8, as part of a larger clinical safety monitoring protocol. The primary efficacy outcome, total PHQ-8 score at the postintervention time point, will be compared between SparkRx and enhanced usual care arms using mixed effect modeling, with baseline PHQ-8 and current antidepressant medication status included as covariates. Secondary efficacy outcomes, including the proportion of participants exhibiting treatment response, remission, and minimal clinically significant improvement (all derived from total PHQ-8 scores), will be compared between groups using chi-square tests. Symptom severity at 1-month follow-up will also be compared between arms. Planned subgroup analyses will examine the robustness of treatment effects to differences in baseline symptom severity (PHQ-8 score <15 or ≥ 15) and age (younger than 18 years and older than 18 years). The primary safety outcome, the number of psychiatric serious adverse events, will be compared between trial arms using the Fisher exact test. All other adverse events will be presented descriptively.

RESULTS

As of May 2023, enrollment into the study has concluded; 223 participants were randomized. The analysis of the efficacy and safety data is expected to be completed by Fall 2023.

CONCLUSIONS

We hypothesize that the results of this trial will support the efficacy and safety of SparkRx in attenuating symptoms of depression in adolescents. Positive results would more broadly support the prospect of using accessible, scientifically validated, digital therapeutics in the adjunct treatment of mental health disorders in this age range.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05462652; https://clinicaltrials.gov/study/NCT05462652.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48740.

The effectiveness of collaborative care delivered via telehealth in a pediatric primary care population

Introduction

The prevalence of mental health conditions among children and adolescents in the United States has become a pressing concern, exacerbated by the COVID-19 pandemic. Collaborative care is an evidence-based model for identifying and treating depression and anxiety in healthcare settings, with additional promise for remote healthcare delivery. This study aims to evaluate the impact of a telehealth collaborative care model for adolescents with depression and anxiety in pediatric and primary care settings.

Methods

Secondary analysis was conducted using de-identified national data from Concert Health, a behavioral health medical group offering remote collaborative care across 17 states. Baseline, 90-day, and 120-day assessments of the PHQ-9 and GAD-7 were collected, along with baseline covariates. Stepwise regression analysis was performed to determine the contribution of select covariates to improvement rates.

Results

Among the analyzed data, 263 participants had complete PHQ-9 data, and 230 had complete GAD-7 data. In both the PHQ-9 and GAD-7 groups, over 50% of patients experienced treatment success based on success at discharge, as well as 90- and 120-day improvement rates. Predictors of success at discharge for the GAD-7 group included age at enrollment (OR 1.2258, 95% CI 1.01-1.496), clinical touchpoints (OR 1.1469, 95% CI 1.086-1.218), and lower baseline GAD-7 score (OR 0.9319, 95% CI 0.874-0.992). For the PHQ-9 group, Medicaid was significantly associated with not achieving a 50% reduction in PHQ-9 score at 120 days (OR 0.5874, 95% CI 0.349-0.979).

Discussion

Collaborative care has demonstrated its effectiveness in treating adolescent populations, providing an opportunity to expand access to evidence-based behavioral health treatment for young individuals. Notably, collaborative care is already integrated into the Medicaid fee schedule for 22 states and accepted by all commercial payers. Given that individuals often turn to their trusted primary care providers for behavioral health care, offering collaborative care to adolescents can play a crucial role in addressing the ongoing mental health crisis.

Peer Activate: A Feasibility Trial of a Peer-Delivered Intervention to Decrease Disparities in Substance Use, Depression, and Linkage to Substance Use Treatment

Although effective evidence-based interventions (EBIs) exist, racial/ethnic minority individuals with lower income are less likely to have access to these interventions and may experience greater stigma in the health care system, resulting in disproportionate rates of morbidity and mortality. Peer recovery specialists (PRSs) may be uniquely suited to address barriers faced by those from impoverished areas; however, peers have not traditionally been trained in implementing EBIs. The current open-label trial (N = 8) was performed to evaluate implementation and preliminary effectiveness of an adapted EBI supporting recovery, linkage to treatment, and reduced depression. Results suggest the intervention was feasible, acceptable, and appropriate for linking individuals from a community setting to substance use treatment and could be delivered with fidelity by a peer interventionist. Participants who completed the intervention demonstrated clinically reliable decreases in substance use and depressive symptoms. Findings provide initial support for PRS dissemination of EBIs to increase linkage to care and support recovery in traditionally underserved populations. [Journal of Psychosocial Nursing and Mental Health Services, 61(11), 23-31.].

Randomised controlled trial of the Community Navigator programme to reduce loneliness and depression for adults with treatment-resistant depression in secondary community mental health services: trial protocol

BACKGROUND

New treatments are needed for people with treatment-resistant depression (TRD), who do not benefit from anti-depressants and many of whom do not recover fully with psychological treatments. The Community Navigator programme was co-produced with service users and practitioners. It is a novel social intervention which aims to reduce loneliness and thus improve health outcomes for people with TRD. Participants receive up to 10 individual meetings with a Community Navigator, who helps them to map their social world and set and enact goals to enhance their social connections and reduce loneliness. Participants may also access group meet-ups with others in the programme every 2 months, and may be offered modest financial support to enable activities to support social connections.

METHODS

A researcher-blind, multi-site, 1:1 randomised controlled trial with N = 306 participants will test the effectiveness of the Community Navigator programme for people with TRD in secondary community mental health teams (CMHTs). Our primary hypothesis is that people who are offered the Community Navigator programme as an addition to usual CMHT care will be less depressed, assessed using the PHQ-9 self-report measure, at 8-month, end-of-treatment follow-up, compared to a control group receiving usual CMHT care and a booklet with information about local social groups and activities. We will follow participants up at end-of-treatment and at 14 months, 6 months after end-of-treatment follow-up. Secondary outcomes include the following: loneliness, anxiety, personal recovery, self-efficacy, social network, social identities. We will collect data about health-related quality of life and service use to investigate the cost-effectiveness of the Community Navigator programme.

DISCUSSION

This trial will provide definitive evidence about the effectiveness and cost-effectiveness of the Community Navigator programme and whether it can be recommended for use in practice. The trial is due to finish in August 2025.

TRIAL REGISTRATION

Prospectively registered on 8th July 2022 at: ISRCTN13205972.

Mental health outcomes for those who have offended and have been given a Mental Health Treatment Requirement as part of a Community Order in England and Wales

BACKGROUND

Growing evidence of mental disorders among people going through the criminal justice system suggests the potential benefit of courts adding a Mental Health Treatment Requirement (MHTR) when sentencing an offender to a Community Order (sentence) in England and Wales. Although available since 2003, MHTRs have not been widely used, and there is little evidence on outcomes.

AIM

To conduct the first large-scale evaluation of mental health outcomes of people with an MHTR as part of their community sentence across multiple sites in England and Wales.

METHODS

Data were collected from 14 sites in England and Wales about individuals who were given an MHTR as part of a community sentence. They were assessed before and after this. During the MHTR, they received a psychotherapeutic intervention by assistant psychologists in a primary care framework. Measures of psychological distress (Clinical Outcomes in Routine Evaluation-Outcome Measure), anxiety (Generalised Anxiety Disorder-7) and depression (Patient Health Questionnaire) were completed before the MHTR was implemented and after completion.

RESULTS

Where paired sample t-tests and Wilcoxon signed ranked tests were used, with samples ranging between 309 and 447 individuals, clinically significant changes were obtained for all measures. Most individuals (63%) were identified as experiencing a reliable change in at least two out of the three scales. Finally, a negative linear relationship, between measures at the start of the intervention and reliable change, was identified with higher pre-measures, indicating that more initial distress, anxiety and/or depression were associated with more sizeable changes.

CONCLUSIONS

This paper provides the first substantial evidence in support of the MHTR within a primary mental healthcare framework as an effective pathway to reduce mental health problems among individuals under probation supervision as part of a sentence after conviction for a criminal offence. This supports the expansion of the provision across England and Wales. Future research should take account of the non-completers and explore the relationship between the MHTR, mental health improvements and reoffending.

Brief relationship support as a selective suicide prevention intervention: Piloting the Relationship Checkup in veteran couples with relationship and mental health concerns

INTRODUCTION

Close relationship problems play a key role in many contemporary theories of suicide. However, the potential of relationship support in suicide prevention is understudied. This study explores the feasibility, safety, acceptability, and promise of utilizing the 3-session Relationship Checkup (RC) in veterans with mental health and romantic relationship concerns.

METHODS

We conducted a single-arm pilot of telehealth RC in veterans with a positive mental health screen and their romantic partners. Couples completed baseline and post-treatment assessments of study outcomes.

RESULTS

Feasibility analyses showed we were able to recruit an elevated-risk sample (30% history of attempts or interrupted attempts), take them through the service (90% treatment completion), and had minimal harm events (no suicidal behavior, no physical harm in arguments). Multimethod acceptability analyses suggested high satisfaction with the program, though some desired more intensive services. Couples reported improvements in relationship functioning, emotional intimacy, thwarted belongingness, depression, and posttraumatic stress. Perceived burdensomeness only improved for identified patients and drinking did not change for either partner.

CONCLUSION

The RC is a feasible, safe, and acceptable strategy for providing relationship support to couples at elevated risk. Although further randomized trials are needed, RC shows promise to reduce relationship-level and individual-level suicide risk factors.

Costs and cost-effectiveness of Shamiri, a brief, layperson-delivered intervention for Kenyan adolescents: a randomized controlled trial

BACKGROUND

Low- and middle-income countries (LMICs) have the highest socio-economic burden of mental health disorders, yet the fewest resources for treatment. Recently, many intervention strategies, including the use of brief, scalable interventions, have emerged as ways of reducing the mental health treatment gap in LMICs. But how do decision makers prioritize and optimize the allocation of limited resources? One approach is through the evaluation of delivery costs alongside intervention effectiveness of various types of interventions. Here, we evaluate the cost-effectiveness of Shamiri, a group- and school-based intervention for adolescent depression and anxiety that is delivered by lay providers and that teaches growth mindset, gratitude, and value affirmation.

METHODS

We estimated the cost-effectiveness of Shamiri using the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) guidelines for economic evaluations. Changes in depression and anxiety were estimated using the Patient Health Questionnaire (PHQ-8) and Generalized Anxiety Disorder questionnaire (GAD-7) at treatment termination and 7-month follow-up using two definitions of treatment benefit. Cost-effectiveness metrics included effectiveness-cost ratios and cost per number needed to treat.

RESULTS

Base case cost assumptions estimated that delivering Shamiri cost $15.17 (in 2021 U.S. dollars) per student. A sensitivity analysis, which varied cost and clinical change definitions, estimated it cost between $48.28 and $172.72 to help 1 student in Shamiri, relative to the control, achieve reliable and clinically significant change in depression and anxiety by 7-month follow-up.

CONCLUSIONS

Shamiri appears to be a low-cost intervention that can produce clinically meaningful reductions in depression and anxiety. Lay providers can deliver effective treatment for a fraction of the training time that is required to become a licensed mental health provider (10 days vs. multiple years), which is a strength from an economic perspective. Additionally, Shamiri produced reliable and clinically significant reductions in depression and anxiety after only four weekly sessions instead of the traditional 12-16 weekly sessions necessary for gold-standard cognitive behavioral therapy. The school setting, group format, and economic context of a LMIC influenced the cost per student; however, broader conclusions about the cost-effectiveness of Shamiri have yet to be determined due to limited economic evaluations of mental health programs in LMICs.

TRIAL REGISTRATION

This study was registered prior to participant enrollment in the Pan-African Clinical Trials Registry (PACTR201906525818462), registered 20 Jun 2019, https://pactr.samrc.ac.za/Search.aspx .

Empowerment group therapy for refugees with affective disorders: results of a multicenter randomized controlled trial

BACKGROUND

Against the background of missing culturally sensitive mental health care services for refugees, we developed a group intervention (Empowerment) for refugees at level 3 within the stratified Stepped and Collaborative Care Model of the project Mental Health in Refugees and Asylum Seekers (MEHIRA). We aim to evaluate the effectiveness of the Empowerment group intervention with its focus on psychoeducation, stress management, and emotion regulation strategies in a culturally sensitive context for refugees with affective disorders compared to treatment-as-usual (TAU).

METHOD

At level 3 of the MEHIRA project, 149 refugees and asylum seekers with clinically relevant depressive symptoms were randomized to the Empowerment group intervention or TAU. Treatment comprised 16 therapy sessions conducted over 12 weeks. Effects were measured with the Patient Health Questionnaire-9 (PHQ-9) and the Montgomery-Åsberg Depression Rating Scale (MÅDRS). Further scales included assessed emotional distress, self-efficacy, resilience, and quality of life.

RESULTS

Intention-to-treat analyses show significant cross-level interactions on both self-rated depressive symptoms (PHQ-9; F(1,147) = 13.32, p < 0.001) and clinician-rated depressive symptoms (MÅDRS; F(1,147) = 6.91, p = 0.01), indicating an improvement in depressive symptoms from baseline to post-intervention in the treatment group compared to the control group. The effect sizes for both scales were moderate (d = 0.68, 95% CI 0.21-1.15 for PHQ-9 and d = 0.51, 95% CI 0.04-0.99 for MÅDRS).

CONCLUSION

In the MEHIRA project comparing an SCCM approach versus TAU, the Empowerment group intervention at level 3 showed effectiveness for refugees with moderately severe depressive symptoms.

The Utility of a Novel, Combined Biofeedback-Virtual Reality Device as Add-on Treatment for Chronic Migraine: A Randomized Pilot Study

OBJECTIVES

To determine if the frequent use of a combined biofeedback-virtual reality device improves headache-related outcomes in chronic migraine.

MATERIALS AND METHODS

In this randomized, controlled pilot study, 50 adults with chronic migraine were randomized to the experimental group (frequent use of a heart rate variability biofeedback-virtual reality device plus standard medical care; n=25) or wait-list control group (standard medical care alone; n=25). The primary outcome was a reduction in mean monthly headache days between groups at 12 weeks. Secondary outcomes included mean change in acute analgesic use frequency, depression, migraine-related disability, stress, insomnia, and catastrophizing between groups at 12 weeks. Tertiary outcomes included change in heart rate variability and device-related user experience measures.

RESULTS

A statistically significant reduction in mean monthly headache days between groups was not demonstrated at 12 weeks. However, statistically significant decreases in the mean frequency of total acute analgesic use per month (65% decrease in the experimental group versus 35% decrease in the control group, P <0.01) and depression score (35% decrease in the experimental group versus 0.5% increase in the control group; P <0.05) were shown at 12 weeks. At study completion, more than 50% of participants reported device satisfaction on a 5-level Likert scale.

DISCUSSION

Frequent use of a portable biofeedback-virtual reality device was associated with decreases in the frequency of acute analgesic use and in depression in individuals with chronic migraine. This platform holds promise as an add-on treatment for chronic migraine, especially for individuals aiming to decrease acute analgesic use or interested in nonmedication approaches.

Impact of an online, individualised, patient reported outcome measures based patient decision aid on patient expectations, decisional regret, satisfaction, and health-related quality-of-life for patients considering total knee arthroplasty: Results from a randomised controlled trial

RATIONALE

Total knee arthroplasty is a common surgical procedure but not appropriate for all patients with knee osteoarthritis. Patient decision aids (PtDAs) can promote shared decision making and enhance understanding and expectations of procedures among patients, resulting in better discussions between patients and healthcare providers about whether total knee arthroplasty is the most appropriate option.

AIMS AND OBJECTIVES

Evaluate impact of an individualised PtDA for osteoarthritis patients considering total knee arthroplasty 1 year after baseline assessment.

METHODS

Prospective, randomised controlled trial comparing an intervention arm (IA) and routine care arm (RCA). The IA included an online individualised patient reported outcome measures (PROMs) based PtDA and one-page summary report for the surgeon. We report secondary outcomes from the final assessment: patient expectations, decisional regret, patient satisfaction with outcomes of knee replacement, health-related quality-of-life (HRQOL) and depression. We report changes in HRQOL between baseline and final assessments, study arms, and surgical versus non-surgical patients. Descriptive statistics were used to describe participant characteristics and continuous variables. Dichotomous outcomes (expectations, decisional regret, satisfaction) were analyzed using logistic regression and continuous outcomes (HRQOL, depression) were modelled using linear regression.

RESULTS

Overall, 140 participants completed all study assessments (IA: n = 69, RCA: n = 71); n = 108 underwent surgery (IA: n = 49, RCA: n = 59). Regardless of study arm, most participants reported expectations were met, minimal decisional regret, satisfaction with outcomes of knee replacement, and had improvements in HRQOL. While no significant differences in study outcomes were found between study arms, IA results were in the direction hypothesised in favour of the PtDA.

CONCLUSIONS

Although we were not able to detect statistically significant benefits associated with implementing this PROMs-based PtDA, there was no apparent negative effect on these outcomes 1 year after baseline. We anticipate there may be benefit to implementing this PtDA earlier in the osteoarthritis care pathway where patients have more opportunities to manage their disease non-surgically.

Using Machine Learning to Predict Antidepressant Treatment Outcome From Electronic Health Records

Objective

To evaluate if a machine learning approach can accurately predict antidepressant treatment outcome using electronic health records (EHRs) from patients with depression.

Method

This study examined 808 patients with depression at a New York City-based outpatient mental health clinic between June 13, 2016 and June 22, 2020. Antidepressant treatment outcome was defined based on trend in depression symptom severity over time and was categorized as either "Recovering" or "Worsening" (i.e., non-Recovering), measured by the slope of individual-level Patient Health Questionnaire-9 (PHQ-9) score trajectory spanning 6 months following treatment initiation. A patient was designated as "Recovering" if the slope is less than 0 and as "Worsening" if the slope was no less than 0. Multiple machine learning (ML) models including L2 norm regularized Logistic Regression, Naive Bayes, Random Forest, and Gradient Boosting Decision Tree (GBDT) were used to predict treatment outcome based on additional data from EHRs, including demographics and diagnoses. Shapley Additive Explanations were applied to identify the most important predictors.

Results

The GBDT achieved the best results of predicting "Recovering" (AUC: 0.7654 ± 0.0227; precision: 0.6002 ± 0.0215; recall: 0.5131 ± 0.0336). When excluding patients with low PHQ-9 scores (<10) at baseline, the results of predicting "Recovering" (AUC: 0.7254 ± 0.0218; precision: 0.5392 ± 0.0437; recall: 0.4431 ± 0.0513) were obtained. Prior diagnosis of anxiety, psychotherapy, recurrent depression, and baseline depression symptom severity were strong predictors.

Conclusions

The results demonstrate the potential utility of using ML in longitudinal EHRs to predict antidepressant treatment outcome. Our predictive tool holds the promise to accelerate personalized medical management in patients with psychiatric illnesses.

Effects of 3D-Printed Models and 3D Printed Pictures on Maternal- and Paternal-Fetal Attachment, Anxiety, and Depression

OBJECTIVE

To compare the effect of a 3D-printed model versus 3D printed pictures on maternal- and paternal-fetal attachment, pregnancy-related anxiety, and depression in parents in the third trimester.

DESIGN

Randomized controlled trial.

SETTING

University- and clinic-affiliated hospital system.

PARTICIPANTS

Between August 2020 and July 2021, we screened 419 women for eligibility. A total of 184 participants (n = 95 women and n = 89 men) were included in the intention-to-treat analysis, of whom 47 women and 44 men received the 3D-printed model, whereas 48 women and 45 men received the 3D printed picture.

METHODS

Participants completed a set of questionnaires before they received third trimester 3D ultrasonography and a second set of questionnaires approximately 14 days after the study ultrasonography. The primary outcome was the global Maternal and Paternal Antenatal Attachment scale scores. Secondary outcomes included the Maternal and Paternal Antenatal Attachment subscale scores, global Generalized Anxiety Disorder-7 scores, global Patient Health Questionnaire-9 scores, and global Pregnancy-Related Anxiety Questionnaire-Revised (second version) scores. We used multilevel models to estimate the effect of the intervention.

RESULTS

We found a statistically significant increase in mean attachment scores after the 3D printed picture and 3D-printed model intervention of 0.26, 95% confidence interval (CI) [0.22, 0.31], p < .001. Additionally, we found statistically significant improvement in depression (mean change = -1.08, 95% CI [-1.54, -0.62], p < .001), anxiety (mean change = -1.38, 95% CI [-1.87, -0.89], p < .001), and pregnancy-related anxiety (mean change = -2.92, 95% CI [-4.11, -1.72], p < .001) scores. We found no statistically significant between-group differences related to maternal or paternal attachment, anxiety, depression, or pregnancy-related anxiety.

CONCLUSIONS

Our findings support the use of 3D printed pictures and 3D-printed models to improve prenatal attachment, anxiety, depression, and pregnancy-related anxiety.

Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia: A Case Report

Despite its well-documented efficacy, few clinicians are trained to deliver Cognitive Behavioral Therapy for Insomnia (CBT-I), and it remains an inaccessible treatment. Therapist-Assisted Internet-Delivered Cognitive Behavioral Therapy for Insomnia (TAI-CBT-I) holds promise for overcoming barriers to accessing this evidence-based treatment. However, to date, there have been no case reports published that describe how to deliver TAI-CBT-I. This case report fills in this gap by illustrating the application and utility of such a treatment on an asynchronous platform. We report on a course of TAI-CBT-I for a 34-year-old Caribbean Canadian male who presented with chronic insomnia characterized by difficulty falling and staying asleep, night awakenings, and reduced helpfulness from medication. Self-report measures of sleep, depression, functioning and ability, and therapist satisfaction were administered throughout treatment, post-discharge, and at follow-up. Improvement was noted across all measures. This case report demonstrates that TAI-CBT-I can be an effective treatment for chronic insomnia and showcases how to deliver it.

Questionnaire-based screening for mental distress in epilepsy: Outline and feasibility of an outpatient screening and intervention pathway

OBJECTIVE

Mental distress is present in a significant proportion of people with epilepsy (PWE), with a negative impact across life domains. It is underdiagnosed and under-treated despite guidelines recommending screening for its presence (e.g., SIGN, 2015). We describe a tertiary-care epilepsy mental distress screening and treatment pathway, with a preliminary investigation of its feasibility.

METHODS

We selected psychometric screening instruments for depression, anxiety, quality of life (QOL), and suicidality, establishing treatment options matched to instrument scores on the Patient Health Questionnaire 9 (PHQ-9), along 'traffic light' lines. We determined feasibility outcomes including recruitment and retention rates, resources required to run the pathway, and level of psychological need. We undertook a preliminary investigation of change in distress scores over a 9-month interval and determined PWE engagement and the perceived usefulness of pathway treatment options.

RESULTS

Two-thirds of eligible PWE were included in the pathway with an 88% retention rate. At the initial screen, 45.8% of PWE required either an 'Amber-2' intervention (for moderate distress) or a 'Red' one (for severe distress). The equivalent figure at the 9-month re-screen was 36.8%, reflective of an improvement in depression and QOL scores. Online charity-delivered well-being sessions and neuropsychology were rated highly for engagement and perceived usefulness, but computerized cognitive behavioral therapy was not. The resources required to run the pathway were modest.

CONCLUSION

Outpatient mental distress screening and intervention are feasible in PWE. The challenge is to optimize methods for screening in busy clinics and to determine the best (and most acceptable) interventions for screening positive PWE.

A randomised controlled trial to investigate the clinical effectiveness and cost effectiveness of Mindfulness-Based Cognitive Therapy (MBCT) for depressed non-responders to Increasing Access to Psychological Therapies (IAPT) high-intensity therapies: study protocol

BACKGROUND

Major depression represents a pressing challenge for health care. In England, Increasing Access to Psychological Therapies (IAPT) services provide evidence-based psychological therapies in a stepped-care approach to patients with depression. While introduction of these services has successfully increased access to therapy, estimates suggest that about 50% of depressed patients who have come to the end of the IAPT pathway still show significant levels of symptoms. This study will investigate whether Mindfulness-Based Cognitive Therapy (MBCT), a group intervention combining training in mindfulness meditation and elements from cognitive therapy, can have beneficial effects in depressed patients who have not responded to high-intensity therapy in IAPT. It will seek to establish the effectiveness and cost-effectiveness of MBCT as compared to the treatment these patients would usually receive.

METHODS

In a 2-arm randomised controlled trial, patients who currently meet the criteria for major depressive disorder and who have not sufficiently responded to at least 12 sessions of IAPT high-intensity therapy will be allocated, at a ratio of 1:1, to receive either MBCT (in addition to treatment as usual [TAU]) or continue with TAU only. Assessments will take place at baseline, 10 weeks and 34 weeks post-randomisation. The primary outcome will be reduction in depression symptomatology 34 weeks post-randomisation as assessed using the Public Health Questionnaire-9 (PHQ-9). Secondary outcomes will include depressive symptomatology at 10 weeks post-randomisation and other clinical outcomes measured at 10-week and 34-week follow-up, along with a series of binarised outcomes to indicate clinically significant and reliable change. Evaluations of cost-effectiveness will be based on assessments of service use costs collected using the Adult Service Use Schedule and health utilities derived from the EQ-5D.

DISCUSSION

This trial will add to the evidence base for the use of MBCT in depressed treatment non-responders. It will constitute the first trial to test MBCT following non-response to psychological therapy, with results providing a direct estimate of efficacy within the IAPT pathway. As such, its results will offer an important basis for decisions regarding the adoption of MBCT for non-responders within IAPT.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05236959. Registered on 11 February 2022. ISRCTN 17755571. Registered on 2 February 2021.

Association of organizational culture and climate with variation in the clinical outcomes of collaborative care for maternal depression in community health centers

Background

Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers.

Method

Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9).

Results

After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of dadj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, dadj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate.

Conclusions

Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

Socio-economic factors associated with mental health outcomes during the COVID-19 pandemic in South Korea

Background

Individuals are at an increased risk of adverse mental health outcomes during the COVID-19 pandemic. To reduce the impact on mental health outcomes that were induced by national-level policies, which may influence an individual at the community level, exploring the comprehensive relations between individual and environmental factors are needed. The aim is to examine socio-ecological factors associated with mental health outcomes, including depressive and anxiety symptoms, with the perspective of support to provide interventions that help the community during future disease outbreaks.

Method

From 5 November to 20 November 2020, a cross-sectional and population-based study was conducted to assess the socio-ecological factors of mental health outcomes during the COVID-19 pandemic. A total of 1,000 participants, aged 20-69 years, in Chungnam Region, South Korea, were included in this study. Multiple linear regression models were used to examine the association between socio-ecological factors and mental health outcomes. The primary outcomes were individuals' mental health outcomes which are measured by PHQ-9 and GAD-7 scores.

Results

Of the 1,000 participants, the average PHQ-9 was 4.39, and GAD-7 was 3.21 during the COVID-19 pandemic. Specifically, the participants with moderate or severe levels of PHQ-9 and GAD-7 were 12.6 and 6.8%, respectively. Higher levels of depressive and anxiety symptoms were associated with participants who were single, reported a lower household income, had decreased support from friends or family, and increased stress from the workplace or home. In subgroup analyses by age, gender, and household income, a similar trend was reported in individual and interpersonal-level factors. There were significant associations between regional-level factors, including gross regional domestic product (GRDP), mental health institutions, psychiatrists, nurse-to-population ratios, and individuals' mental health outcomes.

Conclusion

The management of depressive and anxiety symptoms of individuals during the pandemic was better explained by individual and interpersonal characteristics rather than regional-level factors, highlighting the need for more policies aimed at these lower levels.

Safety and effectiveness of intranasal esketamine for treatment-resistant depression: a real-world retrospective study

Aim: There is limited real-world evidence for patients with treatment-resistant depression (TRD) receiving esketamine nasal spray. Methods: This retrospective cohort study used data collected from a psychiatric clinic's EHR system. Results: A total of 171 TRD patients received esketamine July 2019-June 2021. This predominantly female, white population had several mental health comorbidities and high exposure to psychiatric medications. We observed significant reductions (p < 0.001) in average PHQ-9 and GAD-7 scores from baseline (PHQ-9: mean: 16.7; SD: 5.8; GAD-7: mean: 12.0; SD: 5.8) to last available treatment (PHQ-9: mean: 12.0; SD: 6.4; GAD-7: mean: 8.7; SD: 5.6). There were no reports of serious adverse events. Conclusion: This study found a significant disease burden for patients with TRD. Esketamine appears to be well tolerated and effective in improving depression and anxiety.

Assessment of clinical outcomes of medicinal cannabis therapy for depression: analysis from the UK Medical Cannabis Registry

BACKGROUND

Although pre-clinical experiments associate cannabinoids with reduced depressive symptoms, there is a paucity of clinical evidence. This study aims to analyze the health-related quality of life changes and safety outcomes in patients prescribed cannabis-based medicinal products (CBMPs) for depression.

METHODS

A series of uncontrolled cases from the UK Medical Cannabis Registry were analyzed. The primary outcomes were changes from baseline in the Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), Sleep Quality Scale (SQS), and EQ-5D-5 L at 1, 3, and 6 months. Secondary outcomes included adverse events incidence.

RESULTS

129 patients were identified for inclusion. Median PHQ-9 at baseline was 16.0 (IQR: 9.0-21.0). There were reductions in PHQ-9 at 1-month (median: 8.0; IQR: 4.0-14.0; p < 0.001), 3-months (7.0; 2.3-12.8; p < 0.001), and 6-months (7.0; 2.0-9.5; p < 0.001). Improvements were also observed in GAD-7, SQS, and EQ-5D-5L Index Value at 1, 3, and 6 months (p < 0.050). 153 (118.6%) adverse events were recorded by 14.0% (n = 18) of participants, 87% (n = 133) of which were mild or moderate.

CONCLUSION

CBMP treatment was associated with reductions in depression severity at 1, 3, and 6 months. Limitations of the study design mean that a causal relationship cannot be proven. This analysis provides insights for further study within clinical trial settings.

Value added? A pragmatic analysis of the routine use of PHQ-9 and GAD-7 scales in primary care

BACKGROUND

Depression and anxiety are common and often co-occur. The PHQ-9 and GAD-7 scales are frequently used to measure symptoms and track treatment response in these conditions. These instruments show substantial correlation. This study investigates the similarity between concurrent pairs of PHQ-9 and GAD-7 when used to monitor treatment outcomes.

METHODS

Data originated from a clinical registry within a behavioral health collaborative care program for a large primary care network. A total of 31,974 pairs of PHQ-9 and GAD-7 scores, from 5402 patient care episodes, were analyzed for correlation coefficient, distribution of score differences, and overlap in symptom burden categories. A Number Needed to Identify was calculated to quantify the marginal effect of performing both scales.

RESULTS

The correlation coefficient (Spearman's rho) was 0.74. 78.4% of concurrent scores were within 4 points of each other, and 56.4% of score pairs fell into the same severity class. The Number Needed to Identify for PHQ-9 was 8 while the NNI for GAD-7 was 14.1.

CONCLUSIONS

Concurrent pairs of PHQ-9 and GAD-7 were strongly associated and often similar in severity. In terms of identifying clinically significant symptoms, the marginal effect of using both measures appears moderate.

Brief Adjustment Scale-6 for Measurement-Based Care: Psychometric Properties, Measurement Invariance, and Clinical Utility

The Brief Adjustment Scale-6 (BASE-6) was recently developed for measuring general psychological functioning within measurement-based care (MBC). The present study further evaluated psychometric properties, generalizability to race/ethnic populations, and clinical utility of the BASE-6. Three adult samples, Sample 1: online community participants (n = 394); Sample 2: college students (n = 249); Sample 3: outpatient clinic clients (n = 80), were included. The results demonstrated a high level of internal consistency, good test-retest reliability, and convergent validity in all samples. The unidimensional structure of BASE-6 was confirmed and factorial invariance was established across groups. Finally, the BASE-6 captured change over time by demonstrating a large effect size of pre-post treatment changes and significant linear change in multilevel growth modeling. These results support the BASE-6 as a reliable and valid measure regardless of race/ethnicity and can sensitively detect clinical change over the course of the treatment. Thus, the BASE-6 appears to accurately monitor overall psychological adjustment.

Long-term effectiveness of a prolonged exposure-based intensive outpatient program for veterans with posttraumatic stress disorder

Empirically-supported psychotherapies for posttraumatic stress disorder (PTSD) are highly effective and recommended as first-line treatments, yet dropout rates from standard outpatient therapy are high. Intensive outpatient programs (IOPs) that provide these therapies in condensed format with complementary interventions show promise, as they have demonstrated similar efficacy and higher retention rates. The current study examined initial and long-term outcomes up to 12-months following a 2-week PTSD IOP involving daily prolonged exposure therapy (PE) and adjunctive interventions for veterans and military service members. Participants (N = 376) demonstrated high retention (91%) and large effect size reductions in self-reported PTSD and depression symptoms after two weeks. Small increases in symptoms occurred after 3 months but these stabilized and large reductions compared to baseline were maintained up to 12 months. Piecewise multilevel modeling indicated that demographic variables did not predict PTSD or depression symptom trajectories. Higher PTSD and depression severity at intake predicted higher symptomatology across timepoints and larger relative gains during treatment. Greater alcohol use prior to treatment was associated with higher PTSD symptomatology but did not affect the magnitude of gains. A history of childhood sexual abuse was associated with greater reduction in depression symptoms over treatment, although this effect faded over follow-up. Together these findings underscore the long-term effectiveness of a PE-based IOP across a diverse range of veterans and service members.

Study protocol for pragmatic trials of Internet-delivered guided and unguided cognitive behavior therapy for treating depression and anxiety in university students of two Latin American countries: the Yo Puedo Sentirme Bien study

BACKGROUND

Major depressive disorder (MDD) and generalized anxiety disorder (GAD) are highly prevalent among university students and predict impaired college performance and later life role functioning. Yet most students do not receive treatment, especially in low-middle-income countries (LMICs). We aim to evaluate the effects of expanding treatment using scalable and inexpensive Internet-delivered transdiagnostic cognitive behavioral therapy (iCBT) among college students with symptoms of MDD and/or GAD in two LMICs in Latin America (Colombia and Mexico) and to investigate the feasibility of creating a precision treatment rule (PTR) to predict for whom iCBT is most effective.

METHODS

We will first carry out a multi-site randomized pragmatic clinical trial (N = 1500) of students seeking treatment at student mental health clinics in participating universities or responding to an email offering services. Students on wait lists for clinic services will be randomized to unguided iCBT (33%), guided iCBT (33%), and treatment as usual (TAU) (33%). iCBT will be provided immediately whereas TAU will be whenever a clinic appointment is available. Short-term aggregate effects will be assessed at 90 days and longer-term effects 12 months after randomization. We will use ensemble machine learning to predict heterogeneity of treatment effects of unguided versus guided iCBT versus TAU and develop a precision treatment rule (PTR) to optimize individual student outcome. We will then conduct a second and third trial with separate samples (n = 500 per arm), but with unequal allocation across two arms: 25% will be assigned to the treatment determined to yield optimal outcomes based on the PTR developed in the first trial (PTR for optimal short-term outcomes for Trial 2 and 12-month outcomes for Trial 3), whereas the remaining 75% will be assigned with equal allocation across all three treatment arms.

DISCUSSION

By collecting comprehensive baseline characteristics to evaluate heterogeneity of treatment effects, we will provide valuable and innovative information to optimize treatment effects and guide university mental health treatment planning. Such an effort could have enormous public-health implications for the region by increasing the reach of treatment, decreasing unmet need and clinic wait times, and serving as a model of evidence-based intervention planning and implementation.

TRIAL STATUS

IRB Approval of Protocol Version 1.0; June 3, 2020. Recruitment began on March 1, 2021. Recruitment is tentatively scheduled to be completed on May 30, 2024.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04780542 . First submission date: February 28, 2021.

Efficacy of the Integrative Acupuncture and Moxibustion Treatment in Patients With Major Depressive Disorder: The Study Protocol for a Multicenter, Single-Blinded, Randomized Trial in China

Introduction

Antidepressants are the front-line treatments for major depressive disorder (MDD), but remain unsatisfactory in outcome. An increasing number of patients are interested in acupuncture and moxibustion treatment as complementary therapies. This study aims to evaluate the efficacy and safety of integrative acupuncture and moxibustion (iAM) treatment in patients with MDD.

Methods and Analysis

This multicenter, single-blind, 2 × 2 factorial randomized trial will enroll 592 patients with MDD of moderate severity from nine hospitals. All patients will be randomized, in a ratio of 2:2:2:1, through a computerized central randomization system, into four groups (the combined, iAM-only, sertraline-only, and placebo groups). Participants will undergo a 12-week intervention with either 50 mg of sertraline or a placebo once a day and active/sham iAM treatment three times per week. The primary outcome is depression severity, assessed using the Hamilton Depression Scale-17. The secondary outcomes include self-rated depression severity, anxiety, and sleep quality. The primary and secondary outcomes will be measured at weeks 0, 4, 8, 12, and the 8th week posttreatment. Safety will be evaluated through liver and kidney function tests conducted before and after treatment and through monitoring of daily adverse events. An intent-to-treat principle will be followed for the outcome analyses.

Conclusion

This trial will provide sufficient evidence to ascertain whether iAM is effective and safe for treating MDD and provides a suitable combination strategy for treating MDD.

Clinical Trial Registration

[www.chictr.org.cn], identifier [ChiCTR2100042841].

Rapid transition from in-person to videoconferencing psychotherapy in a counselor training clinic: A safety and feasibility study during the COVID-19 pandemic

Due to the COVID-19 pandemic, many counselor training clinics rapidly transitioned in-person (IP) services to videoconferencing psychotherapy (VCP). Because VCP is a relatively new technology, more research is needed to establish whether this delivery format is a safe and acceptable substitute for IP services in counselor training clinics. The purpose of this study is to explore questions related to how clients perceive VCP versus IP in terms of credibility and expectancy. Results from this investigation demonstrate that clients who participate in VCP, without first meeting their counselor in person, may initially question the credibility and effectiveness of VCP. However, results demonstrated improvement, in both groups, across the duration of therapy. These findings provide both initial support for the safety of VCP in counselor training clinics and justification for further research.

Trauma-Informed Guilt Reduction Therapy: Overview of the Treatment and Research

Purpose of Review

The purpose of this review is to describe Trauma-Informed Guilt Reduction Therapy (TrIGR), the Non-Adaptive Guilt and Shame (NAGS) model that underlies TrIGR, and the research supporting the use of TrIGR to treat the guilt and shame components of moral injury. TriGR is a 6-session individual psychotherapy that helps clients consider their role in the traumatic event and find constructive ways to express important values, so that they no longer need to express values by suffering through guilt and shame.

Recent Findings

A recently completed randomized controlled trial of TrIGR versus supportive care therapy included 144 post-9/11 veterans. TriGR showed greater reductions in trauma-related guilt, PTSD symptoms, and depression symptoms. Participants in TrIGR had greater likelihood of losing their PTSD diagnosis and showing clinical meaningful change in PTSD and depression symptoms. Mean attendance was high; 5.3 out of 6 sessions.

Summary

TrIGR is efficacious in reducing guilt that is common to moral injury as well as PTSD and depression symptoms among combat veterans. The next steps in the program of research to develop and evaluate TrIGR are studies with diverse trauma types and populations as well as relative effectiveness studies comparing TrIGR to other evidence-based treatments for moral injury and PTSD.

A clinical trial comparing trauma-informed guilt reduction therapy (TrIGR), a brief intervention for trauma-related guilt, to supportive care therapy

INTRODUCTION

Trauma-related guilt is common, associated with posttraumatic mental health problems, and can persist after posttraumatic stress disorder (PTSD) treatment. We compared the efficacy of two six-session psychotherapies, Trauma-Informed Guilt Reduction (TrIGR) and Supportive Care Therapy (SCT), for reducing trauma-related guilt. TrIGR helps patients accurately appraise their role in the trauma and re-engage in values. In SCT, patients guide session content.

METHODS

A total of 184 veterans seeking VA mental health services were enrolled across two sites; 145 veterans (mean age: 39.2 [8.1]; 92.4% male; 84.8% with PTSD) who endorsed guilt related to a traumatic event that occurred during a post 9/11 Iraq or Afghanistan deployment were randomized and assessed at baseline, posttreatment, 3- and 6-month follow-up.

RESULTS

Linear mixed models using intent-to-treat analyses showed guilt decreased in both conditions with a greater decrease for TrIGR (treatment × time, -0.22; F _{1, 455.2}  = 18.49, p = .001; d = 0.92) than supportive therapy. PTSD and depressive symptoms showed the same pattern. TrIGR had significantly higher likelihood of PTSD treatment response (67% vs. 40%), loss of PTSD diagnosis (50% vs. 14%), and meaningful change in depression (54% vs. 27%) than supportive therapy. Psychological distress and trait shame improved in both conditions. Quality of life did not change.

CONCLUSIONS

Targeting guilt appears to be an effective means for reducing posttraumatic symptoms and distress.