Effective dose 50 method as the minimal clinically important difference: Evidence from depression trials

Feasibility of online group stress management training compared to web-based individual training for employees-a randomized pilot study

Background

In recent decades, digital stress management training, typically targeted at individuals, has gained increasing attention in health promotion. While these interventions show on average moderate to high effects on stress and other mental health outcomes, their use and acceptance in practice are often low. In contrast, group training may have advantages over these shortcomings. However, despite its widespread use in traditional non-digital health promotion, there is little evidence for digital training delivered in groups.

Objective

This study's aim was to explore the feasibility of live, online stress management training delivered in a group format and compare it to Internet-based training targeting individuals.

Methods

Employees (N = 62), recruited from an open access website, were randomized into either group or individual training. Group training consisted of seven weekly online appointments led by a trainer and conducted via videoconference. Individual training consisted of seven web-based sessions which included written feedback provided by an e-coach after each session. The primary outcome was perceived stress eight weeks after training initiation. Feasibility was analyzed in terms of participants' satisfaction, adherence, and perceived benefits of both training formats, assessed via both written questionnaires and interviews.

Results

Participants in group training [Cohen's d = 0.9 (95% confidence interval: 0.4 to 1.5)] and individual training [1.3 (0.6 to 2.0)] both experienced statistically-significant reductions in stress, with no significant difference between the two training formats [0.25 (-0.32 to 0.83); p = 0.579]. Full adherence rates were 70% in the group training and 50% in the individual training. Participants were satisfied with both formats, appreciating the social support and personal contact of the group setting, while appreciating the time flexibility and personal contact with an e-coach offered through individual training.

Conclusion

This pilot study showed promising effects for the acceptance and health-related effectiveness of stress management training delivered in a group setting via videoconference. The findings highlight the value of personal contact with a coach and peers for positive user experiences during digital stress management interventions.

Clinical trial registration

https://drks.de/search/en/trial/DRKS00024965, DRKS00024965.

A literature review exploring whether meaningful change threshold estimates for patient-reported outcome (PRO) measures vary depending on baseline severity

PURPOSE

Meaningful change thresholds for patient-reported outcome (PRO) measures may differ according to patients' baseline disease severity. This review aimed to explore methods used in the peer-reviewed literature to assess the relationship between baseline severity and meaningful change thresholds and the nature of this relationship.

METHODS

A structured literature review was conducted to identify relevant abstracts published between 2018-2022 reporting estimation of PRO meaningful change thresholds by baseline disease severity. Methods to estimate thresholds and direction of the relationship with baseline severity were extracted.

RESULTS

1029 abstracts were screened and 22 full-text articles were deemed eligible for inclusion in the review. All 22 articles reported meaningful change thresholds that were estimated by baseline severity. Nearly all studies (n = 21) used anchor-based methods and reported thresholds for improvement. Most studies (n = 19) used the baseline score of the PRO being examined to define baseline severity. Baseline severity dependency was often tested by repeating methods within baseline-stratified groups (n = 16). All studies reported at least one PRO score where meaningful change was dependent upon baseline severity. The direction of the relationship for improvement was predominately a larger meaningful change threshold for worse baseline severity (n = 21).

CONCLUSION

Methods used to assess baseline severity dependency for meaningful change thresholds vary, however most studies reviewed concluded that larger thresholds are warranted for worse baseline severity. Future work should explore how to distinguish true baseline severity dependency from statistical artifacts to ensure accurate interpretation of PROs in both clinical trials and clinical practice.

The Immediate Impact of App-Based Psychotherapeutic Exercises on Anxiety: An RCT

Background: Despite the growing integrative trend in psychotherapy, few studies have examined the potential for immediate anxiety relief of many different psychotherapeutic exercises side by side under the same conditions. This information might be important to enhance engagement and self-efficacy, stop negative feedback loops, and prevent avoidant or destructive behavior during crises. Technology-based psychotherapeutic exercises are of particular interest because they are accessible and scalable. Methods: This parallel, double-blind, randomized trial (N = 1092) compared 12 psychotherapeutic exercises of the Mind Ease app against a reading control and a measurement-only control. Efficacy was measured with a custom scale validated against the state subscale of the State-Trait Anxiety Inventory. Results: Each of the 12 exercises significantly reduced anxiety more than controls (p=0.018 to <0.001, η2 ⁣ p =0.06 to 0.37, d=0.5 to 1.5, d [95% CI] for all exercises together vs. reading control = 0.8 [0.6; 1.0], and vs. measurement-only control = 0.8 [0.6; 1.0]). Exercises employing cognitive restructuring had effect sizes d [95% CI] of 0.5 [0.2; 0.8], 0.7 [0.3; 1.0], and 0.9 [0.6; 1.2], diaphragmatic breathing of 0.6 [0.3; 0.9], gratitude practice of 0.8 [0.5; 1.1], positive expressive writing of 1.1 [0.7; 1.4], progressive muscle relaxation of 1.3 [0.9; 1.6], guided imagery of 1.3 [1.0; 1.6], and mindfulness of 0.9 [0.6; 1.2], 1.0 [0.7; 1.3], 1.2 [0.9; 1.5], and 1.5 [1.2; 1.9]. Twenty-eight comparisons between exercises (42%) had p  < 0.05, nine met the Bonferroni-adjusted threshold of p  < 0.0008. Conclusions: The 12 psychotherapeutic exercises proved effective at immediately mitigating anxiety. Differences between exercises were substantial even within categories. Mindfulness tended to have a larger effect than cognitive restructuring. Trial Registration: ClinicalTrials.gov identifier: NCT05850975.

A Randomized, Double Blind, Sham-Controlled Clinical Trial to Evaluate the Efficacy of Electrical Vestibular Nerve Stimulation (VeNS), Compared to a Sham Control for Generalized Anxiety Disorder

Aims and Objectives: It has been hypothesised that vestibular stimulation may have a modulatory effect on anxiety. The aim of this randomised, double blind, sham-controlled trial was to determine the efficacy and safety of a non-invasive electrical vestibular nerve stimulation (VeNS) device as a treatment for anxiety compared to a sham stimulation device. Materials and methods: A total of 60 participants (mean age [SD]: 35.6 [8.1]) with a generalized anxiety disorder assessment (GAD-7) score of ≥10 were randomised to receive either an active VeNS device (n = 34) or a sham control device (n = 26). Both groups were asked to complete 20 stimulation sessions (30 min duration) at a rate of 3-5 sessions per week at a research clinic. The primary outcome was change in GAD-7 score from baseline to the end of study (when each participant finished their 20 stimulation sessions). Secondary outcomes were change in Insomnia Severity Index (ISI), and the Short Form 36 Health Survey (SF-36) scores (8 domains). Results: One participant allocated to the sham group withdrew from the study. The mean (SD) number of weeks it took to complete the 20 stimulation sessions was 5.8. The active group had a statistically greater reduction in GAD-7 score compared to the sham group (-7.4 versus -2.2, P < .001; respectively). A total of 97% (n = 33) of the active group achieved a clinically meaningful reduction (defined as ≥4-point reduction) in GAD-7 from baseline to the follow up visit compared to 24% (n = 6) of the sham group (P < .001). Additionally, the active group showed a significant improvement in ISI (-4.9 versus 2.2, P < .001) and greater improvements on all eight SF36 domains (P < .001) compared with the sham group. There was no device related reported adverse events. Conclusion: Regular non-invasive electrical vestibular nerve stimulation appears to have a clinically meaningful benefit when used as an intervention for Generalized Anxiety Disorder.

Economic Insecurities and Mental Health Among Low-Income Pregnant People in the Central Valley Region of California

BACKGROUND

The association between economic insecurity and mental health among low-income pregnant people is understudied. We examined the relationship between economic insecurity and perinatal stress, anxiety, and depressive symptoms among a low-income, racially/ethnically diverse study population, and differentiated associations by nativity status.

METHODS

We used cross-sectional data from the EMBRACE Study that enrolled Medi-Cal (California's Medicaid program) eligible pregnant people in the Central Valley region of California. Economic insecurity was assessed through measures of food insecurity, low financial well-being, inability to pay an emergency expense, inability to pay bills, fear of eviction, and history of homelessness. We examined the association of these measures with perceived stress (Perceived Stress Scale), generalized anxiety symptoms (Generalized Anxiety Disorder-7), and depressive symptoms (Patient Health Questionnaire-9), adjusting for age, relationship status, and education level. We also examined effect measure modification by nativity among the Latinx population. We report the estimated differences and 95% confidence intervals for each exposure and outcome.

RESULTS

In our sample of 674 participants, we observed associations between economic insecurity and mental health. Among the 24 models, 15 showed medium to large effects (>0.35 standard deviation differences) and only three showed negligible effect sizes. Across all outcomes, we observed a stronger relationship between economic insecurity and mental health for U.S.-born Latinx people compared with their foreign-born (93% Mexico-born) counterparts.

CONCLUSION

We found low-income pregnant people experience significant economic insecurities that may impact mental health adversely. Programs that increase economic supports during pregnancy may serve as important maternal mental health interventions, especially among racial/ethnic minoritized groups.

A digital therapy targeting anxiety in pulmonary fibrosis: A decentralized randomized controlled trial

BACKGROUND AND OBJECTIVE

Pulmonary fibrosis, a manifestation of interstitial lung disease, is frequently associated with anxiety. The objective of this study, COMPANION, was to assess the anxiolytic efficacy of Almee, a digital cognitive behavioural therapy for patients with pulmonary fibrosis, compared to treatment as usual.

METHODS

COMPANION was a randomized, controlled, open-label and partly reader-blinded, decentralized, clinical trial conducted in the United States. Eligible patients had radiology-confirmed pulmonary fibrosis and a Generalized Anxiety Disorder 7-item (GAD-7) score of ≥5 (possible range 0-21). Participants were randomized 1:1 to Almee or no intervention for 9 weeks, with block stratification by anxiety severity. The primary endpoint was change in GAD-7 score from baseline to week 9. Between 20 December 2022 and 14 August 2023, 108 participants were randomized, 54 to Almee and 54 to treatment as usual.

RESULTS

In each arm, 46 participants completed the study; 108 cases were analysed as intention-to-treat. By week 9, average GAD-7 score had improved by 1.8 points (SEM = 2.1) in the Almee group (n = 54) and deteriorated by 0.9 points (SEM = 2.2) in the control group (n = 54), a 2.7-point difference (95% confidence interval: 1.2-4.2, p = 0.0006).

CONCLUSION

Treatment with Almee was well-tolerated and showed clinically meaningful improvement in pulmonary fibrosis-related anxiety. Almee shows promise as a personalized intervention for management of the psychological burden related to living with pulmonary fibrosis.

Continuous Improvement of Chronic Tinnitus Through a 9-Month Smartphone-Based Cognitive Behavioral Therapy: Randomized Controlled Trial

BACKGROUND

Tinnitus is the perception of sound without an external auditive stimulus and can be a severe burden for affected patients. Medical guidelines recommend cognitive behavioral therapy (CBT) for tinnitus treatment, which effectively improves tinnitus-related distress and anxiety.

OBJECTIVE

This study investigates the outcome of a 9-month smartphone-based CBT for patients with tinnitus.

METHODS

The randomized controlled clinical trial in this study investigates the efficacy of a smartphone-based CBT for 187 patients with chronic tinnitus over a 9-month treatment period. In the initial 3 months, a waiting list design was applied, and in the subsequent study phase, the data of both treatment groups were collectively analyzed. The scores on the Tinnitus Questionnaire (TQ); 9-item Patient Health Questionnaire (PHQ-9); 9-item Self-Efficacy, Optimism, Pessimism (SWOP-K9) questionnaire; and 20-item Perceived Stress Questionnaire (PSQ-20) were assessed as endpoints after 3 and 9 months of treatment.

RESULTS

We observed a statistically significant reduction in the tinnitus burden in patients who received the smartphone-based CBT intervention. Although no changes were observed initially in the TQ sum scores in the waiting control group (baseline mean, 37.8, SD 4.7; 3 months mean 37.5, SD 4.8; analysis of covariance [ANCOVA] P=.52), the scores significantly decreased once the app-based CBT had commenced. Data pooled from both groups revealed significant reduction in the TQ sum score by 12.49 (SD 1.44) (ANCOVA, P<.001) and 18.48 (SD 1.85) (ANCOVA, P<.001) points after 3 and 9 months, respectively, which was also clinically important. The calculated Cohen d was 1.38. Similarly, the scores on PSQ-20 (-9.14 points; ANCOVA, P<.001), PHQ-9 (-2.47 points; ANCOVA, P<.001), and SWOP-K9 (0.17 points; ANCOVA, P<.001) were significantly improved at the end of the therapy, with corresponding intermediate effect sizes after 9 months.

CONCLUSIONS

The data in our study provide evidence of statistically significant, clinically relevant, and continuous benefits of an app-based CBT intervention in patients with chronic tinnitus.

TRIAL REGISTRATION

Deutsches Register Klinischer Studien DRKS00022973; https://drks.de/search/de/trial/DRKS00022973.

Acceptance and commitment therapy with Huntington's disease: A narrative review and case report of a caregiver-assisted intervention

Acceptance and commitment therapy (ACT) is an experiential, action-oriented talk therapy that emphasizes acceptance of painful inner experience through increased psychological flexibility. In this narrative review and case report, we first review the extant literature on applications of ACT to patients with a variety of mental and physical health challenges, including neurodegenerative disorders, and their caregivers. We then discuss applications of ACT to Huntington's disease (HD). We provide a case report of a 52-year-old man living with HD who, accompanied by his caregiver, received a virtually-delivered 6-session ACT intervention. We measured the patient's self-reported symptoms of depression (PHQ-9) and anxiety (GAD-7) as well as his health-related quality of life (HDQoL) and level of cognitive fusion (i.e., being attached to his thoughts; CFQ-13) at baseline and following the intervention. At follow-up, the patient had a clinically significant reduction in depressive symptoms (from moderate to mild symptomatology) and cognitive fusion. Further, the patient had improvements in quality of life across the domains of physical functioning, mood, and worries. The promising outcomes of this case, as well as extant literature on the effectiveness of ACT in supporting individuals with similar neurodegenerative disorders, suggests that ACT may hold promise as a scalable and impactful intervention for individuals living with HD and their caregivers. We conclude with a call for further study of ACT with this population to build a more robust evidence base that can be used to benefit individuals living with HD and their caregivers.

Assessing the impact of elexacaftor/tezacaftor/ivacaftor on anxiety & depression symptom scores in adults with Cystic Fibrosis

The mental health effects of elexacaftor/tezacaftor/ivacaftor (ETI) on adults with CF are still uncertain with mixed findings from published studies. To systematically investigate the impact of ETI on symptoms of anxiety and depression in adults with CF, Generalized Anxiety Disorder-7 (GAD-7) and Patient Health Questionnaire (PHQ-9) scores were evaluated at baseline, 6 months, and 12 months post-ETI. Overall, GAD-7 and PHQ-9 scores improved at 6 months post-ETI, with a greater proportion of individuals experiencing a clinically significant improvement (vs. worsening) of their symptoms, which was sustained at 12 months. Factors influencing mental health outcomes included pre-existing psychiatric diagnoses and psychiatric medication use. In conclusion, although there was overall improvement in anxiety and depression symptoms post-ETI, approximately 10 % of individuals experienced clinically significant worsening.

Effectiveness of a guided multicomponent internet and mobile gratitude training program - A pragmatic randomized controlled trial

Objective

To investigate the effectiveness of a guided, internet- and smartphone-based gratitude intervention on the transdiagnostic risk-factor 'repetitive negative thinking'. The multicomponent intervention integrates a variety of gratitude exercises, targeting the cognitive, emotional and behavioural facets of gratitude.

Method

Two hundred adults with pronounced repetitive negative thinking were recruited from the general population. Participants were randomly assigned to either a four-session guided gratitude intervention (n = 100) or waiting list (n = 100). The primary outcome was repetitive negative thinking three months after randomization, with exploratory assessments at six weeks and six months, the latter just for participants in the intervention group.

Results

Following the intention-to-treat principle, by analyses of covariance (ANCOVA), the gratitude intervention group exhibited significantly lower levels of repetitive negative thinking than controls at three months, with d = 0.66, 95 % CI [0.37, 0.94] maintained at six-month follow-up. Significant and meaningful beneficial effects were observed in symptoms of depression (d = 0.42) and generalized anxiety (d = 0.38). These effects were notably stronger in intervention completers who finished at least three sessions.

Conclusions

Results suggest that a multicomponent gratitude intervention is effective at reducing repetitive negative thinking. Multicomponent interventions may be a next step needed to fully realize the potential of gratitude interventions. Such interventions could expand the repertoire of transdiagnostic interventions, especially for repetitive negative thinking. Furthermore, due to its positive connotations, gratitude is a candidate for an indirect intervention aimed at reducing the burden of depression in the general population.

Trial registration

The study is registered in the German Clinical Trial Register (approved primary register of the WHO) as DRKS00006825. The trial protocol can be assessed at: https://www.drks.de/.

Minimal Detectable Changes of the Health Assessment Questionnaire-Disability Index, Patient-Reported Outcomes Measurement Information System-29 Profile Version 2.0 Domains, and Patient Health Questionnaire-8 in People With Systemic Sclerosis: A Scleroderma Patient-Centered Intervention Network Cohort Cross-Sectional Study

OBJECTIVE

Systemic sclerosis (SSc) is a rare, chronic autoimmune disorder associated with disability, diminished physical function, fatigue, pain, and mental health concerns. We assessed minimal detectable changes (MDCs) of the Health Assessment Questionnaire-Disability Index (HAQ-DI), Patient-Reported Outcomes Measurement Information System-29 Profile version 2.0 (PROMIS-29v2.0) domains, and Patient Health Questionnaire (PHQ)-8 in people with SSc.

METHODS

Scleroderma Patient-Centered Intervention Network Cohort participants completed the HAQ-DI, PROMIS-29v2.0 domains, and PHQ-8 at baseline assessments from April 2014 until August 2023. We estimated MDC95 (smallest change that can be detected with 95% certainty) and MDC90 (smallest change that can be detected with 90% certainty) with 95% confidence intervals (CIs) generated via the percentile bootstrapping method resampling 1,000 times. We compared MDC estimates by age, sex, and SSc subtype.

RESULTS

A total of 2,571 participants were included. Most were female (n = 2,241; 87%), and 38% (n = 976) had diffuse SSc. Mean (±SD) age was 54.9 (±12.7) years and duration since onset of first non-Raynaud phenomenon symptom was 10.8 (±8.7) years. MDC95 estimate was 0.41 points (95% CI 0.40-0.42) for the HAQ-DI, between 4.88 points (95% CI 4.72-5.05) and 9.02 points (95% CI 8.80-9.23) for the seven PROMIS-29v2.0 domains, and 5.16 points (95% CI 5.06-5.26) for the PHQ-8. MDC95 estimates were not materially different across subgroups.

CONCLUSION

MDC95 and MDC90 estimates were precise and similar across age, sex, and SSc subtype groups. HAQ-DI MDC95 and MDC90 were substantially larger than previous estimates of HAQ-DI minimal important difference from several small studies. Minimally important differences of all measures should be evaluated in large studies using anchor-based methods.

Changes in patient-reported outcomes during admission to a South African psychiatric facility

Background

Patient-reported outcome measures (PROMs) are used as part of clinical practice to determine the impact of the condition and treatment interventions on a patient's health and quality of life. The Patient Health Questionnaire-9 (PHQ-9) is a self-administered diagnostic tool that has been widely adopted for the detection and monitoring of depression.

Aim

This analysis reports the change in PHQ-9 scores from admission to discharge in patients admitted for depression to a South African acute psychiatric facility and aims to quantify the treatment effect of the admission using the PHQ-9 as the measurement tool.

Setting

South African acute psychiatric facility.

Methods

This was a retrospective observational study of all patients admitted to Netcare Akeso acute psychiatric facilities from 01 January 2018 to 31 October 2022. Patients were included if they were ≥ 18 years of age, admitted with a primary International Classification of Disease (ICD)-10 code for depression (i.e. F32-F33) and fully completed both an admission and discharge PHQ-9 questionnaire. We excluded facilities focusing only on the treatment of patients with specialised conditions such as addiction or eating disorders.

Results

This analysis included 13 308 patients admitted for depression at 10 different facilities. The median PHQ-9 score on admission was 19 (interquartile range [IQR] 14-23) and 5 (IQR 2-11) on discharge, with a median change of -12 (IQR -5 to -18). A minimal clinically important difference was seen in 87.6% patients (n = 10 091/11 515); a treatment effect was seen in 74.5% of patients and a clinically significant improvement was seen in 72.1% of patients.

Conclusion

With the average patient reporting a four-fold reduction in the severity of their depression scores, PROMs provide a critical patient-centred window into the benefit that an inpatient admission has on those suffering with depression.

Contribution

These changes are consistent with those seen internationally and provide a baseline for understanding the treatment efficacy of an inpatient admission for the treatment of depression.

Impact of COVID-19 Vaccine Rollout on Mental Health, Social Determinants of Health, and Attitudes Among Individuals With COPD

Background

Social distancing early in the COVID-19 pandemic helped mitigate viral spread and protect vulnerable populations. Broad availability of vaccines allowed social re-integration, but effects on mental health, social determinants of health, and attitudes among individuals with chronic obstructive pulmonary disease (COPD), who are high risk for adverse outcomes following COVID-19 infection, are unknown.

Methods

Participants in the Losartan Effects on Emphysema Progression trial were recruited into an ancillary study from May to November 2020. Study coordinators administered telephone questionnaires to evaluate respiratory symptoms (COPD Assessment Test [CAT]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]) and depressive (Patient Health Questionnaire [PHQ-8]) symptoms, social isolation, instrumental support, and attitudes and actions related to the COVID-19 pandemic. Generalized estimating equation models evaluated changes in patient-reported scores from the period before vaccine availability (prevaccine, May to December 2020) to the postvaccine period (May 2021 to September 2022).

Results

Of 157 enrolled participants, 138 were interviewed during both periods. Compared with the prevaccine period, severe respiratory symptoms (CAT>20) were higher in the postvaccine period (odds ratio [OR] 1.36, 95% confidence interval [CI] 95%: 1.00-1.85), as were moderate anxiety symptoms (GAD-7≥10; OR 1.65, 95%CI: 1.11-2.46) and moderate depressive symptoms (PHQ-8≥10; OR 1.77, 95%CI: 1.22-2.55). Social isolation improved, though not significantly, and instrumental support was unchanged. In the postvaccine period compliance with COVID-19 mitigation strategies remained high and governmental health care entities were viewed as trustworthy by fewer respondents.

Conclusion

Despite a trend towards less social isolation following broad availability of COVID-19 vaccines, individuals with COPD reported worse symptoms, and greater anxiety and depressive symptoms compared to the prevaccine period.

Individual patient data meta-analysis estimates the minimal detectable change of the Geriatric Depression Scale-15

OBJECTIVES

To use individual participant data meta-analysis (IPDMA) to estimate the minimal detectable change (MDC) of the Geriatric Depression Scale-15 (GDS-15) and to examine whether MDC may differ based on participant characteristics and study-level variables.

STUDY DESIGN AND SETTING

This was a secondary analysis of data from an IPDMA on the depression screening accuracy of the GDS. Datasets from studies published in any language were eligible for the present study if they included GDS-15 scores for participants aged 60 or older. MDC of the GDS-15 was estimated via random-effects meta-analysis using 2.77 (MDC95) and 1.41 (MDC67) standard errors of measurement. Subgroup analyses were used to evaluate differences in MDC by participant age and sex. Meta-regression was conducted to assess for differences based on study-level variables, including mean age, proportion male, proportion with major depression, and recruitment setting.

RESULTS

5876 participants (mean age 76 years, 40% male, 11% with major depression) from 21 studies were included. The MDC95 was 3.81 points (95% confidence interval [CI] 3.59, 4.04), and MDC67 was 1.95 (95% CI 1.83, 2.03). The difference in MDC95 was 0.26 points (95% CI 0.04, 0.48) between ≥80-year-olds and <80-year-olds; MDC95 was similar for females and males (0.05, 95% CI -0.12, 0.22). The MDC95 increased by 0.29 points (95% CI 0.17, 0.41) per 10% increase in proportion of participants with major depression; mean age had a small association (0.04 points, 95% CI 0.00 to 0.09) with MDC95, but sex and recruitment setting were not significantly associated.

CONCLUSION

The MDC95 was 3.81 points and MDC67 was 1.95 points. MDC95 increased with the proportion of participants with major depression. Results can be used to evaluate individual changes in depression symptoms and as a threshold for assessing minimal clinical important difference estimates.

Telehealth vs in-person education for enhancing self-care of ostomy patients (Self-Stoma): Protocol for a noninferiority, randomized, open-label, controlled trial

INTRODUCTION

Postoperative patients with ostomies experience significant changes in their lives as a result of the device implantation. Self-care is important to improve their health outcomes. Telehealth provides an opportunity to expand access to self-care education.

AIM

This is a multicenter, non-inferiority randomized, open-label, controlled trial to evaluate the non-inferiority of a telehealth intervention to the standard in-person approach in improving self-care behaviors.

METHODS AND ANALYSIS

Three hundred and eighty-four patients aged ≥ 18 years, with a recently placed ostomy, no stomal/peristomal complications, and documented cognitive integrity will be randomly assigned (1:1) to receive either a telehealth intervention (four remote educational sessions) or a standard educational approach (four in-person sessions) delivered in outpatient settings. Every session (remote and in-person) will occur on Days 25, 32, 40, and 60 after discharge. Follow-ups will occur 1, 3, and 6 months after the last intervention session. Primary outcome is self-care maintenance measured using the Ostomy Self-care Index (OSCI). Secondary outcomes include self-care monitoring, self-care management, self-efficacy (OSCI), quality of life (Stoma specific quality of Life), depression (Patient Health Questionnaire-9), adjustment (Ostomy Adjustment Inventory-23), stomal and peristomal complication rates, healthcare services utilization, mobility, and number of working days lost. Analyses will be performed per intention-to-treat and per protocol.

ETHICS AND DISSEMINATION

This study has been approved by the Institutional Review Board of the main center (registration number: 119/22). Following completion of the trial, dissemination meetings will be held to share the results of the study with the participants and the health-care team. Adoption of telehealth technologies for ostomy patients can improve service organization by ensuring better integration and continuity of care. If the remote intervention produces comparable effects to the in-person intervention, it would be wise to make telehealth education an alternative treatment for addressing the educational needs of uncomplicated postoperative ostomy patients.

TRIAL REGISTRATION

ClinicalTrials.gov (identifier number: NCT05796544).

Predicting post-treatment symptom severity for adults receiving psychological therapy in routine care for generalised anxiety disorder: a machine learning approach

Approximately half of generalised anxiety disorder (GAD) patients do not recover from first-line treatments, and no validated prediction models exist to inform individuals or clinicians of potential treatment benefits. This study aimed to develop and validate an accurate and explainable prediction model of post-treatment GAD symptom severity. Data from adults receiving treatment for GAD in eight Improving Access to Psychological Therapies (IAPT) services (n=15,859) were separated into training, validation and holdout datasets. Thirteen machine learning algorithms were compared using 10-fold cross-validation, against two simple clinically relevant comparison models. The best-performing model was tested on the holdout dataset and model-specific explainability measures identified the most important predictors. A Bayesian Additive Regression Trees model out-performed all comparison models (MSE=16.54 [95 % CI=15.58; 17.51]; MAE=3.19; R²=0.33, including a single predictor linear regression model: MSE=20.70 [95 % CI=19.58; 21.82]; MAE=3.94; R²=0.14). The five most important predictors were: PHQ-9 anhedonia, GAD-7 annoyance/irritability, restlessness and fear items, then the referral-assessment waiting time. The best-performing model accurately predicted post-treatment GAD symptom severity using only pre-treatment data, outperforming comparison models that approximated clinical judgement and remaining within the GAD-7 error of measurement and minimal clinically important differences. This model could inform treatment decision-making and provide desired information to clinicians and patients receiving treatment for GAD.

Acceptability and Feasibility of the Telehealth Bariatric Behavioral Intervention to Increase Physical Activity Before Bariatric Surgery: A Single-Case Experimental Study (Part I)

BACKGROUND

Physical activity (PA) can play an important role in optimizing metabolic/bariatric surgery (MBS) outcomes. However, many MBS patients have difficulty increasing PA, necessitating the development of theory-driven counseling interventions. This study aimed to (1) assess the feasibility and acceptability of the TELEhealth BARIatric behavioral intervention (TELE-BariACTIV) trial protocol/methods and intervention, which was designed to increase moderate-to-vigorous intensity physical activity (MVPA) in adults awaiting MBS and (2) estimate the effect of the intervention on MVPA.

METHODS

This trial used a repeated single-case experimental design. Twelve insufficiently active adults awaiting MBS received 6 weekly 45-min PA videoconferencing counseling sessions. Feasibility and acceptability data (i.e., refusal, recruitment, retention, attendance, and attrition rates) were tracked and collected via online surveys, and interviews. MVPA was assessed via accelerometry pre-, during, and post-intervention.

RESULTS

Among the 24 patients referred to the research team; five declined to participate (refusal rate = 20.8%) and seven were ineligible or unreachable. The recruitment rate was 1.2 participants per month between 2021-09 and 2022-07. One participant withdrew during the baseline phase, and one after the intervention (retention rate = 83.3%). No participant dropouts occurred during the intervention and 98.6% of sessions were completed. Participants' anticipated and retrospective acceptability of the intervention was 3.2/4 (IQR, 0.5) and 3.0/4 (IQR, 0.2), respectively. There was a statistically significant increase in MVPA [Tau-U = 0.32(0.11; 0.51)] from pre- to post-intervention.

CONCLUSION

Despite a low recruitment rate, which could be explained by circumstances (COVID-19 pandemic), results support feasibility, acceptability, and preliminary efficacy of the TELE-Bari-ACTIV intervention for increasing MVPA in patients awaiting MBS.

Prehabilitation in Adults Undergoing Cancer Surgery: A Comprehensive Review on Rationale, Methodology, and Measures of Effectiveness

Cancer surgery places a significant burden on a patients' functional status and quality of life. In addition, cancer surgery is fraught with postoperative complications, themselves influenced by a patient's functional status. Prehabilitation is a unimodal or multimodal strategy that aims to increase a patient's functional capacity to reduce postoperative complications and improve postoperative recovery and quality of life. In most cases, it involves exercise, nutrition, and anxiety-reducing interventions. The impact of prehabilitation has been explored in several types of cancer surgery, most commonly colorectal and thoracic. Overall, the existing evidence suggests prehabilitation improves physiological outcomes (e.g., lean body mass, maximal oxygen consumption) as well as clinical outcomes (e.g., postoperative complications, quality of life). Notably, the benefit of prehabilitation is additional to that of enhanced recovery after surgery (ERAS) programs. While safe, prehabilitation programs require multidisciplinary coordination preoperatively. Despite the existence of numerous systematic reviews and meta-analyses, the certainty of evidence demonstrating the efficacy and safety of prehabilitation is low to moderate, principally due to significant methodological heterogeneity and small sample sizes. There is a need for more large-scale multicenter randomized controlled trials to draw strong clinical recommendations.

Measurement invariance and differential item functioning of the PHQ-9 and GAD-7 between working age and older adults seeking treatment for common mental disorders

BACKGROUND

The nine-item Patient Health Questionnaire (PHQ-9) and seven-item Generalised Anxiety Disorder (GAD-7) scale are widely used clinically and within research, and so it is important to determine how the measures, and individual items within the measures, are answered by adults of differing ages. This study sought to evaluate measurement invariance and differential item functioning (DIF) of the PHQ-9 and GAD-7 between working age and older adults seeking routine psychological treatment.

METHODS

Data of working age (18-64 years old) and older (≥65) adults in eight Improving Access to Psychological Therapies (IAPT) services were used. Confirmatory factor analysis (CFA) was used to establish unidimensionality of the PHQ-9 and GAD-7, with multiple-group CFA to test measurement invariance and The Multiple Indicators, Multiple Causes Models approach to assess DIF. The employed methods were applied to a propensity score matched (PSM) sample in sensitivity analyses to control for potential confounding.

RESULTS

Data from 166,816 patients (159,325 working age, 7491 older) were used to show measurement invariance for the PHQ-9 and GAD-7, with limited evidence of DIF and similar results found with a PSM sample (n = 5868).

LIMITATIONS

The localised sample creates an inability to detect geographical variance, and the potential effect of unmeasured confounders cannot be ruled out.

CONCLUSIONS

The findings support the use of the PHQ-9 and GAD-7 measures for working age and older adults, both clinically and in research settings. This study validates using the measures for these age groups to assess clinically significant symptom thresholds, and monitor treatment outcomes between them.

Connectivity-guided intermittent theta burst versus repetitive transcranial magnetic stimulation for treatment-resistant depression: a randomized controlled trial

Disruption in reciprocal connectivity between the right anterior insula and the left dorsolateral prefrontal cortex is associated with depression and may be a target for neuromodulation. In a five-center, parallel, double-blind, randomized controlled trial we personalized resting-state functional magnetic resonance imaging neuronavigated connectivity-guided intermittent theta burst stimulation (cgiTBS) at a site based on effective connectivity from the right anterior insula to the left dorsolateral prefrontal cortex. We tested its efficacy in reducing the primary outcome depression symptoms measured by the GRID Hamilton Depression Rating Scale 17-item over 8, 16 and 26 weeks, compared with structural magnetic resonance imaging (MRI) neuronavigated repetitive transcranial magnetic stimulation (rTMS) delivered at the standard stimulation site (F3) in patients with 'treatment-resistant depression'. Participants were randomly assigned to 20 sessions over 4-6 weeks of either cgiTBS (n = 128) or rTMS (n = 127) with resting-state functional MRI at baseline and 16 weeks. Persistent decreases in depressive symptoms were seen over 26 weeks, with no differences between arms on the primary outcome GRID Hamilton Depression Rating Scale 17-item score (intention-to-treat adjusted mean, -0.31, 95% confidence interval (CI) -1.87, 1.24, P = 0.689). Two serious adverse events were possibly related to TMS (mania and psychosis). MRI-neuronavigated cgiTBS and rTMS were equally effective in patients with treatment-resistant depression over 26 weeks (trial registration no. ISRCTN19674644).

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.

Efficacy of manual acupuncture vs. placebo acupuncture for generalized anxiety disorder (GAD) in perimenopausal women: a randomized, single-blinded controlled trial

Background

Generalized anxiety disorder (GAD) is common among perimenopausal women. Acupuncture may be an effective treatment for GAD, but evidence is limited. The pathogenesis of GAD is not yet clear, but it is related to the hypothalamic-pituitary-adrenal axis and its excretion, cortisol (CORT), and the adrenocorticotropic hormone (ACTH). The objective of this study is to evaluate the efficacy of manual acupuncture (MA) vs. placebo acupuncture (PA) for perimenopausal women with GAD.

Methods

This study is a single-center, randomized, single-blind clinical trial conducted in the First Affiliated Hospital of Guangzhou University of Chinese Medicine. A total of 112 eligible patients with GAD were randomly assigned (1:1) to receive MA (n = 56) or PA (n = 56) three times per week for 4 weeks. The primary outcome measure was the HAMA score. The secondary outcome measures were the GAD-7 and PSQI scores and the levels of CORT and ACTH. The evaluation will be executed at the baseline, 2 weeks, the end of the treatment, and a follow-up 3-month period.

Results

Significant improvements in HAMA (p < 0.001, η2p = 0.465), GAD-7 (p < 0.001, η2p = 0.359) and ACTH (p = 0.050) values were found between T0 and T2 in the MA group compared to the PA group. No difference in PSQI (p = 0.613, η2p = 0.011) and CORT (p = 0.903) was found between T0 and T2 in the MA group compared to the PA group. Long-term improvements in HAMA (p < 0.001, p < 0.001) were found in the MA group and PA group.

Conclusion

This study was the first completed study to evaluate the efficacy of acupuncture and placebo acupuncture for GAD in perimenopausal patients. Results suggested that placebo acupuncture has a therapeutic effect, however, acupuncture had a greater therapeutic effect than placebo acupuncture. This study supports the effectiveness of acupuncture and thereby contributes to extended treatment options for GAD.Clinical trial registration:http://www.chictr.org.cn, Chinese Clinical Trial Registry, ID: ChiCTR2100046604. Registered on 22 May 2021.

Can psychological interventions prevent or reduce risk for perinatal anxiety disorders? A systematic review and meta-analysis

OBJECTIVE

Little is known about the extent to which interventions can prevent perinatal anxiety disorders. We conducted a systematic review and meta-analysis to examine whether interventions can decrease the onset and symptoms of perinatal anxiety among individuals without an anxiety disorder diagnosis.

METHOD

We conducted a comprehensive literature search across five databases related to key concepts: (1) anxiety disorders/anxiety symptom severity (2) perinatal (3) interventions (4) prevention. We included studies that examined a perinatal population without an anxiety disorder diagnosis, included a comparator group, and assessed perinatal anxiety. We included interventions focused on perinatal anxiety as well as interventions to prevent perinatal depression or influence related outcomes (e.g., physical activity).

RESULTS

Thirty-six studies were included. No study assessing the incidence of perinatal anxiety disorder (n = 4) found a significant effect of an intervention. Among studies assessing anxiety symptom severity and included in the quantitative analysis (n = 30), a meta-analysis suggested a small standardized mean difference of -0.31 (95% CI [-0.46, -0.16], p < .001) for anxiety at post intervention, favoring the intervention group. Both mindfulness (n = 6), and cognitive behavioral therapy approaches (n = 10) were effective.

CONCLUSIONS

Interventions developed for perinatal anxiety were more effective than interventions to prevent perinatal depression. Psychological interventions show promise for reducing perinatal anxiety symptom severity, though interventions specifically targeting anxiety are needed.

Feasibility and efficacy of a digital resilience training: A pilot study of the strengths-based training RESIST

Background

Work-related stress is a risk factor for a number of adverse health and work outcomes. Resilience trainings are a promising approach for adequately dealing with work stress and keeping employees mentally healthy. However, results of previous resilience trainings have been heterogeneous, ranging from null findings to large effects. Existing digital resilience interventions show a lack of consistency in terms of an underlying theoretical framework and methods used to foster resilience. Positive Appraisal Style Theory of Resilience offers an innovative conceptualization of resilience. Strengths-based cognitive behavioral therapy is a corresponding therapeutically method reflecting resilience as a resource-oriented process of dealing with stress. Based on this background, a new hybrid web-and app-based digital resilience intervention for employees named RESIST was developed.

Objective

The first aim of the study was to investigate the feasibility of the newly developed training RESIST regarding its usability, user behavior, user experience and motivation to use. Second, the study sought to explore preliminary effects of the intervention on reducing stress and enhancing resilience by conducting a pilot randomized controlled trial.

Methods

The feasibility study was conducted in three phases. First, the usability of the app was investigated in a pre-test with five participants using a thinking-aloud method. Second, the preliminary efficacy of the training was examined in a pilot randomized controlled trial. A sample of 30 employees were randomized either to receive the resilience training (n = 15) or to be member of a control group (n = 15). The primary outcome was measuring perceived stress. Secondary outcomes included measures of resilience and depressive symptoms. Third, semi-structured interviews were undertaken with six participants of the resilience training group on training content, motivation for use, and user experience.

Results

Overall, results indicate that RESIST can be a feasible training for resilience promotion and stress reduction with high user satisfaction. Analysis of covariance showed that, relative to controls, participants who received RESIST reported significantly lower stress scores at post-intervention (F1,27 = 16.91, p < 0.001; Cohen's d = 1.57; 95 % CI 0.71-2.43) than controls. Significant differences, with moderate-to-large effect sizes, were also detected for general resilience and various resilience factors.

Conclusions

Results are promising and provide hope that a hybrid web- and app-based resilience intervention based on strengths-based cognitive behavioral therapy can have a positive impact on dealing adequately with stress and improve resilience of employees.

Investigating the factors associated with meaningful improvement on the SF-36-PFS and exploring the appropriateness of this measure for young people with ME/CFS accessing an NHS specialist service: a prospective cohort study

OBJECTIVES

Paediatric myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS) is relatively common and disabling, but little is known about the factors associated with outcome. We aimed to describe the number and characteristics of young people reaching the 10-point minimal clinically important difference (MCID) of SF-36-Physical Function Subscale (SF-36-PFS) and to investigate factors associated with reaching the MCID.

DESIGN

Prospective observational cohort study.

SETTING

A specialist UK National Health Service ME/CFS service, Southwest England; recruitment between March 2014 and August 2015.

PARTICIPANTS

193 eligible patients with ME/CFS aged 8-17 years reported baseline data. 124 (65%) and 121 (63%) with outcome data at 6 and 12 months, respectively.

OUTCOME MEASURES

SF-36-PFS (primary outcome). Chalder Fatigue Questionnaire, school attendance, visual analogue pain scale, Hospital Anxiety and Depression Scale, Spence Young People Anxiety Scale, Clinical Global Impression scale and EQ-5D-Y (secondary).

RESULTS

At 6 months 48/120 (40%) had reached the MCID for SF-36-PFS. This had increased to 63/117 (54%) at 12 months. On the Clinical Global Impressions, 77% and 79% reported feeling either a little better, much better or very much better. Those with worse SF-36-PFS at baseline assessment were more likely to achieve the MCID for SF-36-PFS at 6 months (odds ratio 0.97, 95% confidence interval 0.96 to 0.99, p value 0.003), but there was weaker evidence of effect at 12 months (OR 0.98, 95% CI 0.97 to 1.00, p value 0.038). No other factors at baseline were associated with the odds of reaching the MCID at 6 months. However, at 12 months, there was strong evidence of an effect of pain on MCID (OR 0.97, 95% CI 0.95 to 0.99, p value 0.001) and SF-36-PFS on MCID (OR 0.96, 95% CI 0.94 to 0.98, p value 0.001).

CONCLUSIONS

40% and 54% of young people reached the MCID at 6 and 12 months, respectively. No factors at assessment (other than SF-36-PFS at 6 months, and pain and SF-36-PFS at 12 months) are associated with MCID of SF-36-PFS at either 6 or 12 months. Further work is needed to explore the most appropriate outcome measure for capturing clinical meaningful improvement for young people with ME/CFS.

Comparison Between Burden of Care Partners of Individuals with Alzheimer's Disease Versus Individuals with Other Chronic Diseases

BACKGROUND

Caregiving in Alzheimer's disease (AD) is often provided by informal care partners, who spend more hours per week on average than care partners of individuals with conditions other than AD. However, the burden of care in partners of individuals with AD has not been systematically compared to that of other chronic diseases.

OBJECTIVE

The current study therefore aims to compare the care partner burden of AD to that of other chronic diseases through a systematic literature review.

METHODS

Data was collected from journal articles published in the last 10 years, using two unique search strings in PubMed and analysed using pre-defined patient-reported outcome measures (PROMs) including the EQ-5D-5L, GAD-7, GHQ-12, PHQ-9, WPAI and the ZBI. The data was grouped according to the included PROMs and the diseases studied. The number of participants in the studies reporting burden of caregiving in AD was adjusted to reflect the number of participants in studies reporting care partner burden in other chronic diseases.

RESULTS

All results in this study are reported as a mean value and standard deviation (SD). The ZBI measurement was the most frequently used PROM to collect care partner burden (15 studies) and showed a moderate burden (mean 36.80, SD 18.35) on care partners of individuals with AD, higher than most of the other included diseases except for those characterized by psychiatric symptoms (mean scores 55.92 and 59.11). Other PROMs such as PHQ-9 (six studies) and GHQ-12 (four studies) showed a greater burden on care partners of individuals with other chronic diseases such as heart failure, haematopoietic cell transplantations, cancer and depression compared to AD. Likewise, GAD-7 and EQ-5D-5L measurements showed a lesser burden on care partners of individuals with AD compared to care partners of individuals with anxiety, cancer, asthma and chronic obstructive pulmonary disease. The current study suggests that care partners of individuals with AD experience a moderate burden, but with some variations depending on the PROMs used.

CONCLUSION

The results of this study were mixed with some PROMs indicating a greater burden for care partners of individuals with AD versus other chronic diseases, and other PROMs showing a greater burden for care partners of individuals with other chronic diseases. Psychiatric disorders imposed a greater burden on care partners compared to AD, while somatic diseases in the musculoskeletal system resulted in a significantly smaller burden on care partners compared to AD.

Age and Sex Differences in the Association between Serum Vitamin E Levels and Depressive Symptoms: Korea National Health and Nutrition Examination Survey

Studies have reported inconsistent results regarding the relationship between serum vitamin E levels and depressive symptoms. Furthermore, the potential modulating role of age and sex has been underexplored. We conduct an age- and sex-stratified investigation of the association between serological vitamin E status and depressive symptoms in a large nationwide sample. Data from the Korean National Health and Nutrition Examination Survey were analyzed (n = 4448). The participants were stratified into four groups according to age (<65 vs. ≥65 years) and sex. Each group was divided into tertiles of vitamin E/total lipid ratio, and Patient Health Questionnaire-9 (PHQ-9) scores were compared among the tertiles via multivariable linear regression analyses. The relationship between dietary supplement use and the proportions of tertiles was assessed in each group. With the middle tertile as the reference group, the low tertile of vitamin E/total lipid ratio was associated with increased PHQ-9 scores in younger females and older males after adjusting for all covariates, while the high tertile showed no significant associations with PHQ-9 scores in any group. The low tertile was associated with increased adjusted mean PHQ-9 scores by 0.53 and 1.02 compared to the middle tertile in younger females and older males, respectively. Dietary supplement use was related to higher vitamin E/total lipid ratio in all four groups. In conclusion, younger females and older males with a low vitamin E status showed worse depressive symptoms. These individuals may benefit from dietary interventions to prevent depressive symptoms.

Personalised psychotherapy in primary care: evaluation of data-driven treatment allocation to cognitive-behavioural therapy versus counselling for depression

BACKGROUND

Various effective psychotherapies exist for the treatment of depression; however, only approximately half of patients recover after treatment. In efforts to improve clinical outcomes, research has focused on personalised psychotherapy - an attempt to match patients to treatments they are most likely to respond to.

AIM

The present research aimed to evaluate the benefit of a data-driven model to support clinical decision-making in differential treatment allocation to cognitive-behavioural therapy versus counselling for depression.

METHOD

The present analysis used electronic healthcare records from primary care psychological therapy services for patients receiving cognitive-behavioural therapy (n = 14 544) and counselling for depression (n = 4725). A linear regression with baseline sociodemographic and clinical characteristics was used to differentially predict post-treatment Patient Health Questionnaire (PHQ-9) scores between the two treatments. The benefit of differential prescription was evaluated in a held-out validation sample.

RESULTS

On average, patients who received their model-indicated optimal treatment saw a greater improvement (by 1.78 PHQ-9 points). This translated into 4-10% more patients achieving clinically meaningful changes. However, for individual patients, the estimated differences in benefits of treatments were small and rarely met the threshold for minimal clinically important differences.

CONCLUSION

Precision prescription of psychotherapy based on sociodemographic and clinical characteristics is unlikely to produce large benefits for individual patients. However, the benefits may be meaningful from an aggregate public health perspective when applied at scale.

Clinical effectiveness of active Alpha-Stim AID versus sham Alpha-Stim AID in major depression in primary care in England (Alpha-Stim-D): a multicentre, parallel group, double-blind, randomised controlled trial

BACKGROUND

Randomised sham-controlled trials of cranial electrostimulation with the Alpha-Stim Anxiety Insomnia and Depression (AID) device have reported improved anxiety and depression symptoms; however, no adequately powered sham-controlled trials in major depression are available. We investigated whether active Alpha-Stim AID is superior to sham Alpha-Stim AID in terms of clinical effectiveness for depression symptoms in major depression.

METHODS

The Alpha-Stim-D trial was a multicentre, parallel group, double-blind, randomised controlled trial, recruiting participants from 25 primary care centres in two regions in England, UK. Eligible participants were aged 16 years or older with a current diagnosis of primary major depression, a score of 10-19 on the nine-item Patient Health Questionnaire, and had been offered or prescribed and reported taking antidepressant medication for at least 6 weeks in the previous 3 months. Main exclusion criteria were contraindications to Alpha-Stim AID device use, having persistent suicidal ideation or self-harm, neurological conditions, a substance use disorder or dependence, an eating disorder, bipolar disorder, or non-affective psychosis, or receiving psychological treatment in the past 3 months. Eligible participants were randomly assigned (1:1, minimised by region, anxiety disorder, and antidepressant use) to 1 h daily use of active (100 μA) or sham Alpha-Stim AID treatment for 8 weeks. Randomisation was via an independent web-based system, with participants, outcome assessors, and data analyst masked to treatment assignment. The primary outcome was change from baseline in score on the 17-item Hamilton Depression Rating Scale (HDRS-17, GRID version) at 16 weeks after randomisation, with participants analysed by intention to treat (ITT; all randomly assigned participants). Safety was assessed in all randomly assigned participants. The trial is registered with the ISRCTN registry (ISRCTN11853110); status completed.

FINDINGS

Between Sept 8, 2020, and Jan 14, 2022, 236 eligible participants were randomly assigned to active or sham Alpha-Stim AID (n=118 each). 156 (66%) participants were women, 77 (33%) were men, and three (1%) self-reported as other gender; 200 (85%) were White British or Irish; and the mean age was 38·0 years (SD 15·3; range 16-83). 102 (86%) participants in the active Alpha-Stim AID group and 98 (83%) in the sham group were followed up 16 weeks after randomisation. In the ITT population, mean change in GRID-HDRS-17 at 16 weeks was -5·9 (95% CI -7·1 to -4·8) in the active Alpha-Stim AID group and -6·5 (-7·7 to -5·4) in the sham group (mean change difference -0·6 [95% CI -1·0 to 2·2], p=0·46). Among the 236 participants, 17 adverse events were reported in 17 (7%) participants (nine [8%] participants in the active Alpha-Stim AID group; and eight [7%] participants in the sham group). One serious adverse event of suicidal ideation leading to hospitalisation was reported in the sham group, which was judged to be unrelated to the device.

INTERPRETATION

Active Alpha-Stim AID was safe and acceptable, but no more clinically effective than sham Alpha-Stim AID in major depression.

FUNDING

National Institute for Health Research Applied Research Collaboration East Midlands and Electromedical Products International.

Protocol for the effectiveness evaluation of an antenatal, universally offered, and remotely delivered parenting programme 'Baby Steps' on maternal outcomes: a Born in Bradford's Better Start (BiBBS) study

BACKGROUND

Poor perinatal mental health and maternal sensitivity towards a child in the early years can carry a long-term cost to individuals and to society, and result in negative child outcomes such as poor mental health and social emotional issues. Despite the recognition of early intervention and prevention, there is mixed evidence regarding antenatal parenting interventions that aim to enhance perinatal mental health and maternal sensitivity to prevent negative child outcomes. 'Baby Steps' is a relationship-based antenatal and postnatal parenting programme. The service evaluated in this study is delivered in a low-income and ethnically diverse community via Better Start Bradford. This study aims to assess whether the universally, and remotely delivered Baby Steps programme is effective in improving postnatal maternal sensitivity (primary outcome) and postnatal maternal mental health (secondary outcome) when compared to services as usual 6-10 weeks post-birth. It will also assess differences in birth outcomes, and differences in the prevalence of poor perinatal mental ill health through routine data. The feasibility of collecting cost and health related resource use data for a future economic evaluation will be explored.

METHODS

The study is a quasi-experimental evaluation in a single centre. All participants are drawn from Born in Bradford's Better Start (BiBBS) interventional family cohort study. Intervention participants will be matched to a demographically comparable control group using propensity score matching. The required minimum sample is n = 130 (ratio 1:1) to detect a medium effect (± 2.35, d = .50) on the primary outcome-maternal-child sensitivity, using the Mothers Object Relations Scale Short Form (MORS-SF). Secondary outcomes include the Patient Health Questionnaire (PHQ-8), Generalised Anxiety Disorder assessment 7 (GAD-7), identification of poor perinatal mental health through routine data, and birth outcomes (delivery method, gestation period, low birth weight). Service delivery costs and health resource use will be gathered from routine data.

DISCUSSION

This study will evaluate the effectiveness of Baby Steps for enhancing maternal-child sensitivity and maternal mental health when delivered universally and remotely. The findings regarding programme effectiveness, process, and costs will be relevant for researchers, service commissioners, and service staff.

TRIAL REGISTRATION

This study was prospectively registered with ISRCTN (22/04/2022, ISRCTN12196131).

UK medical cannabis registry: assessment of clinical outcomes in patients with headache disorders

OBJECTIVES

Headache disorders are a common cause of disability and reduced health-related quality of life globally. Growing evidence supports the use of cannabis-based medicinal products (CBMPs) for chronic pain; however, a paucity of research specifically focuses on CBMPs' efficacy and safety in headache disorders. This study aims to assess changes in validated patient-reported outcome measures (PROMs) in patients with headaches prescribed CBMPs and investigate the clinical safety in this population.

METHODS

A case series of the UK Medical Cannabis Registry was conducted. Primary outcomes were changes from baseline in PROMs (Headache Impact Test-6 (HIT-6), Migraine Disability Assessment (MIDAS), EQ-5D-5L, Generalized Anxiety Disorder-7 (GAD-7) questionnaire and Single-Item Sleep Quality Scale (SQS)) at 1-, 3-, and 6-months follow-up. P-values <0.050 were deemed statistically significant.

RESULTS

Ninety-seven patients were identified for inclusion. Improvements in HIT-6, MIDAS, EQ-5D-5L and SQS were observed at 1-, 3-, and 6-months (p < 0.005) follow-up. GAD-7 improved at 1- and 3-months (p < 0.050). Seventeen (17.5%) patients experienced a total of 113 (116.5%) adverse events.

CONCLUSION

Improvements in headache/migraine-specific PROMs and general health-related quality of life were associated with the initiation of CBMPs in patients with headache disorders. Cautious interpretation of results is necessary, and randomized control trials are required to ascertain causality.

What Proportion of Patients With Musculoskeletal Sarcomas Demostrate Symptoms of Depression or Anxiety?

BACKGROUND

It is estimated that the 12-month prevalence of depression in the United States is 8.6%, and for anxiety it is 2.9%. Although prior studies have evaluated depression and anxiety in patients with carcinoma, few have specifically evaluated patients with sarcoma, who often have unique treatment considerations such as mobility changes after surgery.

QUESTIONS/PURPOSES

We evaluated patients with sarcoma seen in our orthopaedic oncology clinic to determine (1) the proportion of patients with depression symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the nine-item Patient Health Questionnaire (PHQ-9), and if their symptoms varied by disease state; (2) the proportion of patients with anxiety symptoms, symptom severity, how many patients triggered a referral to mental health professionals based upon our prespecified cutoff scores on the seven-item Generalized Anxiety Disorder Scale (GAD-7), and if they symptoms varied by disease state; (3) whether other factors were associated with the proportion and severity of symptoms of anxiety or depression, such as tumor location in the body (axial skeleton, upper extremity, or lower extremity), general type of tumor (bone or soft tissue), specific diagnosis, use of chemotherapy, length of follow-up (less than 1 year or greater than 1 year), and gender; and (4) what proportion of patients accepted referrals to mental health professionals, when offered.

METHODS

This study was a cross-sectional survey study performed at a single urban National Cancer Institute-designated Comprehensive Cancer Center from April 2021 until July 2021. All patients seen in the orthopaedic clinic 18 years of age and older with a diagnosis/presumed diagnosis of sarcoma were provided the PHQ-9 as well as the GAD-7 in our clinic. We did not track those who elected not to complete the surveys. Surveys were scored per survey protocol (each question was scored from 0 to 3 and summed). Specifically, PHQ-9 scores the symptoms of depression as 5 to 9 (mild), 10 to 14 (moderate), 15 to 19 (moderately severe), and 20 to 27 (severe). The GAD-7 scores symptoms of anxiety as 5 to 9 (mild), 10 to 14 (moderate), and 15 to 21 (severe). Patients with PHQ-9 or GAD-7 scores of 10 to 14 were referred to social work and those with scores 15 or higher were referred to psychiatry. Patients with thoughts of self-harm were referred regardless of score. Patients were divided based on disease state: patients during their initial management; patients with active, locally recurrent disease; patients with active metastatic disease; patients with prior recurrence or metastatic lesions who were subsequently treated and now have no evidence of disease (considered to be patients with discontinuous no evidence of disease); patients with no evidence of disease; and patients with an active, noncancerous complication but otherwise no evidence of disease. We additionally looked at the association of gender, chemotherapy administration, and tumor location on survey responses. Data are summarized using descriptive statistics. Differences across categories of disease state were tested for statistical significance using Kruskal-Wallis tests for continuous variables and Fisher exact tests for categorical variables as well as pairwise Wilcoxon rank sum tests.

RESULTS

Overall, symptoms of depression were seen in 35% (67 of 190) of patients, at varying levels of severity: 19% (37 of 190) had mild symptoms, 9% (17 of 190) had moderate symptoms, 6% (12 of 190) had moderately severe symptoms, and 1% (1 of 190) had severe symptoms. Depresssion symptoms severe enough to trigger a referral were seen in 17% (32 of 190) of patients overall. Patients scored higher on the PHQ-9 during their initial treatment or when they had recurrent or metastatic disease, and they were more likely to trigger a referral during those timepoints as well. The mean PHQ-9 was 5.7 ± 5.8 during initial treatment, 6.1 ± 4.9 with metastatic disease, and 7.4 ± 5.2 with recurrent disease as compared with 3.2 ± 4.2 if there was no evidence of disease (p = 0.001). Anxiety symptoms were seen in 33% (61 of 185) of patients: 17% (32 of 185) had mild symptoms, 8% (14 of 185) had moderate symptoms, and 8% (15 of 185) had severe symptoms. Anxiety symptoms severe enough to trigger a referral were seen in 16% (29 of 185) of patients overall. Patients scored higher on the GAD-7 during initial treatment and when they had recurrent disease or an active noncancerous complication. The mean GAD-7 was 6.3 ± 3.2 in patients with active noncancerous complications, 6.8 ± 5.8 in patients during initial treatment, and 8.4 ± 8.3 in patients with recurrent disease as compared with 3.1 ± 4.2 in patients with no evidence of disease (p = 0.002). Patients were more likely to trigger a referral during initial treatment (32% [9 of 28]) and with recurrent disease (43% [6 of 14]) compared with those with no evidence of disease (9% [9 of 97]) and those with discontinuous no evidence of disease (6% [1 of 16]; p = 0.004). There was an increase in both PHQ-9 and GAD-7 scores among patients who had chemotherapy. Other factors that were associated with higher PHQ-9 scores were location of tumor (upper extremity versus lower extremity or axial skeleton) and gender. Another factor that was associated with higher GAD-7 scores included general category of diagnosis (bone versus soft tissue sarcoma). Specific diagnosis and length of follow-up had no association with symptoms of depression or anxiety. Overall, 22% (41 of 190) of patients were offered referrals to mental health professionals; 73% (30 of 41) accepted the referral.

CONCLUSION

When treating patients with sarcoma, consideration should be given to potential concomitant psychiatric symptoms. Screening, especially at the highest-risk timepoints such as at the initial diagnosis and the time of recurrence, should be considered. Further work should be done to determine the effect of early psychiatric referral on patient-related outcomes and healthcare costs.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Weill Cornell Medicine Wellness Qlinic: Adapting the Student-Run Clinic Model to Expand Mental Health Services and Medical Education

The Weill Cornell Medicine Wellness Qlinic (Wellness Qlinic) is a student-run mental health clinic serving the lesbian, gay, bisexual, transgender, and queer (LGBTQ +) community in New York City. Student-run clinics have successfully provided primary care to underserved communities experiencing barriers to accessing health care. Psychiatric evaluation and medication management have also been implemented in several student-run clinics, but providing sustainable psychotherapy services has been a challenge. In this paper, we present a student-run mental health program incorporating interdisciplinary trainees to provide robust short-term psychiatric treatment, including individual psychotherapy, medication management, and group therapy. Results of a chart-review study to evaluate patient engagement and treatment outcomes are presented. The Wellness Qlinic's treatment model resulted in 90% patient retention and positive clinical outcomes for patients while addressing an education and training gap in LGBTQ + mental health for multidisciplinary mental health care providers.

Effectiveness of primary care psychological therapy services for the treatment of depression and anxiety in people living with dementia: Evidence from national healthcare records in England

Background

Depression and anxiety are common and deleterious in people living with dementia (PLWD). It is currently unknown whether routinely provided psychological therapy can help reduce these symptoms in PLWD. This study aimed to investigate improvements in depression and anxiety symptoms over the course of therapy offered in primary care psychological therapy services in PLWD and to compare outcomes to people without dementia.

Methods

National data from Improving Access to Psychological Therapies services (IAPT) across England linked with Hospital Episode Statistics data, the Mental Health Services Dataset, and HES-ONS mortality data were used to identify 1,549 PLWD who completed a course of psychological treatment in IAPT between 2012-2019 and a propensity score matched control group without identified dementia. Outcome measures included pre-post intervention changes in depression (PHQ-9) and anxiety (GAD-7) symptoms and therapy outcomes (reliable improvement, recovery, deterioration).

Findings

Symptoms of depression (t(1548)=31·05, p<·001) and anxiety (t(1548)=30·31, p<·001) improved in PLWD over the course of psychological therapy with large effect sizes (depression: d=-0·83; anxiety: d=-0·80). However, PLWD were less likely to reliably improve (OR=·75, 95%CI[·63,·88], p<·001) or recover (OR=·75, 95%CI[·64,·88], p=·001), and more likely to deteriorate (OR=1·35, 95%CI[1·03,1·78], p=·029) than a matched control sample without dementia.

Interpretation

Psychological therapy may be beneficial for PLWD with depression or anxiety, but it is currently not as effective as for people without dementia. More research is needed to improve access to psychological therapies and to understand this discrepancy and how therapies can be adapted to further improve outcomes.

Funding

This work was supported by the Alzheimer's Society.

Relationship between change in social evaluation learning and mood in early antidepressant treatment: A prospective cohort study in primary care

BACKGROUND

Antidepressants are proposed to work by increasing sensitivity to positive versus negative information. Increasing positive affective learning within social contexts may help remediate negative self-schema. We investigated the association between change in biased learning of social evaluations about the self and others, and mood during early antidepressant treatment.

METHOD

Prospective cohort assessing patients recruited from primary care in South West England at four timepoints over the first 8 weeks of antidepressant treatment (n = 29). At each timepoint, participants completed self-report measures of depression (Beck Depression Inventory II (BDI-II) and Patient Health Questionnaire 9 (PHQ-9)), anxiety (Generalised Anxiety Disorder Questionnaire 7 (GAD-7)), and a computerised task measuring learning of social evaluations about the self, a friend and a stranger.

RESULTS

We did not find evidence that learning about the self was associated with a reduction in PHQ-9 (b = 0.08, 95% CI: -0.05, 0.20, p = 0.239) or BDI-II scores (b = 0.10, 95% CI: -0.18, 0.38, p = 0.469). We found some weak evidence that increased positive learning about the friend was associated with a reduction in BDI-II scores (b = 0.30, 95% CI: -0.02, 0.62, p = 0.069). However, exploratory analyses indicated stronger evidence that increased positive learning about the self (b = 0.18, 95% CI: 0.07, 0.28, p = 0.002) and a friend (b = 0.22, 95% CI: 0.10, 0.35, p = 0.001) was associated with reductions in anxiety.

CONCLUSIONS

Change in social evaluation learning was associated with a reduction in anxiety but not depression. Antidepressants may treat anxiety symptoms by remediating negative affective biases towards socially threatening information directed towards the self and close others. However, our findings are based on exploratory analyses within a small sample without a control group and are therefore at risk of type 1 errors and order effects. Further research with larger samples is required.

Acceptability and feasibility of the TELEhealth BARIatric behavioural intervention to increase physical ACTIVity (TELE-BariACTIV): A single-case experimental study protocol (Preprint)

Background

Regular physical activity (PA) is recommended to optimize weight and health outcomes in patients who have undergone metabolic and bariatric surgery (MBS). However, >70% of patients have low PA levels before MBS that persist after MBS. Although behavioral interventions delivered face-to-face have shown promise for increasing PA among patients who have undergone MBS, many may experience barriers, preventing enrollment into and adherence to such interventions. Delivering PA behavior change interventions via telehealth to patients who have undergone MBS may be an effective strategy to increase accessibility and reach, as well as adherence.

Objective

This paper reports the protocol for a study that aims to assess the feasibility and acceptability of the protocol or methods and the Telehealth Bariatric Behavioral Intervention (TELE-BariACTIV). The intervention is designed to increase moderate-to-vigorous intensity PA (MVPA) in patients awaiting bariatric surgery and is guided by a multitheory approach and a patient perspective. Another objective is to estimate the effect of the TELE-BariACTIV intervention on presurgical MVPA to determine the appropriate sample size for a multicenter trial.

Methods

This study is a multicenter trial using a repeated (ABAB’A) single-case experimental design. The A phases are observational phases without intervention (A1=pre-MBS phase; A2=length personalized according to the MBS date; A3=7 months post-MBS phase). The B phases are interventional phases with PA counseling (B1=6 weekly pre-MBS sessions; B2=3 monthly sessions starting 3 months after MBS). The target sample size is set to 12. Participants are inactive adults awaiting sleeve gastrectomy who have access to a computer with internet and an interface with a camera. The participants are randomly allocated to a 1- or 2-week baseline period (A1). Protocol and intervention feasibility and acceptability (primary outcomes) will be assessed by recording missing data, refusal, recruitment, retention, attendance, and attrition rates, as well as via web-based acceptability questionnaires and semistructured interviews. Data collected via accelerometry (7-14 days) on 8 occasions and via questionnaires on 10 occasions will be analyzed to estimate the effect of the intervention on MVPA. Generalization measures assessing the quality of life, anxiety and depressive symptoms, and theory-based constructs (ie, motivational regulations for PA, self-efficacy to overcome barriers to PA, basic psychological needs satisfaction and frustration, PA enjoyment, and social support for PA; secondary outcomes for a future large-scale trial) will be completed via web-based questionnaires on 6-10 occasions. The institutional review board provided ethics approval for the study in June 2021.

Results

Recruitment began in September 2021, and all the participants were enrolled (n=12). Data collection is expected to end in fall 2023, depending on the MBS date of the recruited participants.

Conclusions

The TELE-BariACTIV intervention has the potential for implementation across multiple settings owing to its collaborative construction that can be offered remotely.

International Registered Report Identifier (IRRID)

DERR1-10.2196/39633

The impact of Stress Management and Resilience Training (SMART) on academic physicians during the implementation of a new Health Information System: An exploratory randomized controlled trial

OBJECTIVE

The Stress Management and Resilience Training (SMART) program is an evidence-based intervention designed to build resilience in physicians in clinical practice. The objective of the current study was to assess the impact of the SMART program on academic physicians' levels of resilience, subjective happiness, stress, and anxiety, and specifically during the implementation of a new hospital-wide Health Information System (HIS).

METHODS

A total of 40 physicians in a tertiary care academic hospital were randomized (allocation ratio 1:1) to either the SMART intervention or the control condition. The SMART intervention consisted of one mandatory two-hour in-person workshop and an optional 24-week online program, designed to support the materials delivered in the workshop. Outcome measures were assessed using validated scales administered online at baseline and at 3-months and 6-months follow-up.

RESULTS

After adjusting for baseline levels of each outcome, no statistically significant intervention effect was observed for resilience, subjective happiness, stress or anxiety at 3-months or 6-months follow-up. However, physicians in the intervention group demonstrated improvements in resilience, stress and anxiety at follow-up that were within the range of clinically relevant differences.

CONCLUSIONS

The findings of this exploratory study provide modest support that the SMART intervention may be beneficial for proactively addressing physician wellness during the implementation of a new HIS and that larger randomized trials are warranted.

TRIAL REGISTRATION

NCT04384861.

Interpreting patient reports of perceived change during treatment for depression: Findings from the Veterans Outcome Assessment survey

This study addressed ongoing questions about the meaning of patients' perceptions of change during treatment. The study used data from the Veterans Outcome Assessment survey for patients with a depressive disorder, without mental health comorbidities, treated in Department of Veterans Affairs general mental health clinics (n = 694). Perceived changes in problems/symptoms, other domains, and the quality of communication with providers were evaluated with items from the Experience of Care & Health Outcomes (ECHO) survey. Depressive symptoms were measured with the Patient Health Questionnaire-9 (PHQ-9). Linear regression models evaluated associations of perceived change at 3-months post-baseline with observed change in PHQ-9 scores, scores on other patient-reported outcome measures (PROMs), and ratings of communication with providers. Patients' reports of their clinical condition at follow-up together with ratings of communication accounted for approximately one-third of the variance in patients' perceptions of change. Adding change-scores based on baseline and follow-up scores on the PHQ-9 and other PROMs did not improve model fit. The findings suggest that patient reports of perceived change during treatment reflect their current clinical state and their experience of care more closely than actual changes in the PHQ-9 or other PROMs.