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Cully JA, Hundt NE, Fletcher T, Sansgiry S, Zeno D, Kauth MR, Kunik ME, Sorocco K. Brief Cognitive-Behavioral Therapy for Depression in Community Clinics: A Hybrid Effectiveness-Implementation Trial. Psychiatr Serv 2024; 75:237-245. [PMID: 37674395 DOI: 10.1176/appi.ps.20220582] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023]
Abstract
OBJECTIVE The authors examined whether brief cognitive-behavioral therapy (bCBT) for depression, delivered by mental health providers in community-based outpatient clinics (CBOCs) of the Veterans Health Administration, improved depression outcomes and was feasible and acceptable in clinical settings. METHODS The authors used a type-2 hybrid effectiveness-implementation, patient-randomized trial to compare bCBT with enhanced usual care. Participants (N=189) with moderate symptoms of depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) were enrolled from CBOCs in the southern United States. bCBT (N=109) consisted of three to six sessions, delivered by mental health providers (N=17) as part of routine clinic practices. Providers received comprehensive training and support to facilitate bCBT delivery. Recipients of enhanced usual care (N=80) were given educational materials and encouraged to discuss treatment options with their primary care provider. The primary effectiveness outcome was PHQ-9-assessed depression symptoms posttreatment (4 months after baseline) and at 8- and 12-month follow-ups. Implementation outcomes focused on bCBT dose received, provider fidelity, and satisfaction with bCBT training and support. RESULTS bCBT improved depression symptoms (Cohen's d=0.55, p<0.01) relative to enhanced usual care posttreatment, and the improvement was maintained at 8- and 12-month follow-ups (p=0.004). bCBT participants received a mean±SD of 3.7±2.7 sessions (range 0-9), and 64% completed treatment (≥3 sessions). Providers delivered bCBT with fidelity and reported that bCBT training and support were feasible and effective. CONCLUSIONS bCBT had a modest treatment footprint of approximately four sessions, was acceptable to participants and providers, was feasible for delivery in CBOCs, and produced meaningful sustained improvements in depression.
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Affiliation(s)
- Jeffrey A Cully
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Natalie E Hundt
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Terri Fletcher
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Shubhada Sansgiry
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Darrell Zeno
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Michael R Kauth
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Mark E Kunik
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
| | - Kristen Sorocco
- U.S. Department of Veterans Affairs (VA) Health Services Research and Development (HSR&D) Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, and Baylor College of Medicine, Houston (Cully, Hundt, Fletcher, Sansgiry, Zeno, Kauth, Kunik); VA South Central Mental Illness Research, Education and Clinical Center (MIRECC), virtual (Zeno); Oklahoma City VA Health Care System and University of Oklahoma College of Medicine, Oklahoma City (Sorocco)
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Sauer-Zavala S, Southward MW, Terrill DR, Semcho SA, Stumpp NE. Mechanism engagement as a potential evidence-based approach to personalized treatment termination. Psychother Res 2024; 34:124-136. [PMID: 36669132 DOI: 10.1080/10503307.2023.2168574] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 01/10/2023] [Indexed: 01/22/2023] Open
Abstract
Objective: This study explores whether early change on a putative mechanism maintaining symptoms can serve as a proximal indicator of response to prompt discontinuation. Method: Patients (N = 70; Mage = 33.74, 67% female, 74% white) with heterogeneous anxiety and depressive disorders completed a sequential multiple assignment randomized trial (SMART). Patients received 6 sessions of skill modules from the Unified Protocol and then underwent a second-stage randomization to either receive the remaining 6 sessions (Full duration) or discontinue treatment (Brief duration). All participants completed weekly self-report measures of anxiety and depressive symptoms and distress aversion for the full 12-week treatment window. We used structural equation modeling to test (1) if distress aversion demonstrated significant variability during the first-stage randomization and (2) if distress aversion during the first-stage randomization predicted second-stage changes in anxiety and depression. Results: Participants demonstrated significant variability in first-stage distress aversion. Latent distress aversion slopes significantly predicted latent second-stage anxiety slopes, whereas latent distress aversion intercepts significantly predicted latent second-stage depression slopes. Conclusions: These results suggest that early mechanism engagement may have potential as a trigger to prompt personalized termination. Shorter courses of care may reduce patient costs and increase the mental health service system's capacity.
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Affiliation(s)
| | | | - Doug R Terrill
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Stephen A Semcho
- Department of Psychology, University of Kentucky, Lexington, KY, USA
| | - Nicole E Stumpp
- Department of Psychology, University of Kentucky, Lexington, KY, USA
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Saulnier KG, Panaite V, Ganoczy D, Kim HM, Zivin K, Hofer T, Piette JD, Pfeiffer PN. Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic. Gen Hosp Psychiatry 2023; 85:87-94. [PMID: 37862961 DOI: 10.1016/j.genhosppsych.2023.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 10/12/2023] [Accepted: 10/12/2023] [Indexed: 10/22/2023]
Abstract
OBJECTIVE Evaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. METHOD Veterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. RESULTS A total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. CONCLUSIONS Black race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.
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Affiliation(s)
- K G Saulnier
- VA Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, MI, USA; VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA.
| | - V Panaite
- James A. Haley Veterans' Hospital, Tampa, FL, USA
| | - D Ganoczy
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - H M Kim
- VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Consulting for Statistics, Computing, and Analytics Research, Ann Arbor, MI, USA
| | - K Zivin
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - T Hofer
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - J D Piette
- University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; School of Public Health, University of Michigan, Ann Arbor, MI, USA
| | - P N Pfeiffer
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA; University of Michigan Medical School, Ann Arbor, MI, USA; VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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Thompson-Hollands J, Lunney CA, Sloan DM, Stirman SW, Schnurr PP. Treatment length and symptom improvement in prolonged exposure and present-centered therapy for posttraumatic stress disorder: Comparing dose-response and good-enough level models in two manualized interventions. J Consult Clin Psychol 2023; 91:596-605. [PMID: 37471022 PMCID: PMC10527917 DOI: 10.1037/ccp0000834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/21/2023]
Abstract
OBJECTIVE The dose-response model of change in psychotherapy posits that each session of therapy is incrementally beneficial across patients. The contrasting good-enough level model suggests that patients improve at different rates in therapy and discontinue treatment when they are satisfied with their improvement. Support for each theory has been mixed, and many prior studies have relied on samples of patients receiving unstructured treatment approaches. We conducted this study to compare these two theories across two manualized treatments for posttraumatic stress disorder (PTSD). METHOD Two hundred eighty-four female veterans and military service members with PTSD (Mage = 44.79; 54.6% White non-Hispanic, 6.7% Black non-Hispanic, 37% other) were randomized to receive 10 sessions of prolonged exposure (PE), a trauma-focused therapy, or present-centered therapy (PCT), a non-trauma-focused therapy. Participants completed the PTSD Checklist (PCL) at even-numbered treatment sessions, and the timing of dropout/treatment completion was monitored. RESULTS The point of highest risk for dropout differed between the treatments, with risk in PE corresponding to the beginning of imaginal exposures. In the PE condition, but not in PCT, a higher number of sessions completed increased the likelihood of achieving reliable clinically significant improvement. Across treatments, the rate of change in PTSD symptoms did not differ according to the number of sessions completed (b = 0.06, p = .687). CONCLUSIONS Findings support the dose-response model of change in psychotherapy. There were notable differences in dropout across the treatment conditions, including rates, timing, and implications for outcomes. These differences likely reflect differences in content between the protocols. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Johanna Thompson-Hollands
- National Center for PTSD, Behavioral Science Division, at VA Boston Healthcare System, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Carole A. Lunney
- National Center for PTSD, Executive Division, White River Junction, VT
| | - Denise M. Sloan
- National Center for PTSD, Behavioral Science Division, at VA Boston Healthcare System, Boston, MA
- Boston University Chobanian & Avedisian School of Medicine, Boston, MA
| | - Shannon Wiltsey Stirman
- National Center for PTSD, Dissemination and Training Division, at VA Palo Alto Health Care System, Palo Alto, CA
- Stanford University, Stanford, CA
| | - Paula P. Schnurr
- National Center for PTSD, Executive Division, White River Junction, VT
- Geisel School of Medicine at Dartmouth, Hanover, NH
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Quan L, Lu W, Zhen R, Zhou X. Post-traumatic stress disorders, anxiety, and depression in college students during the COVID-19 pandemic: a cross-sectional study. BMC Psychiatry 2023; 23:228. [PMID: 37016381 PMCID: PMC10072042 DOI: 10.1186/s12888-023-04660-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 03/07/2023] [Indexed: 04/06/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic has caused an increase in psychiatric disorders in college students, particularly posttraumatic stress disorders (PTSD), depression, and anxiety. While existing studies assess the prevalence of these disorders and their predictors, they overlook potential complications caused by comorbidity between these disorders. To fill this gap, this study examined the prevalence of PTSD, depression, anxiety, and their comorbidity to inform targeted intervention for college students during the COVID-19 pandemic. DESIGN Self-report questionnaires were used to assess 6,898 college students about six months after the COVID-19 outbreak. RESULTS The results found that the prevalence of PTSD, depression, and anxiety were 15.5%, 32.2%, and 32.1% respectively, and the prevalence of comorbid PTSD and depression, comorbid PTSD and anxiety, comorbid depression and anxiety, and comorbid PTSD, depression, and anxiety symptoms were 11.5%, 11.6%, 20.4%, and 9.4% respectively. Moreover, left-behind status, lower economic status, previous trauma experiences, exposure to the pandemic, and rumination were risk factors of psychological distress, but self-disclosure was a protective factor for these disorders. CONCLUSION These results indicate that distinct psychiatric disorders may be comorbid in individuals, and are further influenced by pre-, within-, and post-disaster factors. Furthermore, psychological service targeted at college students should pay attention to comorbid symptoms rather than only symptoms of single disorders.
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Affiliation(s)
- Lijuan Quan
- School of Educational Science, Anhui Normal University, Wuhu, 241000, China
| | - Wei Lu
- School of Educational Science, Anhui Normal University, Wuhu, 241000, China
| | - Rui Zhen
- Jing Hengyi School of Education, Hangzhou Normal University, Hangzhou, 311121, China.
| | - Xiao Zhou
- Department of Psychology and Behavioral Sciences, Zhejiang University, Hangzhou, 310028, China
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Grau PP, Sripada RK, Ganoczy D, Weinstein JH, Pfeiffer PN. Outcomes of Acceptance and Commitment Therapy for depression and predictors of treatment response in Veterans Health Administration patients. J Affect Disord 2023; 323:826-833. [PMID: 36529407 DOI: 10.1016/j.jad.2022.12.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 12/06/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND Acceptance and Commitment Therapy for depression (ACT-D) is a promising depression treatment which has not been evaluated on a large scale within VA. This study aimed to evaluate ACT-D's effectiveness in a national, treatment-seeking sample of Veterans. METHODS The sample comprised 831 Veterans who received a primary depression diagnosis and received at least two sessions of ACT-D during fiscal years 2015-2020. We used GLM to measure predictors of symptom change, treatment response (50 % reduction in PHQ-9 and AAQ-II scores), subthreshold depression symptoms (PHQ-9 < 10; AAQ-II < 27), and treatment completion. RESULTS Veterans experienced an average reduction of 3.39 points on the PHQ-9 (Cohen's d = 0.56) and 3.76 points on the AAQ-II (Cohen's d = 0.43). On the PHQ-9, 40 % achieved subthreshold depression symptoms. On the AAQ-II, 36 % of Veterans achieved subthreshold psychological inflexibility scores. Service-connected disability rating for depression and higher levels of medical comorbidity were both related to lower levels of overall depression symptom change and treatment response. Substance use disorder and bipolar/psychosis diagnoses were associated with greater reductions in psychological inflexibility. LIMITATIONS This is an observational study without a control group, so we were unable to compare the effectiveness of ACT-D to other usual care for depression. We were also unable to assess variables that can influence treatment success, such as therapist fidelity and patient engagement. CONCLUSIONS ACT-D achieved similar improvements in depression as reported in controlled trials. Adaptations to ACT-D may be needed to improve outcomes for Veterans with depression and comorbid PTSD.
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Affiliation(s)
- Peter P Grau
- VA Serious Mental Illness Treatment Resource and Evaluation Center (SMITREC), 2800 Plymouth Road, Bldg 16, Ann Arbor, MI 48109, United States; VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States.
| | - Rebecca K Sripada
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Dara Ganoczy
- Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
| | - Jonathan H Weinstein
- VA Northport Medical Center, 79 Middleville Road, Northport, NY 11768, United States
| | - Paul N Pfeiffer
- VA Ann Arbor Healthcare System, 2215 Fuller Road, Ann Arbor, MI 48105, United States; Department of Psychiatry, University of Michigan Medical School, United States; Veterans Affairs Center for Clinical Management Research, Health Services Research and Development, Ann Arbor, MI, United States
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Pfeiffer PN, Zivin K, Hosanagar A, Panaite V, Ganoczy D, Kim HM, Hofer T, Piette JD. Assessment of Outcome-Based Measures of Depression Care Quality in Veterans Health Administration Facilities. J Behav Health Serv Res 2023; 50:49-67. [PMID: 36207569 PMCID: PMC9542458 DOI: 10.1007/s11414-022-09813-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2022] [Indexed: 02/01/2023]
Abstract
To inform the potential use of patient-reported depression symptom outcomes as measures of care quality, this study collected and analyzed longitudinal Patient Health Questionnaire (PHQ9) scores among 1,638 patients who screened positive for major depression according to a PHQ9 ≥ 10 across 29 Department of Veterans Affairs facilities. The study found baseline PHQ9, prior mental health visits, physical functioning, and treatment expectancy were consistently associated with subsequent PHQ9 outcomes. No facilities outperformed any others on PHQ9 scores at the 6-month primary endpoint, and the corresponding intra-class coefficient was ≤ .01 for the entire sample (n = 1,214) and 0.03 for the subgroup of patients with new depression episodes (n = 629). Measures of antidepressant receipt, psychotherapy, or treatment intensification were not associated with 6-month PHQ9 scores. PHQ9 outcomes are therefore unlikely to be useful as quality indicators for VA healthcare facilities due to low inter-facility variation, and new care process measures are needed to inform care for patients with chronic depression prevalent in this sample.
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Affiliation(s)
- Paul N. Pfeiffer
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.413800.e0000 0004 0419 7525Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - Kara Zivin
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370School of Public Health, University of Michigan, Ann Arbor, MI USA
| | - Avinash Hosanagar
- grid.413800.e0000 0004 0419 7525Mental Health Service, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - Vanessa Panaite
- grid.281075.90000 0001 0624 9286James A. Haley Veterans’ Hospital, Tampa, FL USA
| | - Dara Ganoczy
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA
| | - H. Myra Kim
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Consulting for Statistics, Computing, and Analytics Research, Ann Arbor, MI USA
| | - Timothy Hofer
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA
| | - John D. Piette
- grid.413800.e0000 0004 0419 7525VA Center for Clinical Management Research, VA Ann Arbor Healthcare System, Ann Arbor, MI USA ,grid.214458.e0000000086837370University of Michigan Medical School, Ann Arbor, MI USA ,grid.214458.e0000000086837370School of Public Health, University of Michigan, Ann Arbor, MI USA
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Darnell D, Pullmann MD, Hull TD, Chen S, Areán P. Predictors of Disengagement and Symptom Improvement Among Adults With Depression Enrolled in Talkspace, a Technology-Mediated Psychotherapy Platform: Naturalistic Observational Study. JMIR Form Res 2022; 6:e36521. [PMID: 35731563 PMCID: PMC9260528 DOI: 10.2196/36521] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Revised: 05/06/2022] [Accepted: 05/22/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Depression is a common psychiatric condition with an estimated lifetime prevalence for major depression of 16.6% in the US adult population and is effectively treated through psychotherapy. The widespread availability of the internet and personal devices such as smartphones are changing the landscape of delivery of psychotherapy; however, little is known about whether and for whom this type of therapy is beneficial, and whether having synchronous video-based sessions provides additional benefits to clients above and beyond messaging-based therapy. OBJECTIVE This study examined the outcomes associated with the use of a digital platform (Talkspace) for technology-mediated psychotherapy. We examined the duration of client engagement in therapy and client depression score trajectories over 16 weeks. We explored the association of client characteristics, therapist characteristics, and service plan type with time-to-disengagement and trajectories of change in depression scores. METHODS This naturalistic observational study assessed data collected routinely by the platform between January 2016 and January 2018 and examined psychotherapy outcomes among a large representative sample of adult clients with clinically significant depression. Treatment disengagement was defined as a lack of client-initiated communication for more than 4 weeks. Clients completed the Patient Health Questionnaire-8 item (PHQ-8) at intake and every 3 weeks via an in-app survey. Cox regression analysis was used to examine the time until and predictors of disengagement. Changes in depression scores and predictors of change over time were examined using mixed-effects regression. RESULTS The study included 5890 clients and 1271 therapists. Client scores on the PHQ-8 declined over time, with the average client improving from a score of 15 to below the clinical cutoff of 10 by week 6. At the same time point, 37% of clients had disengaged from the therapy. When combined into a final Cox regression model, those who were more likely to disengage were clients aged 18 to 25 years versus those aged ≥50 years (odds ratio [OR] 0.82, 95% CI 0.74-0.9; P<.001), had higher education (OR 1.14, 95% CI 1.06-1.22; P<.001), had been in therapy before (OR 1.09, 95% CI 1.02-1.17; P=.01), and were living with a partner but unmarried versus single (OR 1.14, 95% CI 1.02-1.27; P=.02). Having a therapist with >10 years of experience was related to lower odds of disengagement (OR 0.87, 95% CI 0.8-0.94; P=.01). When combined into a final regression model predicting improvement in depression scores over time, clients showing more improvement were those with an associate's degree or higher (linear estimate=-0.07, P=.002) and higher intake PHQ-8 scores (estimate=3.73, P<.001). There were no differences based on the plan type. CONCLUSIONS Our findings add to the growing literature showing the benefits of technology-mediated psychotherapy over a relatively brief period (16 weeks).
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Affiliation(s)
- Doyanne Darnell
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Michael D Pullmann
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | | | - Shiyu Chen
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
| | - Patricia Areán
- Department of Psychiatry & Behavioral Sciences, University of Washington, Seattle, WA, United States
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