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Hanevik E, Røvik FMG, Bøe T, Knapstad M, Smith ORF. Client predictors of therapy dropout in a primary care setting: a prospective cohort study. BMC Psychiatry 2023; 23:358. [PMID: 37226210 DOI: 10.1186/s12888-023-04878-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/16/2023] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Therapy dropout poses a major challenge. Considerable research has been conducted on predictors of dropout, however none in the context of primary mental health services in Norway. The purpose of this study was to investigate which client characteristics can predict dropout from the service Prompt Mental Health Care (PMHC). METHODS We performed a secondary analysis of a Randomized Controlled Trial (RCT). Our sample consisted of 526 adult participants receiving PMHC-treatment in the municipalities of Sandnes and Kristiansand, between November 2015 to August 2017. Using logistic regression, we investigated the association between nine client characteristics and dropout. RESULTS The dropout rate was 25.3%. The adjusted analysis indicated that older clients had a lower odds ratio (OR) of dropping out compared to younger clients (OR = 0.43, [95% CI = 0.26, 0.71]). Moreover, clients with higher education had a lower odds ratio of dropping out compared to clients with lower levels of education (OR = 00.55, 95% CI [0.34, 0.88]), while clients who were unemployed were more likely to drop-out as compared the regularly employed (OR = 2.30, [95% CI = 1.18, 4.48]). Finally, clients experiencing poor social support had a higher odds ratio of dropping out compared to clients who reported good social support (OR = 1.81, [95% CI = 1.14, 2.87]). Sex, immigrant background, daily functioning, symptom severity and duration of problems did not predict dropout. CONCLUSION The predictors found in this prospective study might help PMHC-therapists identify clients at risk of dropout. Strategies for preventing dropout are discussed.
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Affiliation(s)
- Elin Hanevik
- Søndre Oslo DPS, Helga Vaneks Vei 6, 1281, Oslo, Norway
| | - Frida M G Røvik
- Rask Psykisk Helsehjelp, Bydel Ullern, Hoffsveien 48, 0377, Oslo, Norway
| | - Tormod Bøe
- Department of Psychosocial Science, The University of Bergen, Christies Gate 12, 5015, Bergen, Norway
- RKBU Vest, NORCE Norwegian Research Centre, Bergen, Norway
| | - Marit Knapstad
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes Gate 7, 5015, Bergen, Norway
| | - Otto R F Smith
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes Gate 7, 5015, Bergen, Norway.
- Centre for Evaluation of Public Health Measures, Norwegian Institute of Public Health, Oslo, Norway.
- Department of Teacher Education, NLA University College, Pb 74 Sandviken, 5812, Bergen, Norway.
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Smith ORF, Sæther SMM, Haug E, Knapstad M. Long-term outcomes at 24- and 36-month follow-up in the intervention arm of the randomized controlled trial of Prompt Mental Health Care. BMC Psychiatry 2022; 22:598. [PMID: 36076192 PMCID: PMC9461100 DOI: 10.1186/s12888-022-04227-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 08/24/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Whether long-term symptom improvement is maintained after treatment in services such as the Norwegian Prompt Mental Health Care (PMHC) and the English Improving Access to Psychological Therapies is not yet known. In this prospective study, we investigate whether improvements observed at 6-month follow-up are maintained at 24- and 36-month follow-up among clients who received PMHC. METHOD Data from the treatment arm of the randomized controlled trial of PMHC were used (n = 459). The main outcomes were (reliable) recovery rate and symptoms of depression (PHQ-9) and anxiety (GAD-7). Primary outcome data at 24- and 36-months follow-up were available for 47% and 39% of participants, respectively. Secondary outcomes were work participation, functional status, health-related quality of life, and positive mental well-being. Sensitivity analyses with regard to missing data assumptions were conducted for the primary continuous outcomes. RESULTS Improvements were maintained at 24- and 36-month follow-up for symptoms of depression and anxiety, (reliable) recovery rate, and health-related quality of life. Small linear improvements since 6-month follow-up were observed for work participation, functional status, and positive mental well-being. Sensitivity analyses did not substantially alter the findings for symptoms of depression and anxiety mentioned above. CONCLUSIONS Our findings support the long-term effectiveness of PMHC, but results should be interpreted with caution due to lacking follow-up data at 24- and 36-month in the control group, and substantial attrition.
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Affiliation(s)
- Otto R. F. Smith
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway ,grid.418193.60000 0001 1541 4204Centre for Evaluation of Public Health Measure, Norwegian Institute of Public Health, Bergen, Norway ,grid.458561.b0000 0004 0611 5642Department of Teacher Education, NLA University College, Pb 74 Sandviken, 5812 Bergen, Norway
| | - Solbjørg M. M. Sæther
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway
| | - Ellen Haug
- grid.458561.b0000 0004 0611 5642Department of Teacher Education, NLA University College, Pb 74 Sandviken, 5812 Bergen, Norway ,grid.7914.b0000 0004 1936 7443Department of Health Promotion and Development, University of Bergen, 5020 Bergen, Norway
| | - Marit Knapstad
- grid.418193.60000 0001 1541 4204Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes gate 7, 5015 Bergen, Norway
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Sæther SMM, Knapstad M, Grey N, Smith ORF. Moderators of treatment effect of Prompt Mental Health Care compared to treatment as usual: Results from a randomized controlled trial. Behav Res Ther 2022; 158:104198. [PMID: 36122439 DOI: 10.1016/j.brat.2022.104198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2021] [Revised: 08/29/2022] [Accepted: 09/02/2022] [Indexed: 11/17/2022]
Abstract
BACKGROUND In this exploratory study, we investigated a comprehensive set of potential moderators of response to the primary care service Prompt Mental Health Care (PMHC). METHODS Data from an RCT of PMHC (n = 463) versus treatment as usual (TAU, n = 215) were used. At baseline mean age was 34.8, 66.7% were women, and 91% scored above caseness for depression (PHQ-9) and 87% for anxiety (GAD-7). OUTCOMES change in symptoms of depression and anxiety and change in remission status from baseline to six- and 12- months follow-up. Potential moderators: sociodemographic, lifestyle, social, and cognitive variables, variables related to (mental) health problem and care. Each moderator was examined in generalized linear mixed models with robust maximum likelihood estimation. RESULTS Effect modification was only identified for anxiolytic medication for change in symptoms of depression and anxiety; clients using anxiolytic medication showed less effect of PMHC relative to TAU (all p < 0.001), although this result should be interpreted with caution due to the low number of anxiolytic users in the sample. For remission status, none of the included variables moderated the effect of treatment. CONCLUSION As a treatment for depression and/or anxiety, PMHC mostly seems to work equally well as compared to TAU across a comprehensive set of potential moderators.
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Affiliation(s)
- Solbjørg M M Sæther
- Department of Health Promotion, Norwegian Institute of Public Health, Postboks 973 Sentrum, 5808, Bergen, Norway.
| | - Marit Knapstad
- Department of Health Promotion, Norwegian Institute of Public Health, Postboks 973 Sentrum, 5808, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Postboks 7807 5020, Bergen, Norway.
| | - Nick Grey
- Sussex Partnership NHS Foundation Trust, Swandean, Arundel Road, Worthing, West Sussex, BN13 3EP, United Kingdom; School of Psychology, University of Sussex, Pevensey 1 Building, University of Sussex, Falmer, BN1 9QH, United Kingdom.
| | - Otto R F Smith
- Department of Health Promotion, Norwegian Institute of Public Health, Postboks 973 Sentrum, 5808, Bergen, Norway; Centre for Evaluation of Public Health Measure, Norwegian Institute of Public Health, Bergen, Norway.
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Lervik LV, Hoffart A, Knapstad M, Smith ORF. Exploring the temporal associations between avoidance behavior and cognitions during the course of cognitive behavioral therapy for clients with symptoms of social anxiety disorder. Psychother Res 2021; 32:195-208. [PMID: 34142636 DOI: 10.1080/10503307.2021.1930243] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022] Open
Abstract
OBJECTIVES In cognitive behavioral therapy (CBT) for social anxiety disorder (SAD), avoidance behavior (AB) and cognitions (COG) are two important targets of intervention, but so far no studies have directly examined their relative importance. By means of cross-lagged panel models (CLPM), we examined their temporal associations and impacts on outcome in clients with symptoms of SAD while addressing typical methodological challenges. METHOD We used data from the first six therapy sessions in a sample of 428 primary care clients (mean [SD] age = 34.6 [12.2], 34.3% men), participating in the Prompt Mental Health Care trial. Session-by-session data was collected on AB, COG, depression and general anxiety. Competing multiple indicator CLPMs were tested. RESULTS The Random Intercept-CLPM provided best fit, and indicated that AB predicted COG at subsequent time points (.39 ≤ β ≤ .42 for T2-T5, p < .05), but not vice versa. In addition, AB, but not COG, predicted clients' general anxiety score at subsequent time points. Results were both robust to the inclusion of depressive symptoms as a within-level covariate, and sensitivity tests for stationarity and missing data assumptions. CONCLUSION Targeting avoidance behavior for primary care clients with symptoms of SAD may be more vital for the optimal effect of CBT than targeting cognitions. Methodological considerations and limitations of the study are discussed.Trial registration: ClinicalTrials.gov identifier: NCT03238872.
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Affiliation(s)
- Linn Vathne Lervik
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
| | - Asle Hoffart
- Modum Bad Psychiatric Center, Vikersund, Norway.,Department of Psychology, University of Oslo, Oslo, Norway
| | - Marit Knapstad
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway.,Department of Clinical Psychology, University of Bergen, Bergen, Norway
| | - Otto R F Smith
- Division of Mental and Physical Health, Department of Health Promotion, Norwegian Institute of Public Health, Bergen, Norway
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Knapstad M, Smith ORF. Social anxiety and agoraphobia symptoms effectively treated by Prompt Mental Health Care versus TAU at 6- and 12-month follow-up: Secondary analysis from a randomized controlled trial. Depress Anxiety 2021; 38:351-360. [PMID: 33393688 PMCID: PMC7986705 DOI: 10.1002/da.23132] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 11/17/2020] [Accepted: 12/18/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Prompt Mental Health Care (PMHC, Norwegian adaption of Improving Access to Psychological Therapies) has shown effects on symptoms of anxiety and depression compared to treatment as usual (TAU). In this secondary analysis, we examine the effectiveness of PMHC among clients presenting with symptoms of social anxiety disorder (SAD) and/or agoraphobia on core symptoms at 6- and 12-month follow-up. METHODS Randomized controlled trial in two PMHC sites (70:30 ratio PMHC:TAU). Of participants, 61.3% (n = 472) scored at caseness for SAD and 47.7% (n = 367) for agoraphobia (40% both). Effects on SAD avoidance and physiological discomfort (SPIN-9), SAD cognitions (ATQ-SA), agoraphobic avoidance (MIA-8), and agoraphobic cognitions (ATQ-AP) were examined in piecewise growth models. RESULTS The PMHC group showed substantially greater symptom reduction than the TAU group for all outcomes: At 6-month follow-up, the between-group effect sizes were d -0.60 (95% CI: -0.94 to -0.26) for SPIN-9, -0.45 (95% CI: -0.70 to -0.20) for ATQ-SA, -0.50 (95% CI: -0.87 to -0.13) for MIA-8, and -0.61 (95% CI: -0.92 to -0.31) for ATQ-AP. All effects were sustained at similar level at a 12-month follow-up. CONCLUSION PMHC effectively alleviated SAD and agoraphobia symptoms, and individuals struggling with such symptoms constituted a large proportion of clients. Although results should be interpreted with caution due to risk of attrition bias, they lend further support for a scale-up of PMHC and similar initiatives. Individuals struggling with SAD and/or agoraphobia stood out as relatively high burdened, whereas only one of five had sought help the last 12 months, underscoring the need for the PMHC service.
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Affiliation(s)
- Marit Knapstad
- Department of Health PromotionNorwegian Institute of Public HealthBergenNorway,Department of Clinical PsychologyUniversity of BergenBergenNorway
| | - Otto R. F. Smith
- Department of Health PromotionNorwegian Institute of Public HealthBergenNorway
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Myrtveit Sæther SM, Knapstad M, Grey N, Rognerud MA, Smith ORF. Long-term outcomes of Prompt Mental Health Care: A randomized controlled trial. Behav Res Ther 2020; 135:103758. [PMID: 33129157 DOI: 10.1016/j.brat.2020.103758] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 09/24/2020] [Accepted: 10/16/2020] [Indexed: 12/17/2022]
Abstract
Prompt Mental Health Care (PMHC, Norwegian adaptation of Improving Access to Psychological Therapies) is found successful in alleviating symptoms of anxiety and depression. Here, we investigate whether improvement is maintained over time. A randomized controlled trial was conducted in two PMHC sites from November 2015 to August 2017, randomly assigning 681 adults with anxiety and/or mild to moderate depression (70:30 ratio: PMHC n = 463, TAU n = 218). Main outcomes were recovery rates and changes in symptoms of depression and anxiety from baseline to 12 months. Secondary outcomes were functional status, health-related quality of life, mental wellbeing and work participation. At 12 months after baseline the reliable recovery rate was 59.4% in PMHC and 36.6% in TAU, giving a between-group effect size of 0.51 (95%CI: 0.26, 0.77, p < 0.001). Differences in symptom change gave between-group effect sizes of -0.67 (95%CI: -0.99, -0.36, p < 0.001) for depression and -0.58 (95%CI: -0.91, -0.26, p < 0.001) for anxiety. PMHC was also at 12 months found more effective in improving functional status, health-related quality of life and mental wellbeing, but not work participation. In sum, substantial treatment effects of PMHC remain at 12 months follow-up, although results should be interpreted with caution due to risk of attrition bias.
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Affiliation(s)
| | - Marit Knapstad
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes Gate 7, 5015, Bergen, Norway; Department of Clinical Psychology, University of Bergen, Bergen, Norway.
| | - Nick Grey
- Sussex Partnership NHS Foundation Trust, United Kingdom; School of Psychology, University of Sussex, United Kingdom.
| | | | - Otto R F Smith
- Department of Health Promotion, Norwegian Institute of Public Health, Zander Kaaes Gate 7, 5015, Bergen, Norway.
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