Jaime Delgadillo

Early changes, attrition, and dose-response in low intensity psychological interventions.

OBJECTIVES To investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome. DESIGN Retrospective cohort data analysis. METHOD Clinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change. RESULTS The AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1-3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose-response effect appears to decline in treatments longer than six sessions. CONCLUSIONS Patients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.

How reliable is depression screening in alcohol and drug users? A validation of brief and ultra-brief questionnaires

BACKGROUND Depression is highly comorbid with alcohol and drug problems, resulting in greater impairment, reduced treatment adherence and poor outcomes. Little evidence exists to support the use of mental health screening tools in routine addiction treatment. This study tested the validity and reliability of PHQ-9 and PHQ-2 as depression case finding tools in an outpatient drug treatment sample in the United Kingdom. METHODS A sample of 103 patients took part in diagnostic assessments using CIS-R and completed brief screening questionnaires. A subgroup of 60 patients completed retests after 4 weeks. Diagnostic results were compared to brief measures using receiver operating characteristic (ROC) curves. Psychometric properties were also calculated to evaluate the validity and reliability of self-completed questionnaires. RESULTS A PHQ-9 score ≥ 12 had a sensitivity of 81% and specificity of 75% for major depression, also displaying good retest reliability (intra-class correlation, 0.78) and internal consistency (Cronbachs alpha, 0.84). PHQ-2 had 68% sensitivity and 70% specificity, with more modest retest reliability (0.66) and internal consistency (0.64). LIMITATIONS Diagnostic interviews did not consider the temporal sequencing of the onset of drug use and mental health problems. CONCLUSIONS PHQ-9 is a valid and reliable depression screening tool for drug and alcohol users. The brevity and ease of administration of self-completed questionnaires make them useful clinical tools in addiction services commonly encountering a high prevalence of depression.

Brief case finding tools for anxiety disorders: Validation of GAD-7 and GAD-2 in addictions treatment

BACKGROUND Anxiety disorders are the most common mental health problems and often co-exist with substance use. Little evidence exists to support the use of brief screening tools for anxiety disorders in routine addictions treatment. This is the first study to test the validity and reliability of GAD-7 and GAD-2 in an outpatient drugs treatment population. METHODS A sample of 103 patients completed brief screening questionnaires and took part in structured diagnostic assessments using CIS-R. A subgroup of 60 patients completed retests after 4 weeks. The results of brief questionnaires were compared to those of gold-standard diagnostic interviews using Receiver Operating Characteristic (ROC) curves. Psychometric properties were also calculated to evaluate the validity and reliability of self-completed questionnaires. RESULTS A GAD-7 score ≥ 9 had a sensitivity of 80% and specificity of 86% for any anxiety disorder, also displaying adequate temporal stability at repeated measurements (intra-class correlation=0.85) and high internal consistency (Cronbachs alpha=0.91). A GAD-2 score ≥ 2 had 94% sensitivity and 53% specificity, with adequate internal consistency (0.82). CONCLUSIONS GAD-7 adequately detected the presence of an anxiety disorder in drug and alcohol users; although this study was limited by sample size to determine its reliability for specific diagnoses. Results in this small sample suggest that GAD-7 may be a useful screening tool in addiction services, although replication in a larger sample is warranted.

Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies

This paper aims to provide researchers with practical information on sample sizes for accurate estimations of therapist effects (TEs). The investigations are based on an integrated sample of 48,648 patients treated by 1800 therapists. Multilevel modeling and resampling were used to realize varying sample size conditions to generate empirical estimates of TEs. Sample size tables, including varying sample size conditions, were constructed and study examples given. This study gives an insight into the potential size of the TE and provides researchers with a practical guide to aid the planning of future studies in this field.

Effect of Collaborative Care vs Usual Care on Depressive Symptoms in Older Adults With Subthreshold Depression: The CASPER Randomized Clinical Trial

Importance There is little evidence to guide management of depressive symptoms in older people. Objective To evaluate whether a collaborative care intervention can reduce depressive symptoms and prevent more severe depression in older people. Design, Setting, and Participants Randomized clinical trial conducted from May 24, 2011, to November 14, 2014, in 32 primary care centers in the United Kingdom among 705 participants aged 65 years or older with Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition) subthreshold depression; participants were followed up for 12 months. Interventions Collaborative care (n=344) was coordinated by a case manager who assessed functional impairments relating to mood symptoms. Participants were offered behavioral activation and completed an average of 6 weekly sessions. The control group received usual primary care (n=361). Main Outcomes and Measures The primary outcome was self-reported depression severity at 4-month follow-up on the 9-item Patient Health Questionnaire (PHQ-9; score range, 0-27). Included among 10 prespecified secondary outcomes were the PHQ-9 score at 12-month follow-up and the proportion meeting criteria for depressive disorder (PHQ-9 score ≥10) at 4- and 12-month follow-up. Results The 705 participants were 58% female with a mean age of 77 (SD, 7.1) years. Four-month retention was 83%, with higher loss to follow-up in collaborative care (82/344 [24%]) vs usual care (37/361 [10%]). Collaborative care resulted in lower PHQ-9 scores vs usual care at 4-month follow-up (mean score with collaborative care, 5.36 vs with usual care, 6.67; mean difference, −1.31; 95% CI, −1.95 to −0.67; P < .001). Treatment differences remained at 12 months (mean PHQ-9 score with collaborative care, 5.93 vs with usual care, 7.25; mean difference, −1.33; 95% CI, −2.10 to −0.55). The proportions of participants meeting criteria for depression at 4-month follow-up were 17.2% (45/262) vs 23.5% (76/324), respectively (difference, −6.3% [95% CI, −12.8% to 0.2%]; relative risk, 0.83 [95% CI, 0.61-1.27]; P = .25) and at 12-month follow-up were 15.7% (37/235) vs 27.8% (79/284) (difference, −12.1% [95% CI, −19.1% to −5.1%]; relative risk, 0.65 [95% CI, 0.46-0.91]; P = .01). Conclusions and Relevance Among older adults with subthreshold depression, collaborative care compared with usual care resulted in a statistically significant difference in depressive symptoms at 4-month follow-up, of uncertain clinical importance. Although differences persisted through 12 months, findings are limited by attrition, and further research is needed to assess longer-term efficacy. Trial Registration isrctn.org Identifier: ISRCTN02202951

Benchmarking Routine Psychological Services: A Discussion of Challenges and Methods

BACKGROUND Policy developments in recent years have led to important changes in the level of access to evidence-based psychological treatments. Several methods have been used to investigate the effectiveness of these treatments in routine care, with different approaches to outcome definition and data analysis. AIMS To present a review of challenges and methods for the evaluation of evidence-based treatments delivered in routine mental healthcare. This is followed by a case example of a benchmarking method applied in primary care. METHOD High, average and poor performance benchmarks were calculated through a meta-analysis of published data from services working under the Improving Access to Psychological Therapies (IAPT) Programme in England. Pre-post treatment effect sizes (ES) and confidence intervals were estimated to illustrate a benchmarking method enabling services to evaluate routine clinical outcomes. RESULTS High, average and poor performance ES for routine IAPT services were estimated to be 0.91, 0.73 and 0.46 for depression (using PHQ-9) and 1.02, 0.78 and 0.52 for anxiety (using GAD-7). Data from one specific IAPT service exemplify how to evaluate and contextualize routine clinical performance against these benchmarks. CONCLUSIONS The main contribution of this report is to summarize key recommendations for the selection of an adequate set of psychometric measures, the operational definition of outcomes, and the statistical evaluation of clinical performance. A benchmarking method is also presented, which may enable a robust evaluation of clinical performance against national benchmarks. Some limitations concerned significant heterogeneity among data sources, and wide variations in ES and data completeness.

Feasibility Randomized Controlled Trial of Cognitive and Behavioral Interventions for Depression Symptoms in Patients Accessing Drug and Alcohol Treatment

Depressed mood often co-exists with frequent drug and alcohol use. This trial examined the feasibility of screening, recruitment, randomization and engagement of drug and alcohol users in psychological interventions for depression symptoms. A total of 50 patients involved in community drugs and alcohol treatment (CDAT) were randomly allocated to behavioral activation delivered by psychological therapists (n = 23) or to cognitive behavioral therapy based self-help introduced by CDAT workers (n = 27). We examined recruitment and engagement rates, as well as changes in depression (PHQ-9) symptoms and changes in percent days abstinent (PDA within last month) at 24 weeks follow-up. The ratio of screened to recruited participants was 4 to 1, and the randomization schedule successfully generated 2 groups with comparable characteristics. Follow-up was possible with 78% of participants post-treatment. Overall engagement in psychological interventions was low; only 42% of randomized participants attended at least 1 therapy session. Patients offered therapy appointments co-located in CDAT clinics were more likely to engage with treatment (odds ratio = 7.14, p = .04) compared to those offered appointments in community psychological care clinics. Intention-to-treat analyses indicated no significant between-group differences at follow-up in mean PHQ-9 change scores (p = .59) or in PDA (p = .08). Overall, it was feasible to conduct a pragmatic trial within busy CDAT services, maximizing external validity of study results. Moderate and comparable improvements in depression symptoms over time were observed for participants in both treatment groups.

Negative affectivity as a transdiagnostic factor in patients with common mental disorders.

BACKGROUND Screening and monitoring systems are increasingly used in psychotherapy, but it has been questioned whether outcome measurement using multiple questionnaires is warranted. Arguably, type and number of assessment instruments should be determined by empirical research. This study investigated the latent factor structure of a multi-dimensional outcome measurement strategy used in English services aligned to the Improving Access to Psychological Therapies (IAPT) programme. METHODS Factor analyses and structural equation models were performed on 11,939 intake assessments of outpatients accessing an IAPT service between 2008 and 2010. We examined whether three routinely employed instruments (PHQ-9 for depression, GAD-7 for anxiety, WSAS for functional impairment) assess empirically different dimensions. RESULTS The instruments were found to assess mainly one general dimension and only some items of the GAD-7 and WSAS assess unique variance beyond this general dimension. In a structural equation model the disorder-specific factor scores were predicted by patients׳ diagnostic categories. LIMITATIONS Since a large naturalistic data base was used, missing data for diagnoses and scale items were encountered. Diagnoses were obtained with brief case-finding measures rather than structured diagnostic interviews. CONCLUSION Although the items seem to address mostly one dimension, some variance is due to differences between individuals in anxiety and impairment. While this generally supports multi-dimensional assessment in a primary care population, the clinical upshot of the study is to concentrate attention on transdiagnostic factors as a target for treatment.

Heterogeneity in patient-reported outcomes following low-intensity mental health interventions: a multilevel analysis.

Background Variability in patient-reported outcomes of psychological treatments has been partly attributed to therapists – a phenomenon commonly known as therapist effects. Meta-analytic reviews reveal wide variation in therapist-attributable variability in psychotherapy outcomes, with most studies reporting therapist effects in the region of 5% to 10% and some finding minimal to no therapist effects. However, all except one study to date have been conducted in high-intensity or mixed intervention groups; therefore, there is scarcity of evidence on therapist effects in brief low-intensity psychological interventions. Objective To examine therapist effects in low-intensity interventions for depression and anxiety in a naturalistic setting. Data and Analysis Session-by-session data on patient-reported outcome measures were available for a cohort of 1,376 primary care psychotherapy patients treated by 38 therapists. Outcome measures included PHQ-9 (sensitive to depression) and GAD-7 (sensitive to general anxiety disorder) measures. Three-level hierarchical linear modelling was employed to estimate therapist-attributable proportion of variance in clinical outcomes. Therapist effects were evaluated using the intra-cluster correlation coefficient (ICC) and Bayesian empirical predictions of therapist random effects. Three sensitivity analyses were conducted: 1) using both treatment completers and non-completers; 2) a sub-sample of cases with baseline scores above the conventional clinical thresholds for PHQ-9 and GAD-7; and 3) a two-level model (using patient-level pre- and post-treatment scores nested within therapists). Results The ICC estimates for all outcome measures were very small, ranging between 0% and 1.3%, although most were statistically significant. The Bayesian empirical predictions showed that therapist random effects were not statistically significantly different from each other. Between patient variability explained most of the variance in outcomes. Conclusion Consistent with the only other study to date in low intensity interventions, evidence was found to suggest minimal to no therapist effects in patient-reported outcomes. This draws attention to the more prominent source of variability which is found at the between-patient level.

Confidence in the face of risk: the Risk Assessment and Management Self-Efficacy Study (RAMSES)

Aims and method To evaluate a comprehensive risk management programme. A Risk Assessment and Management Self-Efficacy Scale (RAMSES) was used to evaluate the impact of a clinical guideline and training course. Fifty-three psychological therapists were randomly allocated to training v. waiting list in a controlled, delayed-intervention design. Differences in mean self-efficacy scores between groups were examined using analysis of covariance (ANCOVA). Results The RAMSES measure had adequate factor structure, internal consistency and construct validity. When adjusting for baseline scores and cluster design, the group exposed to training had a higher mean self-efficacy score than controls. Mean differences between groups were not significant after the control group received training, nor at 6 months’ follow-up. Clinical implications Exposure to training and clinical guidelines can improve self-efficacy in risk assessment and management. An important advance put forward by this study is the specification of areas of competence in risk assessment and management, which can be measured using a psychometrically sound tool.