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Demographic and treatment factors
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Background
Depression and anxiety are highly prevalent and represent a significant and well described public health burden. Whilst first line psychological treatments are effective for nearly half of attenders, there remain a substantial number of patients who do not benefit. The main objective of the present project is to establish an infrastructu...
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Background: The number of academic papers referring to patient engagement or to related terms has been rising sharply for at least 20 years; several review articles have recently been published enumerating a wide variety of situations of patient involvement in research and partnership with health professionals.
Objective: As no standardized keywor...
Citations
... This notable reduction was further reflected by the finding that over 50% of respondents at follow-up no longer met clinical caseness for both anxious and depressive symptoms. When considering treatment responsiveness -based on the standard IAPT Reliable Change Index (drop of 6 points for the PHQ-9 or a drop of 5 points for the GAD-7) (Grant et al., 2014) -35.71% of participants responded (i.e., experienced significant drop on at least one symptom) to treatment at post-bMBI and this increased to 56.25% of participants at one-month follow-up (Jacobson & Truax, 1991). ...
Objective
We tested the effectiveness of a brief mindfulness-based intervention (bMBI) for emerging adults (EAs) experiencing anxious and depressive symptoms. Specifically, we examined: (1) whether there are improvements in mental health outcomes among participants at post-intervention and in a one-month follow-up, and (2) whether initial health variables predict overall mental health improvement over the intervention.
Method
Forty-five undergraduate students who were experiencing mood and/or anxiety symptoms participated in a five-session, in-person mindfulness group. Data on anxious symptoms (Generalised Anxiety Disorder-7), depressive symptoms (Patient Health Questionnaire–9), mental well-being (Warwick-Edinburgh Mental Well-Being Scale), perceived stress (10-item Perceived Stress Scale), and self-compassion (12-item Self-Compassion Scale – Short Form) were collected at baseline, immediately prior to the beginning of the intervention, at the beginning of session three, immediately following the intervention and at one-month follow-up.
Results
The preliminary analysis indicated that this five-session bMBI for EAs was: (1) effective in decreasing psychological distress and increasing well-being, with improvements continuing at the follow-up; and (2) that pre-bMBI self-compassion moderated anxious, depressive and well-being scores at mid-bMBI, post-bMBI, and one-month follow-up.
Discussion
The current findings lend support for an effective intervention for EAs and provide direction for increased services and preventative strategies for EAs in post-secondary education. This study is one of the few studies on such therapeutic interventions for mood and anxiety within EA research.
... Predictors were based on relevant literature (e.g., Zonneveld et al., 2012) and their availability in our ROM database. We took several control variables into account for the course of symptoms: pretreatment BSI total, age, sex, and marital status (e.g., Grant et al., 2014;Iezzoni, 2013;Karlsen et al., 2011;Ware et al., 1993;Zonneveld et al., 2012). Predictors for the course of symptoms included education, comorbid disorders (mood disorder, somatoform disorder, mood and somatoform disorder, total comorbid diagnoses), BAS, MADRS, SF-36 physical functioning, SF-36 social functioning, SF-36 general health, and the four separate anxiety-related disorder groups (e.g., Pedersen et al., 2016;Schröder et al., 2012;Wortman et al., 2016;Zonneveld et al., 2012). ...
Anxiety-related disorders constitute the leading prevalent mental disorders, with major burden on patients, their relatives, and society. Moreover, there is considerable treatment nonadherence/nonresponse. We used routine outcome monitoring (ROM) data from outpatients covering four anxiety-related disorders (DSM-IV-R, N = 470) to examine their 6-month treatment course and its predictors: generalized anxiety disorder, panic disorder with agoraphobia, obsessive-compulsive disorder, and posttraumatic stress disorder. Measures included Mini-International Neuropsychiatric Interview Plus, Brief Symptom Inventory (BSI), Montgomery-Åsberg Depression Rating Scale (MADRS), Brief Anxiety Scale (BAS), and Short Form Health Survey 36 (SF-36). On the clinician-rated instruments (MADRS/BAS), all anxiety-related disorder groups showed a significant albeit modest improvement after treatment. On the BSI self-rating, only generalized anxiety disorder and posttraumatic stress disorder showed a significant modest improvement. No anxiety-related disorder groups improved significantly regarding SF-36 physical functioning. For BSI symptom course, significant predictors were comorbid somatoform/total disorders, SF-36 physical functioning/general health, and MADRS score. Clinical implications and future research recommendations are discussed.
... The programme continuously seeks to improve those outcomes. Understanding what factors influence outcomes is important in understanding how clinical care could be improved at the patient level, in understanding variation between services, and in understanding how national and local performance can be improved (Grant et al., 2014;Goddard et al., 2015). ...
Background
Studies on predictors of outcomes of treatment for common mental health disorders (CMDs) in community mental health settings are scarce, and sample sizes are often small. Research on the impact of identifying as a member of an ethnic minority group on treatment outcomes is limited.
Aims
To ascertain whether ethnicity is an independent predictor of outcome and the extent to which any association is mediated by other sociodemographic factors.
Method
Retrospective observational study of anonymised treatment data collected for routine clinical purposes. Data were analysed from nine Improving Access to Psychological Therapy (IAPT) services from 2009 to 2016. Social functioning, ethnic group, age, gender, occupation and baseline severity of the mental health disorder were analysed as predictors of outcome.
Results
Outcomes varied with ethnic group. Levels of occupation, social deprivation, initial morbidity and social functioning varied between ethnic groups at baseline. After adjustment for these factors the impact of ethnicity was attenuated and only some ethnic groups remained as significant independent predictors of treatment outcome.
Conclusions
Ethnic minority status is a marker for multiple disadvantages. Some of the differences in outcome seen between ethnic groups may be the result of more general factors present in all ethnic groups but at greater intensity in some ethnic minority groups.
... At the same time, progression to secondary care remains reserved for those with complex depression and high risk for suicidality. Data from the "Predicting Outcome Following Psychological Therapy in IAPT (PROMPT)" study show that of those who do not respond only 8% receive secondary care interventions [8,9], while the remainder are currently not offered any further-line treatment. Most of these patients are sent back to their GPs, who are likely to prescribe antidepressant medication. ...
... Most of these patients are sent back to their GPs, who are likely to prescribe antidepressant medication. Yet, the majority of IAPT nonresponders are already receiving medications [8,9]. There is therefore a considerable gap in service provision for patients who do not respond sufficiently to highintensity evidence-based psychological therapies-a problem that is likely to come into focus even further as numbers of patients accessing IAPT are increasing. ...
Background
Major depression represents a pressing challenge for health care. In England, Increasing Access to Psychological Therapies (IAPT) services provide evidence-based psychological therapies in a stepped-care approach to patients with depression. While introduction of these services has successfully increased access to therapy, estimates suggest that about 50% of depressed patients who have come to the end of the IAPT pathway still show significant levels of symptoms. This study will investigate whether Mindfulness-Based Cognitive Therapy (MBCT), a group intervention combining training in mindfulness meditation and elements from cognitive therapy, can have beneficial effects in depressed patients who have not responded to high-intensity therapy in IAPT. It will seek to establish the effectiveness and cost-effectiveness of MBCT as compared to the treatment these patients would usually receive.
Methods
In a 2-arm randomised controlled trial, patients who currently meet the criteria for major depressive disorder and who have not sufficiently responded to at least 12 sessions of IAPT high-intensity therapy will be allocated, at a ratio of 1:1, to receive either MBCT (in addition to treatment as usual [TAU]) or continue with TAU only. Assessments will take place at baseline, 10 weeks and 34 weeks post-randomisation. The primary outcome will be reduction in depression symptomatology 34 weeks post-randomisation as assessed using the Public Health Questionnaire-9 (PHQ-9). Secondary outcomes will include depressive symptomatology at 10 weeks post-randomisation and other clinical outcomes measured at 10-week and 34-week follow-up, along with a series of binarised outcomes to indicate clinically significant and reliable change. Evaluations of cost-effectiveness will be based on assessments of service use costs collected using the Adult Service Use Schedule and health utilities derived from the EQ-5D.
Discussion
This trial will add to the evidence base for the use of MBCT in depressed treatment non-responders. It will constitute the first trial to test MBCT following non-response to psychological therapy, with results providing a direct estimate of efficacy within the IAPT pathway. As such, its results will offer an important basis for decisions regarding the adoption of MBCT for non-responders within IAPT.
Trial registration
ClinicalTrials.gov NCT05236959. Registered on 11 February 2022. ISRCTN 17755571. Registered on 2 February 2021.
... At the same time, progression to secondary care remains reserved for those with complex depression and high risk for suicidality. Data from the "Predicting Outcome Following Psychological Therapy in IAPT (PROMPT)" study show that of those who do not respond only 8% receive secondary care interventions [8,9], while the remainder are currently not offered any further-line treatment. Most of these patients are sent back to their GPs, who are likely to prescribe antidepressant medication. ...
... Most of these patients are sent back to their GPs, who are likely to prescribe antidepressant medication. Yet, the majority of IAPT non-responders are already receiving medications [8,9]. There is therefore a considerable gap in service provision for patients who do not respond su ciently to high intensity evidence-based psychological therapies -a problem that is likely to come into focus even further as numbers of patients accessing IAPT are increasing. ...
• Background: Major Depression represents a pressing challenge for health care. In England, Increasing Access to Psychological Therapies (IAPT) services provide evidence-based psychological therapies in a stepped care approach to patients with depression. While introduction of these services has successfully increased access to therapy, estimates suggest that about 50 percent of depressed patients who have come to the end of the IAPT pathway still show significant levels of symptoms. This study will investigate whether Mindfulness-Based Cognitive Therapy (MBCT), a group intervention combining training in mindfulness meditation and elements from cognitive therapy, can have beneficial effects in depressed patients who have not responded to high-intensity therapy in IAPT. It will seek to establish the effectiveness and cost-effectiveness of MBCT as compared to the treatment these patients would usually receive.
• Methods: In a 2-arm randomised controlled trial, patients who currently meet criteria for Major Depressive Disorder and who have not sufficiently responded to at least 12 sessions of IAPT high-intensity therapy will be allocated, at a ratio of 1:1, to receive either MBCT (in addition to treatment as usual [TAU]) or continue with TAU only. Assessments will take place at baseline, 10-weeks and 34-weeks post-randomisation. The primary outcome will be reduction in depression symptomatology 34 weeks post-randomisation as assessed using the Public Health Questionnaire-9 (PHQ-9). Secondary outcomes will include depressive symptomatology at 10-weeks post-randomisation and other clinical outcomes measured at 10-week and 34-week follow-up, along with a series of binarized outcomes to indicate clinically significant and reliable change. Evaluations of cost-effectiveness will be based on assessments of service use costs collected using the Adult Service Use Schedule and health utilities derived from the EQ-5D.
• Discussion: This trial will add to the evidence-base for the use of MBCT in depressed treatment non-responders. It will constitute the first trial to test MBCT following non-response to psychological therapy, with results providing a direct estimate of efficacy within the IAPT pathway. As such, its results will offer an important basis for decisions regarding the adoption of MBCT for non-responders within IAPT.
• Trial registration: ClinicalTrials.gov NCT05236959, 11.02.2022; ISRCTN: 17755571, 02.02.2021
... Derartige Prädiktoren werden auch als Moderatoren für das Ansprechen auf eine Therapie verstanden (Simon & Perlis, 2010). Diese Variablen können bei der Auswahl einer optimalen Behandlung helfen (Cohen & DeRubeis, 2018;Keefe et al., 2020) und dadurch personalisierte Behandlungen (Grant et al., 2014;Simon & Perlis, 2010) ermöglichen. Die Prognoseforschung bietet somit zwar das Potenzial, mögliche Risikoverläufe frühzeitig zu identifizieren und die Zuweisung von Patient_innen zu den für sie bestmöglichen Behandlungen zu unterstützen. ...
In recent decades, randomized-controlled trials (RCTs) have established a broad evidence base of psychotherapy with moderate-to-large effects for various mental disorders. In addition to determining the efficacy of psychotherapy, studies examining its effectiveness under everyday conditions historically paved the way for developing a practice-oriented research paradigm. This paper argues that, within this paradigm, practice-based studies are a valuable complement to RCTs as they can address existing problems in psychotherapy research. In current practice-oriented research, new approaches from personalized medicine and methods from computational psychiatry provide important clues for optimizing effects in psychotherapy. In the context of personalization, for example, clinical multivariable prediction models are being developed that enable evidence-based outcome monitoring through feedback loops to practitioners in the short term and strengthen the German practice-research network in the long term. In conclusion, the paper derives and discusses future directions for practice-oriented research in terms of the “precision mental health care” paradigm.
... The primary study assessed (prior to initiating therapy) a range of factors putatively predicting subsequent response to naturalistic IAPT intervention. Full details of the study are described elsewhere (Grant et al., 2014;Hepgul et al., 2016;Strawbridge et al., 2020). ...
Background
Improving Access to Psychological Therapies (IAPT) is a primary care therapy service commissioned by England's National Health Service (NHS) for people with unipolar depression and anxiety-related disorders. Its scope does not extend to ‘severe mental illness’, including bipolar disorders (BD), but evidence suggests there is a high BD prevalence in ostensibly unipolar major depressive disorder (uMDD) samples. This study aimed to indicate the prevalence and characteristics of people with BD in a naturalistic cohort of IAPT patients.
Methods
371 participants were assessed before initiating therapy. Participants were categorised by indicated diagnoses: BD type-I (BD-I) or type-II (BD-II) as defined using a DSM diagnostic interview, bipolar spectrum (BSp, not meeting diagnostic criteria but exceeding BD screening thresholds), lifetime uMDD or other. Information about psychiatric history and co-morbidities was examined, along with symptoms before and after therapy.
Results
368 patients provided sufficient data to enable classification. 10% of participants were grouped as having BD-I, 20% BD-II, 40% BSp, 25% uMDD and 5% other. BD and uMDD participants had similar demographic characteristics, but patients meeting criteria for BD-I/BD-II had more complex psychiatric presentations. All three ‘bipolar’ groups had particularly high rates of anxiety disorders. IAPT therapy receipt was comparable between groups, as was therapy response ( F 9704 = 1.113, p = 0.351).
Conclusions
Notwithstanding the possibility that bipolar diathesis was overestimated, findings illustrate a high prevalence of BD in groups of people notionally with uMDD or anxiety. As well as improving the detection of BD, further substantive investigation is required to establish whether individuals affected by BD should be eligible for primary care psychological intervention.
... Patients accepted into the UK's IAPT service (Southwark borough, London) and who provided their written informed consent were eligible for participation in the PROMPT study and the following inclusion criteria were applied in line with the primary analyses. The full study protocol has been previously published: 22 (a) ≤1 session within the service before PROMPT baseline assessment; (b) attended ≥2 sessions of low or high intensity therapy; (c) Patient Health Questionnaire (PHQ) score ≥10 at first therapy session; 25 (d) ≤20% missing data for relevant independent variables; (e) available outcome data for the relevant analysis (MSM score or number of antidepressant treatment failures). ...
... (a) the Predicting Outcome following Psychological Therapy (PROMPT) study; (b) the Lithium versus Quetiapine in Depression (LQD) study; and (c) the Affective Disorders Unit (ADU) studies.[22][23][24] Ethical approvalAll studies had ethical approval and written informed consent was obtained from all participants.The authors assert that all procedures contributing to this work comply with the ethical standards of the relevant national and insti-tutional committees on human experimentation and with the Helsinki Declaration of 1975, as revised in 2008. ...
Background
Treatment-resistant depression (TRD) is classically defined according to the number of suboptimal antidepressant responses experienced, but multidimensional assessments of TRD are emerging and may confer some advantages. Patient characteristics have been identified as risk factors for TRD but may also be associated with TRD severity. The identification of individuals at risk of severe TRD would support appropriate prioritisation of intensive and specialist treatments.
Aims
To determine whether TRD risk factors are associated with TRD severity when assessed multidimensionally using the Maudsley Staging Method (MSM), and univariately as the number of antidepressant non-responses, across three cohorts of individuals with depression.
Method
Three cohorts of individuals without significant TRD, with established TRD and with severe TRD, were assessed ( n = 528). Preselected characteristics were included in linear regressions to determine their association with each outcome.
Results
Participants with more severe TRD according to the MSM had a lower age at onset, fewer depressive episodes and more physical comorbidities. These associations were not consistent across cohorts. The number of episodes was associated with the number of antidepressant treatment failures, but the direction of association varied across the cohorts studied.
Conclusions
Several risk factors for TRD were associated with the severity of resistance according to the MSM. Fewer were associated with the raw number of inadequate antidepressant responses. Multidimensional definitions may be more useful for identifying patients at risk of severe TRD. The inconsistency of associations across cohorts has potential implications for the characterisation of TRD.
... Participants were identified following referral for IAPT psychological therapies. A subsample of the 'PROMPT' study (see [22,23] for more details), the majority of participants (n = 87/96) were contacted by the PROMPT team after consenting via IAPT to be contacted by researchers; the other individuals made contact with the study team in response to community advertisements. The two subsamples were comparable in terms of data collection and intervention methods. ...
In people with depression, immune dysfunctions have been linked with treatment non-response, but examinations of psychological therapy outcomes, particularly longitudinal biomarker studies, are rare. This study investigated relationships between inflammation, depressive subtypes and clinical outcomes to psychological therapy. Adults with depression (n = 96) were assessed before and after a course of naturalistically-delivered psychological therapy. In total, 32 serum inflammatory proteins were examined alongside therapy outcomes and depressive subtypes (somatic/cognitive symptom subtype, and bipolar/unipolar depression). Overall, 49% of participants responded to treatment. High levels of tumour necrosis factor (TNFα), interleukin-6 (IL-6) and soluble intracellular adhesion molecule-1 (sICAM1), and low interferon-γ (IFNγ), preceded a poorer response to therapy. After therapy, non-responders had elevated c-reactive protein (CRP), thymus and activation-regulated chemokine (TARC) and macrophage chemoattractant protein-4 (MCP4), and attenuated IFNy. Non-somatic depressive symptoms were universally not associated with proteins, while somatic-depressive symptom severity was positively correlated with several pro-inflammatory markers. In the somatic subgroup only, IL-6 and serum amyloid alpha (SAA) decreased between pre-and post-therapy timepoints. Regardless of treatment response, IL-7, IL-8, IL-15 and IL-17 increased over time. These results suggest that inflammation is associated with somatic symptoms of depression and non-response to psychological therapy. Future work may enhance the prospective prediction of treatment-response by examining larger samples of individuals undertaking standardised treatment programmes.
... We therefore employed a score of 3 or above for inclusion into the study. Furthermore, the SAPAS has been deemed feasible for use in routine clinical practice for the identification of people with personality disorder (Moran et al., 2003) and used in the identification of people with personality disorder co-morbidity in IAPT (Goddard et al., 2015;Grant et al., 2014;Hepgul et al., 2016). Those who met criteria following the screening were sent a detailed participant involvement form. ...
Background:
High numbers of people present with common mental health disorders and co-morbid personality disorder traits in primary care 'Improving Access to Psychological Therapies' (IAPT) services in England and they receive sub-optimal treatments. No previous studies have explored the treatment experiences or needs of this patient population in England.
Aims:
This qualitative study explored the treatment experiences of patients (n = 22) with common mental health difficulties and co-morbid personality disorder as indicated by a score of 3 or more on the 'Standardised Assessment of Personality - Abbreviated Scale' (SAPAS) in receipt of primary care-based IAPT treatment.
Method:
A qualitative health research approach was used. Qualitative individual face-to-face semi-structured interviews were conducted. All interviews were audio recorded, data were transcribed verbatim and analysed using a framework analysis approach.
Results:
Findings revealed a need to adapt away from prescriptive cognitive behavioural therapy (CBT) treatment models towards more flexible, personalised and individualised treatment with this patient group. Time to emotionally offload, build a therapeutic relationship and link past experiences to presenting problems were highlighted as important.
Conclusions:
For the first time, the needs and treatment experiences of this patient group have been explored. This paper provides a unique patient experience insight that should be considered when exploring new approaches to working with and developing effective interventions via a stepped care approach.
