Trajectories of depression and anxiety symptom change during psychological therapy

Rob Saunders,Joshua E.J Buckman,John Cape,Pasco Fearon,Judy Leibowitz,Stephen Pilling

doi:10.1016/j.jad.2019.02.043

Abstract

BackgroundForty-percent of the variance in psychological treatment outcomes is estimated to be explained by symptom change by the third treatment session. However, change may not be uniform across patient groups and symptom domains. This study aimed to identify subgroups of patients with different trajectories of depression and anxiety symptom change during psychological therapy and identify baseline patient characteristics associated with these trajectories. Methods4394 patients attending two psychological treatment services completed sessional, self-report depression and anxiety measures. Trajectories of symptom change were investigated using latent class growth analysis. Multinomial logistic regression was used to explore associations between baseline patient characteristics and trajectory classes. ResultsA number of distinct trajectories were identified. Anxiety symptom trajectories could be distinguished by the third treatment session, but for depression symptoms there was a class displaying limited change until session six followed by rapid improvement in symptoms thereafter. Compared to the non-responding trajectories, depression and anxiety trajectories indicating treatment response were associated with lower baseline severity, better social functioning and lower incidence of phobic anxiety, but not with medication prescription status. LimitationsData came from two services, so wider generalisability is unknown. Predictors were limited to data routinely collected in the services; unmeasured factors may have improved the prediction of trajectories. ConclusionsBaseline characteristics and symptom change early in therapy can help identify different trajectories of symptom change. This knowledge could aid clinical decision making and help improve treatment outcomes. By ignoring distinct trajectories, clinicians may incorrectly consider patients as “not-on-track” and unnecessarily change or end therapy that would otherwise benefit patients.

Highlights

Being able to predict the outcome of treatment may be of significant benefit to patients, clinicians and health care services (Lambert et al, 2001a)
Like previous studies we found some evidence for a clear distinction between patients being “on-track” or “not-on-track” in psychological therapies by session three, we found one trajectory class of depression symptoms that showed slow initial response but rapid later response from session six onwards
It is of interest that the current study identified a ‘late responding’ group of patients based on depression symptom change, this group appears to match a group of “one-step” responders identified in a randomised control trial of cognitive therapy for depression (Vittengl et al, 2013, 2016)

Summary

Introduction

Being able to predict the outcome of treatment may be of significant benefit to patients, clinicians and health care services (Lambert et al, 2001a). Providing feedback to clinicians about whether their patients are “on track” or “not-on-track” during therapy has led to improved post-treatment outcomes in university based counselling services in the USA (Bybee et al, 2007; Lambert and Shimokawa, 2011). This study aimed to identify subgroups of patients with different trajectories of depression and anxiety symptom change during psychological therapy and identify baseline patient characteristics associated with these trajectories. Conclusions: Baseline characteristics and symptom change early in therapy can help identify different trajectories of symptom change. This knowledge could aid clinical decision making and help improve treatment outcomes. Clinicians may incorrectly consider patients as “not-on-track” and unnecessarily change or end therapy that would otherwise benefit patients

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