Stepped-care Approach Research Articles

Design of a randomized controlled trial to assess the comparative effectiveness of a multifaceted intervention to improve three-year adherence to colorectal cancer screening among patients cared for in rural community health centers

Colorectal cancer (CRC) screening has been shown to decrease CRC mortality, yet significant disparities persist among those living in rural areas, from minority backgrounds, and those having low income. The purpose of this two-arm randomized controlled trial is to test the effectiveness and fidelity of a stepped care (increasing intensity as needed) approach to promoting 3-year adherence to CRC screening via fecal immunochemical testing (FIT) or colonoscopy in rural community clinics serving high rates of low-income and minority patients. We hypothesize that, compared to enhanced usual care (EUC), patients receiving the multifaceted CRC screening intervention will demonstrate higher rates of CRC screening completion over 3 years. Participants from six federally qualified health centers (FQHCs; N = 1200 patients) serving predominately low-income populations in rural Louisiana will be randomized to the intervention or EUC arm. All participants will receive health literacy-directed CRC counseling, simplified materials about both the FIT and colonoscopy procedures, and motivational interviewing to aid in the determination of test preference. Participants in the intervention arm will also receive motivational reminder messages from their primary care provider (via audio recording or tailored text) for either a scheduled colonoscopy or return of a completed FIT. Participants in the EUC arm will receive the standard follow-up provided by their clinic or colonoscopy facility. The primary outcome will be completion of either colonoscopy or annual FIT over 3 years. Results will provide evidence on the effectiveness of the intervention to decrease disparities in CRC screening completion related to health literacy, race, and gender.Trial registration:Clinicaltrials.gov Identifier NCT04313114

Evaluation of a Stepped Care Approach to Manage Depression and Diabetes Distress in Patients with Type 1 Diabetes and Type 2 Diabetes: Results of a Randomized Controlled Trial (ECCE HOMO Study)

Introduction: Depression is a common and serious complication of diabetes. Treatment approaches addressing the specific demands of affected patients are scarce. Objective: The aim of this work was to test whether a stepped care approach for patients with diabetes and depression and/or diabetes distress yields greater depression reduction than treatment-as-usual. Methods: Two-hundred and sixty patients with diabetes and elevated depressive symptoms (CES-D ≥16) and/or elevated diabetes distress (PAID ≥40) were randomized to stepped care for depression or diabetes treatment-as-usual. The primary outcome was the rate of meaningful depression reduction at the 12-month follow-up according to the HAMD (score <9 or reduction by ≥50%). Secondary outcomes were changes in depression scores (HAMD/CES-D), diabetes distress (PAID), diabetes acceptance (AADQ), well-being (WHO-5), quality of life (EQ-5D/SF-36), self-care behavior (SDSCA/DSMQ), HbA_1c, and biomarkers of inflammation. Results: One-hundred and thirty-one individuals were assigned to stepped care and 129 to treatment-as-usual. Overall, 15.4% were lost to follow-up. Meaningful depression reduction was observed in 80.2 versus 51.2% in stepped care versus treatment-as-usual (p < 0.001, intention-to-treat analysis). Of the secondary measures, the HAMD (∆ –3.2, p < 0.001), WHO-5 (∆ 1.5, p = 0.007), and AADQ (∆ –1.0, p = 0.008) displayed significant treatment effects, while effects on CES-D (∆ –2.3, p = 0.065), PAID (∆ –3.5, p = 0.109), and SDSCA (∆ 0.20, p = 0.081) were not significantly different. Both groups showed comparable changes in EQ-5D/SF-36, DSMQ, HbA_1c, and biomarkers of inflammation (all p ≥ 0.19). Conclusions: The stepped care approach improved depression, well-being, and acceptance. The results support that increasing treatment intensity on demand is effective and can help provide more optimal treatment. The inclusion of diabetes-specific interventions may be beneficial for patients with diabetes and elevated depression.

Acceptability and fidelity of a psychosocial intervention (PROACTIVE) for older adults with depression in a basic health unit in S\xe3o Paulo, Brazil: a qualitative study

BackgroundDepression is a common condition in older adults, being often detected and treated initially in primary care. Collaborative care models including, for example, task-shifting and stepped-care approaches have been investigated to overcome the current scarcity of strategies and trained mental health professionals to treat depression. The PROACTIVE study developed a psychosocial intervention, which makes extensive use of technology in an intervention delivered mainly by non-specialists to treat older adults with depression. The aim of this qualitative study is to assess: 1. Health workers’ fidelity to the intervention protocol; 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants; and 3. Perceptions of the psychosocial intervention by the health workers.MethodsQualitative methods were used to achieve our aims. The sample included participants (N = 31) receiving the intervention in the pilot trial and health workers (N = 11) working in a Basic Health Unit in the northern area of São Paulo, Brazil. Focus group, non-participant observation and structured interviews were used. Data were analysed using a thematic analysis approach.Results1. Health workers’ fidelity to the intervention protocol: training, supervision and the structured intervention were crucial and guaranteed health workers’ fidelity to the protocol. 2. Acceptability of the psychosocial intervention from the viewpoint of older adult participants: Collaborative care, task-shifting, and stepped-care approaches were well accepted. The structured protocol of the intervention including different activities and videos was important to adherence of older adult participants 3. Perceptions of the psychosocial intervention by the health workers: It was feasible to have the home psychosocial sessions conducted by health workers, who are non-mental health specialists and received 3-day training. Training and supervision were perceived as crucial to support health workers before and during the intervention. Technology served as a tool to structure the sessions, obtain and store patient data, present multi-media content, guarantee fidelity to the protocol and facilitate communication among members of the team. However, extra burden was mentioned by the health workers indicating the need of adjustments in their daily duties.ConclusionsThe PROACTIVE intervention was demonstrated to be feasible and accepted by both health workers and older adult participants. The qualitative assessments suggested improvements in training and supervision to ensure fidelity to protocol. To assess effectiveness a randomised controlled trial of the intervention will be conducted with the addition of improvements suggested by this qualitative study.Trial registrationThe pilot study of which the present study gives support to was registered at the Brazilian Clinical Trials, UTN code: U1111-1218-6717 on 26/09/2018.

Are eHealth interventions for adults who are scheduled for or have undergone bariatric surgery as effective as usual care? A systematic review.

This systematic review aimed to evaluate the effect of eHealth-delivered interventions for adults who undergo bariatric surgery on postoperative weight loss, weight loss maintenance, eating psychopathology, quality of life, depression screening, and self-efficacy. Six electronic databases were searched, with 14 studies (across 17 reports) included, involving 1633 participants. With substantial heterogeneity, qualitative descriptions have been provided. Interventions were delivered via an online program or internet modules (n = 2), telephone (n = 2), text messages (n = 2), videoconferencing (n= 3), mobile application (n = 1), and audiovisual media (n = 1). Three studies included a combination, including internet modules and telephone (n = 1), wireless fidelity scales, emails, and telephone (n = 1), and a combination of online treatment, weekly emails, and access to a private Facebook group (n = 1). All the eHealth interventions, except for one, implemented behavior change techniques, including self-monitoring, problem solving, social support, goal setting, and shaping knowledge. Both eHealth intervention and control groups lost weight across the included studies, and eHealth was found to be as effective as or more effective than the control for weight loss. Two studies measured weight loss maintenance; both eHealth and control groups regained weight in the longer term. The interventions showed significant improvement on assessment measures for eating psychopathology. In conclusion, when bariatric surgery patients have limited or no access to healthcare teams or require additional support, eHealth may be a suitable option. Future studies implementing eHealth interventions would benefit from reporting intervention components as per the behavior change techniques taxonomy and further consideration of delivering eHealth in a stepped care approach would be beneficial.

Women With Postpartum Depression May Benefit From One-Day Online Workshop

Back to table of contents Previous article Next article Clinical & ResearchFull AccessWomen With Postpartum Depression May Benefit From One-Day Online WorkshopNick ZagorskiNick ZagorskiSearch for more papers by this authorPublished Online:30 Nov 2021https://doi.org/10.1176/appi.pn.2021.11.24AbstractThe seven-hour workshop, which incorporated cognitive-behavioral therapy techniques, was more effective than usual care at improving mothers’ mood as well as feelings of being supported and loved.iStock/insta_photosA one-day online workshop based on cognitive-behavioral therapy (CBT) principles can significantly boost mood and social support in women with postpartum depression, a study in JAMA Psychiatry has found. Those who attended the workshop in addition to receiving standard care for postpartum depression experienced greater improvements in depression and anxiety symptoms than those who received standard care alone. The women in the workshop also experienced more positive feelings about motherhood after 12 weeks compared with those who did not attend the workshop.These findings suggest such brief workshops could be an efficient way to increase access to perinatal mental health care, said lead study author Ryan J. Van Lieshout, M.D., Ph.D., the Canada Research Chair in the Perinatal Programming of Mental Disorders at McMaster University in Hamilton, Ontario.“Even before COVID-19, … time, travel, or finding childcare were significant barriers for mothers seeking postpartum depression care,” Van Lieshout said. Since then, the virus has exacerbated these barriers, he noted. The online workshop can accommodate up to 30 participants, and women can join from the comfort of their own homes. The intervention includes four modules that cover the biology of postpartum depression, cognitive coping skills, behavioral coping skills, and setting goals and an action plan.Van Lieshout and his colleagues had been conducting some in-person studies with this CBT-based workshop prior to the pandemic, which gave them the tools needed to rapidly pivot to an online mode of care. Unsure how well the workshop—which combines lectures, group discussions, and role-playing activities—would translate to the virtual world, they enrolled 403 new mothers from Ontario for a clinical trial.All the participants were 18 years or older, had a child younger than 12 months, and had an Edinburgh Postnatal Depression Scale (EPDS) score of at least 10. Half the women were enrolled in the workshop, while the others were put on a wait list and received the workshop after 12 weeks. Both groups had access to standard depression care, including medications and/or psychotherapy, during the 12-week study.Participants in the workshop group attended a one-day Zoom meeting from 9 a.m. to 4 p.m. that was led by Van Lieshout, a perinatal psychiatrist; Erika Haber, M.Sc, a registered psychotherapist; or Meena Rangan, M.Sc., a psychology graduate student. Van Lieshout noted that the workshop leaders were chosen by necessity (as he wanted to start the trial early in the pandemic and the trio had been trained), but having the workshop leaders with diverse clinical expertise allowed the researchers to test whether this had any bearing on participants’ outcomes.After 12 weeks, average EPDS scores dropped by 4.82 points among women who attended the workshop, compared with 1.88 points among women receiving usual care alone; based on previous data, the researchers defined an improvement of four points or more as clinically meaningful. The workshop attendees also reported greater improvements in anxiety symptoms, their perceived social support, and infant bonding compared with the usual care group. The women experienced similar improvements regardless of who led the workshop.Van Lieshout said he believes that the social component of the online workshop helped the participants. “You could see the amazing cohesion and caring among these women during the sessions, and many of the mothers would connect after the workshop and continue supporting each other.”Van Lieshout told Psychiatric News he is planning a follow-up study that will examine which elements of the workshop have the greatest impact on outcomes. The follow-up study will also employ nurses as the workshop leaders.Despite the positive results, Van Lieshout cautioned that the one-day workshop is not a replacement for the 12 to 15 sessions of conventional CBT that is demonstrated to be effective for postpartum depression. “The workshop is well suited as a first step in a stepped care approach,” he explained. “We can treat many women with this brief approach, while also identifying women who need more intensive therapies like CBT or medication.”This study was funded by a grant from the Canadian Institutes of Health Research. ■“Effect of Online 1-Day Cognitive Behavioral Therapy–Based Workshops Plus Usual Care vs Usual Care Alone for Postpartum Depression: A Randomized Clinical Trial” is posted here. ISSUES NewArchived

Towards a Stepped Care Model for Managing Fear of Cancer Recurrence or Progression in Cancer Survivors.

BackgroundFear of cancer recurrence or progression (FCR) is common amongst cancer survivors and an important minority develop clinically significant levels of FCR. However, it is unclear how current clinical services might best support the growing numbers of cancer survivors.PurposeThe aim of this study is to develop recommendations for future research in the management of FCR and propose a model of care to help manage FCR in the growing population of cancer survivors.MethodsThis is a narrative review and synthesis of empirical research relevant to managing FCR. We reviewed meta-analyses, systematic reviews and individual studies that had investigated interventions for FCR.ResultsA recent, well-conducted meta-analysis confirmed a range of moderately effective treatments for FCR. However, many survivors continued to experience clinical levels of FCR after treatment, indicating a clear need to improve the gold standard treatments. Accessibility of interventions is arguably a greater concern. The majority of FCR treatments require face-to-face therapy, with highly skilled psycho-oncologists to produce moderate changes in FCR. With increasing numbers of cancer survivors, we need to consider how to meet the unmet need of cancer survivors in relation to FCR. Although there have been attempts to develop minimal interventions, these are not yet sufficiently well supported to warrant implementation. Attempts to help clinicians to provide information which might prevent the development of clinically significant FCR have shown some early promise, but research is needed to confirm efficacy.ConclusionThe next decade of research needs to focus on developing preventative approaches for FCR, and minimal interventions for those with mild-to-moderate symptoms. When evidence-based approaches to prevent FCR or manage moderate levels of FCR are available, stepped care approaches that could meet the needs of survivors could be implemented. However, we also need to improve existing interventions for severe FCR.

Cancer-related cognitive impairment: a mixed methods evaluation of a standard factsheet.

To understand the impact of cancer survivors accessing a standard factsheet regarding cancer-related cognitive impairment (CRCI), publicly available to the Australian public via Cancer Council Australia's websites. Twenty-three cancer survivors completed a questionnaire assessing pre-factsheet knowledge of CRCI. Semi-structured interviews were conducted to explore participants' experiences of CRCI and perceptions of the factsheet. Interviews were analysed via thematic analysis using a framework approach. Finally, participants completed another questionnaire assessing post-factsheet change in knowledge of CRCI. Pre- and post-factsheet questionnaire change scores indicated increased knowledge and greater confidence about CRCI. Interview data resulted in five themes: generally positive perceptions of the factsheet's layout and wording; survivors, regardless of treatments received, experienced CRCI symptoms, with some having strong negative emotional responses to their symptoms; perceptions of the factsheet's strategies to manage CRCI ranged from relevant and useful, to impractical or unrealistic if symptoms were too severe; interactions with healthcare system influenced survivors' perceptions of help-seeking, with negative healthcare experiences a major barrier; and generally positive impacts of the factsheet, with survivors praising the factsheet's ability to validate the CRCI experience, increase CRCI knowledge, influence health beliefs, and prompt help-seeking. The factsheet presentation and wording were acceptable to participants. Its ability to normalise and raise awareness for CRCI validated participants' symptoms. The factsheet's potential as a first-line intervention in a stepped-care approach was identified, with participants finding the suggested self-management strategies practical. The factsheet may overcome barriers to self-reporting by encouraging patients to talk with HCPs about CRCI.

Tailoring the Unified Protocol for Adolescents for a Stepped-Care Approach: Case Exemplars.

Emotional disorders, including anxiety, depressive, and obsessive-compulsive spectrum disorders are prevalent and impairing for youth. Dissemination efforts have been implemented to address these disorders in youth, but these are limited by cost and barriers to accessing mental health services. Stepped care is a method of treatment delivery meant to be cost-effective and less time intensive than administering a full treatment manual. Much, if not all of the research, assessing the efficacy of stepped care delivery has utilized disorder-specific treatment manuals. However, transdiagnostic stepped care approaches may prove more efficacious given that youth commonly present to treatment with more than one disorder and that such problems are not always comprehensively assessed at intake. This manuscript provides details regarding the implementation of a transdiagnostic stepped-care delivery (UPA-SC) using three case examples. Youth evidenced significant improvement in anxiety, depression, and quality of life. Future work to investigate the efficacy of UPA-SC in a larger, more heterogeneous sample of youth may be warranted.

Implementation of a Depression Screening Tool at the Department of Radiation Oncology

<h3>Purpose/Objective(s)</h3> Depression is a common comorbidity in cancer that has detrimental effects on patient health outcomes and quality of life. Unrecognized depression can impede treatment adherence resulting in disease progression and mortality in cancer patients. Inadequate depression screening and referral practices were observed and verbalized as a concern by internal stakeholders at an academic Radiation Oncology Department (ROD) in Baltimore, Maryland. Thus, the purpose of this Quality Improvement (QI) project was to implement and evaluate the Patient Health Questionnaire (PHQ-9) depression screening tool with subsequent psychosocial referrals for all positive screens. <h3>Materials/Methods</h3> The QI project used the Mobilize-Assess-Plan-Implement-Track (MAP-IT) framework. The QI team implemented four core interventions during the fifteen-week project: Staff education, PHQ-9 screening, provision of mental health resources, and psychosocial referrals for patients with moderate to severe depressive symptoms (PHQ-9 scores of ≥10). A convenience sample of adult cancer patients (≥18 years old) with a confirmed cancer diagnosis and a radiation treatment plan were eligible to participate. Rates of PHQ-9 screening, positive screens, referrals, and social worker follow-up were collected weekly, analyzed, and plotted on run charts. A combination of descriptive statistics, <b>t</b>-tests, and a chi-squared (X²) test examined differences between pre-and post-implementation data for statistical significance. <h3>Results</h3> All targeted staff attended the education session (n = 10), and there was a 100% completion rate for the pre- and post-surveys. Post education, the average score for staff competency significantly increased from 62% to 96% (<i>P</i> = < 0.001; 95% CI [17.5, 57.0]. Post-implementation, PHQ-9 screening compliance increased from 2% baseline to 67% (<i>P</i> = < 0.001, <b>df</b> = 1, n = 145). Of the patients screened, 19% scored above the threshold indicative of a positive screen (n = 27). Subsequently, all positive screens were referred to an Oncology Social Worker (<i>P</i> = < 0.001), and 93% received follow-up care (n = 25). <h3>Conclusion</h3> Routine depression screening and psychosocial referrals among cancer patients receiving radiotherapy in an outpatient setting are feasible when streamlined into the clinical workflow. An integrated care approach with PHQ-9 screening improves the early identification of depression and increases patient access to psycho-oncology care. Registered nurses are in critical positions to perform primary and secondary prevention interventions to reduce the burden of depression. Considerations for future development include a collaborative and stepped care approach to address the unmet psychosocial needs that exist in the oncology population.

A self-help app for Syrian refugees with posttraumatic stress (Sanadak): results of a randomized controlled trial

Abstract Background Syrian refugees often develop posttraumatic stress as a result of the Syrian civil war and migration stressors. However, there is a lack of adequate treatments. The smartphone app Sanadak was developed and evaluated to provide cognitive behavioral therapy-based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Methods In a randomized controlled trial, eligible individuals were allocated to the intervention group (IG; app) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Results Of 170 screened individuals (aged 18-65 years), 133 were eligible and randomized to the IG (n = 65) or CG (n = 68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff -0.90, 95%CI -0.24 to 0.47; P=.52) and after 4 months (Diff -0.39, 95%CI -3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS-stereotype agreement: d = 0.86, 95%CI 0.46 to 1.25; stereotype application: d = 0.60, 95%CI 0.22 to 0.99) and after 4 months (d = 0.52, 95%CI 0.12 to 0.92; d = 0.50, 95%CI 0.10 to 0.90). Conclusions Sanadak reduced mild to moderate posttraumatic stress in Syrian refugees, but not superior to the control condition. Therefore, Sanadak may not be suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach.

Intrinsic capacity and its associations with incident dependence and mortality in 10/66 Dementia Research Group studies in Latin America, India, and China: A population-based cohort study.

BackgroundThe World Health Organization (WHO) has reframed health and healthcare for older people around achieving the goal of healthy ageing. The recent WHO Integrated Care for Older People (ICOPE) guidelines focus on maintaining intrinsic capacity, i.e., addressing declines in neuromusculoskeletal, vitality, sensory, cognitive, psychological, and continence domains, aiming to prevent or delay the onset of dependence. The target group with 1 or more declines in intrinsic capacity (DICs) is broad, and implementation may be challenging in less-resourced settings. We aimed to inform planning by assessing intrinsic capacity prevalence, by characterising the target group, and by validating the general approach—testing hypotheses that DIC was consistently associated with higher risks of incident dependence and death.Methods and findingsWe conducted population-based cohort studies (baseline, 2003–2007) in urban sites in Cuba, Dominican Republic, Puerto Rico, and Venezuela, and rural and urban sites in Peru, Mexico, India, and China. Door-knocking identified eligible participants, aged 65 years and over and normally resident in each geographically defined catchment area. Sociodemographic, behaviour and lifestyle, health, and healthcare utilisation and cost questionnaires, and physical assessments were administered to all participants, with incident dependence and mortality ascertained 3 to 5 years later (2008–2010). In 12 sites in 8 countries, 17,031 participants were surveyed at baseline. Overall mean age was 74.2 years, range of means by site 71.3–76.3 years; 62.4% were female, range 53.4%–67.3%. At baseline, only 30% retained full capacity across all domains. The proportion retaining capacity fell sharply with increasing age, and declines affecting multiple domains were more common. Poverty, morbidity (particularly dementia, depression, and stroke), and disability were concentrated among those with DIC, although only 10% were frail, and a further 9% had needs for care. Hypertension and lifestyle risk factors for chronic disease, and healthcare utilisation and costs, were more evenly distributed in the population. In total, 15,901 participants were included in the mortality cohort (2,602 deaths/53,911 person-years of follow-up), and 12,939 participants in the dependence cohort (1,896 incident cases/38,320 person-years). One or more DICs strongly and independently predicted incident dependence (pooled adjusted subhazard ratio 1.91, 95% CI 1.69–2.17) and death (pooled adjusted hazard ratio 1.66, 95% CI 1.49–1.85). Relative risks were higher for those who were frail, but were also substantially elevated for the much larger sub-groups yet to become frail. Mortality was mainly concentrated in the frail and dependent sub-groups. The main limitations were potential for DIC exposure misclassification and attrition bias.ConclusionsIn this study we observed a high prevalence of DICs, particularly in older age groups. Those affected had substantially increased risks of dependence and death. Most needs for care arose in those with DIC yet to become frail. Our findings provide some support for the strategy of optimising intrinsic capacity in pursuit of healthy ageing. Implementation at scale requires community-based screening and assessment, and a stepped-care intervention approach, with redefined roles for community healthcare workers and efforts to engage, train, and support them in these tasks. ICOPE might be usefully integrated into community programmes for detecting and case managing chronic diseases including hypertension and diabetes.

A pilot study of a motivational early intervention for excessive acquiring behaviours

Researchers have proposed that the excessive acquisition of objects is a more malleable symptom of hoarding disorder (HD) than the symptoms of difficulty discarding and clutter. Thus, early intervention to reduce acquiring among higher-risk individuals may be a key pathway to reduce subsequent hoarding symptoms. Despite emerging research on motivations to acquire objects in HD, scant attention has been paid to the factors surrounding the intention to reduce acquiring. Moreover, few studies have targeted acquiring behaviours specifically. We piloted a brief online motivational intervention to reduce excessive acquisition tendencies among a sample of university students with elevated symptoms of acquiring and difficulty discarding (N=83). We also developed object acquiring insight and readiness to change rulers to address the dearth of HD specific measures of motivation. Participants were randomly allocated to complete either a motivational interviewing style protocol to reduce acquiring or an active control condition (behavioural activation). Results revealed a strong positive association between problem insight and readiness to reduce acquiring. There were no differences post-intervention between participants in the motivational and control conditions with respect to insight, readiness to change, or acquisition of objects. Participants' self-reported acquiring symptoms were significantly reduced one-week post-intervention in both conditions. Thematic analyses of responses within the motivational protocol revealed that the participants’ decisional balance leant towards a change to their acquiring behaviours. Together, the pattern of results provided some support for the further development and testing of the online motivational protocol as an early intervention within a stepped care approach to treating HD.

Beyond Efficacy and Effectiveness: Clinical Efficiency Is Necessary for Dissemination.

Nearly all patients interact with critical gatekeepers-insurance companies or centralized healthcare systems. For mental health dissemination efforts to be successful, these gatekeepers must refer patients to evidence-based care. To make these referral decisions, they require evidence about the amount of resources expended to achieve therapeutic gains. Without this information, a bottleneck to widespread dissemination of evidence-based care will remain. To address this need for information, we introduce a new perspective, clinical efficiency. This approach directly ties resource usage to clinical outcomes. We highlight how cost-effectiveness approaches and other strategies can address clinical efficiency, and we also introduce a related new metric, the incremental time efficiency ratio (ITER). The ITER is particularly useful for quantifying the benefits of low-intensity and concentrated interventions, as well as stepped-care approaches. Given that stakeholders are increasingly requiring information on resource utilization, the ITER is a metric that can be estimated for past and future clinical trials. As a result, the ITER can allow researchers to better communicate desirable aspects of treatment, and an increased focus on clinical efficiency can improve our ability to deliver high-quality treatment to more patients in need.

Views on online self-help programmes from people with eating disorders and their carers in UK.

BackgroundDigitalizing the healthcare system has been declared a priority by the UK government. People with eating disorders (EDs), especially those with bulimia nervosa (BN) or binge eating disorder (BED), and ED carers may benefit from online self-help programmes, due to the shame and stigma associated with EDs and barriers in accessing treatment, skills-training or support. Qualitative studies are needed to explore stakeholders’ needs, attitudes to and views about online self-help, to optimize intervention design and delivery.MethodsFocus groups and telephone interviews were conducted with people with BN or BED, and carers of people with anorexia nervosa, between March and September 2018 in the UK.ResultsPeople with EDs and carers perceived online self-help positively in the context of barriers to seeking and accessing treatment and support, despite some seeing it as inferior to face-to-face support. Most reported little experience with online interventions. Participants thought the disadvantages of online interventions could be overcome by reminders, progress summaries, regular engagement and engaging with peers. Receiving guidance was seen as an important functionality in the intervention by people with EDs.ConclusionsPeople with EDs and their carers are aware of the potential benefits of online self-help despite having little experience with this form of intervention. A stepped-care approach that utilizes technology-based interventions as a first step and makes such interventions available directly to the consumer may fit the attitudes and needs of stakeholders. The study provides a foundation for future research on design and delivery of ED online self-help.

Efficacy of a stepped care approach to deliver cognitive-behavioral therapy for insomnia in cancer patients: a noninferiority randomized controlled trial.

Study ObjectivesCognitive-behavioral therapy for insomnia (CBT-I) is the recommended first-line treatment for cancer-related insomnia, but its accessibility is very limited in routine care. A stepped care approach has been recommended as a cost-effective way to make CBT-I more widely accessible. However, no controlled study has yet been published about the efficacy of this approach. The goal of this noninferiority randomized controlled trial (RCT) was to compare the short and long-term efficacy of a stepped care CBT-I (StepCBT-I) to a standard face-to-face CBT-I (StanCBT-I).MethodsA total of 177 cancer patients were randomized to: (1) StanCBT-I (6 face-to-face CBT-I sessions; n = 59) or (2) StepCBT-I (n = 118). In the StepCBT-I group, patients with less severe insomnia first received a web-based CBT-I (n = 65), while those with more severe insomnia received 6 face-to-face CBT-I sessions (n = 53). In both cases, patients could receive up to three booster sessions of CBT-I if they still had insomnia symptoms following this first step.ResultsResults indicated that the Step-CBT-I group showed an Insomnia Severity Index score reduction and a sleep efficiency (on a sleep diary) increase that was not significantly inferior to that of StanCBT-I at all post-treatment time points. Analyses of secondary outcomes indicated significant time effects (ps < .001) and no significant group-by-time interactions (ps from .07 to .91) on other sleep diary parameters, sleep medication use, depression, anxiety, fatigue, and quality of life scores.Conclusion(s)The efficacy of stepped care CBT-I is not inferior to that of a standard face-to-face intervention and is a valuable approach to making this treatment more widely accessible to cancer patients.Trial registrationClinicalTrials.gov Identifier: NCT01864720 (https://clinicaltrials.gov/ct2/show/NCT01864720?term=Savard&draw=2&rank=6; Stepped Care Model for the Wider Dissemination of Cognitive-Behavioural Therapy for Insomnia Among Cancer Patients).

Integration of mental health and psychosocial support services into primary health care in Gaza: a cross-sectional evaluation

BackgroundIntegration of mental health and psychosocial support (MHPSS) into primary health care in the Gaza Strip involves the delivery of mental health services within the essential service package provided by UNRWA, as recommended by WHO to fill the treatment gap. In early 2016, a successful pilot demonstrated that the integration is achievable in limited resource settings, and resulted in the adoption of a stepped care model to screen, identify, support, and treat patients. This study aimed to evaluate the MHPSS integration process and outcomes at UNRWA health centres in the Gaza Strip. MethodsWe used a descriptive analytical study design, with quantitative and qualitative data collected from records, and individual feedback from patients and health care providers (HCPs). The study was performed in the 22 UNRWA health centres of the Gaza Strip and all participants agreed to participate either verbally or by written consent. Approval was also obtained from the UNRWA Health Program Gaza Field Office. FindingsThe integration process started with the comprehensive training of 460 medical and nursing HCPs, in accordance with the Mental Health Gap Action Programme (mhGAP) Intervention Guide. On completion of training, the HCPs put into practice their learning, under close supervision for the first month and with only technical support thereafter. During the period of technical support, MHPSS activities, referral pathways, and proper reporting were ensured and standardised in all health centres. Overall, the integration process achieved success in training, implementation, and supervision. The success of training was assessed with an evaluation form and participants’ feedback, the success of implementation by the numbers of people who benefitted, their response to the intervention, and their feedback, and the success of supervision by the standardisation of the process and the technical validity of the intervention. By the end of September, 2018, 80 857 high-risk patients were screened using the General Health Questionnaire 12 (GHQ-12) and 9·0% (7327) were identified as requiring intervention and support, and were assisted using the UNRWA stepped care approach. Of the individuals who were assisted, 30·2% (2212 of 7327) showed significant improvement and 38·9% (2849) were identified as having mental health issues according to the mhGAP. In the same period, 1020 patients benefited from 113 support groups, with excellent effects on their physical and mental health as assessed with qualitative data, patients’ testimonies and, in some cases, laboratory investigations. The challenges that were faced were due to manual documentation and reporting, sociopolitical uncertainty, an increase in the number and needs of patients, and the imposed burden on HCPs. In addition, during implementation many individuals who were screened and identified required an urgent response: individuals who were suicidal and individuals whose mental health had been affected by the Great March of Return. InterpretationThe integration showed remarkable success in a short time as a result of the collective effort of all participants. However, there are challenges to overcome, and observation, further evaluation, and refinement of the process are needed to stabilise and sustain the integration of MHPSS services into primary health care for maximum benefit. FundingWHO, and UNRWA resources.

Trajectories of Change in an Open-access Internet-Based Cognitive Behavior Program for Childhood and Adolescent Anxiety: Open Trial.

BackgroundAlthough evidence bolstering the efficacy of internet-based cognitive behavioral therapy (iCBT) for treating childhood anxiety has been growing continuously, there is scant empirical research investigating the timing of benefits made in iCBT programs (eg, early or delayed).ObjectiveThis study aims to examine the patterns of symptom trajectories (changes in anxiety) across an iCBT program for anxiety (BRAVE Self-Help).MethodsThis study’s participants included 10,366 Australian youth aged 7 to 17 years (4140 children aged 7-12 years; 6226 adolescents aged 12-17 years) with elevated anxiety who registered for the BRAVE Self-Help program. Participants self-reported their anxiety symptoms at baseline or session 1 and then at the commencement of each subsequent session.ResultsThe results show that young people completing the BRAVE Self-Help program tend to fall into two trajectory classes that can be reliably identified in terms of high versus moderate baseline levels of anxiety and subsequent reduction in symptoms. Both high and moderate anxiety severity trajectory classes showed significant reductions in anxiety, with the greatest level of change being achieved within the first six sessions for both classes. However, those in the moderate anxiety severity class tended to show reductions in anxiety symptoms to levels below the elevated range, whereas those in the high symptom group tended to remain in the elevated range despite improvements.ConclusionsThese findings suggest that those in the high severity group who do not respond well to iCBT on a self-help basis may benefit from the additional support provided alongside the program or a stepped-care approach where progress is monitored and support can be provided as necessary.

Predictive analytics and tailored interventions improve clinical outcomes in older adults: a randomized controlled trial

This study explored the potential to improve clinical outcomes in patients at risk of moving to the top segment of the cost acuity pyramid. This randomized controlled trial evaluated the impact of a Stepped-Care approach (predictive analytics + tailored nurse-driven interventions) on healthcare utilization among 370 older adult patients enrolled in a homecare management program and using a Personal Emergency Response System. The Control group (CG) received care as usual, while the Intervention group (IG) received Stepped-Care during a 180-day intervention period. The primary outcome, decrease in emergency encounters, was not statistically significant (15%, p = 0.291). However, compared to the CG, the IG had significant reductions in total 90-day readmissions (68%, p = 0.007), patients with 90-day readmissions (76%, p = 0.011), total 180-day readmissions (53%, p = 0.020), and EMS encounters (49%, p = 0.006). Predictive analytics combined with tailored interventions could potentially improve clinical outcomes in older adults, supporting population health management in home or community settings.

Effectiveness and cost-effectiveness of integrating the management of depression into routine HIV Care in Uganda (the HIV\u2009+\u2009D trial): A protocol for a cluster-randomised trial

BackgroundAn estimated 8–30 % of people living with HIV (PLWH) have depressive disorders (DD) in sub-Saharan Africa. Of these, the majority are untreated in most of HIV care services. There is evidence from low- and middle- income countries of the effectiveness of both psychological treatments and antidepressant medication for the treatment of DD among PLWH, but no evidence on how these can be integrated into routine HIV care. This protocol describes a cluster-randomised trial to evaluate the effectiveness and cost-effectiveness of the HIV + D model for the integration of a collaborative stepped care intervention for DD into routine HIV care, which we have developed and piloted in Uganda.MethodsForty public health care facilities that provide HIV care in Kalungu, Masaka and Wakiso Districts will be randomly selected to participate in the trial. Each facility will recruit 10–30 eligible PLWH with DD and the total sample size will be 1200. The clusters will be randomised 1:1 to receive Enhanced Usual Care alone (EUC, i.e. HIV clinicians trained in Mental Health Gap Action Programme including guidelines on when and where to refer patients for psychiatric care) or EUC plus HIV + D (psychoeducation, Behavioural Activation, antidepressant medication and referral to a supervising mental health worker, delivered in a collaborative care stepwise approach). Eligibility criteria are PLWH attending the clinic, aged ≥ 18 years who screen positive on a depression screening questionnaire (Patient Health Questionnaire, PHQ-9 ≥ 10). The primary outcome is the mean depressive disorder symptom severity scores (assessed using the PHQ-9) at 3 months’ post-randomisation, with secondary mental health, disability, HIV and economic outcomes measured at 3 and 12 months. The cost-effectiveness of EUC with HIV + D will be assessed from both the health system and the societal perspectives by collecting health system, patient and productivity costs and mean DD severity scores at 3 months, additional to health and non-health related quality of life measures (EQ-5D-5 L and OxCAP-MH).DiscussionThe study findings will inform policy makers and practitioners on the cost-effectiveness of a stepped care approach to integrate depression management in routine care for PLWH in low-resource settings.Trial registration: ISRCTN, ISRCTN86760765. Registered 07 September 2017, https://doi.org/10.1186/ISRCTN86760765.

Person-centred interventions for problem gaming: a stepped care approach

BackgroundProblem gaming is reported by approximately 1–3% of the population and is associated with decreased health and wellbeing. Research on optimal health responses to problem gaming remains limited. This study aimed to identify and describe the key components of a person-centred approach to interventions for problem gaming for individuals who voluntary seek assistance.MethodsOnline interviews were conducted with 20 adults (90% male; Mage = 23y) currently seeking help for problem gaming. The interview protocol was guided by a health care access framework which investigated participants’ experiences and needs related to accessing professional support. Transcripts were analysed in NVivo using qualitative content analysis to systematically classify participant data into the themes informed by this framework.ResultsParticipants had mixed views on how the negative consequences of problem gaming could be best addressed. Some indicated problems could be addressed through self-help resources whereas others suggested in-person treatment with a health professional who had expertise in gaming. Participants described the essential components of an effective health service for problem gaming as including: valid and reliable screening tools; practitioners with specialist knowledge of gaming; and access to a multimodal system of intervention, including self-help, internet and in-person options that allow gamers to easily transition between types and intensity of support.ConclusionA comprehensive health care approach for interventions for problem gaming is in its infancy, with numerous service access and delivery issues still to be resolved. This study highlights the importance of involving individuals with gaming-related problems in developing solutions that are fit for purpose and address the spectrum of individual preferences and needs. These findings recommend a stepped healthcare system that adheres to evidence-based practice tailored to each individual and the implementation of standard assessment and routine outcome monitoring.