Stepped Care Model Research Articles

Screening for common mental health disorders: a psychometric evaluation of a chatbot system

ABSTRACT The current study presents the psychometrics and screening accuracy properties of a chatbot system that understands free-text responses to mental health screening questions using natural language processing (NLP). The aiCARE system was tested against web-based versions of the Patient Health Questionnaire- 9 (PHQ-9), General Anxiety Disorder-7 (GAD-7), and Posttraumatic Stress Disorder Checklist (PCL-5). The study included 773 volunteers (Mage = 21.28, SD = 5.34) who answered the same free-text (chatbot version) and closed-ended survey questions (standard survey version). Overall, the research found that the proposed chatbot system is reliable in determining whether clinical symptomatology is present or absent based on free-text responses to PHQ-9, GAD-7, and PCL-5 questions. It had comparable sensitivity, specificity, total accuracy, and AUC values to standard web-based survey methods, as well as good internal consistency and convergent validity. The general implications are that chatbot systems could be used to identify common psychopathology as part of a stepped care model. It is not intended to be used in place of clinical diagnosis. Future research is needed to assess its effectiveness in more clinically and demographically diverse populations.

Universal prevention for non-suicidal self-injury in adolescents is scarce - A systematic review.

Non-suicidal self-injury (NSSI) during adolescence is a high-risk marker for the development and persistence of mental health problems and has been recognized as a significant public health problem. Whereas targeted prevention has indeed shown to be effective in reducing NSSI and improve mental health problems, access to such programs is limited. By face validity, universal prevention of NSSI seems an ideal starting point for a stepped-care model to circumvent a lack of resources in the medical care system. However, it is yet unclear how effective such approaches are. Here, we provide a summary of existing work on universal prevention of NSSI in adolescents younger than 21 years based on a systematic literature search. We found that only seven studies are available. None of the programs evaluated was found to be effective in reducing the incidence or frequency of NSSI. After providing a comprehensive summary of the existing work, we evaluate the fact that existing work primarily focusses on selected/targeted prevention and on psychoeducational methods. We derive implications for future directions in the field of universal prevention of NSSI.

Comparison between continued inpatient treatment versus day patient treatment after short inpatient care in early onset anorexia nervosa (COTIDEA trial): a study protocol for a non-inferiority randomised controlled trial

BackgroundIn children with early-onset anorexia nervosa (first symptoms before 13 years old, EO-AN), experts recommend initial outpatient treatment but in-patient treatment (IP) is frequently indicated due to acute medical instability or for those who have not improved with outpatient treatment. This IP can target either a partial weight restauration or a total weight normalization (return to the previous BMI growth trajectory). There are no evidence in the literature on which is the better therapeutic option in EOAN. But as long length of stay induce social isolation, with elevated costs, we wonder if a stepped-care model of daypatient treatment (DP) after short IP stabilisation may be a treatment option as effective as full-time IP to target weight normalization. We designed a two-arm randomised controlled trial testing the non-inferiority of a stepped-care model of DP after short IP stabilisation versus full-time IP.MethodsEighty-eight children aged 8 to 13 years suffering from EOAN with initial severe undernutrition will be randomly allocated to either IP treatment as usual or a stepped care DP model both targeting weight normalization. Assessments will be conducted at inclusion, somatic stabilization, weight normalization, 6 months and 12 months post randomisation. The primary outcome will be BMI at 12 months post-randomisation. Secondaries outcomes will included clinical (tanner stage), biological (prealbumin, leptin, total ghrelin and IGF1) and radiological (bone mineralization and maturation) outcomes, eating symptomatology and psychiatric assessments, motivation to change, treatment acceptability and quality of life assessments, cost-utility and cost-effectiveness analyses.DiscussionCOTIDEA will provide rigorous evaluation of treatment alternative to full-time inpatient treatment to allow a reduction of social iatrogenic link to hospital length of stay and associated costs.Trial registrationTrial is registered on ClinicalTrials.gov (NCT04479683).

Cognitive behavioural therapy for insomnia disorder: Extending the stepped care model.

Despite cognitive behaviour therapy for insomnia (CBT-I) being the first-line intervention for the disorder, it is often not readily available to patients in need. The stepped care model (SCM) represents an approach to facilitating efficient and wide-ranging provision of evidence-based care to those with insomnia. The SCM reflects a pyramid of therapeutics based on CBT-I gradually increasing in clinical intensity and addressing clinical complexity. By applying CBT-I through the SCM it is hoped that the treatment gap can be bridged such that not only more patients can be reached, but that clinical resource can be more effectively distributed, with patients receiving more tailored care as needed. Nevertheless, this should not be done at the risk of a lower quality of care being offered, and high-standard training for clinicians and scrutiny of non-clinician led interventions remains important. As national health laws within European countries have substantial differences, the application of the SCM as it relates to the treatment of insomnia may be challenged by contrasting interpretations. In order that the SCM is appropriately implemented: (a) only evidence-based CBT-I treatments should be promoted within the model; (b) clinicians involved in SCM should be suitably qualified to offer CBT in general, and have appropriate further training in CBT-I; (c) professionals involved in interventions not included in the SCM, but related to it, such as preventive and educational programmes, diagnostic procedures, and pharmacological treatments, should also have good knowledge of the SCM in order to promote correct allocation to the appropriate interventional step.

Improving Pathways to Care for Patients at High Psychosis Risk in Switzerland: PsyYoung Study Protocol.

Psychotic disorders are one of the main causes of chronic disability in young people. An at-risk mental state (ARMS) is represented by subclinical symptoms that precede the first episode of psychosis (FEP). The PsyYoung project aims to optimize the detection of an ARMS while reducing unnecessary psychiatric treatments. It investigates the effects of service changes on the referrals and outcomes of young people with ARMS or a FEP. Six psychiatric outpatient clinics in three cantons (Basel-Stadt, Vaud, and Geneva) participated in the project. They passed through an implementation phase including service changes and the adaptation of a standardized stepped care model for diagnosis and assessment, in addition to measures for increasing the awareness, networking and training of local professionals. All participating cantons had entered the implementation phase. By March 2023, there were 619 referrals to participating sites. A total of 163 patients (37% FEP and 31% ARMS) and 15 close relatives had participated in individual longitudinal assessments, and 26 patients participated in qualitative interviews. This national collaborative project addresses the issue of early intervention for emerging psychoses, and creates spaces for fruitful reflections and collaboration in Switzerland. The ultimate aim of PsyYoung is to harmonize clinical practices in early intervention of psychosis on a national level.

Facilitators and barriers of routine psychosocial distress assessment within a stepped and collaborative care model in a Swiss hospital setting.

Stepped and Collaborative Care Models (SCCMs) have shown potential for improving mental health care. Most SCCMs have been used in primary care settings. At the core of such models are initial psychosocial distress assessments commonly in form of patient screening. We aimed to assess the feasibility of such assessments in a general hospital setting in Switzerland. We conducted and analyzed eighteen semi-structured interviews with nurses and physicians involved in a recent introduction of a SCCM model in a hospital setting, as part of the SomPsyNet project in Basel-Stadt. Following an implementation research approach, we used the Tailored Implementation for Chronic Diseases (TICD) framework for analysis. The TICD distinguishes seven domains: guideline factors, individual healthcare professional factors, patient factors, professional interactions, incentives and resources, capacity for organizational change, and social, political, and legal factors. Domains were split into themes and subthemes, which were used for line-by-line coding. Nurses and physicians reported factors belonging to all seven TICD domains. An appropriate integration of the psychosocial distress assessment into preexisting hospital processes and information technology systems was the most important facilitator. Subjectivity of the assessment, lack of awareness about the assessment, and time constraints, particularly among physicians, were factors undermining and limiting the implementation of the psychosocial distress assessment. Awareness raising through regular training of new employees, feedback on performance and patient benefits, and working with champions and opinion leaders can likely support a successful implementation of routine psychosocial distress assessments. Additionally, aligning psychosocial distress assessments with workflows is essential to assure the sustainability of the procedure in a working context with commonly limited time.

Shared sorrow, shared costs: cost-effectiveness analysis of the Empowerment group therapy approach to treat affective disorders in refugee populations.

Refugees and asylum seekers (RAS) in Germany need tailored and resource-oriented mental healthcare interventions. To evaluate the cost-effectiveness of group psychotherapy for RAS with moderate depressive symptoms. This is a post hoc cost-effectiveness analysis of Empowerment group psychotherapy that was embedded in a stratified stepped and collaborative care model (SCCM) from the multicentre randomised controlled MEHIRA trial. One hundred and forty-nine participants were randomly assigned to SCCM or treatment as usual (TAU) and underwent Empowerment (i.e. level 3 of the SCCM for adults) or TAU. Effects were measured with the nine-item Patient Health Questionnaire (PHQ-9) and quality adjusted life-years (QALY) post-intervention. Health service and intervention costs were measured. Incremental cost-effectiveness ratios (ICER) were estimated and net monetary benefit (NMB) regressions with 95% confidence intervals were performed. Cost-effectiveness was ascertained for different values of willingness to pay (WTP) using cost-effectiveness acceptability curves for probable scenarios. Trial registration number: NCT03109028 on ClinicalTrials.gov. Health service use costs were significantly lower for Empowerment than TAU after 1 year. Intervention costs were on average €409.6. Empowerment led to a significant change in PHQ-9 scores but not QALY. Bootstrapped mean ICER indicated cost-effectiveness according to PHQ-9 and varied considerably for QALY in the base case. NMB for a unit reduction in PHQ-9 score at WTP of €0 was €354.3 (€978.5 to -€269.9). Results were confirmed for different scenarios and varying WTP thresholds. The Empowerment intervention was cost-effective in refugees with moderate depressive symptoms regarding the clinical outcome and led to a reduction in direct healthcare consumption. Concerning QALYs, there was a lack of confidence that Empowerment differed from TAU.

Psychological and medical treatments for binge-eating disorder: A research update

Binge-eating disorder (BED), characterized by recurrent binge eating in the absence of regular weight-compensatory behaviors, is the most common eating disorder, associated with pronounced mental and physical sequelae. An increasing body of research documents the efficacy of diverse approaches to the treatment of this disorder, summarized in meta-analyses. This research update narratively reviewed randomized-controlled trials (RCTs) on the psychological and medical treatment of BED published between January 2018 and November 2022, identified through a systematic literature search. A total of 16 new RCTs and 3 studies on previous RCTs providing efficacy- and safety-related data were included. Regarding psychotherapy, confirmatory evidence supported the use of integrative-cognitive therapy and, with lower effects, brief emotion regulation skills training for binge eating and associated psychopathology. Behavioral weight loss treatment was revealed to be efficacious for binge eating, weight loss, and psychopathology, but its combination with naltrexone-bupropion did not augment efficacy. New treatment approaches were explored, including e-mental-health and brain-directed treatments, mostly targeting emotion and self-regulation. Additionally, different therapeutic approaches were evaluated in complex stepped-care models. In light of these advances, future research is necessary to further optimize effects of evidence-based treatments for BED, through improvement of existing or development of new treatments, based on mechanistic and/or interventional research, and/or tailoring treatments to personal characteristics in a precision medicine approach.

The Electronic Surviving Cancer Competently Intervention Program-a Psychosocial Digital Health Intervention for English- and Spanish-Speaking Parents of Children With Cancer: Protocol for Randomized Controlled Trial.

The psychosocial needs and risks of children with cancer and their families are well-documented including increased risk of parental distress, posttraumatic stress, and anxiety. There is a critical need to provide evidence-based psychosocial care to parents and caregivers of children with cancer. Digital health interventions are important to address many barriers to in-person intervention delivery but are not widely used in pediatric psychosocial cancer care. The COVID-19 pandemic has reinforced the need for flexible, acceptable, and accessible psychosocial digital health interventions. The Electronic Surviving Cancer Competently Intervention Program (eSCCIP) is an innovative digital health intervention for parents and caregivers of children with cancer, delivered through a combination of self-guided web-based content and supplemented by 3 telehealth follow-up sessions with a trained telehealth guide. A Spanish language adaptation of eSCCIP, El Programa Electronico de Intervencion para Superar Cancer Competentemente (eSCCIP-SP), has been developed. The self-guided web-based cores of eSCCIP/eSCCIP-SP are a mix of didactic video content, multifamily video discussion groups featuring parents of children with cancer, and hands-on web-based activities. The objective of this study is to test eSCCIP/eSCCIP-SP in a multisite randomized controlled trial, compared to an internet-based education control condition consisting of information specifically focused on concerns relevant to parents and caregivers of children with cancer. Using a randomized controlled clinical trial design, 350 eligible parents and caregivers of children with cancer will be randomly assigned to the intervention (eSCCIP/eSCCIP-SP) or an education control condition. Data will be collected at 3 time points: preintervention (prior to randomization), immediately post intervention (after 6 weeks), and at a 3-month follow-up (from baseline). Participants randomized to either condition will receive study material (eSCCIP/eSCCIP-SP intervention or education control website) in English or Spanish, based on the primary language spoken in the home and participant preference. The primary study end point is a reduction in acute distress from baseline to postintervention, with secondary end points focused on reductions in symptoms of posttraumatic stress and anxiety, and improvements in coping self-efficacy and cognitive coping. An additional exploratory aim will be focused on implementation strategies and potential costs and cost-savings of eSCCIP/eSCCIP-SP, laying the groundwork for future trials focused on dissemination and implementation, stepped-care models, and intervention refinement. This trial will provide necessary data to evaluate the efficacy of eSCCIP/eSCCIP-SP. This intervention has the potential to be an easily scalable and highly impactful psychosocial treatment option for parents and caregivers of children with cancer. ClinicalTrials.gov NCT05294302; https://clinicaltrials.gov/ct2/show/NCT05294302. PRR1-10.2196/46339.

Partner engagement for planning and development of non-pharmacological care pathways in the AIM-Back trial.

Embedded pragmatic clinical trials are increasingly recommended for non-pharmacological pain care research due to their focus on examining intervention effectiveness within real-world settings. Engagement with patients, health care providers, and other partners is essential, yet there is limited guidance for how to use engagement to meaningfully inform the design of interventions to be tested in pain-related pragmatic clinical trials. This manuscript aims to describe the process and impacts of partner input on the design of two interventions (care pathways) for low back pain currently being tested in an embedded pragmatic trial in the Veterans Affairs health care system. Sequential cohort design for intervention development was followed. Engagement activities were conducted with 25 participants between November 2017 and June 2018. Participants included representatives from multiple groups: clinicians, administrative leadership, patients, and caregivers. Partner feedback led to several changes in each of the care pathways to improve patient experience and usability. Major changes to the sequenced care pathway included transitioning from telephone-based delivery to a flexible telehealth model, increased specificity about pain modulation activities, and reduction of physical therapy visits. Major changes to the pain navigator pathway included transitioning from a traditional stepped care model to one that offers care in a feedback loop, increased flexibility regarding pain navigator provider type, and increased specificity for patient discharge criteria. Centering patient experience emerged as a key consideration from all partner groups. Diverse input is important to consider before implementing new interventions in embedded pragmatic trials. Partner engagement can increase acceptability of new care pathways to patients and providers and enhance uptake of effective interventions by health systems. NCT#04411420. Registered on 2 June 2020.

Chronic, Noncancer Pain Care in the Veterans Administration: Current Trends and Future Directions.

The Veterans Health Administration has always been a leader in the innovation and implementation of evidence-based care. The use of the stepped care model of chronic pain has led to several novel interventions and strong practices in the last several years at each level of care with regard to education, use of technology, and increasing access to evidence-based care (eg, behavioral health, interdisciplinary teams). The Whole Health model is also being implemented nationwide and has the potential to significantly affect chronic pain treatment in the coming decade.

0393 Durability of treatment effects for a stepped-care model integrating digital therapy for insomnia

Abstract Introduction A stepped-care model going from digital cognitive behavioral therapy for insomnia (dCBT-I) to clinician-led CBT-I (fCBT-I) has been shown to be acutely effective. However, the sustainability of the effects over longer periods of time has not yet been examined. This study tested the durability of treatment effects of this stepped-care approach two years following the end of treatment. Methods 1018 individuals with insomnia (DSM-5 diagnostic criteria) were randomized into two conditions at step 1: dCBT-I (N=613), or an online sleep education control (N=624). Participants in the dCBT-I condition who did not remit (ISI>9) were further randomized to either face-to-face CBT-I (N=103) or sleep education (N=104). Insomnia remission and treatment gains at 2-year follow-up were compared across treatment conditions. Results Among step-1 non-remitters, odds of insomnia remission for those who stepped-up to fCBT-I was almost three times higher (60% in remission) than those who received the step-2 control (33% in remission), OR = 2.95, 95% CI [1.3, 6.7]. Odds of remission was not significantly different between those who remitted at step-1 (64% in remission at year 2) and those who received fCBT-I, OR = 3.53, 95% CI [1.7, 7.5]. The treatment gains were higher in the fCBT-I group (9.6 point improvement from baseline) compared to those who remitted at step-1 (7.7 point improvement from baseline) (Cohen’s d = 0.44). Conclusion Preliminary evidence indicate that the treatment effects of this stepped-care model are durable two years after treatment. Support (if any) Support for this study was provided from the National Institute of Mental Health R56MH115150 and R01MH122636 awarded to Dr. Christopher Drake.

Designing and Building a Portfolio of Individual Support Resources for Physicians.

As health care organizations in the United States move toward recovery from the COVID-19 pandemic, physicians and clinical faculty are experiencing occupational burnout and various manifestations of distress. To mitigate these challenges, health care organizations must optimize the work environment and provide support for individual clinicians using a variety of approaches, including mentoring, group-based peer support, individual peer support, coaching, and psychotherapy. While often conflated, each of these approaches offers distinct benefits. Mentoring is a longitudinal 1-on-1 relationship, typically focused on career development, usually with an experienced professional guiding a junior professional. Group-based peer support involves regular, longitudinal meetings of health professionals to discuss meaningful topics, provide mutual support to one another, and foster community. Individual peer support involves training peers to provide timely 1-on-1 support for a distressed colleague dealing with adverse clinical events or other professional challenges. Coaching involves a certified professional helping an individual identify their values and priorities and consider changes that would allow them to adhere to these more fully, and providing longitudinal support that fosters accountability for action. Individual psychotherapy is a longitudinal, short- or long-term professional relationship during which specific therapeutic interventions are delivered by a licensed mental health professional. When distress is severe, this is the best approach. Although some overlap exists, these approaches are distinct and complementary. Individuals may use different methods at different career stages and for different challenges. Organizations seeking to address a specific need should consider which approach is most suitable. Over time, a portfolio of offerings is typically needed to holistically address the diverse needs of clinicians. A stepped care model using a population health approach may be a cost-effective way to promote mental health and prevent occupational distress and general psychiatric symptoms.

T1 Burn Behavioral Health: Development and Preliminary Results of Burn Center-Based Stepped-Care Program for Burn Survivors

Abstract Introduction Annually, nearly half a million people in the U.S. receive medical treatment for burns, 40,000 of whom are hospitalized. Burn patients experience significant psychological burden during acute burn treatment. Long-term psychiatric problems are highly prevalent compared to patients with other injuries. Undetected or untreated psychiatric symptoms can complicate recovery, increase length of stay, and cause long-term problems and readmission. Burn centers are ideally suited to provide these services to burn patients on an inpatient and outpatient basis; however, few burn centers in the U.S. have mental health programs to address patients’ needs. This presentation will describe the Burn Behavioral Health (BBH) program, a burn center-based technology-enhanced stepped-care model of delivering mental health services for burn survivors, spanning the inpatient to outpatient continuum. This model was adapted from the Trauma Resilience and Recovery Program which has been successful in meeting the needs of traumatic injury patients. Methods Data were collected as part of clinical care. BBH includes 4 main steps: (1) initial screening, education, and early intervention; (2) symptom self-monitoring and self-help resources; (3) follow-up screening 30 days post-injury; and (4) provision of best-practice mental health treatment for patients who need it, using both in-person and telehealth modalities, including individual and skill-based group therapy. Results Between February 2021 and September 2022, 384 patients were identified as eligible for BBH services. Of these, 342 (90%) were enrolled in BBH and completed initial screening. 50% of patients screened positive for depression/PTSD risk or symptoms and were offered brief intervention. 54% of enrolled survivors received brief intervention, 21% of whom completed more than one session. We reached 84% of patients for the 30-day follow-up, 20% of whom screened positive for depression/PTSD and 29% were connected to mental health services. Conclusions This study provides preliminary support demonstrating that BBH is sustainable and capable of reaching and engaging a large proportion of burn patients across the inpatient to outpatient continuum. In the U.S., only 25% of burn centers have structured screening in place for inpatient and 11% for outpatient burn survivors. Data from the traumatic injury population (which includes burns) suggest only 10% of patients received intervention after a positive screen and 42% did not know how or where to get help. Psychological recovery is an essential component of a comprehensive burn program and availability of psychological screening and intervention is a requirement for the ABA verification. Applicability of Research to Practice BBH shows promise in increasing access and quality of mental health care to address the unique needs of burn survivors.

Empower Veterans Program (EVP): a chronic pain management program demonstrates positive outcomes among veterans

BackgroundChronic pain is a highly prevalent health condition among veterans. Traditional pharmacological interventions present unique challenges for chronic pain management including prescription opioid addiction and overdose. In alignment with the 2016 Comprehensive Addiction and Recovery Act and VA’s Stepped Care Model to meet veterans’ pain management needs, the Offices of Rural Health and Pain Management, Opioid Safety, and Prescription Drug Monitoring Program (PMOP) funded an enterprise-wide initiative to implement a Step 3 integrated tele-pain program: Empower Veterans Program (EVP). EVP provides veterans with chronic pain self-care skills using a whole health driven approach to pain management.ObjectivesThe Comprehensive Addiction and Recovery Act prompted the strategic approach to offer non-pharmacological options to meet veterans’ pain management needs. EVP, a 10-week interdisciplinary group medical appointment, leverages Acceptance and Commitment Therapy, Mindful Movement, and Whole Health to provide veterans with chronic pain self-care skills. This evaluation was conducted to describe participant characteristics, graduation, and satisfaction rates; and assess pre-post patient-reported outcomes (PRO) associated with EVP participation.MethodsA sample of 639 veterans enrolled in EVP between May, 2015 and December, 2017 provided data to conduct descriptive analyses to assess participant demographics, graduation, and satisfaction rates. PRO data were analyzed using a within-participants pre-post design, and linear mixed-effects models were used to examine pre-post changes in PRO.ResultsOf 639 participants, 444 (69.48%) graduated EVP. Participant median program satisfaction rating was 8.41 (Interquartile Range: 8.20–9.20). Results indicate pre-post EVP improvements (Bonferroni-adjusted p < .003) in the three primary pain outcomes (intensity, interference, catastrophizing), and 12 of 17 secondary outcomes, including physical, psychological, health-related quality of life (HRQoL), acceptance, and mindfulness measures.DiscussionData suggest that EVP has significant positive outcomes in pain, psychological, physical, HRQoL, acceptance, and mindfulness measures for veterans with chronic pain through non-pharmacological means. Future evaluations of intervention dosing effect and long-term effectiveness of the program is needed.

A service evaluation of phased- and stepped-care psychological support for health and social care workers during the COVID-19 pandemic.

The COVID-19 pandemic has disproportionally affected the mental health of health and social care workers (HSCWs), with many experiencing symptoms of depression, anxiety and post-traumatic stress disorder. Psychological interventions have been offered via mental health services and in-house psychology teams, but their effectiveness in this context is not well documented. To evaluate a stepped-care psychological support pathway for HSCWs from Homerton Healthcare Foundation Trust in London, which offered psychological first aid, evidence-based psychological therapies and group-based well-being workshops. The service evaluation used a pre-post approach to assess depression, anxiety, functional impairment and post-traumatic stress disorder symptom change for those who attended sessions of psychological first aid, low- or high-intensity cognitive-behavioural therapy or a combination of these. In addition, the acceptability of the psychological first aid sessions and well-being workshops was explored via feedback data. Across all interventions, statistically significant reductions of depression (d = 1.33), anxiety (d = 1.37) and functional impairment (d = 0.93) were observed, and these reductions were equivalent between the interventions, as well as the demographic and occupational differences between the HSCWs (ethnicity, staff group and redeployment status). HSCWs were highly satisfied with the psychological first aid and well-being workshops. The evaluation supports the utility of evidence-based interventions delivered as part of a stepped-care pathway for HSCWs with common mental health problems in the context of the COVID-19 pandemic. Given the novel integration of psychological first aid within the stepped-care model as a step one intervention, replication and further testing in larger-scale studies is warranted.

Stepped care versus center-based cardiopulmonary rehabilitation for older frail adults living in rural MA: Design of a feasibility randomized controlled trial

BackgroundCardiac and pulmonary rehabilitation programs are grossly underutilized, and participation is particularly low in rural regions. MethodsWe are conducting a 2-arm, randomized controlled feasibility trial. Eligible participants include older frail adults with cardiac or pulmonary disease living in a predominantly rural county in western Massachusetts. Participants are randomized 1:1 to treatment as usual or stepped care. Patients randomized to treatment as usual participate in twice weekly center-based rehabilitation sessions over eight weeks and are encouraged to exercise at home in between sessions. Patients randomized to the stepped-care arm are offered/enrolled in the center-based rehabilitation program followed by possible step up to three interventions based on prespecified non-response criteria: 1) Transportation-assisted center-based rehabilitation, 2) Home-based telerehabilitation, and 3) Community health worker-supported home-based telerehabilitation. The primary feasibility outcomes are average number of eligible patients randomized per month, baseline measure completion, proportion attending at least 70% of the prescribed sessions, average number of sessions attended in the stepped-care arm, and proportion in the stepped-care arm completing patient reported outcome measures. Each of these process indicators is evaluated by preset “Stop” and “Go” thresholds. ConclusionThe proposed stepped-care model is an efficient, patient-centered, approach to expanding access to cardiac and pulmonary rehabilitation. Meeting the “Go” thresholds for the prespecified process indicators will justify conducting a definitive full-scale randomized controlled trial to compare the effectiveness and value (cost-effectiveness) of stepped-care versus center-based rehabilitation in older frail adults living rural counties.

Management of Anxiety and Depression in Adult Survivors of Cancer: ASCO Guideline Update.

To update the American Society of Clinical Oncology guideline on the management of anxiety and depression in adult cancer survivors. A multidisciplinary expert panel convened to update the guideline. A systematic review of evidence published from 2013-2021 was conducted. The evidence base consisted of 17 systematic reviews ± meta analyses (nine for psychosocial interventions, four for physical exercise, three for mindfulness-based stress reduction [MBSR], and one for pharmacologic interventions), and an additional 44 randomized controlled trials. Psychological, educational, and psychosocial interventions led to improvements in depression and anxiety. Evidence for pharmacologic management of depression and anxiety in cancer survivors was inconsistent. The lack of inclusion of survivors from minoritized groups was noted and identified as an important consideration to provide high-quality care for ethnic minority populations. It is recommended to use a stepped-care model, that is, provide the most effective and least resource-intensive intervention based on symptom severity. All oncology patients should be offered education regarding depression and anxiety. For patients with moderate symptoms of depression, clinicians should offer cognitive behavior therapy (CBT), behavioral activation (BA), MBSR, structured physical activity, or empirically supported psychosocial interventions. For patients with moderate symptoms of anxiety, clinicians should offer CBT, BA, structured physical activity, acceptance and commitment therapy, or psychosocial interventions. For patients with severe symptoms of depression or anxiety, clinicians should offer cognitive therapy, BA, CBT, MBSR, or interpersonal therapy. Treating clinicians may offer a pharmacologic regimen for depression or anxiety for patients who do not have access to first-line treatment, prefer pharmacotherapy, have previously responded well to pharmacotherapy, or have not improved following first-line psychological or behavioral management.Additional information is available at www.asco.org/survivorship-guidelines.

The promise of single-session interventions to inform stepped care approaches for complex mental health problems: Commentary on Schleider et al. (2023).

Schleider et al. (2023, International Journal of Eating Disorders) provide an overview and compelling rationale for incorporating single-session interventions (SSIs) into the eating disorder field. As intervention researchers working with complex mental health problems, including suicide risk, we agree that there is much to be gained by developing and deploying SSIs on a broader scale and for historically difficult-to-treat problems. In this commentary, we describe some additional strengths of the SSI approach and highlight their potential in the use of stepped care models of treatment. Ultimately, determining who could benefit from a low dose of treatment and for whom longer treatment is warranted could pave the way for addressing the current mental health burden.

Testing adaptive interventions to improve PTSD treatment outcomes in Federally Qualified Health Centers: Protocol for a randomized clinical trial

BackgroundPosttraumatic stress disorder (PTSD) disproportionately affects low-income individuals and is untreated in 70% of those affected. One third of low-income Americans are treated in Federally Qualified Health Centers (FQHCs), which do not have the capacity to provide all patients with first-line treatments such as Prolonged Exposure (PE). To address this problem, FQHCs could use low-intensity interventions (e.g., Clinician-Supported PTSD Coach: CS PTSD Coach) and medium-intensity interventions (e.g., PE for Primary Care: PE-PC) to treat PTSD with fewer resources. However, some patients will still require high-intensity treatments (e.g., full-length PE) for sustained clinical benefit. Thus, there is a critical need to develop stepped-care models for PTSD in FQHCs. MethodWe are conducting a Sequential, Multiple Assignment, Randomized Trial (SMART) with 430 adults with PTSD in FQHCs. Participants are initially randomized to CS PTSD Coach or PE-PC. After four sessions, early responders step down to lower frequency interaction within their assigned initial treatment strategy. Slow responders are re-randomized to either continue their initial treatment strategy or step up to Full PE for an additional eight weeks. The specific aims are to test the effectiveness of initiating treatment with PE-PC versus CS PTSD Coach in reducing PTSD symptoms and to test the effectiveness of second-stage strategies (continue versus step-up to Full PE) for slow responders. ConclusionsThis project will provide critical evidence to inform the development of an effective stepped-care model for PTSD. Testing scalable, sustainable sequences of PTSD treatments delivered in low-resource community health centers will improve clinical practice for PTSD.