Stepped Care Research Articles

Scaling-up problem management plus for refugees in Switzerland - a qualitative study

BackgroundRefugees are at an increased risk of developing symptoms of mental disorders but face various structural and socio-cultural barriers to accessing mental health care. The SPIRIT project (Scaling-up Psychological Interventions in Refugees In SwiTzerland) seeks to promote the resilience of refugees and improve their access to mental health care. For this purpose, Problem Management Plus (PM+), an evidence-based low-intensity psychological intervention delivered by trained non-specialist “helpers”, is being scaled-up in Switzerland.ObjectiveTo identify factors influencing the process of the large-scale implementation of PM + for refugees in Switzerland and to develop recommendations to guide the implementation process.Methods22 semi-structured interviews were conducted with key informants (Syrian refugees who previously participated in PM+, PM + helpers, health professionals working with refugees and decision-makers from the migration, integration, social, and health sectors). The data were analyzed using thematic analysis, combining an inductive and deductive approach.ResultsThe data revealed three major themes, which might have an impact for the longer-term implementation of PM + in Switzerland. First, preconditions for successful integration in the health system prior to scaling-up such as sustainable funding or the introduction of a stepped care approach. Second, the requirements for the PM + intervention supporting scale-up such as quality control during PM + delivery, PM + modality, time and setting when PM + is offered or the views on task sharing. Third, the perceived benefits of scaling-up PM + in Switzerland.ConclusionsOur results have shown that PM + must be scaled-up within a stepped care approach, including a functioning triage system and sustainable funding. Rather than selecting one modality or setting, it seemed preferable to offer a variety of formats and settings to achieve maximum reach and benefits. A successful scale-up of PM + in Switzerland might have various benefits. Communicating them to policy-makers and health providers, might enhance their acceptability of the intervention and their willingness to adopt PM + in regulatory structure and promote it.

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.

Healthcare utilization patterns for knee and hip osteoarthritis before and after changes in national health insurance coverage: a data linkage study from the Netherlands

IntroductionMedical guidelines aim to stimulate stepped care for knee and hip osteoarthritis, redirecting treatments from hospitals to primary care. In the Netherlands, this development was supported by changing health insurance coverage for physio/exercise therapy. The aim of this study was to evaluate healthcare utilization patterns before and after health changes in health insurance coverage. MethodWe analyzed electronic health records and claims data from patients with osteoarthritis in the knee (N = 32,091) and hip (N = 16,313). Changes between 2013 and 2019 in the proportion of patients treated by the general practitioner, physio/exercise therapist or orthopedic surgeon within 6 months after onset were assessed. ResultsJoint replacement surgeries decreased for knee (OR 0.47 [0.41–0.54]) and hip (OR 0.81 [0.71–0.93]) osteoarthritis between 2013–2019. The use of physio/exercise therapy increased (knee: OR 1.38 [1.24–1.53], hip: OR 1.26 [1.08–1.47]). However, the proportion treated by a physio/exercise therapist decreased for patients that had not depleted their annual deductibles (knee: OR 0.86 [0.79 – 0.94], hip: OR 0.90 [0.79 – 1.02]). This might be affected by the inclusion of physio/exercise therapy in basic health insurance in 2018. ConclusionWe have found a shift from hospitals to primary care in knee and hip osteoarthritis care. However, the use of physio/exercise therapy declined after changes in insurance coverage for patients that had not depleted their deductibles.

A New Treatment Program: Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD).

Bipolar disorder (BD) is complicated by a dynamic, chronic course along with multiple comorbid psychiatric and medical conditions, making it challenging for clinicians to treat and patients to thrive. To efficiently manage the complexity of BD and help patients recover, we developed a Focused Integrated Team-based Treatment Program for Bipolar Disorder (FITT-BD). The purpose of this paper is to describe how we developed this clinic and the lessons we learned. We developed FITT-BD by integrating strategies from stepped care, collaborative care, and learning health care systems. We describe the rationale, details, and lessons learned in developing FITT-BD. By integrating stepped care, collaborative care, and a learning health care system approach, FITT-BD aims to reduce barriers to care, leverage the expertise of a multidisciplinary treatment team, ensure patient-centeredness, and use assessments to inform and continuously improve outcomes in real time. We learned that there are challenges in the creation of a web-based application that tracks the treatment of patients within a network of hospitals. The success of FITT-BD will be determined by the degree to which it can increase treatment access, improve treatment adherence, and help individuals with BD achieve their treatment goals. We expect that FITT-BD will improve outcomes in the context of ongoing clinical care. The treatment of BD is challenging and complex. We propose a new treatment model for BD: FITT-BD. We expect that this program will be a patient-centered approach that improves outcomes in the context of ongoing clinical care for patients with BD.

Wild and Willful Kids: Can We Help Parents? The Effectiveness of a Group Parent Training Program Without a Psychiatric Label.

Many children with a classification of attention-deficit/hyperactivity disorder exhibit mild-to-moderate problem behavior. For these children, a stepped diagnosis and stepped care approach has been proposed. Although a psychiatric classification may bring support to families, it may also have negative consequences. Therefore, in this preliminary study, the effect of a group parent training program without child-bound classifications (named Wild & Willful, Druk & Dwars in Dutch) was investigated. In 7 sessions, groups of parents (experimental, n=63; waiting list control, n=38) learned strategies to deal with wild and willful behavior in their children. Outcome variables were assessed by questionnaires. Multilevel analyses showed that, compared with the control group, the intervention group had significantly lower scores on parental stress and communication problems (Cohen d=0.47 and 0.52, respectively), but not on attention and hyperactivity problems, oppositional defiant problems, and responsivity. Zooming in on the course of outcome variables over time in the intervention group, improvements on all variables were seen, with small to moderate effect sizes (Cohen d=0.30 to 0.52). Overall, the group parent training program without the need for a classification for children seemed beneficial. The training is low cost, brings together parents who are facing similar problems in rearing their children, and may help to reduce overdiagnosis of mild and moderate problems, without risking undertreatment of severe difficulties.

Integration of the Program Evaluation Standards into an Evaluation Toolkit for a Transformative Model of Care for Mental Health Service Delivery

Background: Stepped Care 2.0 (SC2.0) is a transformative model of mental health service delivery. This model was created by Stepped Care Solutions (SCS), a not-for-profit consultancy that collaborates with governments, public service organizations, and other institutions that wish to redesign their mental health and addictions systems of care. The SC2.0 model is based on 10 foundational principles and 9 core components that can be flexibly adapted to an organization’s or community’s needs. The model supports groups to reorganize and deliver mental health care in an evidence-informed, person-centric way. SCS partnered with evaluators from the Centre for Health Evaluation and Outcome Sciences (CHÉOS) to create a toolkit that provides evaluation guidance. The toolkit includes a theory of change, guidance on selecting evaluation questions and designs, and an evaluation matrix including suggested process and outcome metrics, all of which can be tailored to each unique implementation of the SC2.0 model. The objective of this resource is to support organizations and communities to conduct high-quality evaluations for the purpose of continuous improvement (a core component of the model of care) and to assess the model’s impact. Purpose: The purpose of this paper is to discuss the integration of the program evaluation standards (PES) into an evaluation toolkit for SC2.0. Setting: In this paper, we describe the toolkit development, focusing on how the PES were embedded in the process and tools. We explore how the integration of the PES into the toolkit supports evaluators to enhance the quality of their evaluation planning, execution, and meta-evaluation. Intervention: Not applicable Research Design: Not applicable Data Collection and Analysis: Not applicable Findings: In this paper, we describe the toolkit development, focusing on how the PES were embedded in the process and tools. We explore how the integration of the PES into the toolkit supports evaluators to enhance the quality of their evaluation planning, execution, and meta-evaluation. Keywords: program evaluation standards; evaluation; mental health

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.

A multi-site trial of an electronic health integrated physical activity promotion intervention in breast and endometrial cancers survivors: MyActivity study protocol

Despite the known benefits of moderate-to-vigorous physical activity (MVPA) for breast and endometrial cancer survivors, most are insufficiently active, interventions response is heterogeneous, and MVPA programming integration into cancer care is limited. A stepped care approach, in which the least resource-intensive intervention is delivered first and additional components are added based on individual response, is one strategy to enhance uptake of physical activity programming. However, the most effective intervention augmentation strategies are unknown. In this singly randomized trial of post-treatment, inactive breast and endometrial cancer survivors (n = 323), participants receive a minimal intervention including a Fitbit linked with their clinic's patient portal and, in turn, the electronic health record (EHR) with weekly feedback delivered via the portal. MVPA progress summaries are sent to participants' oncology team via the EHR. MVPA adherence is evaluated at 4, 8, 12, 16 and 20 weeks; non-responders (those meeting ≤80% of the MVPA goal over previous 4 weeks) at each timepoint are randomized once for the remainder of the 24-week intervention to one of two “step-up” conditions: (1) online gym or (2) coaching calls, while responders continue with the minimal Fitbit+EHR intervention. The primary outcome is ActiGraph-measured MVPA at 24 and 48 weeks. Secondary outcomes include symptom burden and functional performance at 24 and 48 weeks. This trial will inform development of an effective, scalable, and tailored intervention for survivors by identifying non-responders and providing them with the intervention augmentations necessary to increase MVPA and improve health outcomes.Clinical Trials Registration # NCT04262180

The Perceived Utility of Smartphone and Wearable Sensor Data in Digital Self-tracking Technologies for Mental Health.

Mental health symptoms are commonly discovered in primary care. Yet, these settings are not set up to provide psychological treatment. Digital interventions can play a crucial role in stepped care management of patients' symptoms where patients are offered a low intensity intervention, and treatment evolves to incorporate providers if needed. Though digital interventions often use smartphone and wearable sensor data, little is known about patients' desires to use these data to manage mental health symptoms. In 10 interviews with patients with symptoms of depression and anxiety, we explored their: symptom self-management, current and desired use of sensor data, and comfort sharing such data with providers. Findings support the use digital interventions to manage mental health, yet they also highlight a misalignment in patient needs and current efforts to use sensors. We outline considerations for future research, including extending design thinking to wraparound services that may be necessary to truly reduce healthcare burden.

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.

Guiding Principles for Implementing Stepped Care in Mental Health: Alignment on the Bigger Picture.

Stepped care models are a mental healthcare delivery framework in which a continuum of support allows selection of a range of interventions to match a client's evolving needs and preferences. Currently in use in multiple settings worldwide, stepped care has the potential to provide a needed advance for the development of comprehensive mental health systems. However, definitions of stepped care lack consistency, resulting in differing interpretations reflected in variable implementation, ultimately limiting its replicability, utility and potential for impact. To help foster greater alignment in research and practice, we propose a set of principles for stepped care which can provide guidance on how to bridge multiple mental health services together, reduce fragmentation, and respond to the full breadth of mental health needs along a continuum of care in diverse settings. We hope that articulating these principles will foster discussion and spur mental health stakeholders to translate them into actionable standards.

Long-term effects on depression and anxiety of an internet-based stepped care intervention for patients with cancer and symptoms of depression and anxiety. The U-CARE AdultCan trial

BackgroundCancer is a serious disease that commonly causes significant psychological distress. The internet-based intervention (iCAN-DO), utilizing a stepped care approach for the treatment of anxiety and depression in individuals with cancer, has been shown to have favorable results for symptoms of depression at the primary endpoint, 10 months after randomization compared to standard care (SC). The aim of the present study was to evaluate the long-term effects of the intervention 18 and 24 months after randomization. MethodsPatients with breast, colorectal, or prostate cancer and a score > 7 on either of the Hospital Anxiety and Depression Scale (HADS) subscales (n = 245) were recruited to the study in conjunction with a regular hospital visit. They were randomized to access to the stepwise iCAN-DO intervention for 24 months or to SC. Step 1 of the intervention comprised psycho-educative online material. In Step 2, internet-based cognitive-behavioral therapy with individual online support from a therapist was added. Step 2 was offered to those who reported persistent anxiety or depression symptoms (>7 on HADS), also at 1, 4, and/or 7 months after randomization. Missing data were imputed using the last rank carried forward method and used for the main analyses according to the intention-to-treat approach. Effects sizes (Cohen's d), and minimally clinically important difference (MCID) were calculated. Linear mixed models were used to analyze intervention effects over time. ResultsSymptoms of depression decreased significantly (p < 0.05) in the iCAN-DO group compared with the SC group from baseline to 18 months (d = 0.29), but not to 24 months (d = 0.27). Even though the average iCAN-DO group participant surpassed a MCID in symptoms of anxiety (>2 p) at both long-term follow-ups, the differences did not reach statistical significance, either at 18 months (p = 0.10) or 24 months (p = 0.09). Positive effects of iCAN-DO compared with the SC were also shown for some secondary HRQoL-outcomes; social functioning at 18 months (p = 0.02) and 24 months (p = 0.001), and sleep problems at 24 months (p = 0.01). ConclusionA stepped-care internet-based intervention that has previously shown positive results for symptoms of depression at 10 months did show similar positive long-term effects also at 18 months. For symptoms of anxiety, no effect could be shown. The internet may provide an effective format for interventions to reduce symptoms of depression after cancer at patients' own choice of time, regardless of distance to a psycho-oncology clinic.

An eHealth ecosystem for stepped and early psychosocial care in advanced lung cancer: Rationale and protocol for a randomized control trial

BackgroundReceiving a diagnosis of lung cancer is an emotional event, not least because it is usually diagnosed at advanced stages with limited life expectancy. Although evidence-based educational, emotional, and social interventions exist, they reach few patients and usually when it is too late. ObjectiveThis project will be carried out in a comprehensive center for cancer care and health research, aiming to study the efficacy, costs, and utility of an eHealth ecosystem to meet the psychosocial needs of patients with advanced lung cancer. MethodWe will enroll 76 patients with advanced lung cancer into an eHealth ecosystem of stepped and personalized psychosocial care for 9 months. These patients will be compared with another 76 receiving usual care in a non-inferiority randomized controlled trial. The following main outcomes will be measured every 3 months: emotional distress, spirituality, demoralization, quality of life, and medication adherence. Secondary outcomes will include symptomatology, health education, cost-utility analyses, usability and satisfaction with the platform, and time to detect emotional needs and provide care. Baseline differences between groups will be measured with the Student t-test or chi-square test, as appropriate. We will then compare the main outcomes between groups over time using multilevel linear models, report effect sizes (Hedges' g), and assess non-inferiority. The cost-utility of both interventions will be considered in terms of quality adjusted life years and quality of life given the costs of providing each treatment. DiscussionThis randomized controlled trial should provide new evidence on the efficacy and cost-utility of an eHealth ecosystem to deliver personalized and timely psychosocial care to patients with advanced lung cancer. Trial registrationClinicalTrials.gov ID “NCT05497973”.

Evidence-Based Practice in Psychosocial Oncology from the Perspective of Canadian Service Directors.

Evidence-based practices facilitate the effective delivery of psychological services, yet research on the implementation of evidence-based practices in psychosocial oncology (PSO) is scarce. Responding to this gap, we interviewed a diverse sample of 16 directors of Canadian psychosocial oncology services about (a) how evidence-based practices in psychosocial oncology are being implemented in clinical care and how the service quality is monitored and (b) what are barriers and facilitators to evidence-based practice in psychosocial oncology services? Responses were grouped according to three main themes emerging from the data: screening for distress and referral to PSO services, delivery of evidence-based PSO services, and monitoring of PSO services. Our findings highlight facilitators and barriers to evidence-based practice in psychosocial oncology, which were related to the political, social, economic, and geographic contexts. The stepped care model was identified as a science-informed approach to improve the cost-effectiveness of triage systems and treatment delivery while facilitating more equitable access to services. Other facilitators included electronic screening and referral systems as well as protected time for clinicians to communicate more within their teams and participate in knowledge exchange. High caseloads presented a major barrier to acquiring and implementing evidence-based practices. Recommen-dations include increased support for evidence-based onboarding and continued training as well as for data collection regarding service needs, quality, and quantity to inform service monitoring and advocacy for more financial resources. Our findings are relevant to healthcare decision makers, implementation researchers, as well as service directors and practitioners providing psychosocial oncology care.

Parent-Led Stepped Care Trauma Treatment: Parents’ Experiences With Helping Their Child Recover

PurposeThere is a need for interventions for traumatized children that are easily accessible and effective, and that involve parents directly in the recovery process. To meet this challenge, stepped care trauma-focused cognitive behavioral treatment (SC TF-CBT), which consists of a parent-led therapist-assisted intervention as the first step, was developed. Parent-led trauma-treatment is a promising, but novel approach. The aim of this study was therefore to gain knowledge on how parents experience the model.MethodsParents who participated in a SC TF-CBT feasibility study were consecutively recruited and interviewed with semi-structured interviews, which were then analysed using interpretative phenomenological analysis.ResultsThe parents described that the intervention gave them insights that led to a sense of parental agency. Through the analysis we identified and labelled four themes: (i) understanding my child: how the trauma has affected my child and our relationship; (ii) understanding myself: how my reactions have stood in the way of helping my child; (iii) gaining competence: how to learn specific tasks that were not part of my normal parenting skills; and (iv) receiving support: how guidance, warmth and encouragement was necessary.ConclusionsThe results from this study show how the shifting of therapeutic tasks to parents may facilitate parental empowerment and improve the parent-child relationship. This knowledge may guide clinicians on how to provide support to parents so they can take a leading role in their child’s recovery process after trauma.Trial registrationClinicalTrials.gov, NCT04073862. Retrospectively registered 03 June 2019 (first patient recruited May 2019), https://clinicaltrials.gov/ct2/show/NCT04073862.

A Web-Based Stratified Stepped Care Platform for Mental Well-being (TourHeart+): User-Centered Research and Design.

Internet-based mental health interventions have been demonstrated to be effective in alleviating psychological distress and promoting mental well-being. However, real-world uptake and engagement of such interventions have been low. Rather than being stand-alone interventions, situating internet-based interventions under a stratified stepped care system can support users to continue with mental health practice and monitor their mental health status for timely services that are commensurate with their needs. A user-centered approach should be used in the development of such web-based platforms to understand the facilitators and barriers in user engagement to enhance platform uptake, usability, and adherence so it can support the users' continued adoption and practice of self-care for their mental health. The aim of this study was to describe the design process taken to develop a web-based stratified stepped care mental health platform, TourHeart+, using a user-centered approach that gathers target users' perceptions on mental self-care and feedback on the platform design and incorporates them into the design. The process involved a design workshop with the interdisciplinary development team, user interviews, and 2 usability testing sessions on the flow of registration and mental health assessment and the web-based self-help interventions of the platform. The data collected were summarized as descriptive statistics if appropriate and insights are extracted inductively. Qualitative data were extracted using a thematic coding approach. In the design workshop, the team generated empathy maps and point-of-view statements related to the possible mental health needs of target users. Four user personas and related processes in the mental health self-care journey were developed based on user interviews. Design considerations were derived based on the insights drawn from the personas and mental health self-care journey. Survey results from 104 users during usability testing showed that the overall experience during registration and mental health assessment was friendly, and they felt cared for, although no statistically significant differences on preference ratings were found between using a web-based questionnaire tool and through an interactive chatbot, except that chatbot format was deemed more interesting. Facilitators of and barriers to registering the platform and completing the mental health assessment were identified through user feedback during simulation with mock-ups. In the usability testing for guided self-help interventions, users expressed pain points in course adherence, and corresponding amendments were made in the flow and design of the web-based courses. The design process and findings presented in the study are important in developing a user-centric platform to optimize users' acceptance and usability of a web-based stratified stepped care platform with guided self-help interventions for mental well-being. Accounting for users' perceptions and needs toward mental health self-care and their experiences in the design process can enhance the usability of an evidence-based mental health platform on the web.

Culturally sensitive stepped care for adolescent refugees: efficacy and cost–utility of a multicentric randomized controlled trial

Adolescent refugees and asylum seekers (ARAS) are highly vulnerable to mental health problems. Stepped care models (SCM) and culturally sensitive therapies offer promising treatment approaches to effectively provide necessary medical and psychological support. To our knowledge, we were the first to investigate whether a culturally sensitive SCM will reduce symptoms of depression and PTSD in ARAS more effectively and efficiently than treatment as usual (TAU). We conducted a multicentric, randomized, controlled and rater-blinded trial across Germany with ARAS between the ages of 14 to 21 years. Participants (N = 158) were stratified by their level of depressive symptom severity and then equally randomized to either SCM or TAU. Depending on their severity level, SCM participants were allocated to tailored interventions. Symptom changes were assessed for depression (PHQ) and PTSD (CATS) at four time points, with the primary end point at post-intervention after 12 weeks. Based on an intention-to-treat sample, we used a linear mixed model approach for the main statistical analyses. Further evaluations included cost–utility analyses, sensitivity analyses, follow-up-analyses, response and remission rates and subgroup analysis. We found a significant reduction of PHQ (d = 0.52) and CATS (d = 0.27) scores in both groups. However, there was no significant difference between SCM and TAU. Cost–utility analyses indicated that SCM generated greater cost–utility when measured as quality-adjusted life years compared to TAU. Subgroup analysis revealed different effects for the SCM interventions depending on the outcome measure. Although culturally sensitive, SCMs did not prove to be more effective in symptom change and represent a more cost-effective treatment alternative for mentally burdened ARAS. Our research contributes to the optimization of clinical productivity and the improvement of therapeutic care for ARAS. Disorder-specific interventions should be further investigated.

Navigating nutrition as a childhood cancer survivor: Understanding patient and family needs for nutrition interventions or education.

Nutrition challenges are common during childhood cancer treatment and can persist into survivorship, increasing the risk of non-communicable diseases. Evidence-based practice and implementation of nutrition interventions/education for childhood cancer survivors has been poorly investigated and may influence their future health. This study aimed to explore the nutrition interventions/education needs of childhood cancer survivors and the barriers and facilitators to delivering follow-up services in New Zealand. Semi structured interviews were conducted with childhood cancer survivors and/or their families (n=22) and health professionals (n=9) from a specialist paediatric oncology centre in New Zealand. Interviews were audio-recorded and transcribed verbatim. Transcripts were analysed inductively using thematic analysis. A multi-level consensus coding methodology was used where each theme and associated subthemes were discussed with the study team for confirmation to ensure accurate coding and analysis. Three themes emerged from the analysis: (1) the current survivorship care pathway does not provide adequate interventions/education, (2) weight and dietary changes are common challenges and (3) requirements for interventions/education in survivorship are varied. Common nutrition-related concerns included fussy eating/limited dietary intake, poor diet quality, difficulties with tube weaning, and challenges with weight gain. Participants expressed a desire for education on healthy eating alongside information about cancer-related nutrition issues, such as learned food aversions. A preference for clear referral pathways and multifaceted interventions tailored to individual patient needs was identified. The trifecta of treatment side effects, negative feeding practices and poor messaging from health professionals creates a challenging environment to optimise nutrition. A stepped care model matching the intervention intensity with the childhood cancer survivors is required. Education for healthcare professionals will improve the delivery of timely interventions/education and monitoring practices.

In-person 1-day cognitive behavioral therapy-based workshops for postpartum depression: a randomized controlled trial.

Postpartum depression (PPD) affects up to one in five mothers and birthing parents, yet as few as 10% access evidence-based treatment. One-day cognitive behavioral therapy (CBT)-based workshops for PPD have the potential to reach large numbers of sufferers and be integrated into stepped models of care. This randomized controlled trial of 461 mothers and birthing parents in Ontario, Canada with Edinburgh Postnatal Depression Scale (EPDS) scores ⩾10, age ⩾18 years, and an infant <12 months of age compared the effects of a 1-day CBT-based workshop plus treatment as usual (TAU; i.e. care from any provider(s) they wished) to TAU alone at 12-weeks post-intervention on PPD, anxiety, the mother-infant relationship, offspring behavior, health-related quality of life, and cost-effectiveness. Data were collected via REDCap. Workshops led to meaningful reductions in EPDS scores (m = 15.77 to 11.22; b = -4.6, p < 0.01) and were associated with three times higher odds of a clinically significant decrease in PPD [odds ratio (OR) 3.00, 95% confidence interval (CI) 1.93-4.67]. Anxiety also decreased and participants had three times the odds of clinically significant improvement (OR 3.20, 95% CI 2.03-5.04). Participants reported improvements in mother-infant bonding, infant-focused rejection and anger, and effortful control in their toddlers. The workshop plus TAU achieved similar quality-adjusted life-years at lower costs than TAU alone. One-day CBT-based workshops for PPD can lead to improvements in depression, anxiety, and the mother-infant relationship and are cost-saving. This intervention could represent a perinatal-specific option that can treat larger numbers of individuals and be integrated into stepped care approaches at reasonable cost.

Identifying Symptoms of ADHD and Disruptive Behavior Disorders Most Strongly Associated with Functional Impairment in Children: A Symptom-Level Approach

To enhance the understanding of how symptoms of attention-deficit/hyperactivity disorder (ADHD) and disruptive behavior disorders such as oppositional defiant disorder (ODD), conduct disorder (CD), including callous-unemotional (CU) traits, differentially relate to functional impairment (FI). Participants were 474 German school-age children (age: M = 8.90, SD = 1.49, 81% male) registered for participation in the ESCAschool trial (ESCAschool: Evidence-based, Stepped Care of ADHD in school-aged children). Clinicians assessed the severity of individual symptoms and five FI domains specifically associated with ADHD symptoms or ODD/CD/CU symptoms using a semi-structured clinical interview. We conducted two multiple linear regression analyses, combined with relative importance analyses, to determine the impact of individual symptoms on global FI associated with ADHD and ODD/CD/CU symptoms. Next, we estimated two networks and identified the strongest associations of ADHD symptoms or ODD/CD/CU symptoms with the five FI domains. Symptoms varied substantially in their associations with global FI. The ADHD symptom Easily Distracted (15%) and ODD symptom Argues with Adults (10%) contributed most strongly to the total explained variance. FI related to academic performance, home life and family members, and psychological strain were most strongly associated with ADHD inattention symptoms, whereas FI related to relationships with adults and relationships with children and recreational activities were most strongly associated with hyperactivity-impulsivity symptoms. By comparison, the ODD/CD/CU symptoms most closely linked to FI domains originated from the ODD and CD dimensions. Our findings contribute to a growing body of literature on the importance of analyzing individual symptoms and highlight that symptom-based approaches can be clinically useful.