Refining our understanding of depressive states and state transitions in response to cognitive behavioural therapy using latent Markov modelling

Abstract Background It is increasingly recognized that existing diagnostic approaches do not capture the underlying heterogeneity and complexity of psychiatric disorders such as depression. This study uses a data-driven approach to define fluid depressive states and explore how patients transition between these states in response to cognitive behavioural therapy (CBT). Methods Item-level Patient Health Questionnaire (PHQ-9) data were collected from 9891 patients with a diagnosis of depression, at each CBT treatment session. Latent Markov modelling was used on these data to define depressive states and explore transition probabilities between states. Clinical outcomes and patient demographics were compared between patients starting at different depressive states. Results A model with seven depressive states emerged as the best compromise between optimal fit and interpretability. States loading preferentially on cognitive/affective v. somatic symptoms of depression were identified. Analysis of transition probabilities revealed that patients in cognitive/affective states do not typically transition towards somatic states and vice-versa. Post-hoc analyses also showed that patients who start in a somatic depressive state are less likely to engage with or improve with therapy. These patients are also more likely to be female, suffer from a comorbid long-term physical condition and be taking psychotropic medication. Conclusions This study presents a novel approach for depression sub-typing, defining fluid depressive states and exploring transitions between states in response to CBT. Understanding how different symptom profiles respond to therapy will inform the development and delivery of stratified treatment protocols, improving clinical outcomes and cost-effectiveness of psychological therapies for patients with depression.

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Protocol investigating the clinical outcomes and cost-effectiveness of cognitive–behavioural therapy delivered remotely for unscheduled care users with health anxiety: randomised controlled trial

BJPsych Open ◽

10.1192/bjpo.bp.115.002220 ◽

2016 ◽

Vol 2 (1) ◽

pp. 81-87 ◽

Cited By ~ 6

Author(s):

Shireen Patel ◽

Sam Malins ◽

Boliang Guo ◽

Marilyn James ◽

Joe Kai ◽

...

Keyword(s):

Cost Effectiveness ◽

Randomised Controlled Trial ◽

Clinical Outcomes ◽

Cognitive Behavioural Therapy ◽

Controlled Trial ◽

Health Anxiety ◽

Behavioural Therapy ◽

Unscheduled Care ◽

Cognitive Behavioural ◽

Randomised Controlled

BackgroundHealth anxiety and medically unexplained symptoms cost the National Health Service (NHS) an estimated £3 billion per year in unnecessary costs with little evidence of patient benefit. Effective treatment is rarely taken up due to issues such as stigma or previous negative experiences with mental health services. An approach to overcome this might be to offer remotely delivered psychological therapy, which can be just as effective as face-to-face therapy and may be more accessible and suitable.AimsTo investigate the clinical outcomes and cost-effectiveness of remotely delivered cognitive–behavioural therapy (CBT) to people with high health anxiety repeatedly accessing unscheduled care (trial registration: NCT02298036).MethodA multicentre randomised controlled trial (RCT) will be undertaken in primary and secondary care providers of unscheduled care across the East Midlands. One hundred and forty-four eligible participants will be equally randomised to receive either remote CBT (6–12 sessions) or treatment as usual (TAU). Two doctoral research studies will investigate the barriers and facilitators to delivering the intervention and the factors contributing to the optimisation of therapeutic outcome.ResultsThis trial will be the first to test the clinical outcomes and cost-effectiveness of remotely delivered CBT for the treatment of high health anxiety.ConclusionsThe findings will enable an understanding as to how this intervention might fit into a wider care pathway to enhance patient experience of care.

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Demographic and clinical predictors of response to internet-enabled cognitive–behavioural therapy for depression and anxiety

BJPsych Open ◽

10.1192/bjo.2018.57 ◽

2018 ◽

Vol 4 (5) ◽

pp. 411-418 ◽

Cited By ~ 4

Author(s):

Ana Catarino ◽

Sarah Bateup ◽

Valentin Tablan ◽

Katherine Innes ◽

Stephen Freer ◽

...

Keyword(s):

Clinical Outcomes ◽

Cognitive Behavioural Therapy ◽

Mental Health Problems ◽

Positive Response ◽

Behavioural Therapy ◽

Response To Treatment ◽

The Internet ◽

Clinical Predictors ◽

Predictors Of Response ◽

Cognitive Behavioural

BackgroundCommon mental health problems affect a quarter of the population. Online cognitive–behavioural therapy (CBT) is increasingly used, but the factors modulating response to this treatment modality remain unclear.AimsThis study aims to explore the demographic and clinical predictors of response to one-to-one CBT delivered via the internet.MethodReal-world clinical outcomes data were collected from 2211 NHS England patients completing a course of CBT delivered by a trained clinician via the internet. Logistic regression analyses were performed using patient and service variables to identify significant predictors of response to treatment.ResultsMultiple patient variables were significantly associated with positive response to treatment including older age, absence of long-term physical comorbidities and lower symptom severity at start of treatment. Service variables associated with positive response to treatment included shorter waiting times for initial assessment and longer treatment durations in terms of the number of sessions.ConclusionsKnowledge of which patient and service variables are associated with good clinical outcomes can be used to develop personalised treatment programmes, as part of a quality improvement cycle aiming to drive up standards in mental healthcare. This study exemplifies translational research put into practice and deployed at scale in the National Health Service, demonstrating the value of technology-enabled treatment delivery not only in facilitating access to care, but in enabling accelerated data capture for clinical research purposes.Declaration of interestA.C., S.B., V.T., K.I., S.F., A.R., A.H. and A.D.B. are employees or board members of the sponsor. S.R.C. consults for Cambridge Cognition and Shire. Keywords: Anxiety disorders; cognitive behavioural therapies; depressive disorders; individual psychotherapy

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Using low intensity interventions in the treatment of anxiety disorders

Oxford Guide to Low Intensity CBT Interventions ◽

10.1093/med:psych/9780199590117.003.0015 ◽

2010 ◽

pp. 169-176 ◽

Cited By ~ 1

Author(s):

Nickolai Titov ◽

Gavin Andrews ◽

Peter McEvoy

Keyword(s):

Anxiety Disorders ◽

Cognitive Behavioural Therapy ◽

High Intensity ◽

Behavioural Therapy ◽

Treatment Protocols ◽

Face To Face ◽

Low Intensity ◽

Cognitive Behavioural ◽

Key Issues

Chapter 15 describes key issues in using low intensity (LI) cognitive behavioural therapy (CBT) interventions for anxiety disorders. Treatment protocols for anxiety disorders were originally developed for high intensity (HI) interventions, which unlike LI interventions, traditionally involve high levels of therapist contact and are usually presented via a face-to-face format. It is therefore important to identify how best to modify treatment protocols for effective and acceptable use in LI interventions, which involve limited therapist contact and may be administered remotely.

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Unmet needs for treatment in 102 individuals with brief and limited intermittent psychotic symptoms (BLIPS): implications for current clinical recommendations

Epidemiology and Psychiatric Sciences ◽

10.1017/s2045796019000635 ◽

2019 ◽

Vol 29 ◽

Cited By ~ 6

Author(s):

Paolo Fusar-Poli ◽

Andrea De Micheli ◽

Monica Chalambrides ◽

Aoife Singh ◽

Castagnini Augusto ◽

...

Keyword(s):

High Risk ◽

Clinical Outcomes ◽

Cognitive Behavioural Therapy ◽

Unmet Needs ◽

Behavioural Therapy ◽

Psychotic Symptoms ◽

Antipsychotic Treatment ◽

Poor Prognostic Factor ◽

Cognitive Behavioural

Abstract Aims To investigate clinical outcomes and unmet needs in individuals at Clinical High Risk for Psychosis presenting with Brief and Limited Intermittent Psychotic Symptoms (BLIPS). Methods Prospective naturalistic long-term (up to 9 years) cohort study in individuals meeting BLIPS criteria at the Outreach And Support In South-London (OASIS) up to April 2016. Baseline sociodemographic and clinical characteristics, specific BLIPS features, preventive treatments received and clinical outcomes (psychotic and non-psychotic) were measured. Analyses included Kaplan Meier survival estimates and Cox regression methods. Results One hundred and two BLIPS individuals were followed up to 9 years. Across BLIPS cases, 35% had an abrupt onset; 32% were associated with acute stress, 45% with lifetime trauma and 20% with concurrent illicit substance use. The vast majority (80%) of BLIPS individuals, despite being systematically offered cognitive behavioural therapy for psychosis, did not fully engage with it and did not receive the minimum effective dose. Only 3% of BLIPS individuals received the appropriate dose of cognitive behavioural therapy. At 4-year follow-up, 52% of the BLIPS individuals developed a psychotic disorder, 34% were admitted to hospital and 16% received a compulsory admission. At 3-year follow-up, 52% of them received an antipsychotic treatment; at 4-year follow-up, 26% of them received an antidepressant treatment. The presence of seriously disorganising and dangerous features was a strong poor prognostic factor. Conclusions BLIPS individuals display severe clinical outcomes beyond their very high risk of developing psychosis and show poor compliance with preventive cognitive behavioural therapy. BLIPS individuals have severe needs for treatment that are not met by current preventive strategies.

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