Blended Care Therapy for Depression and Anxiety: Outcomes across Diverse Racial and Ethnic Groups.

BACKGROUND: Studies have reported positive outcomes of blended care therapy (BCT), which combines face-to-face care with internet modules. However, there is insufficient evidence of its effectiveness across racial and ethnic groups. This study evaluated outcomes of a BCT program, which combined video psychotherapy with internet cognitive-behavioral modules, across race and ethnicity. METHODS: Participants were 6492 adults, with elevated anxiety (Generalized Anxiety Disorder-7 [GAD-7] ≥ 8) and/or depression (Patient Health Questionnaire-9 [PHQ-9] ≥ 10) symptoms, enrolled in employer-offered BCT. Changes in anxiety (GAD-7) and depression (PHQ-9) symptoms during treatment were evaluated using individual growth curve models. Interaction terms of time with race and ethnicity tested for between-group differences. Treatment satisfaction was assessed using a Net Promoter measure (range = 1 (lowest satisfaction) to 5 (greatest satisfaction)). RESULTS: Participants' self-reported race and ethnicity included Asian or Pacific Islander (27.5%), Black or African American (5.4%), Hispanic or Latino (9.3%), and White (47.2%). Anxiety symptoms decreased during treatment (p < 0.01), with greater reductions among Hispanic or Latino participants compared to White participants (p < 0.05). Depressive symptoms decreased across treatment (p < 0.01), with significantly greater decreases among some racial and ethnic groups compared to White participants. Declines in anxiety and depressive symptoms slowed across treatment (p's < 0.01), with statistically significant differences in slowing rates of depressive symptoms across some racial and ethnic groups. Among participants with responses (28.45%), average treatment satisfaction ranged from 4.46 (SD = 0.73) to 4.67 (SD = 0.68) across race and ethnicity (p = 0.001). Racial and ethnic differences in outcomes were small in magnitude. CONCLUSIONS: BCT for anxiety and depression can be effective across diverse racial and ethnic groups.

Real-World Evaluation of a Large-Scale Blended Care-Cognitive Behavioral Therapy Program for Symptoms of Anxiety and Depression.

Introduction: Prior studies have supported the effectiveness of blended interventions for anxiety and depression; however, outcomes research of large-scale blended interventions for these conditions is limited. Objective: To investigate the outcomes of scaled-up blended care (BC) cognitive behavioral therapy (CBT), a program that combined video-based psychotherapy with internet CBT, for symptoms of anxiety and depression. Materials and Methods: Participants were 6,738 U.S.-based adults with elevated symptoms of anxiety (Generalized Anxiety Disorder-7 [GAD-7] ≥ 8) and/or depression (Patient Health Questionnaire-9 [PHQ-9] ≥ 10) at baseline who received BC-CBT as an employer-offered mental health benefit. The primary outcomes, anxiety (GAD-7) and depression (PHQ-9) symptoms, were routinely measured in the program. Recovery and reliable improvement in outcomes were calculated, and growth curve models evaluated change in outcomes during treatment and the effects of engaging in psychotherapy sessions on outcomes. Results: On average, participants received treatment for 7.6 (standard deviation = 6.2) weeks. By the end of care, 5,491 (81.5%) participants had reliable improvement in either anxiety or depression symptoms; in addition, 5,535 (82.1%) fell below the clinical threshold for either anxiety or depression symptoms (i.e., recovered). Declines in anxiety and depression symptoms were statistically significant over the course of BC-CBT (both p's < 0.01), with the rate of decline significantly decreasing for each outcome as treatment progressed (both p's < 0.01). Each psychotherapy session completed was significantly associated with lower anxiety and depression symptoms during the week of the session and the subsequent week (all p's < 0.01). Conclusions: This real-world study provides evidence that scaled-up BC-CBT can be effective in the treatment of symptoms of anxiety and depression.

The correspondence of daily and retrospective PTSD reports among female victims of sexual assault.

Research addressing the association between daily and retrospective symptom reports suggests that retrospective reports are typically inflated. The present study examined the association between daily posttraumatic stress disorder (PTSD) symptom reports over 1 month and a corresponding retrospective report (PTSD Checklist [PCL]; Weathers et al., 1993) for both total scores and symptom clusters. The authors hypothesized that greater PTSD symptom instability and greater depression would be associated with poorer agreement between daily and retrospective reports. Data were collected from 132 female college students who were sexually assaulted. Multilevel modeling indicated very strong agreement between mean daily and retrospective reports for total scores and symptom clusters, with pseudo-R2 ranging from .55 to .77. Depression symptoms did not moderate this association, but daily-retrospective agreement was lowest for the avoidance cluster, which was also the most unstable. Finally, retrospective recall for each symptom cluster showed acceptable specificity to the corresponding daily symptom clusters. Overall, these findings suggest that retrospective memories for global PTSD symptoms and symptom clusters, as assessed by the PCL, are consistent with daily reports over a 1-month period. Implications for clinical assessment methodology are discussed.

Symptoms of posttraumatic stress predict craving among alcohol treatment seekers: results of a daily monitoring study.

Alcohol use disorders (AUDs) and Posttraumatic Stress Disorder (PTSD) commonly co-occur. Craving for alcohol is a common aspect of AUD, with and without PTSD, and is one of the key predictors of continued problematic alcohol use among treatment seekers. The present study sought to investigate the self-medication hypothesis using daily Interactive Voice Response (IVR) reports to examine the relationships between PTSD symptomatology and both same-day and next-day alcohol craving. Twenty-nine individuals with an AUD (26 of whom screened positive for PTSD) entering AUD treatment provided daily IVR data for up to 28 days regarding their alcohol use, craving, and 7 symptoms of PTSD. Given the nested nature of daily data, generalized estimating equations using a negative binomial distribution and a log link function were used to test hypotheses. Results suggest that days with greater overall PTSD severity are associated with greater alcohol craving, and greater reports of startle and anger/irritability were particularly associated with same-day craving. The next-day results suggest that the combination of the 7 PTSD symptoms did not predict next-day craving. However, greater distress from nightmares the previous night, emotional numbing, and hypervigilance predicted greater next-day craving, while greater anger/irritability predicted lower next-day craving. These findings highlight the importance of assessing the relationship between specific symptoms of PTSD and alcohol cravings in order to increase our understanding of the functional interplay among them for theory building. Additionally, clinicians may be better able to refine treatment decisions to more efficiently break the cycle between PTSD-related distress and AUD symptoms.

Psychiatric correlates of medical care costs among veterans receiving mental health care.

Research on increased medical care costs associated with posttraumatic sequelae has focused on posttraumatic stress disorder (PTSD). However, the provisional diagnosis of Disorders of Extreme Stress Not Otherwise Specified (DESNOS) encompasses broader trauma-related difficulties and may be uniquely related to medical costs. We investigated whether DESNOS severity was associated with greater nonmental health medical care costs in veterans receiving mental health care. Participants were 106 men and 105 women receiving VA outpatient mental health treatment. A standardized interview assessed DESNOS severity. The dependent variables consisted of primary and specialty medical treatment costs. Sequential zero-inflated negative binomial regression was used to evaluate the variance in medical costs accounted for by DESNOS severity, controlling for PTSD severity and established predisposing, enabling, and need-based health care factors. Contrary to our hypothesis, in fully adjusted models, DESNOS severity independently added a significant amount of variance to lower specialty medical care costs, whereas PTSD did not consistently account for significant variance in medical care costs. Greater DESNOS severity appears to be associated with lower specialty medical care costs but not primary care costs. These findings may indicate that patients with DESNOS symptoms are at risk for being underreferred for specialty care.

A randomized control trial examining the effect of acceptance and commitment training on clinician willingness to use evidence-based pharmacotherapy.

This study evaluated the effectiveness of acceptance and commitment training (ACT) for increasing drug and alcohol counselors' willingness to use evidence-based agonist and antagonist pharmacotherapy. Fifty-nine drug and alcohol counselors were randomly assigned to either a 1-day ACT workshop or a 1-day educational control workshop. Both groups then attended a 2-day workshop on empirically supported treatments for substance abuse. Measures were taken at pre- and posttraining and 3-month follow-up on reported use of pharmacotherapy, willingness to use pharmacotherapy, perceived barriers to implementing new treatments, and general acceptance. As compared with those in the education alone condition, participants in the ACT condition showed significantly higher rates of referrals to pharmacotherapy at follow-up, rated barriers to learning new treatments as less believable at posttraining and follow-up, and showed greater psychological flexibility at posttraining and follow-up. Mediational analyses indicated that reduced believability of barriers and greater psychological flexibility mediated the impact of the intervention. Results support the idea that acceptance-based interventions may be helpful in addressing the psychological factors related to poor adoption of evidence-based treatments.

Assessing referrals for pharmacotherapy: a comparison of therapist and client report.

The primary goal of this study was to assess whether therapist self-reported use of referrals for pharmacotherapy with clients for the treatment of substance abuse disorders is consistent with actual rates of referrals experienced by clients. Participants were 20 substance abuse counselors and 120 clients at a large, multisite substance abuse treatment center. Therapists were asked to complete a brief measure of their current use of referrals for pharmacotherapy, including agonist and antagonist approaches. Clients were asked to complete a brief measure indicating whether their individual counselor had discussed with them a referral for medication. Counselor reports were linked to their individual clients and compared for validation. Results indicate that therapist self-report is significantly correlated with client report of referrals for pharmacotherapy. These results indicate that although therapist self-report of adherence to more involved treatment approaches is often unreliable, substance abuse counselors are able to reliably report their use of referrals.