Initiation of Buprenorphine/Naloxone on Rates of Discharge Against Medical Advice.

Objective: Evidence shows that patients with opioid use disorder (OUD) have an increased rate of discharge against medical advice (DAMA) as well as higher rates of hospital readmission. Therefore, the objective of this study was to determine if inpatient initiation of buprenorphine/naloxone in patients with OUD is associated with decreased rates of DAMA. Methods: This was a single center retrospective cohort study conducted at a level 1, academic medical center. The study included patients with OUD admitted to the Internal Medicine service from January through May of both 2018 and 2019 for an admitting diagnosis other than opioid withdrawal. The primary endpoint was rate of DAMA among OUD patients not initiated on opioid agonist therapy compared to those initiated on buprenorphine/naloxone. The secondary endpoint was the association between factors of the initiation process on rates of DAMA. Patients were excluded if they were discharged in less than 24 hours or received intermittent administration of buprenorphine/naloxone. Results: The rate of DAMA in OUD patients not initiated on buprenorphine/naloxone was 13.85% compared to 2.56% in those initiated on buprenorphine/naloxone (P = .048). Conclusion: In OUD patients initiated on buprenorphine/naloxone, the rate of DAMA was significantly lower than those who were not. This data supports the importance of optimizing the opportunity to initiate buprenorphine/naloxone in the acute care setting to minimize withdrawal symptoms therefore reducing the rate of DAMA. Ultimately increasing the ability to adequately treat the primary reason for admission and potentially decreasing readmission rates. Further studies are needed to evaluate this impact as this study is limited to a small sample size therefore lacking adequate power.

Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial.

Importance: Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. Objectives: To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. Design, Setting, and Participants: This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. Interventions: CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. Main Outcomes and Measures: The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. Results: The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). Conclusions and Relevance: In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT02700009.

Computer-Assisted Cognitive-Behavior Therapy in Medical Care Settings.

PURPOSE OF REVIEW: We reviewed research on computer-assisted cognitive-behavior therapy (CCBT) performed in medical settings with the goals of assessing the effectiveness of this newer method of treatment delivery, evaluating the need for clinician support of therapeutic computer programs, and making suggestions for future research and clinical implementation. RECENT FINDINGS: The overall results of randomized, controlled trials suggest that CCBT can be an effective treatment for depression in primary care patients and health care anxiety. Also, it can be a useful component of treatment for somatic conditions including irritable bowel syndrome, diabetes, fibromyalgia, and chronic pain. The amount and type of clinician support needed for maximizing effectiveness remains unclear. CCBT offers promise for overcoming barriers to delivering effective psychotherapy in medical settings. We recommend that next steps for researchers include more definitive studies of the influence of clinician support, investigations focused on implementation in clinical practices, cost-benefit analyses, and use of technological advances.

Computer-Assisted Cognitive-Behavior Therapy for Depression in Primary Care: Systematic Review and Meta-Analysis.

OBJECTIVE: To examine evidence for the effectiveness of computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care and assess the impact of therapist-supported CCBT versus self-guided CCBT. METHODS: A search for randomized studies of CCBT compared to control groups for treating depression in primary care settings was conducted using Ovid MEDLINE, PsycINFO, PubMed, and Scopus. We extracted the following information from the studies that met inclusion criteria: mean depression rating scale scores before and after treatment, number of patients, type of control group and CCBT program, therapist support time and method of support, and treatment completion rate. Meta-analyses compared differences between posttreatment mean scores in each condition, as well as mean scores at follow-up. Study quality and possible bias also were assessed. RESULTS: Eight studies of CCBT for depression in primary care met inclusion criteria. The overall effect size was g = 0.258, indicating a small but significant advantage for CCBT over control conditions. Therapist support was provided in 4 of the 8 studies. The effect size for therapist-supported CCBT was g = 0.372-a moderate effect. However, the effect size for self-guided CCBT was g = 0.038, indicating little effect. CONCLUSIONS: Implementation of therapist-supported CCBT in primary care settings could enhance treatment efficiency, reduce cost, and improve access to effective treatment for depression. However, evidence to date suggests that self-guided CCBT offers no benefits over usual primary care.