The effectiveness of transdiagnostic cognitive behavioural therapy for anxiety disorders: the role of and impact of comorbid depression.

Transdiagnostic Cognitive Behaviour Therapy (tCBT), an intervention designed to be applicable across multiple diagnoses, was introduced to improve limitations in traditional therapy such as cost and access to trained therapists. It has been established as an effective and efficacious treatment for anxiety disorders, though there has been little research focussed on the role of depression. The current study investigated the role of comorbid depression during tCBT for anxiety disorders in primary care settings as an outcome and a moderator of anxiety outcomes. Results of multi-level ANOVAs indicated no significant difference in anxiety outcomes regardless of whether there was a comorbid depression diagnosis in the tCBT condition, and that individuals with a comorbid depression diagnosis experienced significantly greater reduction in anxiety severity than those without. Depression symptom severity decreased to a significantly greater extent in the tCBT condition than in TAU when the outcome measure of Patient Health Questionnaire was utilised as the outcome measure, but this was not mirrored when the Clinician Severity Rating was utilised as the outcome measure. This study provides preliminary support for the effectiveness of Transdiagnostic Cognitive Behaviour therapy for those with both a principal anxiety disorder and comorbid depression in symptom reduction.

Cost-Effectiveness of Group Transdiagnostic Cognitive Behavioural Therapy for Anxiety Disorders in Primary Care Settings: Economic Evaluation From the Healthcare System Perspective Over a 1-Year Time Horizon.

AIM: To assess the incremental cost-effectiveness ratio (ICER) of group transdiagnostic cognitive-behavioural therapy (tCBT) added to treatment as usual (TAU) for anxiety disorders compared to TAU only from the healthcare system perspective over a 1-year time horizon. METHODS: Data from a pragmatic multisite randomized controlled trial where adults (18-65 years) with an anxiety disorder were randomized to tCBT + TAU (n = 117) or TAU (n = 114). Group tCBT is a 12-week (2h weekly sessions) community-based intervention. Health service utilization and related costs were captured from medico-administrative data and included those for the intervention, ambulatory visits, hospitalizations and medications. Effectiveness was based on quality-adjusted life years (QALYs). The study included measures at baseline, 4, 8, and 12 months. Intention-to-treat and complete case analyses were carried out. Missing data were imputed using multiple imputation analyses. Seemingly unrelated regression analyses were used to assess the effect of the intervention on total costs and QALYs while also adjusting for baseline confounders. The probability of cost-effectiveness of the intervention was assessed according to different willingness-to-pay (WTP) thresholds using the net benefit regression method. RESULTS: The ICER of tCBT + TAU as compared to TAU in the intention-to-treat analysis was $6,581/QALY. Complete case analyses showed a similar ICER of $6,642/QALY. The probability at a WTP threshold of $20,000 and $40,000 that tCBT + TAU as compared to TAU is cost-effective is 93.0% and 99.9%. CONCLUSION: tCBT added to TAU appears to be cost-effective from the healthcare system perspective for treating adult patients with anxiety disorders. Larger trials including young and older adults as well as a range of anxiety disorders are needed to further investigate the cost-effectiveness of tCBT in different patient populations.

Moderators of the cost-effectiveness of transdiagnostic CBT for anxiety disorders over an 8-month time horizon using a net-benefit regression framework.

BACKGROUND: Access to evidence-based psychological treatment is a concern in many parts of the globe due to government-level financial constraints and patient-level barriers. Transdiagnostic cognitive behavioural therapy (tCBT) is an effective treatment approach that uses a single protocol for anxiety disorders which could enhance the dissemination of evidence-based psychotherapy. In a context of limited resources, the study of treatment moderators can allow to identify subgroups for which the cost-effectiveness of an intervention differs, information that could impact decision-making. So far, there has been no economic evaluation of tCBT for different subpopulations. The objectives of this study, using the net-benefit regression framework, were to explore clinical and sociodemographic factors as potential moderators of the cost-effectiveness of tCBT compared to treatment-as-usual (TAU). METHODS: This is a secondary data analysis of a pragmatic randomized controlled trial opposing tCBT added to TAU (n = 117) to TAU only (n = 114). Data on costs from the health system and the limited societal perspectives, as well as anxiety-free days, an effectiveness measure based on the Beck Anxiety Inventory, were collected over an 8-month time horizon and used to derive individual net-benefits. The net-benefit regression framework was used to assess moderators of the cost-effectiveness of tCBT + TAU as opposed to TAU alone. Variables of sociodemographic and clinical nature were assessed. RESULTS: Results showed that the number of comorbid anxiety disorders significantly moderated the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. CONCLUSIONS: The number of comorbid anxiety disorders was identified as a moderator affecting the cost-effectiveness of tCBT + TAU compared to TAU from the limited societal perspective. More research is needed to strengthen the case of tCBT from an economic standpoint for large-scale dissemination. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02811458, 23/06/2016.

An examination of sudden gain prevalence across cognitive-behavioural therapy for anxiety and depressive disorders: A quantitative analysis and meta-analytic review.

Sudden gains, incidences of unexpectedly large and stable session to session symptom reductions during psychotherapy, have been shown in samples of individuals receiving treatment for both anxiety and depressive disorders, although seemingly more frequently in sample receiving treatment for depressive disorders. This may suggest that sudden gains are a function of depression, but the high comorbidity between anxiety and depressive disorders makes this difficult to assess. Study One utilised a sample of 117 adults undergoing CBT for a principal anxiety disorder to explore the effect of comorbid depression on sudden gain prevalence. Results indicated that sudden gains were not more prevalent in the comorbid depression group; however, the frequency of sudden gains was significantly related to comorbid depressive disorder severity. Study Two involved a meta-analysis of 48 studies to compare sudden gain prevalence between trials of CBT for depressive disorders versus anxiety-related disorders. The results of the meta-analysis indicated significantly higher rates of sudden gains in samples with a principal depressive disorder diagnosis, compared to a principal anxiety disorder diagnosis. Sudden gains may therefore be driven by depression, but only at the more severe level.

An analysis of differential improvement by diagnosis in group transdiagnostic cognitive behaviour therapy for anxiety disorders.

INTRODUCTION: Anxiety disorders are the most prevalent among the mental health disorders and have a negative impact on an individual's life. Cognitive behaviour therapy (CBT) is documented as the most effective treatment for anxiety disorders. However, challenges associated with implementing diagnosis-specific CBT have led to transdiagnostic approaches of CBT (tCBT). tCBT uses a single protocol with core elements of CBT for treatment of anxiety disorders broadly. The aim of the current study is to examine whether participants with different principal anxiety diagnoses demonstrate similar anxiety reduction. METHODS: The current study involved a secondary analysis of 117 participants randomly allocated to receive tCBT for anxiety disorders in a pragmatic randomised effectiveness trial. Beck Anxiety Inventory (BAI) and Clinician Severity Ratings (CSR) scales were administered at pre- and post-treatment and one-year follow-up, while the Anxiety Disorder Diagnostic Questionnaire - Weekly (ADDQ-W) was administered each session. RESULTS: Mixed-factorial analyses of variance (ANOVAs) indicated that participants with GAD, SAD and PD/A improved to post-treatment and maintained to follow-up, with no differential improvement across principal diagnoses. Mixed effect regression modelling of session by session measures indicated non-differential negative slopes across principal diagnoses of GAD, SAD and PD/A. CONCLUSION: Overall, results indicate that group tCBT for anxiety disorders shows equal effectiveness for GAD, PD/A, and SAD in real-world conditions.

Cost-effectiveness of transdiagnostic group cognitive behavioural therapy for anxiety disorders v. treatment as usual: economic evaluation of a pragmatic randomized controlled trial over an 8-month time horizon using self-reported data.

BACKGROUND: This economic evaluation supplements a pragmatic randomized controlled trial conducted in community care settings, which showed superior improvement in the symptoms of adults with anxiety disorders who received 12 sessions of transdiagnostic cognitive-behavioural group therapy in addition to treatment as usual (tCBT + TAU) compared to TAU alone. METHODS: This study evaluates the cost-utility and cost-effectiveness of tCBT + TAU over an 8-month time horizon. For the reference case, quality-adjusted life years (QALYs) obtained using the EQ-5D-5L, and the health system perspective were chosen. Alternatively, anxiety-free days (AFDs), derived from the Beck Anxiety Inventory, and the limited societal perspective were considered. Unadjusted incremental cost-effectiveness/utility ratios were calculated. Net-benefit regressions were done for a willingness-to-pay (WTP) thresholds range to build cost-effectiveness acceptability curves (CEAC). Sensitivity analyses were included. RESULTS: Compared to TAU (n = 114), tCBT + TAU (n = 117) generated additional QALYs, AFDs, and higher mental health care costs from the health system perspective. From the health system and the limited societal perspectives, at a WTP of Can$ 50 000/QALY, the CEACs showed that the probability of tCBT + TAU v. TAU being cost-effective was 97 and 89%. Promising cost-effectiveness results using AFDs are also presented. The participation of therapists from the public health sector could increase cost-effectiveness. CONCLUSIONS: From the limited societal and health system perspectives, this first economic evaluation of tCBT shows favourable cost-effectiveness results at a WTP threshold of Can$ 50 000/QALY. Future research is needed to replicate findings in longer follow-up studies and different health system contexts to better inform decision-makers for a full-scale implementation.

Anxiety in bipolar disorder: A review of publication trends.

BACKGROUND: Although anxiety is highly prevalent in people with bipolar disorders and has deleterious impact on the course of the illness, past reviews have shown that many aspects of the topic remain under-researched. This scoping review aims to provide a comprehensive overview of the literature addressing anxiety in bipolar disorder (A-BD) between 2011 and 2020, assess if the interest in the topic has increased over the period and map the publication trends. METHODS: Three databases were systematically searched, and all articles were screened at the title/abstract and full text level based on inclusion and exclusion criteria. Of these, 1099 articles were included in the study. The annual number of articles on A-BD published between 2011 and 2020 was calculated and articles addressing it as a primary topic (n = 310) were classified into 4 categories and 11 subcategories to identify gaps in the knowledge. RESULTS: The results show no clear increase in the number of annual publications during the period and much of the available literature is of a descriptive nature. Less is known about the processes underlying the comorbidity and about treatment approaches. LIMITATIONS: Given the large scope of the research question, no quality assessment of the evidence was made. Only articles in English or French were considered. CONCLUSIONS: These results highlight the need to change the focus of research efforts to better understand and address this unique set of conditions in clinical settings.

[Influence of Comorbidity in Cognitive-Behavioral Treatment of Anxiety and Mood Disorders]. / Influence de la comorbidité dans le traitement cognitif-comportemental des troubles anxieux et de l'humeur.

Objectives Anxiety and depression are the most prevalent disorders observed in health care services and are frequently comorbid with other disorders. Although Cognitive-Behavioral Therapy (CBT) has widely been shown efficacious to treat anxiety and mood disorders, studies that have focused on its effectiveness in the presence of comorbidity have been few and show conflicting results. Thus, the implications of the presence of comorbid disorders for treatment are still unknown. In an attempt to answer these questions, this study explores the impact of comorbidity on CBT for anxiety and mood disorders in a university-based clinic. Methods A total of 293 clients consulting for anxiety and/or mood disorders at the Service de Consultation de l'École de Psychologie de l'Université Laval (SCEP) between 2007 and 2018 took part in the study. Clients were excluded if they presented uncontrolled psychotic, manic or substance abuse symptoms as their principal complaint. Clients without comorbid disorders where compared to clients who had comorbid disorders on different measures before and after receiving therapy to examine if comorbidity had an impact on CBT effectiveness to treat the principal disorder. The impact of treatment on comorbid disorders was also investigated. Effectiveness was assessed on several measures before and after treatment including the severity of diagnoses (measured with a structured interview), anxiety and mood symptoms as well as quality of life. Repeated measures ANOVAs and t-tests were used. Results Before initiating therapy, clients with comorbid disorders had significantly more severe symptoms than clients without comorbid disorders. However, following therapy, both groups had significantly less severe principal disorders and reached a clinically significant change in equivalent proportions. Furthermore, the number and severity of comorbid disorders significantly decreased following therapy. Conclusion These findings suggest that although the presence of comorbid disorders leads to more severe symptoms, it does not affect the effectiveness of CBT for the principal disorder. Furthermore, comorbid disorders improved even though they were not specifically targeted by treatment. In concordance with the literature, it is thus suggested to keep focusing treatment on the principal disorder, whether comorbid disorders are present or not.

Virtually-delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans with PTSD: A study protocol for a nation-wide effectiveness and implementation evaluation.

BACKGROUND: Post-traumatic stress disorder (PTSD) remains a significant treatment challenge among Canadian veterans. Currently accessible pharmacological and non-pharmacological interventions for PTSD often do not lead to resolution of PTSD as a categorical diagnosis and have significant non-response rates. Sudarshan Kriya Yoga (SKY), a complementary and integrative health (CIH) intervention, can improve symptoms of PTSD. In response to the COVID-19 pandemic, this intervention has pivoted to virtual delivery and may be reaching new sets of participants who face multiple barriers to care. OBJECTIVE: To evaluate the implementation and effectiveness of virtually delivered Sudarshan Kriya Yoga (SKY) on decreasing PTSD symptom severity, symptoms of depression, anxiety, and pain, and improving quality of life in Canadian veterans affected by PTSD. METHODS AND ANALYSIS: Using a mixed-methods approach guided by the RE-AIM framework, we will conduct a hybrid type II effectiveness and implementation study of virtually delivered Sudarshan Kriya Yoga (SKY) for Canadian veterans. Effectiveness will be evaluated by comparing virtually delivered SKY to a waitlist control in a single-blinded (investigator and data analyst) randomized controlled trial (RCT). Change in PTSD symptoms (PCL-5) is the primary outcome and quality of life (SF-36), symptoms of depression (PHQ-9), anxiety (GAD-7), and pain (BPI) are secondary outcomes. The SKY intervention will be conducted over a 6-week period with assessments at baseline, 6-weeks, 12-weeks, and 30 weeks. The reach, effectiveness, adoption, implementation, and maintenance of the intervention will be evaluated through one-on-one semi-structured interviews with RCT participants, SKY instructors, health professionals, and administrators that work with veterans. DISCUSSION: This is the first investigation of the virtual delivery of SKY for PTSD in veterans and aims to determine if the intervention is effective and implementable at scale.

French adaptation and validation of the Panic Disorder Severity Scale-self-report.

BACKGROUND: The aims of this study were to conduct a cross-cultural validation of the Panic Disorder Severity Scale - Self-Report (PDSS-SR) and to examine psychometric properties of the French-Canadian version. METHODS: A sample of 256 adults were included in the validation study based on data from the baseline interview of a clinical trial on transdiagnostic cognitive-behavioral therapy for mixed anxiety disorders. Participants completed the Anxiety and Related Disorders Interview Schedule (ADIS-5), and self-report instruments including the PDSS-SR, Beck Anxiety Inventory (BAI), Mobility Inventory for Agoraphobia (MIA), Sheehan Disability Scale (SDS), Patient Health Questionnaire (PHQ-9), Social Phobia Inventory (SPIN), Insomnia Severity Index (ISI) and Penn State Worry Questionnaire (PSWQ). The cross-cultural adaptation in French of the PDSS-SR included a rigorous back-translation process, with an expert committee review. Sensitivity to change was also examined with a subgroup of patients (n = 72) enrolled in the trial. RESULTS: The French version of the PDSS-SR demonstrated good psychometric properties. The exploratory factor analysis supported a one factor structure with an eigenvalue > 1 that explained 64.9% of the total variability. The confirmatory factor analysis (CFA) corroborated a one-factor model with a good model fit. Internal consistency analysis showed a .91 Cronbach's alpha. The convergent validity was adequate with the ADIS-5 clinical severity ratings for panic disorder (r = .56) and agoraphobia (r = .39), as well as for self-report instruments [BAI (r = .63), MIA (accompanied: r = .50; alone: r = .47) and SDS (r = .37)]. With respect to discriminant validity, lower correlations were found with the SPIN (r = .17), PSWQ (r = .11), ISI (r = .19) and PHQ-9 (r = .28). The optimal threshold for probable diagnosis was 9 for the PDSS-SR and 4 for the very brief 2-item version. The French version showed good sensitivity to change. CONCLUSIONS: The French version of the PDSS-SR has psychometric properties consistent with the original version and constitutes a valid brief scale to assess the severity of panic disorder and change in severity over time, both in research and clinical practice.

Evaluating the quality, safety, and functionality of commonly used smartphone apps for bipolar disorder mood and sleep self-management.

BACKGROUND: Individuals with bipolar disorder (BD) are increasingly turning to smartphone applications (apps) for health information and self-management support. While reviews have raised concerns regarding the effectiveness and safety of publicly available apps for BD, apps surveyed may not reflect what individuals with BD are using. The present study had two aims: first, to characterize the use of health apps to support mood and sleep amongst people with BD, and second, to evaluate the quality, safety and functionality of the most commonly used self-management apps. METHODS: A web-based survey was conducted to explore which apps people with BD reported using to support self-management of mood and sleep. The characteristics of the most commonly nominated apps were described using a standardized framework, including their privacy policy, clinical foundations, and functionality. RESULTS: Respondents (n = 919) were 77.9% female with a mean age of 36.9 years. 41.6% of participants (n = 382) reported using a self-management app to support mood or sleep. 110 unique apps were nominated in relation to mood, and 104 unique apps nominated in relation to sleep; however, most apps were only mentioned once. The nine most frequently nominated apps related to mood and sleep were subject to further evaluation. All reviewed apps offered a privacy policy, however user control over data was limited and the complexity of privacy policies was high. Only one app was developed for BD populations. Half of reviewed apps had published peer-reviewed evidence to support their claims of efficacy, but little research was specific to BD. CONCLUSION: Findings illustrate the potential of smartphone apps to increase the reach of psychosocial interventions amongst people with BD. Apps were largely created by commercial developers and designed for the general population, highlighting a gap in the development and dissemination of evidence-informed apps for BD. There may be risks in using generic health apps for BD self-management; clinicians should enquire about patients' app use to foster conversations about their particular benefits and limitations.

Which, who and when? Therapeutic processes in group cognitive behaviour therapy for anxiety disorders.

The evidence for the effect of therapeutic alliance in group cognitive behaviour therapy (CBT) for anxiety disorders is unclear. Identifying whether the alliance-outcome relationship depends on (1) which components are assessed, (2) who is measuring the alliance and (3) when the alliance is measured will help to clarify the role of the client-therapist relationship in therapy. The present study explored the effects of alliance component (agreement vs. bond), rater perspective (client vs. therapist) and timing (early vs. late therapy) on the alliance-outcome relationship. Individuals with an anxiety disorder enrolled into transdiagnostic group CBT were studied, with n = 78 at early therapy and n = 57 at late therapy. Results showed that greater client-rated agreement significantly predicted improved post-treatment outcomes throughout the course of therapy, while stronger client-rated bond in late therapy predicted reduced treatment gains. In contrast, therapist perceptions of agreement and bond were not associated with post-treatment outcomes at any point in therapy. Client-reported group cohesion also was not associated with additional variance in outcome after accounting for client-rated alliance. Overall, the findings highlight the importance of prioritizing the client's perception of the client-therapist relationship in CBT for anxiety disorders, as well as distinguishing the effects of component, rater and timing in future process-outcome studies.

A pragmatic randomized controlled trial of a group self-management support program versus treatment-as-usual for anxiety disorders: study protocol.

BACKGROUND: The integration of a personal recovery-oriented practice in mental health services is an emerging principle in policy planning. Self-management support (SMS) is an intervention promoting recovery that aims at educating patients on the nature of their mental disorder, improving their strategies to manage their day-to-day symptoms, fostering self-efficacy and empowerment, preventing relapse, and promoting well-being. While SMS is well established for chronic physical conditions, there is a lack of evidence to support the implementation of structured SMS programs for common mental disorders, and particularly for anxiety disorders. This study aims to examine the effectiveness of a group-based self-management support program for anxiety disorders as an add-on to treatment-as-usual in community-based care settings. METHODS/DESIGN: We will conduct a multicentre pragmatic randomized controlled trial with a pre-treatment, post-treatment (4-month post-randomization), and follow-ups at 8, 12 and 24-months. TREATMENT AND CONTROL GROUPS: a) group self-management support (10 weekly 2.5-h group web-based sessions with 10-15 patients with two trained facilitators); b) treatment-as-usual. Participants will include adults meeting DSM-5 criteria for Panic Disorder, Agoraphobia, Social Anxiety Disorder, and/or Generalized Anxiety Disorder. The primary outcome measure will be the Beck Anxiety Inventory; secondary outcome measures will comprise self-reported instruments for anxiety and depressive symptoms, recovery, self-management, quality of life, and service utilisation. STATISTICAL ANALYSIS: Data will be analysed based on intention-to-treat with a mixed effects regression model accounting for between and within-subject variations in the effects of the intervention. DISCUSSION: This study will contribute to the limited knowledge base regarding the effectiveness of structured group self-management support for anxiety disorders. It is expected that changes in patients' self-management behaviour will lead to better anxiety management and, consequently, to improved patient outcomes. TRIAL REGISTRATION: ClinicalTrials.gov: NCT05124639 . Prospectively registered 18 November 2021.

Impact of group transdiagnostic cognitive-behavior therapy for anxiety disorders on comorbid diagnoses: Results from a pragmatic randomized clinical trial in primary care.

BACKGROUND: Anxiety and depressive disorders are the most common mental illnesses worldwide, with most individuals meeting criteria for more than one diagnosis. Most cognitive-behavioral therapy (CBT) approaches target only one disorder at a time, resulting in the need to treat comorbid diagnoses sequentially. Transdiagnostic CBT protocols have been developed that simultaneously treat principal and comorbid disorders. METHOD: The current study reports on a secondary analysis of data from a pragmatic effectiveness randomized trial of group tCBT in comparison to treatment-as-usual (TAU) in primary care. Of the trial sample of 231 patients, 191 had at least one comorbid diagnosis of clinical severity at T0. RESULTS: Overall rates of comorbidity decreased over time (82.0% at T0, 45.0% at T1, 45.7% at T3) and those receiving tCBT showed a significantly lower rate of comorbidity at T1 (33.7%) than TAU (55.7%) and at T3 (tCBT: 27.9%, TAU: 60.2%). Comorbid diagnosis severity ratings reduced to a significantly greater extent in tCBT than in TAU. CONCLUSIONS: tCBT is effective in promoting remission of and reducing the severity of comorbid diagnoses. Implications for the treatment of whole persons as opposed to specific diagnoses is discussed.

The Quality of Life in Bipolar Disorder (QoL.BD) Scale: Validation of a French Cross-Cultural Adaptation.

OBJECTIVE: The goal of this study was to validate the French version of the Quality of Life in Bipolar Disorder (QoL.BD) scale, a condition-specific measure for bipolar disorder (BD). METHOD: The QoL.BD scale was translated into French in accordance with the recommendations for transcultural adaptation. It was administered to 125 participants with BD living in Quebec, Canada. Construct validity was evaluated through correlations with other measures of self-reported quality of life (QoL), functioning, and symptoms. Factorial structure was examined through an exploratory factor analysis. RESULTS: Internal reliability and test-retest reliability standards were met. Correlations in expected directions with other QoL, functioning, and depressive symptom scales supported convergent validity. The item loadings structure of the French QoL.BD largely replicated the original English version, with some modifications. CONCLUSION: The French version of the QoL.BD (full and brief) is comparable in its psychometric properties to the English version. It is a valid and sound measure for the evaluation of the QoL of French-speaking patients with BD.

[Effectiveness of Behavioral Activation for the Treatment of Severe Depression in Clinical Settings]. / Évaluation des effets de l'activation comportementale de groupe pour le traitement de la dépression sévère en milieu clinique.

Objectives Among interventions that have been shown to be efficacious in the treatment of depression, behavioural activation (AC) is receiving increasing attention as the evidence supporting its effectiveness continues to accumulate. Although the efficacy of AC for the treatment of depression has been established through numerous randomized controlled trials, studies evaluating the effectiveness of AC when implemented in mental health settings are rare and there is insufficient supportive data. This step is, however, essential to the validity and the generalization of the treatment to the reality of clinical settings. This study focuses on AC applied to take into account the reality of clinical settings and patients seeking treatment. It evaluates the effectiveness of group-based AC for the treatment of severe depression in a clinical setting in a heterogeneous population in terms of diagnosis (unipolar and bipolar depression) and comorbidity (Axis I and II). Methods A sample of 45 participants with severe depression was recruited in a psychiatric hospital. Participants received a 10 sessions group intervention of AC. Questionnaires were administered to obtain pretreatment, post-treatment and four-week post-treatment data. The impact of the intervention was observed on measures of depression, behavioural activation, reinforcement, anxiety, social adjustment and quality of life. Various moderation effects associated with the heterogeneity of the sample were tested on the evolution of depressive symptoms. The integrity of the treatment administered by the therapists and the acceptability of the intervention by participants were also documented. Results Mixed model analyses of variance were performed to assess whether (a) AC caused a significant change at the end of treatment on depressive symptoms, behavioural activation, reinforcement, anxiety, social adjustment and quality of life and whether (b) gains were maintained after four weeks. A significant change was obtained between the pre-post measures on the average score of all these variables, with the exception of a subscale of the quality of life measure. Analyses were also performed to verify various moderating effects on the evolution of depressive symptoms, level of activation and reinforcement. No interaction effects are observed on depression, activation and reinforcement measures. There is no significant difference according to pretreatment severity category, diagnosis (unipolar vs bipolar), presence of comorbidity (other Axis I and/or Axis II disorder) or co-morbidity of Axis II disorder. As for the activation measure in people with bipolar depression versus unipolar depression, it should be noted that the result is at the threshold of statistical significance. Conclusion The results support the effectiveness of group-based AC for the treatment of severe depression in clinical settings in a heterogeneous population, as well as for the maintenance of gains after four weeks. The effectiveness of AC was also observed across all associated psychosocial measures.

[Qualitative Evaluation of the Implementation of Group Psychoeducation for Bipolar Disorder in Clinical Settings in Quebec]. / Évaluation qualitative de l'implantation de groupes psychoéducatifs pour le trouble bipolaire à Québec.

Objectives Bipolar disorder is a chronic condition which significantly impacts the functioning and quality of life of patients with the disorder. Recognized efficacious psychological interventions, such as group psychoeducation, can help better address some of the limitations observed when pharmacotherapy is used alone in the management of bipolar disorder. However, access to these evidence-based interventions seems to be limited for most patients. Indeed, the translation of knowledge acquired through research towards actual clinical settings poses a significant challenge. Assessing the implementation of these efficacious interventions in clinical practice is thus a priority. The objective of this study is to describe the implementation of a psychoeducative intervention, the Life Goals Program (LGP), for the treatment of bipolar disorder in community mental health settings in Quebec City. Methods The LGP was implemented in three different clinical settings located in Quebec City. Fifteen healthcare service providers chosen by their respective clinical site were trained to deliver the intervention. They delivered the treatment to 73 patients with a diagnosis of bipolar disorder. Healthcare service providers filled a log book after each group session, in order to assess whether they had properly delivered the content of the program. At the end of the study, they also participated in a group interview in order to get a better understanding of their experience delivering the intervention and their appreciation of the research process. Results Following qualitative content analysis, four main categories of factors that could influence the implementation of the intervention were identified: 1) healthcare service providers' characteristics (academic training, clinical experience, personality, knowledge of the program, and dynamic between animators); 2) participants' characteristics; 3) organizational context (physical and material environment, staff stability, administrative management and research requirements); and 4) facilitation (perception of research, research team support, and facilitation tools). These categories derived from data analysis coincide with those observed in the literature. The following factors seemed to have had the most impact in the differences observed between sites in the implementation of the LGP: the support offered by the research team; staff stability; and the academic training of healthcare services providers. Conclusion Dissemination and implantation studies can not only help determine factors that are important to consider when implementing a program, but can also help improve and adapt these programs in order to increase acceptability and effectiveness in real world clinical settings.

Group transdiagnostic cognitive-behavior therapy for anxiety disorders: a pragmatic randomized clinical trial.

BACKGROUND: Transdiagnostic group cognitive-behavioral therapy (tCBT) is a delivery model that could help overcome barriers to large-scale implementation of evidence-based psychotherapy for anxiety disorders. The aim of this study was to assess the effectiveness of combining group tCBT with treatment-as-usual (TAU), compared to TAU, for the treatment of anxiety disorders in community-based mental health care. METHODS: In a multicenter single-blind, two-arm pragmatic superiority randomized trial, we recruited participants aged 18-65 who met DSM-5 criteria for principal diagnoses of generalized anxiety disorder, social anxiety disorder, panic disorder, or agoraphobia. Group tCBT consisted of 12 weekly 2 h sessions. There were no restrictions for TAU. The primary outcome measures were the Beck Anxiety Inventory (BAI) and clinician severity rating from the Anxiety and Related Disorders Interview Schedule for DSM-5 (ADIS-5) for the principal anxiety disorder at post-treatment, with intention-to-treat analysis. RESULTS: A total of 231 participants were randomized to either tCBT + TAU (117) or TAU (114), with outcome data available for, respectively, 95 and 106. Results of the mixed-effects regression models showed superior improvement at post-treatment for participants in tCBT + TAU, compared to TAU, for BAI [p < 0.001; unadjusted post-treatment mean (s.d.): 13.20 (9.13) v. 20.85 (10.96), Cohen's d = 0.76] and ADIS-5 [p < 0.001; 3.27 (2.19) v. 4.93 (2.00), Cohen's d = 0.79]. CONCLUSIONS: Our findings suggest that the addition of group tCBT into usual care can reduce symptom severity in patients with anxiety disorders, and support tCBT dissemination in routine community-based care.

Secondary outcomes of the guided self-help behavioral activation and physical activity for depression trial.

Background: This article presents secondary outcome variables from a randomized controlled trial evaluating the efficacy of two guided self-help interventions for the treatment of depression: behavioral activation (BA) and physical activity (PA). Both interventions resulted in significant reductions in depressive symptoms compared to the wait-list control group, however the mechanisms by which these interventions influenced depression were not presented. Purpose: The purpose of this paper was to compare changes in secondary outcome variables to gain insight into the mechanisms by which reactivation interventions reduce depressive symptoms. Results: Mixed-model analysis of variances (ANOVAs) revealed significant increases in life satisfaction (Main effect: F(3, 91.71) = 4.63, p < 0.01) and self-efficacy (Main effect: F(3, 91.32) = 4.05, p < 0.01) as well as significant decreases in negative affect (Main effect: F(2, 75.88) = 5.24, p < 0.01) and loneliness (Main effect: F(2, 71.78) = 7.49, p < 0.01) in both interventions at pre-, mid-, post-intervention and follow-up. The group x time interactions were not significant, suggesting that the PA and BA interventions had comparable effects over time. Conclusion: These findings provide insight into the potential mechanisms underlying the effectiveness of guided self-help PA and BA interventions on depressive symptoms.

Getting better my way: Feasibility study of a self-management support tool for people with mood and anxiety disorders.

OBJECTIVE: Self-management support is recognized as an important component of the management of mood and anxiety disorders. The goal of this feasibility study was to evaluate the acceptability, implementation and perceived usefulness of a new comprehensive self-management tool (Getting better my way) in four care settings in Quebec, Canada. METHOD: Care providers offered the tool to people with difficulties related to mood or anxiety disorders during a 7-month period. A sample of 71 participants filled out an online survey and 27 accepted to participate in a follow-up interview. Focus groups were conducted with 82 care providers. RESULTS: Satisfaction ratings were high for the tool overall, the likelihood of recommending it to friends, its attractiveness and interest, and its completion time. Perceived usefulness was high overall and was not related to most demographic and clinical variables. No adverse effects were reported. CONCLUSION AND IMPLICATIONS FOR PRACTICE: The study highlights that Getting better my way is a comprehensive recovery-oriented tool, considered useful, acceptable and feasible to use in a variety of settings offering services for mood and anxiety disorders. (PsycINFO Database Record (c) 2019 APA, all rights reserved).