Prevalence and Predictors of Long COVID in Patients Accessing a National Digital Mental Health Service.

MindSpot is a national mental health service that provides assessments and treatment to Australian adults online or via telephone. Since the start of 2020, questions related to the mental health impacts of COVID-19 have been routinely administered. The objective of the current study is to report the prevalence and predictors of self-reported "long COVID" in patients completing an assessment at the MindSpot Clinic between 5 September 2022 and 7 May 2023 (n = 17,909). Consistent with the World Health Organization definition, we defined long COVID as the occurrence of ongoing physical or mental health symptoms three months after a COVID-19 infection. We conducted a descriptive univariate analysis of patients who reported: no COVID-19 diagnosis (n = 6151); a current or recent (within 3 months) COVID-19 infection (n = 2417); no symptoms three months post-COVID-19 infection (n = 7468); or COVID-related symptoms at least three months post-infection (n = 1873). Multivariate logistic regression was then used to compare patients with and without symptoms three months post-COVID to identify potential predictors for long COVID. The prevalence of long COVID was 10% of the total sample (1873/17909). Patients reporting symptoms associated with long COVID were older, more likely to be female, and more likely to be depressed and report a reduced ability to perform their usual tasks. Sociodemographic factors, including cultural background, education, and employment, were examined. These results provide evidence of the significant prevalence of symptoms of long COVID in people using a national digital mental health service. Reporting outcomes in an Australian context and in specific sub-populations is important for public health planning and for supporting patients.

An open trial of the feasibility of brief internet-delivered acceptance and aommitment therapy (iACT) for chronic anxiety and depression.

Anxiety and depressive disorders are common, often chronic and result in significant disability and distress. The delivery of psychological interventions via the internet is now recognised to be a safe and effective way to treat these disorders. The predominant therapeutic model in clinical trials and in routine care has been cognitive-behavioural therapy (CBT), which helps patients identify and modify unhelpful thoughts and behaviours. However, other models of treatment for anxiety and depression, such as acceptance and commitment therapy (ACT), which uses the examination of both positive and negative experiences in the service of living a personally meaningful and values-based life, have been developed and tested, although most of these interventions are long and require more clinician support to ensure adherence and achieve positive outcomes. The aim of the present study was to examine the feasibility of a new brief, clinician supported transdiagnostic internet-delivered (iACT) program, designed to treat symptoms of both anxiety and depression and improve social function. A single-group open trial was conducted on 24 adults with long-term symptoms of anxiety and depression. The course is comprised of five online modules delivered over 8 weeks either self-guided or with support from a clinician. There was a high course completion rate (70 %) and a high level of satisfaction with the course (94 % satisfied or very satisfied). Significant clinical improvement in our primary outcome measures (within-group Cohen's d) of anxiety (d ≥ 0.62), depression (d ≥ 0.63), disability (d ≥ 0.43) and quality of life (d ≥ -0.57) were observed at posttreatment. Relatively little clinician time was required per participant (M = 30.6 min, SD = 5.7). The findings of the current study support the feasibility and potential of a transdiagnostic iACT treatment for adults experiencing long-term symptoms of anxiety and depression, including those patients who have not derived benefit from other treatments.

The impact of obesity and overweight on response to internet-delivered cognitive behavioural therapy for adults with chronic health conditions.

BACKGROUND: There is growing evidence that internet-delivered cognitive behavioural therapy (iCBT) can improve functioning and reduce psychological distress in people with chronic health conditions. Obesity frequently co-occurs with chronic health conditions, yet its impact on response to psychological interventions in this population is not known. The current study examined associations between BMI and clinical outcomes (depression, anxiety, disability, and satisfaction with life) following a transdiagnostic iCBT program targeting adjustment to chronic illness. METHODS: Participants from a large randomised controlled trial, who provided information on height and weight, were included (N = 234; mean age= 48.32, SD = 13.80; mean BMI = 30.43, SD = 8.30, range 16.18-67.52; 86.8% female). The influence of baseline BMI range on treatment outcomes at post-treatment and 3-month follow-up was examined using generalized estimating equations. We also examined changes in BMI and in participants' perceived impact of weight on their health. RESULTS: Improvement in all outcomes occurred across BMI ranges; additionally, persons with obesity or overweight generally experienced greater symptom reductions than those within a healthy weight range. A greater proportion of participants with obesity achieved clinically significant change on key outcomes (e.g., depression: 32% [95% CI: 25%, 39%]) than participants with a healthy weight (21% [95% CI: 15%, 26%]) or overweight (24% [95% CI: 18%, 29%], p = 0.016). There were no significant changes in BMI from pre-treatment to 3-month follow-up, however there were significant reductions on the self-rated impact of weight on health. CONCLUSIONS: Persons with chronic health conditions and with obesity or overweight benefit at least as much as those with a healthy BMI from iCBT programs targeting psychological adjustment to chronic illness, even without changes in BMI. iCBT programs may be an important component in the self-management of this population, and may address barriers implicated in health behaviour change.

Predictors of functional impairment at assessment and functional improvement after treatment at a national digital mental health service.

Mental disorders are associated with impairment to daily functioning, which affects both the individual and society. Despite this, most research on treatment outcome only report symptom change. Self-reported days out of role (DOR) is a simple measure of functional impairment used in many population studies. The current study sought to report on the degree of functional impairment measured by DOR in a clinical sample at assessment, the factors associated with this impairment, the predictors of functional improvement after treatment and the relationship between symptomatic and functional change. Using a prospective uncontrolled observational cohort study design with a sample of 17,813 patients accessing a digital mental health service (DMHS), we examined self-reported demographic, psychosocial and clinical data. Using a series of univariate regression models and multivariate classification algorithms, we found that baseline DOR was associated with age, employment and relationship status, symptom severity, symptom chronicity and with the presence of several psychosocial difficulties. Baseline DOR was best predicted by older age, disability payments, higher symptom severity and increasing number of endorsed psychosocial difficulties (R2 = 32.7 %). Forty-one per cent of the sample experienced a >50 % or greater reduction in DOR following treatment. Those who were separated, unemployed or on disability payments, or with severe and chronic depression, experienced the greatest reductions in DOR after treatment. Changes in functioning were independent of changes in symptoms, highlighting the importance of functional impairment as a treatment outcome. This study found that many of the patients who access DMHS have significant levels of functional impairment, a large proportion obtain functional improvement after treatment, and improvement in function after treatment was independent of improvement in symptoms.

Impact of alternative terminology for depression on help-seeking intention: A randomized online trial.

OBJECTIVE: People with depression experience barriers to seeking professional help. Different diagnostic terminology can influence people's treatment/management preferences. The aim of this study was to investigate how alternative depression diagnostic labels and recommendations impact help-seeking intentions and psychosocial outcomes. METHODS: Participants (18-70 years) were recruited using an online panel (Australia) to complete a randomized controlled trial. They read a hypothetical scenario where they discussed experiencing depressive symptoms with their GP and were randomized to receive one of four diagnoses ("depression," "burnout," "functional impairment syndrome" [fictitious label], no label [control]), and one of two follow-up recommendations ("clinical psychologist," "mind coach"). PRIMARY OUTCOME: help-seeking intention (5-point scale, higher = greater intention); secondary outcomes: intention to speak to boss, self-stigma, worry, perceived severity, illness perceptions, and personal stigma. RESULTS: A total of 676 participants completed the survey. There was no main effect of diagnostic label on help-seeking intention or stigma outcomes. Intention to speak to a boss was higher with the depression compared to burnout label (MD = 0.40, 95% CI: 0.14-0.66) and perceived severity was higher with the depression label compared to control (MD = 0.48, 95% CI: 0.22-0.74) and all other labels. Those who received the "clinical psychologist" recommendation reported higher help-seeking intention (MD = 0.43, 95% CI: 0.25-0.60) and treatment control (MD = 0.69, 95% CI: 0.29-1.10) compared to the "mind coach" recommendation. CONCLUSION: Findings highlight the success of efforts to promote help-seeking from clinical psychologists for depression. If burnout is considered a separate diagnostic entity to depression, greater awareness around what such a diagnosis means may be needed. Future research should examine how different terminologies surrounding other mental health conditions impact help-seeking and stigma.

Systematic review of the efficacy, effectiveness, and cost-effectiveness of stepped-care interventions for the prevention and treatment of problematic substance use.

BACKGROUND: Stepped-care is a commonly recommended and implemented care model across health care domains, including substance use. Despite their presumed efficient allocation of treatment resources, a current and robust evidence synthesis is needed on the efficacy, effectiveness and cost-effectiveness of stepped-care for substance use. METHODS: This systematic review analyzed articles describing evaluations of stepped-care models that measured the use of acutely psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in participants over 18 years old. The analysis investigated model and participant characteristics associated with treatment outcomes. RESULTS: The study team conducted a search of five databases of literature (PsychINFO, MEDLINE, Embase, Cochrane Library and Scopus) published between January 1, 2010, and November 1, 2020. The search yielded 1051 unique articles, 19 of which were included in the analysis. The studies had considerable variability in sample sizes (n = 18-2310), time to follow-up (4.5 months to 3 years), and retention rates (35.1-100 %). Studies examined outcomes for either alcohol alone (n = 9), alcohol and other drug use (n = 9), or drug use alone (n = 1). Most studies (n = 13;) were rated as good quality. Three (15.8 %) were rated as fair and three (15.8 %) were rated as poor quality. The evidence regarding the efficacy, effectiveness and cost-effectiveness of stepped-care approaches is limited, but four of seven studies found that adaptive-care interventions delivered in the context of other systemic interventions produced greater benefit than control conditions in relation to at least one alcohol-related outcome. We have insufficient evidence to determine whether the modes or intensity of interventions included in the models, or decision rules used to step people up or down to differing levels of care, have an impact on outcome. CONCLUSION: Heterogeneity between studies with regard to model and evaluation design limited the degree to which the analysis could draw robust conclusions. Sample recruitment and statistical power are particular challenges, and the field needs more innovative evaluation designs to assess the efficacy, effectiveness, and cost-effectiveness of stepped-care models.

The timing and magnitude of symptom improvements during an Internet-delivered transdiagnostic treatment program for anxiety and depression.

OBJECTIVE: In face-to-face treatments, mental health symptoms improve rapidly across the first few treatment sessions, and the pace of improvement slows with additional sessions. Some individuals also report clinically meaningful symptom improvements after only two or three treatment sessions. As the rate of symptom change has been given limited attention within digital treatments, the present study investigated the timing and magnitude of symptom change during an 8-week online treatment for anxiety and depression. METHOD: Three adult samples were derived from previous randomized controlled trials: generalized anxiety disorder (n = 165), major depression (n = 149), and mixed anxiety/depression (n = 262). Symptom scores were compared between consecutive weeks of treatment, and we examined the proportion of individuals who achieved a ≥ 25% or ≥ 50% improvement in symptoms each week. RESULTS: Across all three samples, symptoms improved more rapidly during the first half of treatment compared to the second half of treatment. Within the first 4 weeks, over half of the participants had experienced a ≥ 25% improvement in symptoms, and approximately a third of participants had experienced a ≥ 50% improvement in symptoms. This pattern of change was found irrespective of diagnostic status or outcome measure. CONCLUSIONS: A substantial number of people who receive internet-delivered treatments appear to experience rapid, large, and clinically significant symptom improvement early in treatment. These findings add to our theoretical understanding of symptom improvements during psychotherapy, and further research investigating the mechanisms of such change will inform the development of more effective treatments. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Sudden gains in therapist-guided versus self-guided online treatments for anxiety or depression.

OBJECTIVE: Sudden gains are large, rapid, and sustained symptom improvements, and are associated with improved treatment outcomes across a range of mental health problems. Current theories suggest that therapists are required for sudden gains to be sustained, and to result in improved treatment outcomes. We compared the prevalence and consequences of sudden gains in therapist-guided versus self-guided internet-delivered treatments for anxiety and depression. METHOD: Samples from four previous randomized controlled trials were analyzed: generalized anxiety disorder (n = 259), panic disorder (n = 109), social anxiety disorder (n = 175), and major depressive disorder (n = 209). The prevalence, timing, and reversal rates of sudden gains were compared across therapist-guided and self-guided groups. Generalized estimating equations were used to examine the impact of guidance level and sudden gain status on posttreatment outcomes. RESULTS: Sudden gains were similarly prevalent in therapist-guided and self-guided treatments. In all four diagnostic samples, sudden gains most frequently occurred between Weeks 2 and 3 of treatment, and the rate of reversals did not differ based on the presence of guidance. The association between sudden gains and treatment outcome varied by disorder, such that sudden gains were associated with improved outcomes (irrespective of guidance condition) for participants with social anxiety disorder and major depression, but not generalized anxiety disorder or panic disorder. CONCLUSIONS: Sudden gains can occur, and are maintained, during internet-delivered psychotherapy even in the absence of therapist guidance. Furthermore, sudden gains may be associated with different patterns of symptom improvement depending on diagnostic presentation. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

A systematic review of the efficacy, effectiveness and cost-effectiveness of workplace-based interventions for the prevention and treatment of problematic substance use.

Employee alcohol and other drug use can negatively impact the workplace, resulting in absenteeism, reduced productivity, high turnover, and worksite safety issues. As the workplace can influence employee substance use through environmental and cultural factors, it also presents a key opportunity to deliver interventions, particularly to employees who may not otherwise seek help. This is a systematic review of workplace-based interventions for the prevention and treatment of problematic substance use. Five databases were searched for efficacy, effectiveness and/or cost-effectiveness studies and reviews published since 2010 that measured use of psychoactive substances (i.e., alcohol, cannabis, hallucinogens, inhalants, opioids, sedatives, hypnotics, anxiolytics, and stimulants) as a primary or secondary outcome, in employees aged over 18. Thirty-nine articles were identified, 28 describing primary research and 11 reviews, most of which focused solely on alcohol use. Heterogeneity between studies with respect to intervention and evaluation design limited the degree to which findings could be synthesized, however, there is some promising evidence for workplace-based universal health promotion interventions, targeted brief interventions, and universal substance use screening. The few studies that examined implementation in the workplace revealed specific barriers including lack of engagement with e-health interventions, heavy use and reluctance to seek help amongst male employees, and confidentiality concerns. Tailoring interventions to each workplace, and ease of implementation and employee engagement emerged as facilitators. Further high-quality research is needed to examine the effectiveness of workplace substance use testing, Employee Assistance Programs, and strategies targeting the use of substances other than alcohol in the workplace. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=227598, PROSPERO [CRD42021227598].

A meta-analytic review of randomized clinical trials of online treatments for anxiety: Inclusion/exclusion criteria, uptake, adherence, dropout, and clinical outcomes.

Over the last decade there has been rapid growth in the number of clinical trials examining internet-delivered interventions for anxiety. While there have been numerous analyses of treatment efficacy, few studies have examined treatment engagement. The current meta-analysis examined participant eligibility, uptake, adherence, and drop-out in clinical trials of internet-delivered treatments for anxiety. This meta-analysis used random effects models to obtain estimates of participant inclusion, uptake, adherence, drop-out, and within-group treatment effect size. Moderator analyses examined the effects of anxiety disorder type, treatment type, and level of clinician guidance. After screening, 140 trials with 199 treatment arms (N = 11,021) were included. An average of 46% (95% CI 42, 50) of interested people were included in the clinical trials. In the active treatment arms, 98% (95% CI 97, 99) of participants began treatment, 81% (95% CI 78, 85) of the assigned treatments were completed, 21% (95% CI 18, 23) of individuals dropped out at post-treatment based on questionnaire non-completion, and an overall within-group effect size of g = 1.03 (95% CI 0.94, 1.13) was obtained. Several moderators of interest were significant (e.g., clinical guidance, anxiety disorder type), and there was substantial heterogeneity in estimates. In conclusion, a large number of inclusion and exclusion criteria have been used in trials of internet-delivered treatments for anxiety. Once recruited into a trial, however, most people appear to begin, adhere, and complete internet-delivered treatment for anxiety. Further research exploring various eligibility criteria and their impact on engagement and efficacy is warranted.

Return of comprehensive tumour genomic profiling results to advanced cancer patients: a qualitative study.

PURPOSE: The introduction of comprehensive tumour genomic profiling (CGP) into clinical oncology allows the identification of molecular therapeutic targets. However, the potential complexity of genomic results and their implications may cause confusion and distress for patients undergoing CGP. We investigated the experience of advanced cancer patients receiving CGP results in a research setting. METHODS: Semi-structured interviews with 37 advanced cancer patients were conducted within two weeks of patients receiving CGP results. Interviewees were purposively sampled based on CGP result, cancer type, age and gender to ensure diversity. Themes were derived from interview transcripts using a framework analysis approach. RESULTS: We identified six themes: (1) hoping against the odds; (2) managing expectations; (3) understanding is cursory; (4) communication of results is cursory; (5) genomics and incurable cancer; and (6) decisions about treatment. CONCLUSION: Despite enthusiasm regarding CGP about the hope it provides for new treatments, participants experienced challenges in understanding results, and acceptance of identified treatments was not automatic. Support is needed for patients undergoing CGP to understand the implications of testing and cope with non-actionable results.

Antidepressant medication use by patients accessing a national digital mental health service.

BACKGROUND: Digital mental health services (DMHSs) provide psychological treatments via the internet or phone and are increasingly being offered as part of routine care. This study describes antidepressant (AD) medication use and treatment outcomes in a large sample of routine care patients accessing a DMHS. METHODS: Patients completing an assessment with an Australia-wide DMHS (MindSpot Clinic) from 1st January to 31st December 2020 (n = 17,409) were asked about psychotropic medication use. Demographic characteristics and treatment outcomes on the PHQ-9 (depression), GAD-7 (anxiety), and K-10+ (general distress) were compared for patients taking an AD versus no AD. Treatment outcomes were also analyzed for a subgroup of patients reporting recent commencement of AD medication. RESULTS: Almost one quarter of patients (4141/17409; 23.8%) reported taking an AD, mainly selective serotonin reuptake inhibitors (SSRIs). Patients taking ADs had more severe symptoms however effect sizes were large (Cohen's d's > 1.0). Patients recently commencing ADs had the highest baseline symptoms but showed greater symptom improvement at post-treatment and 3-month follow-up. LIMITATIONS: Treatment trajectory was measured weekly using standardized scales that are sensitive to change, however they did not allow formal clinical diagnoses of depression and were subject to the effects of missing data. The observational design did not control for spontaneous recovery or for comorbid conditions that might influence recovery. CONCLUSIONS: Despite these limitations, online treatment provided by a DMHS as part of routine care is acceptable and effective for patients reporting concurrent AD medication use.

Factors associated with treatment uptake, completion, and subsequent symptom improvement in a national digital mental health service.

Digital mental health services (DMHS) have proven effectiveness and play an important role within the broader mental health system by reducing barriers to evidence-based care. However, improved understanding of the factors associated with successful treatment uptake, treatment completion and positive clinical outcomes will facilitate efforts to maximise outcomes. Previous studies have demonstrated that patient age is positively associated, and initial symptom severity negatively associated with treatment uptake and treatment completion rates in both DMHS and other mental health services. The current study sought to extend these findings by examining the effect of other patient characteristics, in particular, self-reported psychosocial difficulties, using data from a large-scale national DMHS. Using a prospective uncontrolled observational cohort study design, we collected self-reported demographic, psychosocial and clinical data from 15,882 patients who accessed the MindSpot Clinic, Australia, between 1 January and 31 December 2019. Using a series of univariate regression models and multivariate classification algorithms we found that older age, higher educational attainment, and being in a relationship were all positively associated with uptake, completion and significant symptom improvement, while higher initial symptom severity was negatively associated with those outcomes. In addition, self-reported psychosocial difficulties had a significant negative impact on uptake, completion, and symptom improvement. Consistent with previous literature, the presence of these characteristics in isolation or in combination have a significant impact on treatment uptake, completion, and symptomatic improvement. Individual and multiple psychosocial difficulties are associated with reduced capacity to participate in treatment and hence an increased treatment burden. Identifying patients with lower capacity to complete treatment, modifications to treatments and the provision of supports to reduce treatment burden may promote greater engagement and completion of treatments offered by digital mental health services.

Examining the psychometric properties of brief screening measures of depression and anxiety in chronic pain: The Patient Health Questionnaire 2-item and Generalized Anxiety Disorder 2-item.

OBJECTIVE: Individuals with chronic pain experience anxiety and depressive symptoms at rates higher than the general population. The Patient Health Questionnaire 2-item (PHQ-2) and Generalized Anxiety Disorder 2-item (GAD-2) are brief screening measures of depression and anxiety, respectively. These brief scales are well-suited for use in routine care due to their brevity and ease of administration, yet their psychometric properties have not been established in heterogeneous chronic pain samples when administered over the Internet. MATERIALS AND METHODS: Using existing data from randomized controlled trials of an established Internet-delivered pain management program (n = 1333), we assessed the reliability, validity, diagnostic accuracy, and responsiveness to treatment change in the PHQ-2 and GAD-2, as well as the long-form counterparts. Exploratory analyses were conducted to obtain cutoff scores using those participants with diagnostic data (n = 62). RESULTS: The PHQ-2 and GAD-2 demonstrated appropriate reliability (eg, Cronbach's α = 0.79-0.84), validity (eg, higher scores in individuals with a diagnosis; p < 0.001), and responsiveness to treatment change (eg, pre- to post-treatment scores, p < 0.001). The psychometric properties of the short forms compared well with the longer forms. Cutoff scores on the short forms were consistent with general population samples, while cutoff scores on the long forms were higher than previously observed using general population samples. All four scales favored specificity over sensitivity. CONCLUSIONS: The PHQ-2 and GAD-2 demonstrated acceptable psychometric properties in the current sample, as did the long forms. Based on our findings, the PHQ-2 and GAD-2 can be used as screening tools with chronic pain samples when administered over the Internet.

Effectively communicating comprehensive tumor genomic profiling results: Mitigating uncertainty for advanced cancer patients.

OBJECTIVE: To understand advanced cancer patients' experience of uncertainty when receiving comprehensive tumor genomic profiling (CTGP) results, and their perceptions of how healthcare provider (HCP) communication impacts uncertainty. METHODS: Thirty-seven semi-structured interviews with advanced cancer patients were conducted within two weeks of patients receiving CTGP results. Transcripts were thematically analyzed, using an inductive approach. RESULTS: We identified three themes that illustrate patient experience of uncertainties when receiving CTGP results: 1. Type and degree of uncertainty fluctuates along with changing illness circumstances and the nature of the CTGP results; 2. HCPs' co-ordination of care and communication shapes uncertainty, with immediate, clearer and simpler information promoting certainty; and 3. Patients felt that communicating results to reduce relatives' uncertainty is important, with patients choosing the time and process for achieving this and desiring HCPs support. CONCLUSION: Oncology patients are confronted with an array of uncertainties. Clear, simple communication from HCPs about results and their implications, and support to manage uncertainty, will be of benefit. PRACTICE IMPLICATIONS: If CTGP is to become routine clinical practice, clear communication will be crucial in reducing uncertainty. Awareness of potential uncertainties experienced by patients when receiving results, will assist HCPs to address uncertainties, reduce uncertainty where possible, and offer targeted support to patients struggling with uncertainty.

Disability and life satisfaction in neurological disorders: The role of depression and perceived cognitive difficulties.

BACKGROUND: This study assessed factors associated with disability and life satisfaction in a large cohort of 2246 Australian adults with neurological disorders who completed an online survey of mental health and wellbeing. It was hypothesised that depressive symptoms and perceived cognitive difficulties would be significantly associated with both outcomes, even after controlling for significant demographic/medical covariates (e.g., age, marital-status, employment, multi-morbidity, medication). Differences in profiles of four neurological subgroups (i.e., multiple sclerosis; n = 738, epilepsy; n = 672, Parkinson's disease; n = 263, and Acquired Bran Injury; n = 278) were explored. METHODS: Multiple hierarchical linear regressions were run using cross-sectional data. RESULTS: Depressive symptoms made a significant and large unique contribution to higher levels of disability (ß = 0.333, p < .001), and poorer life satisfaction (ß = -0.434, p < .001), in the overall sample and across all four neurological subgroups (ß = 0.349 to 0.513, p < .001) Greater perceived cognitive difficulties were associated with disability in the overall sample (ß = 0.318, p < .001) and across all neurological subgroups (ß = 0.231 to 0.354, p < .001), but only life satisfaction in epilepsy (ß = -0.107, p = 006). CONCLUSIONS: The findings underscore the importance of managing psychological/neuropsychiatric comorbidities in neurological disorders.

Assessing patient information and decision-support needs in problematic alcohol use and co-occurring depression to inform shared decision-making interventions.

The authors assessed the informational and decision-support needs of patients, families, and clinicians when deciding on treatment for problematic alcohol use and depression. Patients (n = 56), family members (n = 16), and clinicians (n = 65) with experience deciding on treatment for problematic alcohol use and depression were eligible. Participants completed an online decisional needs assessment survey. Stakeholder groups identified numerous difficult patient-level treatment decisions and elevated decisional conflict. Participants preferred patient-led or shared treatment decision-making (75%-95.4%). Patients (32.6%) reported not being as involved in treatment decision-making as preferred, a higher proportion than reported by clinicians (16.4%; p = .056). More patients (19.6%) than clinicians (3.6%) reported clinician-led treatment decision-making, with little or no patient involvement (p = .022). Stakeholder preferences for future decision-support resources included online information for use outside consultations.

Shared decision-making among people with problematic alcohol/other drug use and co-occurring mental health conditions: A systematic review.

INTRODUCTION AND AIMS: Over half of people presenting to alcohol/other drug (AOD) treatment services also have a mental health condition. Guidelines support numerous viable treatment options, meaning that treatment decisions need to be evidence based and patients' preferences need to be considered. Shared decision-making (SDM) facilitates evidence- and preference-based decisions and is well researched in other health-care areas. Little is known, however, about people's attitudes towards and experience of SDM in co-occurring AOD and mental health conditions. DESIGN AND METHODS: Systematic literature review via key database searches MEDLINE, EMBASE, PsycINFO, Scopus, the Cochrane Central Register of Controlled Trials and Database of Systematic Reviews (January 2000-July 2019). Two independent reviewers assessed study eligibility, extracted data and rated study quality using a validated tool. RESULTS: Of 2393 articles identified, 10 studies were retained for final inclusion. The reviewed studies suggested that SDM is a well-accepted and preferred approach to treatment decision-making. SDM-based interventions are viewed as feasible, acceptable and useful; are associated with improvements in the quality of the decision-making process and the decision made; and have accrued less consistent evidence to support improvements in patient-related outcomes (e.g. symptoms, treatment adherence/engagement). DISCUSSION AND CONCLUSIONS: This is the first rigorous synthesis of the empirical literature on SDM in co-occurring AOD and mental health conditions. SDM remains a nascent area of research in comorbidity treatment. Preliminary evidence supports SDM's acceptability, feasibility and utility in managing mental health and AOD comorbidities. Further research is needed to build the evidence base, especially with regard to the efficacy of SDM at improving patient-related outcomes.

Improving treatment decision-making in bipolar II disorder: a phase II randomised controlled trial of an online patient decision-aid.

BACKGROUND: Many patients with bipolar II disorder (BPII) prefer to be more informed and involved in their treatment decision-making than they currently are. Limited knowledge and involvement in one's treatment is also likely to compromise optimal BPII management. This Phase II RCT aimed to evaluate the acceptability, feasibility, and safety of a world-first patient decision-aid website (e-DA) to improve treatment decision-making regarding options for relapse prevention in BPII. The e-DA's potential efficacy in terms of improving quality of the decision-making process and quality of the decision made was also explored. METHODS: The e-DA was based on International Patient Decision-Aid Standards and developed via an iterative co-design process. Adults with BPII diagnosis (n = 352) were recruited through a specialist outpatient clinical service and the social media of leading mental health organisations. Participants were randomised (1:1) to receive standard information with/without the e-DA (Intervention versus Control). At baseline (T0), post-treatment decision (T1) and at 3 months' post-decision follow-up (T2), participants completed a series of validated and purpose-designed questionnaires. Self-report and analytics data assessed the acceptability (e.g., perceived ease-of-use, usefulness; completed by Intervention participants only), safety (i.e., self-reported bipolar and/or anxiety symptoms), and feasibility of using the e-DA (% accessed). For all participants, questionnaires assessed constructs related to quality of the decision-making process (e.g., decisional conflict) and quality of the decision made (e.g., knowledge of treatment options and outcomes). RESULTS: Intervention participants endorsed the e-DA as acceptable and feasible to use (82.1-94.6% item agreement); most self-reported using the e-DA either selectively (51.8%; relevant sections only) or thoroughly (34%). Exploratory analyses indicated the e-DA's potential efficacy to improve decision-making quality; most between-group standardised mean differences (SMD) were small-to-moderate. The largest potential effects were detected for objective treatment knowledge (- 0.69, 95% CIs - 1.04, - 0.33 at T1; and - 0.57, 95% CIs - 0.99,-0.14 at T2), decisional regret at T2 (0.42, 95% CIs 0.01, 0.84), preparation for decision-making at T1 (- 0.44, 95% CIs - 0.81, - 0.07), and the Decisional Conflict Scale Uncertainty subscale (0.42, 95% CIs 0.08, 0.08) and Total (0.36, 95% CIs 0.30, 0.69) scores, with all SMDs favouring the Intervention over the Control conditions. Regarding safety, e-DA use was not associated with worse bipolar symptoms or anxiety. CONCLUSION: The e-DA appears to be acceptable, feasible, safe and potentially efficacious at improving patients' decision-making about BPII treatment. Findings also support the future adoption of the e-DA into patient care for BPII to foster treatment decisions based on the best available evidence and patient preferences. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12617000840381 (prospectively registered 07/06/2017).

Phase II Randomised Controlled Trial of a patient decision-aid website to improve treatment decision-making for young adults with bipolar II disorder: A feasibility study protocol.

BACKGROUND/AIMS: This paper describes the protocol for a feasibility study for a parallel Phase II randomised control trial (RCT) aiming to evaluate a novel decision-aid website (e-DA) to support young adults with bipolar II disorder (BPII), and their families. MATERIAL AND METHODS: The e-DA was developed according to the International Patient Decision-Aid Standards (IPDAS). Participants will be 40 young adults (18-30 years) referred to a specialist outpatient clinical facility, who have a confirmed clinical diagnosis of BPII. Participants will be randomised (1:1) to receive access to the clinic's online factsheets/website with (Intervention) or without (Control) the e-DA. A series of validated and purpose-designed questionnaires will be administered at baseline (T0), immediately post-decision (T1), and 3 months post-decision (T2). Questionnaires assess key decision-making constructs related to decision-making quality, including: decisional conflict, subjective and objective treatment knowledge, values-based informed choice, concordance between preferred/actual decision-making involvement, preparation for decision-making, and decisional regret. Self-report symptom severity and anxiety will ascertain the safety of e-DA use. The focus of analyses will be to assess effect sizes, in order to guide a future RCT. DISCUSSION: This feasibility study will evaluate a world first, evidence-based online decision-support resource, a DA website, for young adults with BPII and their families who are deciding on treatment options for relapse prevention. Findings will determine the e-DA's feasibility in RCT procedures (i.e., outpatient clinical setting) and provide estimates of effect sizes on outcomes related to improving treatment decision-making and patient outcomes in a sample of potential end-users, compared to usual care. TRIAL REGISTRATION: This trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR) - ACTRN12617000840381.