Differences in psychological treatment outcomes by ethnicity and gender: an analysis of individual patient data.

PURPOSE: There are discrepancies in mental health treatment outcomes between ethnic groups, which may differ between genders. NHS Talking Therapies for anxiety and depression provide evidence-based psychological therapies for common mental disorders. This study examines the intersection between ethnicity and gender as factors associated with psychological treatment outcomes. Aims were to explore by gender: (1) differences in psychological treatment outcomes for minoritized ethnic people compared to White-British people, (2) whether differences are observed when controlling for clinical and socio-demographic factors associated with outcomes, and (3) whether organization-level factors moderate differences in outcomes between ethnic groups. METHODS: Patient data from eight NHS Talking Therapies for anxiety and depression services (n = 98,063) was used to explore associations between ethnicity and outcomes, using logistic regression. Stratified subsamples were used to separately explore factors associated with outcomes for males and females. RESULTS: In adjusted analyses, Asian (OR = 0.82 [95% CI 0.78; 0.87], p < .001, 'Other' (OR = 0.79 [95%CI 0.72-0.87], p < .001) and White-other (0.93 [95%CI 0.89-0.97], p < .001) ethnic groups were less likely to reliably recover than White-British people. Asian (OR = 1.48 [95% CI 1.35-1.62], p < .001), Mixed (OR = 1.18 [95% CI 1.05-1.34], p = .008), 'Other' (OR = 1.60 [95% CI 1.38-1.84], p < .001) and White-other (OR = 1.18 [95% CI 1.09-1.28], p < .001) groups were more likely to experience a reliable deterioration in symptoms. Poorer outcomes for these groups were consistent across genders. There was some evidence of interactions between ethnic groups and organization-level factors impacting outcomes, but findings were limited. CONCLUSIONS: Across genders, Asian, 'Other' and White-other groups experienced worse treatment outcomes across several measures in adjusted models. Reducing waiting times or offering more treatment sessions might lead to increased engagement and reduced drop-out for some patient groups.

Improvement in IAPT outcomes over time: are they driven by changes in clinical practice?

Treatment outcomes across Improving Access to Psychological Therapies (IAPT) services in England have improved year-on-year, with the national average proportion of patients in recovery at the end of treatment now exceeding the 50% target. This is despite the number of referrals and numbers of treated patients also increasing year-on-year, suggesting that services have evolved local practices and treatment delivery to meet needs whilst improving performance. This study explores whether there have been changes in clinical practice with regard to: (1) the number of sessions and length of treatments; (2) the number of cancellations and non-attendance; and (3) the recording of problem descriptor information, and the association with treatment outcomes in IAPT. Routinely collected data from seven IAPT services involved in the North and Central East London (NCEL) IAPT Service Improvement and Research Network (SIRN) were brought together to form a dataset of nearly 88,000 patients who completed a course of IAPT treatment. Results showed that there was a slight increase in the average number of sessions, and decreases in the length of time in treatment, as well as decreases in both the number of non-attended appointments and the use of inappropriate problem descriptors. These findings highlight a number of areas where potentially small changes to clinical practice may have had positive effects on patient outcomes. The value of using IAPT data to inform service improvement evaluations is discussed. KEY LEARNING AIMS: (1)How changes to treatment-delivery factors are associated with IAPT patient outcomes.(2)The link between clinical practice and potential service performance.(3)How analysing routinely collected data can be used to inform service improvement.

Validation of the Alcohol Use Disorders Identification Test (AUDIT) in urban community outreach and de-addiction center samples in north India.

OBJECTIVE: The Alcohol Use Disorders Identification Test (AUDIT) developed by the World Health Organization for screening disorders related to alcohol use has been shown to have robust psychometric properties. This study compared the performance of AUDIT with that of the Short Michigan Alcoholism Screening Test (SMAST) in a region of North India. METHOD: A total of 297 consecutive subjects who had used alcohol in the past year were recruited from a de-addiction center (DAC) (n = 97) and a community outreach setting (n = 200) in West Delhi. Using International Classification of Diseases, Tenth Edition (ICD-10) criteria, the relative effectiveness of the AUDIT and the SMAST in identifying alcohol-use-related disorders was assessed and compared. Internal consistency and interscale correlations were evaluated, along with sensitivity, specificity and ROC curve analyses. RESULTS: The AUDIT had very high internal reliability (alpha 0.92) in this Indian sample. There was, in general, good correlation between the total and factor scores of the AUDIT and SMAST (ranging from 0.28 to 0.97), which were higher in the community than in the DAC sample. The AUDIT (area under the curve [AUC] = 0.883) and SMAST (AUC = 0.870) were similar in detecting harmful use of alcohol. The AUDIT optimal cutoff score was 16 (sensitivity 85.3, specificity 89.4) for ICD-10 harmful use and 24 (sensitivity 69.4, specificity 87.5) for ICD-10 alcohol dependence. CONCLUSIONS: The AUDIT and SMAST seem to be comparable in their ability to screen subjects with alcohol use disorders. The AUDIT score for screening harmful use in the sample appears to be higher than previously reported. The utility of such high cutoff for screening subjects for intervention is obvious, but it is quite likely that some positive cases might be missed.

Effect of buprenorphine on psychomotor functions in patients on buprenorphine maintenance.

OBJECTIVE: Patients on buprenorphine maintenance for opioid dependence often abuse its additional doses over and above the maintenance dose. Being a psychoactive agent, it may affect psychomotor performance with all its consequences, for example, effect on quality of life. This study was conducted to assess the effects of its additional doses on psychomotor performance in patients who are maintained on it. DESIGN AND SETTING: This was an interventional study, carried out in an in-patient setting in a tertiary care national drug dependence treatment center. PARTICIPANTS: It included 19 subjects maintained on buprenorphine, 4 mg/d (s/L) for at least a month. INTERVENTION: Maintenance dose was followed by three administrations of buprenorphine, 2 mg, at two hourly intervals (cumulative dose design). MAIN OUTCOME MEASURES: Subjects were assessed on digit symbol substitution test, trail making, digit span, and delayed recall, after each administration and the next morning. RESULTS: Performance of subjects on Digit Symbol Substitution Test (chi2 = 52.98, p < 0.000) and Trail Making Test-A (chi2 = 26.29, p < 0.000) and B (chi2 = 42.08, p < 0.000) improved significantly with each assessment while other tests were unaffected. CONCLUSIONS: Improvement in psychomotor performance (which could be true effect of drug itself or a result of other factors, eg, inadequate maintenance dose or practice effect) though contrasting with some of the earlier findings, does have significant clinical implications regarding the long-term use of buprenorphine. It would be worthwhile repeating this type of study in a placebo controlled design to further verify the results.

Feasibility of Self-Assessment of Acute Mania: Comparison of Self-Rated and Observer-Rated Scales of Mania in Naturalistic Setting.

Mania is one of the commonest psychiatric disorders causing severe social and functional disturbances and thus requiring immediate intervention. Rating scales of mania are limited, especially the self-rating scales. Aim: To study correlation between the self-rated and observer rated scales of mania over 4 weeks period; To study the resolution and persistence of symptoms of mania with respect to clinical characteristics and treatment in the naturalistic ward setting over 4 weeks period. Methods: 40 consecutive hospitalized patients of either sex between 15-55 years with diagnosis of Mania (ICD-10 – Diagnostic criteria for research) were recruited for the study. The subjects were assessed using semistructured Performa covering socio-demographic and clinical characteristics of patient and his/her illness and by using following rating scales: Clinician Administered Rating Scale for Mania (CARS-M) [Altman et al, 1994]; Altman Self-Rating Mania scale (ARSM) [Altman et al 1997]; Hamilton Rating Scale for Depression (HAM-D) [M Hamilton 1960]; Clinical Global Impression Scale (CGI) (modified by Brandit et al, 1996). Results: The scores of the CARSM, ARSM, HAM-D, CGIS-S AND CGIS-1 showed the decreasing trends in the subsequent weekly assessments. This indicated improvement in the illness in the due course of treatment, which is an expected phenomenon. The reliability analysis scale (alpha) among the respective ARSM and CARSM scores showed the value as 0.8846 indicating that each self-rating is significantly reliable enough with the respective objective ratings. There are similar correlation patterns among CGI-S scores vs. the ASRM scores. However the correlation between the scores of CGI-I vs. ARSM in the first week does not seem to correlate significantly (p=.568), but the subsequent scores from 2nd through 4th week do correlate significantly. The HAM-D scores do not seem to correlate with the ARSM scale at any point except on the third week of the symptoms that resolved first were the hallucinations and disorientations. Insomnia and disordered thinking (incoherence/ extreme pressure of speech) disappeared nearly at the end of 2 weeks, followed subsequently by distractibility, excess energy and the delusions. Lack of insight and judgment, and euphoric/irritable mood were among the last to disappear.