Early changes, attrition, and dose-response in low intensity psychological interventions

Jaime Delgadillo, Dean McMillan, Michael Lucock, Chris Leach, Shehzad Ali, Simon Gilbody

Research output: Contribution to journalArticle

40 Citations (Scopus)

Abstract

Objectives

To investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome.
Design

Retrospective cohort data analysis.
Method

Clinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change.
Results

The AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1–3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose–response effect appears to decline in treatments longer than six sessions.
Conclusions

Patients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.
Practitioner points

Patients showing early response to low intensity therapy are at least twice as likely to recover at the end of treatment.
Dropout from treatment is associated with poor clinical outcomes.
Optimal recovery rates were observed for treatments with a total length of between four and six sessions; the dose–response declined in lengthier treatments.
Randomization to different treatment lengths is necessary to confirm this dose–response effect with greater certainty.
Original languageEnglish
Pages (from-to)114-130
Number of pages17
JournalBritish Journal of Clinical Psychology
Volume53
Issue number1
DOIs
Publication statusPublished - 30 Sep 2013

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Psychology
Therapeutics
Anxiety Disorders
Area Under Curve
Depression
Cognitive Therapy
Random Allocation
Cohort Studies
Anxiety
Odds Ratio
Outcome Assessment (Health Care)
Education
Health

Cite this

Delgadillo, Jaime ; McMillan, Dean ; Lucock, Michael ; Leach, Chris ; Ali, Shehzad ; Gilbody, Simon. / Early changes, attrition, and dose-response in low intensity psychological interventions. In: British Journal of Clinical Psychology. 2013 ; Vol. 53, No. 1. pp. 114-130.
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abstract = "ObjectivesTo investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome.DesignRetrospective cohort data analysis.MethodClinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change.ResultsThe AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70{\%} of patients with RCSI being accurately identified as early as sessions 1–3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50{\%} RCSI rates, and the dose–response effect appears to decline in treatments longer than six sessions.ConclusionsPatients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.Practitioner pointsPatients showing early response to low intensity therapy are at least twice as likely to recover at the end of treatment.Dropout from treatment is associated with poor clinical outcomes.Optimal recovery rates were observed for treatments with a total length of between four and six sessions; the dose–response declined in lengthier treatments.Randomization to different treatment lengths is necessary to confirm this dose–response effect with greater certainty.",
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Early changes, attrition, and dose-response in low intensity psychological interventions. / Delgadillo, Jaime; McMillan, Dean; Lucock, Michael; Leach, Chris; Ali, Shehzad; Gilbody, Simon.

In: British Journal of Clinical Psychology, Vol. 53, No. 1, 30.09.2013, p. 114-130.

Research output: Contribution to journalArticle

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T1 - Early changes, attrition, and dose-response in low intensity psychological interventions

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AU - McMillan, Dean

AU - Lucock, Michael

AU - Leach, Chris

AU - Ali, Shehzad

AU - Gilbody, Simon

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N2 - ObjectivesTo investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome.DesignRetrospective cohort data analysis.MethodClinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change.ResultsThe AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1–3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose–response effect appears to decline in treatments longer than six sessions.ConclusionsPatients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.Practitioner pointsPatients showing early response to low intensity therapy are at least twice as likely to recover at the end of treatment.Dropout from treatment is associated with poor clinical outcomes.Optimal recovery rates were observed for treatments with a total length of between four and six sessions; the dose–response declined in lengthier treatments.Randomization to different treatment lengths is necessary to confirm this dose–response effect with greater certainty.

AB - ObjectivesTo investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome.DesignRetrospective cohort data analysis.MethodClinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change.ResultsThe AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1–3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose–response effect appears to decline in treatments longer than six sessions.ConclusionsPatients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.Practitioner pointsPatients showing early response to low intensity therapy are at least twice as likely to recover at the end of treatment.Dropout from treatment is associated with poor clinical outcomes.Optimal recovery rates were observed for treatments with a total length of between four and six sessions; the dose–response declined in lengthier treatments.Randomization to different treatment lengths is necessary to confirm this dose–response effect with greater certainty.

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KW - CBT

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JF - British Journal of Clinical Psychology

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