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Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders.

ABSTRACT: Assessment of treatment response in psychotherapies can be undermined by lack of longitudinal measurement invariance (LMI) in symptom self-report inventories, by measurement error, and/or by wrong model assumptions. To understand and compare these threats to validity of outcome assessment in psychotherapy research, we studied LMI, sum scores, and Davidian Curve Item Response Theory models in a naturalistic guided internet psychotherapy treatment register of 2,218 generalized anxiety disorder (GAD) patients and 3,922 depressive disorder (DD) patients (aged ≥16 years). Symptoms were repeatedly assessed by Generalized Anxiety Disorder Assessment-7 (GAD-7) or Beck Depression Inventory. The symptom self-reports adhered to LMI under equivalence testing, suggesting sum scores are reasonable proxies for disorder status. However, the standard LMI assumption of normally distributed latent factors did not hold and inflated treatment response estimates by 0.2 to 0.3 standard deviation units compared with sum scores. Further methodological research on non-normally distributed latent constructs holds promise in advancing LMI and mental health assessment.

SUBMITTER: Rosenstrom TH

PROVIDER: S-EPMC9999284 | biostudies-literature | 2023 Apr

REPOSITORIES: biostudies-literature

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Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders.

Rosenström Tom H TH Ritola Ville V Saarni Suoma S Joffe Grigori G Stenberg Jan-Henry JH

Assessment 20211214 3

Assessment of treatment response in psychotherapies can be undermined by lack of longitudinal measurement invariance (LMI) in symptom self-report inventories, by measurement error, and/or by wrong model assumptions. To understand and compare these threats to validity of outcome assessment in psychotherapy research, we studied LMI, sum scores, and Davidian Curve Item Response Theory models in a naturalistic guided internet psychotherapy treatment register of 2,218 generalized anxiety disorder (GA ...[more]

PMID: 34905968

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Project description:BackgroundDigital interventions present potential solutions for aftercare and relapse prevention in anxiety and depressive disorders. This systematic review synthesizes evidence on the efficacy of internet- and mobile-based interventions for post-acute care in these conditions.MethodsA systematic search was conducted in electronic databases (MEDLINE, CENTRAL, Scopus, Web of Science, PsycINFO, PsycARTICLES, PsycEXTRA, ProQuest Dissertations and Theses Open, Open Access Theses and Dissertations, and Open Grey) for randomized controlled trials evaluating digital aftercare or relapse prevention interventions for adults with anxiety or depressive disorders. Primary outcomes included symptom severity, relapse rates, recurrence rates, and rehospitalization. Secondary outcomes included general quality of life and adherence to primary treatment. Risk of bias was assessed using the Cochrane tool.ResultsNineteen studies (3,206 participants) met the inclusion criteria. Interventions included cognitive-behavioral therapy, mindfulness-based approaches, and supportive text messaging. Most studies focused on depression, with limited evidence for anxiety disorders. Notably, fourteen studies that reported on depressive symptoms demonstrated significant improvements following digital interventions, with effect sizes ranging from small (Cohen's d = 0.20) to large (Cohen's d = 0.80). Five studies investigated relapse or recurrence rates, yielding mixed results. Adherence rates varied significantly across studies, ranging from 50 to 92.3%, highlighting the variability in participant engagement. Methodological quality was also variable, with allocation concealment and blinding being common limitations.ConclusionInternet- and mobile-based interventions show promise for aftercare and relapse prevention in depression, with limited evidence for anxiety disorders. Future research should focus on optimizing engagement, personalizing interventions, standardizing outcome measures, and conducting larger trials with longer follow-up periods. These findings have important implications for integrating digital tools into existing care pathways to improve long-term outcomes for individuals with anxiety and depressive disorders.Systematic review registrationhttps://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020151336, CRD42020151336.

Project description:ImportanceGeneralized anxiety disorder (GAD) is one of the most common mental disorders in adults. Psychotherapies are among the most recommended treatments for GAD, but which should be considered as first-line treatment needs to be clarified.ObjectiveTo use a network meta-analysis to examine the short- and long-term associations of different psychotherapies with outcomes of effectiveness and acceptability in adults with GAD.Data sourcesMEDLINE, Embase, PsycINFO, and the Cochrane Register of Controlled Trials were searched from database inception to January 1, 2023, to identify randomized clinical trials (RCTs) of psychotherapies for adults with GAD.Study selectionRCTs comparing any type of psychotherapy against another or with a control condition for the treatment of adults (≥18 years, both sexes) with a primary diagnosis of GAD were eligible for inclusion.Data extraction and synthesisThis study followed Cochrane standards for extracting data and assessing data quality and used the PRISMA guideline for reporting. Risk of bias of individual studies was assessed using the second version of the Cochrane risk of bias tool, and the Confidence in Network Meta-Analysis was used to rate the certainty of evidence for meta-analytical results.Main outcomes and measuresEight psychotherapies were compared against one another and with 2 control conditions. Primary outcomes were severity of GAD symptoms and acceptability of the psychotherapies. Random-effects model pairwise and network meta-analyses were conducted. For effectiveness, standardized mean differences (SMDs) were pooled, and for acceptability, relative risks with 95% CIs were calculated.ResultsData from 66 RCTs were included. Effect size estimates on data from 5597 participants (mean [SD], 70.9% [11.9%] women; mean [SD] age, 42.2 [12.5] years) suggested that third-wave cognitive behavior therapies (CBTs) (SMD, -0.78 [95% CI, -1.19 to -0.37]; certainty, moderate), CBT (SMD, -0.68 [95% CI, -1.05 to -0.32]; certainty, moderate), and relaxation therapy (SMD, -0.54 [95% CI, -1.04 to -0.05]; certainty, low) were associated with reduced GAD symptoms vs treatment as usual. Relative risks for all-cause discontinuation (indication of acceptability) signaled no differences compared with treatment as usual for all psychotherapies (eg, relative risk, 1.07 [95% CI, 0.73-1.57] for CBT vs treatment as usual). When excluding studies at high risk of bias, relaxation therapy lost its superiority over treatment as usual (SMD, -0.40; 95% CI, -1.15 to 0.34). When considering anxiety severity at 3 to 12 months after completion of the intervention, only CBT remained significantly associated with greater effectiveness than treatment as usual (SMD, -0.58; 95% CI, -0.93 to -0.23).Conclusions and relevanceGiven the evidence in this systematic review and network meta-analysis for its associations with both acute and long-term effectiveness, CBT may represent the first-line therapy of GAD. Third-wave CBTs and relaxation therapy were associated with short-term effectiveness and may also be offered.

Project description:BackgroundDuring adolescence, depressive and anxiety disorders are among the most common mental health disorders. Both disorders tend to persist, are predictive for other mental disorders, and are associated with severe impairment in diverse areas. Although Cognitive Behavioral Therapy (CBT) has proven to be an effective treatment, a considerable number of adolescents do not respond to CBT and residual symptoms often remain. Therefore, it is of great importance to improve treatment outcomes for depressed and/or anxious adolescents. Dysfunctional emotion regulation appears to be a transdiagnostic factor in the development and maintenance of aforementioned disorders. Enhancing emotion regulation skills may therefore reduce symptom severity. In light of this, we developed a guided internet-based emotion regulation training (E-TRAIN) that will be added to CBT. This study aims to evaluate the effectiveness of E-TRAIN + CBT compared to CBT alone on depressive and anxiety outcomes among adolescents with depressive and/or anxiety disorder.MethodsIn this multicenter two-arm randomized controlled trial with parallel group design, we aim to include 138 adolescents, aged 13-19 years, referred for treatment and diagnosed with depressive and/or anxiety disorder. Participants will be allocated to either CBT or CBT + E-TRAIN. Assessments will take place at baseline, and at 3 (T1), 6 (T2) and 12 (T3) months after baseline. We will conduct multi-informant assessments: the adolescent, a parent/caregiver, and the CBT therapist will be asked to fill in questionnaires. The continuous primary outcome measure is self-reported depressive and anxiety symptoms at six months after baseline, measured with the RCADS25. Secondary outcome measures include anxiety or depression diagnosis based on a semi-structured clinical interview, emotion (dys) regulation, and parent-report measures of anxiety, depression and emotion (dys) regulation.DiscussionThis study is the first randomized controlled trial to examine the additional value of a guided internet-based emotion regulation training to regular CBT in adolescents with depressive and/or anxiety disorders. If this intervention is effective, it can be implemented in mental health care and improve treatment for these young people.Trial registrationRegistered on June 23, 2021 in The Netherlands Trial Register (NL9564). Retrospectively registered. Recruitment started in May 2021 and is ongoing.

Project description:BackgroundDuring the COVID-19 pandemic, internet-delivered psychotherapeutic interventions (IPI) move increasingly into the focus of attention.MethodWe reviewed 39 randomized controlled studies of IPIs with 97 study arms (n = 4122 patients) for anxiety disorders (panic disorder/agoraphobia, generalized anxiety disorder, and social anxiety disorder) and performed a meta-analysis. Most studies were conducted with cognitive behavioural approaches (iCBT). Results were compared with a previous meta-analysis examining medications and face-to-face (F2F) psychotherapy.ResultsIn direct comparisons, IPIs were as effective as F2F-CBT and superior to waitlist controls. Programs with more intensive therapist contact yielded higher effect sizes (ES). We compared the obtained ES with a previous comprehensive meta-analysis of 234 studies. In this comparison, iCBT was less effective than individual F2F-CBT and medications, not different from pill placebos, and more effective than psychological placebo and waitlist (p > .0001 for all comparisons). ES of IPIs may be overestimated. Treatments were only compared to waitlist, which is not a sufficient control condition. 97% of the studies were not blinded with regard to the main outcome measure. 32% of the participants received antianxiety drugs during the trials. In 89%, participants were recruited by advertisements rather than from clinical settings, and 63% of the participants had an academic background (students or university employees) which might affect the generalizability of the findings. Remote diagnoses were often made by students without completed training in psychotherapy. In only 15% of the studies, diagnoses were made in personal contact with a psychiatrist or psychologist. In 44% of the studies, the 'therapists' maintaining remote contact with the participants were mostly students without completed psychotherapy education.ConclusionsIPIs may be a useful tool when face-to-face psychotherapy is not easily available, or as an add-on to standard psychotherapeutic or psychopharmacological treatments but should perhaps not be used as monotherapy. We have suggested standards for future research and the practical use of IPIs.

Dataset Information

Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders.

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Measurement Invariant but Non-Normal Treatment Responses in Guided Internet Psychotherapies for Depressive and Generalized Anxiety Disorders.

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