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BackgroundFew studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health.ObjectiveTo determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans.DesignPragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC).ParticipantsA total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics.InterventionbCBT was delivered to 180 participants by staff mental health providers (n = 19). bCBT addressed physical and emotional health using a modular, skill-based approach. bCBT was delivered in person or by telephone over 4 months. Participants randomized to EUC (n = 122) received a mental health assessment documented in their medical record.Main MeasuresPrimary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included health-related quality of life. Assessments occurred at baseline, posttreatment (4 months), and 8- and 12-month follow-up.Key ResultsParticipants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4+ sessions). bCBT improved symptoms of depression (p = 0.004; effect size, d = 0.33) and anxiety (p < 0.001; d = 0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12 months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12 months.ConclusionsIntegrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent, and the impact on physical health outcomes was limited to shorter-term effects and COPD participants.Clinical trials.Gov identifier: NCT01149772

Depression symptoms are present in one-third of patients with diabetes, contributing to significant adverse consequences. Population screening of high-risk patients coupled with telephone delivery of evidence-based therapies for comorbid diabetes may address barriers to care. To evaluate the effectiveness of proactive population screening plus telephone delivery of a collaborative goal-setting intervention among high-risk patients with uncontrolled diabetes and depression. In this randomized clinical trial, 225 participants (intervention [n = 136] and control [n = 89]) were enrolled from a regional Veterans Healthcare System serving Southeast Texas from November 1, 2012, through June 24, 2016. Data were gathered at baseline and 6 and 12 months after intervention. Patients selected had uncontrolled diabetes (hemoglobin A1c [HbA1c] >7.5%]) and clinically significant depression (Patient Health Questionnaire-9 scores [PHQ-9] ≥10) and were living more than 20 miles from the Veterans Affairs medical center. Data collection was completed on December 6, 2016, and final analyses were completed by January 25, 2018. All analyses were intent to treat. Healthy Outcomes Through Patient Empowerment (HOPE) included 9 telephone sessions with 24 trained health care professionals using collaborative goal-setting and behavioral activation methods. The control group received enhanced usual care (EUC) and notification of high-risk status. Change in depression symptoms using PHQ-9 and glycemic control using HbA1c from baseline to 6 months and to 12 months. Secondary analyses evaluated clinically significant responses for these measures. Among 225 participants, 202 (89.8%) were men, the mean (SD) age was 61.9 (8.3) years, 145 (64.4%) were married, and 156 (69.3%) had some education beyond high school. For the overall study, 38 participants (16.9%) were lost to follow-up or withdrew at 6 months and another 21 (9.3%) were lost to follow-up or withdrew at 12 months. Repeated-measures analysis with multiple imputation for missing data assessing the interaction of treatment group (HOPE vs EUC) and time (baseline, 6 months, and 12 months) found no significant improvement in PHQ-9 (β, 1.56; 95% CI, -0.68 to 3.81; P = .17) or HbA1c (β, -0.005; 95% CI, -0.73 to 0.72; P = .82). Analyses using t test for change from baseline to 12 months showed a HOPE vs EUC between-group mean difference for PHQ-9 of 2.14 (95% CI, 0.18 to 4.10; P = .03) and for HbA1c of -0.06% (95% CI, -0.61% to 0.50%; P = .83). A secondary analysis of patients experiencing a clinical response found that 52.1% of HOPE participants had clinically significant responses in PHQ-9 at 12 months vs 32.9% in EUC (difference, 0.19; 95% CI, 0.04-0.33; P = .01). Telephone-delivered, collaborative goal setting produced clinically significant reductions in depression symptoms but not glycemic control among patients who remained engaged at 12 months compared with EUC among a population screened sample of high-risk patients with diabetes and depression. Although the intervention created some lasting effect for depression, additional strategies are needed to maintain engagement of this high-risk population within an interprofessional team approach to primary care. ClinicalTrials.gov identifier: NCT01572389.

[...]few practitioners, even those from mental health programs, are adequately trained to conduct focused, evidence-based psychotherapy approaches, and even fewer are able to adapt such training to fit within non-mental health specialty care settings (e.g., primary care). Select Evidence-Based Intervention Material CA-CBT used established intervention materials (Adjusting to Chronic Conditions with Education, Support and Skills [ACCESS] (12) and training methods (13) as the foundation for the development of the Internet-based CBT training program. The project team also felt it important to convey a \"real-world\" training approach. [...]rather than teaching individual CBT techniques, we sought to develop methods that would facilitate the broader practice of CBT as a psychotherapy with an emphasis on the therapeutic relationship and the need to develop a patient-centered approach to care (e.g., collaborative goal-setting and patient empowerment through skill-development).

Traditional late-life anxiety treatments have a poor track record in terms of reaching minorities that face significant disparities in accessing appropriate treatment. Existing literature lacks evidence on treatments that effectively reduce anxiety in African American elders. Calmer Life is a 3-month treatment for anxiety, designed to address barriers to care faced by African American seniors living in underserved neighborhoods. To increase the reach and outcomes of a skills-based cognitive behavioral approach, an intervention, Calmer Life, was developed that includes cultural and individual tailoring in treatment content and delivery. Participants choose from a variety of options that integrate religious/spiritual themes into skills-based coping; receiving treatment in their homes, at community sites or by telephone; choosing the number of sessions they want to complete; and deciding which skills to learn, based on individual needs. Preliminary data from nine participants show reductions in worry, anxiety and depressive symptoms and 100% retention of all participants at post-treatment. Participants reported a high level of satisfaction with the program and its unique aspects.