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Multimorbidity, Depression, and Mortality in Primary Care: Randomized Clinical Trial of an Evidence-Based Depression Care Management Program on Mortality Risk
BackgroundTwo-thirds of older adults have two or more medical conditions that often take precedence over depression in primary care.ObjectiveWe evaluated whether evidence-based depression care management would improve the long-term mortality risk among older adults with increasing levels of medical comorbidity.DesignLongitudinal analyses of the practice-randomized Prevention of Suicide in Primary Care Elderly: Collaborative Trial (PROSPECT). Twenty primary care practices randomized to intervention or usual care.PatientsThe sample included 1204 older primary care patients completing the Charlson Comorbidity Index (CCI) and other interview questions at baseline.InterventionFor 2 years, a depression care manager worked with primary care physicians to provide algorithm-based care for depression, offering psychotherapy, increasing the antidepressant dose if indicated, and monitoring symptoms, medication adverse effects, and treatment adherence.Main MeasuresDepression status based on clinical interview, CCI to evaluate medical comorbidity, and vital status at 8 years (National Death Index).Key ResultsIn the usual care condition, patients with the highest levels of medical comorbidity and depression were at increased risk of mortality over the course of the follow-up compared to depressed patients with minimal medical comorbidity [hazard ratio 3.02 (95 % CI, 1.32 to 8.72)]. In contrast, in intervention practices, patients with the highest level of medical comorbidity and depression compared to depressed patients with minimal medical comorbidity were not at significantly increased risk [hazard ratio 1.73 (95 % CI, 0.86 to 3.96)]. Nondepressed patients in intervention and usual care practices had similar mortality risk.ConclusionsDepression management mitigated the combined effect of multimorbidity and depression on mortality. Depression management should be integral to optimal patient care, not a secondary focus.
Journal Article
Music therapy : research and evidence-based practice.
Get a quick, expert overview of the clinical and evidence-based use of music interventions in health care. This practical resource compiled by Dr. Olivia Swedberg Yinger provides a concise, useful overview of the profession of music therapy, including a description of each of the research-support practices that occur in the settings where music therapists most commonly work.
Book
Preschool Deployment of Evidence-Based Social Communication Intervention: JASPER in the Classroom
Few research-developed early intervention models have been deployed to and tested in real world preschool programs. In this study, teaching staff implemented a social communication modularized intervention, JASPER, in their daily program. Sixty-six preschool children with autism in twelve classrooms (12 teachers) were randomized to receive immediate JASPER training (IT) or were waitlisted (WL) for 3 months with a 1-month follow up. Measures of core deficits (initiations of joint engagement, joint attention gestures and language, play skills) and standardized cognitive measures were improved for IT over WL children. IT teachers achieved and maintained high fidelity. Teachers can implement evidence-based interventions with significant improvements in core deficits of their children with ASD.
Journal Article
Duration of antibiotic therapy in critically ill patients: a randomized controlled trial of a clinical and C-reactive protein-based protocol versus an evidence-based best practice strategy without biomarkers
Background
The rational use of antibiotics is one of the main strategies to limit the development of bacterial resistance. We therefore sought to evaluate the effectiveness of a C-reactive protein-based protocol in reducing antibiotic treatment time in critically ill patients.
Methods
A randomized, open-label, controlled clinical trial conducted in two intensive care units of a university hospital in Brazil. Critically ill infected adult patients were randomly allocated to (i) intervention to receive antibiotics guided by daily monitoring of CRP levels and (ii) control to receive antibiotics according to the best practices for rational use of antibiotics.
Results
One hundred thirty patients were included in the CRP (
n
= 64) and control (
n
= 66) groups. In the intention-to-treat analysis, the median duration of antibiotic therapy for the index infectious episode was 7.0 (5.0–8.8) days in the CRP and 7.0 (7.0–11.3) days in the control (
p
= 0.011) groups. A significant difference in the treatment time between the two groups was identified in the curve of cumulative suspension of antibiotics, with less exposure in the CRP group only for the index infection episode (
p
= 0.007). In the per protocol analysis, involving 59 patients in each group, the median duration of antibiotic treatment was 6.0 (5.0–8.0) days for the CRP and 7.0 (7.0–10.0) days for the control (
p
= 0.011) groups. There was no between-group difference regarding the total days of antibiotic exposure and antibiotic-free days.
Conclusions
Daily monitoring of CRP levels may allow early interruption of antibiotic therapy in a higher proportion of patients, without an effect on total antibiotic consumption. The clinical and microbiological relevance of this finding remains to be demonstrated.
Trial registry
ClinicalTrials.gov Identifier:
NCT02987790
. Registered 09 December 2016.
Journal Article
A secondary exploratory study of associations between patient- and clinician-reported clinical outcomes and fidelity for four evidence-based psychosis treatments
Background
Implementation of evidence-based practices (EBPs), measured as fidelity to the EBP model, is generally expected to yield significant positive clinical outcomes. However, this association has only partially been established for EBPs used in psychosis treatment. From a cluster-randomized controlled trial (CRCT), we previously reported on the effects of implementation support for four EBPs for psychosis, using fidelity as the measure of implementation success. The current secondary, exploratory study used data from the non-blinded CRCT parent study to investigate the associations between patient- and clinician-reported outcomes and fidelity for these four EBPs.
Methods
Clinical outcomes were measured in a cohort of 325 patients over three six-month periods. Primary outcomes were BASIS-24 (patient-reported) and HoNOS (clinician-reported). Secondary outcomes were selected subscales of these two measures. The EBPs were Physical Health Care, Antipsychotic Medication Management, Family Psychoeducation, and Illness Management and Recovery. In the CRCT, each of 39 clinical units across six health trusts selected two EBPs for implementation. Units were randomized to the intervention group (implementation support) for one EBP and the control group (written manual) for the other. Fidelity of the four EBPs was measured at baseline and every six months for 18 months. We analyzed the associations between outcomes and fidelity using linear mixed models.
Results
BASIS-24 and HoNOS showed improvements for the total sample at 6 and 12 months, and two patient-reported subscales, Symptoms and Relationships, showed improvement at 6 months within two different EBP subsamples. However, no positive associations were found between secondary outcomes and EBP fidelity.
Conclusions
Despite some improvements in primary and secondary outcomes over the first 6 to 12 months, we found no positive associations between outcomes and fidelity. Sample size, attrition, trial design, variance in variables, measurement properties, and low exposure, as well as interaction between such factors, might have contributed to our failure to find positive associations between outcomes and fidelity. Future studies of the association between outcomes and fidelity should involve large samples, use outcome and exposure measures closely related to the EBPs, and track cohorts from the beginning of treatment.
Trial registrations
ClinicalTrials NCT03271242, retrospectively registered 31 August 2017.
Journal Article
Therapists’ Adaptations to an Intervention to Reduce Challenging Behaviors in Children with Autism Spectrum Disorder in Publicly Funded Mental Health Services
Publicly funded mental health services play an important role in serving children with autism spectrum disorder (ASD). Previous research indicates a high likelihood of adaptations when therapists deliver evidence based practices to non-ASD populations, though less is known about therapists’ use of adaptations for children with ASD receiving mental health services. The current study uses a mixed quantitative and qualitative approach to characterize the types and reasons therapists adapted a clinical intervention [An Individualized Mental Health Intervention for Children with ASD (AIM HI)] for delivery with clinically complex children with ASD served in publicly funded mental health settings and identify therapist characteristics that predict use of adaptations. The most common adaptations were characterized as
augmenting
AIM HI and were done to individualize the intervention to fit with therapeutic style, increase caregiver participation, and address clients’ and caregivers’ needs and functioning. No therapist characteristics emerged as significant predictors of adaptations. Results suggest that therapists’ adaptations were largely consistent with the AIM HI protocol while individualizing the model to address the complex needs of youth with ASD.
Journal Article