Alternatives to talking based interventions for anxiety and depression Flashcards
What is the government guidance on anxiety for the UK?
List 3 points
- Step dependent
- Low intensity therapy
- CBT/applied relaxation or drug treatment
- Step dependent
- Low intensity therapy
- CBT/applied relaxation or drug treatment
These are the government guidance on ____ for the UK
a. Bipolar disorder
b. Anxiety
c. Depression
d. Multiple personality disorder
b. Anxiety
State the 4 steps to the UK stepped care model for anxiety
- Identification and assessment; education about GAD and treatment options; active monitoring
- Low-intensity psychological interventions (i.e., self help and psychoeducation)
- High Intensity Intervention OR Drug treatment (SSRI, or SNRI)
- Complex drug/psychological treatment; multiagency teams
List these 4 steps in order of the UK stepped care model for anxiety
Low-intensity psychological interventions (i.e., self help and psychoeducation)
Complex drug/psychological treatment; multiagency teams
Identification and assessment; education about GAD and treatment options; active monitoring
High Intensity Intervention OR Drug treatment (SSRI, or SNRI)
- Identification and assessment; education about GAD and treatment options; active monitoring
- Low-intensity psychological interventions (i.e., self help and psychoeducation)
- High Intensity Intervention OR Drug treatment (SSRI, or SNRI)
- Complex drug/psychological treatment; multiagency teams
How does the UK stepped care model identify and assess anxiety?
List 2 ways
- Education about GAD and treatment options
- Active monitoring
Give 2 examples of low-intensity psychological interventions based on the UK stepped care model for anxiety
- Self help
- Psychoeducation
What is the government guidance on depression for the UK?
List 3 points
- Severity dependent (PHQ-9 score)
- Less severe PHQ<16:CBT, behavioural activation, exercise, anti depressant
- More severe PHQ > 16: CBT, behavioural activation, anti depressant, group exercise
What PHQ-9 score is considered to be associated with severe depression?
PHQ > 16
What PHQ-9 score is considered to be associated with less severe depression?
PHQ < 16
What treatment does the UK government recommend for people with less severe PHQ < 16?
List 4
- CBT
- Behavioural activation
- Exercise
- Anti depressant
What treatment does the UK government recommend for people with more severe PHQ > 16?
List 4
- CBT
- Behavioural activation
- Anti depressant
- Group exercise
What are the top 5 first-line treatments for less severe depression?
- Guided self- help
- Group CBT
- Group behavioural activation
- Individual CBT
- Individual behavioural activation
What are the bottom 6 first-line treatments for less severe depression?
- Group exercise
- Group mindfulness and meditation
- Interpersonal psychotherapy
- SSRI antidepressants
- Counselling
- Short-term psychodynamic psychotherapy
Treatment options for depression are listed in what order?
Order of recommended use, based on the committee’s interpretation of their clinical and cost effectiveness and consideration of implementation factors
What are the top 5 first-line treatments for more severe depression?
- Individual CBT + Anti depressants
- Individual CBT
- Individual behavioural activation
- Antidepressant medication
- Individual problem solving
What are the bottom 5 first-line treatments for more severe depression?
- Counselling
- Short-term psychodynamic psychotherapy
- Interpersonal psychotherapy
- Guided self-help
- Group exercise
What is the government guidance on anxiety for Canada?
List 4 points
Recommended first-line therapy
- Cognitive Behaviour Therapy
- SSRI
- SNRI
- Antidepressant pregabalin
Which countries take a severity approach to mitigating depression?
UK and Canada
What is the government guidance on depression for Canada?
List 5 points
For mild severity depression:
- Psychoeducation
- Self-help
- Psychological therapy (behavioural activation, CBT, interpersonal therapy)
- Exercise
- Pharmacological treatment (SSRI, SNRI)
What is the government guidance on anxiety for the US?
Clinical guidelines for anxiety not published
APA guidelines are provided for PTSD instead
American Psychiatric Association has guidelines for PTSD and panic and OCD
What is the government guidance on depression for the US?
Recommended treatments:
1. CBT, interpersonal psychotherapy (IPT), mindfulness-based cognitive therapy, psychodynamic therapy
- Antidepressant medications
- Combined treatment: CBT or IPT plus ADM
- Exercise (if above not effective)
What is evidence for pharmacotherapy (the use of pharmacological interventions) for anxiety?
Systematic Reviews/Meta-Analyses
Found Pharmacotherapies (SSRI - escitalopram; SNRI -duloxetine, venlaflaxine; Pregabalin) appear to effective at reducing symptoms of anxiety, however the size of the effects are mixed
Systematic Reviews/Meta-Analyses
Found Pharmacotherapies (SSRI - escitalopram; SNRI -duloxetine, venlaflaxine; Pregabalin) appear to effective at reducing symptoms of anxiety, however the size of the effects are mixed
What are the effect sizes reported by Carl et al. (2020)?
g = 0.38
Systematic Reviews/Meta-Analyses
Found Pharmacotherapies (SSRI - escitalopram; SNRI -duloxetine, venlaflaxine; Pregabalin) appear to effective at reducing symptoms of anxiety, however the size of the effects are mixed
What are the effect sizes reported by Leichsenring et al (2022)?
0.01-0.56
Systematic Reviews/Meta-Analyses
Found Pharmacotherapies (SSRI - escitalopram; SNRI -duloxetine, venlaflaxine; Pregabalin) appear to effective at reducing symptoms of anxiety, however the size of the effects are mixed
What was the limitation of the acceptability across active comparisons of these studies, according to Slee et al (2019)?
Acceptability across active comparisons largely involved drugs with acceptability profiles worse than placebo
Simply = Even though pharmacotherapies seem to appear effective in reducing anxiety, patients using it often do not stick to these interventions (they end up choosing to stick to the placebos)
What is evidence for pharmacotherapy (the use of pharmacological interventions) for depression?
Systematic Reviews/Meta-Analyses
Cipriani et al (2018) meta-analysis (n = 522 RCTs; 116 477 patients)
Small effect (SMD = 0.30) favouring pharmacotherapy in comparison to placebo
All active drugs were associated with higher withdrawal rates than placebo with ORs ranging between 1·64 and 4·44,
What was the effect size reported by Cipriani et al (2018) of pharmacotherapy in comparison to placebo?
SMD = 0.30
According to Cipriani et al.’s (2018) meta-analysis, did patients prefer pharmacotherapy or the placebo?
Pharmacotherapy
According to Cipriani et al.’s (2018) meta-analysis, all active drugs were associated with _____ than placebo with ORs ranging between 1·64 and 4·44,
Higher withdrawal rates
According to Cipriani et al.’s (2018) meta-analysis, all active drugs were associated with higher withdrawal rates than placebo with ORs ranging between __ and __
1.64 and 4.44,
What are the 3 limitations of pharmacological therapies?
- Study design
- Bias
- Follow up periods
Why is study design a limitation for pharmacological therapies?
While results are effective meta- analyses predominantly compare results to placebo or non intervention controls.
Why is bias a limitation for pharmacological therapies?
Studies are often completed by pharmaceutical companies
Why is follow up periods a limitation for pharmacological therapies?
Slee et al (2019) noted that follow up period ranged from 4 to 26 weeks
Slee et al (2019) noted that follow up period for pharmacological studies ranged from ___ to ___
4 to 26 weeks
What is the follow up period for psychological interventions?
6-12 months
What is the issue of follow up periods for pharmacological interventions being 4-26 weeks?
It is not clear what the longer term impacts of pharmacological interventions beyond 26 weeks are
Clinical guidelines in the US, UK, Canada, and Australia recommend ____ as a treatment for depression
Exercise
Clinical guidelines in the __, ___, ___ and ___ recommend exercise as a treatment for depression
- US
- UK
- Canada
- Australia
What is the limitation of clinical guidelines in the US, UK, Canada and Australia recommending exercise as a treatment for depression?
Guidelines are unclear on dose or exercise modality
What are the UK guidelines for exercise interventions?
Group exercise/increase any form of physical activity (NICE, 2023)
What are the US guidelines for exercise interventions?
Any dose of aerobic exercise or resistance training (APA, 2010)
What are the Australian guidelines for exercise interventions?
Combination of strength and vigorous aerobic exercise at least 2-3 times a week (Malhi et al 2020)
What is the latest evidence for Exercise Interventions to reduce anxiety?
Evidence from Systematic Reviews & Meta Analyses (Anxiety)
While evidence suggests that exercise may be effective for reducing symptoms of anxiety, although effect sizes are small (g = 0.3-0.4) (Aylett et al., 2018; Gordon et al., 2017)
Evidence from Systematic Reviews & Meta Analyses (Anxiety)
While evidence suggests that exercise may be effective for reducing symptoms of anxiety, although effect sizes are small
What was the effect size reported by Aylett et al. (2018) and Gordon et al. (2017)
0.3-0.4
True or False?
There are very few studies. on exercise for depression, which means there is not enough evidence and guidelines
False
There are very few studies. on exercise for anxiety, which means there is not enough evidence and guidelines
What is the latest evidence for Exercise Interventions to reduce depression?
Evidence from systematic reviews and meta-analyses indicate that exercise is associated with a decrease in symptoms of depression and may be associated with large effects in patients with MDD (Heissel et al., 2023; Noetel et al., 2024; Schuch et al., 2016; Gordon et al., 2018).
Schuch et al (2016) and Noetel et al (2024) suggest that interventions with higher intensities may have greater effects.
Noetel et al (2024) network meta-analysis of RCTs of exercise interventions.
Evidence from systematic reviews and meta-analyses indicate that exercise is associated with a decrease in symptoms of depression and may be associated with large effects in patients with …?
MDD
Evidence from systematic reviews and meta-analyses indicate that exercise is associated with a decrease in symptoms of depression and may be associated with ___ effects in patients with MDD
a. large
b. moderate
c. small
d. no
a. large
According to Schuch et al (2016) and Noetel et al (2024), exercise interventions with higher intensities may have ____ effects
a. smaller
b. greater
b. greater
According to Schuch et al (2016) and Noetel et al (2024), exercise interventions with ____ intensities may have greater effects
a. higher
b. lower
a. higher
According to Schuch et al (2016) and Noetel et al (2024), exercise interventions with higher intensities may have greater effects
What does this suggest about recommending exercise?
Maybe there is a difference in the types of exercise we should be. recommending people with depression
Noetel et al (2024) conducted a network meta-analysis of ____ of exercise interventions
RCTs (randomised control trials)
What are the 2 limitations of meta-analyses?
- Can only compare two interventions at a time
- Can only those evaluated directly in head-to-head trials (i.e., intervention vs control)
Who conducted a network meta-analysis of RCTs of exercise interventions?
Noetel et al (2024)
What are the 2 advantages of network meta-analyses?
- Can compare three or more interventions
- Combines both direct and indirect evidence across a network of studies
Is this a:
Combines both direct and indirect evidence across a network of studies
a. Meta analysis
b. Network meta-analysis
b. Network meta-analysis
Is this a:
Can only compare two interventions at a time
a. Meta analysis
b. Network meta-analysis
a. Meta analysis
Is this a:
Can compare three or more interventions
a. Meta analysis
b. Network meta-analysis
b. Network meta-analysis
Is this a:
Can only those evaluated directly in head-to-head trials (i.e., intervention vs control)
a. Meta analysis
b. Network meta-analysis
a. Meta analysis
Based on Noetel et al’s (2024) network meta-analysis, what were the findings on exercise effect on depression?
Exercise had moderate effect on depression vs active control (both alone or in combination i.e., with CBT)
Exercise had ____ effect on depression vs active control (both alone or in combination i.e., with CBT)
a. Large
b. Small
c. Moderate
c. Moderate
Exercise had moderate effect on depression compared to ____ (both alone or in combination i.e., with CBT)
Active control
What modes of exercise interventions are the most effective in reducing depression, based on Noetel et al’s (2024) network meta-analysis?
List 4 modalities
- Walking/jogging
- Yoga
- Strength training
- Dancing
What modes of exercise interventions are the most effective in reducing depression in both men and women?
Walking/jogging
What modes of exercise interventions are the most effective in reducing depression in only men?
Yoga
What modes of exercise interventions are the most effective in reducing depression in only women?
Strength training
Most effective modality of exercise to reduce depression in ___ is yoga
a. Only women
b. Only men
c. Both men and women
d. Neither men or women
b. Only men
Most effective modality of exercise to reduce depression in ___ is walking/jogging
a. Only women
b. Only men
c. Both men and women
d. Neither men or women
c. Both men and women
Most effective modality of exercise to reduce depression in ___ is strength training
a. Only women
b. Only men
c. Both men and women
d. Neither men or women
a. Only women
Based on Noetel et al’s (2024) network meta-analysis, what were the findings on exercise intensity in reducing depression?
Benefits were proportional to exercise intensity
Exercise with greater intensity were associated with greater benefit
Exercise with greater intensity were associated with ____ benefit towards reducing depression
a. greater
b. smaller
a. greater
What are the limitations of exercise interventions?
While exercise interventions may be effective at reducing symptoms of anxiety and depression, the mechanisms for how they do so is unclear and they are often not based on a psychological theory for reducing symptoms of depression or anxiety
May be effective at reducing symptoms of anxiety and depression, the mechanisms for how they do so is unclear and they are often not based on a psychological theory for reducing symptoms of depression or anxiety
What intervention for anxiety and depression does this limitation apply to?
Exercise Interventions
What is a popular combined treatment to reduce anxiety and depression?
Pharmacological and Psychotherapy combined interventions
What were the findings on the effects of Pharmacological and Psychotherapy combined interventions on depression?
Cuijppers et al (2020) found that combined treatment had greater response rate (RR 1.27) and remission rate (RR 1.22) for reducing depression
What were the findings on the effects of Pharmacological and Psychotherapy combined interventions on anxiety?
Currently there is a lack of sufficient evidence on the combination of psychotherapy and pharmacological therapy for GAD (Cuijpers et al 2014; Bandelow et al 2009)
What were the findings on the effects of Pharmacological and Psychotherapy combined interventions on panic and ocd?
Cuijpers et al (2014) meta analysis found combined treatment to be more effective than pharmacotherapy alone for OCD (g = 0.7) and panic (g = 0.54)
Cuijpers et al (2014) meta analysis found combined treatment to be more effective than pharmacotherapy alone for OCD and panic
What was the effect size for combined treatment for OCD?
g = 0.7
Cuijpers et al (2014) meta analysis found combined treatment to be more effective than pharmacotherapy alone for OCD and panic
What was the effect size for combined treatment for panic?
g = 0.54
Cuijppers et al (2020) found that combined treatment had greater response rate and remission rate for reducing depression
What was the response rate for combined treatment for depression?
1.27
Cuijppers et al (2020) found that combined treatment had greater response rate and remission rate for reducing depression
What was the remission rate for combined treatment for depression?
1.22
What is remission rate?
The rate of the complete disappearance or elimination of symptoms
What is the name of the combined intervention involving exercise and psychological intervention?
Cardiac Rehabilitation
When are patients offered Cardiac Rehabilitation (CR)?
After a cardiac event
After a cardiac event patients are offered what kind of intervention/treatment?
Cardiac Rehabilitation (CR)
What 3 interventions does Cardiac Rehabilitation (CR) include?
- Exercise
- Education
- Stress management/relaxation
How many patients with cardio vascular disease have clinically significant anxiety and/or depression?
1 in 3 patients
1 in 3 patients with cardio vascular disease have clinically significant …?
Anxiety and/or depression
What is increased anxiety/depression associated with?
List 3 points
- Increased morbidity
- Mortality
- Reduced quality of life
- Increased morbidity
- Mortality
- Reduced quality of life
What are these consequences associated with?
Anxiety/depression
Does Cardiac Rehabilitation (CR) reduce symptoms of anxiety and depression?
Yes
While Cardiac Rehabilitation (CR) reduces symptoms of anxiety and depression, what did Yohannes et al (2010) report about patient benefits?
Not all patients benefit from Cardiac Rehabilitation (CR), with 30% of patients experiencing elevated anxiety and depression
Not all patients benefit from Cardiac Rehabilitation (CR), with ____% of patients experiencing elevated anxiety and depression
a. 40%
b. 72%
c. 28%
d. 30%
d. 30%
Not all patients benefit from Cardiac Rehabilitation (CR), with 30% of patients experiencing …?
Elevated anxiety and depression
Despite some services offering tailored support to patients in managing anxiety and depression most do not offer …?
Support
How many studies were analysed in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
35
How many patients were in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
10 703 patients
How many studies used multifaceted interventions (i.e. multi therapy components) in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
23/35
How many studies used relaxation interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
20
How many studies used self awareness/self-monitoring interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
20
How many studies used emotional support/client led discussion interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
15
How many studies used cognitive challenging/restricting interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
19
How many studies used increased awareness of cardiac risk factors interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
16
How many studies used reducing risk factors interventions/therapy components in Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR)?
19
According to Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR), what was the effect size of CR on reducing anxiety?
0.24
According to Richards et al.’s (2017) meta analysis on Cardiac Rehabilitation (CR), what was the effect size of CR on reducing depression?
0.27
Describe Wells et al.’s (2021) pathway trial study on Cardiac Rehabilitation (CR)
Wells et al (2021) compared cardiac rehabilitation alone vs cardiac rehabilitaiton plus group based metacognitive therapy
Describe the aim of Wells et al.’s (2021) pathway trial study on Cardiac Rehabilitation (CR)
Is MCT+CR more effective than CR-alone at reducing anxiety and depression in cardiac rehabilitation patients (n = 332)
True or False?
It can be difficult to use CBT alone on patients with cardiovascular disease
True
Describe the findings of Wells et al.’s (2021) pathway trial study on Cardiac Rehabilitation (CR)
There was a significant decrease in anxiety and depression in group-MCT + CR vs CR alone
There was a significant ____ in anxiety and depression in group-MCT + CR vs CR alone
a. decrease
b. increase
a. decrease
There was a significant decrease in anxiety and depression in:
a. Cardiac Rehabilitation (CR) alone
b. Neither Cardiac Rehabilitation (CR) alone or Group-MCT plus Cardiac Rehabilitation (CR)
c. Both Cardiac Rehabilitation (CR) alone and Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
Which intervention is more reliable after a 4 month follow up?
a. Cardiac Rehabilitation (CR) alone
b. Neither Cardiac Rehabilitation (CR) alone or Group-MCT plus Cardiac Rehabilitation (CR)
c. Both Cardiac Rehabilitation (CR) alone and Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
Which intervention resulted in the improvement of anxiety and depression symptoms after a 4 month follow up?
a. Cardiac Rehabilitation (CR) alone
b. Neither Cardiac Rehabilitation (CR) alone or Group-MCT plus Cardiac Rehabilitation (CR)
c. Both Cardiac Rehabilitation (CR) alone and Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
Which intervention resulted in the deterioration of anxiety and depression symptoms after a 4 month follow up?
a. Cardiac Rehabilitation (CR) alone
b. Neither Cardiac Rehabilitation (CR) alone or Group-MCT plus Cardiac Rehabilitation (CR)
c. Both Cardiac Rehabilitation (CR) alone and Group-MCT plus Cardiac Rehabilitation (CR)
d. Group-MCT plus Cardiac Rehabilitation (CR)
a. Cardiac Rehabilitation (CR) alone
What are the 3 implications (results) of Group-MCT plus Cardiac Rehabilitation (CR)?
- Improved Mental Health Outcomes
- Improved Access to Psychological Therapies
- Meets Patients Needs
How many patients experienced improvement in mental health outcomes through Group-MCT plus Cardiac Rehabilitation (CR)?
And what was the deterioration rate?
1 in 3 patients
Halved the deterioration rate
How does Group-MCT plus Cardiac Rehabilitation (CR) improve access to psychological therapies?
Group-MCT provided access to psychological support within Cardiac Rehabilitation (CR) where psychological support is minimal or unavailable
How does Group-MCT plus Cardiac Rehabilitation (CR) meets patients needs?
Patients described engaging in chronic worry and rumination, and how current Cardiac Rehabilitation (CR) techniques felt superficial and difficult to apply in real life
MCT overcomes limitations with current psychological support in Cardiac Rehabilitation (CR)
What % of patients who underwent Cardiac Rehabilitation (CR) alone made a reliable change post treatment (after 4 months)?
20%
What % of patients who underwent Group-MCT plus Cardiac Rehabilitation (CR) made a reliable change post treatment (after 4 months)?
33%
What % of patients who underwent Cardiac Rehabilitation (CR) alone had gotten worse post treatment (after 4 months)?
15%
What % of patients who underwent Group-MCT plus Cardiac Rehabilitation (CR) had gotten worse post treatment (after 4 months)?
4-5%
Name one new frontier of interventions for heart conditions
CardioActive
What intervention is recommended for children and adolescents with heart conditions?
CardioActive
What is the study design of CardioActive?
Feasibility and acceptability trial
What is the study aim of CardioActive?
Evaluate the acceptability and feasibility of a cardiac rehabilitation programme for children and young people with heart conditions
What activities/therapies are included in CardioActive?
- Exercise
- Education
- Based on psychological theory (Metacogntive Model)
How does CardioActive support adjusting to living with a heart condition in children and adolecents?
It is based on psychological theory (Metacogntive Model)
True or False?
UK, Canada and USA have similar guidelines to treating anxiety and depression
True
Beyond talking based therapies there are a number of interventions that have demonstrated efficacy for treating anxiety and depression
Name 3 of these interventions
- Pharmacological interventions
- Exercise
- Combined interventions
Which is more beneficial for people with depression and/or anxietyt?
Combined interventions (i.e., pharmacological and talking based therapies) or pharmacological interventions alone?
Combined interventions (i.e., pharmacological and talking based therapies)