✅ L8 - Non-psychotherapeutic interventions

Question 1

What is the government guidance for anxiety disorder and depression interventions in the UK? (compared to Canada and the US)

Answer 1

FOR GENERALISED ANXIETY DISORDER: Step-cared model:
1. GAD identification and treatment plan
2. Low intensity (self-help and psychoeducation)
3. High intensity intervention OR drug treatment
4. Complex drug/psychological treatment with multiagency teams
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FOR DEPRESSION: Severity-dependent (PHQ-9 score)
- Less severe (PHQ<16): CBT, behavioural activation, exercise, anti-depressants
- More severe (PHQ>16): intense CBT, behavioural activation, group exercise, anti-depressants
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Comparison to Canada’s and US’s guidelines:
- Canada: Includes pregabalin as first-line therapy for anxiety, plus interpersonal therapy (IPT) for mild severity depression
- The US: no clinical guideline for anxiety so used the same one for PTSD, combined treatments (CBT or IPT, plus ADM) for depression.

Question 2

Is pharmacological interventions are effective treatments for anxiety and depression?

Answer 2

1. Evidence for Anxiety:
   - Pharmacotherapies (SSRI; SNRI) seems effective at reducing anxiety symptoms, but mixed effect sizes and quite small (0.01 - 0.56)
   - However, drug acceptability favours placebo over active drugs -> problem.
2. Evidence for Depression (Cipriani et al, 2018)
   - Small effect (0.30) compared to placebo
   - All active drugs were associated with higher withdrawal rates than placebo (OR = 1.64 - 4.44)

Question 3

What are the limitations of pharmacological, exercise interventions?

Answer 3

Pharmalogical:
1. Study design: While results are effective meta-analyses predominantly compare results to placebo or non intervention controls.
2. Bias: Studies are often completed by pharmaceutical companies. (ethical?)
3. Follow-up: follow up period ranged from 4-26 weeks => can’t access long-term effect + relapse.
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Exercise:
- Unclear mechanism
- Personalised recommendation? (dose?)
- Often not based on a psychological theory to reduce symptoms of depression or anxiety.

Question 4

What is the government guidance for exercise interventions (UK, US, Australia)? Why not recommended as anxiety treatment? What is the evidence for exercise’s effectiveness in treating depression?

Answer 4

• All 3 countries recommended exercises as treatment for depression, BUT NOT anxiety.
• Why? While evidence efficacy in reducing anxiety symptoms, effect sizes are small (g = 0.3-0.4)
• Limitation: Guidelines are unclear on dose or exercise modality (except for Australia)

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Evidence for efficacy in treating depression? (e.g. Noetel et al., 2024; Schuch et al., 2016)
1. Exercise associated with decrease in symptoms of depression & large effects in patients with MDD.
2. Moderate effect on depression vs. active control (alone or combined e.g. with CBT)
3. Intervention mode: Most effective modalities were walking/jogging (both), yoga (women < men), strength training (men < women) and dancing.
4. Benefits were proportional to exercise intensity.

=> Notes: meta-analysis only compare 2 interventions; network meta-analysis can compare >3 interventions, with both direct and indirect evidence across studies.

Question 5

What is the effectiveness of combined interventions

Answer 5

FOR Pharmacological + Pharmacotherapy Cuijppers et al (2014; 2020):
- Depression: combined treatment had greater response rate (RR 1.27) and remission rate (RR 1.22)
- Anxiety: Currently lack of sufficient evidence for GAD => instead: combined treatment more effectivethan pharmacotherapy alone for OCD (g = 0.7) and panic (g = 0.54)
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FOR Exercise + Psychological interventions (Cardiac rehab: Richard et al., 2017; Yohannes et al., 2010)
- After a cardiac event, patients are offered cardiac rehabilitation (CR) which includes: exercise, education and stress management/relaxation
- 1/3 patients with CVD have clinically significant anxiety and/or depression -> associated with increased mortality and reduced quality of life
- Result: CR reduces symptoms of anxiety and depression, but not all (30% increased anxiety and depression)
- Richard et al., 2017 => Results: small effect sizes for both Anxiety (0.24) and Depression (0.27)
- Most services do not offer support for managing anxiety and depression.

=> Why CR not effective? May not fit, can’t challenge patients on their instincts

Question 6

What is the efficacy of combining Group-MCT + CR to treat anxiety/depression in patients?

Answer 6

1. HOW: Wells et al. (2021) compared CR alone vs. group-MCT + CR combined
2. Result:
   - Significant decrease in anxiety and depression in group-MCT + CR vs CR alone.
   - Reliable change after 4-month follow up: more improved and less deteriorated
3. Implications:
   - Improved mental health outcomes: for 1-3 patients and halved the deterioration rate
   - Improved access to psychological therapies: provide access to psych support with CR, where it used to be minimal/unavailable
   - Meets patients needs: MCT overcomes limitation with current CR (CR techniques felt difficult to apply irl)
4. New Programme: CardioActive
   - Study aim: Evaluate the acceptability and feasibility of a cardiac rehabilitation programme for children and young people with heart conditions
   - HOW? Comparing CardioActive vs. Usual care
   => Programme includes exercise and education based on MCT to support adjusting to living with heart condition.