Lecture 8 - Non-psychotherapeutic interventions

Question 1

What is UK government guidance for anxiety?

Answer 1

Step dependent, low intensity therapy, CBT/applied relaxation/drug treatments

Step 1: Identification, assessment, education, active monitoring

Step 2: low intensity psychological interventions (self help/psychoeducation)

Step 3: High intensity interventions/drug treatment (SSRIs)

Step 4: Complex drug/psychological treatment, continue CBT

Question 2

What is UK government’s guidance for depression?

Answer 2

Severity dependent, less severe - CBT/behavioural activation/exercise/etc., more severe (>PHQ 16) - CBT/behavioural activation/antidepressants/group exercise

See NICE guidelines (model in slides)
Less severe: guided self help - group - individual - group mindfulness - counselling
More severe: individual CBT - antidepressants - counselling - interpersonal psychotherapy - guided self help

Question 3

What is Canada’s government guidance for anxiety?

Answer 3

CBT, SSRI, SNRI, antidepressants, pregabalin

Question 4

What is Canada’s government guidance for depression?

Answer 4

Psychoeducation, self help, psychological therapy, CBT, interpersonal therapy, pharmacological treatment

Question 5

What is USA’s government guidance for anxiety?

Answer 5

Clinical guidelines for anxiety not published, guidelines by APA for PTSD, panic, OCD

Question 6

What is USA’s government guidance for depression?

Answer 6

CBT, IPT, mindfulness-based cognitive therapy

Antidepressants

Combined treatments

Exercise

Question 7

Are pharmacological interventions effective?

Answer 7

Systematic reviews/meta-analyses: pharmacotherapies (SSRI, SNRI, etc.) appear to be effective at reducing symptoms of anxiety but size of effects mixed

Acceptability across active comparisons largely involved drugs w/ acceptability profiles worse than placebos

Question 8

What did Cipriani et al (2018) find?

Answer 8

Meta-analysis, small effect favouring pharmacotherapy in comparison to placebo, all active drugs had higher withdrawal rates than placebos

Limitations: study design (meta-analyses predominantly compare results to placebo/non-intervention controls), bias (studies by pharmaceutical companies), follow up (follow up period ranged from 4 to 26 weeks)

Question 9

How does the UK/US/Australia recommend exercise as treatment?

Answer 9

Recommended, but limitations: unclear on dose or exercise modality

Latest evidence: meta-analyses/reviews suggest very small effects for reducing symptoms of anxiety through exercise

However, studies do indicate greater effects for exercising reducing symptoms for depression

Question 10

What is a meta-analysis?

Answer 10

Only compare two interventions at a time, only those evaluated directly in head-to-head trials (intervention vs control)

Question 11

What is a network meta-analysis?

Answer 11

Compare three or more interventions, combines both direct/indirect evidence across network of studies

Line thickness = number of comparisons between arms (thicker is more), size of point = greater size = larger number of participants in arm

Question 12

What is effect of exercise on depression?

Answer 12

Moderate effect on depression vs active control, most effective modalities walking/jogging, yoga, strength training, dancing (strength more effective for women, yoga more effective for men, walking/jogging effective for both, benefits proportional to exercise intensity (greater = more benefit)

Limitations: mechanisms for how exercise interventions reduce symptoms unclear + not based on psychological theories

Question 13

What is effect of combined intervention of pharmacological + psychotherapy?

Answer 13

Depression – combined treatment had greater response + remission rate (Cuijppers 2020)

Anxiety – lack of sufficient evidence of this combo for GAD

OCD/Panic - meta-analysis says combined treatment more effective than pharmatherapy alone

Question 14

What is the effect of combined intervention of exercise + psychological?

Answer 14

Cardiac Rehabilitation: exercise, education, stress management/relaxation as interventions, 1/3 patients with cardiovascular disease have clinically significant anxiety/depression, increased morbidity/mortality/reduced QoL

1/3 patients continue to experience elevated anxiety/depression, not much tailored support

Question 15

What is the PATHWAY trial?

Answer 15

Compared cardiac rehab alone vs cardiac rehab + group based metacognitive therapy

Question 16

What did the PATHWAY trial find?

Answer 16

Found significant decrease in anxiety + depression in group-MCT + CR vs CR alone

Reliable change: 4 month follow up – 20% reliable change in cardiac rehab, 33% reliable change in cardiac + psychological therapy

Implicatios: Group MCT + CR improved outcomes for 1 in 3 patients, provided access to psychological support (IAPT), meets patients needs