Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial

Importance Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. Objectives To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. Design, Setting, and Participants This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire–9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. Interventions CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master’s level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. Main Outcomes and Measures The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder–7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire–8. Results The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, −2.5; 95% CI, −4.5 to −0.8; P = .005) and 3 month (mean difference, −2.3; 95% CI, −4.5 to −0.8; P = .006) and 6 month (mean difference, −3.2; 95% CI, −4.5 to −0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). Conclusions and Relevance In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome

Addressing disproportionality and disparity in child welfare: Evaluation of an anti-racism training for community service providers

Concerns persist about the overrepresentation and differential treatment of children and families of color within the child welfare system. Although many researchers and practitioners have considered ways to combat these problems, there continues to be a shortage of empirical support for proposed interventions. This article describes the evaluation of an anti-racism training designed to address disproportionality and disparity by educating members of the child welfare community about issues of race, power, and oppression. Pre- and post-training evaluation questionnaires were completed by 462 training participants between June 2007 and June 2008. Questionnaires measured changes in participants' attitudes toward race and knowledge of key concepts regarding race and racism, as well as their satisfaction with the training, and expected practice changes. Preliminary findings indicate that participants were very satisfied with the training, increased their knowledge of issues pertaining to race and racism, and became more aware of racial dynamics.Child welfare Training evaluation Anti-racism Disproportionality Disparity Undoing Racism

Healthy relationship education for dating violence prevention among high-risk youth

A federal grant was awarded to provide the Love U2 healthy relationship curriculum to low-income, high-risk youth. This research sought to examine the relative effectiveness of a brief intervention with this curriculum compared to the much more intensive relationship education programs that have been previously provided to high-risk youth. Data were collected from 233 participants through measures of training and relationship outcomes pre- and post-training. Participants experienced high levels of training satisfaction, significant increases in relationship knowledge and self-efficacy related to conflict resolution. They also experienced a significant improvement in attitudes toward couple violence in the desired direction. Implications of these findings for promoting healthy relationships and reducing dating violence among high-risk youth are discussed.Relationship education High-risk youth Violence prevention Healthy Relationships

Training the child welfare workforce in healthy couple relationships: An examination of attitudes and outcomes

The purpose of the current research is to address a gap in the literature related to attitudes and other training outcomes through an evaluation of a healthy marriage/couple relationship training for public child welfare workers. Given the sensitivity of this topic and numerous barriers to trainee acceptance of the material, this training provided a particularly fertile context for these research questions. This research utilized a quasi-experimental design with pre-, multiple post-training measures for the experimental (training) group and control (no training) group. Data were collected using reliable and valid standardized scales on training satisfaction, knowledge gain, transfer of new skills, and attitude change, as well as potential individual and organizational mediators of these outcomes. Results indicated that experimental group participants reported higher levels of knowledge than controls and knowledge gain in certain areas. Knowledge gain was related to training satisfaction. Experimental group participants also reported higher levels of training transfer and an increase in positive attitudes toward the importance of couple issues for child welfare, with these attitudes significantly predicting transfer of skills. Implications for general child welfare training and the integration of couple issues into child welfare practice are discussed.Training evaluation Child welfare Healthy marriage initiative Attitudes Training transfer

Dissemination of Computer-assisted Cognitive-behavior Therapy for Depression in Primary Care

Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care – a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients – a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care