Predictors of school-based cognitive behavior therapy outcome for youth with anxiety

Meta-analyses of school-based CBT have shown that prevention for anxiety symptoms typically report small but significant effects. There is limited knowledge regarding which youths may benefit most and least from such programs, and characteristics of youth who respond differentially to interventions of different intensity. The present study examined predictors of school-based CBT outcomes among 302 youths (mean age 14.0 years, SD 0.8, 84% female) who participated in a randomized waitlist-controlled trial comparing a 10-session and a 5-session group intervention. Potential predictors included youth and parental factors, and credibility and expectancy of the interventions. Pre-intervention anxiety and depression levels, and clinician rated severity were examined as moderators of intervention effects. Outcomes were youth-, and parent-reported youth anxiety and depressive symptoms at post-intervention and 1-year follow-up. Higher parent-reported impairment from youth anxiety predicted larger parent-reported anxiety and depressive symptom change, whereas higher caregiver strain was associated with less symptom change. Higher parent rated credibility and expectancy was associated with improved outcomes at post-intervention. At 1-year follow-up, no predictors of outcome were identified. No moderators were identified. Families with high levels of caregiver strain associated with youth anxiety may need extra support regardless of length of intervention program. Parents’ credibility and expectancy of interventions should be targeted to optimize school-based CBT.publishedVersio

Protocol for the effect evaluation of independent medical evaluation after six months sick leave: a randomized controlled trial of independent medical evaluation versus treatment as usual in Norway

Abstract Background It has been discussed whether the relationship between a patient on sick leave and his/her general practitioner (GP) is too close, as this may hinder the GP’s objective evaluation of need for sick leave. Independent medical evaluation involves an independent physician consulting the patient. This could lead to new perspectives on sick leave and how to follow-up the patient. Methods/design The current study is a randomized controlled trial in a Norwegian primary care context, involving an effect evaluation, a cost/benefit analysis, and a qualitative evaluation. Independent medical evaluation will be compared to treatment as usual, i.e., the physicians’ and social insurance agencies’ current management of long-term sick-listed patients. Individuals aged 18–65 years, sick listed by their GP and on full or partial sick leave for the past 6 months in Hordaland county will be included. Exclusion criteria are pregnancy, cancer, dementia or an ICD-10 diagnosis. A total sample of 3800 will be randomly assigned to either independent medical evaluation or treatment as usual. Official register data will be used to measure the primary outcome; change in sickness benefits at 7, 9 and 12 months. Sick listed in other counties will serve as a second control group, if appropriate under the “common trend” assumption. Discussion The Norwegian effect evaluation of independent medical evaluation after 6 months sick leave is a large randomized controlled trial, and the first of its kind, to evaluate this type of intervention as a means of getting people back to work after long-term sickness absence. Trial registration ClinicalTrials.gov NCT02524392 . Registered June 23, 2015

What is the effect of independent medical evaluation on days on sickness benefits for long-term sick listed employees in Norway? A pragmatic randomised controlled trial, the NIME-trial

Background Independent medical evaluations are used to evaluate degree and reason for work disability, uncertainty around the functional status, and/or the employee’s rehabilitation potential in several jurisdictions, but not in Norway. The main aim of this trial was to test the return to work effect of independent medical evaluation (IME) (summoning and consultation) compared to treatment as usual (TAU) in Norway, for workers who have been on continuous sick leave for 6 months. Methods This was a pragmatic randomised controlled trial including all employees aged 18–65 years, sick-listed by their general practitioner and on full or partial sick leave for the past 26 weeks in Hordaland County, Norway in 2015/16. Trial candidates were drawn from a central register at the Norwegian Labour and Welfare Administration at 22 weeks of sick leave. Pregnant women, individuals with cancer or dementia diagnoses, those with secret address, employed by NAV or sick listed by the specialist health services were excluded. Separate regression analyses were conducted to investigate the “intention-to-treat” and “treatment on the treated” effects, using the ordinary least squares and instrumental variable methods, respectively. Results After exemption based on predefined exclusion criteria, 5888 individuals were randomised to either IME (n = 2616) or TAU (n = 2599). The final intervention group constitutes 1698 individuals, of which 937 attended the IME consultation. No baseline differences were found between the IME and TAU group regarding gender, age, and previous sick leave. Individuals attending the IME were older than those who cancelled the appointment ((47/45), p = 0.006) and those who did not show up without cancelling ((47/42), p < 0.001). Mainly the IME physician agreed with the regular GP upon level of sick leave. In cases with different assessments, the difference tended to be towards a lower sick leave level. There were no intention to treat or treatment on the treated effect on days of sick leave after randomisation during follow up. Conclusions Overall, the analyses showed no effect of IME on changes in sick leave for sick listed employees. This result was consistent for those who were offered an IME consultation (intention to treat) and those who undertook an IME consultation (treatment on the treated)

What is the effect of independent medical evaluation on days on sickness benefits for long-term sick listed employees in Norway? A pragmatic randomised controlled trial, the NIME-trial

Background Independent medical evaluations are used to evaluate degree and reason for work disability, uncertainty around the functional status, and/or the employee’s rehabilitation potential in several jurisdictions, but not in Norway. The main aim of this trial was to test the return to work effect of independent medical evaluation (IME) (summoning and consultation) compared to treatment as usual (TAU) in Norway, for workers who have been on continuous sick leave for 6 months. Methods This was a pragmatic randomised controlled trial including all employees aged 18–65 years, sick-listed by their general practitioner and on full or partial sick leave for the past 26 weeks in Hordaland County, Norway in 2015/16. Trial candidates were drawn from a central register at the Norwegian Labour and Welfare Administration at 22 weeks of sick leave. Pregnant women, individuals with cancer or dementia diagnoses, those with secret address, employed by NAV or sick listed by the specialist health services were excluded. Separate regression analyses were conducted to investigate the “intention-to-treat” and “treatment on the treated” effects, using the ordinary least squares and instrumental variable methods, respectively. Results After exemption based on predefined exclusion criteria, 5888 individuals were randomised to either IME (n = 2616) or TAU (n = 2599). The final intervention group constitutes 1698 individuals, of which 937 attended the IME consultation. No baseline differences were found between the IME and TAU group regarding gender, age, and previous sick leave. Individuals attending the IME were older than those who cancelled the appointment ((47/45), p = 0.006) and those who did not show up without cancelling ((47/42), p < 0.001). Mainly the IME physician agreed with the regular GP upon level of sick leave. In cases with different assessments, the difference tended to be towards a lower sick leave level. There were no intention to treat or treatment on the treated effect on days of sick leave after randomisation during follow up. Conclusions Overall, the analyses showed no effect of IME on changes in sick leave for sick listed employees. This result was consistent for those who were offered an IME consultation (intention to treat) and those who undertook an IME consultation (treatment on the treated).publishedVersio

Effectiveness of Brief and Standard School-Based Cognitive-Behavioral Interventions for Adolescents With Anxiety: A Randomized Noninferiority Study

Objective We examined the effectiveness of targeted school-based cognitive-behavioral therapy (CBT) for adolescents (12−16 years of age) with anxiety, and tested whether brief CBT was noninferior to standard duration CBT. Method A randomized controlled study of 313 adolescents (mean 14.0 years, SD = 0.84, 84% girls) were recruited through school health services to 10 weeks CBT group interventions. Groups of 5 to 8 adolescents were randomly allocated to brief (5 sessions, comprising 5.5 hours) or standard CBT (10 sessions, comprising 15 hours), or 10 weeks waitlist (WL). Self-reported and parent-reported youth anxiety symptoms, impairment from anxiety, depressive symptoms,and clinical severity were assessed pre- and postintervention, after WL, and at 1-year follow-up. Results Targeted school based CBT significantly reduced adolescents’ anxiety symptoms with small to moderate effect sizes compared to WL (Cohen d = 0.34 for youth report and d = 0.53 for parent report). According to the parents, also adolescents’ impairment from anxiety was significantly reduced compared to WL (d = 0.51). Pre to post changes in anxiety symptoms were small to moderate (within-group effect sizes between d = 0.41 and d = 0.67). Although no significant differences in effects were found between brief and standard CBT, brief CBT was not noninferior to standard CBT. Outcomes from both interventions were sustained at 1-year follow-up. Conclusion Targeted school-based CBT interventions reduced anxiety, impairment, and depressive symptoms in adolescents. Both brief and standard CBT demonstrated efficacy, but brief CBT was not noninferior to standard CBT. By administering school-based CBT to youths with anxiety symptoms, we may reach young people with effective interventions at an earlier phase in their lives

Effectiveness of Brief and Standard School-Based Cognitive-Behavioral Interventions for Adolescents With Anxiety: A Randomized Noninferiority Study

Objective We examined the effectiveness of targeted school-based cognitive-behavioral therapy (CBT) for adolescents (12−16 years of age) with anxiety, and tested whether brief CBT was noninferior to standard duration CBT. Method A randomized controlled study of 313 adolescents (mean 14.0 years, SD = 0.84, 84% girls) were recruited through school health services to 10 weeks CBT group interventions. Groups of 5 to 8 adolescents were randomly allocated to brief (5 sessions, comprising 5.5 hours) or standard CBT (10 sessions, comprising 15 hours), or 10 weeks waitlist (WL). Self-reported and parent-reported youth anxiety symptoms, impairment from anxiety, depressive symptoms,and clinical severity were assessed pre- and postintervention, after WL, and at 1-year follow-up. Results Targeted school based CBT significantly reduced adolescents’ anxiety symptoms with small to moderate effect sizes compared to WL (Cohen d = 0.34 for youth report and d = 0.53 for parent report). According to the parents, also adolescents’ impairment from anxiety was significantly reduced compared to WL (d = 0.51). Pre to post changes in anxiety symptoms were small to moderate (within-group effect sizes between d = 0.41 and d = 0.67). Although no significant differences in effects were found between brief and standard CBT, brief CBT was not noninferior to standard CBT. Outcomes from both interventions were sustained at 1-year follow-up. Conclusion Targeted school-based CBT interventions reduced anxiety, impairment, and depressive symptoms in adolescents. Both brief and standard CBT demonstrated efficacy, but brief CBT was not noninferior to standard CBT. By administering school-based CBT to youths with anxiety symptoms, we may reach young people with effective interventions at an earlier phase in their lives

Treatment Fidelity in Brief Versus Standard-Length School-Based Interventions for Youth with Anxiety

To examine treatment fidelity in a randomized controlled trial of indicated school-based cognitive-behavioral therapy (CBT) delivered in groups to youth with anxiety. We investigated whether adherence and competence (a) differed across brief and standard-length CBT, and (b) if adherence and competence predicted change in anxiety symptoms and impairment. Method: Sessions were observationally coded with the Competence and Adherence Scale for CBT for Anxiety Disorders in Youth. Coders (N = 7) rated 104 sessions from 52 groups delivered by 32 facilitators (M age = 43.2 years, SD = 8.1) to 295 youth (M age = 14.0 years, SD = 0.8). Outcomes were youth- and parent-reported anxiety symptoms and impairment at post-intervention and 1-year follow-up. Linear mixed effect models were used to analyze whether fidelity predicted clinical outcomes. Results: Levels of adherence and competence were adequate in both programs, but higher in brief compared to standard-length CBT p < .001 and p = .010, respectively). Neither adherence nor competence predicted clinical outcomes at any timepoints. Conclusion: Higher levels of adherence and competence in brief CBT suggest that it may be easier for novice CBT providers to achieve fidelity in simplified and less flexible interventions. Contrary to expectation, adherence and competence did not predict clinical outcomes

Treatment Fidelity in Brief Versus Standard-Length School-Based Interventions for Youth with Anxiety

To examine treatment fidelity in a randomized controlled trial of indicated school-based cognitive-behavioral therapy (CBT) delivered in groups to youth with anxiety. We investigated whether adherence and competence (a) differed across brief and standard-length CBT, and (b) if adherence and competence predicted change in anxiety symptoms and impairment. Method: Sessions were observationally coded with the Competence and Adherence Scale for CBT for Anxiety Disorders in Youth. Coders (N = 7) rated 104 sessions from 52 groups delivered by 32 facilitators (M age = 43.2 years, SD = 8.1) to 295 youth (M age = 14.0 years, SD = 0.8). Outcomes were youth- and parent-reported anxiety symptoms and impairment at post-intervention and 1-year follow-up. Linear mixed effect models were used to analyze whether fidelity predicted clinical outcomes. Results: Levels of adherence and competence were adequate in both programs, but higher in brief compared to standard-length CBT p < .001 and p = .010, respectively). Neither adherence nor competence predicted clinical outcomes at any timepoints. Conclusion: Higher levels of adherence and competence in brief CBT suggest that it may be easier for novice CBT providers to achieve fidelity in simplified and less flexible interventions. Contrary to expectation, adherence and competence did not predict clinical outcomes

Treatment Fidelity in Brief Versus Standard-Length School-Based Interventions for Youth with Anxiety

To examine treatment fidelity in a randomized controlled trial of indicated school-based cognitive-behavioral therapy (CBT) delivered in groups to youth with anxiety. We investigated whether adherence and competence (a) differed across brief and standard-length CBT, and (b) if adherence and competence predicted change in anxiety symptoms and impairment. Method: Sessions were observationally coded with the Competence and Adherence Scale for CBT for Anxiety Disorders in Youth. Coders (N = 7) rated 104 sessions from 52 groups delivered by 32 facilitators (M age = 43.2 years, SD = 8.1) to 295 youth (M age = 14.0 years, SD = 0.8). Outcomes were youth- and parent-reported anxiety symptoms and impairment at post-intervention and 1-year follow-up. Linear mixed effect models were used to analyze whether fidelity predicted clinical outcomes. Results: Levels of adherence and competence were adequate in both programs, but higher in brief compared to standard-length CBT p < .001 and p = .010, respectively). Neither adherence nor competence predicted clinical outcomes at any timepoints. Conclusion: Higher levels of adherence and competence in brief CBT suggest that it may be easier for novice CBT providers to achieve fidelity in simplified and less flexible interventions. Contrary to expectation, adherence and competence did not predict clinical outcomes