Predicting treatment outcome in psychological treatment services by identifying latent profiles of patients

BACKGROUND: The outcomes of psychological therapies for anxiety and depression vary across individuals and symptom domains. Being able to predict treatment response from readily available patient data at presentation has potentially important benefits in aiding decisions about the most suitable interventions for a patient. This paper presents a method of identifying subgroups of patients using latent profile analysis, and comparing response to psychological treatments between these profiles. METHODS: All outpatients taken into treatment at two psychological treatment services in London, UK and who provided basic demographic information and standardized symptom measures were included in the analysis (n=16636). RESULTS: Latent Profile Analysis was performed on intake data to identify statistically different groups of patients, which were then examined in longitudinal analyses to determine their capacity to predict treatment outcomes. Comparison between profiles showed considerable variation in recovery (74-15%), deterioration rates (5-20%), and levels of attrition (17-40%). Further variation in outcomes was found within the profiles when different intensities of psychological intervention were delivered. LIMITATIONS: Latent profiles were identified using data from two services, so generalisability to other services should be considered. Routinely collected patient data was included, additional patient information may further enhance utility of the profiles. CONCLUSIONS: These results suggest that intake data can be used to reliably classify patients into profiles that are predictive of outcome to different intensities of psychological treatment in routine care. Algorithms based on these kinds of data could be used to optimize decision-making and aid the appropriate matching of patients to treatment

Dynamic interpersonal therapy for moderate to severe depression: A pilot randomized controlled and feasibility trial

Background: Improving Access to Psychological Therapies (IAPT) services treat most patients in England who present to primary care with major depression. Psychodynamic psychotherapy is one of the psychotherapies offered. Dynamic Interpersonal Therapy (DIT) is a psychodynamic and mentalization-based treatment for depression. 16 sessions are delivered over approximately 5 months. Neither DIT's effectiveness relative to low-intensity treatment (LIT), nor the feasibility of randomizing patients to psychodynamic or cognitive-behavioural treatments (CBT) in an IAPT setting has been demonstrated. Methods: 147 patients were randomized in a 3:2:1 ratio to DIT (n = 73), LIT (control intervention; n = 54) or CBT (n = 20) in four IAPT treatment services in a combined superiority and feasibility design. Patients meeting criteria for major depressive disorder were assessed at baseline, mid-treatment (3 months) and post-treatment (6 months) using the Hamilton Rating Scale for Depression (HRSD-17), Beck Depression Inventory-II (BDI-II) and other self-rated questionnaire measures. Patients receiving DIT were also followed up 6 months post-completion. Results: The DIT arm showed significantly lower HRSD-17 scores at the 6-month primary end-point compared with LIT (d = 0.70). Significantly more DIT patients (51%) showed clinically significant change on the HRSD-17 compared with LIT (9%). The DIT and CBT arms showed equivalence on most outcomes. Results were similar with the BDI-II. DIT showed benefit across a range of secondary outcomes.ConclusionsDIT delivered in a primary care setting is superior to LIT and can be appropriately compared with CBT in future RCTs

In the Interests of clients or commerce? Legal aid, supply, demand, and 'ethical indeterminacy' in criminal defence work

As a professional, a lawyer's first duty is to serve the client's best interests, before simple monetary gain. In criminal defence work, this duty has been questioned in the debate about the causes of growth in legal aid spending: is it driven by lawyers (suppliers) inducing unnecessary demand for their services or are they merely responding to increased demand? Research reported here found clear evidence of a change in the handling of cases in response to new payment structures, though in ways unexpected by the policy's proponents. The paper develops the concept of 'ethical indeterminacy' as a way of understanding how defence lawyers seek to reconcile the interests of commerce and clients. Ethical indeterminacy suggests that where different courses of action could each be said to benefit the client, the lawyer will tend to advise the client to decide in the lawyer's own interests. Ethical indeterminacy is mediated by a range of competing conceptions of 'quality' and 'need'. The paper goes on to question the very distinction between 'supply' and 'demand' in the provision of legal services

Trajectories of depression and anxiety symptom change during psychological therapy

BACKGROUND: Forty-percent of the variance in psychological treatment outcomes is estimated to be explained by symptom change by the third treatment session. However, change may not be uniform across patient groups and symptom domains. This study aimed to identify subgroups of patients with different trajectories of depression and anxiety symptom change during psychological therapy and identify baseline patient characteristics associated with these trajectories. METHODS: 4394 patients attending two psychological treatment services completed sessional, self-report depression and anxiety measures. Trajectories of symptom change were investigated using latent class growth analysis. Multinomial logistic regression was used to explore associations between baseline patient characteristics and trajectory classes. RESULTS: A number of distinct trajectories were identified. Anxiety symptom trajectories could be distinguished by the third treatment session, but for depression symptoms there was a class displaying limited change until session six followed by rapid improvement in symptoms thereafter. Compared to the non-responding trajectories, depression and anxiety trajectories indicating treatment response were associated with lower baseline severity, better social functioning and lower incidence of phobic anxiety, but not with medication prescription status. LIMITATIONS: Data came from two services, so wider generalisability is unknown. Predictors were limited to data routinely collected in the services; unmeasured factors may have improved the prediction of trajectories. CONCLUSIONS: Baseline characteristics and symptom change early in therapy can help identify different trajectories of symptom change. This knowledge could aid clinical decision making and help improve treatment outcomes. By ignoring distinct trajectories, clinicians may incorrectly consider patients as "not-on-track" and unnecessarily change or end therapy that would otherwise benefit patients

Does tendering create travesties of justice?

Legal aid in criminal proceedings exists to avoid defendants being presented as victims of an overbearing state, which assumes that ‘the two sides have access to roughly equivalent resources and expertise’ (Young and Wall, 1996). Recent governments have however focussed on value for money, which ignores political debate about what actually constitutes value in specific circumstances. It is against this background that the Ministry of Justice released its consultation paper including proposals to introduce Price Competitive Tendering (PCT) in most criminal proceedings

The Shapes of Flux Domains in the Intermediate State of Type-I Superconductors

In the intermediate state of a thin type-I superconductor magnetic flux penetrates in a disordered set of highly branched and fingered macroscopic domains. To understand these shapes, we study in detail a recently proposed "current-loop" (CL) model that models the intermediate state as a collection of tense current ribbons flowing along the superconducting-normal interfaces and subject to the constraint of global flux conservation. The validity of this model is tested through a detailed reanalysis of Landau's original conformal mapping treatment of the laminar state, in which the superconductor-normal interfaces are flared within the slab, and of a closely-related straight-lamina model. A simplified dynamical model is described that elucidates the nature of possible shape instabilities of flux stripes and stripe arrays, and numerical studies of the highly nonlinear regime of those instabilities demonstrate patterns like those seen experimentally. Of particular interest is the buckling instability commonly seen in the intermediate state. The free-boundary approach further allows for a calculation of the elastic properties of the laminar state, which closely resembles that of smectic liquid crystals. We suggest several new experiments to explore of flux domain shape instabilities, including an Eckhaus instability induced by changing the out-of-plane magnetic field, and an analog of the Helfrich-Hurault instability of smectics induced by an in-plane field.Comment: 23 pages, 22 bitmapped postscript figures, RevTex 3.0, submitted to Phys. Rev. B. Higher resolution figures may be obtained by contacting the author

Photosynthetic growth despite a broken Q-cycle

Central in respiration or photosynthesis, the cytochrome bc1 and b6f complexes are regarded as functionally similar quinol oxidoreductases. They both catalyse a redox loop, the Q-cycle, which couples electron and proton transfer. This loop involves a bifurcated electron transfer step considered as being mechanistically mandatory, making the Q-cycle indispensable for growth. Attempts to falsify this paradigm in the case of cytochrome bc1 have failed. The rapid proteolytic degradation of b6f complexes bearing mutations aimed at hindering the Q-cycle has precluded so far the experimental assessment of this model in the photosynthetic chain. Here we combine mutations in Chlamydomonas that inactivate the redox loop but preserve high accumulation levels of b6f complexes. The oxidoreductase activity of these crippled complexes is sufficient to sustain photosynthetic growth, which demonstrates that the Q-cycle is dispensable for oxygenic photosynthesis

Cognitive behaviour therapy versus counselling intervention for anxiety in young people with high-functioning autism spectrum disorders: a pilot randomised controlled trial

The use of cognitive-behavioural therapy (CBT) as a treatment for children and adolescents with autism spectrum disorder (ASD) has been explored in a number of trials. Whilst CBT appears superior to no treatment or treatment as usual, few studies have assessed CBT against a control group receiving an alternative therapy. Our randomised controlled trial compared use of CBT against person-centred counselling for anxiety in 36 young people with ASD, ages 12–18. Outcome measures included parent- teacher- and self-reports of anxiety and social disability. Whilst each therapy produced improvements inparticipants, neither therapy was superior to the other to a significant degree on any measure. This is consistent with findings for adults

Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation

<p>Abstract</p> <p>Background</p> <p>Patients with psychosocial problems may benefit from a variety of community, educational, recreational and voluntary sector resources, but GPs often under-refer to these through lack of knowledge and time. This study evaluated the acceptability and effectiveness of graduate primary care mental health workers (GPCMHWs) facilitating access to voluntary and community sector services for patients with psychosocial problems.</p> <p>Methods</p> <p>Patients with psychosocial problems from 13 general practices in London were referred to a GPCMHW Community Link scheme providing information and support to access voluntary and community resources. Patient satisfaction, mental health and social outcomes, and use of primary care resources, were evaluated.</p> <p>Results</p> <p>108 patients consented to take part in the study. At three-month follow-up, 63 (58%) had made contact with a community service identified as suitable for their needs. Most were satisfied with the help provided by the GPCMHW in identifying and supporting access to a suitable service. There was a reduction in the number of patients with a probable mental health problem on the GHQ-12 from 83% to 52% (difference 31% (95% CI, 17% – 44%). Social adjustment improved and frequencies of primary care consultations and of prescription of psychotropic medications were reduced.</p> <p>Conclusion</p> <p>Graduates with limited training in mental health and no prior knowledge of local community resources can help patients with psychosocial problems access voluntary and community services, and patients value such a scheme. There was some evidence of effectiveness in reducing psychosocial and mental health problems.</p

Research to action to address inequities: the experience of the Cape Town Equity Gauge

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