Preventing mood and anxiety disorders in youth: a multi-centre RCT in the high risk offspring of depressed and anxious patients

<p>Abstract</p> <p>Background</p> <p>Anxiety and mood disorders are highly prevalent and pose a huge burden on patients. Their offspring is at increased risk of developing these disorders as well, indicating a clear need for prevention of psychopathology in this group. Given high comorbidity and non-specificity of intergenerational transmission of disorders, prevention programs should target both anxiety and depression. Further, while the indication for preventive interventions is often elevated symptoms, offspring with other high risk profiles may also benefit from resilience-based prevention programs.</p> <p>Method/design</p> <p>The current STERK-study (Screening and Training: Enhancing Resilience in Kids) is a randomized controlled clinical trial combining selected and indicated prevention: it is targeted at both high risk individuals without symptoms and at those with subsyndromal symptoms. Individuals without symptoms meet two of three criteria of the High Risk Index (HRI; female gender, both parents affected, history of a parental suicide (attempt). This index was developed in an earlier study and corresponds with elevated risk in offspring of depressed patients. Children aged 8–17 years (n = 204) with subthreshold symptoms or meeting the criteria on the HRI are randomised to one of two treatment conditions, namely (a) 10 weekly individual child CBT sessions and 2 parent sessions or (b) minimal information. Assessments are held at pre-test, post-test and at 12 and 24 months follow-up. Primary outcome is the time to onset of a mood or anxiety disorder in the offspring. Secondary outcome measures include number of days with depression or anxiety, child and parent symptom levels, quality of life, and cost-effectiveness. Based on models of aetiology of mood and anxiety disorders as well as mechanisms of change during interventions, we selected potential mediators and moderators of treatment outcome, namely coping, parent–child interaction, self-associations, optimism/pessimism, temperament, and emotion processing.</p> <p>Discussion</p> <p>The current intervention trial aims to significantly reduce the risk of intergenerational transmission of mood and anxiety disorders with a short and well targeted intervention that is directed at strengthening the resilience in potentially vulnerable children. We plan to evaluate the effectiveness and cost-effectiveness of such an intervention and to identify mechanisms of change.</p> <p>Trial registration</p> <p>NTR2888</p

Comparative analysis of algorithm-guided treatment and predefined duration treatment programmes for depression: exploring cost-effectiveness using routine care data.

BACKGROUND: More knowledge on the cost-effectiveness of various depression treatment programmes can promote efficient treatment allocation and improve the quality of depression care.OBJECTIVE: This study aims to compare the real-world cost-effectiveness of an algorithm-guided programme focused on remission to a predefined duration, patient preference-centred treatment programme focused on response using routine care data.METHODS: A naturalistic study (n=6295 in the raw dataset) was used to compare the costs and outcomes of two programmes in terms of quality-adjusted life years (QALY) and depression-free days (DFD). Analyses were performed from a healthcare system perspective over a 2-year time horizon. Incremental cost-effectiveness ratios were calculated, and the uncertainty of results was assessed using bootstrapping and sensitivity analysis.FINDINGS: The algorithm-guided treatment programme per client yielded more DFDs (12) and more QALYs (0.013) at a higher cost (€3070) than the predefined duration treatment programme. The incremental cost-effectiveness ratios (ICERs) were around €256/DFD and €236 154/QALY for the algorithm guided compared with the predefined duration treatment programme. At a threshold value of €50 000/QALY gained, the programme had a probability of &lt;10% of being considered cost-effective. Sensitivity analyses confirmed the robustness of these findings.CONCLUSIONS: The algorithm-guided programme led to larger health gains than the predefined duration treatment programme, but it was considerably more expensive, and hence not cost-effective at current Dutch thresholds. Depending on the preferences and budgets available, each programme has its own benefits.CLINICAL IMPLICATION: This study provides valuable information to decision-makers for optimising treatment allocation and enhancing quality of care cost-effectively.</p

The clinical effectiveness of an algorithm-guided treatment program for depression in specialized mental healthcare: A comparison with efficacy trials.

Background: Doubts exist on whether effects found in randomized controlled trials (RCTs) are directly generalizable to daily clinical practice. This study aimed (a) to investigate the effectiveness of treatment options within an algorithm-guided treatment (AGT) program for depression and compare their effectiveness with outcomes of efficacy trials and (b) to assess the relation between treatment continuity and outcomes. Methods: This naturalistic study linked treatment data from January 2012 to November 2014 from a Dutch mental healthcare provider, to routine outcome monitoring (ROM) data (N = 351). Effectiveness of the treatment options (pharmacotherapy, psychotherapy and their combination) was compared to the efficacy reported in the meta-analyses. We included treatment continuity as binary variable "early terminators versus completers of the recommended number of treatment sessions". Results: Remission rates for psychotherapy (38% [95% CI: 32-45]), pharmacotherapy (31% [95% CI: 22-42]) and combination therapy (46% [95% CI: 19-75]) were respectively lower, comparable, and comparable to those reported in the meta-analyses. Similarly, response rates were respectively lower (24% [95% CI: 19-30]), lower (21% [95% CI: 13-31]), and comparable (46% [95% CI: 19-75]) to meta-analyses results. A similar share of early terminators and completers achieved remission and response. Limitations: A substantial proportion of patients had incomplete ROM data after data linkage. Limited set of patient characteristics to check for selection bias. Conclusions: Despite the more heterogeneous patient population in clinical practice, the effectiveness of an AGT program, emphasizing strict guideline adherence, approached that found in RCTs. A fixed number of treatment sessions may not suit all individual patients

Doomed for Disorder? High Incidence of Mood and Anxiety Disorders in Offspring of Depressed and Anxious Patients:A Prospective Cohort Study

Objective: Early recognition of individuals at risk for depressive and anxiety disorders is key in influencing onset and course of these disorders. Parental history is a potent risk factor for the development of these disorders in offspring. However, knowledge about the magnitude of this risk is limited as large-scale longitudinal studies with a follow-up into adulthood are scarce. Those offspring at highest risk may possibly be identified by easy-to-determine parental psychiatric characteristics, family context, and offspring characteristics. Methods: From 2000-2002, we recruited 523 offspring (age 13-25 years) of 366 patients who had received specialized treatment for depressive and/or anxiety disorder. Offspring DSM-IV mood (major depressive disorder, dysthymia, and bipolar disorder) and anxiety disorders (generalized anxiety disorder, social phobia, panic disorder, and agoraphobia) were assessed at baseline and at 4-, 6-, 8-, and 10-year follow-up. Results: Kaplan-Meier analysis showed that the cumulative incidence of mood and/or anxiety disorder was 38.0% at age 20 years and 64.7% at age 35 years. Parental early disorder onset (hazard ratio [HR] = 1.33; 95% CI, 1.00-1.77), having 2 affected parents (HR = 1.58; 95% CI, 1.10-2.27), and offspring female gender (HR = 2.34; 95% CI, 1.74-3.15) were independent predictors of offspring mood and/or anxiety disorder. Balanced family functioning (HR = 0.73; 95% CI, 0.56-0.96) was found to be protective against offspring risk. Conclusions: Offspring of depressed and anxious patients are at very high risk of a mood and/or anxiety disorder themselves. Parental early onset, having 2 affected parents, female gender, and family functioning are important additional markers that can be used in clinical practice to identify those offspring at greatest risk