Publications (34)112.91 Total impact
- [Show abstract] [Hide abstract] ABSTRACT: Importance Adolescents whose parents have a history of depression are at risk for developing depression and functional impairment. The long-term effects of prevention programs on adolescent depression and functioning are not known.Objective To determine whether a cognitive-behavioral prevention (CBP) program reduced the incidence of depressive episodes, increased depression-free days, and improved developmental competence 6 years after implementation.Design, Setting, and Participants A 4-site randomized clinical trial compared the effect of CBP plus usual care vs usual care, through follow-up 75 months after the intervention (88% retention), with recruitment from August 2003 through February 2006 at a health maintenance organization, university medical centers, and a community mental health center. A total of 316 participants were 13 to 17 years of age at enrollment and had at least 1 parent with current or prior depressive episodes. Participants could not be in a current depressive episode but had to have subsyndromal depressive symptoms or a prior depressive episode currently in remission. Analysis was conducted between August 2014 and June 2015.Interventions The CBP program consisted of 8 weekly 90-minute group sessions followed by 6 monthly continuation sessions. Usual care consisted of any family-initiated mental health treatment.Main Outcomes and Measures The Depression Symptoms Rating scale was used to assess the primary outcome, new onsets of depressive episodes, and to calculate depression-free days. A modified Status Questionnaire assessed developmental competence (eg, academic or interpersonal) in young adulthood.Results Over the 75-month follow-up, youths assigned to CBP had a lower incidence of depression, adjusting for current parental depression at enrollment, site, and all interactions (hazard ratio, 0.71 [95% CI, 0.53-0.96]). The CBP program’s overall significant effect was driven by a lower incidence of depressive episodes during the first 9 months after enrollment. The CBP program’s benefit was seen in youths whose index parent was not depressed at enrollment, on depression incidence (hazard ratio, 0.54 [95% CI, 0.36-0.81]), depression-free days (d = 0.34, P = .01), and developmental competence (d = 0.36, P = .04); these effects on developmental competence were mediated via the CBP program’s effect on depression-free days.Conclusions and Relevance The effect of CBP on new onsets of depression was strongest early and was maintained throughout the follow-up period; developmental competence was positively affected 6 years later. The effectiveness of CBP may be enhanced by additional booster sessions and concomitant treatment of parental depression.Trial Registration clinicaltrials.gov Identifier:NCT00073671
- [Show abstract] [Hide abstract] ABSTRACT: To describe acupuncture and chiropractic use among patients with chronic musculoskeletal pain (CMP) at a health maintenance organization, and explore issues of benefit design and electronic medical record (EMR) capture. Cross-sectional survey. Kaiser Permanente members meeting EMR diagnostic criteria for CMP were invited to participate. The survey included questions about self-identified presence of CMP, use of acupuncture and chiropractic care, use of ancillary self-care modalities, and communication with conventional medicine practitioners. Analysis of survey data was supplemented with a retrospective review of EMR utilization data. Of 6068 survey respondents, 32% reported acupuncture use, 47% reported chiropractic use, 21% used both, and 42% used neither. For 25% of patients using acupuncture and 43% of those using chiropractic care, utilization was undetected by the EMR. Thirty-five percent of acupuncture users and 42% of chiropractic users did not discuss this care with their health maintenance organization (HMO) clinicians. Among chiropractic users, those accessing care out of plan were older (P < .01), were more likely to use long-term opioids (P = .03), and had more pain diagnoses (P = .01) than those accessing care via clinician referral or self-referral. For acupuncture, those using the clinician referral mechanism exhibited these same characteristics. A majority of participants had used acupuncture, chiropractic care, or both. While benefit structure may materially influence utilization patterns, many patients with CMP use acupuncture and chiropractic care without regard to their insurance coverage. A substantial percentage of acupuncture and chiropractic use thus occurs beyond detection of EMR systems, and many patients do not report such care to their HMO clinicians.
- [Show abstract] [Hide abstract] ABSTRACT: We tested whether augmenting conventional depression treatment in youth by treating sleep issues with cognitive behavioral therapy for insomnia (CBT-I) improved depression outcomes. We randomized youth 12-20 years of age to 10 weekly sessions of a sleep hygiene control condition (SH) combined with CBT for depression (CBT-D) (n = 20), or an experimental condition consisting of CBT-I combined with CBT-D (n = 21). We assessed outcomes through 26 weeks of follow-up and found medium-large effects favoring the experimental CBT-I arm on some sleep outcomes (actigraphy total sleep time and Insomnia Severity Index "caseness") and depression outcomes (higher percentage recovered, faster time to recovery), but little effect on other measures. Total sleep time improved by 99 min from baseline to week 12 in the CBT-I arm, but not in the SH arm. In addition, our pilot yielded important products to facilitate future studies: the youth-adapted CBT-I program; the study protocol; estimates of recruitment, retention, and attrition; and performance and parameters of candidate outcome measures. ClinicalTrials.gov Identifier NCT00949689. Copyright © 2015 Elsevier Ltd. All rights reserved.
- [Show abstract] [Hide abstract] ABSTRACT: Purpose: To evaluate long-term cost effectiveness of the “Prevention of depression in at-risk adolescents” (POD) randomized control trial from a societal perspective. Method: The POD trial was designed to establish clinical and cost effectiveness of a cognitive behavioral prevention program (CBP) compared to usual care (UC). Participants were assessed at baseline, 3, 9, 21, and 33 months post baseline. Depression-free-days (DFDs), the primary clinical outcome in the cost effectiveness analysis, were calculated from the Children’s Depression Rating Scale (CDRS). Cost data were collected concurrently through the Child and Adolescent Services Assessment (CASA), financial records, and interviews with study staff. The population studied was a community sample collected from four US sites of adolescents whose parent(s) had a history depression (N=316). Participants were 13-17 years old and had a prior depressive episode and/or current subsyndromal depressive symptoms. Result: Analyses were conducted on the 268 participants (85% of the sample) who had complete data. Total costs were not significantly different between groups (p=.437), although on average costs were higher in CBP (M=4,344, SD=23,435) than UC (M=2,910, SD=7,574). DFDs were significantly (p < .05) greater in CBP (M=882.1, SD=167.7) than UC (M=836.6, SD=198.5). Calculation of an incremental cost effectiveness ratio resulted in 31.55 dollars (2009 US) per additional DFD. Instrumentation to isolate the causal effects of participation in CBP on costs and outcomes is currently underway, as is multiple imputation of missing data. Conclusion: The CBP intervention was significantly better than UC with regard to the number of DFDs through the longer-term follow-up in this community sample of adolescents at high risk for depression. The primary clinical and cost effectiveness analyses of the POD trial, conducted with data through the nine month assessment, found strong clinical effects that were shown to be cost effective by widely accepted guidelines (Lynch et al., 2011). The longer-term incremental cost effectiveness ratio of DFDs is consistent with results of our short-term cost effectiveness analyses, supporting the sustainability of these effects. Thus, results from both the short- and longer-term analyses provide important information about the strength and durability of CBP in preventing depression in high-risk adolescents.
- [Show abstract] [Hide abstract] ABSTRACT: There is a need for treatment interventions to address the high prevalence of disordered eating throughout adolescence and early adulthood. We developed an adolescent-specific manualized CBT protocol to treat female adolescents with recurrent binge eating and tested its efficacy in a small, pilot randomized controlled trial. We present lessons learned in recruiting adolescents, a description of our treatment approach, acceptability of the treatment for teens and parents, as well as results from the pilot trial. Participants in the CBT group had significantly fewer posttreatment eating binges than those in a treatment as usual/delayed treatment (TAU-DT) control group; 100% of CBT participants were abstinent at follow-up. Our results provide preliminary support for the efficacy of this adolescent adaptation of evidence-based CBT for recurrent binge eating. The large, robust effect size estimate observed for the main outcome (NNT=2) places this among the larger effects observed for any mental health intervention.
- [Show abstract] [Hide abstract] ABSTRACT: Of 1 million cases of child maltreatment identified every year in the United States, one-fifth result in foster care. Many of these children suffer from significant emotional and behavioral conditions. Decision-makers must allocate highly constrained budgets to serve these children. Recent evidence suggests that Multidimensional Treatment Foster Care for Preschoolers can reduce negative outcomes for these children, but the relative benefits and costs of the program have not been evaluated. The objective of this study was to assess net benefit, over 24 months, of Multidimensional Treatment Foster Care for Preschoolers compared to regular foster care. Data were from a randomized controlled trial of 117 young children entering a new foster placement. A subsample exhibited placement instability (n = 52). Intervention services including parent training, lasted 9–12 months. Multidimensional Treatment Foster Care for Preschoolers significantly increased permanent placements for the placement instability sample. Average total cost for the new intervention sample was significantly less than for regular foster care (full sample: $27,204 vs. $30,090; P = .004; placement instability sample: $29,595 vs. $36,061; P = .045). Incremental average net benefit was positive at all levels of willingness to pay of zero or greater, indicating that the value of benefits exceeded costs. Multidimensional Treatment Foster Care for Preschoolers has significant benefit for preschool children in foster care with emotional and behavioral disorders compared to regular foster care services. At even modest levels of willingness to pay, benefits exceed costs indicating a strong likeliness that this program is an efficient choice for improving outcomes for young children with emotional and behavioral disorders in foster care.
- [Show abstract] [Hide abstract] ABSTRACT: Background/Aims Adolescent depression is common and leads to many negative personal, social, and economic consequences for youth and their families; unfortunately, most youth who experience major depression do not receive any treatment. Depression prevention programs can reduce these negative consequences, but they must be affordable to be widely disseminated and useful for health care systems. Decision-makers need to weigh relative costs and benefits of providing efficacious prevention programs to depressed adolescents, but little cost-effectiveness analysis exists. The Prevention of Depression trial (POD) was a brief prevention program that compared a group cognitive- behavioral preventive (CBP) intervention to usual care (UC) to reduce depression risk in at-risk youth; the intervention decreased the number of days with depression. We present an incremental cost- effectiveness analysis of the group CBP program relative to UC, from the societal perspective, for 9 months following the intervention. Methods POD was conducted in four U.S. academic and community clinics. Participants were 316 youth aged 13-17 with a past history of depression and/or current elevated, but sub-diagnostic, depressive symptoms. They were randomly assigned to the CBP group consisting of 8 weekly, 90- minute group sessions followed by 6 monthly continuation sessions or to UC alone. The main clinical outcome measures were depression-free days (DFD) and quality-adjusted life-years based on DFD (DFD-QALYs). Costs of intervention, non-protocol services, and families were included. Results CBP achieved 13 additional DFD (p=.008), 0.022 more DFD-QALYs (p=.008). CBP cost $591 (SD=286) on average. Cost per DFD was $59 (ICER = $59; 95% CI: 11-263), $35,434 per DFD-QALY (ICER=$35,434; 95% CI: 6,350 - 157,594). Cost-effectiveness acceptability curve analyses suggest a 69% probability that CBP is more cost-effective at a willingness to pay of $50,000 per QALY. CBP had a higher net benefit for youth whose parent's depression was in remission at baseline. Discussion The societal cost-effectiveness of POD is comparable to or better than that of many health care services currently covered under most insurance programs. The program is particularly cost effective for the sub-group of youth whose parent's depression was in remission at baseline.
- [Show abstract] [Hide abstract] ABSTRACT: Background/Aims Care of children with mental health and developmental conditions (MHC) is often demanding and expensive, imposing both financial and time costs on families. Because costs to families are relatively difficult to quantify, most studies have focused on studying family costs using health system data which are more readily available. Few studies have collected cost data directly from families. Methods This study presents results of psychometric analyses of a new instrument that directly measures family costs, the Family Economic Impact Interview (FEII). Reliability and validity of the FEII was evaluated as part of a developmental study which recruited a random sample of 70 parents of children with MHC between the ages of 3 and 12 years old from a large integrated health system. Parents were invited to participate in two interviews within a two week time period. Kappa statistics were calculated to evaluate the agreement between categorical variables. Results We used standard cut off values (values over .75 - excellent agreement, values between .40 and .75 - good agreement, and values less than .40 - poor agreement). Reliability of parents' reports of time spent in activities related to MHC were also good. In 20 of 24 time use categories, kappas ranged from .60 to 1.00. Validity of the FEII was assessed by examining the relationship between the degree of emotional burden a parent perceived from MHC and the amount of family costs measured by the FEII. We used regression analyses to examine whether there was a significant relationship between the main FEII outcomes and family emotional burden. Discussion As hypothesized, we found significant positive association between emotional burden of care and family costs (p<.001). Preliminary analyses of the FEII indicate that a wide range of parents' can complete the FEII, that parents' can reliably report a variety of family costs including out-of-pocket financial costs and time costs, and that many families with children with MHC experience a wide range of costs - many of which have not been measured in previous studies.
- [Show abstract] [Hide abstract] ABSTRACT: To identify symptom dimensions of depression that predict recovery among selective serotonin reuptake inhibitor (SSRI) treatment-resistant adolescents undergoing second-step treatment. The Treatment of Resistant Depression in Adolescents (TORDIA) trial included 334 SSRI treatment-resistant youth randomized to a medication switch, or a medication switch plus CBT. This study examined five established symptom dimensions (Child Depression Rating Scale-Revised) at baseline as they predicted recovery over 24 weeks of acute and continuation treatment. The two indices of recovery that were evaluated were time to remission and number of depression-free days. Multivariate analyses examining all five depression symptom dimensions simultaneously indicated that anhedonia was the only dimension to predict a longer time to remission, and also the only dimension to predict fewer depression-free days. In addition, when anhedonia and CDRS-total score were evaluated simultaneously, anhedonia continued to uniquely predict longer time to remission and fewer depression-free days. Anhedonia may represent an important negative prognostic indicator among treatment-resistant depressed adolescents. Further research is needed to elucidate neurobehavioral underpinnings of anhedonia, and to test treatments that target anhedonia in the context of overall treatment of depression.
- [Show abstract] [Hide abstract] ABSTRACT: Most clinic-based weight control treatments for youth have been designed for preadolescent children by using family-based care. However, as adolescents become more autonomous and less motivated by parental influence, this strategy may be less appropriate. This study evaluated a primary care-based, multicomponent lifestyle intervention specifically tailored for overweight adolescent females. Adolescent girls (N = 208) 12 to 17 years of age (mean ± SD: 14.1 ± 1.4 years), with a mean ± SD BMI percentile of 97.09 ± 2.27, were assigned randomly to the intervention or usual care control group. The gender and developmentally tailored intervention included a focus on adoptable healthy lifestyle behaviors and was reinforced by ongoing feedback from the teen's primary care physician. Of those randomized, 195 (94%) completed the 6-month posttreatment assessment, and 173 (83%) completed the 12-month follow-up. The primary outcome was reduction in BMI z score. The decrease in BMI z score over time was significantly greater for intervention participants compared with usual care participants (-0.15 in BMI z score among intervention participants compared with -0.08 among usual care participants; P = .012). The 2 groups did not differ in secondary metabolic or psychosocial outcomes. Compared with usual care, intervention participants reported less reduction in frequency of family meals and less fast-food intake. A 5-month, medium-intensity, primary care-based, multicomponent behavioral intervention was associated with significant and sustained decreases in BMI z scores among obese adolescent girls compared with those receiving usual care.
- [Show abstract] [Hide abstract] ABSTRACT: Antidepressant (AD) dispensing for depression in youth declined in the years following the 2003-04 Food and Drug Administration actions regarding increased risk of suicidal behavior. To extend observation of youth AD dispensing and associated characteristics through 2009 to determine if AD dispensing continues to decline, has stabilized, or has rebounded. Design: Retrospective time series design. Sample: Youth (n=57,782) ages 10 to 17 inclusive. Both new (incident) and refill AD dispensing continued to decline through 2009, with no sign of leveling off. However, among youth who started AD treatment the cumulative supply of AD medication remained consistent across the pre- and postperiods, suggesting that cumulative treatment episode duration has not been degraded--possibly as a function of greater days supply with each new refill in the postperiod. Prescribers dramatically curtailed preauthorized refills in the postwarning period. Declines in AD dispensing to depressed youth may not reflect less intensive treatment for those youth who persist beyond the initial dispense. Lower rates of preauthorized refills may have been an attempt by prescribers to encourage return visits to evaluate response and adverse consequences.
- [Show abstract] [Hide abstract] ABSTRACT: Substantial recent research examines the efficacy of many types of complementary and alternative (CAM) therapies. However, outcomes associated with the "real-world" use of CAM has been largely overlooked, despite calls for CAM therapies to be studied in the manner in which they are practiced. Americans seek CAM treatments far more often for chronic musculoskeletal pain (CMP) than for any other condition. Among CAM treatments for CMP, acupuncture and chiropractic (A/C) care are among those with the highest acceptance by physician groups and the best evidence to support their use. Further, recent alarming increases in delivery of opioid treatment and surgical interventions for chronic pain--despite their high costs, potential adverse effects, and modest efficacy--suggests the need to evaluate real world outcomes associated with promising non-pharmacological/non-surgical CAM treatments for CMP, which are often well accepted by patients and increasingly used in the community. This multi-phase, mixed methods study will: (1) conduct a retrospective study using information from electronic medical records (EMRs) of a large HMO to identify unique clusters of patients with CMP (e.g., those with differing demographics, histories of pain condition, use of allopathic and CAM health services, and comorbidity profiles) that may be associated with different propensities for A/C utilization and/or differential outcomes associated with such care; (2) use qualitative interviews to explore allopathic providers' recommendations for A/C and patients' decisions to pursue and retain CAM care; and (3) prospectively evaluate health services/costs and broader clinical and functional outcomes associated with the receipt of A/C relative to carefully matched comparison participants receiving traditional CMP services. Sensitivity analyses will compare methods relying solely on EMR-derived data versus analyses supplementing EMR data with conventionally collected patient and clinician data. Successful completion of these aggregate aims will provide an evaluation of outcomes associated with the real-world use of A/C services. The trio of retrospective, qualitative, and prospective study will also provide a clearer understanding of the decision-making processes behind the use of A/C for CMP and a transportable methodology that can be applied to other health care settings, CAM treatments, and clinical populations. ClinicalTrials.gov: NCT01345409.
- [Show abstract] [Hide abstract] ABSTRACT: To compare health-care utilization between participants who met DSM-IV criteria for binge eating disorder (BED) and those engaged in recurrent binge eating (RBE) and to evaluate whether objective binge eating (OBE) days, a key measurement for diagnosing BED, predicted health-care costs. We obtained utilization and cost data from electronic medical records to augment patient reported data for 100 adult female members of a large health maintenance organization who were enrolled in a randomized clinical trial to treat binge eating. Total costs did not differ between the BED and RBE groups (β = -0.117, z = -0.48, p = .629), nor did the number of OBE days predict total costs (β = -0.017, z = -1.01, p = .313). Findings suggest that the medical impairment, as assessed through health care costs, caused by BED may not be greater than impairment caused by RBE. The current threshold number of two OBE days/week as a criterion for BED may need to be reconsidered.
- [Show abstract] [Hide abstract] ABSTRACT: The aim of this study was to replicate and extend results of a previous blended efficacy and effectiveness trial of a low-intensity, manual-based guided self-help form of cognitive-behavioral therapy (CBT-GSH) for the treatment of binge eating disorders in a large health maintenance organization (HMO) and to compare them with usual care. To extend previous findings, the investigators modified earlier recruitment and assessment approaches and conducted a randomized clinical trial to better reflect procedures that may be reasonably carried out in real-world practices. The intervention was delivered by master's-level interventionists to 160 female members of a health maintenance organization who met diagnostic criteria for recurrent binge eating. Data collected at baseline, immediately posttreatment, and at six- and 12-month follow-ups were used in intent-to-treat analyses. At the 12-month follow-up, CBT-GSH resulted in greater remission from binge eating (35%, N=26) than usual care (14%, N=10) (number needed to treat=5). The CBT-GSH group also demonstrated greater improvements in dietary restraint (d=.71) and eating, shape, and weight concerns (d=1.10, 1.24, and .98, respectively) but not weight change. Replication of the pattern of previous findings suggests that CBT-GSH is a robust treatment for patients with recurrent binge eating. The magnitude of changes was significantly smaller than in the original study, however, suggesting that patients recruited and assessed with less intensive procedures may respond differently from their counterparts enrolled in trials requiring more comprehensive procedures.
- [Show abstract] [Hide abstract] ABSTRACT: Many youth with depression do not respond to initial treatment with selective serotonin reuptake inhibitors (SSRIs), and this is associated with higher costs. More effective treatment for these youth may be cost-effective. To evaluate the incremental cost-effectiveness over 24 weeks of combined cognitive behavior therapy plus switch to a different antidepressant medication vs medication switch only in adolescents who continued to have depression despite adequate initial treatment with an SSRI. Randomized controlled trial. Six US academic and community clinics. Three hundred thirty-four patients aged 12 to 18 years with SSRI-resistant depression. Participants were randomly assigned to (1) switch to a different medication only or (2) switch to a different medication plus cognitive behavior therapy. Clinical outcomes were depression-free days (DFDs), depression-improvement days (DIDs), and quality-adjusted life-years based on DFDs (DFD-QALYs). Costs of intervention, nonprotocol services, and families were included. Combined treatment achieved 8.3 additional DFDs (P = .03), 0.020 more DFD-QALYs (P = .03), and 11.0 more DIDs (P = .04). Combined therapy cost $1633 more (P = .01). Cost per DFD was $188 (incremental cost-effectiveness ratio [ICER] = $188; 95% confidence interval [CI], -$22 to $1613), $142 per DID (ICER = $142; 95% CI, -$14 to $2529), and $78,948 per DFD-QALY (ICER = $78,948; 95% CI, -$9261 to $677,448). Cost-effectiveness acceptability curve analyses suggest a 61% probability that combined treatment is more cost-effective at a willingness to pay $100,000 per QALY. Combined treatment had a higher net benefit for subgroups of youth without a history of abuse, with lower levels of hopelessness, and with comorbid conditions. For youth with SSRI-resistant depression, combined treatment decreases the number of days with depression and is more costly. Depending on a decision maker's willingness to pay, combined therapy may be cost-effective, particularly for some subgroups. clinicaltrials.gov Identifier: NCT00018902.
Kaiser PermanenteOakland, California, United States