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      Engagement and outcomes for a computerised cognitive–behavioural therapy intervention for anxiety and depression in African Americans

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          Abstract

          Background

          Computerised cognitive–behavioural therapy (CCBT) helps improve mental health outcomes in White populations. However, no studies have examined whether CCBT is acceptable and beneficial for African Americans.

          Aims

          We studied differences in CCBT use and self-reported change in depression and anxiety symptoms among 91 African Americans and 499 White primary care patients aged 18–75, enrolled in a randomised clinical trial of collaborative care embedded with an online treatment for depression and anxiety.

          Method

          Patients with moderate levels of mood and/or anxiety symptoms (PHQ-9 or GAD-7≥10) were randomised to receive either care-manager-guided access to the proven-effective Beating the Blues ® CCBT programme or usual care from their primary care doctor.

          Results

          Compared with White participants, African Americans were less likely to start the CCBT programme ( P=0.01), and those who did completed fewer sessions and were less likely to complete the full programme ( P=0.03). Despite lower engagement, however, African Americans who started the CCBT programme experienced a greater decrease in self-reported depressive symptoms (estimated 8-session change: −6.6 v. −5.5; P=0.06) and similar decrease in anxiety symptoms (−5.3 v. −5.6; P=0.80) compared with White participants.

          Conclusions

          CCBT may be an efficient and scalable first-step to improving minority mental health and reducing disparities in access to evidence-based healthcare.

          Declaration of interest

          None.

          Copyright and usage

          © The Royal College of Psychiatrists 2017. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

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          Utility of a new procedure for diagnosing mental disorders in primary care. The PRIME-MD 1000 study.

          R L Spitzer, J. Williams, K Kroenke … (1994)
          To assess the validity and utility of PRIME-MD (Primary Care Evaluation of Mental Disorders), a new rapid procedure for diagnosing mental disorders by primary care physicians. Survey; criterion standard. Four primary care clinics. A total of 1000 adult patients (369 selected by convenience and 631 selected by site-specific methods to avoid sampling bias) assessed by 31 primary care physicians. PRIME-MD diagnoses, independent diagnoses made by mental health professionals, functional status measures (Short-Form General Health Survey), disability days, health care utilization, and treatment/referral decisions. Twenty-six percent of the patients had a PRIME-MD diagnosis that met full criteria for a specific disorder according to the Diagnostic and Statistical Manual of Mental Disorders, Revised Third Edition. The average time required of the primary care physician to complete the PRIME-MD evaluation was 8.4 minutes. There was good agreement between PRIME-MD diagnoses and those of independent mental health professionals (for the diagnosis of any PRIME-MD disorder, kappa = 0.71; overall accuracy rate = 88%). Patients with PRIME-MD diagnoses had lower functioning, more disability days, and higher rates of health care utilization than did patients without PRIME-MD diagnoses (for all measures, P < .005). Nearly half (48%) of 287 patients with a PRIME-MD diagnosis who were somewhat or fairly well-known to their physicians had not been recognized to have that diagnosis before the PRIME-MD evaluation. A new treatment or referral was initiated for 62% of the 125 patients with a PRIME-MD diagnosis who were not already being treated. PRIME-MD appears to be a useful tool for identifying mental disorders in primary care practice and research.
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            Prevalence and distribution of major depressive disorder in African Americans, Caribbean blacks, and non-Hispanic whites: results from the National Survey of American Life.

            David Williams, Hector M González, Harold Neighbors … (2007)
            Little is known about the relationship between race/ethnicity and depression among US blacks. To estimate the prevalence, persistence, treatment, and disability of depression in African Americans, Caribbean blacks, and non-Hispanic whites in the National Survey of American Life. A slightly modified adaptation of the World Health Organization World Mental Health version of the Composite International Diagnostic Interview. National household probability samples of noninstitutionalized African Americans, Caribbean blacks, and non-Hispanic whites in the United States conducted between February 2, 2001, and June 30, 2003. A total of 3570 African Americans, 1621 Caribbean blacks, and 891 non-Hispanic whites aged 18 years and older (N = 6082). Lifetime and 12-month diagnoses of DSM-IV major depressive disorder (MDD), 12-month mental health services use, and MDD disability as quantified using the Sheehan Disability Scale and the World Health Organization's Disability Assessment Schedule II. Lifetime MDD prevalence estimates were highest for whites (17.9%), followed by Caribbean blacks (12.9%) and African Americans (10.4%); however, 12-month MDD estimates across groups were similar. The chronicity of MDD was higher for both black groups (56.5% for African Americans and 56.0% for Caribbean blacks) than for whites (38.6%). Fewer than half of the African Americans (45.0%) and fewer than a quarter (24.3%) of the Caribbean blacks who met the criteria received any form of MDD therapy. In addition, relative to whites, both black groups were more likely to rate their MDD as severe or very severe and more disabling. When MDD affects African Americans and Caribbean blacks, it is usually untreated and is more severe and disabling compared with that in non-Hispanic whites. The burden of mental disorders, especially depressive disorders, may be higher among US blacks than in US whites.
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              Barriers to the uptake of computerized cognitive behavioural therapy: a systematic review of the quantitative and qualitative evidence.

              Emma Waller, S Gilbody (2009)
              Studies of cognitive behavioural therapy delivered by computer (cCBT) show clinical efficacy for treating anxiety and depression, but have not focused on barriers to uptake. Potential barriers include adverse consequences, accessibility and acceptability. An integrated systematic review was conducted of quantitative and qualitative studies and surveys from multiple electronic databases where computers delivered cCBT for anxiety or depression. Substantial numbers of potential participants are lost prior to trials commencing with little explanation. Among trial participants, drop-outs may be higher in the cCBT groups (odds ratio 2.03, 95% confidence interval 0.81-5.09). Only a median of 56% completed a full course of cCBT and personal circumstance was a more common cause of drop-out than difficulties with the technology or social background. Risk was rarely assessed in the majority of programs. Significant staff time was needed to support clients. Therapists were more negative about cCBT than clients. While cCBT is likely to be an effective and acceptable intervention for some people, there are barriers to its uptake that will substantially limit its impact if not addressed. These included investigating the outcome and attitudes of those who do not make it as far as cCBT trials and why so few finish a full course of cCBT.
              Article 0 comments Cited 178 times – based on 0 reviews     Review now
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                Author and article information

                Journal
                Journal ID (nlm-ta): BJPsych Open
                Journal ID (iso-abbrev): BJPsych Open
                Journal ID (publisher-id): bjporcpsych
                Journal ID (hwp): bjporcpsych
                Title: BJPsych Open
                Publisher: The Royal College of Psychiatrists
                ISSN (Electronic): 2056-4724
                Publication date (Electronic): 2 January 2017
                Publication date Collection: January 2017
                Volume: 3
                Issue: 1
                Pages: 1-5
                Affiliations
                [1] Charles R. Jonassaint, PhD, MHS, Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, USA
                [2] Patrice Gibbs, MS, Center for Research on Health Care Data Center, University of Pittsburgh, Pittsburgh, PA, USA
                [3] Bea Herbeck Belnap, Dr Biol Hum, Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, USA
                [4] Jordan F. Karp, MD, Department of Psychiatry, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA; Geriatric Research, Education, and Clinical Center, VA Pittsburgh Health System, Pittsburgh, PA, USA
                [5] Kaleab K. Abebe, PhD, Center for Clinical Trials & Data Coordination, University of Pittsburgh, Pittsburgh, PA, USA
                [6] Bruce L. Rollman, MD, MPH, Center for Behavioral Health and Smart Technology, University of Pittsburgh, Pittsburgh, PA, USA
                Author notes
                Correspondence: Charles R. Jonassaint, School of Medicine, University of Pittsburgh, 230 McKee Pl, Suite 600, Pittsburgh, PA 15213, USA. Email: jonassaintcr@ 123456upmc.edu
                Article
                Publisher ID: bjporcpsych003657
                DOI: 10.1192/bjpo.bp.116.003657
                PMC ID: 5204129
                PubMed ID: 28058109
                SO-VID: be24f414-a66f-459c-a295-777c64a408d3
                Copyright © © 2017 The Royal College of Psychiatrists
                License:

                This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license ( http://creativecommons.org/licenses/by-nc-nd/4.0/).

                History
                Date received : 21 July 2016
                Date revision received : 25 September 2016
                Date accepted : 27 November 2016
                Categories
                Subject: Paper

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