title: Early changes, attrition, and dose-response in low intensity psychological interventions.
abstract: OBJECTIVE
  To investigate if early symptom changes in brief low intensity psychological interventions (guided self-help and psycho-education using cognitive behavioural therapy principles) are predictive of final treatment outcome.
  
  
  METHODS
  Retrospective cohort data analysis.
  
  
  METHODS
  Clinical records for 1,850 patients who screened positive for depression and/or an anxiety disorder were analysed. Reliable and clinically significant improvement (RCSI) on depression (Patient Health Questionnaire-9: PHQ-9) or anxiety (generalized anxiety disorder-7: GAD-7) outcome measures after treatment was the primary outcome. Change scores ≥6 on PHQ-9 and ≥5 on GAD-7 were taken as indicative of reliable improvement (RI). The model assumed that RI in the earliest treatment sessions would be predictive of RCSI post-treatment. Predictive accuracy was assessed by calculating the area under the curve (AUC), as well as positive and negative predictive values. Diagnostic odds ratios were also estimated, adjusting for confounders such as baseline severity, use of medication, and pre-treatment symptom change.
  
  
  RESULTS
  The AUC estimates for session-to-session change scores ranged between .62 and .88, indicative of modest to high predictive reliability. Predictive accuracy was higher for patients who had four or more treatment sessions, with more than 70% of patients with RCSI being accurately identified as early as sessions 1-3. Attrition rates were significantly associated with poor outcomes. Results suggest that at least four therapy sessions are necessary to achieve more than 50% RCSI rates, and the dose-response effect appears to decline in treatments longer than six sessions.
  
  
  CONCLUSIONS
  Patients showing RI early in treatment were at least twice as likely to fully recover compared to those without early RI.
authors.affiliation: Primary Care Mental Health Service, Leeds Community Healthcare NHS Trust, Leeds, UK.
authors.forename: Jaime
authors.initials: J
authors.lastname: Delgadillo
authors.forename: Dean
authors.initials: D
authors.lastname: McMillan
authors.forename: Mike
authors.initials: M
authors.lastname: Lucock
authors.forename: Chris
authors.initials: C
authors.lastname: Leach
authors.forename: Shehzad
authors.initials: S
authors.lastname: Ali
authors.forename: Simon
authors.initials: S
authors.lastname: Gilbody
mesh_terms: D000328:Adult; D001007:Anxiety / Q000523:psychology / Q000628:therapy; D001008:Anxiety Disorders / Q000523:psychology / Q000628:therapy*; D015928:Cognitive Behavioral Therapy / Q000379:methods*; D003863:Depression / Q000523:psychology / Q000628:therapy; D003866:Depressive Disorder / Q000523:psychology / Q000628:therapy*; D005260:Female; D006801:Humans; D007407:Interviews as Topic; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D011237:Predictive Value of Tests; D011574:Psychoanalytic Theory; D015203:Reproducibility of Results; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: IAPT; attrition; dose-response; early gains; psychosocial interventions