Improving Patient Reported Outcomes and Preventing Depression and Anxiety in Older Adults With Knee Osteoarthritis: Results of a Sequenced Multiple Assignment Randomized Trial (SMART) Study

Jordan F. Karp, Jun Zhang, Abdus S. Wahed, Stewart Anderson, Mary Amanda Dew, G. Kelley Fitzgerald, Debra K. Weiner, Steve Albert, Ari Gildengers, Meryl Butters, Charles F. Reynolds

Research output: Contribution to journalArticlepeer-review

8 Scopus citations

Abstract

Objective: Older adults with knee osteoarthritis (OA) and comorbid subsyndromal depressive symptoms are at elevated risk for incidental major depression or anxiety disorders. Using an indicated prevention paradigm, the authors conducted a sequenced multiple assignment randomized trial (SMART) to: 1) evaluate the effect of cognitive behavioral therapy (CBT) and physical therapy (PT), together with the temporal ordering of these interventions, on patient-reported global impression of change (P-GIC), mood, anxiety, and pain; and 2) compare the strategies’ impact on incidence of common psychiatric disorders over 12-months. Methods: This intervention development trial compared four adaptive strategies delivered in two stages (each up to 8 weeks), contrasted with enhanced usual care (EUC). The strategies were CBT followed by an increased dose of CBT (CBT-CBT), CBT followed by PT (CBT-PT), PT followed by an increased dose of PT (PT-PT), and PT followed by CBT (PT-CBT). Participants (n = 99) were aged 60 years and older and met clinical criteria for knee OA and subthreshold depression. Response was defined as at least “much better” on the P-GIC. Participants were assessed quarterly for 12 months for incidence of psychiatric disorders. Results: Stage 1 response was higher for PT (47.5%) compared to CBT (20.5%). Non-responders receiving an additional dose of the same intervention experienced a response rate of 73%, higher than for switching to a different intervention. All strategies were superior to EUC (5%). Although not powered to detect effects on disorders, neither intervention strategy nor response status affected 12-month incidence of depression and anxiety disorders. Conclusion: As response rates were similar for PT-PT and CBT-CBT, it may be dose and not type of these interventions that are necessary for clinical benefit. For non-responders, this finding may guide providers to stay the clinical course for up to 12 weeks before switching. These results support future trials of SMART designs in late-life depression prevention.

Original languageEnglish (US)
Pages (from-to)1035-1045
Number of pages11
JournalAmerican Journal of Geriatric Psychiatry
Volume27
Issue number10
DOIs
StatePublished - Oct 2019
Externally publishedYes

Keywords

  • anxiety
  • cognitive behavioral therapy
  • depression
  • Knee arthritis
  • physical therapy
  • prevention

ASJC Scopus subject areas

  • Geriatrics and Gerontology
  • Psychiatry and Mental health

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