Predicting development and psychological treatment outcome of common mental health problems (CMHP) in older adults.

Anxiety and Depression in Older People PhD Scholarship 2019: School of Psychology, University of Sussex

Supervisor: Dr Darya Gaysina, Dr Clara Strauss, Dr Nick Grey

Lay Summary:

One in five older adults is affected with depression and/or anxiety and needs professional help. Improving Access to Psychological Therapies (IAPT) services are open to all adults, however very fewer older adults access it, and only half of those who receive treatment get better. Because our population is getting older, we urgently need to know who are at a higher risk of depression and anxiety in late adulthood, and how to develop effective treatments for everyone. This PhD project will identify predictors of depression and anxiety, and outcomes of psychological treatments, in older adults. To achieve this, two complementary approaches will be used. First, the project will develop a new prediction model for depression and anxiety using data from the oldest British birth cohort that follows >5000 men and women born in Britain in 1946 through their entire life (up to age 69). Second, the project will test whether tools to identify the risk of depression and anxiety could be used to predict who will benefit most from psychological treatments offered by the IAPT service. Findings of the project will have important implications for developing more effective preventions and treatments against depression and anxiety in late life.

Research Student Student: Alexandra Schmidt

Hello, I’m Ali and I’m due to start my PhD at the University of Sussex in September 2019.

Following a successful professional career in Finance, I completed an Access to Higher Education Diploma in Psychology from City College Brighton & Hove. During this time, I also volunteered at a day centre for people living with a personality disorder.

I have recently completed my undergraduate degree at the University of Sussex, where I graduated with a first class honours. For my dissertation, I investigated the effects of lifetime physical activity on cognitive function and mental health in midlife.

I have gained research experience as a Junior Research Assistant programme at the University of Sussex during which I looked at the association between physical activity and depressive symptoms for individuals having had adverse childhood experiences. I presented my findings in poster exhibitions and a national conference. I further volunteered as a Research Assistant supporting a study looking at the association between sleep and cognitive function in older adults.

Depression and anxiety are highly prevalent in older people and are often viewed as normal part of growing old. Volunteering as a befriender for elderly people I have experienced the effects of social isolation, which is one of the contributors to depression in older life and I am therefore eager to start my research into the predictors for development and treatment of depression and anxiety in older people.

I look forward to working with Dr Darya Gaysina, Dr Nick Grey and Dr Clara Strauss and am very grateful to Mental Health Research UK for this fantastic opportunity.

Scientific Goal: The scientific goal of the proposed PhD project is to identify factors that contribute to an increased risk of common mental disorders, such as depression and anxiety, in older adults. Specifically, key research objectives are: 1) to identify the state of the art and gaps in the existing research on predictors of common mental disorders, as well as on access, use, and outcomes of psychological treatments, in older adults; 2) to develop a new prediction model using information on multiple risk and protective factors for the development of common mental disorders in a general population; 3) to investigate whether tools to identify the risk of common mental disorders could be integrated into health care services to predict engaging with and benefitting from current psychological treatments offered by the Improving Access to Psychological Therapies (IAPT) services.

Progress Report Year 4 2023

Background to my PhD research

My PhD has three main aims:

To conduct a systematic literature review and meta-analysis on predictors of psychological treatment outcomes for older adults.
To investigate predictors for engagement in and outcome of psychological treatment for NHS Talking Therapy (formerly IAPT) service users
To explore risk factors and their combination and develop prediction models for CMHP, taking a life-course approach in a nationally representative cohort.

My 4th year (part-time)

Systematic literature review

The systematic literature review is complete and the revisions to the manuscript addressing the reviewers’ comments were submitted in September 2022. I am currently waiting to hear back from the journal. Last month, I was pleased to be able to share the findings of my review at the European Congress of Psychology in Brighton.

PRedictors Of Psychological trEatment outcomes for common mentaL health problems in the NHS Talking Therapy Services (formerly IAPT) service users (‘PROPEL’)

The main focus of this year was to progress my study in the NHS Talking Therapy Services (formerly IAPT). After the initial engagement with several sites, it became apparent that due to the (sometimes) long waiting and treatment times in the NHS Talking Therapy Services, more time was needed to allow the study run its course and to be able to collect complete post-treatment data. I therefore decided to move my PhD part-time from September 2022 and I am grateful to MHRUK for agreeing to this approach. The recruitment of participants ran from July 2022 to March 2023, and the second phase of obtaining NHS system data is due to complete in March 2024. Overall, we recruited over 1,200 participants across 21 different sites across England. The overall sample met and exceeded our original target which I was very pleased with. During this time, I have met and worked with many amazingly supportive NHS Talking Therapy staff, and I am very grateful for the effort and enthusiasm they have shown in recruiting for the study.

Results from preliminary analyses on the baseline measures of the study indicate some differences between working age and older adults. For example, older adults reported higher levels of self-compassion and lower levels of loneliness than working age adults. Looking at health problems, fewer older adults reported concurring mental health problems than working age adults, but more older than working age adults reported physical health problems. It will be interesting to see if any of these factors may also impact psychological treatment outcomes differently. Whilst I am waiting to collect the post-treatment data from the services, I am working on finalising and publishing my analysis plan and I will be presenting some of my initial findings at the Society for Social Medicine and Population Health conference in Newcastle in September. In the next coming months, I also plan to engage PPI groups to discuss the approach of sharing the study findings.

NSHD birth cohort study

I will be working with the 1946 National Survey of Health and Development, the oldest birth cohort in the UK. The aim is to gradually build up a model of risk and protective factors for affective symptoms in later life and to investigate how they add to and interact with each other, and I am in the process of creating an analysis plan for this study. Initially, I will be investigating the role of cognitive function at age 53 and its impact on mental health trajectories from mid to later life. There is evidence of the effect of affective symptoms on cognitive function, however, less is known on the reverse, the effect of cognitive function on affective symptoms, especially in mid to older age and I hope to shed some light on this with this study.

Alongside my PhD, I have continued to teach in various undergraduate modules and to run a team of mentors for undergraduate and Master’s students. I was also very excited to deliver my first lecture in a 3rd year undergraduate module.

I would like to thank MHRUK, the NHS Talking Therapy Services and my supervisors for their continued support and I look forward to bringing all my projects together over the coming year.

Progress Report Year 3, 2022

Background to my PhD research

My PhD has three main aims:

To conduct a systematic literature review and meta-analysis on predictors of psychological treatment outcomes for older adults.
To investigate predictors for engagement in and outcome of psychological treatment for Improving Access to Psychological Therapies (IAPT) service users
To explore risk factors and their combination and develop prediction models for CMHP, taking a life-course approach in a nationally representative cohort

My 3rd year

Systematic literature review

With regards to research aim 1, the main activities this year was to write up the findings from my systematic review to submit to a journal. In this review I collated research findings for my systematic literature review looking into the predictors of psychological treatment outcomes for depression and anxiety disorders in older adults. Baseline symptom severity was the most frequently studied factor with the largest effect sizes and homework completion, i.e. tasks set for the patient to complete between sessions, was the most consistent predictor of treatment outcome. However, overall, the review has highlighted that research in this area is very exploratory at this point with studies having small sample sizes and varying findings, hence further replication is required. This is what I am aiming to do with my study in the NHS Improving Access to Psychological Therapies (IAPT) services. I am currently working on revisions to the manuscript for this study addressing the journal reviewers’ comments.

PRedictors Of Psychological trEatment outcomes for common mentaL health problems in Improving Access to Psychological Therapy (IAPT) service users (‘PROPEL’)

Looking at research aim 2, the major activity this year was to gain NHS ethics approval and start the roll out of my study in the NHS talking therapy service IAPT. In this study, we are including adults 18+ years who are about to start treatment in the IAPT service. The aim is to identify factors that could predict who does or does not benefit from psychological treatment in the IAPT services and secondly, to see if these factors differ between working age (18 – 64 years) and older adults (65+ years). To do this, we are asking patients who have been accepted into the service and are currently awaiting the start of their treatment to complete a questionnaire, which will later be complemented with post-treatment data extracted from the respective IAPT service’s system. My study was adopted to the NIHR portfolio, which means that it can be rolled out to other interested NHS sites across England and get support from the Clinical Research Network. This was great news as I have a challenging recruitment target and throughout this year, I have been busy engaging and working with a lot of amazing people at various NHS sites across the country. A number of these have already started recruiting participants to the study and it is exciting to see the first responses coming in. Recruitment to the study will carry on until the end of this year.

NSHD birth cohort study

For this study, I will be working with the 1946 National Survey of Health and Development, the oldest birth cohort in the UK. The key objective of this study is to investigate different affective symptoms trajectories from mid-life (age 53) to older age (age 69) and factors which may predict these different trajectories. The birth cohort contains a wide range of data, which makes it possible to look at a number of predictors across different domains: socioeconomic (educational level, employment/retirement), health-related (acute/chronic conditions, hospital admissions, previous mental health problems), psychosocial (e.g. relationships, social activities, stressful life events), lifestyle factors (e.g. physical activity, diet, smoking and alcohol consumption), cognitive function (e.g. memory, verbal fluency) and biomarkers (e.g. metabolic, inflammatory and neuroendocrine markers). My data access request has been approved, I have completed the necessary data security and induction training and have requested the variables needed for the analysis. Further, I have completed advanced statistical training on path modelling which will help me carry out this analysis. The next step is to commence the analysis and gradually build up a model of risk and protective factors for affective symptoms in later life and to investigate how they add to and interact with each other.

Outside of my PhD projects, I have continued to be engaged in teaching in undergraduate modules and mentoring of undergraduate and Master’s students and I have recently also acted as a reviewer for a journal which was an interesting and insightful experience.

I look forward to continuing with the data collection and analysis for my NHS study and to exploring the rich data of the NSHD birth cohort.

Progress Report Year 2, 2021

Background to my PhD research

Worldwide, the human population is ageing and life expectancy is increasing. However, healthy life expectancy does not keep track with this development, and time spent in poor health has increased. Depression and anxiety are common amongst older adults and are linked with other health conditions and higher mortality. This places a burden on the older person, their carer and society as a whole. This is exacerbated by the current pandemic that has seen the proportion of older adults being affected by common mental health problems increase and has left many older adults facing difficult situations, where they are afraid to go outside yet struggle to cope with the loneliness and isolation of lockdown.

Psychological treatments, such as cognitive-behavioural therapy, have been found to be effective in treating CMHP in older adults, however, only for around half of the treated adults. The identification of predictors treatment outcomes of psychological therapy for CMHP for older adults could have important clinical implications, such as the tailoring of treatments to individuals or the development of new interventions for people that do not respond to current approaches.

My PhD has three main aims:

To conduct a systematic literature review and meta-analysis on predictors of psychological treatment outcomes for older adults.
To investigate predictors for engagement in and outcome of psychological treatment for Improving Access to Psychological Therapies (IAPT) service users
To explore risk factors and their combination and develop prediction models for CMHP, taking a life-course approach in a nationally representative cohort

This year:

With regards to research aim 1, the main activities this year was to review and collate research findings for my systematic literature review looking into the predictors of psychological treatment outcomes for depression and anxiety disorders in older adults. I have pre-registered the review protocol PROSPERO and after review of over 2,000 articles left 34 articles for inclusion in the review. The findings show that various factors may impact treatment outcomes across different areas: psychosocial (e.g. coping style), clinical (e.g. baseline symptom severity), treatment related (e.g. homework compliance), neurobiological (e.g. cognitive flexibility) and socio-demographic (e.g. education). However, overall, the process has highlighted that research in this area is relatively sparse, very varied and requires replication, which I aim to do in my next study.

Earlier this year, I was accepted to present the findings of the review at a national conference, the MQ Mental Health Summit (see poster attached). I am now in the process of writing up the findings of my systematic review, which I aim to submit for publication in the next month.

Looking at research aim 2, the major activity was to prepare the NHS ethics application documentation for my study running in the Improving Access to Psychological Therapies (IAPT) in the NHS. Informed by the findings of my systematic review, the aim is to see if any of the factors identified in the review could predict who does or does not benefit from psychological treatment in the IAPT services. To this end, I have created a baseline questionnaire of potential treatment outcome predictors which study participants will be asked to complete prior to commencing treatment. Applying for NHS ethics approval is lengthy and complex process and requires the preparation of various different documents, for example the development of a detailed research protocol. However, this preparation has certainly helped me to think through how my study will work and has allowed me to gain vital research experience, for example, engagement with the lived experienced advisory panel, who have provided invaluable feedback into the study design and documentation. Following the NHS ethics approval, my plan is to begin recruitment and data collection in autumn this year which will continue until end of 2022.

Work on research aim 3 will commence this autumn. I plan to apply for ethical approval for the study as well as access to the birth cohort data; I am also enrolled on a course on path modelling at the University of Cambridge to aid with the data analysis for this study.

Outside of my PhD projects, I have continued to be engaged in teaching in an undergraduate statistic module and completed an assignment to gain associate fellowship of the Higher Education Academy. I have also collaborated with a couple of Masters students on different projects. For one of these, we have submitted the following article for publication:

Rozanski, S., Schmidt, A., John, A.; Gaysina, D. (in press) Childhood neglect and trajectories of affective symptoms throughout adulthood: a British birth cohort study, Journal of Affective Disorders.

I have also continued my voluntary work as a befriender for elderly people, which has continued to be very insightful and rewarding.

Progress Report Year 1, 2020

Background to my PhD research

The overarching aim of my PhD is to investigate risk and protective factors for depression and anxiety in older adults. Moreover, I aim to identify factors affecting engagement in and outcomes of psychological treatments for depression and anxiety in older people. Identification of these factors would be an important step to ensure protection and improvement of mental health in older adults and associated quality of life.

This year:

My first year has been very busy and engaging. In order to aid my transition from undergraduate to postgraduate study, I have enrolled and completed several Master-level courses on advanced research and statistical training. In order to strengthen my statistical knowledge further, I also engaged in teaching in a 1st year undergraduate statistic module. This has helped improve my confidence in using statistical software and I very much enjoyed the experience of supporting other students in their learning.

The first study of my PhD focuses on the comparison between older and working age adults in working age and older adults on access, waiting times and treatment outcomes in the Health in Mind Improving Access to Psychological Therapies (IAPT) services in East Sussex. I have been lucky to work with and learn from a visiting post-doctoral researcher from Norway – Dr Makalani Myrtveit. In this collaborative study, we utilised routinely collected data by the IAPT services, which comprised over 20,000 individuals and nearly 50,000 sessions over a four year period. Our preliminary findings indicate that older people benefit from treatment in IAPT services; both older age groups (65 – 74 and 75 and above) had shorter waiting times and higher recovery and reliable recovery rates compared to working age adults. Currently, I am in the process of drafting an article for publication.

The second study of my PhD is a systematic literature review, where I investigate predictors for treatment outcomes of psychological therapies for older adults. I have identified and agreed search terms and databases to be searched with my supervisors, and I am in the process of preparing the pre-registration protocol for the review. The review will cover common mental disorders and all available treatments for these offered in the IAPT services, covering both low-intensity treatments, such as self-guided help and high intensity treatments, such as cognitive behavioural therapy.

This year, I was accepted to present my research findings at two national conferences, however, these were postponed until next year due to the current situation. In addition, I have enjoyed participating in a public engagement day organised by Alzheimer’s Research UK. This was a great opportunity to engage with the public about the importance of mental health in older adults (see picture attached). Further, I have continued my voluntary work as a befriender for elderly people, which has been more important than ever in these challenging times.

Next steps

In the next few months, I plan to focus on the systematic literature review to synthesise findings on predictors for treatment outcomes.

Following findings of my systematic literature review, planning will commence on the design for my larger study looking at predictors for treatment outcomes for older people accessing IAPT treatment. Due to the current situation, the initial plans for participant recruitment and data collection will have to be adapted and alternative methods found, such as online or via telephone interview. It is also planned to apply for adoption of the study into the National Institute for Health Research (NIHR) portfolio, which will be immensely beneficial to the recruitment and running of the study. As this is a rather lengthy process planning for this is going to start shortly in order to start recruitment this time next year.

Further, I also plan to conduct a study on predictors for development and trajectories of depression and anxiety in older people using existing birth cohort resources. I will utilise a life-course approach using longitudinal data from the National Survey of Health and Development (NSHD), the oldest birth cohort in the UK.