Abstract
Background. Anxiety and mood disorders are prevalent, chronic and highly comorbid in adolescence, with detrimental personal, societal and economic outcomes. Given the high rates of attrition and limited resources available in psychiatric settings, the importance of engaging adolescents in evidence based treatments cannot be overstated. Barriers to treatment access include: (a) the availability of effective and efficient delivery of psychological treatment, such as Cognitive Behavioural Therapy (CBT), and (b) lost opportunity to offer such treatment packages to adolescents due to poor engagement.
Aims. The primary aim of this study was to examine the efficacy of Motivational Interviewing (MI), as a brief pre-treatment intervention, to enhance treatment engagement in an evidence-based treatment (group cognitive behavioural therapy; gCBT) for adolescents with anxiety and mood disorders. The secondary aim was to evaluate whether there was a net effect of MI on clinical and quality of life outcomes following gCBT, and to gain some insight into the experience of participants and referring clinicians.
Method. Participants were ninety six adolescents (13–18 years) with a primary diagnosis of an anxiety or mood disorder who were outpatients at two publicly-funded child and adolescent mental health services. Participants were randomly assigned to individually-administered MI for treatment engagement prior to gCBT (MI+gCBT) or to an individually-administered active control (Befriending) prior to gCBT (Befriending + gCBt). A total of eight pairs of gCBT were run in parallel. The outcome measures for the primary research question were the mean number of gCBT sessions attended, treatment initiation, and ratings of readiness for treatment. Therapeutic alliance and perceived coercion were also rated following the pre-treatment sessions. Outcome measures for the secondary aim were self-rated symptoms of anxiety and depression, as well as self- and clinician-rated quality of life. Qualitative feedback (written responses) from participants and referring health professionals was requested to provide insight into the experience of those involved in the study and analysed using Qualitative Description.
Results. Participants randomised to MI as a pre-treatment intervention attended significantly more therapy sessions. The MI group also demonstrated greater treatment initiation (whether participants attended any sessions), and ratings of treatment readiness were significantly higher for those randomised to MI. There were no significant differences in self-rated therapeutic alliance and perceived coercion scores were low for both groups. In regard to secondary outcomes, there were no significant differences between the MI and Befriending conditions. There was a reduction in scores for symptoms of depression and anxiety (physiological symptoms and social anxiety subscales) at three months follow up for participants in both conditions. With regards to self-reported quality of life, participants demonstrated a significant increase in physical wellbeing, psychological wellbeing, parental relations, and school wellbeing. Similarly, there was improvement in clinician-rated quality of life scores across both conditions.
Qualitative Description revealed that, for the young people who attended gCBT, the key themes of shared experience and connection with other youth, the practical skills and strategies, the non-judgmental environment, and provision of food were important to them. Themes that emerged from clinician feedback point to the therapeutic benefit to participants, as well as feasibility of incorporating gCBT into existing systems at CAMHS.
Conclusion. Results suggest that as a brief and effective pre-treatment intervention, MI may be a feasible approach to include in adolescent mental health settings to support a collaborative therapeutic relationship and improve engagement in evidence-based interventions such as gCBT. This is likely to occur when the focus of the MI session is on attending treatment. As such, this thesis provides empirical support for the use of MI with a focus on enhancing motivation for treatment engagement, when the desired outcome is treatment engagement. Trans-diagnostic interventions are gaining support as a pragmatic approach to psychotherapy with potential to increase access for individuals with a range of anxiety and mood and possibly other psychiatric disorders. It is proposed that MI may have the capacity to facilitate uptake of such evidenced based approaches, particularly when delivered in a group format, adding further to their utility. This may enhance efficiencies in services and improve outcomes for clients, reducing costs to psychiatric services and clients.