Research paperA prognostic index (PI) as a moderator of outcomes in the treatment of depression: A proof of concept combining multiple variables to inform risk-stratified stepped care models

- Many patients with depression respond to treatments of different intensity.
- Developed prognostic index to guide selection of treatments of different intensity.
- For patient with a poorer prognosis, CBT was superior to brief therapy and TAU.
- No differences for those with a good prognosis, who comprised most of the sample.

BackgroundPrognostic indices (PIs) combining variables to predict future depression risk may help guide the selection of treatments that differ in intensity. We develop a PI and show its promise in guiding treatment decisions between treatment as usual (TAU), treatment starting with a low-intensity treatment (brief therapy (BT)), or treatment starting with a high-intensity treatment intervention (cognitive-behavioral therapy (CBT)).MethodsWe utilized data from depressed patients (N=622) who participated in a randomized comparison of TAU, BT, and CBT in which no statistically significant differences in the primary outcomes emerged between the three treatments. We developed a PI by predicting depression risk at follow-up using a LASSO-style bootstrap variable selection procedure. We then examined between-treatment differences in outcome as a function of the PI.ResultsUnemployment, depression severity, hostility, sleep problems, and lower positive emotionality at baseline predicted a lower likelihood of recovery across treatments. The PI incorporating these variables produced a fair classification accuracy (c=0.73). Among patients with a high PI (75% percent of the sample), recovery rates were high and did not differ between treatments (79-86%). Among the patients with the poorest prognosis, recovery rates were substantially higher in the CBT condition (60%) than in TAU (39%) or BT (44%).LimitationsNo information on additional treatment sought. Prospective tests needed.ConclusionReplicable PIs may aid treatment selection and help streamline stepped models of care. Differences between treatments for depression that differ in intensity may only emerge for patients with the poorest prognosis.