Please Answer Questions CAREFULLY and PAY ATTENTION TO DETAILS. ANSWERS ARE ATTACHED

Please Answer Questions CAREFULLY and PAY ATTENTION TO DETAILS. ANSWERS ARE ATTACHED
Include 2 supplemental scholarly (.edu, .gov, .org) links cited and referenced in APA style with 300 words. 1. Please watch the following two films: a. Milgram: https://www.youtube.com/watch?v=fCVlI-_4GZQ b. Zimbardo: https://www.youtube.com/watch?v=sZwfNs1pqG0 Consider both films and discuss what ethical violations may have occurred. Note specifically which General Principles (e.g., Principle A) might be relevant. What are some other ways that the research could be carried out with less potential harm? 2. please review the following case studies: 1) John: His primary physician referred John to a clinical psychologist after several episodes of sudden violence and rage. John claimed to have limited or no memory of the incidents. His mother described him as typically being a shy, quiet, and even withdrawn adolescent. This was the 15-year-old’s first psychological evaluation. During one of John’s episodes, his anger was so out of control that he broke dishes, punched holes in the wall, and did hundreds of dollars of damage to his room. His mother worried that John’s anger might soon turn to violence against himself or others. She further described him as having low energy, sometimes being sullen, and wanting to sleep a lot. He was unhappy in school, falling far behind his classmates, and in danger of repeating the ninth grade. 2) Nick: Nick is a 10-year-old boy whose pediatrician has referred him for a psychological evaluation because of concerns about his behavior at school and at home. Although his teacher thinks he is smart and capable of more than he is currently demonstrating, she has suggested that he be evaluated for ADHD. Nick’s academic performance has declined, and the teacher complains that he is impulsive and has difficulties focusing. His parents report that “homework is a nightmare” because Nick cannot sit still and becomes very frustrated when he does not know how to solve problems. Nightly battles over homework have become the norm. Lately, Nick has been referring to himself as “stupid,” and he shows poor motivation when it comes to schoolwork.  When reviewing the case studies, what would you consider for a diagnosis for each? Why? What other questions might you want to ask to learn more? What would be the advantages and disadvantages of making a diagnosis at all? 3. What are the differences between structured, semi-structured, and unstructured interviews (give examples)? What are the advantages and disadvantages of each? When would you use each? What is important to keep in mind when writing up an intake interview? 4. what are the differences between objective and subjective tests (give examples), and what are the pros and cons for each measurement type? When and how should behavioral assessments (give examples) be used? Which is your favorite type of test and why? 5. what are the differences between psychoanalytic, psychodynamic, and humanistic theoretical orientations? If you were a client, which style would you like your therapist to have, and why? 6. what are the differences between behavioral therapy, Beck’s cognitive therapy, and Ellis’ rational emotive behavior therapy? If you were a client, which style would you like your therapist to have, and why? 7. you’ve now learned a ton about individual psychotherapy, family psychotherapy, neuropsychology, forensic psychology, and health psychology. What are some of the main roles that each contribute to the field of psychology? Which one(s) are your favorites, and why?
Please Answer Questions CAREFULLY and PAY ATTENTION TO DETAILS. ANSWERS ARE ATTACHED
For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. Give examples on ways that existing public policies and legislation address the needs of older adults. What are obstacles to meeting stated goals as the numbers of elderly individuals in the U.S. population increase? 2. For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. Have you ever witnessed or heard about age discrimination in the workforce? Please describe.  What could you tell a prospective employer about the benefits and challenges of hiring older adults? Many people assume that Social Security will support them in old age. Why is this assumption untrue? 3. For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. What is “food insecurity”? What is the status of food insecurity among older adults nationwide?  What challenges will existing nutrition programs for the elderly face in the future, and how might these be addressed? 4. For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. Why might older adults be reluctant to seek mental health care? How can these obstacles be overcome? What community based mental health services are available, and what types of agencies generally provide these services? 5. For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Write in complete sentences, without grammatical or spelling errors. Respond thoughtfully to the posts of at least two of your classmates. How does the lack of available transportation affect the lives of frail elderly? In what ways can communities address the mobility needs of older adults who do not drive? In most states an individual must be at least 16 to drive. Do you think there should be a maximum age limit as well? 6. For full credit, provide a full, well-substantiated response to the discussion question, referencing this week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. What does it mean to be dual eligible? Define case management and describe the core elements of the care management process. Based on findings from the PACE program and other national demonstration projects, how successful are case management programs? What are the major strengths and weaknesses of the programs? 7. For full credit, provide a full, well-substantiated response to the discussion question, referencing past week’s readings and/or (cited) outside sources. Respond thoughtfully to the posts of at least two of your classmates. How will the changes in U.S demographics impact service provision to vulnerable older populations? Do you think federal, state, and local governments should reassess budgeting for social services? Why/Why not?
Please Answer Questions CAREFULLY and PAY ATTENTION TO DETAILS. ANSWERS ARE ATTACHED
Sexual Orientation Differences in Psychological Treatment Outcomes for Depression and Anxiety: National Cohort Study Katharine A. Rimes and Denisa Ion Institute of Psychiatry, Psychology and Neuroscience, King’s College London Janet Wingrove South London and Maudsley NHS Foundation Trust, London, United Kingdom Ben Carter Institute of Psychiatry, Psychology and Neuroscience, King’s College London Objective:This study investigates whether sexual minority patients have poorer treatment outcomes than heterosexual patients in England’s Improving Access to Psychological Therapies (IAPT) services. These services provide evidence-based psychological interventions for people with depression or anxiety.Method: National routinely collected data were analyzed for a cohort who had attended at least 2 treatment sessions and were discharged between April 2013–March, 2015. Depression, anxiety and functional impairment were compared for 85,831 women (83,482 [97.2%] heterosexual; 1,285 [1.5%] lesbian; 1,064 [1.2%] bisexual) and 47,092 men (44,969 [95.5%] heterosexual; 1,734 [3.7%] gay; 389 [0.8%] bisexual). Linear and logistic models were fitted adjusting for baseline scores, and sociodemographic and treatment characteristics.Results: Compared to heterosexual women, lesbian and bisexual women had higher final-session severity for depres- sion, anxiety, and functional impairment and increased risk of not attaining reliable recovery in depression/ anxiety or functioning (aORs 1.3–1.4) and reliable improvement in depression/anxiety or functioning (aORs 1.2–1.3). Compared to heterosexual and gay men, bisexual men had higher final-session severity for depression, anxiety, and functioning and increased risk of not attaining reliable recovery for depression/ anxiety or functioning (aORs 1.5–1.7) and reliable improvement in depression/anxiety or functioning (aORs 1.3–1.4). Gay and heterosexual men did not differ on treatment outcomes. Racial minority lesbian/gay or bisexual patients did not have significantly different outcomes to their White lesbian/gay or bisexual counterparts.Conclusions:The reasons for treatment outcome inequities for bisexual patients and lesbian women (e.g., 30 –70% increased risk of not recovering) need investigation. Health services should address these inequalities. What is the public health significance of this article? Lesbian, gay, bisexual, queer, and other sexual minority (LGBQ ) individuals have greater mental health needs than heterosexual people. This study found that compared to heterosexual patients, bisexual men and women showed less benefit from psychological treatments such as cognitive behavior therapy (CBT). In addition, lesbian women benefitted less than heterosexual women. In line with public health priorities to reduce inequities of health care provision for all, health services need to provide different or additional psychological treatment for bisexual people and lesbian women. Keywords:sexual orientation, therapy, treatment, disparities, health care inequalities Supplemental materials:http://dx.doi.org/10.1037/ccp0000416.supp People identifying as lesbian, gay, or bisexual (LGB), some- times referred to as sexual minority individuals, have elevatedrates of depression and anxiety relative to heterosexual people (King et al., 2008;Plöderl & Tremblay, 2015). Sexual minority individuals are approximately 1.5 times as likely to report such problems as heterosexual individuals. Minority stress theories (Hatzenbuehler, 2009;Meyer, 2003) propose that societal stigma causes the excess of mental health problems in these groups through chronic stress and minority- specific factors such as prejudice events, internalized stigma, expectations of rejection and sexual orientation concealment (Pachankis, Sullivan, Feinstein, & Newcomb, 2018;Robinson, Espelage, & Rivers, 2013;Woodhead et al., 2016). There is some evidence consistent withHatzenbuehler’s (2009)suggestion that minority stressors increase general psychological processes asso- Katharine A. Rimes and Denisa Ion, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London; Janet Wing- rove, Talking Therapies Southwark, South London and Maudsley NHS Founda- tion Trust, London, United Kingdom; Ben Carter, Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London. Correspondence concerning this article should be addressed to Katharine A. Rimes, Department of Psychology, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, 16 De Crespigny Park, Camberwell, London SE5 8AF, United Kingdom. E-mail:[email protected] This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. Journal of Consulting and Clinical Psychology © 2019 American Psychological Association2019, Vol. 87, No. 7, 577–589 0022-006X/19/$12.00http://dx.doi.org/10.1037/ccp0000416 577 ciated with increased risk of psychopathology, such as unhelpful coping behaviors (Feinstein, Davila, & Dyar, 2017), emotion dys- regulation (Hatzenbuehler, Dovidio, Nolen-Hoeksema, & Phills, 2009), interpersonal difficulties (Feinstein, McConnell, Dyar, Mustanski, & Newcomb, 2018) and cognitive factors such as negative beliefs about the self, world, or future (Feinstein, Davila, & Yoneda, 2012). Furthermore, sexual minorities are more likely to experience childhood abuse and this is associated with higher rates of mental health problems (Boroughs et al., 2015). Risk of mental health problems is often reported to be higher in bisexual people than lesbian or gay individuals (Feinstein & Dyar, 2017; Ross et al., 2018). This may be a result of different experiences of minority stressors by this group including greater concealment, invisibility, and victimization, as well as stigmatization from les- bian and gay individuals in addition to that from heterosexuals (Dodge et al., 2016;Feinstein & Dyar, 2017). However, most studies are cross-sectional and any causal role of stigma and victimization processes on sexual orientation mental health dispar- ities requires further investigation. Although sexual minorities have greater need for treatment for depression and anxiety (Bränström, Hatzenbuehler, Tinghög, & Pachankis, 2018;Cochran, Björkenstam, & Mays, 2017), rela- tively little is known about whether they benefit from psycholog- ical interventions for these problems to the same extent as hetero- sexual patients. It is possible that the processes hypothesized to contribute to the elevated rates of mental illness in sexual minority individuals also negatively impact on their ability to benefit from psychological interventions for depression and anxiety, or may even have adverse effects. For example, sexual minority patients can anticipate or experience prejudice, discrimination, or lack of understanding from health care providers, which can add to dis- tress and sexual orientation concealment (King, Semlyen, Kil- laspy, Nazareth, & Osborn, 2007;Smith & Turell, 2017). Sexual minority participants are more likely to report unfavorable health care experiences and lower satisfaction than heterosexual patients (Blosnich, 2017;Elliott et al., 2015). Sexual minority stressors outside of health care may also reduce the likelihood of symptom- atic improvement after treatment due to the ongoing negative impact on mental health (Rimes et al., 2018). A study of four psychological intervention services providing treatment for depression or anxiety in London, U.K. found poorer treatment outcomes for lesbian and bisexual women than hetero- sexual women, after adjusting for age, race, employment, baseline symptoms, number of sessions, and type of intervention (Rimes et al., 2018). In contrast, bisexual and gay men exhibited similar outcomes to heterosexual men, although the bisexual comparison was underpowered. Evidence that some sexual minority subgroups may be particularly at risk for poorer treatment outcomes was reported byBeard et al. (2017). Overall they found comparable effectiveness for people attending a partial hospital program in New England involving cognitive behavior therapy (CBT) and dialectical behavior therapy (DBT) for sexual minority participants experiencing a range of psychiatric disorders including mood, anxiety, personality, and psychotic disorders. However, subgroup analysis indicated that bisexual individuals had higher levels of self-injurious and suicidal thoughts at discharge and higher rates of rehospitalization than other sexual orientation groups (although the latter was nonsignificant after adjustment for baseline characteris- tics).Plöderl et al. (2017)found comparable improvement insexual minority and heterosexual individuals who attended a sui- cide prevention inpatient program in Salzburg, Austria, but they did not investigate bisexual individuals separately from lesbian, gay, or other sexual minority subgroups. Neither of the hospital studies was analyzed separately by gender. None of the three previous treatment studies investigated pos- sible interactions between sexual orientation and race or ethnicity on treatment outcomes. According to minority stress theory, one might expect the poorest treatment outcomes in people experienc- ing the most minority stress, that is, both in relation to sexual orientation and race/ethnicity and their interaction. Previous anal- ysis of national clinical data from psychological therapies services in the United Kingdom indicates that racial and ethnic minority patients have poorer treatment outcomes than White patients (NHS Digital, 2017). Research is needed investigating whether sexual minority patients who are also racial/ethnic minorities have poorer outcomes than White sexual minority patients. The previous three studies were all limited by their focus on a single hospital program or a small number of mental health ser- vices. The current study expands on previous research by analyz- ing routinely collected national data from Improving Access to Psychological Therapies (or IAPT) services in England. These are public mental health services present in every local health area in England. Individuals may self-refer or be referred by their general practitioner or another health care professional. These services provide evidence-based psychological interventions for depression or anxiety consistent with stepped care clinical guidelines from the U.K.’s National Institute for Health and Care Excellence (NICE). The predominant treatment approach is CBT, which is recom- mended for all anxiety disorders. For depression, other psycholog- ical interventions include interpersonal psychotherapy (IPT), be- havioral activation (BA), couple therapy for depression, brief psychodynamic therapy, and counseling. A stepped-care approach is generally applied in which the least resource intensive (“low intensity”) treatments are delivered first, with patients then “stepped up” to “high intensity” interventions if clinically re- quired. The IAPT training curricula addresses cultural competence including developing an ability to recognize one’s reactions to people perceived to be different in relation to sexual orientation, age, ethnicity, disability, or in other ways, to be able to work effectively with them. The UK’s“Equality Act”, 2010requires public organizations to eliminate unlawful discrimination and fos- ter equality of opportunity for people with protected characteristics (age; disability; gender reassignment; marriage or civil partner- ship; pregnancy and maternity; race; religion or belief; sex; sexual orientation). All major U.K. therapy bodies support a consensus document stating that attempts to change or alter sexual orientation through psychological therapies are unethical and potential harm- ful (“Memorandum of Understanding of Conversion Therapy in the U.K.”, 2015). This study compares outcomes for sexual minority patients relative to heterosexual patients, investigating the effect of adjust- ing for key confounders such as age, employment status, whether the patient is living in a more or less socially deprived neighbor- hood (e.g., in relation to income and housing), number of therapy sessions, and treatment intensity (high/low). Given the evidence of particularly elevated rates mental illness and stigma processes experienced by bisexual individuals, and previous preliminary evidence of poorer treatment outcomes for bisexual people, it was This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 578 RIMES, ION, WINGROVE, AND CARTER predicted that psychological treatment outcomes would be worse for bisexual patients than those for heterosexual patients. In line with evidence from the only previous study that separated by sex (Rimes et al., 2018), it was expected that lesbian women would show poorer outcomes than heterosexual women, whereas gay men would show similar outcomes to heterosexual men. The possibility that sexual minority patients who were from a racial minority group would have poorer treatment outcomes than White sexual minority patients due to higher levels of minority stress was also investigated. Thus the objectives of the study were to inves- tigate the effects of minority sexual orientation, the interaction between minority sexual orientation and sex, and interaction be- tween minority sexual orientation and racial minority status, on treatment outcomes. Method Study Design This prospective clinical cohort study reports from the routinely collected National Health Service (NHS) data from first and last psychological treatment sessions for a consecutive cohort of pa- tients attending all Improving Access to Psychological Therapies (IAPT) services in England, over a 2-year period (April 2013 to March, 2015). Treatment Provision Evidence-based psychological interventions were provided by all NHS Improving Access to Psychological Therapies (IAPT) services in England (Clark, 2018). They provide evidence-based psychological treatments specified in clinical guidelines produced by the U.K.’s National Institute for Health and Care Excellence (NICE, 2018). For some disorders (e.g., posttraumatic stress dis- order), NICE recommends that high-intensity treatment isprovided because there is not a strong evidence base for low-intensity inter- ventions. Low-intensity treatments include workshops, groups, guided self-help using workbooks or online packages. High-intensity interventions usuallyinvolve weekly one-to-one sessions. Sessions were recorded in relation to occasions of therapist contact; for example, an individual session (either face-to-face or by telephone or online), a group session, a therapist review of progress with a self-help manual or a workshop were recorded as single sessions. The teams consist of low-intensity practitioners and high-intensity therapists who together provide a range of interventions within the stepped-care model. Therapists providing high-intensity interven- tions have undertaken a postgraduate qualification in the interven- tions they offer. Low-intensity interventions are typically provided by “Psychological Wellbeing Practitioners” (PWPs) who complete a postgraduate qualification in delivering interventions such as guided self-help and psychoeducational workshops. There are na- tional training curricula for low- and high-intensity therapists specified by the U.K.’s Department of Health. Therapists are trained in evidence-based treatment protocols. Data Collection This study used routinely collected, nonidentifiable data that is sent by all IAPT services to National Health Service (NHS)Digital, a national information and technology partner to the health system in England (https://digital.nhs.uk/). An application was made to NHS Digital (then called the Health and Social Care Information Centre) for this specific dataset. Patients are informed that their data are collected and reported nationally and they are given the option of declining consent to their information being used in this way, without this decision affecting their treatment in any way. They are aware that it is not possible to identify them from national data analyses. Consultation with the local ethics committees (equivalent to Institutional Review Boards) indicated that under these conditions ethical approval was not required. Participants Patients were included if they had attended at least two treat- ment sessions, with outcomes available for both, had been dis- charged from the service, and if data were available for their gender, sexual orientation, race, age, employment status, depriva- tion indicator, number of treatment sessions, and treatment inten- sity. Patients were not included in the main analyses if they indicated that they were unsure about their sexual orientation or had declined to report their sexual orientation. Measures Treatment outcomes.Patients completed three validated questionnaires at every clinical contact; depressive symptoms, anxiety, and functional impairment. IAPT services have scores recorded on depression and anxiety at the beginning and end of treatment for 98% of patients, including those with unplanned endings, that is, where the treatment was incomplete (Clark, 2018). Depressive symptoms over the past 2 weeks were assessed with the Patient Health Questionnaire Depression Scale (PHQ-9), which has established reliability and validity (Kroenke, Spitzer, & Wil- liams, 2001). This is a nine-item, 4-point Likert (0 to 3) scale; higher scores indicate greater symptom severity. Scores over 9 are likely to correspond to “caseness” for depression (Löwe, Kroenke, Herzog, & Gräfe, 2004). The seven-item Generalized Anxiety Disorder Scale (GAD-7) was used to assess anxiety symptoms (Spitzer, Kroenke, Williams, & Löwe, 2006). This uses a 4-point Likert scale from 0 to 3; higher scores indicate greater symptom severity. Scores greater than 7 are typically regarded as corre- sponding to caseness. The GAD-7 was originally designed to measure generalized anxiety disorder but gives elevated scores in other anxiety disorders, has good internal consistency, and is sensitive to change (Kroenke, Spitzer, Williams, Monahan, & Löwe, 2007). The Work and Social Adjustment Scale (WSAS) measures functional impairment in work, home management, so- cial and private activities and relationships (Mundt, Marks, Shear, & Greist, 2002). It is a five-item scale with responses from 0 (not at all impaired)to8(very severely impaired)with established reliability and validity. Scores of 10 or above indicate significant functional impairment to a clinical degree (Mundt et al., 2002). In addition to final session scores on the three measures being used as outcomes,reliable improvementfor depression/anxiety was investigated, in line with standard reporting for these health services (Clark, 2018). This was indicated by scores on depression or anxiety or both,having reduced by a reliable amount and with neither measure showing a reliable increase, usingJacobson and This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 579 SEXUAL MINORITY TREATMENT OUTCOMES Truax’s (1991)reliable change index. Reliable change means that the difference between pre- and postoutcome measures is larger than the measurementerror of the questionnaire, to help ensure that any change reflects more than fluctuations in an imprecise measuring tool. Reliable improvement for impairment was indicated by im- provement on the Work and Social Adjustment Scale exceeding the measurement error for this scale (Zahra et al., 2014). Reliable improvement (yes/no) for depression/anxiety and functional im- pairment were calculated per patient. Reliable recoverywas also investigated. This is defined in IAPT services as having occurred if the patient met caseness criteria (10 or more on the PHQ-9; 8 or more on the GAD-7) at the beginning of treatment, showed reliable improvement and did not meet caseness criteria on either the PHQ-9 or GAD-7 at the last treat- ment session (Clark, 2018). For the present study, recovery in functioning was also investigated. A patient was considered to have met reliable recovery for functional impairment if they scored at least 10 on the WSAS in Session 1, showed reliable improve- ment on this measure, and were below cut-off at the last session. Failure to meet recovery criteria for depression/anxiety and func- tional impairment were used as two binary outcome variables. Other measures.Sociodemographic information (age, sex, sexual orientation, ethnicity, employment status) was recorded according to national procedures for these IAPT services. Sexual orientation information had been coded in the dataset using the following categories: heterosexual, homosexual/gay/lesbian, bi- sexual, person asked and does not know or is not sure, person asked but declined to provide a response, and unknown. Patients were asked about their sexual orientation either in a registration form, in person, or on the telephone. The different ethnic sub- groups were combined into White versus Black or other minority group, to indicate race. Deprivation according to the Index of Multiple Deprivation (Department of Communities & Local Gov- ernment, 2015) was coded as top 50% and bottom 50%. This measure of relative social deprivation includes domains such as income, employment, education, skills and training, barriers to services, and crime. Therapists documented treatment sessions and whether treatment was high or low intensity; the latter information was taken from the last treatment session. Data Analysis A complete-case analysis was carried out using IBM SPSS Statistics v24. Continuous outcomes (depression, anxiety, and functional impairment) were summarized with a mean andSD, whereas dichotomous outcomes (failure of reliable improvement and recovery) were summarized with a proportion. Baseline con- tinuous data were analyzed with a one-way analysis of variance (ANOVA) or Studentttest, then post hoc comparisons were investigated using Bonferroni-adjustment. Studentttests and chi- square analyses were used to compare the characteristics of people who indicated their sexual orientation with those who said they were unsure or declined to say. We analyzed the extent of missing data for the outcomes as well as all covariates and compared data from patients with and without missing data on these variables. All inferential analyses were carried out using a complete-case anal- ysis due to the anticipated low proportion of missing data (Jako- bsen, Gluud, Wetterslev, & Winkel, 2017).For the continuous outcomes, general linear models were fitted, and first compared the outcomes with sexual orientation (with heterosexual as the reference category, compared separately to bisexual and to lesbian/gay); sex; sex-by-sexual-orientation inter- action; and baseline score (Model 1). Fully adjusted linear models (Model 2) additionally adjusted for: age; race; employment status; deprivation; number of therapy sessions; and treatment intensity (high/low). An a priori planned set of comparisons were conducted investigating outcomes for lesbian and bisexual women compared to heterosexual women and for gay men and bisexual men com- pared to heterosexual men. Post hoc comparisons were also con- ducted comparing lesbian women with bisexual women and com- paring gay men with bisexual men. Adjusted mean differences (aMD), standard errors, confidence intervals andpvalues are presented from the general linear models. Similar general linear models with post hoc comparisons were used to the investigate race-by-sexual-orientation interactions, adjusting for baseline scores (Model 1) and additionally adjusting for age, sex, employ- ment status, deprivation, number of therapy sessions, and treat- ment intensity (Model 2). Dichotomous outcomes (failure of improvement and recovery) were analyzed with logistic regression analyses with the same comparisons and adjusting for the same covariates described above in the models for the continuous outcomes. Adjusted odds ratios (aOR), with associated 95% confidence intervals andpvalues are presented. Results Sample There were 265,221 patients who had attended two or more treatment sessions, had first and last treatment data and had been discharged. Of these, 181,761 had sexual orientation information available; that is, indicated that they were heterosexual, lesbian, gay or bisexual—132,923 participants had data available for all the other study variables and were included in this study. Therefore the study sample consisted of 44,969 (33.8%) heterosexual men, 83,482 (62.8%) heterosexual women, 1,734 (1.3%) gay men, 1,285 (1.0%) lesbian women, 389 (0.3%) bisexual men, and 1,064 (0.8%) bisexual women. Within female participants, the propor- tions of lesbian and bisexual women were 1.5% and 1.2% respec- tively. Within male participants, the proportions of gay and bisex- ual men were 3.7% and 0.8% respectively. See theonline supplementary Table 1for (a) information about the proportions of missing data for the covariates and outcome variables and (b) treatment outcome comparisons between those with and without missing data. All outcomes were complete due to the nature of the cohort data collection protocols; only employment status and de- privation covariates were found to have missing data greater than 5% (online supplementary Table 1). To check for the impact of missing employment and deprivation data, supplementary analyses were performed in which cases with missing values on these variables were included as a separate category within the modeling procedure (Burton & Altman, 2004). These analyses showed the same pattern of significant results to the original analyses with one exception (seeonline supplementary Table 1). Supplementary analyses that were also conducted with patients who preferred not to disclose their sexual orientation (n 3,168) or were unsure This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 580 RIMES, ION, WINGROVE, AND CARTER (n 13,837) are described in the next section and inonline supplementary Table 2. The remainder of the patients, not used for this study, had sexual orientation or other study data missing (e.g., they had not been asked, or if they had been asked, the information had not been recorded). Association Between Patient Characteristics and Sexual Orientation Data To investigate possible bias, the characteristics of people who indicated their sexual orientation were compared with those who declined to disclose their sexual orientation or who stated they were unsure (online supplementary Table 2). All overall group effects were significant (p .05) although the effect sizes were very small ( 0.05). Those who were unsure of their sexual ori- entation were younger and were more likely to be male, unem- ployed, from a minority racial group, living in a higher deprivation area and had higher baseline symptomatology and fewer treatment sessions than those who stated their sexual orientation. People who declined to report their sexual orientation were not significantly different from those who indicated their sexual orientation, except that they were more likely to live in a higher deprivation area. For further information seeonline supplementary Table 2. Sociodemographic, Clinical, and Treatment Characteristics of Heterosexual, Lesbian, Gay and Bisexual Patients Sociodemographic characteristics of sexual orientation by sex groups.There were baseline differences between groups divided by sexual orientation and sex for: age, race, employment, and deprivation (pvalues .001; seeTable 1). Lesbian, gay, and bisexual patients were younger and more likely to live in a de- prived area than those who were heterosexual, and bisexual pa- tients were less likely to be in paid employment (pvalues .003). Baseline clinical characteristics.Baseline depression, anxi- ety, and functional impairment differed across the groups (pval- ues .001; seeTable 1). Bisexual patients and lesbian women had higher baseline depression, anxiety and functional impairment than heterosexual patients (pvalues .003). Gay men had higher baseline functional impairment than heterosexual patients and higher depression than heterosexual women but had lower depres- sion than lesbian women (seeTable 1). Treatment characteristics.The number of treatment sessions and the proportion who had a high-intensity treatment differed across the groups (pvalues .001; seeTable 1). Heterosexual patients were less likely to receive a high intensity intervention than lesbian or gay patients (pvalues .0003). For the number of treatment sessions there was no clear pattern of difference between heterosexual and sexual minority patients. For full details see Table 1. Sociodemographic, Clinical and Treatment Characteristics of White and Racial Minority Groups by Sexual Orientation For the groups divided by sexual orientation and race, there were significant differences on all baseline variables but with small effect sizes (seeonline supplementary Table 3for further Table 1 Sociodemographic Characteristics, Baseline Clinical Measures, and Treatment Characteristics (N 132,923) VariablesHeterosexual men (n 44,969)Heterosexual women (n 83,482)Gay men (n 1,734)Lesbian women (n 1,285)Bisexual men (n 389)Bisexual women (n 1,064) Statistical test andpvalue Sociodemographic characteristics Age–M(SD) 42.5 (14.8) 41.4 (15.3) 36.9 (12.8) 34.5 (12.4) a 32.9 (13.5) a 28.2 (10.6)F(5, 132917) 316.9,p .001 Age range 16–90 16–90 16–90 16–83 16–70 16–73 Racial minority–N(%) 3,857 (8.6) a 7,621 (9.1) b 135 (7.8) a,b,c 71 (5.5) c 47 (12.1) a,b 100 (9.4) a,b 2(5) 37.1,p .001 Ethnic groups White 41,112 (91.4) 75,861 (90.9) 1,599 (92.2) 1,214 (94.5) 342 (87.9) 1214 (94.5) Mixed ethnicity 758 (1.7) 1,657 (2.0) 47 (2.7) 30 (2.3) 14 (3.6) 30 (2.3) Black/Black British 1,738 (3.9) 2,976 (3.6) 28 (1.6) 11 (.9) 12 (3.1) 11 (.9) Asian or Asian British 858 (1.9) 2,005 (2.4) 30 (1.7) 18 (1.4) 12 (3.1) 18 (1.4) Other ethnic groups 503 (1.1) 983 (1.2) 30 (1.7) 12 (.9) 9 (2.3) 12 (.9) Paid employment–N(%) 27,144 (60.4) a 48,295 (57.9) b 1,107 (63.8) a 817 (63.6) a 196 (50.4) c 565 (53.1) c 2(5) 132.2,p .001 High deprivation–N(%) 22,580 (50.2) a 41,191 (49.3) b 1,006 (58.0) c 789 (61.4) c 220 (56.6) a,c 639 (60.1) c 2(5) 176.4,p .001 Baseline clinical measures Depression (PHQ-9)–M(SD)–Range 14.4 (6.3) a,b0–2714.3 (6.2) a0–2714.8 (6.3) b0–2715.5 (6.0) c0–2715.9 (5.5) c,d0–2716.4 (5.7) d0–27F(5, 132917) 39.4,p .001 Anxiety (GAD-7)–M(SD)–Range 12.8 (5.2) a0–2113.2 (5.1) b0–2113.3 (5.0) b,c0–2113.7 (4.9) c,d0–2113.4 (4.8) a,b,c,d 0–2113.9 (4.9) d0–21F(5, 132917) 48.5,p .001 Functional impairment (WSAS)–M(SD)–Range 18.1 (9.5) 0–40 17.7 (9.5) 0–40 19.5 (9.1) a,b0–4019.1 (8.8) a0–4020.8 (8.6) b0–4020.2 (8.6) b0–40F(5, 132917) 42.7,p .001 Treatment characteristics Number of treatment sessions–M(SD)–Range 5.5 (3.4) a2–345.6 (3.5) b2–395.9 (3.7) c2–245.7 (3.8) a,b,c 2–325.6 (3.7) a,b,c 2–235.5 (3.6) a,b2–24F(5, 132917) 9.8,p .001 High-intensity treatment–N(%) 23,672 (52.6) a 45,677 (54.7) b 1,014 (58.5) c 761 (59.2) c 239 (61.4) b,c 587 (55.2) a,b,c 2(5) 87.1,p .001 Note. PHQ-9 Patient Health Questionnaire Depression Scale; GAD-7 Generalized Anxiety Disorder Scale; WSAS Work and Social Adjustment Scale.a,b,c,d Values on the same row sharing a superscript are not significantly different from each other, based on Bonferroni-corrected comparisons.This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 581 SEXUAL MINORITY TREATMENT OUTCOMES details). There were no clear patterns of differences between white and racial minority patients within each of the three sexual orien- tation groups. Symptom Severity and Impairment at Final Session The unadjusted means at first and last session for depression, anxiety, and functional impairment are shown inFigure 1for groups divided by sexual orientation and sex. Adjusted estimated marginal means are shown inonline supplementary Table 4.For final session scores for depression, there were consistently higher scores in bisexual relative to heterosexual patients adjusted for baseline scores (aMD 1.28 (95% CI [.6, 1.86]),p .009; Model 1,Table 2), and intensity of therapy, number of treatment sessions, age, race, employment status, and deprivation (aMD 0.75 (95% CI [.1, 1.30]),p .009; Model 2,Table 2). Higher scores were also apparent for anxiety and functional impairment, with the largest effects of all three outcomes being those for functional impairment. Relative to lesbian/gay patients, bisexual patients also had higher final-session depression, anxiety, and functional im- pairment scores, again with the largesteffects for functional impairment; for anxiety, differences were only significant prior to adjustment for all confounders. Some of the main effects for bisexual patients found after adjustment for baseline scores only (Model 1,Table 2) were reduced after full adjustment in Model 2 (seeTable 2). Sexual orientation group comparisons for male and female patients.As predicted, there was also a sex-by-lesbian/gay in- teraction in Models 1 and 2 for depression, anxiety, and functional impairment (seeTable 2). Planned comparisons indicated that relative to heterosexual women, lesbian women had significantly higher final session scores for depression Model 1 aMD .75 (95% CI [.43, 1.07]); Model 2 aMD .58 (95% CI [.27, .89]); anxiety Model 1 aMD .72 (95% CI [.44, 1.01]); Model 2 aMD .55 (95% CI [.28, .83]) and functional impairment Model 1 aMD 1.23 (95% CI [.76, 1.69]); Model 2 aMD 1.31 (95% CI [.86, 1.76]), allp values .001. In contrast, gay men did not differ significantly from heterosexual men for depression, anxiety, or functional im- pairment (pvalues .20). Although the sex-by-bisexual interaction was not significant, planned comparisons were also conducted comparing bisexual women with lesbian and heterosexual women, and comparing bisexual men with gay men and heterosexual men. Relative to heterosexual women, bisexual women had signifi- cantly higher final session scores for depression Model 1 aMD 1.44 (95% CI [1.08, 1.79]); Model 2 aMD .83 (95% CI [.49, 1.17]), anxiety Model 1 aMD 1.24 (95% CI [.92, 1.55]); Model 2 .66 (95% CI [.36, .97]) and functional impairment Model 1 aMD 1.86 (95% CI [1.36, 2.37]); Model 2 aMD 1.14 (95% CI [.64, 1.63]). Relative to lesbian women, bisexual women had significantly higher final session scores for Model 1 depression aMD .69 (95% CI [.22, 1.16]) and anxiety aMD .51 (95% CI [.09, .94]) but they were not significantly different in Model 1 functional impairment aMD .34 (95% CI [ .33, 1.03];p .32). There were no significant differences between bisexual and lesbian women for any of the fully adjusted Model 2 analyses; depression (aMD .24 (95% CI [ .21, .70]),p .28); anxiety (aMD .11 (95% CI [ .30, .52]),p .60), or functional impairment (aMD .17 (95% CI [ .84, .50]),p .41). Compared to heterosexual men, bisexual men had significantly higher final session scores for depression Model 1 aMD 1.27 (95% CI [.69, 1.86]),p .001; Model 2 aMD .62 (95% CI [.28, .96]), p .001), anxiety (Model 1 aMD 1.02 (95% CI [.50, 1.54]),p .001; Model 2 aMD .51 (95% CI [.01, 1.01]),p .044), and functional impairment (Model 1 aMD 2.33 (95% CI [1.49, 3.16]), p .01; Model 2 aMD 1.65 (95% CI [.83, 2.47]),p .001). Compared to gay men, bisexual men had significantly higher final session scores for depression Model 1 aMD 1.32 (95% CI [.68, 1.96]); Model 2 aMD .85 (95% CI [.23, 1.46]) and for 0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 18.00 First session Last session Depression Bisexual Women Bisexual Men Lesbian Women Gay Men Heterosexual Men Heterosexual Women 0.00 2.00 4.00 6.00 8.00 10.00 12.00 14.00 16.00 First session Last session Anxiety Bisexual Women Bisexual Men Lesbian Women Gay Men Heterosexual Women Heterosexual Men 0.00 5.00 10.00 15.00 20.00 25.00 First session Last session Functional impairment Bisexual Men Bisexual Women Lesbian Women Gay Men Heterosexual Men Heterosexual Women Figure 1.Depression, anxiety, and functional impairment at first and final session (unadjusted means). This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 582 RIMES, ION, WINGROVE, AND CARTER functional impairment Model 1 aMD 2.06 (95% CI [1.14, 2.98]); Model 2 aMD 1.49 (95% CI [.59, 2.39]), allpvalues .005. For anxiety, bisexual men had higher scores than gay men in Model 1 aMD .93 (95% CI [.36, 1.51]) but the differences were not signif- icant in Model 2 (aMD .48 (95% CI [ .06, 1.04]);p .083). Interactions between race and sexual orientation.The un- adjusted means at first and last session for depression, anxiety, and functional impairment are shown inonline supplementary Figure 1for groups divided by sexual orientation and race. Adjusted estimated marginal means are shown inonline sup- plementary Table 5. For Model 1 (adjusting for baseline), there were significant interactions for race-by-lesbian/gay orientation for posttreatment anxiety and functional impairment; seeonline supplementary Ta- ble 6. Racial minority heterosexual patients had significantly higher posttreatment anxiety scores than White heterosexual pa- tients (aMD .91 (95% CI [.80, 1.02]);p .01) and White lesbian or gay patients (aMD .50 (95% CI [.26, .74]);p .001); none of the other differences were significant. Racial minority heterosex- ual patients had significantly higher posttreatment functional im- pairment scores than White heterosexual patients (aMD 1.19 (95% CI [1.03, 1.35]);p .01). White lesbian or gay patients had significantly higher posttreatment functional impairment than White heterosexual patients (aMD .98 (95% CI [.67, 1.30]);p .001). None of the other comparisons were significant. In the fully adjusted models (Model 2), none of the race-by- lesbian/gay or bisexual interactions were significant; seeonline supplementary Table 6. Clinical measures at first and last session by sexual orien- tation, sex, and race.Although this study was not designed to investigate three-way interactions between sexual orientation, sex, and race, for information the unadjusted pre- and postscores onmeasures of depression, anxiety, and functional impairment are provided inonline supplementary Table 7. Reliable Improvement and Recovery The proportions of patients who failed to attain reliable im- provement for depression/anxiety ranged from 36.3% of hetero- sexual women to 44.2% of bisexual men. For the failure to reliably recover for depression/anxiety, the proportions range from 50.7% for heterosexual women to 64.5% for bisexual men. The propor- tions showing failure to reliably improve in functioning ranged from 57.3% of gay men to 64.3% of bisexual men. Failure to recover in functional impairment ranges from 66.7% of heterosex- ual women to 78.0% of bisexual men. SeeTable 3for full results. The failure to improve (or recover) analyses had similar findings to the symptom severity above (Table 2andTable 4). After adjustment for baseline score only, there were increased odds of 40% for failure to improve in depression/anxiety for bisexuals (aOR 1.40 (95% CI [1.14, 1.72]),p .001; Model 1,Table 4); however, after adjustment for all covariates the odds of failure to improve were reduced (aOR 1.23 (95% CI [.99, 1.53]),p .06; Model 2,Table 4). In the fully adjusted models the bisexual patients were more likely to show failure to recover from depres- sion/anxiety aOR 1.43 (95% CI [1.13, 1.80]), failure to improve in functional impairment aOR 1.43 (95% CI [1.14, 1.80]) and failure to recover from functional impairment (aOR 1.49 (95% CI [1.15, 1.93]); Model 2,Table 4). For the comparisons between bisexual and lesbian/gay patients, the adjusted odds ratios were similar to those for the bisexual/ heterosexual comparisons (seeTable 4). Again, the odds ratios were greater in the Model 1 analyses, adjusted for only baseline Table 2 Severity of Depression, Anxiety and Functional Impairment at Final Session; Mean Difference Mean difference (MD) Psychological variable by group and sex-by- group interactionsModel 1. Adjusted for baseline score a Model 2. Fully adjusted b Reference groupMD SE95% CIpvalueMD SE95% CIpvalue Depression Bisexual Heterosexual 1.28 .30 [.69, 1.86] .001 .75 .28 [.19, 1.30] .009 Bisexual Lesbian/gay 1.32 .33 [.68, 1.96] .001 .85 .14 [ .17, .37] .007 Lesbian or gay Heterosexual .04 .14 [ .32, .24] .77 .10 .14 [ .37, .17] .47 Sex-by-bisexual .17 .35 [ .52, .84] .64 .08 .33 [ .57, .73] .81 Sex-by-lesbian/gay .79 .22 [.37, 1.22] .001 .68 .21 [.27, 1.09] .001 Anxiety Bisexual Heterosexual 1.02 .27 [.50, 1.54] .001 .51 .26 [.01, 1.02] .04 Bisexual Lesbian/gay .93 .29 [.36, 1.51] .001 .49 .28 [ .06, 1.04] .083 Lesbian or gay Heterosexual .09 .13 [ .17, .34] .50 .03 .12 [ .22, .27] .83 Sex-by-bisexual .22 .31 [ .40, .83] .49 .15 .30 [ .44, .73] .62 Sex-by-lesbian/gay .64 .20 [.26, 1.02] .001 .53 .19 [.16, .89] .005 Functional impairment Bisexual Heterosexual 2.33 .43 [1.49, 3.17] .001 1.65 .42 [.83, 2.47] .001 Bisexual Lesbian/gay 2.01 .47 [1.14, 2.98] .001 1.49 .46 [.58, 2.39] .001 Lesbian or gay Heterosexual .27 .21 [ .14, .67] .20 .16 .20 [ .23, .56] .41 Sex-by-bisexual .46 .50 [ 1.44, .52] .35 .51 .49 [ 1.47, .44] .29 Sex-by-lesbian/gay 1.25 .31 [.64, 1.86] .001 1.14 .31 [.54, 1.74] .001 Note. Depression assessed by PHQ-9; Anxiety assessed by GAD-7; Functioning assessed by WSAS. aAdjusted for baseline score on outcome measure. bAdjusted for intensity of therapy, number of treatment sessions, age, race, employment status, and deprivation. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 583 SEXUAL MINORITY TREATMENT OUTCOMES scores (aOR from 1.43 to 1.58) than in the fully adjusted models (Model 2; aOR from 1.25 to 1.44). Lesbian women and gay men compared to heterosexual men and women.As predicted, there was a sex-by-lesbian/gay inter- action in Models 1 and 2 for the failure to improve and recover (seeTable 3). Planned comparisons indicated that relative to heterosexual women, lesbian women had increased risk of failure to reliably improve in depression/anxiety (Model 1 aOR 1.23 (95% CI [1.10, 1.38]),p .001; Model 2 aOR 1.18 (95% CI [1.05, 1.33]),p .008), to show reliable recovery for depression/anxiety (Model 1 aOR 1.33 (95% CI [1.27, 1.61]),p .001; Model 2 aOR 1.30 (95% CI [1.15, 1.47]),p .001), to reliably improve in functional impairment (Model 1 aOR 1.33 (95% CI [1.17, 1.50]), p .001; Model 2 aOR 1.31 (95% CI [1.16, 1.48]),p .001) and reliably recover for functional impairment (aOR 1.43 (95% CI [1.25, 1.64]),p .001; Model 2 aOR 1.38 (95% CI [1.21, 1.59]), p .001). For similar comparisons between gay men and hetero- sexual men, no group differences were significant (pvalues 0.41).Bisexual men and women compared to other groups. Although the sex-by-bisexual interaction was not significant, planned comparisons were undertaken to compare bisexual pa- tients with heterosexual and lesbian/gay patients for improvement and recovery rates. Relative to heterosexual women, planned comparisons indicated that bisexual women had increased risk of failure to reliably improve in depression/anxiety (Model 1 aOR 1.52 (95% CI [1.34, 1.72]),p .001; Model 2 aOR 1.31 (95% CI [1.16, 1.49]),p .001), to show reliable recovery for depression/anxiety (Model 1 aOR 1.59 (95% CI [1.40, 1.82]),p .001; Model 2 aOR 1.32 (95% CI [1.15, 1.52]),p .001), to reliably improve in functional impairment (Model 1 aOR 1.40 (95% CI [1.23, 1.60]),p .001; Model 2 aOR 1.25 (95% CI [1.09, 1.43]),p .001) and reliably recover for functional impairment (aOR 1.42 (95% CI [1.22, 1.65]),p .001; Model 2 aOR 1.25 (95% CI [1.07, 1.45]),p .004). Relative to lesbian women, planned comparisons indicated that bisexual women had increased risk of failure to reliably improve in Table 3 Failure to Reliably Improve and Reliably Recover Psychological variables and outcomesHeterosexual men Heterosexual women Gay men Lesbian women Bisexual men Bisexual women n(%)n(%)n(%)n(%)n(%)n(%) Depression and anxiety Failure to reliably improve 17,436 (38.8) 30,264 (36.3) 650 (37.5) 502 (39.1) 172 (44.2) 455 (42.8) Failure to reliably recover a 20,610 (51.7) 38,123 (50.7) 817 (52.5) 711 (59.6) 234 (64.5) 643 (63.9) Functional impairment Failure to reliably improve 26,899 (59.8) 49,843 (59.7) 994 (57.3) 809 (63.0) 250 (64.3) 657 (61.7) Failure to reliably recover b 24,405 (67.5) 44,060 (66.7) 1,022 (68.9) 811 (74.3) 273 (78.0) 696 (74.6) aReliable recovery analyses for depression/anxiety involved 119,108 (89.6%) patients who met baseline caseness criteria for the PHQ-9 or GAD- 7.bReliable recovery analyses for functional impairment involved 106,115 (79.8%) patients who met baseline caseness criteria on the Work and Social Adjustment Scale. Table 4 Risk of Failure to Reliably Improve and Reliably Recover, Adjusted Odds Ratio (AOR) of Failure to Improve/Recover Depression and anxiety Functional impairment Failure to improve (N 132,923)Failure to recover (N 119,108)Failure to improve (N 132,923)Failure to recover (N 106,115) Group or sex-by- group interactions Ref a aOR [95% CI]paOR [95% CI]paOR [95% CI]paOR [95% CI]p Model 1. Adjusted for baseline Bisexual Het 1.40 [1.14, 1.72] .001 1.63 [1.31, 2.03] .001 1.59 [1.27, 1.99] .001 1.65 [1.28, 2.14] .001 Bisexual L/G 1.43 [1.14, 1.79] .002 1.64 [1.28, 2.08] .001 1.58 [1.24, 2.02] .001 1.58 [1.19, 2.08] .001 Lesbian/gay Het .99 [.89, 1.09] .77 1.00 [.90, 1.11] .94 1.01 [.91, 1.12] .91 1.05 [.94, 1.18] .40 Sex-by-bisexual 1.08 [.85, 1.38] .52 .98 [.76, 1.27] .87 .88 [.68, 1.13] .31 .86 [.64, 1.15] .31 Sex-by-lesbian/gay 1.25 [1.07, 1.46] .004 1.37 [1.17, 1.61] .001 1.32 [1.12, 1.55] .001 1.36 [1.14, 1.63] .001 Model 2. Fully adjusted for baseline score on relevant outcome measure, treatment intensity, number of sessions, age, race, deprivation, employment Bisexual Het 1.23 [.99, 1.53] .06 1.43 [1.13, 1.80] .003 1.43 [1.14, 1.80] .002 1.49 [1.15, 1.93] .002 Bisexual L/G 1.25 [.99, 1.59] .07 1.46 [1.14, 1.89] .003 1.43 [1.11,1.83] .005 1.44 [1.09, 1.91] .011 Lesbian/gay Het .98 [.89, 1.09] .77 .97 [.87, 1.08] .63 1.01 [.91, 1.12] .91 1.04 [.92, 1.16] .55 Sex-by-bisexual 1.06 [.83, 1.37] .64 .93 [.71, 1.21] .57 .86 [.66, 1.12] .27 .83 [.62, 1.12] .23 Sex-by-lesbian/gay 1.21 [1.03, 1.42] .02 1.34 [1.14, 1.58] .001 1.30 [1.10, 1.53] .002 1.34 [1.12, 1.60] .001 aReference category: Het heterosexual, L/G lesbian or gay. Depression assessed by PHQ-9; Anxiety assessed by GAD-7; Functional impairment assessed by WSAS. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 584 RIMES, ION, WINGROVE, AND CARTER depression/anxiety in Model 1 (aOR 1.22 (95% CI [1.03, 1.44]), p .021) but there was no significant difference in the fully adjusted model (Model 2 aOR 1.08 (95% CI [.90, 1.29]),p .440). For reliable recovery for depression/anxiety and reliable improvement or recovery in functional impairment there were no significant differences between lesbian and bisexual women in Models 1 or 2 (pvalues 0.05). Relative to heterosexual men, planned comparisons indicated that bisexual men had increased risk of failure to reliably improve in depression/anxiety (Model 1 aOR 1.40 (95% CI [1.14, 1.72]), p .001; Model 2 aOR 1.31 (95% CI [1.03, 1.68]),p .027), to show reliable recovery for depression/anxiety (Model 1 aOR 1.63 (95% CI [1.31, 2.03]),p .001; Model 2 aOR 1.41 (95% CI [1.12, 1.78]),p .004), to reliably improve in functional impairment (Model 1 aOR 1.57 (95% CI [1.26, 1.96]),p .001; Model 2 aOR 1.39 (95% CI [1.11, 1.75]),p .004) and reliably recover for functional impairment (aOR 1.65 (95% CI [1.28, 2.13]),p .001; Model 2 aOR 1.47 (95% CI [1.14, 1.91]),p .004). Relative to gay men, planned comparisons indicated that bisex- ual men had increased risk of failure to reliably improve in depression/anxiety (Model 1 aOR 1.52 (95% CI [1.20, 1.93]),p .001; Model 2 aOR 1.43 (95% CI [1.12, 1.83]),p .05), to show reliable recovery for depression/anxiety (Model 1 aOR 1.64 (95% CI [1.28, 2.08]),p .001; Model 2 aOR 1.52 (95% CI [1.52, 1.96]),p .002), to reliably improve in functional impairment (Model 1 aOR 1.52 (95% CI [1.20, 1.93]),p .001; Model 2 aOR 1.43 (95% CI [1.11, 1.83]),p .005) and reliably recover for functional impairment (aOR 1.57 (95% CI [1.19, 2.07]),p .002; Model 2 aOR 1.51 (95% CI [1.13, 2.01]),p .005). Interactions between race and sexual orientation.There was a significant race-by-lesbian/gay sexual orientation interaction for the failure to improve in depression or anxiety, in Model 1 (adjusted for baseline) but not in the fully adjusted model. In Model 1, compared to White heterosexual patients, failure to improve was significantly more likely for racial minority hetero- sexual patients (aOR 1.30 (95% CI [1.25, 1.36]),p .001) and White gay or lesbian patients (aOR 1.17 (95% CI [1.08, 1.27]), p .001). Racial minority heterosexual patients were more likely to fail to improve than White gay or lesbian patients (aOR 1.11 (95% CI [1.01, 1.21]),p .023). There was no significant differ- ence between racial minority gay or lesbian patients compared to White or racial minority heterosexual patients or White gay or lesbian patients (pvalues .05). None of the other logistic regression analyses indicated signif- icant interactions between race and sexual orientation for reliable recovery in depression/anxiety or reliable improvement or recov- ery in functioning. Seeonline supplementary Table 8for the proportions reaching improvement and recovery criteria in each group andonline supplementary Table 9for results of the race by sexual orientation interaction tests. Discussion This is the first study to compare psychological intervention outcomes across different sexual orientation groups using national routinely collected data from a clinical cohort. As predicted, bi- sexual patients exhibited poorer treatment outcomes than hetero- sexual patients, in terms of symptom severity, reliable improve- ment, and reliable recovery after adjustment for baseline symptomseverity and key treatment and sociodemographic variables. Bi- sexual men also had poorer treatment outcomes than gay men. In contrast, none of the comparisons between bisexual and lesbian women were significant in the models adjusting for confounders. In line with the second prediction, lesbian women had poorer outcomes than heterosexual women, while treatment outcomes for gay men did not differ significantly from those of heterosexual men. The effect sizes were generally largest for the bisexual men. For example, bisexual men had increased risk of failure to recover for depression/anxiety or functional impairment of 1.5–1.7 in the fully adjusted models compared to heterosexual or gay men; for bisexual and lesbian women compared to heterosexual women, the odds ratios were 1.3–1.4. Therefore the risk of failure to recover is approximately 30 – 40% higher for sexual minority women and 50 –70% higher for bisexual men, indicating important treatment outcome disparities relative to heterosexual patients. The poorer treatment outcomes for three of the sexual minority groups are consistent with results of a previous study of four services in South East London, U.K. (Rimes et al., 2018), but the current study is much larger and involves national cohort data. The findings of poorer outcomes for bisexual patients in the current study are consistent with some subgroup analyses byBeard et al.’s (2017)study of a hospital-based program.Plöderl et al. (2017)did not find significant differences in treatment outcomes in a hospital- based suicide prevention program for sexual minority patients versus heterosexual individuals, but they did not investigate bisex- ual patients separately. Multiple factors varied across these two studies and the current one, making it impossible to draw any firm conclusions. In addition to being hospital-based and being in different countries (United States and Austria), the two previous studies involved patients with a higher level of treatment needs such as personality disorders or psychosis, who had received a greater amount of psychological treatment alongside psychiatric input rather than psychological intervention alone. Further, those smaller studies did not investigate outcomes by sex, and the current findings highlight the importance of considering both sex differences and variations across sexual minority subgroups. It had already been demonstrated that White patients in IAPT services have better treatment outcomes than racial minority patients, but this is the first study to investigate the interaction between sexual orientation and racial minority status. Contrary to expectations, there was no evidence that racial minority lesbian/gay patients had poorer treatment outcomes than White lesbian/gay patients, or that racial minority bisexual patients had poorer outcomes than White bisexual patients. In contrast, within heterosexual patients, differences between White and racial minority patients were larger and sometimes signif- icant. This may indicate that racial and sexual minority statuses have relatively separate rather than interacting effects on treatment out- comes and that sexual minority status has a more dominant effect than racial minority status. Although the study was not sufficiently pow- ered to investigate the three-way interaction between sexual orienta- tion, sex, and race statistically, inspection of unadjusted final session symptom severity scores indicates that White gay men had consis- tently lower symptom severity than lesbians or bisexual patients who were White or a racial minority. However, caution is warranted in drawing firm conclusions. The sample is predominantly White, with a smaller proportion of racial minority patients (8.9%) than the pro- portion of racial minority individuals recorded in the 2011 Census in England (14%), indicating that racial minority individuals may be This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 585 SEXUAL MINORITY TREATMENT OUTCOMES underaccessing IAPT services. Also people with missing ethnicity data were excluded from the present analyses, although this was only a small proportion of the cohort population. Research is required into the reasons for the poorer treatment outcomes for bisexual people and lesbian women. There was no evidence that this was due to group differences in age, race, employ- ment status, deprivation, baseline symptom severity, number of treat- ment sessions or intensity of treatment, as these were all adjusted for in the analyses. Future studies should include examination of their treatment experiences, including factors influencing engagement, the therapeutic alliance, treatment completion, or onward referral. Re- search should investigate the possible role of lack of understanding, stigma, or discrimination within health services (King, 2015). Al- though therapists in these health services will have received some cultural competences training, it is possible that many have received little specific education about working sexual minority patients. Re- search indicates that outpatient psychotherapy patients are more likely to terminate treatment prematurely if they perceive their therapist to be low in multicultural competence (Anderson, Bautista, & Hope, 2019). Sexual minority patients may have had previous negative experiences in mental health services that could have influenced therapeutic engagement or trust in their therapist, with subsequent impact on outcomes. For example, although all U.K. therapy bodies recently stated that conversion therapy should not be provided, a U.K. survey in 2002–2003 found that 17% of therapists reported having provided treatment to reduce same-sex attractions or behavior (King, 2015). Past or ongoing stigma and other stressors outside of the treat- ment setting may play a role in poorer treatment outcomes for the bisexual patients and lesbian women. Although gay men experi- ence social disadvantages associated with being a sexual minority, bisexual individuals experience greater stigma, sexual orientation concealment, and invisibility than lesbian/gay people (Dodge et al., 2016;Ross et al., 2018). These may have direct effects on mental health or factors that affect mental health such as partner relationships (Dyar, Feinstein, Schick, & Davila, 2017). Further- more, sexual minority women are more likely than heterosexual women to report childhood trauma (Austin et al., 2008) and interpersonal violence in adulthood (Szalacha, Hughes, McNair, & Loxton, 2017). There is evidence that daily heterosexism experi- enced by sexual minority women can maintain symptoms of post- traumatic stress disorder in sexual minority women (Dworkin et al., 2018). In addition to heterosexism, sexual minority women will have experienced lifelong gender-based prejudice and dis- crimination that may contribute to the increased prevalence in common mental health problems in women relative to men in the general population (Platt, Prins, Bates, & Keyes, 2016). The in- teracting influences of heterosexism and sexism may help explain why sexual minority women experienced worse treatment out- comes than heterosexual women, whereas there were no signifi- cant differences for gay versus heterosexual men. Reduced social support in sexual minority subgroups may also affect mental health (Bränström, 2017;Pollitt, Muraco, Grossman, & Russell, 2017) and treatment outcomes. Assessment of sexual minority individu- als should include the possible mental health impact of stigma or victimization, disclosure, and social support. The bisexual and lesbian patients were younger than the other groups, consistent with some previous evidence of earlier age at onset for psychopathology in sexual minority individuals (Cochran &Mays, 2000). However, they also had higher presenting levels of depression, anxiety, and functional impairment than the heterosexual patients and gay men. Future research could investigate whether these individuals are more likely to delay treatment seeking than hetero- sexual individuals or gay men. These three groups were also more likely to be living in a high deprivation area than heterosexual indi- viduals, and bisexual patients were more likely to be unemployed than all groups except heterosexual women. Although the group differ- ences remained after adjustment for the confounding effects of race, baseline symptoms/impairment, unemployment, deprivation and so on, it is likely that they are markers for unmeasured negative influ- ences on mental health and recovery. Multiple and intersecting social disadvantages and stigma can act as both etiological agents and chronic stressors that are likely to make it harder to benefit from psychological interventions. In line with their higher baseline scores, bisexual men and lesbian women were more likely to receive high-intensity treatment than their heterosexual counterparts, but they did not have the corresponding greater number of treatment sessions that would be expected. Bisexual women were not more likely than heterosexual women to receive a higher intensity treatment and did not receive more treatment ses- sions, despite their greater need. The reasons for these findings should be urgently explored. It may be that bisexual and lesbian patients were more likely to choose to end treatment early, perhaps due to reduced likelihood of establishing a trusting therapeutic alliance, or lower treatment satisfaction or benefit. Minority sexual orientation has been found to be associated with higher rates of premature therapy termi- nation (Anderson et al., 2019). Limitations and Future Research The post hoc comparisons regarding bisexual versus lesbian/gay participants and White compared to racial minority participants require replication in other samples, especially as the latter may have been underpowered. Limitations of sexual orientation record- ing in the present study and comparison data sets mean that it is difficult to compare the proportions of our sexual minority patients to general population rates. Of the women who indicated their sexual orientation, 1.5% were lesbian and 1.2% were bisexual; for the men, the figures were 3.7% gay and 0.8% bisexual. General population estimates from the U.K. Office for National Statistics (ONS, 2014) were 0.8% lesbian women, 0.6% bisexual women, 1.5% gay men, 0.4% bisexual men. Higher treatment access is to be expected for sexual minorities given their increased rates of mental illness. However, the proportion in the ONS who say that they do not know or refuse to answer was 4% compared to 11% in the current study, and the ONS study had no completely missing sexual orientation data, making direct comparisons more difficult. Sexual orientation data collection in IAPT services only began in 2012 and the proportion of missing data has been decreasing over time as more therapists/services collect and input the data. The ONS study also includes an “other” category (0.3%); at the time of the data collection, the data standard for IAPT services did not include a sexual orientation category such as “other sexual orien- tation not listed.” Future research should investigate treatment outcomes for individuals who do not identify as heterosexual, lesbian, gay, or bisexual, including those identifying as asexual. Younger people in particular often have more diverse sexual identities or resist labels. This document is copyrighted by the American Psychological Association or one of its allied publishers. This article is intended solely for the personal use of the individual user and is not to be disseminated broadly. 586 RIMES, ION, WINGROVE, AND CARTER Future research should also investigate treatment outcomes for people who say that they are unsure of their sexual orientation, who may have specific therapeutic needs. In the present study those who stated that they did not know or were unsure of their sexual orientation were younger and were more likely to be male, unemployed, from a minority racial group, living in a higher deprivation area, and had higher baseline symptomatology and fewer treatment sessions than those who stated their sexual orien- tation. The effect sizes were very small, but some of these findings are consistent with previous reports that more socially disadvan- taged individuals can be less likely to state a sexual orientation (Aspinall, 2009). Some of these factors are associated with poorer treatment outcomes, so people who are unsure of their sexual orientation may require additional or different treatment. There is also evidence that subgroups such as “mostly heterosexual” indi- viduals may have distinct characteristics (Savin-Williams & Vran- galova, 2013) and could be researched as a separate group. The paper presents findings for patients with data for all the study variables. Participants with missing data had smaller reduc- tions in symptom levels than those with data present, so the first-to-last session changes presented here should not be viewed as representative of all patients receiving IAPT interventions. Deprivation and employment data exceeded 5%, so the primary analyses were repeated including participants with missing depri- vation or employment data. A similar pattern of significant group effects and interactions were found with just one exception (for failure to recover in functional impairment, the sex-by-lesbian/gay interaction now had limited statistical significance). However, future research should further investigate the impact of missing data. In addition, the results may not generalize outside of English IAPT psychological intervention services that are free at the point of delivery. Future studies should adjust for additional confounders not included in the present study such as the duration of the presenting problem, medication or amount of previous therapy. Information about gender minority status was not recorded in the dataset and therefore could be reported or analyzed here. Future research should also compare treatment outcomes in sexual mi- nority people with and without additional socially disadvantaged statuses such as lower socioeconomic status, disabilities, or long- term physical health conditions. Clinical Implications The present findings of treatment inequities highlight the impor- tance of sexual orientation data collection and audit in health care settings. Health professionals should be encouraged to support the recording of sexual orientation data; this should be carefully repeated for any subsequent treatment episodes to allow people to report different sexual identities over time (Diamond, Dickenson, & Blair, 2017;Everett, Talley, Hughes, Wilsnack, & Johnson, 2016). Although the present study cannot identify reasons for the poorer treatment outcomes in bisexual people and lesbian women, these are likely to be multifaceted. Some therapists may require more training in working with bisexual patients, such as not making assumptions about a monosexual orientation based on the patient’s current or previous partner history and understanding that biphobia may be experienced from lesbian or gay as well as heterosexual individuals. Therapists should also consider how issues relating to minority sexual orientation may be different for lesbian women and may interact withgender-based social disadvantages. Training about working with sex- ual minorities should be provided to everyone in the health service as previous negative experiences with receptionists, administrators, nurses, and general practitioners may all set up negative expectations in sexual minority patients that may adversely impact on the thera- peutic relationship. Training guidelines for everyone working with mental health patients should require learning about the specific needs of sexual minority patients. For therapists, this should include being trained in asking sensitively about sexual orientation and assessing and treating any lasting impact of stigma-related experiences. Service managers should be advised to analyze treatment outcomes to inves- tigate whether they are providing an equitable service for sexual minority patients. However, societal-level interventions are needed to reduce sexism, biphobia, and homophobia to help prevent the asso- ciated adverse mental health consequences rather than merely trying to repair them. The role of what the patient brings to the treatment should also be investigated in relation to treatment outcomes. For example, internalized societal stigma about minority sexual orientation and previous or ongoing stigma experiences could influence not only the presenting mental health problem and recovery, but the pa- tient’s willingness to disclose about sexual orientation itself, or discuss related issues. Concerns about possible negative attitudes from the therapist about sexual orientation could also reduce trust in the therapist and therapy engagement more generally. For those receiving a group intervention, similar factors could affect inter- actions with other group members and group engagement. Until we know more about the reasons for these poorer treat- ment outcomes, mental health professionals should consider the possibility that sexual minority women and bisexual men may require additional treatment sessions or different interventions. For example, there is promising preliminary evidence from an uncon- trolled study of group CBT for people with depression (Ross, Doctor, Dimito, Kuehl, & Armstrong, 2007) and a randomized trial of LGB-affirmative CBT, although the latter only included sexual minority young men (Pachankis, Hatzenbuehler, Rendina, Safren, & Parsons, 2015). A novel CBT intervention to address trauma symptoms and sexual risk taking in sexual minority men with childhood sexual abuse is also being investigated (Taylor, Goshe, Marquez, Safren, & O’Cleirigh, 2018). Providing interven- tions as early as possible is important prevention work, and there is promising evidence from a feasibility study for a brief affirma- tive CBT intervention for sexual and gender minority youth (Craig & Austin, 2016). There is very little LGB-specific service provi- sion in England’s NHS mental health care, such as group inter- ventions for LGB patients. Conclusions The findings highlight the importance of researching mental health outcomes separately by type of sexual orientation (e.g., bisexual vs. lesbian/gay) in interaction with sex and race. Further research is needed into the reasons for poorer psychological treat- ment outcomes for depression and anxiety in bisexual men and women, and lesbian women. Therapists should be aware that sexual minority patients may have different or additional treatment needs. This document is copyrighted by the American Psychological Association or one of its allied publishers. 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