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

•What is the primary question addressed by this study? Older adults with knee osteoarthritis (OA) and comorbid subsyndromal depressive symptoms are at elevated risk for incidental major depression or anxiety disorders. The aims of this intervention–development SMART trial were to evaluate the clinical effect of CBT and PT, as well as the order effects of the interventions, on patient–reported outcomes. We also compared both the strategies and response status on the prevention of common psychiatric disorders during one-year follow–up.•What is the main finding of this study? Stage 1 response was higher for PT (47.5%) compared to CBT (20.5%). Nonresponders re-randomized to an increased dose of the same intervention experienced a response rate of 73%, higher than for switching. All strategies were superior to enhanced usual care (5%). Neither intervention strategy nor response status affected twelve-month incidental depression and anxiety disorders.•What is the meaning of the finding? it may be dose and not type of these interventions that is necessary for clinical benefit. This finding may guide providers to stay the clinical course for up to 12 weeks before switching. a SMART trial may be an efficient and clinically relevant approach for testing prevention strategies for late-life psychiatric disease.