The contribution of reliable and clinically significant change methods to evidence-based mental health

Severity of Substance Use Disorder: Utility as an Outcome in Clinical Settings

BACKGROUND

Some authors have pointed out the usefulness of the levels of substance use disorder (SUD) as a treatment outcome. However, in order to use this variable as an outcome measure, its impact needs to be addressed within a clinical context. The aim of this study was to analyze the sensitivity of SUD levels as a measure for detecting reliable changes and to make a comparison between the changes in SUD levels detected when using the number of criteria fulfilled and when using the reliable change index (RCI).

METHODS

The sample consisted of 206 (106 in follow-up) patients diagnosed with abuse/dependence on alcohol and cocaine, according to DSM-IV criteria. The Substance Dependence Severity Scale for DSM-5 was used to determine current alcohol use disorder (AUD) and cocaine use disorder (CUD). Number of DSM-5 criteria fulfilled and RCI were used to determine the change in SUD levels.

RESULTS

No association was found between adherence to/abandonment of treatment and AUD severity levels (χ2  = 7.029, p = 0.071) or CUD severity levels (χ2  = 2.044, p = 0.413). Statistical significant differences for levels of AUD (z = -3.870, p = 0.000) and CUD (z = -5.382, p = 0.000) were found between baseline assessment and follow-up. According to the number of DSM-5 criteria and RCI, the Kappa coefficient for the change in patient status (improved, worsened, or no change) was k = 0.61 for alcohol patients and k = 0.64 for cocaine patients. The "mild" category showed the greatest inconsistency between both procedures.

CONCLUSIONS

Levels of SUD are sensitive to the impact of treatment as measured by the difference between the baseline assessment and 3-month follow-up. However, conclusions differ according to whether the DSM-5 criteria or the RCI is applied.

In the Absence of Effects: An Individual Patient Data Meta-Analysis of Non-response and Its Predictors in Internet-Based Cognitive Behavior Therapy

Background: Negative effects of psychological treatments have recently received increased attention in both research and clinical practice. Most investigations have focused on determining the occurrence and characteristics of deterioration and other adverse and unwanted events, such as interpersonal issues, indicating that patients quite frequently experience such incidents in treatment. However, non-response is also negative if it might have prolonged an ongoing condition and caused unnecessary suffering. Yet few attempts have been made to directly explore non-response in psychological treatment or its plausible causes. Internet-based cognitive behavior therapy (ICBT) has been found effective for a number of diagnoses but has not yet been systematically explored with regard to those patients who do not respond. Methods: The current study collected and aggregated data from 2,866 patients in 29 clinical randomized trials of ICBT for three categories of diagnoses: anxiety disorders, depression, and other (erectile dysfunction, relationship problems, and gambling disorder). Raw scores from each patient variable were used in an individual patient data meta-analysis to determine the rate of non-response on the primary outcome measure for each clinical trial, while its potential predictors were examined using binomial logistic regression. The reliable change index (RCI) was used to classify patients as non-responders. Results: Of the 2,118 patients receiving treatment, and when applying a RCI of z ≥ 1.96, 567 (26.8%) were classified as non-responders. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline, Odds Ratio (OR) = 2.04, having a primary anxiety disorder (OR = 5.75), and being of male gender (OR = 1.80), might have higher odds of not responding to treatment. Conclusion: Non-response seems to occur among approximately a quarter of all patients in ICBT, with predictors related to greater symptoms, anxiety disorders, and gender indicating increasing the odds of not responding. However, the results need to be replicated before establishing their clinical relevance, and the use of the RCI as a way of determining non-response needs to be validated by other means, such as by interviewing patients classified as non-responders.

Efficacy of an internet-based self-management intervention for depression or dysthymia - a study protocol of an RCT using an active control condition

BACKGROUND

The treatment of major depressive disorder, a highly prevalent disorder associated with pronounced burden, is a large challenge to healthcare systems worldwide. Internet based self-management interventions seem to be a cost effective way to complement the treatment of depressed patients, but the accumulating evidence is mainly based on the comparison to waitlist controls and treatment as usual, which might lead to an overestimation of effects. Furthermore, studies assessing long-term effects and possible negative outcomes are still rare.

METHODS/DESIGN

The proposed study evaluates the efficacy of the German version of the iFightDepression® tool in comparison to an active control condition. A total of 360 patients with mild to moderate depressive symptoms are included into a two-armed randomized controlled trial. They receive one of two six week interventions; either the iFightDepression® tool or progressive muscle relaxation serving as the control condition. Both intervention groups receive information material, weekly tasks via the internet and regular phone calls as part of the intervention. The primary outcome is change in depressive symptoms after the intervention period, as measured with the Inventory of Depressive Symptomatology. Satisfaction with the program, usability, changes in perceived quality of life, and possible negative effects are assessed as secondary outcomes.

DISCUSSION

This study represents the first randomized controlled trial on the iFightDepression® self-management tool in its German version, aiming at efficacy, but also at providing new insights into so far understudied aspects of E-mental health programs, namely the specificity of the treatment effect compared to an active control condition, it's continuity over a time course of 12 months, and possible negative effects of these internet based interventions.

TRIAL REGISTRATION

International trial-registration took place through the "international clinical trials registry platform" (WHO) with the secondary ID 080-15-09032015. German Clinical Trial Registration: DRKS00009323 (DRKS.de, registered on 25 February 2016).

An Uncontrolled Open Trial of a Brief Behavioural Activation Treatment for Depression in Patients with Chronic Spontaneous Urticaria

Chronic spontaneous urticaria (CSU) has been associated with depression and can have an impact on quality of life. Therefore, researchers have suggested the potential utility of psychological interventions for targeting depression among CSU patients. Psychological interventions that may hold the most promise are those that are brief and easily transportable, such as brief behavioural activation treatment for depression. We report results of a preliminary investigation of an uncontrolled open trial of a one-session behavioural activation treatment for depression designed for patients with CSU (BATD-CSU) at a university-based allergy and immunology clinic. Participants were 11 females with chronic, poorly controlled urticaria and symptoms of depression. Following the completion of pretreatment questionnaires, participants were administered BATD-CSU primarily by non-mental health professionals trained and supervised in its delivery. One month post-BATD-CSU, participants completed follow-up questionnaires. Participants exhibited significant reductions in depression severity, avoidance/rumination, and work/school impairment. BATD-CSU was also associated with improvements in urticaria control one month post-treatment. Moreover, five of nine patients reported reliable and clinically significant improvement on at least one outcome. Results demonstrate that BATD-CSU may have benefits for CSU patients even when consisting of one session and delivered by professionals with limited background in psychological interventions, thus speaking to its feasibility and transportability.

Structure and Connectivity of Depressive Symptom Networks Corresponding to Early Treatment Response

BACKGROUND

There are suggestions that denser network connectivity (i.e., the strength of associations between individual symptoms) may be a prognostic indicator of poor treatment response in depression. We sought to examine this aspect of depressive symptom networks in the context of early responses to treatment in adolescents.

METHODS

Routine psychiatric data were obtained for child/adolescent service users who underwent at least three treatment sessions in publicly funded services in England between 2011 and 2015 (N = 3017, 78% female; mean age [SD] = 14.43 years [1.75]). Depressive symptoms were assessed using the Revised Children's Anxiety and Depression Scale at presentation, and again after three treatment sessions. Treatment response was determined using the Reliable Change Index. Network analysis was used to compare the depressive symptom structure and connectivity of sub-samples who, after three treatment sessions had: 1) positively responded (n = 566), 2) not reliably changed (n = 2277), and 3) reliably deteriorated (n = 174), using matched samples to control for baseline severity.

FINDINGS

Overall connectivity (i.e., the summed total of weighted connections) was significantly weaker for the positive treatment response group at baseline (compared with unchanged and deteriorated groups), however, this group saw the largest increase in connectivity over the course of treatment. With regard to the overall importance of specific symptoms within the networks, fatigue was highest in strength for the unchanged and deteriorated groups, whereas low mood was highest in strength for the improved group.

INTERPRETATION

This study demonstrates that adolescents who respond early to treatment for depression are characterised by symptom networks that are less densely connected initially, yet increase in connectivity over the course of treatment. This may be indicative of 'positive spirals' whereby improvement in one symptom triggers improvements in other symptoms, thereby increasing symptom-symptom associations even as severity decreases.

FUNDING

The study was supported by the Wellcome Trust grant 204366/Z/16/Z. The funders had no role in the study design, data collection, data analysis, interpretation, or writing of the report.

Response and Remission Rates in Internet-Based Cognitive Behavior Therapy: An Individual Patient Data Meta-Analysis

Background: Internet-delivered cognitive behavior therapy (ICBT) was developed over 20 years ago and has since undergone a number of controlled trials, as well as several systematic reviews and meta-analyses. However, the crucial question of response rates remains to be systematically investigated. The aim of this individual patient meta-analysis (IPDMA) was to use a large dataset of trials conducted in Sweden to determine reliable change and recovery rates across trials for a range of conditions. Methods: We used previously collected and aggregated data from 2,866 patients in 29 Swedish clinical trials of ICBT for three categories of conditions: anxiety disorders, depression, and others. Raw scores at pre-treatment and post-treatment were used in an IPDMA to determine the rate of reliable change and recovery. Jacobson and Truax's, (1991) reliable change index (RCI) was calculated for each primary outcome measure in the trials as well as the recovery rates for each patient, with the additional requirement of having improved substantially. We subsequently explored potential predictors using binomial logistic regression. Results: In applying an RCI of z = 1.96, 1,162 (65.6%) of the patients receiving treatment were classified as achieving recovery, and 620 (35.0%) were classified as reaching remission. In terms of predictors, patients with higher symptom severity on the primary outcome measure at baseline [odds ratio (OR) = 1.36] and being female (OR = 2.22) increased the odds of responding to treatment. Having an anxiety disorder was found to decrease the response to treatment (OR = 0.51). Remission was predicted by diagnosis in the same direction (OR = 0.28), whereas symptom severity was inversely predictive of worse outcome (OR = 0.81). Conclusions: Response seems to occur among approximately half of all clients administered ICBT, whereas about a third reach remission. This indicates that the efficacy of ICBT is in line with that of CBT based in prior trials, with a possible caveat being the lower remission rates. Having more symptoms and being female might increase the chances of improvement, and a small negative effect of having anxiety disorder versus depression and other conditions may also exist. A limitation of the IPDMA was that only studies conducted in Sweden were included.

Deterioration rates in Virtual Reality Therapy: An individual patient data level meta-analysis

Ample evidence supports the use of Virtual Reality (VR) for anxiety disorders. Nonetheless, currently there is no evidence about moderators or potential negative effects of VR treatment strategies. An Individual Patient Data (IPD) approach was employed with 15 retrieved datasets. The current study sample was composed of 810 patients. Randomized control trials (RCTs) for each primary outcome measure were performed, in addition to moderator analyses of the socio-demographic variables. Deterioration rates were 14 patients (4.0%) in VR, 8 (2.8%) in active control conditions, and 27 (15%) in the WL condition. With regard to receiving treatment, patients in a waiting list control condition had greater odds of deteriorating than in the two active conditions, odds ratios (ORs) 4.87, 95% confidence interval (CI) [0.05, 0.67]. In the case of the socio-demographic variables, none of them were associated with higher or lower odds of deterioration, with the exception of marital status in the WL condition; married people presented a significantly lower probability of deterioration, OR 0.19, 95% CI [0.05, 0.67]. Finally, when comparing pooled effects of VR versus all control conditions, the OR was 0.61 (95% CI 0.31-1.23) in favor of VR, although this result was not statistically significant. This study provides evidence about the deterioration rates of a therapeutic VR approach, showing that the number of deteriorated patients coincides with other therapeutic approaches, and that deterioration is less likely to occur, compared to patients in WL control groups.

Memory Strategy Training in Older Adults with Subjective Memory Complaints: A Randomized Controlled Trial

OBJECTIVES

Subjective memory complaints (SMC) in older adults are associated with a decline in everyday functioning and an increased risk for future cognitive decline. This study examines the effect of a memory strategy training compared to a control memory training on memory functioning in daily life.

METHODS

This was a randomized controlled trial with baseline, post-treatment, and 6-month follow-up assessments conducted in 60 older adults (50-87 years) with SMC. Participants were randomly assigned to either seven sessions of memory strategy training or seven sessions of control memory training. Both interventions were given in small groups and included psycho-education. Primary outcome measure was memory functioning in daily life. Objective measures of memory performance and self-reported measures of strategy use were included as secondary outcome measures.

RESULTS

Participants in each intervention group reported an improvement in personal memory goals (p<.0005), up to 6 months after training. An interaction effect showed that participants following memory strategy training reported a larger improvement in personal memory goals (p=.002). Both intervention groups improved on two memory tests (p<.001 and p<.01). In the memory strategy training group, an increase in strategy use in daily life was the strongest predictor (p<.05) of improvement in subjective memory functioning.

CONCLUSIONS

Older adults with subjective memory complaints benefit from memory strategy training, especially in their memory functioning in daily life. (JINS, 2018, 24, 1110-1120).

The effectiveness of high-intensity CBT and counselling alone and following low-intensity CBT: a reanalysis of the 2nd UK National Audit of Psychological Therapies data

BACKGROUND

A previously published article in this journal reported the service effects from 103 services within the UK Improving Access to Psychological Therapies (IAPT) initiative and the comparative effectiveness of CBT and Counselling provision. All patients received High-intensity CBT or High-intensity Counselling, but some also received Low-intensity CBT before being stepped-up to High intensity treatments. The report did not distinguish between patients who received low-intensity CBT before being stepped-up. This article clarifies the basis for collapsing low- and high-intensity interventions by analysing the four treatment conditions separately.

METHOD

Data from 33,243 patients included in the second round of the National Audit of Psychological Therapies (NAPT) were re-analysed as four separate conditions: High-intensity CBT only (n = 5975); High-intensity Counselling only (n = 3003); Low-intensity CBT plus High-intensity CBT (n = 17,620); and Low-intensity CBT plus High-intensity Counselling (n = 6645). Analyses considered levels of pre-post therapy effect sizes (ESs), reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.

RESULTS

Significant differences obtained on various outcome indices but were so small they carried no clinical significance. Including the four treatment groups in a multilevel model comprising patient intake severity, patient ethnicity and number of sessions attended showed no significant differences between the four treatment groups. Comparisons between the two high-intensity interventions only (N = 8978) indicated Counselling showed more improvement than CBT by 0.3 of a point on PHQ-9 for the mean number of sessions attended. However, this result was moderated by the number of sessions and for 12 or more sessions, the advantage went to CBT.

CONCLUSIONS

This re-analysis showed no evidence of clinically meaningful differences between the four treatment conditions using standard indices of patient outcomes. However, a differential advantage to high-intensity Counselling for fewer than average sessions attended and high-intensity CBT for more than average sessions attended has important service implications. The finding of equivalent outcomes between high-intensity CBT and Counselling for more severe patients also has important policy implications. Empirically-informed procedures (e.g., predictive modelling) for assigning patients to interventions need to be considered to improve patient outcomes.

Individual trajectories of cognitive performance in first episode psychosis: a 2-year follow-up study

Individual changes over time in cognition in patients with psychotic disorders have been studied very little, especially in the case of first episode psychosis (FEP). We aimed to establish whether change in individual trajectories in cognition over 2 years of a sample of 159 FEP patients was reliable and clinically significant, using the reliable change index (RCI) and clinically significant change (CSC) methods. We also studied a sample of 151 matched healthy controls. Patients and controls were assessed with a set of neuropsychological tests, as well as premorbid, clinical and functionality measures. We analysed the course of cognitive measures over time, using analysis of variance, and the individual trajectories in the cognitive measures with the regression-based RCI (RCI_SRB) and the CSC. The RCI_SRB showed that between 5.4 and 31.2% of the patients showed deterioration patterns, and between 0.6 and 8.8% showed improvement patterns in these tests over time. Patients showing better cognitive profiles according to RCI_SRB (worsening in zero to two cognitive measures) showed better premorbid, clinical and functional profiles than patients showing deterioration patterns in more than three tests. When combining RCI_SRB and CSC values, we found that less than 10% of patients showed improvement or deterioration patterns in executive function and attention measures. These results support the view that cognitive impairments are stable over the first 2 years of illness, but also that the analysis of individual trajectories could help to identify a subgroup of patients with particular phenotypes, who may require specific interventions.

Studying the Efficacy of Psychodrama With the Hermeneutic Single Case Efficacy Design: Results From a Longitudinal Study

Throughout the last decades, scientific and therapeutic communities have made common efforts to collect reliable information concerning the efficacy of psychotherapies. One of these initiatives has, recently, involved the psychodrama community and its desire to achieve progress in the validation of this therapy. Based on Robert Elliott's Hermeneutic Single Case Efficacy Design, we followed five participants (three women, two men, aged 27-48 years) of a psychodrama group over the course of their therapeutic process, which ranged from 24 months to 5 years. For the single case study, we selected the participant who had the longest data collecting record, including one follow-up. Participants generally reported improvement in their personal therapeutic goals, decrease in symptoms and life problems, and some showed a marked increase in spontaneity levels. In the single case, these results are confirmed, and following decision criteria it is possible to assert that the participant improved in all the variables assessed and that therapy is the main cause of these changes. Furthermore, the participant frequently rated psychodrama sessions as being helpful and stated they had a transformational impact on his life. This research contributes toward validating psychodrama as an efficient therapeutic method, hopefully stimulating practitioners to integrate therapy and research-which, for years, were considered independent and incompatible-and to facilitate their use in a complementary way.

Prospective observational cohort study of 'treatment as usual' over four years for patients with schizophrenia in a national forensic hospital

BACKGROUND

We evaluated change in response to multi-modal psychosocial 'treatment as usual' programs offered within a forensic hospital.

METHODS

Sixty nine patients with a diagnosis of schizophrenia or schizoaffective disorder were followed for up to four years. Patient progress was evaluated using the DUNDRUM-3, a measure of patient ability to participate and benefit from multi-modal psychosocial programs and the HCR-20 dynamic items, a measure of violence proneness. We report reliable change index (RCI) and reliable and clinically meaningful change (RMC). We assessed patients' cognition using the MCCB, psychopathology using the PANSS. The effect of cognition and psychopathology on change in DUNDRUM-3 was examined using hierarchical multiple regression with age, gender, and baseline DUNDRUM-3 scores.

RESULTS

The DUNDRUM-3 changed significantly (p < 0.004, d = 0.367, RCI 32% of 69 cases, RMC 23%) and HCR-20-C (p < 0.003, d = 0.377, RCI 10%). Both cognition and psychopathology accounted for significant variance in DUNDRUM-3 at follow up. Those hospitalized for less than five years at baseline changed more than longer stay patients. Mediation analysis demonstrated that the relationship between cognition and change in violence proneness (HCR-20-C) was both directly affected and indirectly mediated by change in DUNDRUM-3.

CONCLUSIONS

Change in response to multi-modal psychosocial programs (DUNDRUM-3) reduced a measure of violence proneness over four years. Forensic in-patients' ability to benefit from psychosocial treatment appears to be a function of the outcome measure used, unit of measurement employed, degree of cognitive impairment, psychopathology, and length of stay. Lower risk of re-offending may be partially attributable to participation and engagement in psychosocial interventions.

Longitudinal analysis of statistical and clinically significant psychosocial change following mental health rehabilitation

Purpose: With appropriate mental health rehabilitation, schizophrenia is increasingly associated with reports of recovery and stability. However, there is little empirical evidence evaluating the efficacy of services delivering this care. This study evaluated the effectiveness of rehabilitation for improving psychosocial function in consumers with schizophrenia.Methods: An electronic database of standardized assessment instruments mandated and maintained by the health service was retrospectively reviewed to extract ratings of psychosocial function, daily living skills, and mood state from consecutive admissions to an inpatient rehabilitation service. Outcomes were compared at admission, discharge, and one-year follow-up to identify statistically significant change. Individual reliable and clinically significant change was also assessed by comparison with a normative group of clients functioning independently in the community.Results: From admission to discharge the rehabilitation group made statistically significant gains in psychosocial function and daily living skills. Improvements were reliable and clinically significant in one-quarter to one-third of individual consumers. Approximately half sustained their improvements at follow-up, although this represented only a small fraction of the overall cohort. Consumers not demonstrating gains exhibited psychometric floor effects at admission.Conclusions: Rehabilitation can produce statistically and clinically significant immediate improvement in psychosocial function for a sub-set of consumers with elevated scores at admission. The durability of any gains is less clear, and strategies promoting longer-term maintenance are encouraged. Furthermore, currently mandated outcome measures are confounded by issues of sensitivity and reporting compliance, and exploration of alternative instruments for assessing recovery is recommended.Implications for RehabilitationRoutinely collected standardized outcome measures can be used to investigate the effectiveness of mental health rehabilitationIn addition to statistical significance, the clinical significance of outcomes should be evaluated to identify change that is individually meaningfulCurrently mandated outcomes instruments do not adequately evaluate many individuals' recovery journeyMental health service evaluation and quality improvement processes would likely benefit from adoption of recovery-oriented measures.

Evaluation of reliable improvement rates in depression and anxiety at the end of treatment in adolescents

BACKGROUND

Literature has focused on effect sizes rather than individual-level improvement rates to determine how effectively services address burgeoning numbers of adolescents with anxiety and depression.AimsTo consider how many adolescents report reliable improvement in anxiety, depression and comorbid depression and anxiety by end of treatment.

METHOD

The primary outcome was reliable improvement (i.e. change greater than likely the result of measurement error) in self-reported anxiety and depression for N = 4464 adolescents (mean age 14.5 years, s.d. = 1.9; 75% female; 61% White) seen in specialist mental health services in England.

RESULTS

In total, 53% of those with anxiety, 44% with depression, and 35% with comorbid depression and anxiety showed reliable improvement.

CONCLUSIONS

Improvement rates were higher than previously reported, but lower than generally used in advice to the public. There may be a need to set more realistic expectations, including with young people who seek help.Declaration of interestAll authors were involved in the programme of service transformation that this report draws on. M.W. led the outcomes and evaluation group that agreed the approach to measurement used in the initiative.

GET.HAPPY - Acceptance of an internet-based self-management positive psychology intervention for adult primary care patients with mild and moderate depression or dysthymia: A pilot study

INTRODUCTION

A growing number of internet interventions have been shown to help in alleviating symptoms of depression. So far, only little research has focused on other methods than CBT. The present study aimed to investigate the level of satisfaction with a positive psychology online training among patients with mild and moderate depression or dysthymia. Secondary outcome measures included changes in symptom severity, health related quality of life, and negative effects.

METHODS

A total of 81 participants were allocated to the intervention. They were asked to complete online questionnaires and were called by one of the study psychologists at baseline, at post-treatment, and at follow-up (3 months after completion of the intervention). Shorter questionnaires were administered after each module.

RESULTS

Overall satisfaction was promising. While participants seemed to be very satisfied with many aspects of the program itself, they were slightly less satisfied with its impact on the problems they sought to solve. Overall, negative effects attributed to the program were small with one exception. At post-treatment, 22.6% of the participants felt that they or their problems were not taken seriously by the program. Symptom severity decreased over time with mild to moderate effect sizes. There was a moderate increase in satisfaction with mental health at both post-treatment and follow-up.

CONCLUSIONS

The online program investigated here may be a useful resource-oriented addition to the standard treatment of depression.

Guided Web-Based Cognitive Behavior Therapy for Perfectionism: Results From Two Different Randomized Controlled Trials

BACKGROUND

Perfectionism can become a debilitating condition that may negatively affect functioning in multiple areas, including mental health. Prior research has indicated that internet-based cognitive behavioral therapy can be beneficial, but few studies have included follow-up data.

OBJECTIVE

The objective of this study was to explore the outcomes at follow-up of internet-based cognitive behavioral therapy with guided self-help, delivered as 2 separate randomized controlled trials conducted in Sweden and the United Kingdom.

METHODS

In total, 120 participants randomly assigned to internet-based cognitive behavioral therapy were included in both intention-to-treat and completer analyses: 78 in the Swedish trial and 62 in the UK trial. The primary outcome measure was the Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale (FMPS CM). Secondary outcome measures varied between the trials and consisted of the Clinical Perfectionism Questionnaire (CPQ; both trials), the 9-item Patient Health Questionnaire (PHQ-9; Swedish trial), the 7-item Generalized Anxiety Disorder scale (GAD-7; Swedish trial), and the 21-item Depression Anxiety Stress Scale (DASS-21; UK trial). Follow-up occurred after 6 months for the UK trial and after 12 months for the Swedish trial.

RESULTS

Analysis of covariance revealed a significant difference between pretreatment and follow-up in both studies. Intention-to-treat within-group Cohen <italic>d</italic> effect sizes were 1.21 (Swedish trial; 95% CI 0.86-1.54) and 1.24 (UK trial; 95% CI 0.85-1.62) for the FMPS CM. Furthermore, 29 (59%; Swedish trial) and 15 (43%; UK trial) of the participants met the criteria for recovery on the FMPS CM. Improvements were also significant for the CPQ, with effect sizes of 1.32 (Swedish trial; 95% CI 0.97-1.66) and 1.49 (UK trial; 95% CI 1.09-1.88); the PHQ-9, effect size 0.60 (95% CI 0.28-0.92); the GAD-7, effect size 0.67 (95% CI 0.34-0.99); and the DASS-21, effect size 0.50 (95% CI 0.13-0.85).

CONCLUSIONS

The results are promising for the use of internet-based cognitive behavioral therapy as a way of targeting perfectionism, but the findings need to be replicated and include a comparison condition.

Teaching Recovery Techniques: evaluation of a group intervention for unaccompanied refugee minors with symptoms of PTSD in Sweden

In 2015, a total of 35,369 unaccompanied refugee minors (URMs) sought asylum in Sweden. In a previous study of 208 URMs, we found that 76% screened positive for PTSD. This study aimed to (1) evaluate the indicated prevention program Teaching Recovery Techniques (TRT) in a community setting and describe the program's effects on symptoms of PTSD and depression in URMs; and (2) examine participants' experiences of the program. The study included 10 groups. Methods for evaluation included the Children's Revised Impact of Event Scale (CRIES-8) and the Montgomery-Åsberg Depression Rating Scale Self-report (MADRS-S) at baseline and at post-intervention. Qualitative interviews were conducted with 22 participating URMs to elicit their experiences. Pre- and post-measures were available for 46 participants. At baseline, 83% of the participants reported moderate or severe depression and 48% suicidal ideation or plans. Although more than half (62%) of the participants reported negative life events during the study period, both PTSD (CRIES-8) and depression (MADRS-S) symptoms decreased significantly after the intervention (p = 0.017, 95% CI - 5.55; - 0.58; and p < 0.001, 95% CI - 8.94; - 2.88, respectively). The qualitative content analysis resulted in six overall categories: social support, normalisation, valuable tools, comprehensibility, manageability, and meaningfulness when the youth described their experiences of the program, well reflecting TRT's program theory. Overall, results indicate that TRT, delivered in a community setting, is a promising indicated preventive intervention for URMs with PTSD symptoms. This successful evaluation should be followed up with a controlled study.

Treating Procrastination Using Cognitive Behavior Therapy: A Pragmatic Randomized Controlled Trial Comparing Treatment Delivered via the Internet or in Groups

Procrastination is a common problem among university students, with at least half of the population reporting great difficulties initiating or completing tasks and assignments. Procrastination can have a negative impact on course grades and the ability to achieve a university degree, but can also lead to psychological distress. Cognitive behavior therapy (CBT) is believed to reduce procrastination, but few studies have investigated its effectiveness in a regular clinical setting. The current study explored its effects using a pragmatic randomized controlled trial comparing treatment delivered during 8 weeks as self-guided CBT via the Internet (ICBT) or as group CBT. In total, 92 university students with severe procrastination were included in the study (registered as a clinical trial on Clinicaltrials.gov: NCT02112383). Outcome measures on procrastination, depression, anxiety, and well-being were distributed at pre- and posttreatment as well as 6-month follow-up. An outcome measure of procrastination was administered weekly. Linear mixed and fixed effects models were calculated, along with improvement and deterioration rates. The results showed large within-group effect sizes on procrastination, Cohen's d of 1.29 for ICBT, 95% Confidence Interval (CI) [0.81, 1.74], and d of 1.24 for group CBT, 95% CI [0.76, 1.70], and small to moderate benefits for depression, anxiety, and well-being. In total, 33.7% were regarded as improved at posttreatment and 46.7% at follow-up. No differences between conditions were observed after the treatment period, however, participants in group CBT continued or maintained their improvement at follow-up, while participants in self-guided ICBT showed some signs of deterioration. The findings from the current study suggest that CBT might be an effective treatment for those struggling with severe procrastination, but that a group format may be better for some to sustain their benefits over time and that the clinical significance of the results need to be investigated further.

Using the Five Areas cognitive–behavioural therapy model with psychiatric patients

In the first article in this series (Williams & Garland, 2002) we encouraged readers to try out elements of the Five Areas model of cognitive–behavioural therapy (CBT) with some patients. Before we further discuss the model it might be of value to reflect on your experiences. If you did try, was it successful? Did it teach you anything about your clinical skills and the patients' problems? Can you build on this experience and use the Five Areas model more widely in your practice? If you did not try this out, why not? Were you prevented by internal factors (too busy, could not see the patient, thought you could not do it) or problems beyond your control (the patient failed to turn up)? How can you overcome these obstacles?

Psychometric Properties of the Hoarding Rating Scale-Interview

The present study tested the psychometric properties of an expanded version of the Hoarding Rating Scale (HRS-I), a semistructured interview for hoarding disorder (HD). Eighty-seven adults with HD and 44 healthy control (HC) participants were assessed using the HRS-I and completed a battery of self-report measures of HD severity, negative affect, and functional impairment. All interviews were audio recorded. From the HD participants, 21 were randomly selected for inter-rater reliability (IRR) analysis and 11 for test-retest reliability (TRR) analysis. The HRS-I showed excellent internal consistency (α = 0.87). IRR and TRR in the HD sample were good (intra-class coefficients = 0.81 and 0.85, respectively). HRS-I scores correlated strongly with scores on the self-report Saving Inventory-Revised (SI-R); partial correlations indicated that the HRS-I clutter, difficulty discarding, and acquiring items correlated significantly and at least moderately with corresponding SI-R subscales, when controlling for the other SI-R subscales. The HD group scored significantly higher on all items than did the HC group, with large effect sizes (d = 1.28 to 6.58). ROC analysis showed excellent sensitivity (1.00) and specificity (1.00) for distinguishing the HD and HC groups with a cutoff score of 11. Results and limitations are discussed in light of prior research.

The Effect of EMDR and CBT on Low Self-esteem in a General Psychiatric Population: A Randomized Controlled Trial

Although low self-esteem has been found to be an important factor in the development and maintenance of psychopathology, surprisingly little is known about its treatment. This study investigated the effectiveness of Eye Movement Desensitization and Reprocessing (EMDR) therapy and Cognitive Behavioural Therapy (CBT), regarding their capacities in enhancing self-esteem in a general psychiatric secondary health care population. A randomized controlled trial with two parallel groups was used. Participants were randomly allocated to either 10 weekly sessions of EMDR (n = 15) or CBT (n = 15). They were assessed pre-treatment, after each session, post treatment and at 3 months follow-up on self-esteem (Rosenberg Self-esteem Scale and Credibility of Core Beliefs), psychological symptoms (Brief Symptom Inventory), social anxiety, and social interaction (Inventory of Interpersonal Situations) (IIS). The data were analyzed using repeated measures ANOVA for the complete cases (n = 19) and intention-to-treat (n = 30) to examine differences over time and between conditions. Both groups, EMDR as well as CBT, showed significant improvements on self-esteem, increasing two standard deviations on the main parameter (RSES). Furthermore, the results showed significant reductions in general psychiatric symptoms. The effects were maintained at 3 months follow-up. No between-group differences could be detected. Although the small sample requires to exercise caution in the interpretation of the findings, the results suggest that, when offering an adequate number of sessions, both EMDR and CBT have the potential to be effective treatments for patients with low self-esteem and a wide range of comorbid psychiatric conditions. This study was registered at www.trialregister.nl with identifier NTR4611.

The Finnish Clinical Outcome in Routine Evaluation Outcome Measure: psychometric exploration in clinical and non-clinical samples

The Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) is a 34-item self-report measure designed to monitor changes in psychiatric patients. It has been translated into 25 languages, including Finnish. This is the first psychometric exploration of Finnish CORE-OM data. The aim of the study is to examine acceptability, internal consistency and convergent validity of the Finnish CORE-OM scores. Translation of the CORE-OM from English to Finnish was undertaken according to recommended protocols. Psychometric exploration was conducted in two samples: psychiatric patients (N = 201) and non-clinical participants (N = 209). Participation was voluntary and involved completion of all scales. Convergent validity was tested in terms of the mean score differences between clinical and non-clinical samples and correlations against the Beck Depression Inventory (BDI) and the Symptom Checklist (SCL-90). Among the clinical sample, all domains showed good or acceptable internal reliability. In the non-clinical sample, the alphas of domains were good or acceptable, with only the alphas of the Risk domain registering as low. There were no marked gender or age effects. CORE-OM scores correlated strongly with both the BDI and SCL-90, particularly in patients' data. Some possible effects of Finnish language were found. The Finnish translation of the CORE-OM is psychometrically sound and can be recommended for use in Finnish mental health and clinical settings. However, further investigation in larger and different samples will clarify the generalizability its psychometric properties. Clinical services are encouraged to contribute to the creation of a collaborative Finnish CORE practice research network.

Validation of a Smartphone Application Measuring Motor Function in Parkinson's Disease

BACKGROUND

Measurement of motor function is critical to the assessment and management of Parkinson's disease. Ambulatory motor assessment has the potential to provide a glimpse of the patient's clinical state beyond the consultation. We custom-designed a smartphone application that quantitatively measures hand dexterity and hypothesized that this can give an indication of a patient's overall motor function.

OBJECTIVE

The aims of this study were to (i) validate this smartphone application against MDS-UPDRS motor assessment (MDS-UPDRS-III) and the two-target tapping test; (ii) generate a prediction model for MDS-UPDRS-III; (iii) assess repeatability of our smartphone application and (iv) examine compliance and user-satisfaction of this application.

METHODS

103 patients with Parkinson's disease were recruited from two movement disorders clinics. After initial assessment, a group of patients underwent repeat assessment within two weeks. Patients were invited to use the smartphone application at home over three days, followed by a survey to assess their experience.

RESULTS

Significant correlation between key smartphone application test parameters and MDS-UPDRS-III (r = 0.281-0.608, p < 0.0001) was demonstrated. A prediction model based on these parameters accounted for 52.3% of variation in MDS-UPDRS-III (R2 = 0.523, F(4,93) = 25.48, p < 0.0001). Forty-eight patients underwent repeat assessment under identical clinical conditions. Repeatability of key smartphone application tests parameters and predicted MDS-UPDRS-III was moderate to strong (intraclass correlation coefficient 0.584-0.763, p < 0.0001). The follow-up survey identified that our patients were very comfortable with the smartphone application and mobile technology.

CONCLUSIONS

Our smartphone application demonstrated satisfactory repeatability and validity when measured against MDS-UPDRS-III. Its performance is acceptable considering our smartphone application measures hand dexterity only.

The feasibility of brief dog-assisted therapy on university students stress levels: the PAwS study

BACKGROUND

Pet therapy is becoming increasingly popular and is used in a variety of ways from encouraging communication in older adults to improving wellbeing in those with serious mental illness. Increasingly Universities have been offering pet therapy to students in an effort to reduce stress. However, little evidence currently exists to support the effectiveness of reducing measurable stress levels after a standalone drop-in unstructured session. The University of Sheffield's Counselling Service works in partnership with Guide Dogs for the Blind to give students access to calm, well-trained animals for informal group stress relief.

AIMS

To assess the feasibility of implementing and evaluating unstructured group interventions with a Guide Dog in training within the university student population.

METHODS

One hundred and thirty-one students who attended pet therapy at the University Counselling Service were recruited on a voluntary basis to take part in the research. Stress, measured on the state trait anxiety inventory, and blood pressure were taken before and after a 15-min intervention.

RESULTS

All measures showed a statistically significant reduction immediately after the intervention.

CONCLUSION

Short interactions with a Guide Dog in training appear to reduce stress in University students. A controlled study is required to investigate further.

An Initial Open Trial of a Brief Behavioral Activation Treatment for Depression and Medication Adherence in HIV-Infected Patients

Advances in HIV treatment through highly active antiretroviral therapy (HAART) have led to a steady decline in HIV-related mortality rates. However, HAART requires adherence to strict and often complicated medication regimens, and nonadherence to HAART can significantly decrease its effectiveness. Depression has consistently shown a robust association with medication nonadherence; consequently, numerous psychological interventions have been developed to target depression and increase medication adherence among HIV-infected individuals. The length of these interventions, however, may be prohibitive for certain HIV-infected populations, such as patients in rural areas. Therefore, this study provides an initial investigation of a one-session behavioral activation treatment for depression designed specifically for HIV-infected patients (BATD-HIV) at a community infectious disease clinic serving a largely rural population. In this initial uncontrolled open trial, BATD-HIV was administered to 10 HIV-infected patients with elevated symptoms of depression following their clinic appointment. Depression, anxiety, and stress symptom severity; behavioral activation processes; medication adherence; and CD4 T-cell count were assessed pre- and 1 month postintervention. Participants exhibited significant reductions in anxiety symptom severity and avoidance of negative aversive states and rumination from pre- to 1 month posttreatment. Although nonsignificant, participants also showed medium effect size reductions in depression and stress symptoms and work/school and social impairment, and medium effect size improvements in medication adherence and CD4 T-cell counts. Despite the preliminary nature of this study, results suggest that BATD-HIV may have utility as a brief treatment for HIV-infected patients with depression and warrants further investigation in larger scale randomized controlled trials.

Four years comparative follow-up evaluation of community-based, step-down, and residential specialist psychodynamic programmes for personality disorders

Although the fulcrum of service provision for personality disorder (PD) has shifted from hospital-based to psychodynamically- and cognitively-oriented outpatient programmes, very few studies have attempted to compare specialist moderate intensity outpatient programmes with specialist high-intensity residential models, or to explore whether a period of inpatient treatment may be necessary to improve outcome and prognosis. In this article, we prospectively compare changes over a 4-year period in 3 groups of patients with personality disorders (N = 162) treated in a specialist community-based (CBP, N = 30), a step-down (RT-CBP, N = 87), and a specialist residential programme (RT, N = 45) in psychiatric distress, deliberate self-injury, and suicide attempt using multilevel modelling and multivariate logistic regression analyses. The results showed that percentages of early-dropout were significantly different (p = .0001) for the 3 programmes (CBP = 13.4%, RT-CBP = 10.2%, and RT = 41.4%). A significant interaction between treatment model and time was found for psychiatric distress (p = .001), with CBP and RT-CBP achieving more marked changes (g = 1.20 and g = 0.68, respectively) compared to RT (g = 0.30) at 48-month follow-up. CBP and RT-CBP were found to significantly reduce impulsive behaviour (deliberate self-injury and suicide attempt) compared to RT. Severity of presentation was not found to be a significant predictor of outcome. Long-term RT showed no advantage over long-term CBP, either as stand-alone or as step-down treatment. Replication may be needed to confirm generalizability of results, and a number of limitations in the study design may moderate the inferences that can be drawn from the results.

Predictors of return to work among patients in treatment for common mental disorders: a pre-post study

Background

Effects of return to work (RTW) interventions vary, and more knowledge is needed about the factors that contribute to RTW. This study investigated changes in work participation and mental health, and predictors of RTW among patients being treated for common mental disorders (CMDs).

Methods

The study was a prospective pre–post study of 164 patients treated at an RTW outpatient clinic for CMDs. Differences between before and after treatment were analysed using paired t tests for continuous variables and marginal homogeneity test for categorical variables. Univariable and multivariable logistic regression analyses were used to identify factors associated with RTW. Baseline data (patient characteristics, clinical status, generalized self-efficacy, expectations of future work ability) and treatment variables were used as independent variables in logistic regressions. Further analysis investigated whether improvements in symptoms, work ability, expectations of future work ability and generalized self-efficacy were associated with RTW.

Results

Number of individuals with full work participation increased, and there were improvements in symptoms, work ability and generalized self-efficacy. In the final model for predicting RTW, baseline work ability and expectancy of future work ability, a history of psychiatric treatment and focus on RTW in the treatment predicted RTW. Improvement in expectations of future work ability at post-treatment did also predict RTW.

Conclusions

Assessing work ability and expectations of RTW at the beginning of treatment is recommended to identify patients at risk of long-term sick leave. Individuals with a history of psychiatric treatment are also risking long-term work disability. It is essential that treatment focus not only on symptom-relief, but also on improving work ability and expectations of RTW. An RTW-focused approach in therapy is associated with RTW.

Trail registration

ClinicalTrails.gov ID NCT01181635. Registered 08/12/2010.

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-017-4581-4) contains supplementary material, which is available to authorized users.

Reduction of diabetes-related distress predicts improved depressive symptoms: A secondary analysis of the DIAMOS study

Objective

Depressive symptoms in people with diabetes are associated with increased risk of adverse outcomes. Although successful psychosocial treatment options are available, little is known about factors that facilitate treatment response for depression in diabetes. This prospective study aims to examine the impact of known risk factors on improvement of depressive symptoms with a special interest in the role of diabetes-related distress.

Methods

181 people with diabetes participated in a randomized controlled trial. Diabetes-related distress was assessed using the Problem Areas In Diabetes (PAID) scale; depressive symptoms were assessed using the Center for Epidemiologic Studies Depression (CES-D) scale. Multiple logistic and linear regression analyses were used to assess associations between risk factors for depression (independent variables) and improvement of depressive symptoms (dependent variable). Reliable change indices were established as criteria of meaningful reductions in diabetes distress and depressive symptoms.

Results

A reliable reduction of diabetes-related distress (15.43 points in the PAID) was significantly associated with fourfold increased odds for reliable improvement of depressive symptoms (OR = 4.25, 95% CI: 2.05–8.79; P<0.001). This result was corroborated using continuous measures of diabetes distress and depressive symptoms, showing that greater reduction of diabetes-related distress independently predicted greater improvement in depressive symptoms (ß = -0.40; P<0.001). Higher age had a positive (Odds Ratio = 2.04, 95% CI: 1.21–3.43; P<0.01) and type 2 diabetes had a negative effect on the meaningful reduction of depressive symptoms (Odds Ratio = 0.12, 95% CI: 0.04–0.35; P<0.001).

Conclusions

The reduction of diabetes distress is a statistical predictor of improvement of depressive symptoms. Diabetes patients with comorbid depressive symptomatology might benefit from treatments to reduce diabetes-related distress.

Behavioural activation by mental health nurses for late-life depression in primary care: a randomized controlled trial

BACKGROUND

Depressive symptoms are common in older adults. The effectiveness of pharmacological treatments and the availability of psychological treatments in primary care are limited. A behavioural approach to depression treatment might be beneficial to many older adults but such care is still largely unavailable. Behavioural Activation (BA) protocols are less complicated and more easy to train than other psychological therapies, making them very suitable for delivery by less specialised therapists. The recent introduction of the mental health nurse in primary care centres in the Netherlands has created major opportunities for improving the accessibility of psychological treatments for late-life depression in primary care. BA may thus address the needs of older patients while improving treatment outcome and lowering costs.The primary objective of this study is to compare the effectiveness and cost-effectiveness of BA in comparison with treatment as usual (TAU) for late-life depression in Dutch primary care. A secondary goal is to explore several potential mechanisms of change, as well as predictors and moderators of treatment outcome of BA for late-life depression.

METHODS/DESIGN

Cluster-randomised controlled multicentre trial with two parallel groups: a) behavioural activation, and b) treatment as usual, conducted in primary care centres with a follow-up of 52 weeks. The main inclusion criterion is a PHQ-9 score > 9. Patients are excluded from the trial in case of severe mental illness that requires specialized treatment, high suicide risk, drug and/or alcohol abuse, prior psychotherapy, change in dosage or type of prescribed antidepressants in the previous 12 weeks, or moderate to severe cognitive impairment. The intervention consists of 8 weekly 30-min BA sessions delivered by a trained mental health nurse.

DISCUSSION

We expect BA to be an effective and cost-effective treatment for late-life depression compared to TAU. BA delivered by mental health nurses could increase the availability and accessibility of non-pharmacological treatments for late-life depression in primary care.

TRIAL REGISTRATION

This study is retrospectively registered in the Dutch Clinical Trial Register NTR6013 on August 25th 2016.

The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2nd UK National Audit of psychological therapies

BACKGROUND

Cognitive Behaviour Therapy (CBT) is the front-line psychological intervention for step 3 within UK psychological therapy services. Counselling is recommended only when other interventions have failed and its effectiveness has been questioned.

METHOD

A secondary data analysis was conducted of data collected from 33,243 patients across 103 Improving Access to Psychological Therapies (IAPT) services as part of the second round of the National Audit of Psychological Therapies (NAPT). Initial analysis considered levels of pre-post therapy effect sizes (ESs) and reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.

RESULTS

Counselling received more referrals from patients experiencing moderate to severe depression than CBT. For patients scoring above the clinical cut-off on the PHQ-9 at intake, the pre-post ES (95% CI) for CBT was 1.59 (1.58, 1.62) with 46.6% making RCSI criteria and for counselling the pre-post ES was 1.55 (1.52, 1.59) with 44.3% of patients meeting RCSI criteria. Multilevel modelling revealed a significant site effect of 1.8%, while therapy type was not a predictor of outcome. A significant interaction was found between the number of sessions attended and therapy type, with patients attending fewer sessions on average for counselling [M = 7.5 (5.54) sessions and a median (IQR) of 6 (3-10)] than CBT [M = 8.9 (6.34) sessions and a median (IQR) of 7 (4-12)]. Only where patients had 18 or 20 sessions was CBT significantly more effective than counselling, with recovery rates (95% CIs) of 62.2% (57.1, 66.9) and 62.4% (56.5, 68.0) respectively, compared with 44.4% (32.7, 56.6) and 42.6% (30.0, 55.9) for counselling. Counselling was significantly more effective at two sessions with a recovery rate of 34.9% (31.9, 37.9) compared with 22.2% (20.5, 24.0) for CBT.

CONCLUSIONS

Outcomes for counselling and CBT in the treatment of depression were comparable. Research efforts should focus on factors other than therapy type that may influence outcomes, namely the inherent variability between services, and adopt multilevel modelling as the given analytic approach in order to capture the naturally nested nature of the implementation and delivery of psychological therapies. It is of concern that half of all patients, regardless of type of intervention, did not show reliable improvement.

Integrated Trauma-Focused Cognitive-Behavioural Therapy for Post-traumatic Stress and Psychotic Symptoms: A Case-Series Study Using Imaginal Reprocessing Strategies

Despite high rates of trauma in individuals with psychotic symptoms, post-traumatic stress symptoms are frequently overlooked in clinical practice. There is also reluctance to treat post-traumatic symptoms in case the therapeutic procedure of reprocessing the trauma exacerbates psychotic symptoms. Recent evidence demonstrates that it is safe to use reprocessing strategies in this population. However, most published studies have been based on treating post-traumatic symptoms in isolation from psychotic symptoms. The aims of the current case series were to assess the acceptability, feasibility, and preliminary effectiveness of integrating cognitive-behavioural approaches for post-traumatic stress and psychotic symptoms into a single protocol. Nine participants reporting distressing psychotic and post-traumatic symptoms were recruited from a specialist psychological therapies service for psychosis. Clients were assessed at five time points (baseline, pre, mid, end of therapy, and at 6+ months of follow-up) by an independent assessor on measures of current symptoms of psychosis, post-traumatic stress, emotional problems, and well-being. Therapy was formulation based and individualised, depending on presenting symptoms and trauma type. It consisted of five broad, flexible phases, and included imaginal reprocessing strategies (reliving and/or rescripting). The intervention was well received, with positive post-therapy feedback and satisfaction ratings. Unusually for this population, no-one dropped out of therapy. Post therapy, all but one (88% of participants) achieved a reliable improvement compared to pre-therapy on at least one outcome measure: post-traumatic symptoms (63%), voices (25%), delusions (50%), depression (50%), anxiety (36%), and well-being (40%). Follow-up assessments were completed by 78% (n = 7) of whom 86% (n = 6) maintained at least one reliable improvement. Rates of improvements following therapy (average of 44% across measures post therapy; 32% at follow-up) were over twice those found during the waiting list period (19%). No participant indicated a reliable worsening of any symptoms during or after therapy. The study shows that an integrative therapy incorporating reprocessing strategies was an acceptable and feasible intervention for this small sample, with promising effectiveness. A randomised controlled trial is warranted to test the efficacy of the intervention for this population.

Changes in J-SOAP-II and SAVRY Scores Over the Course of Residential, Cognitive-Behavioral Treatment for Adolescent Sexual Offending

Although the Juvenile Sex Offender Assessment Protocol-II (J-SOAP-II) and the Structured Assessment of Violence Risk in Youth (SAVRY) include an emphasis on dynamic, or modifiable factors, there has been little research on dynamic changes on these tools. To help address this gap, we compared admission and discharge scores of 163 adolescents who attended a residential, cognitive-behavioral treatment program for sexual offending. Based on reliable change indices, one half of youth showed a reliable decrease on the J-SOAP-II Dynamic Risk Total Score and one third of youth showed a reliable decrease on the SAVRY Dynamic Risk Total Score. Contrary to expectations, decreases in risk factors and increases in protective factors did not predict reduced sexual, violent nonsexual, or any reoffending. In addition, no associations were found between scores on the Psychopathy Checklist:Youth Version and levels of change. Overall, the J-SOAP-II and the SAVRY hold promise in measuring change, but further research is needed.

The Score Family Assessment Questionnaire: A Decade of Progress

This paper reviews a decade of research (2006-2016) on a family assessment instrument called the Systemic Clinical Outcome and Routine Evaluation (SCORE). The SCORE was developed in Europe to monitor progress and outcome in systemic therapy and has been adopted by the European Family Therapy Association as the main instrument for assessing the outcome in systemic family and couple therapy. There are currently six main versions of this instrument: SCORE-40, SCORE-15, SCORE-28, SCORE-29, Child SCORE-15, and Relational SCORE-15. It has also been translated into a number of European languages. Fifteen empirical studies of the SCORE "family of measures" have been conducted. Most have aimed to establish psychometric properties of these instruments in English and other languages. Others have used the SCORE to document the level of family adjustment in clinical samples or evaluate outcome in treatment trials. There is now sufficient evidence for the reliability and validity of the SCORE to justify the use of brief versions of this instrument to monitor progress and outcome in the routine practice of systemic therapy.

Is the devil in the detail? A randomised controlled trial of guided internet-based CBT for perfectionism

An internet guided self-help cognitive-behavioural treatment (ICBT) for perfectionism was recently found to be effective (see this issue). Such studies stand in need of replication. The aim of this study was to report the outcomes and predictors of change when the treatment is delivered in a UK setting. A total of 120 people (Mean = 28.9 years; 79% female) were randomised to receive ICBT or wait-list control over 12 weeks (trial registration: NCT02756871). While there were strong similarities between the current study and its Swedish counterpart, there were also important differences in procedural details. There was a significant impact of the intervention on the primary outcome measure (Frost Multidimensional Perfectionism Scale, Concern over Mistakes subscale) and also on the Clinical Perfectionism Questionnaire (between group effect sizes d = 0.98 (95% CI: 0.60-1.36) and d = 1.04 (95% CI: 0.66-1.43) respectively using intent-to-treat analyses). Unlike the Swedish study, there was significant non-engagement and non-completion of modules with 71% of participants completing fewer than half the modules. The number of modules completed moderated the rate of change in clinical perfectionism over time. In conclusion, the study indicates the intervention is effective in a UK setting but highlighted the importance of procedural details to optimise retention.

Objective Measurement and Characterization of Sleep Benefit in Parkinson's Disease

Background

Sleep benefit (SB) in Parkinson's disease refers to improved motor symptoms upon waking despite an entire night without medications. Although it was first proposed 30 years ago, this phenomenon proved difficult to investigate, and its true prevalence and underlying mechanisms remain unclear.

Objective

This study aimed to identify and quantify SB through measurement of motor function using a validated smartphone application and to identify disease characteristics that predicted SB.

Methods

Ninety-two patients recruited from 2 Movement Disorder Services were clinically assessed at home using a validated smartphone application. Each patient was tested in the on-state, at the end of dose, and on waking (before medications) 3 times. Differences between the 3 states were used to determine the impact of sleep and levodopa on motor function. SB was considered to be a "measurable improvement in parkinsonism from the end of dose."

Results

The morning waking motor function of 20 patients (22%) improved compared with the end-of-dose function, with 9 patients demonstrating superior function compared with their on-state. No clinical features predicted SB. Although all participants subjectively reported motor fluctuations, only 35 patients (38%) demonstrated an objective improvement with levodopa. Patients who had SB more often demonstrated objective motor fluctuations compared with those who did not (65% vs. 31%; P = 0.008).

Conclusions

SB is a genuine motor phenomenon: 1 in 5 patients have a measurable improvement in motor function on waking. It remains questionable whether this improvement is a direct effect of sleep. Until its underlying mechanism is better understood, it is more appropriate to refer to this phenomenon as simply morning improvement or diurnal fluctuation of motor symptoms.

Percentile ranks and benchmark estimates of change for the Health Education Impact Questionnaire: Normative data from an Australian sample

Objective:

Participant self-report data play an essential role in the evaluation of health education activities, programmes and policies. When questionnaire items do not have a clear mapping to a performance-based continuum, percentile norms are useful for communicating individual test results to users. Similarly, when assessing programme impact, the comparison of effect sizes for group differences or baseline to follow-up change with effect sizes observed in relevant normative data provides more directly useful information compared with statistical tests of mean differences and the evaluation of effect sizes for substantive significance using universal rule-of-thumb such as those for Cohen’s ‘d’. This article aims to assist managers, programme staff and clinicians of healthcare organisations who use the Health Education Impact Questionnaire interpret their results using percentile norms for individual baseline and follow-up scores together with group effect sizes for change across the duration of typical chronic disease self-management and support programme.

Methods:

Percentile norms for individual Health Education Impact Questionnaire scale scores and effect sizes for group change were calculated using freely available software for each of the eight Health Education Impact Questionnaire scales. Data used were archived responses of 2157 participants of chronic disease self-management programmes conducted by a wide range of organisations in Australia between July 2007 and March 2013.

Results:

Tables of percentile norms and three possible effect size benchmarks for baseline to follow-up change are provided together with two worked examples to assist interpretation.

Conclusion:

While the norms and benchmarks presented will be particularly relevant for Australian organisations and others using the English-language version of the Health Education Impact Questionnaire, they will also be useful for translated versions as a guide to the sensitivity of the scales and the extent of the changes that might be anticipated from attendance at a typical chronic disease self-management or health education programme.

A pragmatic randomised controlled trial assessing the non-inferiority of counselling for depression versus cognitive-behaviour therapy for patients in primary care meeting a diagnosis of moderate or severe depression (PRaCTICED): Study protocol for a randomised controlled trial

BACKGROUND

NICE guidelines state cognitive behavioural therapy (CBT) is a front-line psychological treatment for people presenting with depression in primary care. Counselling for Depression (CfD), a form of Person-Centred Experiential therapy, is also offered within Improving Access to Psychological Therapies (IAPT) services for moderate depression but its effectiveness for severe depression has not been investigated. A full-scale randomised controlled trial to determine the efficacy and cost-effectiveness of CfD is required.

METHODS

PRaCTICED is a two-arm, parallel group, non-inferiority randomised controlled trial comparing CfD against CBT. It is embedded within the local IAPT service using a stepped care service delivery model where CBT and CfD are routinely offered at step 3. Trial inclusion criteria comprise patients aged 18 years or over, wishing to work on their depression, judged to require a step 3 intervention, and meeting an ICD-10 diagnosis of moderate or severe depression. Patients are randomised using a centralised, web-based system to CfD or CBT with each treatment being delivered up to a maximum 20 sessions. Both interventions are manualised with treatment fidelity tested via supervision and random sampling of sessions using adherence/competency scales. The primary outcome measure is the Patient Health Questionnaire-9 collected at baseline, 6 and 12 months. Secondary outcome measures tap depression, generic psychological distress, anxiety, functioning and quality of life. Cost-effectiveness is determined by a patient service receipt questionnaire. Exit interviews are conducted with patients by research assessors blind to treatment allocation. The trial requires 500 patients (250 per arm) to test the non-inferiority hypothesis of -2 PHQ-9 points at the one-sided, 2.5% significance level with 90% power, assuming no underlying difference and a standard deviation of 6.9. The primary analysis will be undertaken on all patients randomised (intent to treat) alongside per-protocol and complier-average causal effect analyses as recommended by the extension to the CONSORT statement for non-inferiority trials.

DISCUSSION

This large-scale trial utilises routinely collected outcome data as well as specific trial data to provide evidence of the comparative efficacy and cost-effectiveness of Counselling for Depression compared with Cognitive Behaviour Therapy as delivered within the UK government's Improving Access to Psychological Therapies initiative.

TRIAL REGISTRATION

Controlled Trials ISRCTN Registry, ISRCTN06461651 . Registered on 14 September 2014.

Cognitive Analytic Therapy for Bipolar Disorder: A Pilot Randomized Controlled Trial

The evidence base for treatment of bipolar affective disorder (BD) demands the evaluation of new psychotherapies in order to broaden patient choice. This study reports on the feasibility, safety, helpfulness and effectiveness of cognitive analytic therapy (CAT). In a pilot randomized controlled trial, BD patients in remission were randomized to either receiving 24 sessions of CAT (n = 9) or treatment as usual (n = 9) and were assessed in terms of symptoms, functioning and service usage over time. In the CAT arm no adverse events occurred, 8/9 completed treatment, 5/8 attended all 24 sessions and 2/8 were categorized as recovered. The most common helpful event during CAT was recognition of patterns in mood variability, with helpfulness themes changing according to phase of therapy. No major differences were found when comparing the arms over time in terms of service usage or psychometric outcomes. The study suggests that conducting further research into the effectiveness of CAT in treating BD is warranted and guidance regarding future trials is provided. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

Treating BD with CAT appears feasible and safe. Retaining fidelity to the reformulation, recognition and revision structure of CAT appears useful. Participants stated that across the phases of CAT, focussing on patterns of mood variability was consistently helpful.

Changes in posttraumatic stress disorders symptoms during and after therapeutic community drug and alcohol treatment

Purpose

The purpose of this paper is to investigate the changes in posttraumatic stress disorder (PTSD) symptomatology during treatment in a drug and alcohol therapeutic community.

Design/methodology/approach

A repeated measures design was employed that looked at PTSD, depression, anxiety, and stress at a pre- and post-timepoint. A second sample was then evaluated at time of program completion to seven months post-treatment.

Findings

PTSD symptomatology significantly decreased in individuals who had undertaken treatment, and continued to decline post-treatment. This finding was irrespective of any PTSD-specific treatment.

Research limitations/implications

PTSD specific treatment is not necessary to lower the symptomatology. Furthermore, this provides evidence that PTSD and substance use disorders are so highly intertwined that the comorbidity can almost be considered a single, diagnosis.

Originality/value

This is a partial replication of previous research which had not previously been replicated. This research also adds to the limited research which looks at PTSD from the perspective of drug and alcohol rehabilitation.

Changes in coping behavior in a randomized controlled trial of concurrent treatment for PTSD and alcohol dependence

OBJECTIVE

The current study examines changes in coping among 165 adults meeting DSM-IV criteria for co-morbid posttraumatic stress disorder (PTSD) and alcohol dependence (AD).

METHOD

Participants were randomized to receive naltrexone or placebo, with or without prolonged exposure (PE). All participants received supportive counseling focused on alcohol use (BRENDA). Assessments of coping, PTSD, and AD were conducted at pre-treatment, mid-treatment, post-treatment, 3-month follow-up, and 6-month follow-up.

RESULTS

Participants exhibited significant decreases in both avoidant coping and adaptive coping from pre-treatment to 6-month follow-up across all groups. Participants who received PE showed faster decreases in avoidant coping during this period than participants who did not receive PE. PTSD symptom reduction was associated with changes in both avoidant and adaptive coping across groups. Improvement in PTSD symptoms was related to a faster rate of reduction in avoidant coping in the PE groups compared to those receiving BRENDA alone.

CONCLUSIONS

The current results suggest that concurrent treatment for co-morbid PTSD-AD decreases avoidant and adaptive coping, and participants who show greater reductions in PTSD symptoms also show greater changes in coping style. Consistent with theorized mechanisms of change in PE, the addition of PE to supportive counseling for AD was associated with a greater reduction of avoidant coping than supportive counseling alone.

The theoretical and practical determination of clinical cut-offs for the British Sign Language versions of PHQ-9 and GAD-7

BACKGROUND

The PHQ-9 and the GAD-7 assess depression and anxiety respectively. There are standardised, reliability-tested versions in BSL (British Sign Language) that are used with Deaf users of the IAPT service. The aim of this study is to determine their appropriate clinical cut-offs when used with Deaf people who sign and to examine the operating characteristics for PHQ-9 BSL and GAD-7 BSL with a clinical Deaf population.

METHODS

Two datasets were compared: (i) dataset (n = 502) from a specialist IAPT service for Deaf people; and (ii) dataset (n = 85) from our existing study of Deaf people who self-reported having no mental health difficulties. Parameter estimates, with the precision of AUC value, sensitivity, specificity, positive predicted value (ppv) and negative predicted value (npv), were carried out to provide the details of the clinical cut-offs. Three statistical choices were included: Maximising (Youden: maximising sensitivity + specificity), Equalising (Sensitivity = Specificity) and Prioritising treatment (False Negative twice as bad as False Positive). Standard measures (as defined by IAPT) were applied to examine caseness, recovery, reliable change and reliable recovery for the first dataset.

RESULTS

The clinical cut-offs for PHQ-9 BSL and GAD-7 BSL are 8 and 6 respectively. This compares with the original English version cut-offs in the hearing population of 10 and 8 respectively. The three different statistical choices for calculating clinical cut-offs all showed a lower clinical cut-off for the Deaf population with respect to the PHQ-9 BSL and GAD-7 BSL with the exception of the Maximising criteria when used with the PHQ-9 BSL. Applying the new clinical cut-offs, the percentage of Deaf BSL IAPT service users showing reliable recovery is 54.0 % compared to 63.7 % using the cut-off scores used for English speaking hearing people. These compare favourably with national IAPT data for the general population.

CONCLUSIONS

The correct clinical cut-offs for the PHQ-9 BSL and GAD-7 BSL enable meaningful measures of clinical effectiveness and facilitate appropriate access to treatment when required.

Overcoming procrastination: one-year follow-up and predictors of change in a randomized controlled trial of Internet-based cognitive behavior therapy

Procrastination is a common self-regulatory failure that can have a negative impact on well-being and performance. However, few clinical trials have been conducted, and no follow-up has ever been performed. The current study therefore aimed to provide evidence for the long-term benefits and investigate predictors of a positive treatment outcome among patients receiving Internet-based cognitive behavior therapy (ICBT). A total of 150 self-recruited participants were randomized to guided or unguided ICBT. Self-report measures of procrastination, depression, anxiety, and quality of life were distributed at pre-treatment assessment, post-treatment assessment, and one-year follow-up. Mixed effects models were used to investigate the long-term gains, and multiple linear regression for predictors of a positive treatment outcome, using the change score on the Irrational Procrastination Scale as the dependent variable. Intention-to-treat was implemented for all statistical analyses. Large within-group effect sizes for guided and unguided ICBT, Cohen's d = .97-1.64, were found for self-report measures of procrastination, together with d = .56-.66 for depression and anxiety. Gains were maintained, and, in some cases, improved at follow-up. Guided and unguided ICBT did not differ from each other, mean differences -.31-1.17, 95% CIs [-2.59-3.22], and none of the predictors were associated with a better result, bs -1.45-1.61, 95% CIs [-3.14-4.26]. In sum, ICBT could be useful and beneficial in relation to managing procrastination, yielding great benefits up to one year after the treatment period has ended, with comparable results between guided and unguided ICBT.

Motivation-Matched Approach to the Treatment of Problem Gambling: A Case Series Pilot Study

The aim of the present case series was to provide a preliminary assessment of the utility of a motivation-matched treatment for problem gamblers. On the basis of their primary underlying motivations for gambling, 6 problem gamblers received either action-motivated (n = 4) or escape-motivated (n = 2) treatment. Drawing upon a cognitive-behavioural framework, this 6-session motivation-matched treatment was designed to address gamblers' maladaptive motivations for gambling (i.e., the need or desire for "escape" or "action"), as well as the effects of conditioning and maladaptive thinking patterns unique to each gambling motive subtype. Assessments were conducted at pre-treatment, post-treatment, and 3- and 6-month follow-up. Primary outcome measures included gambling behaviour (i.e., gambling frequency, time, and money spent gambling), severity of gambling problems, and gambling-related impairment or disability; secondary outcome measures included gambling-related craving, gambling abstinence self-efficacy, positively and negatively reinforcing gambling situations, and gambling outcome expectancies. Overall, participants showed pre- to post-treatment improvements on the majority of these measures, with relatively less immediate post-treatment treatment gains observed on measures that assessed positively and negatively reinforcing gambling situations and gambling-related impairment or disability. However, treatment gains at the 3- and 6-month follow-up were shown for most participants on these latter measures as well. Findings suggest promise for this novel treatment approach. The next step in this line of research is to conduct a randomized, controlled trial to compare the efficacy of this motivation-matched treatment for disordered gambling with treatment as usual.

Predicting treatment outcome in psychological treatment services by identifying latent profiles of patients

BACKGROUND

The outcomes of psychological therapies for anxiety and depression vary across individuals and symptom domains. Being able to predict treatment response from readily available patient data at presentation has potentially important benefits in aiding decisions about the most suitable interventions for a patient. This paper presents a method of identifying subgroups of patients using latent profile analysis, and comparing response to psychological treatments between these profiles.

METHODS

All outpatients taken into treatment at two psychological treatment services in London, UK and who provided basic demographic information and standardized symptom measures were included in the analysis (n=16636).

RESULTS

Latent Profile Analysis was performed on intake data to identify statistically different groups of patients, which were then examined in longitudinal analyses to determine their capacity to predict treatment outcomes. Comparison between profiles showed considerable variation in recovery (74-15%), deterioration rates (5-20%), and levels of attrition (17-40%). Further variation in outcomes was found within the profiles when different intensities of psychological intervention were delivered.

LIMITATIONS

Latent profiles were identified using data from two services, so generalisability to other services should be considered. Routinely collected patient data was included, additional patient information may further enhance utility of the profiles.

CONCLUSIONS

These results suggest that intake data can be used to reliably classify patients into profiles that are predictive of outcome to different intensities of psychological treatment in routine care. Algorithms based on these kinds of data could be used to optimize decision-making and aid the appropriate matching of patients to treatment.

Using a Brief Parent-Report Measure to Track Outcomes for Children and Teens with ADHD

The Pediatric Symptom Checklist (PSC) is a widely used, parent-completed measure of children's emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, parents and clinicians of 1736 patients aged 17 or younger completed standardized measures at intake and 3-month follow-up appointments. We assessed the 5-item PSC Attention Subscale (PSC-AS) as a longitudinal measure of attention-related symptoms in routine outpatient psychiatry treatment. Secondarily, we compared PSC-AS scores with clinician-reported diagnoses, psychomotor excitation symptoms, and overall functioning. Change scores on the PSC-AS were larger among patients with ADHD diagnoses than those with non-ADHD diagnoses. Comparisons between PSC-AS scores and clinician reports also showed acceptable levels of agreement. Given its effectiveness in tracking attention-related symptoms, the PSC may be particularly useful as a quality assurance or treatment outcome measure for clinicians treating ADHD.

Acceptability, reliability, referential distributions and sensitivity to change in the Young Person's Clinical Outcomes in Routine Evaluation (YP-CORE) outcome measure: replication and refinement

BACKGROUND

Many outcome measures for young people exist, but the choices for services are limited when seeking measures that (a) are free to use in both paper and electronic format, and (b) have evidence of good psychometric properties.

METHOD

Data on the Young Person's Clinical Outcomes in Routine Evaluation (YP-CORE), completed by young people aged 11-16, are reported for a clinical sample (N = 1269) drawn from seven services and a nonclinical sample (N = 380). Analyses report item omission, reliability, referential distributions and sensitivity to change.

RESULTS

The YP-CORE had a very low rate of missing items, with 95.6% of forms at preintervention fully completed. The overall alpha was .80, with the values for all four subsamples (11-13 and 14-16 by gender) exceeding .70. There were significant differences in mean YP-CORE scores by gender and age band, as well as distinct reliable change indices and clinically significant change cut-off points.

CONCLUSIONS

These findings suggest that the YP-CORE satisfies standard psychometric requirements for use as a routine outcome measure for young people. Its status as a free to use measure and the availability of an increasing number of translations makes the YP-CORE a candidate outcome measure to be considered for routine services.