Prediction of dose-response relations based on patient characteristics

Using clinician and patient input to assess utility, accuracy, efficiency, and therapeutic implementation of a new data-driven digital therapeutic for personalized clinical eating disorder treatment: Awaken digital guide

OBJECTIVE

Eating disorders (EDs) take a life every 52 minutes and treatments are ineffective for ∼50% of individuals. Though EDs are heterogeneous illnesses, current evidence-based treatments take a "one-size-fits-all" approach. Network-Informed Personalized Treatment is a new promising treatment for EDs, but clinician-patient-friendly software tools are needed to integrate this guidance system into routine treatment. Adoption is key for impact, necessitating the inclusion of clinicians in the software development. The current pilot assessed a new data-driven clinician-guidance therapeutic.

METHOD

A two-part pilot was analyzed for quantitative (0-not at all to 10-extremely) and qualitative input on user perception through quantitative and open-ended prompted questions evaluating using personalizing ED treatment with the Awaken Digital Guide therapeutic.

RESULTS

Results demonstrated that clinicians in a focus group (N = 9) and clinician/patient dyads within implementation (N = 10) endorsed improved efficiency, effectiveness, self-awareness, and accuracy using Awaken Digital Guide compared to current treatment as suggested by quantitative and qualitative results. Both clinicians and patients rated the tool positively (6.8-9.6/5.8-8.6, respectively) with an average rating of good and excellent.

CONCLUSION

Findings suggest that ED-specialized clinicians desire data-driven guidance on personalizing ED treatment. Users perceive Awaken Digital Guide therapeutic with potential to increase collaboration, motivation, efficiency, and effectiveness of ED personalized treatment.

BUILDING A DOSE TOXO-EQUIVALENCE MODEL FROM A BAYESIAN META-ANALYSIS OF PUBLISHED CLINICAL TRIALS

In clinical practice medications are often interchanged in treatment protocols when a patient negatively reacts to their first line of therapy. Although switching between medications is common, clinicians often lack structured guidance when choosing the initial dose and frequency of a new medication, given the former with respect to risk of adverse events. In this paper we propose to establish this dose toxo-equivalence relationship using published clinical trial results with one or both drugs of interest via a Bayesian meta-analysis model that accounts for both within- and between-study variances. With the posterior parameter samples from this model, we compute median and 95% credible intervals for equivalent dose pairs of the two drugs that are predicted to produce equal rates of an adverse outcome, relying solely on study-level information. Via extensive simulations, we show that this approach approximates well the true dose toxo-equivalence relationship, considering different study designs, levels of between-study variance, and the inclusion/exclusion of nonconfounder/nonmodifier subject-level covariates in addition to study-level covariates. We compare the performance of this study-level meta-analysis estimate to the equivalent individual patient data meta-analysis model and find comparable bias and minimal efficiency loss in the study-level coefficients used in the dose toxo-equivalence relationship. Finally, we present the findings of our dose toxo-equivalence model applied to two chemotherapy drugs, based on data from 169 published clinical trials.

Effectiveness of relaxation techniques 'as an active ingredient of psychological interventions' to reduce distress, anxiety and depression in adolescents: a systematic review and meta-analysis

BACKGROUND

Adolescent depression and anxiety are among the leading contributors to health burden worldwide. 'Relaxation Techniques (RTs)' are a "set of strategies to improve physiological response to stress" and are frequently cited as an active ingredient of trans-diagnostic, psychosocial interventions for scaling-up care for preventing and treating these conditions in adolescents. However, there is a little evidence on the effectiveness of 'relaxation techniques' for this age group.

AIM

As a part of the Wellcome Trust's Active Ingredients commission, we did a systematic review and meta-analysis to evaluate the effectiveness of RTs to reduce the symptoms of distress, anxiety and depression in young people, aged 14 to 24 years old, globally.

METHODS

We searched 10 academic databases to include 65 Randomized Controlled Trials (RCTs) of relaxation-based interventions for young people with the symptoms of anxiety and depression. Primary outcomes were reduction in symptoms of distress, anxiety and/or depression. We employed the Cochrane risk of bias tool and GRADE (Grading of Recommendations, Assessment, Development and Evaluations) guidelines to assess certainty of outcomes pertaining to anxiety, depression and distress. Standardized mean difference was estimated using effect size.

RESULTS

The analysis of 65 RCTs with 8009 young people showed that RTs were highly effective in treating anxiety (pooled effect size of (Standardized Mean Difference-SMD) - 0.54 (95% CI - 0.69 to - 0.40); moderately effective in reducing distress (SMD = - 0.48, 95% CI - 0.71 to - 0.24) and had only a weak effect on improving depression in young people (SMD = - 0.28 (95% CI - 0.40% to - 0.15). Face-to-face delivered relaxation techniques yielded higher effect size (SMD = - 0.47, 95% CI - 0.64 to - 0.30) compared to online delivery (SMD = - 0.22, 95% CI - 0.48 to 0.04) for anxiety.

CONCLUSION

Most of the included studies were from High Income Countries (HICs) and had a high risk of bias. Further high-quality studies with low risk of bias, especially from low resource settings are needed to evaluate the evidence for effectiveness of RTs as an active ingredient of psychological interventions to reduce the symptoms of distress, anxiety and depression in young people.

Volunteer Recovery Support for Adolescents: Using propensity score based methods to understand dosage effects within a randomized controlled trial

BACKGROUND

In a recently published randomized controlled trial (RCT) of Volunteer Recovery Support for Adolescents (VRSA), a secondary finding indicated that better adherence to planned VRSA telephone session frequency resulted in significantly higher remission rates relative to lower session adherence. However, interpretation of this dose-response relationship may have been confounded by participant characteristics such as baseline levels of substance use and mental health problems.

METHODS

The present study used statistical methods designed to approximate RCTs when comparing more than two nonequivalent groups that include an assessment of the potential impact of omitted variables. Classification and Regression Tree (CRT) analysis was used to establish the cut-point between high (H) and low (L) VRSA dosage groups. Because we were interested in generalizing to youth with poor attendance, the L-VRSA group served as the reference group. Balancing weights for H-VRSA and a services as usual (SAU) control group were calculated to ensure similarity of baseline pretreatment characteristics to the reference group, and sensitivity of findings to unobserved confounding variables was assessed.

RESULTS

Findings suggested that superior remission rates at the end of the intervention phase were the result of high adherence to planned VRSA session frequency. Recommendations to achieve high VRSA participation among a larger segment of youth and to test whether longer VRSA duration improves the stability of recovery outcomes are provided.

CONCLUSION

Few published dose-response studies have adequately controlled for selection confounds from both observed and unobserved confounding. As such, the present study aims to both assess the impact of different dosage levels of VRSA and provide a template for how to apply state-of-the-art statistical methods designed to approximate randomized controlled trials to such studies.

Patient-reported outcome measurements (PROMs) and provider assessment in mental health: a systematic review of the context of implementation

Purpose

To review and integrate the vast amount of literature yielded by recent growing interest in patient-reported outcome measurement and routine outcome measures (PROMs/ROMs), in order to suggest options and improvements for implementation. PROMs are the systematic assessment of service users’ health using standardized self-report measures. Specifically, for ROMs, it includes routine provider or caretaker assessment measures. Both are administered to ascertain routinely, the impact of treatment in mental health settings and to improve care. A review is needed because of the large differences in setting, conceptualization, practice and implementation. Here, we examine the different major projects worldwide.

Data sources

Psych INFO and PubMed including Medline, Biomed Central, EMBASE Psychiatry and Elsevier Science’s Direct.

Study selection

We conducted a systematized review of the literature published from 2000 to 2018 on the implementation and sustainability of PROMs and ROMs in mental health services for adults.

Data extraction, synthesis and Results

We described and characterized the programs in different countries worldwide. We identified 103 articles that met the inclusion criteria, representing over 80 PROMs/ROMs initiatives in 15 countries. National policy and structure of mental health services were found to be major factors in implementation. We discuss the great variability in PROMs/ROMs models in different countries, making suggestions for their streamlining and improvement.

Conclusion

We extracted valuable information on the different characteristics of the numerous PROMs/ROMs initiatives worldwide. However, in the absence of a strong nationwide policy effort and support, implementation seems scattered and irregular. Thus, development of the implementation of PROMs/ROMs is left to groups of enthusiastic clinicians and researchers, making sustainability problematic.

Estimating outcome probabilities from early symptom changes in cognitive therapy for recurrent depression

OBJECTIVE

Acute-phase cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD) producing benefits comparable to pharmacotherapy, but not all patients respond or remit. The purpose of the current analyses was to estimate CT patients' probability of nonresponse and remission from symptom improvement early in treatment.

METHOD

Data from 2 clinical trials of acute-phase CT for recurrent depression were pooled for analysis (N = 679). Adult outpatients received 16- or 20-session CT protocols. Symptoms were measured repeatedly with the clinician-report Hamilton Rating Scale for Depression (HRSD) and Inventory of Depressive Symptomatology-Self-Report (IDS-SR). Outcomes at exit from CT were nonresponse (<50% reduction in HRSD scores) and remission (no MDD and HRSD score ≤6).

RESULTS

The nonresponse rate was 45.7%, and the remission rate was 33.4%. In logistic regression models, improvements on the HRSD or IDS-SR from intake to CT Sessions 3, 5, 7, 9, or 11 significantly predicted both outcomes, with prediction gaining in accuracy in later sessions. Clinician and self-report assessments yielded similar results. Prediction of outcomes replicated across data sets. Patients with no symptom improvement by CT Session 9 (Week 5) had ≤10% probability of remission and >75% probability of nonresponse.

CONCLUSIONS

Outcomes of CT for depression are predictable from early symptom changes. Clinicians may find nonresponse and remission probability estimates useful in the informed consent process and in choosing whether to continue, augment, or switch treatments for CT patients with recurrent MDD. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Are we overdosing treatment? Secondary findings from a study following women with bulimia nervosa after inpatient treatment

OBJECTIVE

Provision of eating disorder (ED) treatment in practice is often guided by national health service structures rather than evidence-based treatment recommendations. Especially for more severely or chronically ill patients, clinicians seem to advocate a "the more the better" strategy of treatment provision. Exploring the dose-response relationship in ED treatment may shed light on both beneficial and detrimental effects of prolonged treatment provision.

METHOD

We utilized data from 64 women from the treatment-as-usual (TAU) group of a randomized controlled trial on Internet-based aftercare for women with bulimia nervosa who had received inpatient treatment. We examined the relationship between treatment duration and dose and (1) baseline patient characteristics and (2) treatment outcomes (abstinence from binge eating and compensatory behaviors, frequency of binge eating and vomiting, thin ideal internalization, and general psychopathology) at 18-month follow up.

RESULTS

On average, the women in our study were hospitalized for 9 weeks and most received high doses of subsequent outpatient psychotherapy (median: 45 sessions). The severity of symptoms that a patient experienced at hospital admission or discharge was largely unrelated to the amount of outpatient treatment she subsequently received. Longer inpatient treatments or higher doses of subsequent outpatient treatment did not result in more favorable outcomes.

DISCUSSION

Our findings suggest that, instead of providing costly long treatment without evidenced benefit to patients, there is a need for further exploration of and discussion about the risks and benefits of providing high doses of treatment for both individuals and the health care system.

Pattern of Changes during Treatment: A Comparison between a Positive Psychology Intervention and a Cognitive Behavioral Treatment for Clinical Depression

Research on psychotherapy has traditionally focused on analyzing changes between the beginning and the end of a treatment. Few studies have addressed the pattern of therapeutic change during treatment. The aim of this study was to examine the pattern of changes in clinical and well-being variables during a cognitive behavioral therapy (CBT) program compared with an integrative positive psychology interventions program for clinical depression IPPI-D. 128 women with a diagnosis of major depression or dysthymia were assigned to the CBT or PPI group. A measure of depressive symptoms (i.e., Beck Depression Inventory) and well-being (i.e., Pemberton Happiness Index) were administered four times: at the beginning and end of the treatment, as well as during treatment (at sessions 4 and 7). Through mixed-model repeated measures ANOVAs, both depressive symptoms (p < .001, partial η2 = .52) and well-being (p < .001, partial η2 = .29) showed a significant improvement through the four assessment times. No significant interactions between time and treatment modality were found (ps > .08). The percentage of improvement in depressive symptoms in the first treatment period was higher than in the later ones (ps < .005). On the contrary, well-being showed a more gradual improvement (p = .15). These results highlight the importance of assessing the pattern of changes in symptoms and well-being separately.

Exposition aus Sicht niedergelassener Verhaltenstherapeutinnen und Verhaltenstherapeuten

Zusammenfassung. Theoretischer Hintergrund: Expositionsbasierte Interventionen gehören zu den wirksamsten Methoden bei der Behandlung von Angststörungen. Dennoch legen vergangene Studien nahe, dass Exposition in der verhaltenstherapeutischen Routinepraxis nur selten eingesetzt wird. Barrieren, die eine Anwendung verhindern, wurden bisher nicht systematisch erfasst. Fragestellung und Methode: Hauptziel dieser Studie war eine praxis-orientierte Erhebung systemischer Barrieren und Veränderungswünschen bei der Anwendung von Exposition aus Sicht ambulant tätiger Verhaltenstherapeutinnen und -therapeuten. Mittels postalischer Befragung wurden diese Barrieren sowie die Anwendungshäufigkeit von expositionsbasierten Interventionen erfasst (N = 684). Ergebnisse: Gemäß Selbstbericht wurde bei weniger als der Hälfte der Behandlungen von Angststörungen eine Form der Exposition eingesetzt (46.8 %), wobei die Anwendungshäufigkeit stark zwischen den Behandelnden variierte. Exposition wurde hauptsächlich in der eigenen Praxis, durchschnittlich für eine Dauer von einer Stunde und mit einer wöchentlichen bis zweiwöchentlichen Frequenz eingesetzt. Eine häufigere Anwendung war mit jüngerem Alter, weniger Berufsjahren und mehr expositionsspezifischen Aus- und Weiterbildungsstunden assoziiert. Systemische Barrieren bezogen sich besonders auf finanzielle Aspekte und das Aufwand-Vergütungsverhältnis, Unklarheiten bezüglich Versicherungs- und Abrechnungsaspekten, sowie das begrenzte Stundenkontingent. Schlussfolgerung: Exposition bei Angststörungen scheint nicht so häufig und intensiv eingesetzt zu werden, wie in aktuellen evidenzbasierten Leitlinien empfohlen wird. Diverse systemische Barrieren erschweren die Anwendung in der ambulanten Routineversorgung.

Dispositional optimism as predictor of outcome in short- and long-term psychotherapy

OBJECTIVES

Dispositional optimism predicts various beneficial outcomes in somatic health and treatment, but has been little studied in psychotherapy. This study investigated whether an optimistic disposition differentially predicts patients' ability to benefit from short-term versus long-term psychotherapy.

DESIGN

A total of 326 adult outpatients with mood and/or anxiety disorder were randomized into short-term (solution-focused or short-term psychodynamic) or long-term psychodynamic therapy and followed up for 3 years.

METHODS

Dispositional optimism was assessed by patients at baseline with the self-rated Life Orientation Test (LOT) questionnaire. Outcome was assessed at baseline and seven times during the follow-up, in terms of depressive (BDI, HDRS), anxiety (SCL-90-ANX, HARS), and general psychiatric symptoms (SCL-90-GSI), all seven follow-up points including patients' self-reports and three including interview-based measures.

RESULTS

Lower dispositional optimism predicted faster symptom reduction in short-term than in long-term psychotherapy. Higher optimism predicted equally rapid and eventually greater benefits in long-term, as compared to short-term, psychotherapy.

CONCLUSIONS

Weaker optimism appeared to predict sustenance of problems early in long-term therapy. Stronger optimism seems to best facilitate engaging in and benefiting from a long-term therapy process. Closer research might clarify the psychological processes responsible for these effects and help fine-tune both briefer and longer interventions to optimize treatment effectiveness for particular patients and their psychological qualities.

PRACTITIONER POINTS

Weaker dispositional optimism does not appear to inhibit brief therapy from effecting symptomatic recovery. Patients with weaker optimism do not seem to gain added benefits from long-term therapy, but instead may be susceptible to prolonged psychiatric symptoms in the early stages of long-term therapy.

Using Psychoeducation and Role Induction to Improve Completion Rates in Cognitive Behavioural Therapy

BACKGROUND

Pre-treatment role induction interventions have been suggested to potentially enhance attendance and clinical outcomes in psychotherapy.

AIMS

This study aimed to evaluate the effects of a programme of three transdiagnostic seminars (TDS) for patients with common mental disorders accessing cognitive behavioural therapy (CBT) in primary care. TDS included CBT psychoeducation and role induction.

METHOD

A random sample of patients (n = 49) participated in TDS followed by CBT (TDS+CBT) and they were compared with matched controls (n = 49) accessing usual CBT. TDS participants rated the relevance and quality of this intervention using an acceptability questionnaire (AQ). Treatment completion (vs dropout) rates were compared across groups using chi-square tests. Post-treatment changes in depression (PHQ-9) and anxiety (GAD-7) symptoms were compared between groups using analysis of covariance controlling for potential confounders. Analyses were based on intention-to-treat principles.

RESULTS

Mean AQ ratings of the TDS intervention were comparable across diagnostic groups (p = .05). Treatment completion rates were significantly higher (p = .02) in the TDS+CBT group (87.8%) by comparison with usual CBT (68.8%). However, no significant differences in post-treatment symptom changes were found for depression (p = .34) or anxiety measures (p = .71).

CONCLUSIONS

Incorporating a psychoeducational role induction prior to CBT significantly improved treatment retention, but not overall symptom reductions.

Using daily monitoring of psychiatric symptoms to evaluate hospital length of stay

BACKGROUND

Routine symptom monitoring and feedback improves out-patient outcomes, but the feasibility of its use to inform decisions about discharge from in-patient care has not been explored.

AIMS

To examine the potential value to clinical decision-making of monitoring symptoms during psychiatric in-patient hospitalisation.

METHOD

A total of 1102 in-patients in a private psychiatric hospital, primarily with affective and neurotic disorders, rated daily distress levels throughout their hospital stay. The trajectories of patients who had, and had not, met a criterion of clinically significant improvement were examined.

RESULTS

Two-thirds of patients (n=604) met the clinically significant improvement criterion at discharge, and three-quarters (n=867) met the criterion earlier during their hospital stay. After meeting the criterion, the majority (73.2%) showed stable symptoms across the remainder of their hospital stay, and both classes showed substantially lower symptoms than at admission.

CONCLUSIONS

Monitoring of progress towards this criterion provides additional information regarding significant treatment response that could inform clinical decisions around discharge readiness.

DECLARATION OF INTEREST

None.

COPYRIGHT AND USAGE

© The Royal College of Psychiatrists 2016. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) license.

Symptom Reduction Without Remoralization: A Randomized, Waiting-List Controlled Study Aimed at Separating Two Beneficial Psychotherapy Outcome Effects

OBJECTIVE

Treatment effects in psychotherapy outcome research are generally based on the reduction of symptoms. Standard inclusion of other beneficial treatment effects such as remoralization (increase of hope, self-efficacy, well-being) might lead to more elaborate findings in the field of psychotherapy. On the other hand, it is also possible that symptom reduction and remoralization always go hand in hand in the experience of patients. The present study sought to experimentally test this assumption.

METHOD

A total of 78 patients suffering from panic disorder were randomly assigned to brief remoralization treatment, brief exposure treatment, or waiting list (WL).

RESULTS

Both treatments increased remoralization and both reduced symptoms of panic disorder as compared to WL.

CONCLUSION

It is unlikely that patients experience remoralization without symptom reduction or symptom reduction without remoralization. These findings do not favor the assumption that conclusions within psychotherapy outcome research are flawed because of its heavy reliance on measurements of symptom reduction.

Practitioners’ Attitudes Toward the Use of Treatment Progress and Outcomes Data in Child Mental Health Services

This study focused on practitioners’ attitudes toward child mental health services data collection and outcomes measurement in university-based and community-based clinics. It is relevant to the burgeoning field of empirically based mental health therapy management because it examines one potential barrier to psychotherapy and pharmacotherapy strategies (i.e., practitioners’ attitudes toward outcomes measurement) that are informed by real-time, clinically relevant data. Two site differences were noted regarding the utility of specific questionnaires and the perceived burden of conducting outcomes measurement. At both sites, practitioners held positive attitudes about outcomes measurement. Compared with psychologists and other child mental health specialists, psychiatrists had less favorable attitudes toward outcomes evaluation. Practitioners who rated outcomes evaluation as more important also perceived less burden associated with such evaluation efforts. Increased understanding of the utility of systematic clinical data collection is more likely to occur in an organizational culture in which treatment progress and outcomes measurement is integral to clinical work.

A randomized clinical trial of the efficacy of a self-care intervention to improve cancer pain management

BACKGROUND

The undertreatment of cancer pain remains a significant clinical problem.

OBJECTIVE

The aim of this randomized controlled trial was to evaluate the efficacy of the PRO-SELF Pain Control Program that was modified for Norwegian cancer patients in decreasing pain and increasing opioid intake compared with control care.

INTERVENTIONS/METHODS

Oncology outpatients with pain from bone metastasis were randomized into the PRO-SELF (n = 87) or control (n = 92) groups. A nurse visited patients in the PRO-SELF group in their home at weeks 1, 3, and 6 and conducted telephone interviews at weeks 2, 4, and 5. Patients in both groups completed a daily diary of pain intensity ratings and analgesic intake.

RESULTS

For both groups, significant decreases in pain intensity scores and in hours per day in pain (both, P < .001) were found over the 6 weeks of the study. However, no significant group × time interactions were found for any of the pain measures. In both groups, total dose of opioid taken increased over time. However, no significant group × time interactions were found for changes over time in the total dose, around-the-clock dose, or as-needed dose of opioid analgesics taken.

CONCLUSIONS

Possible reasons for the lack of efficacy include an inadequate dose of the psychoeducational intervention, inadequate changes in analgesic prescriptions, and/or the impact of attention provided to the control group.

IMPLICATIONS FOR PRACTICE

Coaching, nursing support, and the use of a pain diary may be important interventions to reduce pain intensity.

Toward an online cognitive and emotional battery to predict treatment remission in depression

PURPOSE

To evaluate the performance of a cognitive and emotional test battery in a representative sample of depressed outpatients to inform likelihood of remission over 8 weeks of treatment with each of three common antidepressant medications.

PATIENTS AND METHODS

Outpatients 18-65 years old with nonpsychotic major depressive disorder (17 sites) were randomized to escitalopram, sertraline or venlafaxine-XR (extended release). Participants scored ≥12 on the baseline 16-item Quick Inventory of Depressive Symptomatology - Self-Report and completed 8 weeks of treatment. The baseline test battery measured cognitive and emotional status. Exploratory multivariate logistic regression models predicting remission (16-item Quick Inventory of Depressive Symptomatology - Self-Report score ≤5 at 8 weeks) were developed independently for each medication in subgroups stratified by age, sex, or cognitive and emotional test performance. The model with the highest cross-validated accuracy determined the participant proportion in each arm for whom remission could be predicted with an accuracy ≥10% above chance. The proportion for whom a prediction could be made with very high certainty (positive predictive value and negative predictive value exceeding 80%) was calculated by incrementally increasing test battery thresholds to predict remission/non-remission.

RESULTS

The test battery, individually developed for each medication, improved identification of remitting and non-remitting participants by ≥10% beyond chance for 243 of 467 participants. The overall remission rates were escitalopram: 40.8%, sertraline: 30.3%, and venlafaxine-XR: 31.1%. Within this subset for whom prediction exceeded chance, test battery thresholds established a negative predictive value of ≥80%, which identified 40.9% of participants not remitting on escitalopram, 77.1% of participants not remitting on sertraline, and 38.7% of participants not remitting on venlafaxine-XR (all including 20% false negatives).

CONCLUSION

The test battery identified about 50% of each medication group as being ≥10% more or less likely to remit than by chance, and identified about 38% of individuals who did not remit with ≥80% certainty. Clinicians might choose to avoid this specific medication in these particular patients.

Decision Making in Stepped Care: How Do Therapists Decide Whether to Prolong Treatment or Not?

Background: The efficiency of stepped care systems partly relies on systematic monitoring of patient outcomes and timely decisions to “step up” patients without any clear therapeutic gains to the next level of treatment. Qualitative evidence has suggested that this does not occur consistently, nor always congruently with clinical guidelines. Aims: To investigate factors that influence psychological therapists’ decisions to prolong or to conclude treatment in cases with little evidence of therapeutic gains. Method: Eighty-two clinicians in stepped care services completed questionnaires about the likelihood of “holding” non-improving patients in treatment, and factors associated with referrals and holding (FARAH-Q). The factor structure, internal consistency and test-retest reliability of the measures was examined prior to assessing correlations between FARAH-Q items and likelihood of holding. Results: A 4-factor solution indicated that clinicians’ decision making is influenced by a complex interplay between beliefs, attitudes, subjective norms and self-efficacy. Correlational analysis indicated that holding is more likely to happen if there are perceived barriers to refer the patient for further treatment, if the therapist likes the patient and has a good therapeutic alliance, and if the therapist feels confident that s/he has the ability to achieve a positive outcome by prolonging treatment. Conclusions: Decisions to prolong or conclude treatment are not only influenced by evidence and guidelines, but also subjective beliefs, norms and attitudes. Understanding this decision making process is relevant to clinicians and supervisors interested in enhancing the efficiency of stepped care.

'Painting a path to wellness': correlations between participating in a creative activity group and improved measured mental health outcome

Responding to a call for quantitative outcome evidence about the therapeutic relationship between creative activity and mental health, this study examined the mental health outcomes of inpatients participating in art- and craft-based creative therapies at a private psychiatric hospital over a 5-year period. The creative activity group sample (n= 403) improved from admission to discharge across four different psychometric measures with moderate to strong mean effect sizes. Reductions from pre- to post-treatment in both self-reported and clinician-rated symptoms are clearly demonstrated for the creative activity group participant sample. Research findings establish that participation in creative activity has potential benefits for people experiencing mental health problems.

Client-Focused Research: New Directions in Outcome Assessment

The emergence of client-focused research has led to substantial change in the field of outcome assessment. Using the client's clinical characteristics to determine expected outcome, client monitoring assists clinicians in assessing the current treatment plan and client progress. The methodology has been shown to be effective in outpatient samples, by implementing change in real time for the benefit of the individual (Lambert, Harmon, Slade, Whipple, & Hawkins, 2005). Accordingly, the framework is an appropriate and important addition to the assessment of clinical practice.

Cognitive-Behavioral Perspective and Cognitive-Behavioral Therapy for People With Chronic Pain: Distinctions, Outcomes, and Innovations

This article reviews the cognitive-behavioral (CB) perspective on chronic pain and discusses the distinction between this perspective and cognitive and behavioral techniques. We describe the general efficacy of cognitive-behavioral therapy (CBT) in the treatment of people with chronic pain along with some of the limitations of published outcome studies. We discuss advances in moderation and mediation of treatment outcomes. Lastly, we discuss the need for research that takes into account growing interest in evidence-based medicine, methods that address responders and nonresponders, individual trajectories, how we might advance and refine CBT, and strategies related to relapse prevention, maintenance, and adherence enhancement taking advantage of evolving technological methods of service delivery. We provide recommendations on how to approach studies of CBT efficacy as a function of better understanding of patient characteristics and context. We advocate for the potential of the CB perspective for all healthcare providers regardless of discipline or training.

Therapist effectiveness: implications for accountability and patient care

Significant therapist variability has been demonstrated in both psychotherapy outcomes and process (e.g., the working alliance). In an attempt to provide prevalence estimates of "effective" and "harmful" therapists, the outcomes of 6960 patients seen by 696 therapists in the context of naturalistic treatment were analyzed across multiple symptom and functioning domains. Therapists were defined based on whether their average client reliably improved, worsened, or neither improved nor worsened. Results varied by domain with the widespread pervasiveness of unclassifiable/ineffective and harmful therapists ranging from 33 to 65%. Harmful therapists demonstrated large, negative treatment effect sizes (d= -0.91 to -1.49) while effective therapists demonstrated large, positive treatment effect sizes (d=1.00 to 1.52). Therapist domain-specific effectiveness correlated poorly across domains, suggesting that therapist competencies may be domain or disorder specific, rather than reflecting a core attribute or underlying therapeutic skill construct. Public policy and clinical implications of these findings are discussed, including the importance of integrating benchmarked outcome measurement into both routine care and training.

Sleep disturbance interventions in oncology patients and family caregivers: a comprehensive review and meta-analysis

Sleep disturbance is a significant problem for both oncology patients and family caregivers (FCs), and is associated with poorer functional status, quality of life, and potentially disease progression. This review describes a comprehensive literature search and meta-analysis of the efficacy of interventions for sleep disturbance in oncology patients and their FCs. This search revealed 47 studies that evaluated the effects of a number of interventions on sleep disturbance/sleep quality, as a primary or secondary outcome in oncology patients. The primary purposes of the review were to synthesize findings from intervention studies for sleep disturbance in oncology patients and their FCs; to evaluate the efficacy of these interventions; to identify gaps in the literature; and to provide directions for future research. In addition, all 47 intervention studies were evaluated in terms of key intervention and study characteristics. Both strong patterns and inconsistencies were identified among the studies, which complicate an evaluation of the efficacy of interventions, and may collectively guide future research. Finally, the importance of including the FC in sleep disturbance interventions is discussed. In light of the detrimental effects that sleep disturbance has on both the patient and the FC, this systematic review may better inform essential future intervention efforts.

Replicating and extending the good-enough level model of change: considering session frequency

The good-enough level (GEL) model posits that the rate of change in psychotherapy is related to the total dose of therapy. The psychotherapy dose-response literature has typically measured dose as number of sessions attended without considering the number of days or weeks it takes to complete the sessions (session frequency). The current study sought to replicate the GEL model and explore if session frequency moderates the influence that the number of sessions has on the rate of change in psychotherapy. An archived naturalistic data set with a US university counseling center sample (n=1,207), with treatment progress measured using the Outcome Questionnaire-45 (Lambert et al., 1996), was used. Our results are consistent with the GEL model (i.e., clients who attended fewer sessions evidenced faster rates of change), but extended it by showing that the rate of change was also influenced by session frequency (i.e., clients who attended more sessions on average per week demonstrated more rapid improvement). Evidence suggests that clinicians and researchers should give consideration to session frequency, both in their work with clients and how "dose" is operationalized in psychotherapy research.

A priori power analysis in longitudinal three-level multilevel models: an example with therapist effects

Over the last few years, three-level longitudinal models have become more common in psychotherapy research, particularly in therapist-effect or group-effect studies. Thus far, limited attention has been paid to power analysis in these models. This article demonstrates the effects of intraclass correlation, level of randomization, sample size, covariates and drop-out on power, using data from a routine outcome monitoring study. Results indicate that randomization at the patient level is the most efficient, and that increasing the number of measurements does not increase power much. Adding a covariate or having a 25% drop-out rate had limited effects on study power in our data. In addition, the results demonstrate that sufficient power can be reached with small sample sizes, but that larger sample sizes are needed to prevent estimation bias for the model parameters and standard errors.

Treatment of major depressive disorder in the Finnish general population

BACKGROUND

Few general population studies of the treatment of major depressive disorder (MDD) have included the whole spectrum of treatments. We estimated the rates of different treatments and the effect of individual and disorder characteristics plus provider type on treatment received.

METHODS

In the Health 2000 Study, a representative sample (n=6,005) from the adult Finnish population (> or =30 years) were interviewed (CIDI) in 2000-2001 for the presence of DSM-IV mental disorders during the past 12 months. Logistic regression models were used to examine factors influencing the type of treatment: either pharmacotherapies (antidepressants, anxiolytics, sedatives/hypnotics, antipsychotics) or psychological treatment.

RESULTS

Of the individuals with MDD (n=288), currently 24% used antidepressants, 11% anxiolytics, 16% sedatives/hypnotics, 5% antipsychotics, and 17% reported having received psychological treatment. Overall, 31% received antidepressants or psychological treatment or both; 18% received minimally adequate treatment. Of those 33% (n=94) using health care services for mental reasons, 76% received antidepressants or psychological treatment or both; 54% received minimal adequate treatment. In logistic regression models, the use of antidepressants was associated with female sex, being single, severe MDD, perceived disability, and comorbid dysthymic disorder; psychological treatment with being divorced, perceived disability, and comorbid anxiety disorder.

CONCLUSIONS

Due to the low use of health services for mental reasons, only one-third of subjects with MDD use antidepressants, and less than one-fifth receives psychological treatment. The treatments provided are determined mostly by clinical factors such as severity and comorbidity, in part by sex and marital status, but not education or income.

Future perspectives in psychotherapy

To date, the effectiveness of psychotherapy for the treatment of most mental disorders is empirically well documented. From an "evidence-based medicine" viewpoint, psychotherapy, as compared to other treatments in medicine, can be regarded as one of the most effective therapeutic approaches. The superiority of psychotherapy over pharmacotherapy is particularly pronounced in long-term treatment outcome studies. It is especially cognitive behavioral approaches, such as exposure response management and cognitive restructuring that have shown strong evidence of their efficacy and effectiveness in various populations and settings. However, evidence-based medicine is by definition oriented toward the past, as it only informs us about the well-established, empirically supported treatments. If we rely only on the currently available scientific evidence, new developments will be blocked. Since, for instance, many patients decline treatment, or do not seek professional help at all, there is a need for improvements regarding acceptance of established therapies. In addition, there ought to be scope for new, creative approaches, for which scientific evidence is not yet available. Promising developments include the mindfulness-based therapies, well-being therapy, the use of cognitive enhancers such as D-cycloserine, and Web-based therapies. There is also a trend in psychotherapy training toward teaching specific, disorder-oriented protocols or modules rather than universally applicable therapies. Finally, given the globalization of our societies, culture-sensitive psychotherapists should try to understand the cultural components of a patient's illness and help-seeking behaviors, as well as their expectations with regard to treatment.

Factors associated with use of psychotherapy

CONTEXT

Psychotherapies are recommended in manuals of good practice. There is however little epidemiological data assessing access to this type of treatment, and in particular the combined role of the offer and socio-demographic characteristics. The present research aims to contribute data on the profiles of a sample of individuals who underwent psychotherapy in France, and on the respective impact of various factors such as mental health status, socio-demographic characteristics, life events and the care offer, focusing on a specific population for whom the mode of financial cover for this type of care is governed by a complementary health insurance (MGEN).

METHODS

Between June 1999 and March 2000 a survey using a self-administered questionnaire was conducted on a sample of MGEN-insured individuals. Ten thousand individuals aged between 20 and 60 were selected randomly, received a questionnaire, and up to three recalls in case of non-response. The overall response rate was 66.5%. The questionnaire comprised 261 questions enabling data collection concerning the main socio-demographic, professional and mental health variables.

RESULTS

In this population aged from 20 to 60, lifetime prevalence of recourse to psychotherapy was 11.8%. The main factor associated with use of psychotherapy is the severity of the clinical condition (assessed in terms of comorbidity). Certain traumatic events experienced in childhood are also related. The effect of socio-demographic variables varies according to severity, although it was noted that being female, having high educational status, and being single were consistently related to wider use of psychotherapy. The analysis also evidenced the importance of the density of the care offer.

CONCLUSION

Our results suggest that the use of psychotherapy, within a well-informed population with high quality insurance cover, is related primarily to clinical condition rather than to socio-demographic status, especially in people with high levels of comorbidity, although the effect of educational status remains. However, this study only looked at mere use of psychotherapy, without determining the suitability of the treatment provided. It is indeed possible, and even probable, that variables such as educational status, income, or care offer may have a link with resorting to the right type of care, in terms of both relevance and adequate duration.

The use of a responder analysis to identify differences in patient outcomes following a self-care intervention to improve cancer pain management

Previously, we demonstrated, in a randomized clinical trial, the effectiveness of a psychoeducational intervention to decrease pain intensity scores and increase patients' knowledge of cancer pain management with a sample of oncology patients with pain from bone metastasis. In the present study, we evaluated for changes in mood states (measured using the Profile of Mood States), quality of life (QOL; measured using the Medical Outcomes Study Short Form-36 (SF-36)), and pain's level of interference with function (measured using the Brief Pain Inventory (BPI)) from baseline to the end of the intervention first between the intervention and the standard care groups and then within the intervention group based on the patients' level of response to the intervention (i.e., patients were classified as non-responders, partial responders, or responders). No differences were found in any of these outcome measures between patients in the standard care and intervention groups. However, when patients in the intervention group were categorized using a responder analysis approach, significant differences in the various outcome measures were found among the three respondent groups. Differences in the physical and mental component summary scores on the SF-36 and the interference items on the BPI, among the three respondent groups, were not only statistically significant but also clinically significant. The use of responder analysis in analgesic trials may help to identify unique subgroups of patients and lead to the development of more effective psychoeducational interventions.

Multidimensional patterns of change in outpatient psychotherapy: The phase model revisited

In this study, groups of psychotherapy outpatients were identified on the basis of shared change patterns in the three dimensions of the phase model of psychotherapeutic outcome: well-being, symptom distress, and life functioning. Treatment courses provided by a national provider network of a managed care company in the United States (N = 1128) were analyzed using growth mixture models. Several initial patient characteristics (treatment expectations, amount of prior psychotherapy, and global assessment of functioning) allowed for the discrimination between three patient groups of shared change patterns. Those patterns can be classified into three groups as phase model consistent, partial rapid responders, or symptomatically highly impaired patients with each having typical change patterns.

Mehrebenenanalysen in der psychologischen Forschung

Zusammenfassung. Daten mit Mehrebenenstruktur liegen vor, wenn für jede Versuchsperson eine Vielzahl von Messungen erhoben wird (z.B. in Tagebuchstudien) oder wenn Individuen in Gruppen analysiert werden. Derartige Daten können mit Hilfe von Mehrebenenanalysen ausgewertet werden. Der vorliegende Artikel erläutert das Prinzip der Mehrebenenmodellierung mit Zufallskoeffizienten, nennt Vorteile gegenüber herkömmlichen Analysestrategien und liefert Beispiele aus empirischen Studien. Außerdem wird diskutiert, welche Aspekte bei Mehrebenenanalysen zu beachten sind. Hierzu gehören die Zentrierung von Prädiktoren, die Fixierung von Koeffizienten und die Zahl der Analyseebenen.

Dose-effect relations and responsive regulation of treatment duration: the good enough level

This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (N=1,868; 73.1% female; 92.4% White; average age=40), who were seen for a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (n=1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (r=-.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a good enough level of improvement.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Zur Entwicklung von Entscheidungsregeln in der Psychotherapie

Zusammenfassung. Theoretischer Hintergrund und Fragestellung: Das Monitoring von Psychotherapieverläufen, d.h. die wiederholte Messung der durch die psychotherapeutische Behandlung bewirkten Veränderungen beim einzelnen Patienten und der Vergleich mit statistisch vorhergesagten Veränderungen, kann die Entscheidungsprozeduren hinsichtlich des therapeutischen Vorgehens, gerade in etablierten Wissenschaftler-Praktiker-Netzwerken, maßgeblich unterstützen. Die vorliegende Arbeit adaptiert eine bereits in der Lawinenforschung etablierte Strategie zur Vorhersagen auf der Basis ähnlicher Gruppen, um ein enstprechendes differenzielles Vorhersagesystem für psychotherapeutische Behandlungsverläufe zu entwickeln. Methode und Ergebnisse: Die Studie basiert auf insgesamt 618 Patientinnen und Patienten mit breitem Diagnosespektrum, welche entweder mit einem kombiniert bewältigungs- und klärungsorientierten (n = 356) oder einem rein bewältigungsorientierten Vorgehen (n = 262) behandelt wurden. Bei diesem Vorgehen wurden die Patienten in einem ersten Schritt in homogene Subgruppen eingeteilt, um in einem zweiten Schritt mit Hilfe von Wachstumsanalysen ihren Psychotherapieverlauf vorherzusagen und mit dem tatsächlichen Verlauf vergleichen zu können. Die Validität der statistischen Vorhersagemodelle für die einzelnen Patienten und Behandlungsmodalitäten wurde mit einer sequenzanalytischen Verfahren überprüft. Schlussfolgerungen: Mögliche Anwendungen und Implikationen für die klinische Praxis, welche sowohl mehr Informationen über die Patienten zur Verfügung stellen als auch damit klinische Entscheidungsprozesse verbessern können, werden diskutiert. Momentane Grenzen des Ansatzes sowie notwendige weitere Forschungsaspekte werden aufgezeigt.

Efficacy, effectiveness, and expected treatment response in psychotherapy

This article provides a summary of "The Evaluation of Psychotherapy: Efficacy, Effectiveness, and Patient Progress" (Howard, Moras, Brill, Martinovich, & Lutz, 1996) and an introduction to the "patient profiling" method. First, the difference between the two main approaches to treatment research in psychotherapy, efficacy research and effectiveness research, are discussed. Next, the idea is introduced that both types of treatment-focused research strategies need to be supplemented by a patient-focused research strategy. The concept of patient profiling is presented as an application of such a patient-focused research strategy. The usefulness of patient profiling for monitoring and evaluating individual patients' progress in ongoing psychotherapy as well as for clinical decision making is described. An expression of the personal and professional impact of Ken Howard on the author is provided.

Some relationships among assessments of depression

The Directions program provides an administratively efficient method to screen for psychological disorders in a primary-care setting (FOCUS), confirm the need for treatment, and monitor progress (COMPASS-PC). The instruments are psychometrically sound and grounded in an established theory of mental-health treatment. The present study reports the relationships between FOCUS, COMPASS-PC, and the Hamilton Depression scale for a sample of patients who have been diagnosed as major depressive disorder, dysthymia, or depressive syndrome by standardized criteria (i.e., SCID-IV and DSM-IV). Moreover, Focus and COMPASS-PC are evaluated for their ability to detect depression as defined by SCID-IV and DSM IV. Furthermore, we examine the relationship between the different instruments in their ability to measure response to treatment over time.