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

Direction of dependence analysis for pre-post assessments using non-Gaussian methods: a tutorial

OBJECTIVE

We introduced methods for solving causal direction of dependence between variables observed in pre- and post-psychotherapy assessments, showing how to apply them and investigate their properties via simulations. In addition, we investigated whether changes in depressive symptoms drive changes in social and occupational functioning as suggested by the phase model of psychotherapy or vice versa, or neither.

METHOD

As a Gaussian (normal-distribution) model is unidentifiable here, we used an identifiable linear non-Gaussian structural vector autoregression model, conceptualizing instantaneous effects as during-psychotherapy causation and lagged effects as pre-treatment predictors of change. We tested six alternative estimators in six simulation settings that captured different real-world scenarios, and used real psychotherapy data from 1428 adult patients (Finnish Psychotherapy Quality Registry; assessments on Patient Health Questionnaire-9 and Social and Occupational Functioning Assessment Schedule).

RESULTS

The methodology was successful in identifying causal directions in simulated data. The real-data results provided no evidence for single direction of dependence, suggesting shared or reciprocal causation.

CONCLUSIONS

A powerful new tool was presented to investigate the process of psychotherapy using observational data. Application to patient data suggested that depression symptoms and functioning may reciprocate or reflect third variables instead of one predominantly driving the other during psychotherapy.

Associations between specific depressive symptoms and psychosocial functioning in psychotherapy

BACKGROUND

Psychotherapy for depression aims to reduce symptoms and to improve psychosocial functioning. We examined whether some symptoms are more important than others in the association between depression and functioning over the course of psychotherapy treatment.

METHODS

We studied associations between specific symptoms of depression (PHQ-9) and change in social and occupational functioning (SOFAS), both with structural equation models (considering liabilities of depression and each specific symptom) and with logistic regression models (considering the risk for individual patients). The study sample consisted of adult patients (n = 771) from the Finnish Psychotherapy Quality Registry (FPQR) who completed psychotherapy treatment between September 2018 and September 2021.

RESULTS

Based on our results of logistic regression analyses and SEM models, the baseline measures of depression symptoms were not associated with changes in functioning. Changes in depressed mood or hopelessness, problems with sleep, feeling tired, and feeling little interest or pleasure were associated with improved functioning during psychotherapy. The strongest evidence for symptom-specific effects was found for the symptom of depressed mood or hopelessness.

LIMITATIONS

Due to our naturalistic study design containing only two measurement points, we were unable to study the causal relationship between symptoms and functioning.

CONCLUSIONS

Changes in certain symptoms during psychotherapy may affect functioning independently of underlying depression. Knowledge about the dynamics between symptoms and functioning could be used in treatment planning or implementation. Depressed mood or hopelessness appears to have a role in the dynamic relationship between depression and functioning.

Trajectories of depression in psychotherapy: How client characteristics predict clinical improvement

OBJECTIVE

The current study aims to ascertain the trajectories of psychotherapy clients' symptom change and identify client factors that predict treatment outcome.

METHOD

We conducted a latent growth mixture model (LGMM) to identify the change trajectories of 44 clients' depression scores during psychotherapy. Client characteristics were then explored to determine whether any were associated with change trajectories. We examined whether the number of physician visits and/or client self-concealment scores predict 63 clients' improvement after controlling for initial symptom severity.

RESULTS

Two trajectories of clients' symptom change were identified: nonimprovers (52.3%) and improvers (47.7%). Nonimprovers had higher levels of self-concealment and baseline depression than improvers. The number of physician visits was associated with higher depression scores at baseline and greater clinical improvement during psychotherapy.

CONCLUSION

Clients showed distinct trajectories of symptom change in psychotherapy. Early identification of clients at risk for treatment failure may increase the probability of therapeutic success.

Basale Wirkmodelle in der Psychotherapie

Der Beitrag gibt einen Überblick über verschiedene Ansätze, wie die Wirkungsweise von Psychotherapie erklärt werden kann. Basierend auf dem biopsychosozialen Rahmenmodell postuliert die evidenzbasierte Praxis einen Rahmen des professionellen psychotherapeutischen Handelns. Grundsätzlich haben alle an der Therapie beteiligten Personen aktive Mitwirkung. Allgemeine Wirkfaktoren wie beispielsweise die Bereitschaft der Patient*innen zur Veränderung, die Qualität der gemeinsamen Arbeitsallianz oder die Auseinandersetzung der Therapeut*innen mit systematischem Feedback werden dabei als übergeordnete störungs- und therapieschulenübergreifende Wirkkomponenten verstanden.

Predicting future courses of psychotherapy within a grouped LASSO framework

Objective: There is a paucity of studies examining the experience of clients who undergo multiple courses of psychotherapy. Conducted within a large practice research network, this study demonstrated that returning therapy clients comprise a considerable portion of the clinical population in university counseling settings, and identified variables associated with return to therapy. Method: Utilizing data spanning 2013 to 2017, statistical variable selection for predicting return to therapy was conducted via grouped least absolute shrinkage and selection operator (grouped LASSO) applied to logistic regression. The grouped LASSO approach is described in detail to facilitate learning and replication. The paper also addresses methodological considerations related to this approach, such as sample size, generalizability, as well as general strengths and limitations. Results: Attendance rate, duration of initial treatment course, social anxiety, perceived social support, academic distress, and alcohol use were identified as predictive of return to therapy. Conclusions: Findings could help inform more cost-effective policies for session limits (e.g., extending session limits for clients with social anxiety), referral decisions (e.g., for clients with alcohol use problems), and appointment reminders (based on the association between poor attendance rate and return to therapy). Taking into account the many reasons that can explain why clients do or do not return to therapy, these findings also could inform clinicians' early case conceptualizations and treatment interventions.

The effectiveness of initial therapy contact: A systematic review

'Initial therapy contacts', defined as (the first) 3 h or less of face-to-face psychological treatment, encompassing both the early phase of a longer therapy and one-off single session therapies, are seen as a critical phase of treatment. However, little is known about the direct effect of initial therapy contacts on change in common symptoms typically presented by patients in psychological therapy services. Our systematic literature search resulted in 35 identified empirical studies on the effect of initial therapy contacts. These studies were analyzed in three stages: 1) A systematic comparison of study characteristics using the preferred reporting items for systematic reviews and meta-analyses; 2) A domain-based evaluation of methodological rigor of the studies, in line with Cochrane's guidelines on assessing risk of bias; 3) A narrative synthesis of reported findings. The considerable variability in therapy format (a stand-alone single session, 2 + 1 format, or initial session of multisession therapy) and study design (post/pre-post measurement, with/without control) limited comparability of studies. The quality assessment indicated that the majority of studies had relatively weak methodologies overall. Qualitative synthesis of the effectiveness results suggests that a significant proportion of patients reported benefits, including symptom change. This positive effect is especially clear when compared to no-treatment controls, and appears to be maintained at follow-up. The findings suggest that a broad range of initial therapy formats, could in itself be beneficial to patients in primary care treatment settings, and that further research is warranted.

How to customize a bona fide psychotherapy for generalized anxiety disorder? A two-arms, patient blinded, ABAB crossed-therapist randomized clinical implementation trial design [IMPLEMENT 2.0]

BACKGROUND

Bona fide psychotherapy approaches are effective treatments for generalized anxiety disorder (GAD) compared to no-treatment conditions. Treatment manuals and protocols allow a relatively high degree of freedom for the way therapists implement these overall treatment packages and there is a systematic lack of knowledge on how therapists should customize these treatments. The present study experimentally examines two implementation strategies of customizing a bona fide psychotherapy approach based on a 16 session time-limited cognitive-behavioral therapy (CBT) protocol and their relation to the post-session and ultimate treatment outcomes.

METHODS

This trial contrasts two different implementation strategies of how to customize the in-session structure of a manual-based CBT-protocol for GAD. The patients will be randomly assigned to two implementation conditions: (1) a systematic focus on subtle changes lasting from 7 to 20 min at the check-in phase of every psychotherapy session and (2) a state-of-the-art (SOTA) check-in phase lasting several minutes mainly focused on the session goals. Potential therapist effects will be examined based on an ABAB crossed-therapist design. Treatment outcomes will be assessed at the following times: post-session outcomes, treatment outcome at post assessment and 6- as well as 12-month follow-up.

DISCUSSION

The proposed randomized clinical implementation trial addresses the clinically relevant question of how to customize a bona fide psychotherapy protocol experimentally contrasting two implementation strategies. Through the development and testing of the proposed implementation design, this trial has the potential to inform therapists about efficacious implementation strategies of how to customize a manual-based treatment protocol in respect to the timing of the in-session structure.

TRIAL REGISTRATION

This trial was registered at ClinicalTrials.gov ( NCT03079336 ) at March 14, 2017.

The Psychotherapy Outcome Problem: The Development of the Outcome Stability Index

OBJECTIVE

Psychotherapy research commonly utilizes clients' last session score as an indicator of treatment outcome. We examined whether this last session score is consistent with what would be predicted based on clients' general trajectory in psychological functioning across sessions. We focused on the unstandardized residual variance at the last session, as this represents the degree to which the session score is divergent (or not) from what is predicted from the previous sessions (i.e., Outcome Stability Index; OSI).

METHOD

The sample included 27,958 clients who attended on average 9.41 sessions. Each session, clients completed the Behavioral Health Measure-20 as a measure of psychological functioning. We converted the unstandardized residual variance for clients' last session score into a Cohen's d coefficient to aid in interpretation.

RESULTS

The mean OSI was 0.07 (SD = 0.58), suggesting excellent stability in their last session therapy outcome scores. However, approximately 33% of clients demonstrated poor or extremely problematic stability in their last session therapy outcome scores. Clients who demonstrated poor stability were classified as demonstrating reliable deterioration.

CONCLUSIONS

Researchers may want to consider reporting OSI to assist readers' understanding of the stability of therapy outcomes. Clinical or methodological significance of this article: Therapy outcome scores can vary from session to session, which can influence how we understand therapy outcomes that rely on last session scores. Studies examining therapy outcomes could report the Outcome Stability Index to better contextualize the results.

Readiness to change as a moderator of therapy outcome in patients with somatoform disorders

OBJECTIVE

A considerable amount of patients with somatoform disorders do not benefit from psychotherapy as much as expected. Our aim was to explore whether readiness to change moderates the relationship between the intensity of symptoms and therapy outcome in the early stages of psychotherapy.

METHOD

144 patients with somatoform disorders received an outpatient cognitive-behavioural intervention. Symptom intensity was measured with the Screening for Somatoform Disorders (SOMS-7). For readiness to change, a German modification of the Pain Stages of Change Questionnaire (PSOCQ) was used, which comprises four subscales (FF-STABS). Regression analyses were carried out, with baseline symptoms and the readiness to change subscales as predictors and symptom reduction as the outcome variable.

RESULTS

Moderation analyses revealed significant interaction effects between baseline symptoms and the precontemplation subscale, as well as between baseline symptoms and the action subscale. For preparation and maintenance, no significant interaction effects were found.

CONCLUSIONS

The results suggest that readiness to change is a variable that can be used to differentiate between patients, with low precontemplation and action scores indicating a better chance for positive outcome, even with high initial impairment. Rather than using readiness to change sum scores, the sub-aspects of this construct should be the subject of future research.

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.

Predicting Response Trajectories during Cognitive-Behavioural Therapy for Panic Disorder: No Association with the BDNF Gene or Childhood Maltreatment

BACKGROUND

Anxiety disorders are highly prevalent and result in low quality of life and a high social and economic cost. The efficacy of cognitive-behavioural therapy (CBT) for anxiety disorders is well established, but a substantial proportion of patients do not respond to this treatment. Understanding which genetic and environmental factors are responsible for this differential response to treatment is a key step towards "personalized medicine". Based on previous research, our objective was to test whether the BDNF Val66Met polymorphism and/or childhood maltreatment are associated with response trajectories during exposure-based CBT for panic disorder (PD).

METHOD

We used Growth Mixture Modeling to identify latent classes of change (response trajectories) in patients with PD (N = 97) who underwent group manualized exposure-based CBT. We conducted logistic regression to investigate the effect on these trajectories of the BDNF Val66Met polymorphism and two different types of childhood maltreatment, abuse and neglect.

RESULTS

We identified two response trajectories ("high response" and "low response"), and found that they were not significantly associated with either the genetic (BDNF Val66Met polymorphism) or childhood trauma-related variables of interest, nor with an interaction between these variables.

CONCLUSIONS

We found no evidence to support an effect of the BDNF gene or childhood trauma-related variables on CBT outcome in PD. Future studies in this field may benefit from looking at other genotypes or using different (e.g. whole-genome) approaches.

[Typical patterns of depressive disorders during outpatient psychotherapy and their prediction]

OBJECTIVES

Are there typical patterns of outpatient psychotherapy among depressed patients? What characterizes patients with different patterns?

METHODS

We examined N= 548 patients with primary depressive disorders using a naturalistic design. Using a latent-state-mixture model and depression measures at baseline, therapy end and 1-year follow-up we found a total of five patterns. Subgroups were compared with respect to sociodemographic and treatment-related variables.

RESULTS

Responders with moderate depressive symptoms at baseline and responders with severe symptoms at baseline were most common (54% and 25% of the sample, respectively) compared to late responders (9 %), small-response patients (9 %) and recidivists (4 %). Patterns of change were related to symptom intensity at baseline and ratings of perceived helpfulness at the end of treatment.

CONCLUSIONS

Since psychometric scales better predicted change pattern than sociodemographic characteristics, primary and secondary diagnoses, psychometric assessments and feedback systems could be a useful supplement to traditional quality assurance procedures.

Identifying risk of deliberate self-harm through longitudinal monitoring of psychological distress in an inpatient psychiatric population

BACKGROUND

While cross-sectional correlates of deliberate self-harm, such as psychological distress, have been identified; it is still difficult to predict which individuals experiencing distress will engage in deliberate self-harm, and when this may occur. Therefore, this study aimed to explore the ability of longitudinal measurements of psychological distress to predict deliberate self-harm in a psychiatric population.

METHOD

Participants (N = 933; age range 14-93 (M = 38.95, SD = 14.64; 70% female) were monitored daily in terms of suicidal ideation, depression, anxiety, worthlessness and perceptions of not coping. Latent Growth Curve Analysis was used to check if groups of inpatients reporting suicidal ideation, who shared early change in measures of psychological distress, existed. Logistic regression tested whether different groups were at higher (or lower) risks of deliberate self-harm.

RESULTS

Four groups were found. Of these, Non-Responders (high symptoms, remaining high) were more likely to engage in deliberate self-harm than patients with high, medium and low symptoms which improved over one week. Group membership was a greater predictor of deliberate self-harm than initial distress scores. Females and patients with personality disorders were significantly more likely to be Non-Responders.

CONCLUSIONS

Continuous monitoring and subsequent grouping of inpatients according to their early change in psychological distress provides a novel and practical approach to risk management. A lack of early improvement in psychological distress may indicate a higher risk of deliberate self-harm.

Do patterns of change during treatment for panic disorder predict future panic symptoms?

BACKGROUND AND OBJECTIVES

Cognitive-behavioral therapies are currently the gold standard for panic disorder treatment, with well-documented treatment response. However, following interventions, some individuals continue to improve, while others experience a return of symptoms. The field lacks reliable ways to predict follow-up symptomatology. In the current study, a cluster analysis with a repeated measures design was conducted to examine change patterns over 12 weeks of cognitive behavioral group therapy for panic disorder. The central aim of the study was to evaluate if change patterns predict level of panic symptom severity at a six month follow-up in this sample.

METHODS

Individuals with panic disorder (N = 36) completed a measure of panic symptoms (Panic Disorder Severity Scale) at the outset of every therapy session and at a six month follow-up.

RESULTS

Results revealed three patterns of change in this specific trial, which significantly predicted level of panic symptoms six months post-treatment, beyond initial or final level of panic symptoms, and beyond total symptom change.

LIMITATIONS

Given the relatively small, lab-based sample, replications in other settings and samples will be important.

CONCLUSIONS

Overall, results provide initial evidence that change patterns are meaningful predictors of panic symptom severity well after the final session of treatment.

Is the relation between early post-session reports and treatment outcome an epiphenomenon of intake distress and early response? A multi-predictor analysis in outpatient psychotherapy

The early phase of psychotherapy has been regarded as a sensitive period in the unfolding of psychotherapy leading to positive outcomes. However, there is disagreement about the degree to which early (especially relationship-related) session experiences predict outcome over and above initial levels of distress and early response to treatment. The goal of the present study was to simultaneously examine outcome at post treatment as a function of (a) intake symptom and interpersonal distress as well as early change in well-being and symptoms, (b) the patient's early session-experiences, (c) the therapist's early session-experiences/interventions, and (d) their interactions. The data of 430 psychotherapy completers treated by 151 therapists were analyzed using hierarchical linear models. Results indicate that early positive intra- and interpersonal session experiences as reported by patients and therapists after the sessions explained 58% of variance of a composite outcome measure, taking intake distress and early response into account. All predictors (other than problem-activating therapists' interventions) contributed to later treatment outcomes if entered as single predictors. However, the multi-predictor analyses indicated that interpersonal distress at intake as well as the early interpersonal session experiences by patients and therapists remained robust predictors of outcome. The findings underscore that early in therapy therapists (and their supervisors) need to understand and monitor multiple interconnected components simultaneously.

The future and promise of cognitive behavioral therapy: a commentary

The Academy for Psychological Clinical Science and the independent accrediting entity it created, the Psychological Clinical Science Accreditation system, have recently launched a movement aimed at reforming all of clinical psychology. If this movement is successful, it will result in a greater emphasis on empirical science in the practice of clinical psychology. As cognitive behavioral therapy (CBT) is the approach that currently has the greatest number of controlled scientific studies supporting it, this should be an impetus for CBT to grow. The very same scientific evidence that supports the efficacy of CBT, however, also shows that CBT is far from fully efficacious. Several recent trends that hold great promise to enhance the effectiveness of CBT are discussed, such as greater integration of CBT with biological approaches, cognitive science, systemic approaches, motivational interviewing, and strengths-based approaches.

Understanding how and why psychotherapy leads to change

The rich research literature on psychotherapies for children, adolescents, and adults has identified several interventions that can ameliorate or effect significant change in psychiatric disorders and a variety of social, behavioral, and emotional problems and can enhance medical outcomes and recovery. After decades of psychotherapy research and thousands of studies, there is no evidence-based explanation of how or why even the most well-studied interventions produce change, that is, the mechanisms through which treatments operate. This article discusses central requirements for demonstrating mediators and mechanisms of change. Also presented are promising lines of work to identify mediators and mechanisms, ways of bringing to bear multiple types of evidence, recommendations to make progress in understanding how therapy works, and conceptual and research challenges in evaluating mediators and mechanisms.

Examining differential effects of psychosocial treatments for cocaine dependence: an application of latent trajectory analyses

BACKGROUND

The NIDA Collaborative Cocaine Treatment Study yielded different efficacies for different psychosocial treatments for cocaine dependence. However, substantial heterogeneity of patient outcomes was evident. Longitudinal data analysis techniques can be helpful in examining differential effects of psychosocial interventions on specific subpopulations of patients.

METHODS

Overall drug and cocaine use of 346 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions were assessed monthly during 6-month treatment. Growth mixture models were used to identify patient subgroups based on typical patterns of change in substance use during treatment and to evaluate differential treatment effects within these subgroups.

RESULTS

Three patient subgroups following different change patterns in cocaine and overall drug use were identified irrespective of the treatment type: (a) those with moderate baseline severity of drug use and very rapid reduction of drug use during treatment, (b) those with moderate baseline severity of drug use and moderate reduction of drug use during treatment, and (c) those with severe levels of baseline drug use with moderate reduction of drug use during treatment. Patient baseline characteristics enabled discrimination between these subgroups. Individual drug counseling was most efficacious among those patients with moderate baseline severity and moderate treatment response. There were no differential treatment effects in the two other patient subgroups.

CONCLUSIONS

The population of treatment-seeking cocaine dependent individuals is heterogeneous. Research on patient subgroups with different change patterns revealed its potential to enable classifications of patients that indicate which treatment is most effective for which type of patient.

Antidepressant response trajectories and quantitative electroencephalography (QEEG) biomarkers in major depressive disorder

Individuals with Major Depressive Disorder (MDD) vary regarding the rate, magnitude and stability of symptom changes during antidepressant treatment. Growth mixture modeling (GMM) can be used to identify patterns of change in symptom severity over time. Quantitative electroencephalographic (QEEG) cordance within the first week of treatment has been associated with endpoint clinical outcomes but has not been examined in relation to patterns of symptom change. Ninety-four adults with MDD were randomized to eight weeks of double-blinded treatment with fluoxetine 20mg or venlafaxine 150mg (n=49) or placebo (n=45). An exploratory random effect GMM was applied to Hamilton Depression Rating Scale (Ham-D(17)) scores over 11 timepoints. Linear mixed models examined 48-h, and 1-week changes in QEEG midline-and-right-frontal (MRF) cordance for subjects in the GMM trajectory classes. Among medication subjects an estimated 62% of subjects were classified as responders, 21% as non-responders, and 17% as symptomatically volatile-i.e., showing a course of alternating improvement and worsening. MRF cordance showed a significant class-by-time interaction (F((2,41))=6.82, p=.003); as hypothesized, the responders showed a significantly greater 1-week decrease in cordance as compared to non-responders (mean difference=-.76, Std. Error=.34, df=73, p=.03) but not volatile subjects. Subjects with a volatile course of symptom change may merit special clinical consideration and, from a research perspective, may confound the interpretation of typical binary endpoint outcomes. Statistical methods such as GMM are needed to identify clinically relevant symptom response trajectories.

Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders

BACKGROUND

While highlighting the efficacy of different treatments for major depressive disorders (MDD), findings of the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) often are interpreted as supporting the idea of treatment non-specificity for MDD. However, heterogeneity in treatment courses and outcomes might be undetected when focusing only on types of treatment in terms of sample means without taking into account early change in treatment.

METHOD

In this study, growth mixture models (GMM) were used in the completer sample of N=162 patients from the NIMH TDCRP to identify meaningful patterns of early change of depression severity that are shared by many individual patients.

RESULTS

Results revealed three typical patterns of early change over the first 8 weeks of treatment irrespective of the type of treatment protocol provided: (a) moderate to severe depression with moderate early improvement, (b) moderate to severe depression with rapid early improvement, and (c) mild to moderate depression with moderate early improvement. In contrast to the type of treatment, these differential patterns of early response (together with overall pre-treatment symptom severity) predicted outcomes (i.e. depression severity) at treatment termination and over the 1.5-year follow-up period.

LIMITATIONS

Due to the small sample size and the controlled setting of this study the degree to which these results can be generalized to clinical practice has to be further investigated.

CONCLUSIONS

The findings provide further support for the assumption that early change is an important factor for the prediction of short- and long-term outcome in psychotherapy.