Patients' Outcome Expectations Matter in Psychological Interventions for Patients with Diabetes and Comorbid Depressive Symptoms

Predictors of engagement with between-session work in Cognitive Behavioural Therapy (CBT)-based interventions: a mixed-methods systematic review and "best fit" framework synthesis

Between-session work (BSW) acts as the vehicle to translate skills learnt in therapy sessions into adaptive changes in everyday life, a key goal in Cognitive Behavioural Therapies (CBT). Despite a well-established relationship between engagement with BSW and enhanced treatment outcomes, difficulties completing between-session tasks are common and factors affecting patient engagement with BSW are poorly understood. This mixed-methods systematic review and "best fit" framework synthesis explored predictors of engagement with BSW in CBT-based interventions. Comprehensive searches were conducted across five databases, identifying 59 eligible studies. This combined theory and empirical evidence approach depicted ten predictor themes related to between-session engagement, spanning individual, relational and contextual concepts. While ambiguous findings were generated by existing evidence, several factors emerged as relatively consistent predictors of engagement with BSW: positive patient beliefs regarding BSW and treatment such as perceived helpfulness, and practitioner competency in planning and reviewing BSW, including providing a rationale and addressing difficulties were associated with greater engagement. Conversely, patient in-session resistance, including counter change talk, was an indicator of disengagement between-sessions. The impact of patient symptomology, sociocultural environment, practitioner beliefs and the therapeutic relationship is unclear. The conceptual model presented offers a testable framework for researchers and a guideline for practitioners.

First impressions matter: The influence of initial assessments on psychological treatment initiation and subsequent dropout

OBJECTIVE

This study investigated if patients' experience of an initial assessment may be associated with outcome expectations, and with subsequent treatment attendance.

METHOD

The sample comprised n = 6051 patients with depression/anxiety disorders, nested within k = 148 assessing therapists. Multilevel modelling (MLM) was used to examine therapist effects on treatment initiation and subsequent dropout, adjusting for patient-level characteristics. We tested associations between early outcome expectancy measured at an initial assessment with attendance at a first therapy session, and with dropout after initiation. Variability in mean expectancy ratings in the caseloads of assessing therapists was examined using the intracluster correlation coefficient (ICC).

RESULTS

Therapist effects partly explained the variance in treatment initiation and dropout. Pre-treatment outcome expectations significantly predicted treatment initiation but not dropout for the subgroup of patients who started treatment. Approximately 16% of variability in mean expectancy ratings was explained by therapist effects (ICC = 0.159) after controlling for patient-level covariates.

CONCLUSIONS

Patients assessed by some therapists are more likely to have higher outcome expectations, which influences their decision to initiate treatment thereafter. Once patients start therapy, early expectancy measured at assessment no longer influences their attendance, but the "first impression" from an initial assessment does influence their subsequent likelihood of dropout.

Changing attitudes towards psychotherapy via social observations: are similarities more important than discrepancies?

OBJECTIVES

Therapy expectations and attitudes towards psychotherapy contribute substantially to the outcome, process and duration of psychotherapy. The a priori use of role model videos seems to be promising for changing expectations and attitudes towards psychotherapy. In contrast, underlying mechanisms, like identifying with the role model, have been sparsely investigated in studies so far. For instance, the effects of similarities and differences between the role model and the observer are not clear yet.

METHODS

A total of 158 persons were recruited and randomly assigned to four groups. In one of three experimental groups, participants watched an expectation-optimised video with patients giving information about their mostly positive therapy outcomes (positive model). Two further experimental groups saw the same video, but either received instructions to focus on similarities (similarity group) or on differences (discrepancy group) between the patients and themselves. A further control group watched a video with patients who gave information about their symptoms. As the primary outcome variable, we assessed attitudes towards psychotherapy using the Questionnaire on Attitudes towards Psychotherapy (QAPT). It was filled in before and after watching the video and after a two-week follow-up period.

RESULTS

Contrary to the hypotheses, the discrepancy group and the experimental group without further intervention (positive model) showed significant improvements in their attitudes towards psychotherapy after watching the video, while such an effect was not found in the similarity group or control group.

CONCLUSION

Focusing on similarities between patient examples and the observer does not support a change in therapy expectations or attitudes through observation, while a positive video model without instructions, or with the instruction to focus on differences does. Attentional interference and depth of cognitive evaluation are discussed as possible reasons.

TRIAL REGISTRATION

Ethical approval (2018-19k) was obtained from the ethics committee of the Psychological Department, University of Marburg, and the trial was registered at Aspredicted.org (#22,205; 16.04.2019).

A Psychometric Evaluation of the Stanford Expectations of Treatment Scale (SETS) in the Context of a Smoking Cessation Trial

INTRODUCTION

Although treatment outcome expectancies (TOEs) may influence clinical outcomes, TOEs are rarely reported in the smoking cessation literature, in part because of the lack of validated measures. Therefore, we conducted a psychometric evaluation of TOEs scores with the Stanford Expectations of Treatment Scale (SETS) in the context of a smoking cessation clinical trial.

METHODS

Participants were 320 adults enrolled in a randomized controlled trial of extended versus standard pre-quit varenicline treatment for smoking cessation (clinicaltrials.gov ID: NCT03262662). Across an 8-week treatment period, we examined the nature and stability of the factor structure using confirmatory factor analysis (CFA), evaluated discriminant validity by examining correlations with abstinence self-efficacy and positive/negative affect (PA/NA), and assessed internal consistency and test-retest reliability of SETS scores.

RESULTS

CFAs supported a 2-factor structure that was stable (ie, invariant) across weeks. Positive and negative TOEs were each reflected in three-item subscales that exhibited acceptable to excellent internal consistency (Cronbach's alphas ≥ .77). Positive and negative TOEs were modestly correlated with PA and NA (all |rs| <.27, p < .05). Positive TOEs, but not negative TOEs, were moderately correlated with abstinence self-efficacy (rs = .45 to .61, p < .01). Both positive and negative TOEs scores demonstrated moderate test-retest reliability between assessments (rs = .54 to .72).

CONCLUSIONS

SETS scores generally reflect a valid and reliable assessment of positive and negative TOEs in a sample of adults enrolled in a smoking cessation trial. The SETS appears to be a reasonable option for assessing TOEs in future smoking treatment studies.

IMPLICATIONS

Assessments of treatment outcome expectancies are rarely reported in the smoking cessation literature. The present results support the validity and reliability of the SETS scores among adults seeking treatment for their smoking behavior.

Do I really have to do my homework? The role of homework compliance in cognitive behavioral therapy for irritable bowel syndrome

Treatment guidelines identify cognitive behavioral therapy (CBT) as a treatment of choice for irritable bowel syndrome (IBS). As a learning-based treatment, homework assignments are regarded as important for optimizing outcomes for CBT-treated patients. However, their actual benefit for IBS is unknown. This study examined whether homework completion corresponds with immediate and sustained treatment response in IBS patients enrolled in CBT treatment. Subjects were 358 IBS patients receiving clinic-based CBT (10 session), home-based CBT (4 session), or a 4 session, non-specific IBS education comparator as part of a large NIH trial. Homework completion was rated by clinician at each session. IBS symptom improvement was measured with the Clinician Global Improvement Scale at treatment week 5, post-treatment (week 12), and at follow-ups (weeks 22, 34, 46, 62). Homework completion rates over the 10-week acute phase corresponded with greater IBS symptom improvement and patient satisfaction at post-treatment. Early treatment homework completion did not predict early treatment response. Contrary to expectations, homework compliance rates were not greater among in-clinic session patients than home-based patients. Data lend empirical support to the clinical value of homework in teaching patients how to self-manage painful GI symptoms refractory to conventional medical and dietary therapies.

Implementation of a New Hampshire community-initiated response to the opioid crisis: A mixed-methods process evaluation of Safe Station

BACKGROUND

New Hampshire (NH) ranked first for fentanyl- and all opioid-related overdose deaths per capita from 2014 to 2016 and third in 2017 with no rate reduction from the previous year relative to all other states in the US. In response to the opioid crisis in NH, Manchester Fire Department (MFD), the state's largest city fire department, launched the Safe Station program in 2016 in partnership with other community organizations. This community-based response to the crisis-described as a connection to recovery-focuses on reducing barriers to accessing resources for people with substance use and related problems. The study aim is to characterize the multi-organizational partnerships and workflow of the Safe Station model and identify key components that are engaging, effective, replicable, and sustainable.

METHODS

A mixed-methods design included: semi-structured qualitative interviews conducted with 110 stakeholders from six groups of community partners (Safe Station clients, MFD staff and leadership, and local emergency department, ambulance, and treatment partner staff); implementation and sustainability surveys (completed by MFD stakeholders); and ethnographic observations conducted at MFD. Qualitative data were content analyzed and coded using the Consolidated Framework for Implementation Research. Survey subscales were scored and evaluated to corroborate the qualitative findings.

RESULTS

Community partners identified key program characteristics including firefighter compassion, low-threshold access, and immediacy of service linkage. Implementation and sustainability survey data corroborate the qualitative interview and observation data in these areas. All participants agreed that community partnerships are key to the program's success. There were mixed evaluations of the quality of communication among the organizations.

CONCLUSION

Safe Station is a novel response to the opioid crisis in New Hampshire that offers immediate, non-judgmental access to services for persons with opioid use disorders requiring community-wide engagement and communication. Data convergence provides guidance to the sustainability and replicability of the program.

Psychedelics and Psychotherapy

Psychedelics have shown great promise in modern clinical trials for treating various psychiatric conditions. As a transdiagnostic treatment that exerts its effects through subjective experiences that leave enduring effects, it is akin to psychotherapy. To date, there has been insufficient discussion of how psychedelic therapy is similar to and different from conventional psychotherapy. In this article, we review the shared features of effective conventional psychotherapies and situate therapeutic psychedelic effects within those. We then discuss how psychedelic drug effects might amplify conventional psychotherapeutic processes-particularly via effects on meaning and relationship-as well as features that make psychedelic treatment unique. Taking into account shared features of conventional psychotherapies and unique psychedelic drug effects, we create a framework for understanding why psychedelics are likely to be effective with very diverse types of psychotherapies. We also review the formal psychotherapies that have been adjunctively included in modern psychedelic trials and extend the understanding of psychedelics as psychotherapy towards implications for clinical ethics and trial design. We aim to provide some common conceptual vocabulary that can be used to frame therapeutic psychedelic effects beyond the confines of any one specific modality.

Relationship Between Patient Engagement and Depressive Symptoms Among People Living With HIV in a Mobile Health Intervention: Secondary Analysis of a Randomized Controlled Trial

BACKGROUND

Associations between higher levels of patient engagement and better health outcomes have been found in face-to-face interventions; studies on such associations with mobile health (mHealth) interventions have been limited and the results are inconclusive.

OBJECTIVE

The objective of this study is to investigate the relationship between patient engagement in an mHealth intervention and depressive symptoms using repeated measures of both patient engagement and patient outcomes at 4 time points.

METHODS

Data were drawn from a randomized controlled trial (RCT) of an mHealth intervention aimed at reducing depressive symptoms among people living with HIV and elevated depressive symptoms. We examined the association between patient engagement and depressive symptoms in the intervention group (n=150) where participants received an adapted cognitive-behavioral stress management (CBSM) course and physical activity promotion on their WeChat social media app. Depressive symptoms were repeatedly measured using the Patient Health Questionnaire (PHQ-9) at baseline and 1 month, 2 months, and 3 months. Patient engagement was correspondingly measured by the completion rate, frequency of items completed, and time spent on the program at 1 month, 2 months, and 3 months. Latent growth curve models (LGCMs) were used to explore the relationship between patient engagement and depressive symptoms at multiple time points in the intervention.

RESULTS

The mean PHQ-9 scores were 10.2 (SD 4.5), 7.7 (SD 4.8), 6.5 (SD 4.7), and 6.7 (SD 4.1) at baseline, 1 month, 2 months, and 3 months, respectively. The mean completion rates were 50.6% (SD 31.8%), 51.5% (SD 32.2%), and 50.8% (SD 33.7%) at 1, 2, and 3 months, respectively; the average frequencies of items completed were 18.0 (SD 14.6), 32.6 (SD 24.8), and 47.5 (SD 37.2) at 1, 2, and 3 months, respectively, and the mean times spent on the program were 32.7 (SD 66.7), 65.4 (SD 120.8), and 96.4 (SD 180.4) minutes at 1, 2, and 3 months, respectively. LGCMs showed good model fit and indicated that a higher completion rate (β at 3 months=-2.184, P=.048) and a greater frequency of items completed (β at 3 months=-0.018, P=.04) were associated with fewer depressive symptoms at 3 months. Although not significant, similar trends were found in the abovementioned relationships at 1 and 2 months. There was no significant relationship between time spent on the program and depressive symptoms.

CONCLUSIONS

This study revealed a positive association between patient engagement and health outcomes at 3 months of an mHealth intervention using LGCMs and repeated measures data. The results underscore the importance of improving patient engagement in mHealth interventions to improve patient-centered health outcomes.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR-IPR-17012606; https://tinyurl.com/yxb64mef.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR2-10.1186/s12889-018-5693-1.

"I am getting something out of this, so I am going to stick with it": supporting participants' home practice in Mindfulness-Based Programmes

BACKGROUND

The practice of mindfulness at home is a core component of standard eight-week mindfulness-based programmes (MBP). Teachers of mindfulness courses require an understanding of the factors that need to be addressed to support participants in establishing and maintaining a mindfulness practice.

METHOD

Here, we present a review of seven factors that we argue are important for participants' practice of mindfulness. We use the well-established model of Behaviour Change, the COM-B model (Capability, Opportunity, Motivation and Behaviour) to organise and consider these factors. For each factor, we first present a definition and then a discussion in relation to psychological, health and Buddhist literature. We illustrate the importance of each factor with quotes from MBP participant interviews.

RESULTS

We discuss participants' Capability (planning/commitment, physical space), Opportunity (social support, the relationship with the teacher) and Motivation (readiness for self-care, beliefs about practice, self-efficacy, experiencing the rewards of practice), and how these lead to the target Behaviour (mindfulness practice).

CONCLUSIONS

Our understanding, as teachers and researchers, of how best to support and guide participants during MBPs is at an early stage. We draw out practical lessons around each of the seven factors for mindfulness teachers in supporting participants' home practice.

Generating Expectations: What Pediatric Rehabilitation Can Learn From Mental Health Literature

Family-Centered Care (FCC) represents the ideal service delivery approach in pediatric rehabilitation. Nonetheless, implementing FCC as intended in clinical settings continues to be hindered by knowledge gaps. One overlooked gap is our understanding of clients' therapy expectations. This perspective article synthesizes knowledge from the mental health services literature on strategies recommended to service providers for generating transparent and congruent therapy expectations with clients, and applies this knowledge to the pediatric rehabilitation literature, where this topic has been researched significantly less, for the purpose of improving FCC implementation. Dimensions of the Measure of Processes of Care, an assessment tool that measures clients' perceptions of the extent a service is family-centered, inform the organization of therapy expectation-generating strategies: (1) Providing Respectful and Supportive Care (assessing and validating clients' expectations); (2) General and Specific Information (foreshadowing therapy journeys, explaining treatment rationale, and conveying service provider qualifications); (3) Coordinated and Comprehensive Care (socializing clients to roles and reflecting on past socialization); and (4) Enabling and Partnership (applying a negotiation framework and fostering spaces safe to critique). Strategies can help pediatric rehabilitation service providers work with families to reframe unrealistic expectations, establish congruent beliefs supporting effective partnerships, and prevent possible disillusionment with therapy over time.

Explaining variability in therapist adherence and patient depressive symptom improvement: The role of therapist interpersonal skills and patient engagement

Understanding why therapists deviate from a treatment manual is crucial to interpret the mixed findings on the adherence–outcome association. The current study aims to examine whether therapists' interpersonal behaviours and patients' active engagement predict treatment outcome and therapist adherence in cognitive behaviour therapy (CBT) and mindfulness‐based cognitive therapy (MBCT) for depressive symptoms. In addition, the study explores rater's explanations for therapist nonadherence at sessions in which therapist adherence was low. Study participants were 61 patients with diabetes and depressive symptoms who were randomized to either CBT or MBCT. Depressive symptoms were assessed by the Beck Depression Inventory‐II. Therapist adherence, therapist interpersonal skills (i.e., empathy, warmth, and involvement), patients' active engagement, and reasons for nonadherence were assessed by two independent raters (based on digital video recordings). Therapist adherence, therapists' interpersonal skills, and patients' active engagement did not predict posttreatment depressive symptom reduction. Patients' active engagement was positively associated with therapist adherence in CBT and in MBCT. This indicates that adherence may be hampered when patients are not actively engaged in treatment. Observed reasons for nonadherence mostly covered responses to patient's in‐session behaviour. The variety of reasons for therapist nonadherence might explain why therapist adherence was not associated with outcomes of CBT and MBCT.

Understandings of psychological difficulties in people with the Huntington's disease gene and their expectations of psychological therapy

OBJECTIVES

This study sought to investigate how people who had tested positive for the Huntington's disease (HD) gene mutation understood and experienced psychological distress and their expectations of psychological therapy.

DESIGN

A qualitative methodology was adopted involving semi-structured interviews and interpretative phenomenological analysis (IPA).

METHOD

A total of nine participants (five women and four men) who had opted to engage in psychological therapy were recruited and interviewed prior to the start of this particular psychological therapeutic intervention. Interviews were transcribed verbatim and analysed using IPA whereby themes were analysed within and across transcripts and classified into superordinate themes.

RESULTS

Three superordinate themes were developed: Attributing psychological distress to HD: 'you're blaming everything on that now'; Changes in attributions of distress over time: 'in the past you'd just get on with it'; and Approaching therapy with an open mind, commitment, and hope: 'a light at the end of the tunnel'.

CONCLUSION

Understandings of psychological distress in HD included biological and psychological explanations, with both often being accepted simultaneously by the same individual but with biomedical accounts generally dominating. Individual experience seemed to reflect a dynamic process whereby people's understanding and experience of their distress changed over time. Psychological therapy was accepted as a positive alternative to medication, providing people with HD with hope that their psychological well-being could be enhanced.

PRACTITIONER POINTS

People with the Huntington's disease gene mutation have largely biomedical understandings of their psychological distress. This largely biomedical understanding does not, however, preclude them for being interested in the potential gains resulting from psychological therapy. The mechanisms of psychological therapy should be explained in detail before therapy and explored along with current attributions of distress.

Home practice in Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction: A systematic review and meta-analysis of participants' mindfulness practice and its association with outcomes

Mindfulness-Based Cognitive Therapy (MBCT) and Mindfulness-Based Stress Reduction (MBSR) emphasize the importance of mindfulness practice at home as an integral part of the program. However, the extent to which participants complete their assigned practice is not yet clear, nor is it clear whether this practice is associated with positive outcomes.

For this systematic review and meta-analysis, searches were performed using Scopus and PubMed for studies published through to the end of 2015, reporting on formal home practice of mindfulness by MBSR or MBCT participants.

Across 43 studies (N = 1427), the pooled estimate for participants' home practice was 64% of the assigned amount, equating to about 30 minutes per day, six days per week [95% CI 60–69%]. There was substantial heterogeneity associated with this estimate. Across 28 studies (N = 898), there was a small but significant association between participants’ self-reported home practice and intervention outcomes (r = 0·26, 95% CI 0·19,–0·34).

MBSR and MBCT participants report completing substantial formal mindfulness practice at home over the eight-week intervention, albeit less than assigned amounts. There is a small but significant association between the extent of formal practice and positive intervention outcomes for a wide range of participants.

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Standard mindfulness interventions assign significant home practice.

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This meta-analysis estimated participants' typical practice completion.

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Average mindfulness home practice time equated to 30 min per day, 6 days per week.

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The extent of practice positively correlated with intervention outcomes.

Examining Impacts of Mindfulness in Requesting Job Accommodations for Individuals With Disabilities

This study aimed to examine the relationship between mindfulness and the request for job accommodations among individuals with disabilities. One hundred fifty individuals with disabilities who needed a job accommodation completed a survey assessing the cognitive, affective, and mindfulness factors involved with requesting job accommodations. Pearson correlations were calculated between scales and subscales measuring mindfulness, positive affect, self-efficacy, outcome expectations, and intentions to request accommodations. The results showed significant correlations between mindfulness and all other scales. In addition, multiple regression and logistic regression analyses were conducted to examine the impacts of cognitive, affective, and mindfulness factors on an individual’s intention and decision to request or withhold a request for an accommodation. Mindfulness was not found significant in predicting the intention to request accommodations; however, positive affect, self-efficacy, and outcome expectations accounted for 35% of the variance in intention to request. The interaction between mindfulness and intention to request, along with self-efficacy, was found significant in predicting request behavior. Mindfulness and the interaction between mindfulness and intention to request contributed an additional 8% of the variance in requesting behavior. The results of this study indicate the need for more research into the relationship of mindfulness and the decision to request accommodations.

Group and Individual Mindfulness-Based Cognitive Therapy (MBCT) Are Both Effective: a Pilot Randomized Controlled Trial in Depressed People with a Somatic Disease

Depressive symptoms are commonly reported by individuals suffering from a chronic medical condition. Mindfulness-based cognitive therapy (MBCT) has been shown to be an effective psychological intervention for reducing depressive symptoms in a range of populations. MBCT is traditionally given in a group format. The aim of the current pilot RCT was to examine the effects of group-based MBCT and individually based MBCT for reducing depressive symptoms in adults suffering from one or more somatic diseases. In this study, 56 people with a somatic condition and comorbid depressive symptoms (i.e., Beck Depression Inventory-II [BDI-II] ≥14) were randomized to group MBCT (n = 28) or individual MBCT (n = 28). Patients filled out questionnaires at three points in time (i.e., pre-intervention, post-intervention, 3 months follow-up). Primary outcome measure was severity of depressive symptoms. Anxiety and positive well-being as well as mindfulness and self-compassion were also assessed. We found significant improvements in all outcomes in those receiving group or individual MBCT, with no significant differences between the two conditions regarding these improvements. Although preliminary (given the pilot nature and lack of control group), results suggest that both group MBCT and individual MBCT are associated with improvements in psychological well-being and enhanced skills of mindfulness and self-compassion in individuals with a chronic somatic condition and comorbid depressive symptoms. Our findings merit future non-inferiority trials in larger samples to be able to draw more firm conclusions about the effectiveness of both formats of MBCT.