Patient recall of specific cognitive therapy contents predicts adherence and outcome in adults with major depressive disorder

Cognitive Therapy-as-Usual versus Cognitive Therapy plus the Memory Support Intervention for adults with depression: 12-month outcomes and opportunities for improved efficacy in a secondary analysis of a randomized controlled trial

OBJECTIVE

Patient memory for treatment is emerging as an important transdiagnostic mechanism of treatment outcomes. However, patient memory for treatment is limited. The Memory Support Intervention was developed to improve patient memory for treatment and thereby strengthen treatment outcomes. In this secondary analysis, the primary, preregistered aim was to test the 12-month follow-up outcomes of the Memory Support Intervention when used with cognitive therapy (CT + MS) for major depressive disorder, relative to CT-as-usual. The secondary, exploratory aim was to investigate opportunities to improve efficacy of the Memory Support Intervention.

METHOD

Adults (N = 178) with major depressive disorder were randomized to CT-as-usual or CT + MS. Therapist use of memory support and patient memory for treatment, depression symptoms, and overall functioning were measured in blind assessments.

RESULTS

Findings did not support differences between treatment conditions at 12-month follow-up. Therapists used memory support strategies with a narrow subset of treatment contents, and similarly, patients recalled a narrow subset of treatment contents.

CONCLUSIONS

The findings highlight ways to strengthen the efficacy of the Memory Support Intervention, such as applying memory support strategies across a wider variety of treatment contents, which in turn, may boost patient recall and outcomes.

Skill Improvement Through Learning in Therapy (SKILT): A Study Protocol for a Randomized Trial Testing the Direct Effects of Cognitive Behavioral Therapy Skill Acquisition and Role of Learning Capacity in Depression

Background

To improve psychological treatments for major depressive disorder (MDD), a better understanding on how symptoms ameliorate during treatment is essential. In cognitive behavioral therapy (CBT), it is unclear whether procedures focused on the acquisition of CBT skills play a causal role in the improvement of CBT skills. In this randomized trial, we isolate a single CBT Skill Acquisition Procedure (CBTSAP) and test its direct effects on CBT skills and related therapy processes (i.e., change in (idiosyncratic) dysfunctional thinking and reward processing). We hypothesize that the CBTSAP causes improvements in CBT skills and related therapy processes compared to an active control condition. In addition, we hypothesize that individual differences in attentional bias and memory functioning (defined as learning capacity) moderate the effects of CBTSAP on outcomes and that using mental imagery as a cognitive support strategy to strengthen the effects of the CBTSAP will be most beneficial for patients with low learning capacity.

Method

150 patients with MDD will be randomized to one of three conditions: 1. an active control condition, 2. CBTSAP, 2. CBTSAP plus mental imagery, all consisting of three sessions. Primary outcomes will be change in CBT skills, changes in (idiosyncratic) dysfunctional thoughts and behaviors, reward processing. Depressive symptoms are a secondary outcome. Measures of learning capacity will be conducted at baseline and tested as a potential moderator.

Discussion

Knowing whether and for whom the acquisition of CBT skills leads to change in therapy processes and a subsequent reduction of depressive symptoms will inform on how to personalize and optimize psychotherapy outcomes for depression.

Trial registration

The trial is registered at the German Clinical Trial Register (DKTR; registration number: DRKS00024116).

Serial Mediators of Memory Support Strategies Used With Cognitive Therapy for Depression: Improving Outcomes Through Patient Adherence and Treatment Skills

Patient memory for treatment is poor. Memory support strategies can be integrated within evidence-based psychological treatments to improve patient memory for treatment, and thereby enhance patient outcomes. The present study evaluated possible mechanisms of these memory support strategies. Specifically, we tested whether therapist use of memory support strategies indirectly predicts improved patient outcomes via serial improvements in (a) patient adherence throughout treatment and (b) patient utilization and competency of treatment skills. Adults with major depressive disorder (N = 178, mean age = 37.93, 63% female, 17% Hispanic or Latino) were randomized to Cognitive Therapy plus a Memory Support Intervention or Cognitive Therapy-as-usual. Because therapists from both treatment groups used memory support strategies, data from conditions were combined. Blind assessments of depression severity and overall impairment were conducted before treatment, immediately posttreatment (POST), at 6-month follow-up (6FU), and at 12-month follow-up (12FU). Patient adherence to treatment was rated by therapists and averaged across treatment sessions. Patients completed measures of treatment mechanisms-namely, utilization and competency in cognitive therapy skills-at POST, 6FU, and 12FU. Results of serial mediation models indicated that more therapist use of memory support predicted lower depression severity at POST, 6FU, and 12FU indirectly and sequentially through (a) increased patient adherence during treatment and (b) more utilization and competency of Cognitive Therapy skills at POST, 6FU, and 12FU. The same patterns were found for serial mediation models predicting lower overall impairment at POST, 6FU, and 12FU. Together, boosting memory for treatment may represent a promising means to enhance pantreatment mechanisms (i.e., adherence and treatment skills) as well as patient outcomes.

Memory and learning for sleep and circadian treatment in serious mental illness treated in a community mental health setting

OBJECTIVE

Existing research has demonstrated that patient memory and learning of treatment contents are poor and poorer learning is associated with worse treatment outcome. Most prior studies have included individuals from only a single diagnostic group, offer limited data on possible contributors to poor memory and learning, and have included small samples recruited in university settings. This study sought to describe patient recall of treatment contents, describe patient learning of treatment contents, examine contributors to patient recall and learning of treatment contents, and examine the association of patient recall and learning of treatment contents with treatment outcome.

METHODS

Adults with serious mental illness and sleep and circadian dysfunction (N = 99) received the Transdiagnostic Intervention for Sleep and Circadian Dysfunction in a community mental health setting. Measures of recall, learning, age, years of education, symptom severity, and treatment outcome were collected at post-treatment and 6-month follow-up.

RESULTS

Recall and learning were poor, fewer years of education was associated with worse recall and learning, and recall and learning were not associated with treatment outcome.

CONCLUSIONS

The findings offer evidence that poor patient memory for, and learning of, treatment contents extends to community settings and are transdiagnostic concerns.

Measuring Memory for Treatment Using Patient Conceptualizations of Clinical Vignettes: A Pilot Psychometric Study in the Context of Cognitive Therapy for Depression

Background

Patient memory for psychological treatment contents is a promising transdiagnostic mechanism of change, but there is little consensus concerning its measurement. We conducted a pilot psychometric investigation of the Conceptualization Task, a novel measure of patient memory for treatment.

Methods

Data were from a trial comparing cognitive therapy-as-usual to cognitive therapy plus the Memory Support Intervention (MSI) for adults with depression (N = 171). For the Conceptualization Task, patients read clinical vignettes and provided written responses to assess three facets of conceptualization: identifying contributing factors to psychopathology, making intervention recommendations, and providing a rationale for recommendations. Higher scores were given to responses reflecting accurate memory for the theoretical model and change strategies used in treatment.

Results

The Conceptualization Task showed excellent inter-rater reliability and sensitivity to change during treatment, but only fair test–retest reliability and insufficient internal consistency. Findings supported discriminant validity with measures of education, IQ, and general memory functioning, but not convergent validity with existing measures of patient memory for treatment. Criterion validity analyses showed that some aspects of the Conceptualization Task were associated with therapist use of memory support strategies from the MSI and treatment outcome. However, findings were mixed, effect sizes were small, and some results did not remain statistically significant after correcting for multiple comparisons.

Conclusions

Further refinement and testing is needed before the Conceptualization Task may be used to assess the patient memory for treatment contents.

What helps implement smartphone systems designed to improve quality of life for people with substance use disorder: an interim report on a randomized controlled trial with SUD providers in Iowa (Preprint)

Background

Researchers have conducted numerous studies seeking to understand how to improve the implementation of changes in health care organizations, but less focus has been given to applying lessons already learned from implementation science. Finding innovative ways to apply these findings efficiently and consistently will improve current research on implementation strategies and allow organizations utilizing these techniques to make changes more effectively.

Objective

This research aims to compare a practical implementation approach that uses principles from prior implementation studies to more traditional ways of implementing change.

Methods

A total of 43 addiction treatment sites in Iowa were randomly assigned to 2 different implementation strategies in a randomized comparative effectiveness trial studying the implementation of an eHealth substance use disorder treatment technology. One strategy used an adaptation of the Network for the Improvement of Addiction Treatment (NIATx) improvement approach, while the other used a traditional product training model. This paper discusses lessons learned about implementation.

Results

This midterm report indicates that use of the NIATx approach appears to be leading to improved outcomes on several measures, including initial and sustained use of new technology by both counselors and patients. Additionally, this research indicates that seamlessly integrating organizational changes into existing workflows and using coaching to overcome hurdles and assess progress are important to improve implementation projects.

Conclusions

At this interim point in the study, it appears that the use of the NIATx improvement process leads to better outcomes in implementation of changes within health care organizations. Moreover, some strategies used in this improvement process are particularly useful and should be drawn on more heavily in future implementation efforts.

Trial Registration

ClinicalTrials.gov NCT03954184; https://clinicaltrials.gov/ct2/show/NCT03954184

Longitudinal Changes of Cognitive Deficits and Treatment Outcome of Cognitive Behavioral Therapy for Major Depression

ABSTRACT

The current study examined neuropsychological changes over the course of cognitive behavioral therapy (CBT) in outpatients with major depressive disorder and the influence of cognitive deficits as predictors of clinical outcome in depression. A neuropsychological test battery was carried out on depressed outpatients (N = 54) at the beginning and at the end of CBT. Small improvements were found in divided attention, figural memory, and processing speed from pre- to posttreatment. Cognitive deficits in executive functions before treatment predicted the clinical outcome at the end of CBT. The present study reveals that attention and memory deficits are most likely to improve over the course of treatment, whereas executive functions remain stable in the long term. Depressed patients with worse executive functions at the beginning of treatment seem to benefit more from long-term CBT therapy.

Therapist and client attitudes toward client independent review of psychotherapy sessions

OBJECTIVES

Little consideration has been given to the possibility that clients may find therapeutic value in reviewing (i.e., watching, listening, or reading transcripts of) their own therapy sessions independently. This study aimed to evaluate prevalence, interest, and preferences in this practice, beliefs regarding potential benefits and concerns, and overall attitudes.

METHODS

A diverse sample of clients (N = 275) as well as trainee (N = 85) and Master's/doctoral-level (N = 89) therapists of different therapeutic approaches completed forms online. Descriptive statistics, frequency counts, and one-way analysis of variance tests were used to analyze the data.

RESULTS

Relatively few clients and therapists have engaged in this practice, but clients report interest in doing so. All participant groups identified several advantages and concerns. Clients rated overall helpfulness and harm significantly higher than therapists.

CONCLUSION

Client independent review of sessions may be a promising transdiagnostic and transtheoretical treatment intervention. Future research is needed to evaluate its impact on treatment.

Client memory and learning of treatment contents: An experimental study of intervention strategies and relationship to outcome in a brief treatment for procrastination

BACKGROUND AND OBJECTIVES

Client memory and learning is limited for psychological treatment contents. This study investigated different approaches to support client memory and learning of treatment contents and the relationship between memory and learning of treatment contents and outcome.

METHODS

Adult participants (n = 428) were recruited through Amazon's Mechanical Turk and randomized to complete one of three versions of a one-session procrastination intervention. Two versions of the intervention included different amounts of memory support strategy types from the Memory Support Intervention. A control version did not include any types of memory support. Memory and learning of treatment contents were assessed immediately after the intervention and one week later. Procrastination and two mechanisms of procrastination (impulsiveness and self-efficacy) were assessed at baseline and one week after the intervention.

RESULTS

Contrary to the hypotheses, a version of the intervention with multiple types of memory support strategies was not associated with better memory and learning of treatment contents than a version of the intervention with only one type of memory support strategy or the control intervention. Greater memory and learning of treatment contents predicted improvement in mechanisms of procrastination, but not procrastination itself.

LIMITATIONS

The mean level of procrastination in this study was lower than in other treatment studies of procrastination.

CONCLUSIONS

Results partially support the rationale for the Memory Support Intervention that improving client memory and learning of treatment contents can improve outcome. Findings suggest that the Memory Support Intervention may be simplified to include fewer strategies without compromising efficacy.

Patient constructive learning behavior in cognitive therapy: A pathway for improving patient memory for treatment?

Patient memory for treatment is poor and associated with worse outcome. The Memory Support Intervention was designed to improve outcome by enhancing patient memory for treatment. Half of the strategies comprising the Memory Support Intervention (termed constructive memory support strategies) involve therapists inviting patients to construct new ideas, inferences, or connections related to treatment material that go beyond information already presented by therapists. This study investigated the relationship between patient responses to therapist use of constructive memory support strategies and patient recall of treatment contents. Therapist uses of constructive memory support strategies were coded from sessions recorded during a pilot trial of the Memory Support Intervention in the context of cognitive therapy for depression (n = 44 patients). Patients who successfully constructed new ideas, inferences, or connections (termed patient constructive learning behavior) in response to therapist use of constructive memory support strategies showed greater recall of treatment contents. Mediation analyses provided some evidence that patient constructive learning behavior may be a mechanism through which the Memory Support Intervention results in enhanced patient memory. Results highlight patient constructive learning behavior as a potential pathway for improving patient memory for treatment.

Patient Memory for Psychological Treatment Contents: Assessment, Intervention, and Future Directions for a Novel Transdiagnostic Mechanism of Change

Patient memory for treatment contents is defined as memory for the ideas, concepts, skills, and/or insights (termed treatment points) that the therapist thinks are important for the patient to remember and implement as a part of therapy. This article reviews key findings on patient memory for treatment contents, describes the development and evaluation of the Memory Support Intervention (MSI), and outlines future directions for research. Patient memory for treatment contents is poor, and worse memory is associated with worse treatment outcome. The MSI is composed of eight memory support strategies that therapists incorporate frequently alongside treatment points delivered during treatment-as-usual. Training therapists to deliver the MSI may yield better treatment outcomes by enhancing patient memory for treatment contents. Future research is needed to understand how to best measure patient memory for treatment contents, and the mediators, moderators, and dissemination potential of the MSI.

Memory performance predicts response to psychotherapy for depression in bipolar disorder: A pilot randomized controlled trial with exploratory functional magnetic resonance imaging

OBJECTIVE

This pilot randomized controlled trial compared Cognitive Behavior Therapy (CBT) and Supportive Psychotherapy (SP) for the treatment of depression in bipolar I disorder. We also examined whether exploratory verbal memory, executive functioning, and neural correlates of verbal memory during functional magnetic resonance imaging (fMRI) predicted change in depression severity.

METHODS

Thirty-two adults (ages 18-65) with DSM-IV bipolar I disorder meeting current criteria for a major depressive episode were randomized to 18 weeks of CBT or SP. Symptom severity was assessed before, at the mid-point, and after the 18-week intervention. All participants completed a brief pre-treatment neuropsychological testing battery (including the California Verbal Learning Test-2nd Edition, Delis Kaplan Executive Functioning System [DKEFS] Trail-making Test, and DKEFS Sorting Test), and a sub-set of 17 participants provided usable fMRI data while completing a verbal learning paradigm that consisted of encoding word lists.

RESULTS

CBT and SP yielded comparable improvement in depressive symptoms from pre- to post-treatment. Better retention of learned information (CVLT-II long delay free recall vs. Trial 5) and recognition (CVLT-II hits) were associated with greater improvement in depression in both treatments. Increased activation in the left dorsolateral prefrontal cortex and right hippocampus during encoding was also related to depressive symptom improvement.

LIMITATIONS

Sample size precluded tests of clinical factors that may interact with cognitive/neural function to predict treatment outcome.

CONCLUSION

Neuropsychological assessment and fMRI offer additive information regarding who is most likely to benefit from psychotherapy for bipolar depression.

Can integrating the Memory Support Intervention into cognitive therapy improve depression outcome? Study protocol for a randomized controlled trial

Background

The Memory Support Intervention was developed in response to evidence showing that: (1) patient memory for treatment is poor, (2) poor memory for treatment is associated with poorer adherence and poorer outcome, (3) the impact of memory impairment can be minimized by the use of memory support strategies and (4) improved memory for treatment improves outcome. The aim of this study protocol is to conduct a confirmatory efficacy trial to test whether the Memory Support Intervention improves illness course and functional outcomes. As a “platform” for the next step in investigating this approach, we focus on major depressive disorder (MDD) and cognitive therapy (CT).

Method/design

Adults with MDD (n = 178, including 20% for potential attrition) will be randomly allocated to CT + Memory Support or CT-as-usual and will be assessed at baseline, post treatment and at 6 and 12 months’ follow-up (6FU and 12FU). We will compare the effects of CT + Memory Support vs. CT-as-usual to determine if the new intervention improves the course of illness and reduces functional impairment (aim 1). We will determine if patient memory for treatment mediates the relationship between treatment condition and outcome (aim 2). We will evaluate if previously reported poor treatment response subgroups moderate target engagement (aim 3).

Discussion

The Memory Support Intervention has been developed to be “transdiagnostic” (relevant to a broad range of mental disorders) and “pantreatment” (relevant to a broad range of types of treatment). This study protocol describes a “next step” in the treatment development process by testing the Memory Support Intervention for major depressive disorder (MDD) and cognitive therapy (CT). If the results are promising, future directions will test the applicability to other kinds of interventions and disorders and in other settings.

Trial registration

ClinicalTrials.gov, ID: NCT01790919. Registered on 6 October 2016.

Electronic supplementary material

The online version of this article (doi:10.1186/s13063-017-2276-x) contains supplementary material, which is available to authorized users.