Treatment as usual and routine care in research and clinical practice

Comparison of effects of interventions to promote the mental health of parents of children with autism: A systematic review and network meta-analysis

Individuals diagnosed with autism spectrum disorders often face persistent challenges in social interaction and engage in repetitive and stereotyped behaviors. Parenting a child with autism can profoundly affect parents both physically and psychologically, potentially leading to negative impacts on their mental health. This study employs a network meta-analysis methodology to evaluate the comparative effectiveness of mental health interventions specifically designed for parents of autistic children. A total of 69 empirical intervention studies involving 4213 parents of autistic children were included in the analysis. Employing the frequency framework model and utilizing Stata 16.0 software, we quantitatively analyzed the impact of various interventions on anxiety, depression, parenting stress, and parenting self-efficacy. Our findings indicate that mindfulness-based interventions demonstrate the highest efficacy in reducing parenting stress, while cognitive behavioral therapy is effective in alleviating anxiety and depression in parents of children with autism. Psychoeducational interventions have shown significant benefits in mitigating parental anxiety, depression, and parenting stress, and acceptance and commitment (ACT) displays promising outcomes in reducing depression. We also elaborate on the underlying mechanisms that contribute to the effectiveness of these interventions. This network meta-analysis presents valuable insights for the development of targeted interventions to provide support to parents of children with autism.

A bayesian network meta-analysis to explore modifying factors in randomized controlled trials: what works for whom to reduce depression in nursing home residents?

BACKGROUND

Reviews of depression interventions in nursing home residents resulted in positive findings. However, because of the heterogeneity of the studies, it remains unclear what works for whom. Considering moderator effects may contribute to a comprehensive understanding of depression treatment in residents. Therefore, this study aims to review depression interventions, examining moderator effects of (1) residents' factors, and (2) components specific of interventions.

METHODS

A Bayesian network meta-analysis of randomized controlled trials primarily aimed at reducing depressive symptoms among residents was conducted. First, intervention types, e.g., exercise interventions, were compared to care as usual. Second, meta-regression analyses were conducted for moderator effects of residents' factors (i.e., severity of depressive symptoms, physical dependency, and cognitive impairment) and components identified as specific to an intervention (e.g., music, creativity, positivity).

RESULTS

Our search across six databases resulted in 118 eligible studies: 16 on neurobiological interventions, 102 on non-pharmacological interventions. Compared to care as usual, cognitive interventions, such as cognitive behavioral therapy and goal-oriented therapy, showed the strongest effects (MD = -1.00, 95% CrI [-1.40 to -0.66]). Furthermore, the severity of depressive symptoms moderated the effect of interventions (ƅ = -0.63, CrI 95% [-1.04 to -0.22]), while none of fifteen identified intervention-specific components did. In residents with a depression diagnosis, there were larger effect sizes for interventions including daily structure, psychoeducation, healthy food, creativity, positivity, and an activating/encouraging environment, whereas interventions focusing on distraction and relaxation had larger effect sizes in those residents without.

CONCLUSIONS

By examining the moderator effects, we provided an integrative perspective on the observed variations in effects across different target groups, and components of depression interventions. This approach underscores the complex nature of interventions, emphasizing the need for continued transdisciplinary research, and the exploration of potential moderators. Future investigations should carefully assess residents' factors and choose interventions and their components accordingly.

Clinically representative therapy for Nordic adult outpatients with common mental health problems: A systematic review and meta-analysis

There is a knowledge gap regarding clinically representative therapy given in routine settings, that is treatment as usual (TAU), for patients with common mental health problems (CMHP). This review and meta-analysis aimed to investigate what characterizes clinically representative therapy in Nordic routine clinics and meta-analyze the outcome of such treatment. Databases (PubMed, EMBASE, PsychINFO, and SveMed+) were searched for TAU, CMHP, and Nordic countries, together with backward and forward search in Scopus (7 November 2022). Studies were either randomized controlled trials (RCT) or open trials, using prospective study designs, examining heterogeneous outpatient groups in routine treatment. Within- and between-group effect sizes (ES), using random effects model, and moderator analyses were calculated. Eleven studies (n = 1,413), demonstrated a small to moderate within-group ES with high heterogeneity (g = 0.49, I2  = 90%). ESs in RCTs were significantly smaller than in open trials. TAU had a marginally smaller ES (g = -0.21; adjusted for publication bias g = -0.06) compared to a broad set of clinical interventions. Clinically representative therapy in the Nordic countries demonstrated a wide variety of characteristics and also a marginally lower ES compared to other interventions. The ESs were smaller than other meta-analyses examining evidence-based treatments in routine treatment.

The therapeutic alliance in couple therapy: Patterns by treatment and sex in a randomized controlled trial of emotionally focused therapy and treatment as usual

The formation and development of the therapeutic alliance in couple therapy is a complex process and a key contributor to positive treatment outcomes. This study explored differences in trajectories of therapeutic alliance by sex and treatment condition among 24 couples randomized to receive Emotionally Focused Therapy or treatment as usual. The results identified a curvilinear growth pattern for alliance across both treatment groups. Female partners reported higher alliance than male partners after the first session across treatment groups, and female partners receiving Emotionally Focused Therapy reported higher initial alliance than female partners receiving treatment as usual. The rates of change for alliance did not differ by sex or treatment condition. The implications of the change pattern and differences in alliance formation by sex and treatment are discussed.

Cognitive behavioral therapies for depression and anxiety in people with chronic disease: A systematic review and meta-analysis

OBJECTIVE

Anxiety and depression in chronic disease are common and burdensome co-morbidities. There has been growing interest in cognitive and behavioral therapies (CBTs) for anxiety and depression in chronic disease, however their efficacy has not been well-established. This study examined the efficacy of CBTs for depression and/or anxiety symptoms within chronic disease and explored the moderating role of clinical and methodological characteristics.

METHODS

Following prospective registration, electronic databases were searched up to 2023 for randomized controlled trials (RCTs) examining CBTs for depression and/or anxiety in any adult chronic disease population.

RESULTS

We included 56 RCTs. The overall effect of CBTs was g = 0.61 (95% CI, 0.49, 0.72) for depression and g = 0.56 (95% CI, 0.42, 0.70) for anxiety. A range of methodological features significantly moderated the effect sizes obtained, including type of control group and the outcome measure used. Risk of Bias ratings indicated some concerns regarding RCT conduct and reporting.

CONCLUSIONS

CBTs lead to moderate improvements in both depression and anxiety symptoms among people with chronic disease. However, the efficacy of CBT should be interpreted considering certain study and sample characteristics. It is recommended that future studies make improvements to study methodology and reporting.

Examination of the knowledge gap of return-to-work outcomes in routine outpatient treatment for common mental disorders: a systematic review

Objective

Little is known about the effects of routine mental health care on return-to-work (RTW) outcomes. This systematic review aimed to summarize and evaluate the effects of clinical representative psychotherapy on RTW among patients with a common mental disorder (CMD), treated within public mental health care.

Method

A systematic search was conducted using PubMed, PsycINFO, Embase, and SveMED+. Primary outcomes were RTW, sick leave status, or self-reported work functioning. Studies limited to specific treatments and/or specific patient groups were excluded.

Results

Out of 1,422 records, only one article met the preregistered inclusion criteria. After broadening of criteria, a total of nine studies were included. Six were randomized controlled trials (RCT), two were register-based studies, and one was a quasi-experimental study. Descriptions of treatment duration and intensity of usual care were rarely specified but ranged from a few sessions to 3 years of psychotherapy. In the RCTs, two studies favored the intervention, one favored routine care, and three found no difference between conditions. Choice of outcomes differed greatly and included RTW rates (full or partial), number of days until RTW, change in sick leave status, and net days/months of work absence. Time points for outcome assessment also varied greatly from 3 months to 5 years after treatment.

Conclusion

There is inconclusive evidence to establish to what extent routine mental healthcare is associated with improved RTW outcomes for patients with CMD. There is a need for more and better clinical trials and naturalistic studies detailing the content of routine treatment and its effect on RTW.

Systematic review registration

This study was pre-registered at PROSPERO (CRD42022304967), https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022304967.

Treating children's aggressive behavior problems using cognitive behavior therapy with virtual reality: A multicenter randomized controlled trial

This multicenter randomized controlled trial investigated whether interactive virtual reality enhanced effectiveness of Cognitive Behavioral Therapy (CBT) to reduce children's aggressive behavior problems. Boys with aggressive behavior problems (N = 115; Mage  = 10.58, SD = 1.48; 95.7% born in Netherlands) were randomized into three groups: CBT with virtual reality, CBT with roleplays, or care-as-usual. Bayesian analyses showed that CBT with virtual reality more likely reduced aggressive behavior compared to care-as-usual for six of seven outcomes (ds 0.19-0.95), and compared to CBT with roleplays for four outcomes (ds 0.14-0.68). Moreover, compared to roleplays, virtual reality more likely enhanced children's emotional engagement, practice immersion, and treatment appreciation. Thus, virtual reality may be a promising tool to enhance CBT effectiveness for children with aggressive behavior problems.

Drawing causal inferences from randomized controlled trials in psychotherapy research

OBJECTIVE

Randomized control trials (RCTs) have played a critical role in psychotherapy research. This article discusses RCTs in the context of the criteria for drawing causal inferences in psychotherapy and intervention research more generally. The article also highlights underused variations of RCTs and how they not only establish causal relations but also address critical questions that can improve our intervention portfolio and patient care.

CONCLUSION

Random assignment is discussed in terms of what it can and cannot do in relation to drawing conclusions about the effects of interventions. Finally, RCTs are examined in the context of multiple questions that can guide therapy research, improve patient care, and develop treatments that reach people in need of psychological services.

Mitigating Multiple Sources of Bias in a Quasi-Experimental Integrative Data Analysis: Does Treating Childhood Anxiety Prevent Substance Use Disorders in Late Adolescence/Young Adulthood?

Psychiatric epidemiologists, developmental psychopathologists, prevention scientists, and treatment researchers have long speculated that treating child anxiety disorders could prevent alcohol and other drug use disorders in young adulthood. A primary challenge in examining long-term effects of anxiety disorder treatment from randomized controlled trials is that all participants receive an immediate or delayed study-related treatment prior to long-term follow-up assessment. Thus, if a long-term follow-up is conducted, a comparison condition no longer exists within the trial. Quasi-experimental designs (QEDs) pairing such clinical samples with comparable untreated epidemiological samples offer a method of addressing this challenge. Selection bias, often a concern in QEDs, can be mitigated by propensity score weighting. A second challenge may arise because the clinical and epidemiological studies may not have used identical measures, necessitating Integrative Data Analysis (IDA) for measure harmonization and scale score estimation. The present study uses a combination of propensity score weighting, zero-inflated mixture moderated nonlinear factor analysis (ZIM-MNLFA), and potential outcomes mediation in a child anxiety treatment QED/IDA (n = 396). Under propensity score-weighted potential outcomes mediation, CBT led to reductions in substance use disorder severity, the effects of which were mediated by reductions in anxiety severity in young adulthood. Sensitivity analyses highlighted the importance of attending to multiple types of bias. This study illustrates how hybrid QED/IDAs can be used in secondary prevention contexts for improved measurement and causal inference, particularly when control participants in clinical trials receive study-related treatment prior to long-term assessment.

Toward a synthesis of cognitive behaviour therapy via component analysis of self-regulation

The cognitive behavioural therapies (CBTs) are the choice psychotherapies for many clinicians treating a wide range of adult psychological disorders including various anxieties, mood, substance use, eating, schizophrenia and personality-related. Empirical research in the CBTs is ever increasing, and the accumulating evidence supporting efficacious treatments is substantial and well documented. However, with prolific research comes a seemingly accelerating and worrying trend of purportedly different therapies, and numerous hybrids and combinations of therapies and techniques. For many clinicians this is increasingly confusing and not helpful in clinical practice. This article is a critique of current trends and directions in clinical research, which show signs of limited effectiveness, fragmentation, and obfuscation. An alternative strategy is proposed-examining transdiagnostic therapeutic effects, which appear related to treating pervasive dysregulated emotions, with component analyses of four principal self-regulation components (viz., self-monitoring; functional analysis; identifying values, goals and treatment-plans; and feedback). Such a strategy is likely to lead to a more coherently synthesized and effective CBT.

Good behavior game - study protocol for a randomized controlled trial of a preventive behavior management program in a Swedish school context

Background

Early conduct problems and school failure are prominent risk factors for several adverse outcomes in later life. With the potential of reaching many children at early stages of their life, school-based interventions constitute a valuable approach to universal prevention. Good behavior game (GBG) is a promising school-based behavior management program, having shown immediate reductions in conduct problems along with several long-term positive effects. Adapting interventions to new contexts may however affect their effectiveness. The current study aims to evaluate the effectiveness of a Swedish adaption of GBG under pragmatic conditions. The intervention is hypothesized to reduce conduct problems in the classroom (primary outcome). Secondary analyses will investigate changes in conduct problems in common school areas, classroom climate, teacher collective efficacy, on-task behavior, as well as investigating behavioral management practices, implementation, and barriers to implementation.

Methods

This is a cluster-randomized trial with two parallel groups. Schools will be randomized (1,1, stratified by their areas sociodemographic index score) to be provided training in GBG or perform business-as-usual. The intervention and data collection lasts for a school year. Data will be collected at three time points: at baseline in the beginning of the school year (prior to training in GBG), after three months, and after nine months (at the end of the school year; primary endpoint). Data consists of teacher-rated measures of conduct problems, classroom climate, teacher collective efficacy, behavior management practices, and implementation factors, along with demographic factors. In addition, data will be collected by independent and blinded observers using corresponding measures in a subset of randomly chosen classrooms. Procedural fidelity will be rated and collected by GBG-trainers during nine observations throughout the school year. Statistical analysis will include frequentist intention-to-treat analysis, and comparisons of estimates with a corresponding Bayesian model using weakly informative priors. The study has currently completed data collection.

Discussion

This study will provide knowledge in universal prevention and school-based interventions with high reach, as well as specific knowledge concerning the effectiveness of an adapted version of GBG under real-world conditions, along with factors affecting its implementation and effects.

Clinical trial registration

ClinicalTrials.gov, identifier NCT05794893.

Mentalization-oriented psychodynamic group therapy for patients with personality disorders: a naturalistic prospective cohort study

OBJECTIVES

Patients with personality disorders (PDs) are often treated with non-manualized psychodynamic group therapy (PDT) lasting for several years. Non-manualized PDT often combines a variety of therapeutic approaches from different PDT traditions, including mentalization-based therapy. Currently, little is known about the effect of this long-term, costly treatment. This study investigated the extent to which patients with different PDs benefit from mentalization-oriented PDT as it is implemented in clinical practice in terms of symptom severity, interpersonal problems, and general functioning.

METHODS

The design was a naturalistic, prospective cohort study. Seventy-five consecutive PD patients were assessed before treatment with the Symptom Checklist-90 Revised (SCL-90-R) as the primary outcome measure and the Inventory of Interpersonal Problems (IIP) and Global Assessment of Functioning (GAF) as secondary outcome measures. The sample was repeatedly assessed every 12 months for up to 36 months. Paired t-tests were applied to examine the effectiveness of the intervention.

RESULTS

Among completers (n = 42; 56%), improvement was observed on the SCL-90-R: Global Severity Index (mean change = -0.45 [95% CI = -0.72, -0.19]; Cohen's d = -0.55), Positive Symptom Distress Index (-0.40 [-0.63, -0.17]; -0.56); Positive Symptoms Total (-10.70 [-17.31, -4.09]; -0.52). Secondary outcomes also improved: IIP-total (mean change = -0.50 [95%CI = -0.74, -0.25]; Cohen's d = -0.66); GAF-Functioning (8.79 [6.32, 11.27]; 1.15); and GAF-Symptoms (10.67 [8.09, 13.25]; 1.34).

CONCLUSIONS

Completers improved on symptom severity, interpersonal problems, and general functioning, with within-group effect sizes ranging from medium to large. Approximately half the sample dropped out, suggesting that mentalization-oriented PDT spanning several years may be unrealistic for many patients with PD. Significant outcomesThere are no clear guidelines for psychological interventions targeting personality disorders (PDs), and currently eclectic and non-manualized psychodynamic approaches lasting for up to 3 years are prevailing in some clinical practices.Although this treatment approach may have an effect on compliant patients, the high drop-out rate indicates that it may not be suitable for a large proportion of PD patients since it requires long-term commitment. Furthermore, it is difficult to identify the content of the non-manualized psychodynamic therapy and what helps the patients.More specific clinical guidelines emphasizing the application of evidence-based treatments or at least manualized treatments are warranted for the treatment of emotionally unstable PDs and other PDs. LimitationsThe naturalistic study design, without any control group, limits conclusions about mechanisms of action of the intervention.Since the intervention was not manualized, it is unknown exactly which treatment was actually administered, which reduces external validity.The outcomes are based on completer data of a relatively small sample size with high drop-out rate.

The Efficacy of Targeted Mindfulness-Based Interventions for Improving Mental Health and Cognition Among Youth and Adults with ACE Histories: A Systematic Mixed Studies Review

Mindfulness-based interventions (MBIs) are associated with increased psychological wellbeing. The literature suggests that individuals exposed to adverse childhood experiences (ACEs) may benefit greatly from MBIs. However, research has tended to focus on universal MBIs for this population with less attention on the effectiveness of targeted approaches. Moreover, there is growing concern regarding the methodological rigor of MBI research. This systematic mixed studies review (SMRS) reports the effectiveness of MBIs for improving mental health and cognition among individuals with ACE histories. Additionally, the review reports the quality and rigor of the included research. Systematic searches of PsycInfo, EMBASE, MEDLINE, ProQuest Dissertations and Theses, ProQuest Social Science database and the Child Development and Adolescent Studies database were conducted. Results were screened and data were extracted then synthesized using a data-based convergent synthesis design. Thirteen studies were included in the final review. Six prominent themes emerged. Themes indicated that MBIs were effective for improving mental health and cognition for individuals with ACEs. For example, improvements in mood and anxieties, as well as a better ability to manage emotions. Shortcomings in the quality of MBI research included lack of reporting of methodological details (e.g., randomization procedures) and not systematically reporting adverse event evaluations. Recommendations are made for future research to strengthen the evidence base for MBIs for individuals with ACEs.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-022-00454-5.

Elements in Mental Health Interventions Associated with Effects on Emotion Regulation in Adolescents: A Meta-Analysis

PURPOSE

Adolescence is a sensitive period for developing mental health problems. Interventions targeting emotion regulation have shown promising transdiagnostic effects for this group, but optimization efforts are called for. In the current study, we used an element-based approach to identify potentially active ingredients in interventions measuring emotion regulation, to guide further optimization.

METHODS

We coded practice elements in 30 studies based on a systematic review of mental health interventions measuring emotion regulation in adolescents (N = 2,389 participants, mean age 13-17 years). Using a three-level modeling approach, we then investigated the difference in effect on emotion regulation between studies of interventions with and without these practice elements.

RESULTS

We identified 75 practice elements and 15 element categories used in the included interventions. Results showed significantly stronger effects on emotion regulation when interventions included the practice elements Setting goals for treatment (difference in d = 0.40, 95% CI [0.09, 0.70], p = .012) and Psychoeducation about acceptance (difference in d = 0.58, 95% CI [0.09, 1.07], p = .021). Furthermore, a total of 11 elements and four overall categories were identified as potentially active ingredients, based on an effect size difference of > 0.20 between interventions with and without the elements.

CONCLUSION

The results can direct experimental research into the selection of practices that are most likely key to mechanisms of change in interventions addressing emotion regulation for adolescents. The challenge of measuring emotion regulation is discussed.

Expanding the scope, reach, and impact of evidence-based psychological treatments

The development and evaluation of evidence-based treatments (EBTs) for mental disorders represent an enormous advance with continued progress designed to understand the techniques and increase their use in clinical practice. This article suggests ways of expanding research along several fronts including the extension of the types of randomized controlled trials that are conducted, the use of more diverse samples to encompass different cultures and countries, the expansion of assessments to better reflect client functioning in everyday life, consideration of the impact of treatments for mental disorders on physical health, the careful evaluation of exceptional responders, the use of mixed-methods research, and the development of versions of EBTs that can be scaled. EBTs have been studied in well-controlled settings and extended to clinical settings, albeit less often. The least attention has been accorded their evaluation on a large scale to reach a greater portion of people in need of services but who do not receive any treatment.

Using Artificial Intelligence to Enhance Ongoing Psychological Interventions for Emotional Problems in Real- or Close to Real-Time: A Systematic Review

Emotional disorders are the most common mental disorders globally. Psychological treatments have been found to be useful for a significant number of cases, but up to 40% of patients do not respond to psychotherapy as expected. Artificial intelligence (AI) methods might enhance psychotherapy by providing therapists and patients with real- or close to real-time recommendations according to the patient's response to treatment. The goal of this investigation is to systematically review the evidence on the use of AI-based methods to enhance outcomes in psychological interventions in real-time or close to real-time. The search included studies indexed in the electronic databases Scopus, Pubmed, Web of Science, and Cochrane Library. The terms used for the electronic search included variations of the words "psychotherapy", "artificial intelligence", and "emotional disorders". From the 85 full texts assessed, only 10 studies met our eligibility criteria. In these, the most frequently used AI technique was conversational AI agents, which are chatbots based on software that can be accessed online with a computer or a smartphone. Overall, the reviewed investigations indicated significant positive consequences of using AI to enhance psychotherapy and reduce clinical symptomatology. Additionally, most studies reported high satisfaction, engagement, and retention rates when implementing AI to enhance psychotherapy in real- or close to real-time. Despite the potential of AI to make interventions more flexible and tailored to patients' needs, more methodologically robust studies are needed.

Improving treatment outcomes for adolescents with borderline personality disorder through a socioecological approach

BACKGROUND

There is a dearth of studies evaluating treatment efficacy for adolescents diagnosed with borderline personality disorder. The few available randomized controlled trials that have been conducted show modest results and treatments appear to have equivalent effects. The current paper draws on (a) the lessons learnt from the last 50 years of psychotherapy research in general and (b) recent advances in mentalization-based understanding of why treatment works, which together point to the importance of following a socioecological approach in the treatment of personality problems in adolescence - a developmental period that insists on a treatment approach that goes beyond the therapist-client dyad.

CASE PRESENTATION

Here, we describe such an approach, and offer a clinical case example with a young 16-year old girl diagnosed with borderline personality disorder, to illustrate what a shift toward a more socioecological approach would entail.

CONCLUSIONS

The clinical impact of the socioecological approach and the potential benefits as illustrated in the current case illustration, offers a framework that justifies and allows for the expansion of service delivery for youth with borderline personality disorder beyond dyadic therapist-client work.

Intensity of Treatment as Usual and Its Impact on the Effects of Face-to-Face and Internet-Based Psychotherapy for Depression: A Preregistered Meta-Analysis of Randomized Controlled Trials

INTRODUCTION

Treatment as usual (TAU) is the most frequently used control group in randomized trials of psychotherapy for depression. Concerns have been raised that the heterogeneity of treatments in TAU leads to biased estimates of psychotherapy efficacy and to an unclear difference between TAU and control groups like waiting list (WL).

OBJECTIVE

We investigated the impact of control group intensity (i.e., amount and degree to which elements of common depression treatments are provided) on the effects of face-to-face and internet-based psychotherapy for depression.

METHODS

We conducted a preregistered meta-analysis (www.osf.io/4mzyd). We included trials comparing psychotherapy with TAU or WL in patients with symptoms of unipolar depression. Six indicators were used to assess control group intensity.

PRIMARY OUTCOME

Standardized mean difference (SMD) of psychotherapy and control in depressive symptoms at treatment termination.

RESULTS

We included 89 trials randomizing 14,474 patients to 113 psychotherapy conditions and 89 control groups (TAU in 42 trials, WL in 47 trials). Control group intensity predicted trial results in preregistered (one-sided ps < 0.042) and exploratory analyses. Psychotherapy effects were significantly smaller (one-sided p = 0.002) in trials with higher intensity TAU (SMD = 0.324, CI 0.209 to 0.439) than in trials with lower intensity TAU (SMD = 0.628, CI 0.455 to 0.801). Psychotherapy effects against lower intensity TAU did not differ from effects against WL (two-sided p = 0.663).

CONCLUSIONS

Our results suggest that variation in TAU intensity impacts the outcome of trials. More scrutiny in the design of control groups for clinical trials is recommended.

Control interventions in randomised trials among people with mental health disorders

BACKGROUND

Control interventions in randomised trials provide a frame of reference for the experimental interventions and enable estimations of causality. In the case of randomised trials assessing patients with mental health disorders, many different control interventions are used, and the choice of control intervention may have considerable impact on the estimated effects of the treatments being evaluated.

OBJECTIVES

To assess the benefits and harms of typical control interventions in randomised trials with patients with mental health disorders. The difference in effects between control interventions translates directly to the impact a control group has on the estimated effect of an experimental intervention. We aimed primarily to assess the difference in effects between (i) wait-list versus no-treatment, (ii) usual care versus wait-list or no-treatment, and (iii) placebo interventions (all placebo interventions combined or psychological, pharmacological, and physical placebos individually) versus wait-list or no-treatment. Wait-list patients are offered the experimental intervention by the researchers after the trial has been finalised if it offers more benefits than harms, while no-treatment participants are not offered the experimental intervention by the researchers.

SEARCH METHODS

In March 2018, we searched MEDLINE, PsycInfo, Embase, CENTRAL, and seven other databases and six trials registers.

SELECTION CRITERIA

We included randomised trials assessing patients with a mental health disorder that compared wait-list, usual care, or placebo interventions with wait-list or no-treatment .

DATA COLLECTION AND ANALYSIS

Titles, abstracts, and full texts were reviewed for eligibility. Review authors independently extracted data and assessed risk of bias using Cochrane's risk of bias tool. GRADE was used to assess the quality of the evidence. We contacted researchers working in the field to ask for data from additional published and unpublished trials. A pre-planned decision hierarchy was used to select one benefit and one harm outcome from each trial. For the assessment of benefits, we summarised continuous data as standardised mean differences (SMDs) and dichotomous data as risk ratios (RRs). We used risk differences (RDs) for the assessment of adverse events. We used random-effects models for all statistical analyses. We used subgroup analysis to explore potential causes for heterogeneity (e.g. type of placebo) and sensitivity analyses to explore the robustness of the primary analyses (e.g. fixed-effect model).

MAIN RESULTS

We included 96 randomised trials (4200 participants), ranging from 8 to 393 participants in each trial. 83 trials (3614 participants) provided usable data. The trials included 15 different mental health disorders, the most common being anxiety (25 trials), depression (16 trials), and sleep-wake disorders (11 trials). All 96 trials were assessed as high risk of bias partly because of the inability to blind participants and personnel in trials with two control interventions. The quality of evidence was rated low to very low, mostly due to risk of bias, imprecision in estimates, and heterogeneity. Only one trial compared wait-list versus no-treatment directly but the authors were not able to provide us with any usable data on the comparison. Five trials compared usual care versus wait-list or no-treatment and found a SMD -0.33 (95% CI -0.83 to 0.16, I² = 86%, 523 participants) on benefits. The difference between all placebo interventions combined versus wait-list or no-treatment was SMD -0.37 (95% CI -0.49 to -0.25, I² = 41%, 65 trials, 2446 participants) on benefits. There was evidence of some asymmetry in the funnel plot (Egger's test P value of 0.087). Almost all the trials were small. Subgroup analysis found a moderate effect in favour of psychological placebos SMD -0.49 (95% CI -0.64 to -0.30; I² = 53%, 39 trials, 1656 participants). The effect of pharmacological placebos versus wait-list or no-treatment on benefits was SMD -0.14 (95% CI -0.39 to 0.11, 9 trials, 279 participants) and the effect of physical placebos was SMD -0.21 (95% CI -0.35 to -0.08, I² = 0%, 17 trials, 896 participants). We found large variations in effect sizes in the psychological and pharmacological placebo comparisons. For specific mental health disorders, we found significant differences in favour of all placebos for sleep-wake disorders, major depressive disorder, and anxiety disorders, but the analyses were imprecise due to sparse data. We found no significant differences in harms for any of the comparisons but the analyses suffered from sparse data. When using a fixed-effect model in a sensitivity analysis on the comparison for usual care versus wait-list and no-treatment, the results were significant with an SMD of -0.46 (95 % CI -0.64 to -0.28). We reported an alternative risk of bias model where we excluded the blinding domains seeing how issues with blinding may be seen as part of the review investigation itself. However, this did not markedly change the overall risk of bias profile as most of the trials still included one or more unclear bias domains.

AUTHORS' CONCLUSIONS

We found marked variations in effects between placebo versus no-treatment and wait-list and between subtypes of placebo with the same comparisons. Almost all the trials were small with considerable methodological and clinical variability in factors such as mental health population, contents of the included control interventions, and outcome domains. All trials were assessed as high risk of bias and the evidence quality was low to very low. When researchers decide to use placebos or usual care control interventions in trials with people with mental health disorders it will often lead to lower estimated effects of the experimental intervention than when using wait-list or no-treatment controls. The choice of a control intervention therefore has considerable impact on how effective a mental health treatment appears to be. Methodological guideline development is needed to reach a consensus on future standards for the design and reporting of control interventions in mental health intervention research.

Nurturing compassion in schools: A randomized controlled trial of the effectiveness of a Compassionate Mind Training program for teachers

OBJECTIVES

Schools are experiencing an unprecedented mental health crisis, with teachers reporting high levels of stress and burnout, which has adverse consequences to their mental and physical health. Addressing mental and physical health problems and promoting wellbeing in educational settings is thus a global priority. This study investigated the feasibility and effectiveness of an 8-week Compassionate Mind Training program for Teachers (CMT-T) on indicators of psychological and physiological wellbeing.

METHODS

A pragmatic randomized controlled study with a stepped-wedge design was conducted in a sample of 155 public school teachers, who were randomized to CMT-T (n = 80) or a waitlist control group (WLC; n = 75). Participants completed self-report measures of psychological distress, burnout, overall and professional wellbeing, compassion and self-criticism at baseline, post-intervention, and 3-months follow-up. In a sub-sample (CMT-T, n = 51; WLC n = 36) resting heart-rate variability (HRV) was measured at baseline and post-intervention.

RESULTS

CMT-T was feasible and effective. Compared to the WLC, the CMT-T group showed improvements in self-compassion, compassion to others, positive affect, and HRV as well as reductions in fears of compassion, anxiety and depression. WLC participants who received CMT-T revealed additional improvements in compassion for others and from others, and satisfaction with professional life, along with decreases in burnout and stress. Teachers scoring higher in self-criticism at baseline revealed greater improvements post CMT-T. At 3-month follow-up improvements were retained.

CONCLUSIONS

CMT-T shows promise as a compassion-focused intervention for enhancing compassion, wellbeing and reducing psychophysiological distress in teachers, contributing to nurturing compassionate, prosocial and resilient educational environments. Given its favourable and sustainable effects on wellbeing and psychophysiological distress, and low cost to deliver, broader implementation and dissemination of CMT-T is encouraged.

Clinical Efficacy and Psychological Mechanisms of an App-Based Digital Therapeutic for Generalized Anxiety Disorder: Randomized Controlled Trial

Background

Current treatments for generalized anxiety disorder (GAD) often yield suboptimal outcomes, partly because of insufficient targeting of underlying psychological mechanisms (eg, avoidance reinforcement learning). Mindfulness training (MT) has shown efficacy for anxiety; yet, widespread adoption has been limited, partly because of the difficulty in scaling in-person–based delivery. Digital therapeutics are emerging as potentially viable treatments; however, very few have been empirically validated.

Objective

The aim of this study is to test the efficacy and mechanism of an app-delivered MT that was designed to target a potential mechanism of anxiety (reinforcement learning), based on which previous studies have shown concern regarding feedback and the perpetuation of anxiety through negative reinforcement.

Methods

Individuals with GAD were recruited using social media advertisements and randomized during an in-person visit to receive treatment as usual (n=33) or treatment as usual+app−delivered MT (Unwinding Anxiety; n=32). The latter was composed of 30 modules to be completed over a 2-month period. Associated changes in outcomes were assessed using self-report questionnaires 1 and 2 months after treatment initiation.

Results

We randomized 65 participants in this study, and a modified intent-to-treat approach was used for analysis. The median number of modules completed by the MT group was 25.5 (IQR 17) out of 30; 46% (13/28) of the participants completed the program. In addition, the MT group demonstrated a significant reduction in anxiety (GAD-7) compared with the control group at 2 months (67% vs 14%; median change in GAD-7: –8.5 [IQR 6.5] vs –1.0 [IQR 5.0]; P<.001; 95% CI 6-10). Increases in mindfulness at 1 month (nonreactivity subscale) mediated decreases in worry at 2 months (Penn State Worry Questionnaire; P=.02) and decreases in worry at 1 month mediated reductions in anxiety at 2 months (P=.03).

Conclusions

To our knowledge, this is the first report on the efficacy and mechanism of an app-delivered MT for GAD. These findings demonstrate the clinical efficacy of MT as a digital therapeutic for individuals with anxiety (number needed to treat=1.6). These results also link recent advances in our mechanistic understanding of anxiety with treatment development, showing that app-delivered MT targets key reinforcement learning pathways, resulting in tangible, clinically meaningful reductions in worry and anxiety. Evidence-based, mechanistically targeted digital therapeutics have the potential to improve health at a population level at a low cost.

Trial Registration

ClinicalTrials.gov NCT03683472; https://clinicaltrials.gov/ct2/show/NCT03683472

Training coping skills and coping with stress self-efficacy for successful daily functioning and improved clinical status in patients with psychosis: A randomized controlled pilot study

Due to the symptom diversity and pervasive function impairments (e.g. in perception, cognition, language, affect, behavior, daily and social functioning and sense of self), recurrent relapses, elevated disability, high rates of (co)morbidity, heightened premature mortality and high burden of care of psychotic disorders, psychosocial interventions are part of patients' standard care. There is growing evidence on the relevance of self-efficacy for well-being and functioning among these patients, but specific coping with stress self-efficacy has rarely been investigated. This study explored the outcomes of an intervention for the improvement of coping resources based on training in coping skills and coping with stress self-efficacy. Fourteen adult volunteers with schizophrenia (n = 12) or schizoaffective disorder (n = 2) were matched in clinical and sociodemographic characteristics and randomly assigned to the study groups. The intervention group received the training-with 15 twice per week sessions (8 weeks)-along with their pharmacological therapy; the control group received their prescribed drug therapy. Participants completed self-reports on coping with stress self-efficacy, perceived successful daily functioning based on coping skills and clinical status (Expanded Brief Psychiatric Rating Scale). Trained patients showed a significant increase in coping with stress self-efficacy and reported greater successful functioning status, and significant improvements in their clinical status were also observed. All these enhancements remained at 3-month and 6-month follow-ups. The intervention condition interacted with coping with stress self-efficacy and perceived coping functioning in explaining improvements in clinical status: in the treatment group, greater coping with stress self-efficacy translated into enhanced daily functioning, and this improvement predicted better clinical status. These findings stress the relevance of promoting coping resources in psychotic disorders and provide preliminary evidence for the potential benefits of coping with stress self-efficacy.

Efficacy of acupuncture in refractory irritable bowel syndrome: study protocol for a randomised controlled trial

INTRODUCTION

Irritable bowel syndrome (IBS) is a common chronic functional gastrointestinal disorder that presents with abdominal pain/discomfort and altered bowel patterns. IBS has multiple potential causes for which conventional medicines have had limited success, resulting in a significant number of patients who do not sensitively respond to pharmacotherapy for a period of 12 months and who develop a continuing symptom profile (described as refractory IBS) and seek help through (non)pharmacological treatments. The aim of this study is to investigate the efficacy and safety of acupuncture therapy for refractory IBS on the basis of conventional treatments.

METHODS AND ANALYSIS

A total of 170 eligible patients who meet the Rome IV criteria for refractory IBS will be randomly allocated to receive acupuncture or sham acupuncture. Each patient will receive 12 sessions of acupuncture over 4 weeks and a 4-week follow-up. The primary outcome will be the IBS Symptom Severity Score. Secondary outcomes will include the proportion of participants experiencing adequate relief of global IBS symptoms, the weekly frequency of defecation, the stool properties assessed by the Bristol Grading Scale, the Work and Social Adjustment Scale, the IBS-Quality of Life score, and the Self-Rating Depression Scale and Self-Rating Anxiety Scale anxiety and depression scores. Outcome measures will be collected at baseline, 2 and 4 weeks of the intervention, and 6 and 8 weeks after the intervention. Categorical variables will be compared with Fisher's exact test or the Wilcoxon rank-sum test, and continuous variables will be compared using Student's t-test or the Wilcoxon rank-sum test.

ETHICS AND DISSEMINATION

The entire project has been approved by the ethics committees of Beijing University of Chinese Medicine (2020BZYLL0507) and Sichuan Province Regional Institution for Conducting Research on Traditional Chinese Medicine (2020KL-025). The outcomes of the trial will be disseminated through peer-reviewed publications.

TRIAL REGISTRATION NUMBER

NCT04276961.

Mindfulness-based cognitive therapy in functional dyspepsia: A pilot randomized trial

BACKGROUND AND AIM

Patients with functional dyspepsia (FD) often have concomitant anxiety and depression. Mindfulness-based cognitive therapy (MBCT) combines the principles of cognitive behavioral therapy and mindfulness. It is a group-based therapy and has been shown to be efficacious in functional gastrointestinal disorders. There are no randomized controlled trials (RCTs) evaluating MBCT in FD. We aimed to evaluate feasibility and efficacy of MBCT in FD management.

METHODS

We performed a mixed-method single-center pilot randomized trial of 28 patients fulfilling ROME-III criteria for FD. Fifteen patients were randomized to an 8-week MBCT program while 13 underwent treatment-as-usual (TAU). Patients completed questionnaires at baseline and at week 8. Two focus-groups were conducted. Feasibility of recruitment, acceptability of randomization, procedures and intervention, handout compliance and feasibility of quantitative measures were assessed. The primary outcome was subjective-clinical-assessment of FD symptoms (SCA-FD). Secondary outcome measures included Short-form Nepean Dyspepsia Index (SF-NDI), subjective-clinical-assessment of general health (SCA-GH), EuroQoL-Visual Analog Scale (EuroQoL-VAS), and Depression, Anxiety and Stress Scale-21 Items (DASS-21).

RESULTS

Twelve of 15 patients in the MBCT group completed the program. There was a trend towards symptom improvement, with 90% in the MBCT group reporting improvement in SCA-FD compared with 45% in TAU(P = 0.063). Patients who underwent MBCT reported greater improvement in SF-NDI (mean change: -8.8 (SD: 7.5) vs -0.7 (7.2), P = 0.018) and DASS-21 (-19.8 (29.5) vs -5.5 (6.6) P = 0.13) compared with TAU. There was no difference in SCA-GH and EuroQoL-VAS. Based on SCA-FD improvement, the eventual RCT will require 50 patients (25 in each group).

CONCLUSIONS

Mindfulness-based cognitive therapy is likely efficacious for FD, and it would be feasible to conduct a RCT.

Psychological Treatments for Depression in Adolescents: More Than Three Decades Later

Depression is a common and impairing disorder which is a serious public health problem. For some individuals, depression has a chronic course and is recurrent, particularly when its onset is during adolescence. The purpose of the current paper was to review the clinical trials conducted between 1980 and 2020 in adolescents with a primary diagnosis of a depressive disorder, excluding indicated prevention trials for depressive symptomatology. Cognitive behavioral therapy (CBT) is the pre-eminent treatment and is well established from an evidence-based treatment perspective. The body of research on the remaining treatments is smaller and the status of these treatments is varied: interpersonal therapy (IPT) is well established; family therapy (FT) is possibly effective; and short-term psychoanalytic therapy (PT) is experimental treatment. Implementation of the two treatments that work well-CBT and IPT-has more support when provided individually as compared to in groups. Research on depression treatments has been expanding through using transdiagnostic and modular protocols, implementation through information and communication technologies, and indicated prevention programs. Despite significant progress, however, questions remain regarding the rate of non-response to treatment, the fading of specific treatment effects over time, and the contribution of parental involvement in therapy.

Blended transdiagnostic group CBT for emotional disorders: A feasibility trial protocol

INTRODUCTION

Emotional disorders (anxiety and depressive disorders) are a relevant public health concern associated with high prevalence, high costs, and important disability. Therefore, research priorities include designing and testing cost-effective interventions to reach everyone in need. Internet-delivered interventions for emotional disorders are effective and can help to disseminate and implement evidence-based treatments. However, although these treatments are generally effective, not all patients benefit from this treatment format equally. Blended treatments are a new form of intervention that combines the strengths of face-to-face and Internet approaches. Nevertheless, research on blended interventions has focused primarily on individual therapy, and less attention has been paid to the potential of using this format in group psychotherapy. This study aims to analyze the feasibility of blended transdiagnostic group CBT for emotional disorders. The current article describes the study protocol for this trial.

METHOD AND ANALYSIS

A one-armed pilot trial will be conducted. Participants will be 30 adults suffering from DSM-5 anxiety and/or depressive disorders. The treatment consists of a blended transdiagnostic group intervention delivered during a period of 24 weeks. Groups of 6 to 10 patients will attend a total of eight 2-hour, face-to-face sessions, alternated with the use of an online platform where they will find the contents of the treatment protocol. The intervention has four core components: present-focused awareness, cognitive flexibility, identification and modification of behavioral and cognitive patterns of emotional avoidance, and interoceptive and situational exposure. These components are delivered in 16 modules. Assessments will be performed at baseline, during the treatment, at post-treatment, and at 3-month follow-up. Clinical and treatment acceptability outcomes will be included. Quantitative and qualitative data (participants' views about blended group psychotherapy) will be analyzed.

ETHICS AND DISSEMINATION

The trial has received ethical approval from the Ethics Committee of Universitat Jaume I (September 2019) and will be conducted in accordance with the study protocol, the Declaration of Helsinki, and good clinical practice. The results of this study will be disseminated by presentation at conferences and will be submitted for publication in a peer-reviewed journal.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04008576. Registered 05 July 2019, https://clinicaltrials.gov/ct2/show/NCT04008576.

Effectiveness of a Brief Psychological Intervention Delivered by Nurse for Depression in Pregnancy: Study Protocol for a Multicentric Randomized Controlled Trial from India

BACKGROUND

Perinatal depression (PD) has important implications for maternal and infant well-being but largely goes undetected. There is a need to develop low-intensity psychosocial interventions applicable to obstetric health care facilities.

OBJECTIVE

To assess the effectiveness of a brief psychological intervention for mild to moderate PD delivered by a nurse as compared to treatment-as-usual (TAU).

METHODS

This study is a randomized, open-label, parallel-group, multicentric trial being conducted in four sites of India. A total of 816 pregnant women with mild to moderately severe depression (Patient Health Questionaire-9 score of 5-19) are being assessed for the effectiveness of the intervention. Participants are randomly allocated to two groups of trial intervention (psychological intervention given by nurse) and TAU. The primary outcome is to compare the proportion of women reporting improvement across both groups. Participants are serially followed-up in each trimester and at 6, 10, 14 weeks, and 6 months postpartum. Secondary outcomes include pregnancy outcomes, feeding practices, physical growth, and immunization status of the infants.

CONCLUSION

It is a prospective pregnancy birth cohort with a robust design and long-term follow-up. This is one of the largest studies utilizing non-specialist health workers for the screening and management of PD. This study also holds promise to cast light on the course and outcome of depression during pregnancy in different parts of India. It is envisaged to help in developing a sound screening and referral-based protocol for obstetric settings.

Practices Derived from the Evidence Base for Depression Predict Disruptive Behavior Progress in Adolescent Community Mental Health Care

Disruptive behavior problems develop along multiple causal pathways and are associated with a wide variety of co-occurring problems, including mood disorders. In usual care, effective treatment practices for youth disruptive behavior might differ from what the efficacy research suggests, given treatment setting and population demographic differences. The current study examined whether practices derived from the evidence base for disruptive behavior and/or depressed mood predicted progress on disruptive behavior problems in an adolescent usual care sample. Monthly clinical data, including therapeutic practices, treatment targets, and progress on selected treatment targets, for 1210 youth ages 13-17 who received intensive in-home services and were treated for disruptive behavior problems were examined utilizing multilevel modeling techniques. Practices derived from the evidence base for only depressed mood and practices derived from both disruptive behavior and depressed mood literatures predicted disruptive behavior progress, while practices derived from only the disruptive behavior evidence-based literature did not. All five practice elements exclusive to depressed mood treatment predicted positive disruptive behavior progress, while two of eleven disruptive behavior practices and four of seven practices derived from both problem areas predicted positive progress. Findings held when other predictors were included as covariates, including youth age and functional impairment. Although directionality remains unclear and further research is vital, usual care settings might present barriers to disruptive behavior treatment as prescribed by the evidence base, and youth-focused treatments based on depressed mood treatments merit further examination as a potentially promising route to effective treatment in such settings.

Effectiveness of a Transdiagnostic Guided Internet-Delivered Protocol for Emotional Disorders Versus Treatment as Usual in Specialized Care: Randomized Controlled Trial

Background

Anxiety disorders and depression (emotional disorders) are highly prevalent mental disorders. Extensive empirical evidence supports the efficacy of cognitive behavioral therapy (CBT) for the treatment of these disorders. However, there are still some barriers related to their dissemination and implementation, which make it difficult for patients to receive these treatments, especially in public health care settings where resources are limited. Recent advances in improving CBT dissemination encompass different perspectives. One is the transdiagnostic approach, which offers treatment protocols that can be used for a range of emotional disorders. Another approach is the use of the internet to reach a larger number of people who could benefit from CBT.

Objective

This study aimed to analyze the effectiveness and acceptability of a transdiagnostic internet-delivered protocol (EmotionRegulation) with human and automated guidance in patients from public specialized mental health care settings.

Methods

A 2-armed randomized controlled trial (RCT) was conducted to compare the effectiveness of EmotionRegulation with treatment as usual (TAU) in specialized mental health care. In all, 214 participants were randomly assigned to receive either EmotionRegulation (n=106) or TAU (n=108). Measurement assessments were conducted at pre- and postintervention and at a 3-month follow-up.

Results

The results revealed the superiority of EmotionRegulation over TAU on measures of depression (d=0.41), anxiety (d=0.35), and health-related quality of life (d=−0.45) at posttreatment, and these gains were maintained at the 3-month follow-up. Furthermore, the results for expectations and opinions showed that EmotionRegulation was well accepted by participants.

Conclusions

EmotionRegulation was more effective than TAU for the treatment of emotional disorders in the Spanish public mental health system. The implications of this RCT, limitations, and suggestions for future research are discussed.

Trial Registration

ClinicalTrials.gov NCT02345668; https://clinicaltrials.gov/ct2/show/NCT02345668

Changes in Traumatic Memories and Posttraumatic Cognitions Associate with PTSD Symptom Improvement in Treatment of Multiply Traumatized Children and Adolescents

Refinement, targeting, and better dissemination of trauma-focused therapies requires understanding their underlying mechanisms of change. Research on such mechanisms among multiply traumatized children and adolescents is scarce. We examined the role of improvements in problematic qualities of traumatic memories and maladaptive posttraumatic cognitions in PTSD symptom reduction, in a randomized, pragmatic trial of narrative exposure therapy vs. treatment as usual with 40 participants 9-17 years old (48% female, 75% refugee background) repeatedly exposed to war or family violence related trauma. Posttraumatic cognitions, quality of traumatic memories and PTSD symptoms were assessed by self-report before and after treatment. Improvements in both quality of traumatic memories (r _MI = .36) and posttraumatic cognitions (r _MI = .46) correlated with symptom reduction. However, improvement during treatment was only significant for quality of traumatic memories (F _MI(11,333.56) = 4.77), not for posttraumatic cognitions. We detected no difference in effects of narrative exposure therapy and treatment as usual on cognitions or memories. We tentatively suggest problematic, overly sensory and incoherent quality of traumatic memories may be a useful target in the treatment of PTSD symptoms among multiply traumatized children and adolescents. Changing maladaptive posttraumatic cognitions, though important, may be challenging among those with severe, repeated trauma.

Parent- and Teacher-Rated Effectiveness of Cognitive-Behavioral Therapy for Children and Adolescents Under Usual Care Conditions in a University Outpatient Clinic

Compared to randomized controlled trials, studies examining the effectiveness of cognitive behavioral therapy (CBT) in children and adolescents with mental disorders are rare, and a teacher perspective is scarce. The present study investigated the effectiveness of routine CBT in 519 patients aged 6-18 years with mental disorders. Changes in mental health problems were assessed in teacher (Teacher Report Form, TRF) and parent rating (Child Behavior Checklist, CBCL) and were analyzed within the total sample, yielding statistically significant, small to medium effect sizes (teacher rating: d = .74-2.39; parent rating: d = .65-1.18). Changes in a subgroup of patients with elevated symptom scores at treatment start were compared to a historical control group receiving weekly academic tutoring. Net total score effect sizes lay between d = 0.98 and d = 1.29 for teacher rating (parent rating: d = 0.84 to d = 1.01). Nevertheless, a substantial number of patients remained in the clinical range. Symptom changes during family- and patient-based CBT interventions did not differ from treatments including additional school-based interventions, as was also the case for the comparison of treatments with and without additional pharmacotherapy.

Disruptive Behavior Treatment Progress as a Function of Therapy Focus and Youth Diagnosis in a Community Mental Health Setting

Monthly disruptive behavior treatment progress for 613 youth ages 7-18 receiving intensive in-home services was examined. Multilevel modeling indicated carrying a depressive mood diagnosis predicted less disruptive behavior progress compared to youth with only externalizing diagnoses. Paradoxically, more monthly focus on disruptive behavior treatment targets predicted lower concurrent progress ratings, while greater focus on depressive mood targets predicted greater disruptive behavior progress for youth with a depressive mood diagnosis. Findings held when other predictors of disruptive behavior progress were included as covariates, including episode length, youth age, and functional impairment. Treatment and research implications are discussed.

Examining the "usual" in usual care: a critical review and recommendations for usual care conditions in psycho-oncology

PURPOSE

Within psycho-oncology clinical trials, usual care (UC) represents a common and important control condition. Yet recent shifts in oncology, coupled with insufficient description of such conditions, threaten to render UC increasingly difficult to define and interpret. This paper offers evidence of these shifts and recommendations for addressing them.

METHODS

The broader literature on usual care as a control condition in psychosocial/behavioral intervention trials was assessed, and usual care-controlled trials in psycho-oncology were selectively reviewed, toward to goal of conceptual synthesis.

RESULTS

We offer evidence that (1) UC control conditions are often insufficiently defined and assessed; and (2) the context of supportive care in oncology has shifted in a manner that contributes to this problem, with implications for interpreting and comparing findings across clinical trials. Three converging findings support these conclusions. First, the scientific literature increasingly documents the diversity in how "usual care" conditions are defined across psychosocial and behavioral trials, with important considerations for trial interpretation. Second, evidence suggests that the availability of psychosocial oncology care has increased over the past few decades. The increasing availability and variety of psychosocial care introduces potential confounds for UC conditions. Third, mental health care trends in the general population affect the supportive interventions available to oncology patients in UC conditions today versus in the past.

CONCLUSIONS

Shifts in psychosocial oncology and broader mental health care underscore the importance of carefully defining and assessing UC in psycho-oncology trials. Recommendations are offered for improving the design, evaluation, and interpretation of UC conditions, toward the ultimate goal of improving the quality of the evidence in psycho-oncology.

Annual Research Review: Expanding mental health services through novel models of intervention delivery

Currently, in the United States and worldwide, the vast majority of children and adolescents in need of mental health services receive no treatment. Although there are many barriers, a key barrier is the dominant model of delivering psychosocial interventions. That model includes one-to-one, in-person treatment, with a trained mental health professional, provided in clinical setting (e.g., clinic, private practice office, health-care facility). That model greatly limits the scale and reach of psychosocial interventions. The article discusses many novel models of delivering interventions that permit scaling treatment to encompass children and adolescents who are not likely to receive services. Special attention is accorded the use of social media, socially assistive robots, and social networks that not only convey the ability to scale interventions but also encompass interventions that depart from the usual forms of intervention that currently dominate psychosocial treatment research.

Single-case experimental designs. Evaluating interventions in research and clinical practice

Single-case designs refer to a methodological approach that can be used to investigate the effectiveness of treatment with the individual client. The designs permit scientifically valid inferences to be drawn about the effects of treatment and hence offer advantages over alternative strategies such as the uncontrolled case study or open study that are used with the individual case. The present article discusses the key features of the methodology, illustrates specific designs and how inferences are drawn, and discusses critical issues (feasibility, generality of results, ethical issues) in the use of the designs. Essential features of the design, including ongoing assessment and drawing on the underlying thinking and logic of the designs can improve the clinical care for individual clients, even when the rigors of experimentation are not feasible or desirable. Lamentably, single-case methods are rarely trained among researchers or practitioners in psychology or related mental health professions. The designs could play a special role by improving individual care and therapeutic change, apart from the strength of the methodology as a purely research tool.

Feasibility and acceptability of two incentive-based implementation strategies for mental health therapists implementing cognitive-behavioral therapy: a pilot study to inform a randomized controlled trial

BACKGROUND

Informed by our prior work indicating that therapists do not feel recognized or rewarded for implementation of evidence-based practices, we tested the feasibility and acceptability of two incentive-based implementation strategies that seek to improve therapist adherence to cognitive-behavioral therapy for youth, an evidence-based practice.

METHODS

This study was conducted over 6 weeks in two community mental health agencies with therapists (n = 11) and leaders (n = 4). Therapists were randomized to receive either a financial or social incentive if they achieved a predetermined criterion on adherence to cognitive-behavioral therapy. In the first intervention period (block 1; 2 weeks), therapists received the reward they were initially randomized to if they achieved criterion. In the second intervention period (block 2; 2 weeks), therapists received both rewards if they achieved criterion. Therapists recorded 41 sessions across 15 unique clients over the project period. Primary outcomes included feasibility and acceptability. Feasibility was assessed quantitatively. Fifteen semi-structured interviews were conducted with therapists and leaders to assess acceptability. Difference in therapist adherence by condition was examined as an exploratory outcome. Adherence ratings were ascertained using an established and validated observational coding system of cognitive-behavioral therapy.

RESULTS

Both implementation strategies were feasible and acceptable-however, modifications to study design for the larger trial will be necessary based on participant feedback. With respect to our exploratory analysis, we found a trend suggesting the financial reward may have had a more robust effect on therapist adherence than the social reward.

CONCLUSIONS

Incentive-based implementation strategies can be feasibly administered in community mental health agencies with good acceptability, although iterative pilot work is essential. Larger, fully powered trials are needed to compare the effectiveness of implementation strategies to incentivize and enhance therapists' adherence to evidence-based practices such as cognitive-behavioral therapy.

Compassion interventions: The programmes, the evidence, and implications for research and practice

PURPOSE

Over the last 10-15 years, there has been a substantive increase in compassion-based interventions aiming to improve psychological functioning and well-being.

METHODS

This study provides an overview and synthesis of the currently available compassion-based interventions. What do these programmes looks like, what are their aims, and what is the state of evidence underpinning each of them?

RESULTS

This overview has found at least eight different compassion-based interventions (e.g., Compassion-Focused Therapy, Mindful Self-Compassion, Cultivating Compassion Training, Cognitively Based Compassion Training), with six having been evaluated in randomized controlled trials, and with a recent meta-analysis finding that compassion-based interventions produce moderate effect sizes for suffering and improved life satisfaction.

CONCLUSIONS

Although further research is warranted, the current state of evidence highlights the potential benefits of compassion-based interventions on a range of outcomes that clinicians can use in clinical practice with clients.

PRACTITIONER POINTS

There are eight established compassion intervention programmes with six having RCT evidence. The most evaluated intervention to date is compassion-focused therapy. Further RCTs are needed in clinical populations for all compassion interventions. Ten recommendations are provided to improve the evidence-base of compassion interventions.

Advancing Personalized Medicine: Application of a Novel Statistical Method to Identify Treatment Moderators in the Coordinated Anxiety Learning and Management Study

There has been increasing recognition of the value of personalized medicine where the most effective treatment is selected based on individual characteristics. This study used a new method to identify a composite moderator of response to evidence-based anxiety treatment (CALM) compared to Usual Care. Eight hundred seventy-six patients diagnosed with one or multiple anxiety disorders were assigned to CALM or Usual Care. Using the method proposed by Kraemer (2013), 35 possible moderators were examined for individual effect sizes then entered into a forward-stepwise regression model predicting differential treatment response. K-fold cross validation was used to identify the number of variables to include in the final moderator. Ten variables were selected for a final composite moderator. The composite moderator effect size (r = .20) was twice as large as the strongest individual moderator effect size (r = .10). Although on average patients benefitted more from CALM, 19% of patients had equal or greater treatment response in Usual Care. The effect size for the CALM intervention increased from d = .34 to d = .54 when accounting for the moderator. Findings support the utility of composite moderators. Results were used to develop a program that allows mental health professionals to prescribe treatment for anxiety based on baseline characteristics (http://anxiety.psych.ucla.edu/treatmatch.html).

A longitudinal examination of dyadic distress patterns following a skills intervention for carers of adolescents with anorexia nervosa

Family interventions in anorexia nervosa (AN) have been developed to ameliorate maladaptive patterns of patient-carer interaction that can play a role in illness maintenance. The primary aim of this study is to examine the inter-relationship between baseline and post-treatment distress in dyads of carers and patients with AN to examine the interdependence between carers and patients. The secondary aim is to examine whether a carer skills intervention [Experienced Carer Helping Others (ECHO)] impacts on this inter-relationship. Dyads consisting of treatment-seeking adolescents with AN and their primary carer (n = 149; mostly mothers) were randomised to receive a carer skills intervention (ECHO) in addition to treatment as usual (TAU), or TAU alone, as part of a larger clinical trial. Carers and patients completed a standardised measure of psychological distress (The Depression, Anxiety, and Stress Scale) at baseline and 12 months post-treatment. The Actor Partner Interdependence Model was used to examine longitudinal changes in interdependence by treatment group. As expected, post-treatment levels of distress were related to baseline levels in both groups (actor effects). Moreover, carer distress at 12 months was related to patient distress at baseline for the TAU (partner effects), but not for the ECHO group. Finally, carers' distress change was not a significant predictor of patients' body mass index (BMI) change in the two treatment conditions. These findings are limited to predominantly mother-offspring dyads and may not generalise to other relationships. The ECHO intervention which is designed to teach carers skills in illness management and emotion regulation may be an effective addition to TAU for ameliorating interdependence of distress in patients and their primary carers over time.

Aligning organizational priorities with ARC to improve youth mental health service outcomes

OBJECTIVE

The Availability, Responsiveness, and Continuity (ARC) organizational intervention is designed to improve community-based youth mental health services by aligning organizational priorities with 5 principles of effective service organizations (i.e., mission driven, results oriented, improvement directed, relationship centered, participation based). This study assessed the effect of the ARC intervention on youth outcomes and the mediating role of organizational priorities as a mechanism linking the ARC intervention to outcomes.

METHOD

Fourteen community-based mental health agencies in a midwestern metropolis along with 475 clinicians and 605 youth (ages 5-18) served by those agencies were randomly assigned to the 3-year ARC intervention or control condition. The agencies' priorities were measured with the ARC Principles Questionnaire (APQ) completed by clinicians at the end of the intervention. Youth outcomes were measured as total problems in psychosocial functioning described by their caregivers using the Shortform Assessment for Children (SAC) at 6 monthly intervals.

RESULTS

The rate of improvement in youths' psychosocial functioning in agencies assigned to the ARC condition was 1.6 times the rate of improvement in agencies assigned to the control condition, creating a standardized difference in functioning of d = .23 between the 2 groups at the 6-month follow-up. The effect on youth outcomes was fully mediated by the alignment of organizational priorities described in the 5 ARC principles (d = .21).

CONCLUSION

The ARC organizational intervention improves youth outcomes by aligning organizational priorities with the 5 ARC principles. The findings suggest that organizational priorities explain why some community mental health agencies are more effective than others. (PsycINFO Database Record

Gestalt Therapy Applied: A Case Study with an Inpatient Diagnosed with Substance Use and Bipolar Disorders

AIM

The aim of the present paper is to open the discourse regarding the unmet needs of specific patients, especially those with substance use disorder and/or personality disorder where 'multimorbidities', and/or 'overdiagnosis' and/or 'diagnosis overlap' are frequent. An additional aim is to review the main therapeutic purpose and concepts of Gestalt therapy which might be appropriate in the treatment of these patients often characterized by their difficulties in being aware and in contact in the 'here and now'.

METHODS

I first start with an overview of Gestalt therapy concepts. Then, I illustrate Gestalt's 'here and now' and awareness concepts applied during 18 sessions with an inpatient diagnosed with substance use and bipolar disorders. In addition, the patient had to face an open criminal charge, was regarded as having an antisocial personality disorder and argued suffering from post-traumatic stress disorder.

RESULTS

After this two-month therapy period, the patient entered for the first time a daily rehabilitation program in the community, where he was doing well (this after a few prior hospitalizations). The awareness development in the 'here and now' through which different contact styles and cycles of experiences are experienced is a process that allowed the patient to start experiencing contact with himself, his true needs and his environment. This contributed to his well-being improvement, led and supported his rehabilitation and reinsertion within the society and decrease his relapses, either with drugs or criminal activities. Copyright © 2016 John Wiley & Sons, Ltd.

KEY PRACTITIONER MESSAGE

People with substance use disorder (where 'multimorbidities', 'overdiagnosis' or 'diagnosis overlap' are frequent), people with personality disorder(s) or people who have difficulties in defining what really disturbs them are the same people who could benefit of GT encouraging awareness and contact development in the 'here and now'. Gestalt therapy should not be regarded as a practitioner's toolbox but as a therapeutic process allowing awareness and I-boundaries development in the 'here and now' through authentic and genuine relationships. The therapist's awareness and contact with themselves and their environment are reflected in the therapist's relaxed but awake and aware state of mind as well as their wise, spontaneous and mindful approach.