Changes in sick leave one year before and after starting treatment: a naturalistic study of employed outpatients with common mental health disorders

BACKGROUND

This study explores sick leave changes 1-year pre- and post-treatment start for common mental health issues and their associations with self-reported symptoms, functioning, and health changes.

METHODS

Ninety-five employed patients, without previous disability benefits, underwent treatment at a public mental health outpatient clinic. Sick leave data was obtained from the Norwegian Labour and Welfare Administration. Symptoms, work/social functioning, and health quality were self-reported at treatment onset and completion.

RESULTS

Twelve months before starting treatment, only 6.3% were on sick leave, contrasting with 69.5% at treatment start. At post-treatment, 25% received work assessment allowance (WAA), 63% were off sick leave, and 12% were on sick leave. Sick leave days exhibited an inverted U-shape for non-WAA recipients. Those on sick leave post-treatment reported less improvement in symptoms and health, while the WAA group showed diminished work functioning enhancement.

DISCUSSION

Evaluating the effect mental health treatment has on sick leave is clearly affected by the timing of assessments. Treatment seems associated with improved sick leave outcomes compared with status at treatment start, but less so when compared with status one year before starting treatment. Also, a large group of patients went on to receive WAA, constituting a group in need of further longitudinal evaluations and interventions.

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.

Process and outcome of outpatient psychotherapies under clinically representative conditions in Austria: protocol and feasibility of an ongoing study

Background

While most studies assessing psychotherapy efficacy are randomized-controlled trials conducted in research institutions or short clinical treatments, the understanding of psychotherapy effectiveness under regular, clinically representative conditions, particularly in outpatient practice, remains limited. Representative data examining the effectiveness of psychotherapy under real-world conditions in Austria is lacking.

Aims and Methods

This paper introduces a naturalistic observational combined process- and outcome study, implementing a dual-perspective approach through standardised pre- and post-treatment questionnaires and evaluating changes in the therapeutic alliance after each session. Further, semi-structured qualitative interviews aim to illuminate the personal experiences of patients and therapists. The primary objective of the presented study is to discern whether symptoms markedly decrease following therapy. A significant secondary goal is to trace the therapeutic alliance's evolution from both patient and therapist viewpoints, emphasising the alliance-outcome association and gender dynamics within the pairs. This paper discusses the project's feasibility after three years and shares key insights.

Discussion

Recruitment for this study has posed substantial challenges due to psychotherapists' concerns regarding data protection, extensive documentation, and philosophical reservations about the study design. Consequently, we recruited fewer participants than initially planned. Despite these hurdles, qualitative data collection has shown notable success. Given psychotherapists' busy schedules and reluctance to participate, more potent external incentives or a legal obligation may be necessary to encourage participation in future studies.

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.

Graded exercise therapy for patients with chronic fatigue syndrome in secondary care - a benchmarking study

OBJECTIVE

We investigated the effectiveness of graded exercise therapy (GET) delivered to patients with chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) in a routine, specialist clinic by measuring patient-reported outcome data collected prospectively over several timepoints alongside therapy. Benchmarking analyses were used to compare our results with those found in randomised controlled trials (RCTs).

METHODS

Data were collected from patients, with a diagnosis of CFS/ME, who had been referred to a specialist clinical service in South London. Measures included Chalder Fatigue Questionnaire, Physical Functioning Subscale of the Short-Form Health Questionnaire, and the Work and Social Adjustment Scale. Change on each measure was calculated over time using linear mixed-model analyses. Within group effect sizes were calculated and compared with previous RCTs.

RESULTS

Fatigue scores were significantly reduced by session 4 (-5.18, 95%CIs -7.90, -2.45) and at follow-up (-4.73, 95%CIs -7.60, -1.85). Work and social adjustment and physical functioning progressively improved over the course of therapy, reaching significance at discharge and maintained at follow-up (WSAS -4.97, 95%CIs -7.97, -1.97; SF-36 10.75, 95%CIs 2.19, 19.31).

CONCLUSIONS

GET is an effective treatment for CFS/ME within clinical practice. However, effect sizes were smaller in routine clinical practice than RCTs suggesting that avenues for augmentation need to be considered.Implications for rehabilitationIt is important to assess whether patient reported outcomes of treatments that have been evaluated in the context of clinical trials are similar in routine clinical practice.This study shows fatigue severity, physical functioning, and work and social adjustment can significantly improve after graded exercise therapy for patients with chronic fatigue syndrome within a specialist service.Benchmarking methods showed clinical outcomes obtained smaller effect sizes than randomised controlled trials - techniques to maximise patient outcomes should be considered.

Praxisorientierte Forschung in der Psychotherapie

Zusammenfassung. In den letzten Jahrzehnten hat sich durch randomisiert-kontrollierte Studien (RCTs) eine breite Evidenzbasis von Psychotherapie mit mittleren bis großen Effekten für verschiedene psychische Störungen gebildet. Neben der Bestimmung dieser Wirksamkeit („Efficacy“) ebneten Studien zur Wirksamkeit unter alltäglichen Routinebedingungen („Effectiveness“) historisch den Weg zur Entwicklung eines praxisorientierten Forschungsparadigmas. Im Beitrag wird argumentiert, dass im Rahmen dieses Paradigmas praxisbasierte Studien eine wertvolle Ergänzung zu RCTs darstellen, da sie existierende Probleme in der Psychotherapieforschung adressieren können. In der gegenwärtigen praxisorientierten Forschung liefern dabei neue Ansätze aus der personalisierten Medizin und Methoden aus der ‚Computational Psychiatry‘ wichtige Anhaltspunkte zur Optimierung von Effekten in der Psychotherapie. Im Kontext der Personalisierung werden bspw. klinische multivariable Prädiktionsmodelle entwickelt, welche durch Rückmeldeschleifen an Praktiker_innen kurzfristig ein evidenzbasiertes Outcome-Monitoring ermöglicht und langfristig das Praxis-Forschungsnetzwerk in Deutschland stärkt. Am Ende des Beitrags werden zukünftige Richtungen für die praxisorientierte Forschung im Sinne des ‘Precision Mental Health Care’ -Paradigmas abgeleitet und diskutiert.

Effectiveness of Open-Ended Psychotherapy Under Clinically Representative Conditions

OBJECTIVE

This study investigates the effectiveness of open-ended psychotherapy in a large, naturalistic, and diverse patient cohort using rigorous and multifaceted assessments.

METHOD

Patients (N = 370) in open-ended psychotherapy completed an extensive set of self-report measures and diagnostic interviews, including long-term follow-up in order to assess stability of outcomes. About half of the patients qualified for a personality disorder at the onset of treatment. Treatments were open-ended, and on average therapists provided substantially larger treatment doses than common in the literature.

RESULTS

A substantial majority recovered from their respective Axis I (58%) and/or Axis II (55%) disorders during treatment. Patients also experienced large positive changes in self-report measures of overall psychiatric symptoms and moderate positive changes in self-reported interpersonal problems, while very few (< 3%) demonstrated negative development. The patients maintained their diagnostic and self-assessed changes at a two-and-a-half-year follow-up. In contrast, self-reported occupational functioning showed minimal improvement throughout the treatment and follow-up phase.

CONCLUSION

A naturalistic patient cohort undergoing open-ended psychotherapy demonstrates substantial and stable improvements.

Foundations of idiographic methods in psychology and applications for psychotherapy

Researchers have long called for greater recognition and use of longitudinal, individual-level research in the study of psychopathology and psychotherapy. Much of our current research attempts to indirectly investigate individual-level, or idiographic, psychological processes via group-based, or nomothetic, designs. However, results from nomothetic research do not necessarily translate to the individual-level. In this review, we discuss how idiographic analyses can be integrated into psychotherapy and psychotherapy research. We examine and review key statistical methods for conducting idiographic analyses. These methods include factor-based and vector autoregressive approaches using longitudinal data. The theoretical framework behind each approach is reviewed and critically evaluated. Empirical examples of each approach are discussed, with the aim of helping interested readers consider how they may use idiographic methods to analyze longitudinal data and psychological processes. Finally, we conclude by citing key limitations of the idiographic approach, calling for greater development of these analyses to ease their successful integration into clinical settings.

Internet-Delivered Cognitive Behavioral Therapy for Anxiety Disorders in Open Community Versus Clinical Service Recruitment: Meta-Analysis

BACKGROUND

Ample studies have shown the effectiveness of internet-delivered cognitive behavioral therapy (iCBT) for anxiety disorders. These studies recruited their participants mainly from the community and, to a lesser extent, from within routine care services. Little is known about whether different recruitment strategies lead to different treatment effects.

OBJECTIVE

This meta-analysis compared clinical results obtained in trials with recruitment from the community versus results obtained in trials with clinical service recruitment and explored factors that may mediate differences in treatment outcome.

METHODS

We included randomized controlled trials in which the clinical effects of iCBT for anxiety disorders were compared with a control condition (waitlist controls or face-to-face cognitive behavioral therapy). We classified trials as open recruitment trials (recruitment from the community) or clinical service recruitment trials (recruitment through outpatient clinics). Pooled effect sizes based on measures examining anxiety symptoms, depressive symptoms, and quality of life were computed for each type of trial. Subgroup analyses examined whether clinical results from open recruitment trials differed from those obtained in clinical service recruitment trials. Additional analyses explored which demographic, clinical, and treatment-related factors contributed to differences in effect sizes of open recruitment versus clinical service recruitment trials.

RESULTS

We included 42 studies with 53 comparisons (43 open recruitment comparisons and 10 clinical recruitment comparisons). Analyses of anxiety measures revealed, first, that iCBT open recruitment studies with waitlist control comparators showed a significantly higher effect size for decrease in anxiety symptoms than did those with clinical recruitment (Q=10.09; P=.001). This association between recruitment method and effect size was no longer significant in a multivariate metaregression with treatment adherence and exclusion of patients with depressive symptoms entered as additional predictors of effect size. Second, effect size for decrease in anxiety symptoms did not differ significantly between clinical recruitment and open recruitment studies with face-to-face cognitive behavioral therapy comparators. The effects of open recruitment trials and clinical recruitment trials did not differ significantly for the secondary outcomes, compared with face-to-face cognitive behavioral therapy and waitlist controls.

CONCLUSIONS

iCBT was effective in samples recruited in clinical practice, but effect sizes were smaller than those found in trials with an open recruitment method for studies with waitlist control comparators. Hence, for patients with anxiety disorders in routine care, the impact of iCBT may not be as positive as for study participants recruited from the community. The difference between open recruitment trials and clinical service recruitment trials might be partly explained by patients' greater therapy adherence in open recruitment trials and the stricter exclusion of patients with severe depressive symptoms in these studies. Since most trials in this meta-analysis applied an open recruitment method, more studies with routine care populations are needed to further validate these findings.

Guided Internet-Based Cognitive Behavioral Therapy for Adult Depression and Anxiety in Routine Secondary Care: Observational Study

BACKGROUND

Internet-based cognitive behavioral therapy (iCBT) is a promising new treatment method for depression and anxiety. However, it is important to determine whether its results can be replicated in routine care before its implementation on a large scale. Although many studies have demonstrated the efficacy of iCBT under controlled conditions, only a few studies have investigated its effectiveness in routine care. Furthermore, several effects of iCBT such as treatment effects in routine care are unclear.

OBJECTIVE

This study aimed to evaluate the clinical effectiveness of iCBT for depression and anxiety in routine secondary care.

METHODS

n a retrospective cohort study, we analysed patients treated for depression or anxiety in a dedicated iCBT clinic in secondary care in Denmark. Patients were examined before treatment and weekly thereafter by using the Patient Health Questionnaire-9 and the Generalized Anxiety Disorder-7 scales for the diagnoses of depression and anxiety, respectively. Primary analyses were conducted using a linear mixed-effects model with random slope and intercept. Secondary analyses were conducted using baseline characteristics as predictors (gender, age, highest level of education, occupational status, marital status, psychotropic medication use, consumption of alcohol, and leisure drugs). Additionally, logistic regression analyses were used to predict noncompletion of treatment.

RESULTS

A total of 203 (depression, N=60; anxiety, N=143) patients were included. Participants were mainly female (78.3% with depression and 65.7% with anxiety), with a mean age of 36.03 (SD 10.97) years (range, 19-67 years) for patients with depression and 36.80 (SD 13.55) years (range, 19-69 years) for patients with anxiety. The completion rates were 62% (37) and 40% (57) for depression and anxiety treatments, respectively. The primary analyses revealed large and significant reductions in the symptom levels of depression (beta=-6.27, SE 0.83, P<.001, d=1.0) and anxiety (beta=-3.78, SE 0.43, P<.001, d=1.1). High baseline severity of the primary disorder was associated with high treatment gains (r=-0.31 for depression; r=-0.41 for anxiety). In patients with anxiety, high baseline severity also predicted a high risk of noncompletion (odds ratio=1.08, CI=1.01-1.16, P=.03). An increase in the baseline severity of the comorbid disorder slightly increased the risk of noncompletion for both disorders (depression: odds ratio=1.03, CI=1.01-1.06, P=.02; anxiety: odds ratio=1.08, CI=1.01-1.16, P=.03).

CONCLUSIONS

iCBT can be clinically effective in routine care. Since depression and anxiety are costly and debilitating disorders that are vastly undertreated, this finding is important. Additionally, iCBT may help bridge the gap between the need for treatment and its provision. Our results are comparable to the within-group results of efficacy and effectiveness studies. Our noncompletion rates are similar to those observed in psychotherapy but are higher than those reported in similar clinics. Multiple factors predicted outcome and noncompletion. However, all predictor effects were statistically weak.

Cognitive behaviour therapy for distress in people with inflammatory bowel disease: A benchmarking study

OBJECTIVE

Anxiety and depression are common in inflammatory bowel disease (IBD) and have been linked to clinical recurrence. Previous randomized controlled trials (RCT's) have found no evidence that psychological interventions enhance outcomes for people with IBD but have recruited patients without distress. This study investigates the clinical benefits of a nonrandomized uncontrolled study of clinic based cognitive behaviour therapy (CBT) for people with IBD who had moderate-severe levels of anxiety or low mood and compares the results with a previous RCT of CBT in this population.

METHOD

Assessments were completed at baseline and end of treatment and included measures of low mood, generalized anxiety, quality of life (QOL), and symptomatic disease activity. The patient health questionnaire and generalized anxiety disorder 7 measures were the primary outcomes. Results in the form of a standardized effect size of treatment were compared with a previous RCT to consider if CBT had greater benefits for those with distress.

RESULTS

Thirty patients were deemed appropriate for CBT, and 28 accepted treatment. The results from this clinic based CBT intervention suggest statistically significant reductions in symptoms of anxiety (<0.001), low mood (<0.001), and disease activity (p < 0.01) and increases in QOL (p < 0.001). The uncontrolled effect sizes were large and superior to those found in published RCTs.

CONCLUSION

This nonrandomized uncontrolled trial of a clinic-based CBT intervention suggests that CBT may have benefits for those with moderate-severe disturbances to mood and that effect sizes can be improved by targeting those with distress. RCTs are required to establish efficacy.

Internet interventions: Past, present and future

Internet interventions have been around now for about 20 years. While the field still suffers from a scattered terminology a large number of programs and studies exist. In the present paper I present an overview of my experiences of studying internet-supported cognitive-behaviour therapy (ICBT), but also mention other approaches including the use of smartphones. The paper covers the history of ICBT, short-term effects in controlled trials for a range of conditions, long-term effects, comparisons against face-to-face therapy, effectiveness studies, prediction studies, how the treatment is perceived, critique, and finally future directions. I conclude that we have now reached a stage in which we have numerous evidence-based treatments and procedures, and increasingly internet interventions including ICBT are disseminated.

Clinical effectiveness of cognitive behavioral therapy for depression in routine care: A propensity score based comparison between randomized controlled trials and clinical practice

BACKGROUND

The efficacy of cognitive behavioral therapy (CBT) for the treatment of depressive disorders has been demonstrated in many randomized controlled trials (RCTs). This study investigated whether for CBT similar effects can be expected under routine care conditions when the patients are comparable to those examined in RCTs.

METHOD

N=574 CBT patients from an outpatient clinic were stepwise matched to the patients undergoing CBT in the National Institute of Mental Health Treatment of Depression Collaborative Research Program (TDCRP). First, the exclusion criteria of the RCT were applied to the naturalistic sample of the outpatient clinic. Second, propensity score matching (PSM) was used to adjust the remaining naturalistic sample on the basis of baseline covariate distributions. Matched samples were then compared regarding treatment effects using effect sizes, average treatment effect on the treated (ATT) and recovery rates.

RESULTS

CBT in the adjusted naturalistic subsample was as effective as in the RCT. However, treatments lasted significantly longer under routine care conditions.

LIMITATIONS

The samples included only a limited amount of common predictor variables and stemmed from different countries. There might be additional covariates, which could potentially further improve the matching between the samples.

CONCLUSIONS

CBT for depression in clinical practice might be equally effective as manual-based treatments in RCTs when they are applied to comparable patients. The fact that similar effects under routine conditions were reached with more sessions, however, points to the potential to optimize treatments in clinical practice with respect to their efficiency.

Effectiveness of cognitive behavioral group therapy for depression in routine practice

BACKGROUND

Previous research has shown that cognitive- behavioral group therapy (group CBT) is an effective treatment for depression. However, the effectiveness of this approach in routine care needs more research. The current study retrospectively examines the outcomes of patients who received group CBT for depression at a psychiatric outpatient clinic between 2003 and 2013.

METHODS

Based on patient records, 143 patients were identified as having received the treatment, and 88 patients were included in the outcome analyses. The Beck Depression Inventory (BDI-II) score was the main outcome measure.

RESULTS

The dropout rate was 17.5%. The average BDI-II score decreased from 28.5 to 18.5 from pre-treatment to post-treatment and remained stable at 3-months follow-up. The effect sizes at post-treatment and follow-up were large (d = .97 and d = 1.10, respectively). At post-treatment, 44% of the patients showed a significant improvement in depression, including 30% who recovered; at follow-up, the proportions increased to 57% and 40%, respectively. No predictors of dropout or treatment response were found.

CONCLUSIONS

Group CBT for depression can be delivered in routine care settings with good results. However, there are still many patients who drop out or do not benefit from treatment.

Effectiveness and cost-effectiveness of individually tailored Internet-delivered cognitive behavior therapy for anxiety disorders in a primary care population: a randomized controlled trial

A significant proportion of the general population suffers from anxiety disorders, often with comorbid psychiatric conditions. Internet-delivered cognitive behavior therapy (ICBT) has been found to be a potent treatment for patients with specific psychiatric conditions. The aim of this trial was to investigate the effectiveness and cost-effectiveness of ICBT when tailoring the treatment to address comorbidities and preferences for primary-care patients with a principal anxiety disorder. One hundred participants were recruited through their primary-care contact and randomized to either treatment or an active control group. The treatment consisted of 7-10 weekly individually assigned modules guided by online therapists. At post-treatment, 46% of the treatment group had achieved clinically significant improvement on the primary outcome measure (CORE-OM) and between-group effect sizes ranged from d = 0.20 to 0.86, with a mean effect of d = 0.59. At one-year follow-up, within-group effect sizes varied between d = 0.53 to 1.00. Cost analysis showed significant reduction of total costs for the ICBT group, the results were maintained at one-year follow-up and the incremental cost-effectiveness ratio favored ICBT compared to control group. Individually tailored ICBT is an effective and cost-effective treatment for primary-care patients with anxiety disorders with or without comorbidities.

TRIAL REGISTRATION

Clinicaltrials.gov: NCT01390168.

Die Evaluation von Therapieeffekten bei sozialen Angststörungen in einer Hochschulambulanz mit verhaltenstherapeutischem Schwerpunkt

Hintergrund: Verhaltenstherapie hat sich bei sozialen Angststörungen in zahlreichen randomisiert-kontrollierten Studien als wirksam erwiesen. Entsprechende Nachweise unter Routinebedingungen sind bislang selten. Fragestellung: Welche Effektstärken, Response- und Remissionsraten können unter Routinebedingungen in einer verhaltenstherapeutisch orientierten Hochschulambulanz bei sozialen Angststörungen erreicht werden? Methode: Es wurden insgesamt 247 Patienten mit sozialer Angststörung zu Therapiebeginn, -ende sowie nach 6 und 12 Monaten untersucht. Ergebnisse: Es ergeben sich signifikante Unterschiede zwischen Prä- und Postmesszeitpunkt. Die Effektstärke der Completer erreichte d = 1.04 und zeigte sich auch zu den Katamnesezeitpunkten stabil. Die Kriterien für Response erreichten 62,5 % der Completer, 39,6 % erreichten durch die Therapie die Kriterien für Remission. Diskussion: Die Therapieeffekte, die unter Routinebedingungen erreicht werden konnten, gelten nach den Konventionen nach Cohen (1992) als hoch und lagen im guten Mittel im Vergleich zu RCTs sowie naturalistischen Studien.

What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing

This study examined client perception of the therapeutic impact of two models of therapy delivered by mental health nurses and clinical psychologists respectively - psychodynamic interpersonal therapy (PIT) and cognitive behavioural therapy (CBT). A non-equivalent groups design was used in order to benchmark results against Llewelyn et al.: one group received PIT and the other received CBT. This design was utilized principally because the research was conducted across two practice settings where randomization was not feasible. We used two intact groups in practice research settings that received the therapies as reported in Llewelyn et al. Sixty-one clients receiving CBT or PIT in practice research settings completed a Helpful Aspects of Therapy form after each session in order to measure client perceptions of helpful and hindering events in therapy. Only two out of the 13 impacts were rated as significantly different. PIT clients reported higher levels of 'awareness' than CBT clients, whereas CBT clients reported higher levels of problem solution than PIT clients. The results replicate Llewelyn et al.'s findings in that clients experienced theoretically different models of therapy as broadly similar in their therapeutic impact. We argue that this provides some support for the influence of 'common' rather than 'specific' factors in psychotherapy effectiveness in mental health nursing.

Cognitive behaviour therapy for common mental disorders in people with Multiple Sclerosis: A bench marking study

BACKGROUND

Mental health problems such as depression and anxiety are common in Multiple Sclerosis (MS) and are often under treated.

AIMS

This paper reports on the clinical effectiveness of a cognitive behaviour therapy service for common mental disorders in people with MS and compares it to previous randomised controlled trials (RCTs) of cognitive behaviour therapy (CBT) in this population.

METHODS

49 patients were deemed appropriate for CBT and 29 accepted treatment. Assessments were completed at baseline and end of treatment and included the Hospital Anxiety & Depression Scale. Results in the form of a standardized effect of treatment were compared with five previous RCTs.

RESULTS

The results from this clinical service indicated statistically significant outcomes with reductions in depression and anxiety. The uncontrolled effect size was large but inferior to those found in published RCTs.

CONCLUSIONS

Cognitive behaviour therapy is effective for people with MS in routine clinical practice. Possible limits on effectiveness include more liberal patient selection, lack of specificity in rating scales and heterogeneity of target problems. Given the high rates of distress in this population, routine psychological interventions within neurology services are justifiable. Future research should aim to maximise CBT in such settings.

The clinical effectiveness of evidence-based interventions for depression: a pragmatic trial in routine practice

BACKGROUND

Controversy persists about how effectively empirically-supported treatments for major depression work in actual clinical practice as well as how patients choose among them. We examined the acute phase effectiveness of cognitive therapy (CT), interpersonal psychotherapy (IPT), and combined psychotherapy-pharmacotherapy (PHT) in a naturalistic setting, allowing patients their choice of treatment.

METHODS

The study compared CT (n=63), IPT (n=56), CT-PHT (n=34), and IPT-PHT (n=21) for 174 subjects with major depression in a secondary care mood disorders clinic. Patient preference, rather than randomization, determined treatment selection. The Beck Depression Inventory-II (BDI) was the primary outcome variable. Exclusion criteria were minimal.

RESULTS

All treatments were associated with a reduction in depressive symptoms, with a 35% remission rate by week 26. Overall improvement was well within ranges reported in efficacy trials. On average, treatment effects of the different interventions straddled the same range, but moderation analyses revealed that BDI scores dropped faster in the first 16 weeks in patients who received CT alone than patients who received CT and pharmacotherapy, a pattern not found in patients who received IPT (with or without pharmacotherapy).

LIMITATIONS

Limitations consist of a modest sample size, choice of treatment was made by participants which may have been influenced by many sources, and the absence of a non-active control group.

CONCLUSIONS

This study supports the effectiveness of empirically-supported antidepressant treatments selected by patients in routine settings, and provides an indication that speed of therapeutic response may vary amongst treatments.

Internet-based cognitive behaviour therapy for tinnitus patients delivered in a regular clinical setting: outcome and analysis of treatment dropout

Cognitive behaviour therapy (CBT) can reduce tinnitus distress but is not available for most patients. Therapist guided, internet-based CBT (ICBT) increase availability and has been shown to be effective. However, the initial positive results need to be replicated in larger samples, and treatment dropout has not been thoroughly studied. Moreover, it has not been evaluated if a low-intensity version of ICBT without therapist contact could be an alternative for patients who do not need or are able to manage the full ICBT-program. This study evaluated two parallel interventions delivered in regular care: ICBT for tinnitus distress (n = 293) and a low-intensity version of ICBT (n = 81) for patients with lower levels of tinnitus distress. We also explored predictors of dropout from ICBT and if dropout influences outcome. Tinnitus Reaction Questionnaire (Wilson, Henry, Bowen, & Haralambous, 1991) was used as the primary outcome. Secondary outcomes were measures of depression, anxiety, sleep, and sound sensitivity. Significant reductions following ICBT were found on all measures after treatment and also at a three-month follow-up. Patients receiving low-intensity ICBT showed a significant reduction in distress, even when they had low levels of distress initially. Treatment dropout was preceded by an increase in days spent at each treatment step but not by an increased distress. Early dropout was related to worse outcome. ICBT can be used in a regular clinical setting to reduce tinnitus distress. Early dropouts may need additional management. For help-seeking patients with lower distress, a low-intensity version of ICBT can be used.

A Study of Patients who go to a Psychology Clinic Seeking Treatment

In order to characterize a typical clinical context, as opposed to an academic or research context, this article will analyze the sociodemographic and clinical characteristics of patients who turn to a psychology clinic in need of professional help. This study was conducted using an initial sample of 1,305 patients at the Universidad Complutense de Madrid (UCM) Clínica Universitaria de Psicología. Of the sociodemographic characteristics studied, it is noteworthy that the majority of patients were women (65%) and relatively young (the average age is 29.7 years-old). The disorders for which psychological help was most often needed were anxiety and mood disorders and relationship problems, which together made up 50% of cases. In 17.70% of cases, patients had at least one comorbid disorder in addition to the one that brought them to the clinic. The generalizability and implications of the results are discussed.

Effectiveness of cognitive-behavioral treatment for major depressive disorder in a university psychology clinic

Major Depressive Disorder (MDD) is the most prevalent mental disorder in our environment, and one of the main causes of disability. While several empirically supported treatments (ESTs) for MDD exist, some doubts have been cast on the applicability--in time, components, and effectiveness--of these ESTs in routine clinical practice. A few attempts have been made to contrast the effectiveness of ESTs, but usually the precise components of the treatment developed are not considered in detail. The purpose of this study is to analyze the components of an EST-based treatment on a sample of 69 MDD cases from a University Psychology Clinic, and to benchmark them against the results of published efficacy studies on ESTs (behavioral activation, cognitive therapy, interpersonal therapy). Results show that treatments delivered at this clinical facility are similar in components, length, and effectiveness (in effect size, completers and improved ratio) to the benchmarked studies. Cognitive restructuring is the most frequent component of the delivered treatments. Therapy results show a 3.12 effect size, and a 55.1% improved ratio over initial sample, an 80% of completers. Results and limitations of the current study, especially those related to sample and center characteristics, are discussed.

Clinically representative research in the psychological therapies: an emerging paradigm

This paper considers the tension between the ‘biology’ and the ‘therapeutic relationship’ camps within mental health nursing, which is focussed on differing conceptualisations of what it is that constitutes evidence and appropriate lines of inquiry. I argue that the struggle that mental health nurses have experienced in delivering evidence-based practice also resides in the thorny issue of methodological inquiry and how it is written into nursing practice. I would suggest that what is alienating to practitioners is the way in which evidence and evidence-based enquiry is generated. This paper offers a line of methodological inquiry that is based in clinical representativeness, a way of conducting and evaluating research to produce an evidence base that is informed from the ‘bottom up’ by ‘practice’. This paper not only contributes to the knowledge base of clinically representative research (CRR) but examines the ways in which this knowledge base has been produced and is currently perpetuated. The following themes are addressed: Processes and outcomes in CRR: I identify key treatment outcomes and processes operating in practice settings and consider with what confidence we can make conclusions on observed outcomes in these settings. I also examine key moderating and mediating processes influencing such outcomes. Practice of CRR: I reflect on the paradigm of CRR giving particular attention to how the paradigm has developed and is maintained. I look at how the relationship of CRR to effifficacy research has influenced paradigm development. Future directions of CRR: I summarise the conclusions of CRR to date and identify points of consensus, disagreement and clarity suggesting in what areas the field has moved forward and whether there are instances where points of conflict have contributed to growth.

Outcomes Following Mindfulness-Based Cognitive Therapy in a Heterogeneous Sample of Adult Outpatients

Research on mindfulness-based cognitive therapy (MBCT; Segal, Williams, & Teasdale, 2002a) has supported the effectiveness of this approach for use with preventing relapse in recurrent depression. This study evaluated the use of MBCT in a heterogeneous sample of 26 psychiatric outpatients with mood and/or anxiety disorders. Results from both completer and intent to treat analyses showed that MBCT was associated with statistically significant improvements in depression, anxiety, stress, and insomnia symptoms. Rates of clinically significant improvement were comparable with effectiveness studies of cognitive behaviour therapy and mindfulness-based stress reduction in heterogeneous samples. It is concluded that MBCT may be of value for a range of psychological presentations, administered in heterogeneous groups. Future, controlled, research is required to further evaluate this conclusion and to investigate mechanisms of change.

Influence of depressive and eating disorders on short- and long-term course of weight after surgical and nonsurgical weight loss treatment

OBJECTIVE

To investigate the influence of depressive and eating disorders on short- and long-term weight loss after surgical and non-surgical weight-reduction treatment. Covariations between the disorders were considered.

METHOD

In a longitudinal naturalistic study, current diagnoses at baseline and lifetime diagnoses of depressive and eating disorders were assessed in participants who were undertaking a very-low-calorie diet (n = 250) and in bariatric surgery patients (n = 153). Lifetime diagnosis of a mental disorder was defined as presence of a mental disorder only in the past. Body weight was measured at baseline, 1 year after baseline, and 4 years after baseline. Mental comorbidity was assessed through use of standardized interviews at baseline. A structural equation modeling procedure was applied to test the associations between course of weight and mental disorders. Analyses were based on the intention to treat samples. Missing values were replaced by use of multiple imputation procedures.

RESULTS

Neither depression nor eating disorders were associated with weight changes at the 1-year follow-up, but a specific effect emerged for bariatric surgery patients after 4 years: depression (current and lifetime) predicted smaller body mass index loss, whereas lifetime diagnosis of eating disorder was associated with greater weight loss.

CONCLUSIONS

Individuals who report depressive disorders prior to bariatric surgery should be monitored more closely in order to identify patients who would benefit from additional therapy with the goal of improving weight-loss outcome.

Effects of the Transcendental Meditation Program on Substance Use among University Students

A randomized wait-list controlled trial (N = 295 university students) of the effects of the Transcendental Meditation program was conducted in an urban setting. Substance use was assessed by self-report at baseline and 3 months later. For smoking and illicit drug use, there were no significant differences between conditions. For alcohol use, sex X intervention condition interactions were significant; TM instruction lowered drinking rates among male but not female students. TM instruction could play a valuable role in reducing alcohol use among male university students. Limitations are noted, along with suggestions for further research.

[Evidence-based treatment of depression: what does the new S3- and national healthcare guideline Unipolar Depression really recommend?]

The paper reflects central recommendations and methodological issues of the new German guidelines for the treatment of depression, as discussed in the article New German Guidelines for the Treatment of Depression - The Central Role of Psychotherapy (Schauenburg et al. 2009). Members of the steering group for these guidelines disagree with the authors' description in several points, especially with reference to the efficacy of pharmacotherapy with antidepressants and psychotherapy, as well as the relationship between both strategies of therapy and their combination in diverse phases of treatment (acute/maintenance). Furthermore, we try to clarify some misunderstandings in matters of the guideline's methodology which arose in the paper cited.

Vorschläge zur Evaluation regulärer Psychotherapien an Hochschulambulanzen im Sinne der Phase-IV-Therapieforschung

Zusammenfassung. Durch den Aufbau psychotherapeutischer Hochschulambulanzen an Universitätsinstituten ist in den letzten Jahren ein enormes Potenzial für die naturalistische Phase-IV-Therapieforschung entstanden. Viele Ambulanzen haben ein System zur kontinuierlichen Evaluation der Behandlungen eingeführt. Das methodische Vorgehen dabei ist jedoch heterogen und erscheint mehr von den lokalen Möglichkeiten als von übergeordneten wissenschaftlichen Überlegungen bestimmt. Dies betrifft die Organisation der Datenerhebung, die Definition des „Produkts Psychotherapie” sowie die Auswertung und Präsentation der Daten. Ein Vergleich zwischen den Ambulanzen und die Zusammenführung von Datensätzen zu ambulanzübergreifenden Analysen ist dadurch erschwert. In diesem Artikel wird daher ein Katalog von Methoden und Vorgehensweisen vorgeschlagen, die aufgrund mehrjähriger Erfahrungen an den Hochschulambulanzen Mainz und Münster entwickelt worden sind. Ziel ist ein möglichst hoher Qualitätsstandard für die Zusammenstellung von Stichproben und die Datenauswertung, der sich an den internationalen Standards randomisiert-kontrollierter Therapiestudien (RCTs) orientiert.

The clinical effectiveness of cognitive therapy for depression in an outpatient clinic

BACKGROUND

Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.

METHOD

This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N=217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.

RESULTS

The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.

LIMITATIONS

The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.

CONCLUSIONS

Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.

Dissemination of cognitive-behavioral treatments for anxiety disorders: Overcoming barriers and improving patient access

Cognitive-behavioral therapies for anxiety disorders are highly efficacious (e.g., Butler, Chapman, Forman, & Beck, 2006; Deacon & Abramowitz, 2004). These treatments nevertheless remain underutilized and difficult to access for many of the patients who suffer from these conditions (e.g., Norton & Hope, 2005). We identify various barriers to the wide-scale dissemination of these treatments, including those that are applicable to empirically supported treatments more generally (e.g., lack of training opportunities, failure to address practitioner concerns) as well as those that may be relatively specific to CBT for anxiety disorders (e.g., practitioner concerns around using exposure interventions). We offer suggestions for overcoming these barriers, including specific guidance about continued accumulation of a supportive research base, making the appeals that are necessary to obtain required funding and organizational support, and the training of practitioners to deliver these treatments. Advocates of CBT for anxiety disorders will need to demonstrate that these treatments are cost effective, if wide-scale dissemination is to occur. In the United States, advocacy with third party payers will also be necessary. Although providing such steps may prove to be a difficult endeavour, the patients who stand to benefit from this work deserve nothing less.

Systematic review of practice-based research on psychological therapies in routine clinic settings

PURPOSE

To review the published material on practice-based research and to compare results with benchmarks derived from efficacy studies.

METHODS

Electronic and manual searches were carried out up to and including 2008. Studies were screened for content relevance and selected according to specified inclusion criteria. Data were extracted from all studies that met criteria and were quality assessed using an adapted version of a checklist designed for the appraisal of both randomized and non-randomized studies of health care interventions. Studies were synthesized according to (1) the type of problem being treated and (2) study design using descriptive and meta-analytic methods where appropriate.

RESULTS

Psychological treatment conducted in routine clinic settings is effective for a range of client problems, particularly common mental health problems (uncontrolled effect size = 1.29; 95% CI = 1.26-1.33, N = 10,842). When benchmarked against data from efficacy studies, practice-based studies yielded effect sizes that fell short of the selected benchmark. In contrast, the practice-based studies achieved the benchmark for percentage of clients meeting a stringent criterion for recovery.

CONCLUSIONS

Clients receiving treatment as normally delivered within routine practice report significant relief of symptoms. However, the result of comparisons with efficacy benchmarks is dependent on the outcome index used. Notwithstanding this, substantive factors are also likely to contribute. Therefore, in addition to attending to methodological issues, further work is required to understand the relative contribution of these factors.

An effectiveness study of group therapy for anxiety disorders

This work examines the transportability of group cognitive-behavioral therapy (GCBT) for a wide range of anxiety disorders to a college counseling center. Participants were 31 clients with a primary diagnosis of generalized anxiety disorder, panic disorder with agoraphobia, social phobia, specific phobia, or obsessive-compulsive disorder who identified dysfunction in one or more of eight daily function areas. Clients were not excluded on the basis of medication use, severity or frequency of panic attacks, age, or comorbidity. Of the 31 participants, there were 17 treatment completers, defined by a minimum of 20 sessions in a flexibly bounded psychotherapy group, who achieved significant reductions in levels of anxiety-related dysfunction. The present study suggests that group cognitive behavioral therapy can be transported to a college counseling center.

Family interventions in the treatment of alcohol and drug problems

Alcohol and drug problems affect not only those using these substances but also family members of the substance user. In this review evidence of the negative impacts substance misuse may have upon families are examined, following which family-focused interventions are reviewed. Several family-focused interventions have been developed. They can be broadly grouped into three types: (1) working with family members to promote the entry and engagement of substance misusers into treatment; (2) joint involvement of family members and substance misusing relatives in the treatment of the latter; and (3) interventions responding to the needs of the family members in their own right. The evidence base for each of the three types is reviewed. Despite methodological weaknesses in this area, a number of conclusions can be advanced that support wider use of family focused interventions in routine practice. Future research needs to focus on (1) pragmatic trials that are more representative of routine clinical settings; (2) cost-effectiveness analyses, in terms of treatment costs and the impact of interventions on costs to society; (3) explore treatment process; and (4) make use of qualitative methods. In addition, there is a need to define more clearly the conceptual underpinnings of the family intervention under study.

Comparison of therapeutic action, style and content in cognitive-behavioural and psychodynamic group therapy under clinically representative conditions

It is still an open question whether psychotherapists adhere to their therapeutic conceptions in routine practice (clinician's treatment adherence) and thus to what extent the two most common approaches, cognitive-behavioural (CBT) and psychodynamic therapy (PDT), differ from each other as theoretically expected (treatment differentiation). This holds true especially in case of group therapy.The study compares essential process components of CBT and PDT group treatments under clinically representative conditions using non-participating observer ratings. Results demonstrate that CBT group therapists use more cognitive, behavioural and psychoeducational strategies, foster self-efficacy to a larger extent and are more supporting and empathetic. PDT group therapists use more interpretative and confrontative interventions and focus on interactional and dynamic aspects. The results strongly support that not only in individual psychotherapy-as shown in prior research-but also in the group setting do CBT and PDT reveal very distinct profiles and that therapists primarily abide by their theoretical training also in clinical practice. They allow one to identify differential process components of the group setting and to trace back parameters of outcome to the process of CBT and PDT for clinical routines.

The Causal Generalization Paradox: The Case of Treatment Outcome Research

Data from psychological experiments pose a causal generalization paradox. Unless the experimental results have some generality, they contribute little to scientific knowledge. Yet, because most experiments use convenience samples rather than probability-based samples, there is almost never a formal justification, or set of rigorous guidelines, for generalizing the study's findings to other populations. This article discusses the causal generalization paradox in the context of outcome findings from experimental evaluations of psychological treatment programs and services. In grappling with the generalization paradox, researchers often make misleading (or at least oversimplified) assumptions. The article analyzes 10 such assumptions, including the belief that a significant experimental treatment effect is likely to be causally generalizable and the belief that the magnitude of a significant experimental effect provides a sound effect size estimate for causal generalization. The article then outlines 10 constructive strategies for assessing and enhancing causal generality. They include strategies involving the scaling level of outcome measures, variable treatment dosages, effectiveness designs, multiple measures, corroboration from observational designs, and the synthesis of multiple studies. Finally, the article's discussion section reviews the conditions under which causal generalizations are justified.

The effectiveness of psychodynamic-interpersonal therapy (PIT) in routine clinical practice: a benchmarking comparison

AIMS

To investigate the effectiveness of psychodynamic-interpersonal therapy (PIT) in a routine clinical practice setting.

METHODS

Full pre-post data were available on 62 out of a total of 67 patients aged between 19 and 60 years. Patients were seen over a 52-month period (2001-2005) receiving a course of PIT therapy (mean number of sessions = 16.9, median number of sessions = 16). The outcomes were assessed using a range of outcome measures: the 32-item version of the Inventory of Interpersonal Problems (IIP-32), the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and the Beck Depression Inventory - Second Edition (BDI-II). Study data were benchmarked against comparative national and local data.

RESULTS

There were significant pre-post reductions on all measures: IIP-32 effect size (ES) = 0.56; CORE-OM ES = 0.76; BDI-II ES = 0.76. Reliable and clinically significant change was achieved by 34% of clients on the BDI-II and by 40% of clients on the CORE-OM. Clients with high pre-therapy levels of interpersonal problems had poorer outcomes.

CONCLUSION

Benchmarking our results against both national and local comparative data showed that our results were less favourable than those obtained where PIT had been used in efficacy trials, but were comparable with reports of other therapies (including cognitive behavioural therapy (CBT)) in routine practice settings. The results show that PIT can yield acceptable clinical outcomes, comparable to CBT in a routine care setting, within the context of current limitations of the practice-based evidence paradigm.

The difficulty of making psychology research and clinical practice relevant to medicine: experiences and observations

Psychology and medicine research and practice have demonstrated substantial and unique bodies of knowledge designed to both improve patient care and respond to contemporary health care needs for use of evidence and cost consciousness. At their full potential they represent a significant paradigm shift in healthcare. Despite impressive successes, it is clear that we are just on the cusp of such a change. These findings have had limited impact and penetration into medical practice, particularly outside of academic medicine and large, organized systems of health care, and there are multiple examples of such limitations in various arenas of health care. There also appear to be common themes to such examples which provide us opportunities to consider how psychologists might move things ahead. They also suggest how our unique position in academic medicine can both limit our impact and provide ways of creating continued shifts in the healthcare paradigm.

Bias in Meta-Analytic Estimates of the Absolute Efficacy of Psychotherapy

Meta-analytic estimates of the absolute efficacy of psychotherapy indicate an effect size of approximately 0.80. However, various biases in primary and meta-analytic studies may have influenced this estimate. This study examines 4 nonsystematic biases that increase error variance (i.e., nonrandomized designs, methodological deficiencies, failure to use the study as the unit of analysis, and violations of homogeneity), 4 underestimation biases that primarily concern psychometric issues (i.e., unreliability of outcome measures, failure to report nonsignificant effect sizes, nonoptimal composite outcome measures, and nonstandardized outcome measures), and 8 overestimation biases (i.e., excluding nonsignificant effects from calculations of effect size estimates, failure to adjust for small sample bias, failure to separate studies using single-group pre–post designs vs. control group designs, using unweighted average effect sizes, analyzing biased partial samples that reflect treatment dropout and research attrition, researcher allegiance bias, publication bias, and wait-list control group bias). Wherever possible, evidence regarding the magnitude of these biases is presented, and methods for addressing these biases separately and collectively are discussed. Implications of the meta-analytic evidence on psychotherapy for the effect sizes of other psychological interventions are also considered.

A vision of the next generation of behavioral therapies research in the addictions

Whither, or wither, empirically supported therapies? Increasingly rigorous research in behavioral therapies has yielded a large number of effective therapies, but comparatively little work, demonstrating that integrating empirically supported therapies (ESTs) into standard practice results in meaningful improvements in patient outcomes. Methodology and strategies for evaluating ESTs and their effectiveness in clinical practice is a fairly recent innovation, and a host of unanswered questions remain regarding issues such as selection among different ESTs and what type of ESTs should be emphasized in dissemination efforts, what type of clinicians should be trained in what type of ESTs, the most effective training strategies for various types of clinicians, the need for ongoing supervision to maintain minimum levels of treatment fidelity and skill. In this review, we call for broader use of new research strategies and methods relevant to dissemination of ESTs; these may include adaptive designs, identification of mechanisms of action to foster greater emphasis on effective change principles, training and adoption trials, as well as novel implementation strategies including computer-assisted therapy and computer-assisted training.