Investigating the dose–response effect in open-ended psychotherapy

Empirical examination of long-term and intensive psychodynamic psychotherapy for severely disturbed patients

Objectives This study examines the effectiveness and efficiency of intensive psychodynamic psychotherapy for severely impaired patients. Method: 104 patients in four public mental health centers underwent intensive psychodynamic psychotherapy. The number and duration of psychiatric hospitalizations were monitored for these patients from one year before therapy to eight years after. Several outcome variables were measured every six months, six times in total over two and a half years, using a longitudinal design. A multi-level analytic approach was applied to account for repeated measurements and missing data. Results: Significant improvement was found in all three symptomatic outcome measures (SCL-90, OQ-45, BDI) throughout treatment. The numbers of psychiatric hospitalizations and psychiatric hospitalization days decreased significantly from the level they were in the year before the start of psychodynamic treatment to three years after the start of treatment. These results were maintained for at least up to eight years. After capitalization, the overall cumulative 127.47-day decrease in hospitalization days equals savings of 115,850 NIS. The average cost of treatment after capitalization was 26,770 NIS. The insurer's estimated direct savings is 89,080 NIS (24,054 $). Conclusion: These findings support the hypothesis that psychodynamic psychotherapy is clinically effective and economically efficient for severely impaired patients.

[Rehabilitation success after psychosomatic rehabilitation as a function of psychotherapy dose]

BACKGROUND

Increasing the effectiveness of psychosomatic rehabilitation by prolonging the treatment is a subject of controversial debate. The number of sessions over time defines the dosage in psychotherapy. While the dose-response model assumes an optimal therapy dose, the good-enough level model assumes a correlation of the rate of change with the total sessions. A randomized control group study was conducted to investigate the extent to which an adaptive therapy concept with a two-week intensive phase and early intervention could increase rehabilitation success.

METHOD

A total of 494 rehabilitants between the ages of 21 and 64 (47% women) who completed a classical or an integrative psychosomatic rehabilitation at the Rehazentrum Oberharz between 2020 and 2022 were analysed. Rehabilitation success was mapped by the Reliable Change Index of individual symptom reduction (depression severity or psychological and somatoform disorders) and as a socio-medical parameter (physician's assessment of potential work ability (WA) after two weeks). Two-factorial ANOVAs and hierarchical binary logistic regressions were calculated, and sick leave before rehabilitation was statistically controlled.

RESULTS

Dosage showed no effect on symptom reduction (p = 0.29) and potential WA after two weeks (p = 0.90). However, when stratified by disease severity, there was a mean effect of dosage (p = 0.05) and twice the probability of WA after two weeks (odds 2.13; p = 0.01) for those with mild disease at the start of measure (p = 0.05).

DISCUSSION

In the early stages of an affective disorder, early and intensified intervention can counteract the chronification of mental disorders.

Socioeconomic status, psychotherapy duration, and return to work from disability due to common mental disorders

Objective Low socioeconomic status (SES) is a risk factor for work disability due to common mental disorders (CMDs), one possible reason being inequal use of services. Psychotherapy is an evidence-based treatment for CMDs. This study examines socioeconomic and sociodemographic differences in psychotherapy attendance and an association of psychotherapy duration with return to work (RTW).Methods The study subjects (N = 12,263) were all Finnish citizens granted a disability pension (DP) due to CMDs in 2010-2012. Numbers of psychotherapy sessions (maximum 200) were collected from the nine-year interval around the DP grant. Socioeconomic and sociodemographic differences in psychotherapy duration (dependent variable) among DP recipients were studied using multinomial logistic regression models, likewise, the association between psychotherapy duration and RTW (dependent variable) among temporary DP recipients was examined.Results Higher SES, female gender, and younger age were positively associated with attending longer psychotherapies and surpassing the early treatment termination level (>10 sessions). Attending 11-60 psychotherapy sessions was positively associated with full RTW and partial RTW, whereas longer psychotherapies were not. Early termination was positively associated with partial RTW only.Conclusion This study demonstrates varying tendencies among CMD patients from different backgrounds to attend long rehabilitative psychotherapies, which may create inequalities in RTW.

Bridging the feedback implementation gap: A comparison of empirical and rational decision rules in naturalistic psychotherapy

Objective: Previous research indicates positive effects of feedback based on rational or empirical decision rules in psychotherapy. The implementation of these usually session-to-session-based feedback systems into clinical practice, however, remains challenging. This study aims to evaluate decision rules based on routine outcome monitoring with reduced assessment frequency. Method: Data routinely collected every 5-20 sessions of N = 3758 patients treated with CBT in an outpatient clinic (Msessions = 42.8, SD = 15.4) were used to develop feedback decision rules based on the expected treatment response and nearest neighbors approach, the reliable change index, and method of percental improvement. The detection of patients at risk of treatment failure served as primary endpoint. Results: Significantly lower reliable improvement, higher reliable deterioration rates, and smaller effect sizes were found for patients identified at risk of treatment failure by all rules. The nearest neighbors-based approach showed the highest sensitivity regarding the detection of reliably deteriorated cases. Conclusion: Consistent with previous research, the empirical models outperformed the rational rules. Still, the first-time used percental improvement-based rule also showed satisfactory results. Overall, the results point to the potential of basic feedback systems that might be easier to implement in practice than session-to-session based systems.

A randomized controlled trial of mindfulness-based cognitive therapy for major depressive disorder in undergraduate students: Dose- response effect, inflammatory markers and BDNF

To examine the dose-response effect of mindfulness-based cognitive therapy (MBCT) for college students with major depressive disorder (MDD), a randomized control trial with MBCT and a wait-list (WL) group was performed. All participants were invited to self-administer a set of questionnaires at baseline, mid-intervention (4th week), and post-intervention (8th week) by the 9-item Patient Health Questionnaire (PHQ-9), the 7-item Generalized Anxiety Disorder scale (GAD-7), the Pittsburgh Sleep Quality Index (PSQI), the Five Facet Mindfulness Questionnaire (FFMQ), the Self-Compassion Scale (SCS). The serum levels of IL-1β, IL-6, IL-8, TNF-α, BDNF were detected at baseline and post-intervention. After intervention, the scores of PHQ-9, GAD-7, PSQI, and the levels of IL-1β, IL-6, IL-8 and TNF-α in the MBCT were significantly lower than those in WL group, and total scores of FFMQ, SCS, and the level of BDNF were significantly higher than those in WL group. In MBCT group, daily practice time and session numbers positively related to reduction rates of PHQ-9, GAD-7 and PSQI at post-intervention. The reduction rate of PHQ-9, GAD-7 and PSQI at post-intervention in the completers were higher significantly than those in the partial attendees. These findings suggested MBCT is effective for MDD, and the intervention has a dose-response effect. TRIAL REGISTRATION: Registration number is [ChiCTR2100044309].

Reduction of Mental Health-Related Emergency Department Admissions for Youth and Young Adults Following a Remote Intensive Outpatient Program: Quality Improvement Analysis

BACKGROUND

Pediatric mental health emergency department (ED) visits are increasing at 6% to 10% per year, at substantial cost, while 13% of youth with psychiatric hospitalizations are readmitted in the following weeks. Hospitals do not have the resources to meet escalating youth's mental health needs. Intensive outpatient (IOP) programs, which provide multiple hours of care each week, have the power to reduce the number of patients in need of hospitalized care and provide a step-down option for patients discharging from ED's in order to prevent readmissions.

OBJECTIVE

The purpose of this program evaluation was to assess (1) whether youth and young adult ED admission rates decreased following participation in a remote IOP program and (2) whether there were differences in readmission rates between youth and young adults by gender identity, sexual orientation, race, or ethnicity.

METHODS

Data were collected from intake and 3-month postdischarge surveys for 735 clients who attended at least 6 sessions of a remote IOP program for youth and young adults. Patients reported if they had been admitted to an ED within the previous 30 days and the admission reason. Over half (407/707, 57.6%) of clients were adolescents and the rest were young adults (300/707, 42.4%; mean age 18.25, SD 4.94 years). The sample was diverse in gender identity (329/687, 47.9% female; 196/687, 28.5% male; and 65/669, 9.7% nonbinary) and sexual orientation (248/635, 39.1% heterosexual; 137/635, 21.6% bisexual; 80/635, 10.9% pansexual; and 170/635, 26.8% other sexual orientation) and represented several racial (9/481, 1.9% Asian; 48/481, 10% Black; 9/481, 1.9% Indigenous; 380/481, 79% White; and 35/481, 7.2% other) and ethnic identities (112/455, 24.6% Hispanic and 28/455, 6.2% other ethnic identity).

RESULTS

Mental health-related ED admissions significantly decreased between intake and 3 months after discharge, such that 94% (65/69) of clients with a recent history of mental health-related ED admissions at IOP intake reported no mental health-related ED admissions at 3 months after discharge from treatment (χ21=38.8, P<.001). There were no differences in ED admissions at intake or in improvement at 3 months after discharge by age, gender, sexuality, race, or ethnicity.

CONCLUSIONS

This study documents a decrease in ED admissions between intake and 3 months after discharge among both youth and young adults who engage in IOP care following ED visits. The similar outcomes across demographic groups indicate that youth and young adults experience similar decreases after the current tracks of programming. Future research could conduct a full return-on-investment analysis for intensive mental health services for youth and young adults.

Trajectories of change among highly challenging patients in intensive long-term psychoanalytic psychotherapy

OBJECTIVES

This study aimed to identify and describe trajectories of change in distress among highly challenging patients who had received long and intensive psychoanalytic psychotherapy.

METHODS

The longitudinal version of the K-means algorithm was applied to the outcome measures data of 74 patients treated in four public mental health centers. The patients were measured five times at 6-month intervals for three outcome measures.

RESULTS

For the OQ45 and Symptom Checklist-90, one trajectory was marked by a lower initial distress level. In this trajectory, the improvement occurred in the first half of the measurements, with a plateau thereafter. A second trajectory was characterized by higher initial severity and an improvement, mainly in the second part of the measurements. For the Beck Depression Inventory, one trajectory was marked by lower initial distress. In this group, the improvement occurred throughout the entire period. The remaining patients were characterized by higher initial distress and a decreased level of distress in the last part of treatment. They began to improve only during the third year of therapy.

CONCLUSION

The response to treatment is not uniform in long-term treatment for highly challenging patients. A significant number of patients require a longer period of therapy to ignite improvement.

Transgender and gender diverse adults' self-reported mental health diagnoses, engagement in mental health services, and perceptions of therapists

OBJECTIVE

Transgender and gender diverse (TGD) people face various challenges when seeking therapy. Given this, we wanted to understand more about TGD people's perceptions of providers and how these compare to researcher ratings of providers on metrics of affirming practice.

METHOD

The sample included 158 TGD adults (M_age = 33.06); 57.6% were in therapy. Participants completed measures about mental health, resilience, and therapy. We systematically coded provider websites and intake forms.

RESULTS

Participants in therapy were older, had higher depression, and lower resilience than participants not in therapy. Non-binary/genderqueer participants rated providers as less knowledgeable compared to trans feminine participants. Overall, participants appeared satisfied (71.4% extremely satisfied) and viewed providers as at least moderately knowledgeable (89.1%). Provider coding revealed variation across the markers of affirmation; 66.04% identified a TGD-specialty and only 26.42% shared provider pronouns. Higher frequency of inclusivity (via coding) was related to higher ratings of provider knowledge and more of a focus on gender, however, there was not a significant association with satisfaction.

CONCLUSIONS

Providers who engaged in more affirming practices were more knowledgeable compared to those who engaged in fewer affirming practices. This may influence the content of therapy and whether clients feel comfortable discussing gender.

Digital Interventions to Enhance Readiness for Psychological Therapy: Scoping Review

BACKGROUND

Psychological therapy is an effective treatment method for mental illness; however, many people with mental illness do not seek treatment or drop out of treatment early. Increasing client uptake and engagement in therapy is key to addressing the escalating global problem of mental illness. Attitudinal barriers, such as a lack of motivation, are a leading cause of low engagement in therapy. Digital interventions to increase motivation and readiness for change hold promise as accessible and scalable solutions; however, little is known about the range of interventions being used and their feasibility as a means to increase engagement with therapy.

OBJECTIVE

This review aimed to define the emerging field of digital interventions to enhance readiness for psychological therapy and detect gaps in the literature.

METHODS

A literature search was conducted in PubMed, PsycINFO, PsycARTICLES, Scopus, Embase, ACM Guide to Computing Literature, and IEEE Xplore Digital Library from January 1, 2006, to November 30, 2021. The PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) methodology was applied. Publications were included when they concerned a digitally delivered intervention, a specific target of which was enhancing engagement with further psychological treatment, and when this intervention occurred before the target psychological treatment.

RESULTS

A total of 45 publications met the inclusion criteria. The conditions included depression, unspecified general mental health, comorbid anxiety and depression, smoking, eating disorders, suicide, social anxiety, substance use, gambling, and psychosis. Almost half of the interventions (22/48, 46%) were web-based programs; the other formats included screening tools, videos, apps, and websites. The components of the interventions included psychoeducation, symptom assessment and feedback, information on treatment options and referrals, client testimonials, expectation management, and pro-con lists. Regarding feasibility, of the 16 controlled studies, 7 (44%) measuring actual behavior or action showed evidence of intervention effectiveness compared with controls, 7 (44%) found no differences, and 2 (12%) indicated worse behavioral outcomes. In general, the outcomes were mixed and inconclusive owing to variations in trial designs, control types, and outcome measures.

CONCLUSIONS

Digital interventions to enhance readiness for psychological therapy are broad and varied. Although these easily accessible digital approaches show potential as a means of preparing people for therapy, they are not without risks. The complex nature of stigma, motivation, and individual emotional responses toward engaging in treatment for mental health difficulties suggests that a careful approach is needed when developing and evaluating digital readiness interventions. Further qualitative, naturalistic, and longitudinal research is needed to deepen our knowledge in this area.

Effectiveness of Nature- and Animal Assisted Mindfulness for Relapse Prevention in Depressed Patients With a History of Childhood Maltreatment

BACKGROUND

For relapse prevention in depression, conventional mindfulness programs such as the mindfulness-based cognitive therapy proved to be useful. However, early life trauma is a risk factor for having adverse experiences during meditation. Thus, for this patient group mindfulness skills are often difficult to learn and may be facilitated by using animals and a nature setting.

METHODS

The aim of the study was to evaluate the preventative efficacy of a nature- and animal assisted mindfulness program (NAM) over the course of 1 year in unstable or partially remitted depressed patients with a history of early life trauma. NAM included 8 group sessions of 150 min each over 8 weeks plus one booster session. Sixty-seven participants were randomized to either NAM combined with treatment-as-usual (TAU; guideline oriented treatment) or TAU alone. The primary outcome was depression diagnosis over the course of 12 months after end of treatment. Secondary outcomes included clinician- and self-rated depressive symptoms, quality of life, mindfulness skills, and rumination post, and 12 months after the intervention. In addition, we evaluated the participants' satisfaction with the program.

RESULTS

Analyses revealed significant differences in relapse rates and number of weeks depressed throughout the course in favor of NAM. Furthermore, global quality of life improved significantly more in the NAM group. There was no significant difference for other secondary outcomes. Satisfaction with the program was high with a low drop-out rate of 6%. The vast majority of the participants felt safe practicing mindfulness in nature and found sheep for assistance helpful and motivating.

CONCLUSIONS

A nature- and animal assisted mindfulness program proved to be feasible, highly acceptable, and more effective than standard treatment in preventing relapses in recurrently depressed patients with childhood maltreatment. Nature and animals can facilitate the engagement in the treatment process for individuals with a history of early trauma. However, further evidence in multicenter trials is necessary.

Measurement-Based and Data-Informed Psychological Therapy

Outcome measurement in the field of psychotherapy has developed considerably in the last decade. This review discusses key issues related to outcome measurement, modeling, and implementation of data-informed and measurement-based psychological therapy. First, an overview is provided, covering the rationale of outcome measurement by acknowledging some of the limitations of clinical judgment. Second, different models of outcome measurement are discussed, including pre-post, session-by-session, and higher-resolution intensive outcome assessments. Third, important concepts related to modeling patterns of change are addressed, including early response, dose-response, and nonlinear change. Furthermore, rational and empirical decision tools are discussed as the foundation for measurement-based therapy. Fourth, examples of clinical applications are presented, which show great promise to support the personalization of therapy and to prevent treatment failure. Finally, we build on continuous outcome measurement as the basis for a broader understanding of clinical concepts and data-driven clinical practice in the future. Expected final online publication date for the Annual Review of Clinical Psychology, Volume 18 is May 2022. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

Matching research and practice: Prediction of individual patient progress and dropout risk for basic routine outcome monitoring

OBJECTIVE

Despite evidence showing that systematic outcome monitoring can prevent treatment failure, the practical conditions that allow for implementation are seldom met in naturalistic psychological services. In the context of limited time and resources, session-by-session evaluation is rare in most clinical settings. This study aimed to validate innovative prediction methods for individual treatment progress and dropout risk based on basic outcome monitoring.

METHODS

Routine data of a naturalistic psychotherapy outpatient sample were analyzed (N = 3902). Patients were treated with cognitive behavioral therapy with up to 95 sessions (M = 39.19, SD = 16.99) and assessment intervals of 5-15 sessions. Treatment progress and dropout risk were predicted in two independent analyses using the nearest neighbor method and least absolute shrinkage and selection operator regression, respectively.

RESULTS

The correlation between observed and predicted patient progress was r = .46. Intrinsic treatment motivation, previous inpatient treatment, university-entrance qualification, baseline impairment, diagnosed personality disorder, and diagnosed eating disorder were identified as significant predictors of dropout, explaining 11% of variance.

CONCLUSIONS

Innovative outcome prediction in naturalistic psychotherapy is not limited to elaborated progress monitoring. This study demonstrates a reasonable approach for tracking patient progress as long as session-by-session assessment is not a valid standard.