Assessing practical implementation of modular psychotherapy for youth in community-based settings using benchmarking

Algorithm-based modular psychotherapy vs. cognitive-behavioral therapy for patients with depression, psychiatric comorbidities and early trauma: a proof-of-concept randomized controlled trial

Effect sizes of psychotherapies currently stagnate at a low-to-moderate level. Personalizing psychotherapy by algorithm-based modular procedures promises improved outcomes, greater flexibility, and a better fit between research and practice. However, evidence for the feasibility and efficacy of modular-based psychotherapy, using a personalized treatment algorithm, is lacking. This proof-of-concept randomized controlled trial was conducted in 70 adult outpatients with a primary DSM-5 diagnosis of major depressive disorder, a score higher than 18 on the 24-item Hamilton Rating Scale for Depression (HRSD-24), at least one comorbid psychiatric diagnosis according to the Structured Clinical Interview for DSM-5 (SCID-5), a history of at least "moderate to severe" childhood maltreatment on at least one domain of the Childhood Trauma Questionnaire (CTQ), and exceeding the cut-off value on at least one of three measures of early trauma-related transdiagnostic mechanisms: the Rejection Sensitivity Questionnaire (RSQ), the Interpersonal Reactivity Index (IRI), and the Difficulties in Emotion Regulation Scale-16 (DERS-16). Patients were randomized to 20 sessions of either standard cognitive-behavioral therapy alone (CBT) or CBT plus transdiagnostic modules according to a mechanism-based treatment algorithm (MoBa), over 16 weeks. We aimed to assess the feasibility of MoBa, and to compare MoBa vs. CBT with respect to participants' and therapists' overall satisfaction and ratings of therapeutic alliance (using the Working Alliance Inventory - Short Revised, WAI-SR), efficacy, impact on early trauma-related transdiagnostic mechanisms, and safety. The primary outcome for efficacy was the HRSD-24 score at post-treatment. Secondary outcomes included, among others, the rate of response (defined as a reduction of the HRSD-24 score by at least 50% from baseline and a score <16 at post-treatment), the rate of remission (defined as a HRSD-24 score ≤8 at post-treatment), and improvements in early trauma-related mechanisms of social threat response, hyperarousal, and social processes/empathy. We found no difficulties in the selection of the transdiagnostic modules in the individual patients, applying the above-mentioned cut-offs, and in the implementation of MoBa. Both participants and therapists reported higher overall satisfaction and had higher WAI-SR ratings with MoBa than CBT. Both approaches led to major reductions of depressive symptoms at post-treatment, with a non-significant superiority of MoBa over CBT. Patients randomized to MoBa were nearly three times as likely to experience remission at the end of therapy (29.4% vs. 11.4%; odds ratio, OR = 3.2, 95% CI: 0.9-11.6). Among mechanism-based outcomes, MoBa patients showed a significantly higher post-treatment effect on social processes/empathy (p<0.05) compared to CBT patients, who presented an exacerbation on this domain at post-treatment. Substantially less adverse events were reported for MoBa compared to CBT. These results suggest the feasibility and acceptability of an algorithm-based modular psychotherapy complementing CBT in depressed patients with psychiatric comorbidities and early trauma. While initial evidence of efficacy was observed, potential clinical advantages and interindividual heterogeneity in treatment outcomes will have to be investigated in fully powered confirmation trials.

A Pilot Project to Integrate Individualized Measurement Into Measurement-Based Care in a Child Partial Hospitalization Program

Measurement-based care (MBC), or the regular use of progress measures to inform clinical decision-making, improves quality of care and clinical outcomes. MBC typically focuses on standardized rather than individualized outcome measurement. In this pilot study, we examined the clinical utility of integrating individualized measurement with existing standardized outcome monitoring in a children's partial hospitalization program. Participants were 48 youth (M age 10.13 ± 1.39; 54.2% male, 41.7% female, 4.2% transgender or nonbinary). Comorbidity was common; 83.4% of youth had more than one diagnosis at intake. Using the Youth Top Problems for individualized outcome measurement, we examined Top Problem content and clinical improvement over time. Finally, we examined completion rates and describe implementation issues. Top Problems were heterogeneous and sensitive to change. Of the 144 problems, 107 (74%) had a focus consistent with measures used in program, while 37 (26%) were not captured by standardized measures used in program. Effect sizes from admission to final measurement ranged from Cohen's d = .75 - 1.00. Initial adoption of the MBC was strong, but sustained use of the system over the treatment course was challenging. Individualized outcome measurement in children's partial hospitalization programs is feasible to administer and sensitive to clinical change that is unique from change captured in standardized measures. Parents were able to self-identify clinically meaningful, highly individualized Top Problems. Challenges of implementation and clinical assessment in acute settings and potential strategies for improving implementation are discussed.