The generalizability of psychotherapy efficacy trials in major depressive disorder: an analysis of the influence of patient selection in efficacy trials on symptom outcome in daily practice

Model of integrated mental health video consultations for people with depression or anxiety in primary care (PROVIDE-C): assessor masked, multicentre, randomised controlled trial

OBJECTIVE

To evaluate whether an integrated mental health video consultation approach (PROVIDE model) can improve symptoms compared with usual care in adults with depression and anxiety disorders attending primary care.

DESIGN

Assessor masked, multicentre, randomised controlled trial (PROVIDE-C).

SETTING

In 29 primary care practices in Germany, working remotely online from one trial hub.

PARTICIPANTS

376 adults (18-81 years) who presented to their general practitioner (GP) with depression or anxiety, or both.

INTERVENTION

Participants were randomised (1:1) to receive the PROVIDE model (n=187) or usual care (n=189). Usual care was provided by GPs through interventions such as brief counselling and psychotropic medication prescriptions and may or may not have included referrals to mental health specialists. The PROVIDE model comprised transdiagnostic treatment provided through five real-time video sessions between the patient at the primary care practice and a mental health specialist at an offsite location.

MAIN OUTCOME MEASURES

The primary outcome was the absolute change in the mean severity of depressive and anxiety symptoms measured using the patient health questionnaire anxiety and depression scale (PHQ-ADS) at six months, in the intention-to-treat population. Secondary outcomes, measured at six and 12 months, included PHQ-ADS subscores, psychological distress related to somatic symptoms, recovery, health related quality of life, quality and patient centredness of chronic illness care, and adverse events.

RESULTS

Between 24 March 2020 and 23 November 2021, 376 patients were randomised into treatment groups. Mean age was 45 years (standard deviation (SD) 14), 63% of the participants were female, and mean PHQ-ADS-score was 26 points (SD 7.6). Compared with usual care, the PROVIDE intervention led to improvements in severity of depressive and anxiety symptom (adjusted mean change difference in the PHQ-ADS score -2.4 points (95% confidence interval -4.5 to -0.4), P=0.02) at six months. The effects were sustained at 12 months (-2.9 (-5.0 to -0.7), P<0.01). No serious adverse events were reported in either group.

CONCLUSIONS

Through relatively low intensity treatment, the PROVIDE model led to a decrease in depressive and anxiety symptoms with small effects in the short and long term. Depression and anxiety disorders are prevalent and therefore the small effect might cumulatively impact on population health in this population.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04316572.

The outcomes of mental health care for depression over time: A meta-regression analysis of response rates in usual care

BACKGROUND

Over the past decades dozens of randomized trials have shown that psychological treatments are more effective than care-as-usual (CAU). It could be expected that these treatments are implemented in routine care and that the response rates in usual care improve over time. The aim of the current meta-analysis is to examine if response and remission rates in usual care have improved over time.

METHODS

We used an existing meta-analytic database of randomized controlled trials examining the effects of psychological treatments of depression and selected CAU control groups from these trials. We only included CAU conditions in primary care, specialized mental health care, perinatal care and general medical care. The response rate (50 % symptom reduction) was the primary outcome.

RESULTS

We included 125 CAU control groups (8542 participants). The response rate for all CAU control groups was 0.22 (95 % CI: 0.19; 0.24) with high heterogeneity (I2 = 83; 95 % CI: 80; 85), with somewhat higher rates in primary care (0.27; 95 % CI: 0.23; 0.31). We found hardly any indications that the outcomes have improved over the years. The meta-regression analysis with publication year as predictor in the full dataset resulted in a coefficient of 0.1 (SE = 0.01; p = 0.0.35). A series of sensitivity analyses supported the main findings. Remission rates and pre-post effect sizes also did not significantly improve over time.

CONCLUSIONS

Response and remission rates in usual care are low, with the large majority of patients not responding or remitting, and the outcomes have probably not improved over time.

Internet-Guided Cognitive Behavioral Therapy for Insomnia Among Patients With Traumatic Brain Injury: A Randomized Clinical Trial

Importance

Many military service members and veterans report insomnia after sustaining traumatic brain injury (TBI). Limitations of first-line treatment, cognitive-behavioral therapy for insomnia (CBT-I), include availability of qualified clinicians, low completion rates, and cost.

Objective

To investigate the feasibility and efficacy of internet-guided CBT-I (eCBT-I) in military service members and veterans with insomnia and a history of TBI.

Design, Setting, and Participants

This randomized clinical trial of fully remote internet-based interventions and evaluations was conducted from September 1, 2020, to June 30, 2021, with 3 months of follow-up. Participants included a volunteer sample of military service members and veterans aged 18 to 64 years with a history of mild TBI/concussion and at least moderately severe insomnia defined as an insomnia severity index (ISI) score of greater than 14 and Pittsburgh Sleep Quality Index of greater than 4. Self-reported race, ethnicity, and educational level were generally representative of the US military. Data were analyzed from October 21, 2021, to April 29, 2024.

Intervention

Internet-based CBT-I delivered over 6 weekly lesson modules with assigned homework activities.

Main Outcomes and Measures

The prespecified primary outcome measure was change in ISI score over time. Prespecified secondary outcome measures included self-reported measures of depression symptoms, posttraumatic stress disorder (PTSD) symptoms, sleep quality, migraine impact, and fatigue.

Results

Of 204 people screened, 125 were randomized 3:1 to eCBT-I vs online sleep education, and 106 completed baseline evaluations (83 men [78.3%]; mean [SD] age, 42 [12] years). Of these, 22 participants (20.8%) were Hispanic or Latino and 78 (73.6%) were White. Fifty participants completed postintervention evaluations, and 41 completed the 3-month follow-up. Baseline mean (SD) ISI scores were 19.7 (4.0) in those randomized to eCBT-I and 18.9 (5.0) in those randomized to sleep education. After intervention, mean (SD) ISI scores were 13.7 (5.6) in those randomized to eCBT-I and 16.6 (5.7) in those randomized to sleep education. The difference in the extent of reduction in ISI scores between groups was 3.5 (95% CI,-6.5 to -0.4 [P = .03]; Cohen d, -0.32 [95% CI, -0.70 to -0.04]). In the eCBT-I group, the extent of insomnia improvement correlated with the extent of depressive symptom improvement (Spearman ρ = 0.68 [P < .001]), PTSD symptoms (ρ = 0.36 [P = .04]), sleep quality (ρ = 0.54 [P = .001]), and fatigue impact (ρ = -0.58 [P < .001]) but not migraine-related disability.

Conclusions and Relevance

The findings of this randomized clinical trial suggest that fully remote eCBT-I was moderately feasible and effective for self-reported insomnia and depression symptoms in military service members and veterans with a history of TBI. There is great potential benefit for eCBT-I due to low availability and cost of qualified CBT-I clinicians, although optimization of completion rates remains a challenge. Future studies may use home-based objective sleep assessments and should increase study retention.

Trial Registration

ClinicalTrials.gov Identifier: NCT04377009.

The Effectiveness of Psychological Interventions Delivered in Routine Practice: Systematic Review and Meta-analysis

This review presents a comprehensive evaluation of the effectiveness of routinely delivered psychological therapies across inpatient, outpatient and University-based clinics. This was a pre-registered systematic-review of studies meeting pre-specified inclusion criteria (CRD42020175235). Eligible studies were searched in three databases: MEDLINE, CINAHL and PsycInfo. Pre-post treatment (uncontrolled) effect sizes were calculated and pooled using random effects meta-analysis to generate effectiveness benchmarks. Moderator analyses were used to examine sources of heterogeneity in effect sizes. Overall, 252 studies (k = 298 samples) were identified, of which 223 (k = 263 samples) provided sufficient data for inclusion in meta-analysis. Results showed large pre-post treatment effects for depression [d = 0.96, (CI 0.88-1.04), p ≤ 0.001, k = 122], anxiety [d = 0.8 (CI 0.71-0.9), p ≤ 0.001, k = 69], and other outcomes [d = 1.01 (CI 0.93-1.09), p ≤ 0.001, k = 158]. This review provides support for the effectiveness of routinely delivered psychological therapy. Effectiveness benchmarks are supplied to support service evaluations across multiple settings.

Psychological online interventions for problem gambling and gambling disorder - A meta-analytic approach

OBJECTIVE

The Covid-19 pandemic has reignited discussions about the prevalence of and treatment options for problem gambling and gambling disorder (PGGD). Since affected persons seldom seek professional help, online interventions can improve accessibility. Thus, this study aimed to investigate the effectiveness of psychological online interventions on PGGD.

METHODS

We conducted a systematic review and meta-analysis and searched in PubMed, PsycINFO, and Google Scholar for peer-reviewed experimental and quasi-experimental research published between 2010 and 2021. We calculated two meta-anlyses, one for treatment control comparisons (TCC), and one for pre-post-comparisons (PCC).

RESULTS

We included six studies (ten TCC and n = 2076) in meta-analysis 1 and five studies (six PCC and n = 781) in meta-analysis 2. Online interventions turned out to be effective in both analyses with Hedges g = 0.41, 95% confidence interval = [0.22 to 0.60], p < .001, for meta-anaylsis 1 and Hegdes g = 1.28, 95% confidence interval = [0.85 to 1.71], p < .001, for meta-analysis 2.

CONCLUSIONS

We identified significant effects of online interventions on PGGD in both analyses, indicating the potential of online applications. We discuss methodological aspects and further research directions.

Telehealth Services for Substance Use Disorders During the COVID-19 Pandemic: Longitudinal Assessment of Intensive Outpatient Programming and Data Collection Practices

BACKGROUND

The onset of the COVID-19 pandemic necessitated the rapid transition of many types of substance use disorder (SUD) treatments to telehealth formats, despite limited information about what makes treatment effective in this novel format.

OBJECTIVE

This study aims to examine the feasibility and effectiveness of virtual intensive outpatient programming (IOP) treatment for SUD in the context of a global pandemic, while considering the unique challenges posed to data collection during an unprecedented public health crisis.

METHODS

The study is based on a longitudinal study with a baseline sample of 3642 patients who enrolled in intensive outpatient addiction treatment (in-person, hybrid, or virtual care) from January 2020 to March 2021 at a large substance use treatment center in the United States. The analytical sample consisted of patients who completed the 3-month postdischarge outcome survey as part of routine outcome monitoring (n=1060, 29.1% response rate).

RESULTS

No significant differences were detected by delivery format in continuous abstinence (χ22=0.4, P=.81), overall quality of life (F2,826=2.06, P=.13), financial well-being (F2,767=2.30, P=.10), psychological well-being (F2,918=0.72, P=.49), and confidence in one's ability to stay sober (F2,941=0.21, P=.81). Individuals in hybrid programming were more likely to report a higher level of general health than those in virtual IOP (F2,917=4.19, P=.01).

CONCLUSIONS

Virtual outpatient care for the treatment of SUD is a feasible alternative to in-person-only programming, leading to similar self-reported outcomes at 3 months postdischarge. Given the many obstacles presented throughout data collection during a pandemic, further research is needed to better understand under what conditions telehealth is an acceptable alternative to in-person care.

More treatment but no less depression: The treatment-prevalence paradox

Treatments for depression have improved, and their availability has markedly increased since the 1980s. Mysteriously the general population prevalence of depression has not decreased. This "treatment-prevalence paradox" (TPP) raises fundamental questions about the diagnosis and treatment of depression. We propose and evaluate seven explanations for the TPP. First, two explanations assume that improved and more widely available treatments have reduced prevalence, but that the reduction has been offset by an increase in: 1) misdiagnosing distress as depression, yielding more "false positive" diagnoses; or 2) an actual increase in depression incidence. Second, the remaining five explanations assume prevalence has not decreased, but suggest that: 3) treatments are less efficacious and 4) less enduring than the literature suggests; 5) trial efficacy doesn't generalize to real-world settings; 6) population-level treatment impact differs for chronic-recurrent versus non-recurrent cases; and 7) treatments have some iatrogenic consequences. Any of these seven explanations could undermine treatment impact on prevalence, thereby helping to explain the TPP. Our analysis reveals that there is little evidence that incidence or prevalence have increased as a result of error or fact (Explanations 1 and 2), and strong evidence that (a) the published literature overestimates short- and long-term treatment efficacy, (b) treatments are considerably less effective as deployed in "real world" settings, and (c) treatment impact differs substantially for chronic-recurrent cases relative to non-recurrent cases. Collectively, these a-c explanations likely account for most of the TPP. Lastly, little research exists on iatrogenic effects of current treatments (Explanation 7), but further exploration is critical.

Interpersonal Psychotherapy: A Scoping Review and Historical Perspective (1974-2017)

BACKGROUND

Interpersonal Psychotherapy (IPT) is an affect- and relationally focused, time-limited treatment supported by research spanning >4 decades. IPT focuses on stressful interpersonal experiences of loss, life changes, disputes, and social isolation. It emphasizes the role of relationships in recovery. This scoping review describes, within a historical perspective, IPT's evolution as an evidence-supported treatment of psychiatric disorders.

METHODS

English-language publications (n = 1119) identified via EMBASE, MEDLINE, PsycINFO, and Web of Science databases (1974-2017), augmented with manual reference searches, were coded for clinical focus, population demographics, format, setting, publication type, and research type. Quantitative and qualitative analyses identified IPT publications' characteristics and trends over four epochs of psychotherapy research.

RESULTS

IPT literature primarily focused on depression (n = 772 articles; 69%), eating disorders (n = 135; 12%), anxiety disorders (n = 68; 6%), and bipolar disorder (n = 44; 4%), with rising publication rates and numbers of well-conducted randomized, controlled trials over time, justifying inclusion in consensus treatment guidelines. Research trends shifted from efficacy trials to effectiveness studies and population-based dissemination initiatives. Process research examined correlates of improvement and efficacy moderators. Innovations included global initiatives, prevention trials, and digital, web-based training and treatment.

CONCLUSION

Sparked by clinical innovations and scientific advances, IPT has evolved as an effective treatment of psychiatric disorders across the lifespan for diverse patients, including underserved clinical populations. Future research to elucidate mechanisms of change, improve access, and adapt to changing frameworks of psychopathology and treatment planning is needed. IPT addresses the universal centrality of relationships to mental health, which is as relevant today as it was over 40 years ago.

Lower versus higher frequency of sessions in starting outpatient mental health care and the risk of a chronic course; a naturalistic cohort study

BACKGROUND

An adequate frequency of treatment might be a prerequisite for a favorable outcome. Unfortunately, there is a diversity of factors that interfere with an adequate frequency of sessions. This occurs especially in the first phase of treatment, while the first phase seems vital for the rest of treatment. The aim of this naturalistic study was to explore the impact of the initial frequency of treatment sessions on treatment outcome in a diverse mental health care population.

METHODS

Anonymized data were analyzed from 2,634 patients allocated for anxiety disorders, depressive disorders, and personality disorders to outpatient treatment programs in a large general mental health care facility. Patients' treatment outcome was routinely monitored with the Outcome Questionnaire-45 (OQ-45.2), every 12 weeks. Frequency of sessions was assessed for the first three months of treatment. Using Cox-proportional-hazard models, we explored the associations between initial frequency and improvement (reliable significant change) and recovery (reliable and clinically significant change).

RESULTS

Improvement and recovery were associated with symptom severity and functional impairment at start of treatment, the year the treatment started, number of measurements, the treatment program (anxiety disorders, depressive disorders, and personality disorders) and receiving group therapy other than psychotherapy. In all diagnostic groups, both improvement and recovery were associated with a higher frequency of sessions during the first three months of treatment. For improvement, this effect diminished after three years in treatment; however, for recovery this association was sustained.

CONCLUSIONS

In addition to severity at start of treatment and other predictors of outcome, a low frequency of initial treatment sessions might lead to a less favorable outcome and a more chronic course of the mental disorder. This association seems not to be limited to a specific diagnostic group, but was found in a large group of patients with common mental disorders (depression and anxiety disorders) and patients with a personality disorder. Despite organizational obstacles, more effort should be made to start treatment quickly by an effective frequency of session.

Psychology's Replication Crisis and Clinical Psychological Science

Despite psychological scientists' increasing interest in replicability, open science, research transparency, and the improvement of methods and practices, the clinical psychology community has been slow to engage. This has been shifting more recently, and with this review, we hope to facilitate this emerging dialogue. We begin by examining some potential areas of weakness in clinical psychology in terms of methods, practices, and evidentiary base. We then discuss a select overview of solutions, tools, and current concerns of the reform movement from a clinical psychological science perspective. We examine areas of clinical science expertise (e.g., implementation science) that should be leveraged to inform open science and reform efforts. Finally, we reiterate the call to clinical psychologists to increase their efforts toward reform that can further improve the credibility of clinical psychological science.

The Generalizability of Randomized Controlled Trials of Self-Guided Internet-Based Cognitive Behavioral Therapy for Depressive Symptoms: Systematic Review and Meta-Regression Analysis

Background

Self-guided internet-based cognitive behavioral therapies (iCBTs) for depressive symptoms may substantially increase accessibility to mental health treatment. Despite this, questions remain as to the generalizability of the research on self-guided iCBT.

Objective

We sought to describe the clinical entry criteria used in studies of self-guided iCBT, explore the criteria’s effects on study outcomes, and compare the frequency of use of these criteria with their use in studies of face-to-face psychotherapy and antidepressant medications. We hypothesized that self-guided iCBT studies would use more stringent criteria that would bias the sample toward those with a less complex clinical profile, thus inflating treatment outcomes.

Methods

We updated a recently published meta-analysis by conducting a systematic literature search in PubMed, MEDLINE, PsycINFO, and EMBASE. We conducted a meta-regression analysis to test the effect of the different commonly used psychiatric entry criteria on the treatment-control differences. We also compared the frequency with which exclusion criteria were used in the self-guided iCBT studies versus studies of face-to-face psychotherapy and antidepressants from a recently published review.

Results

Our search yielded 5 additional studies, which we added to the 16 studies identified by Karyotaki and colleagues in 2017. Few self-guided iCBT studies excluded patients with severe depressive symptoms (6/21, 29%), but self-guided iCBT studies were more likely than antidepressant (14/170, 8.2%) studies to use this criterion. However, self-guided iCBT studies did not use this criterion more frequently than face-to-face psychotherapy studies (6/16, 38%). Beyond this, we found no evidence that self-guided iCBTs used more stringent entry criteria. Strong evidence suggested that they were actually less likely to use most entry criteria, especially exclusions on the basis of substance use or personality pathology. None of the entry criteria used had an effect on outcomes.

Conclusions

A conservative interpretation of our findings is that the patient population sampled in the literature on self-guided iCBT is relatively comparable with that of studies of antidepressants or face-to-face psychotherapy. Alternatively, studies of unguided cognitive behavioral therapy may sample from a more heterogeneous and representative patient population. Until evidence emerges to suggest otherwise, the patient population sampled in self-guided iCBT studies cannot be considered as less complex than the patient population from face-to-face psychotherapy or antidepressant studies.

Clinical and sociodemographic associations with treatment selection in major depression

OBJECTIVE

To investigate treatment selection in a naturalistic sample of MDD outpatients and the factors influencing treatment selection in specialized psychiatric care.

METHOD

Multinomial Logistic Regression analysis investigated associations between treatment selection and patients' sociodemographic and clinical characteristics, using retrospective chart review data and Routine Outcome Monitoring (ROM) data of MDD outpatients.

RESULTS

Of the patients included for analyses (N = 263), 34% received psychotherapy, 32% received an antidepressant (AD) and 35% received a combination. Men were more likely than women to receive AD with reference to psychotherapy (OR_AD = 5.57, 95% CI 2.38-13.00). Patients with severe depression and patients with AD use upon referral, prescribed by their general practitioner, were more likely to receive AD (OR_{severe depression} = 5.34, 95% CI 1.70-16.78/OR_{AD GP} = 9.26, 95% CI 2.53-33.90) or combined treatment (OR_{severe depression} = 6.32, 95% CI 1.86-21.49/OR_{AD GP} = 22.36, 95% CI 5.89-83.59) with respect to psychotherapy. More severe patients with AD upon referral received combined treatment less often compared to psychotherapy (OR = 0.14, 95% CI 0.03-0.68).

CONCLUSION

AD prescriptions in primary care, severity and gender influenced treatment selection for depressive disorders in secondary psychiatric care. Other factors such as the accessibility of treatment and patient preferences may have played a role in treatment selection in this setting and need further investigation.

Are studies of psychotherapies for depression more or less generalizable than studies of antidepressants?

BACKGROUND

The generalizability of findings from studies exploring the efficacy of psychotherapy and antidepressants has been called into question in part because studies exclude many patients. Despite this, the frequency with which psychotherapy and antidepressant studies use specific inclusion and exclusion criteria has never been compared. We explored the exclusion criteria used in psychotherapy and pharmacotherapy studies from 1995 to 2014.

METHOD

Systematic literature searches were conducted in PubMed, Medline, PsycINFO, and Embase of published randomized controlled trials (RCTs) of the treatment of major depressive disorder (MDD) in adults with either antidepressants (vs. placebos) or psychotherapy (vs. placebos, treatments as usual, or other controls).

RESULTS

Most psychotherapy (81%) and antidepressant (100%) trials excluded patients with milder symptoms as well as patients with elevated suicidal risk (56-75%), psychotic symptoms (84-88%), or substance misuse (75-81%). Psychotherapy studies were less likely to exclude patients on the basis of brief episode duration (0% vs. 48%) and co-morbid Axis I disorders (6% vs. 27%). However, psychotherapy studies excluded patients with more severe symptoms more frequently (38%) than antidepressant studies (8%).

CONCLUSIONS

Overall, psychotherapy studies appear somewhat more inclusive than antidepressant studies. On average, antidepressant studies appear to target patients with more chronic and severe, as well as more purely depressive presentations.

Pre-post effect sizes should be avoided in meta-analyses

Aims The standardised mean difference (SMD) is one of the most used effect sizes to indicate the effects of treatments. It indicates the difference between a treatment and comparison group after treatment has ended, in terms of standard deviations. Some meta-analyses, including several highly cited and influential ones, use the pre-post SMD, indicating the difference between baseline and post-test within one (treatment group).

METHODS

In this paper, we argue that these pre-post SMDs should be avoided in meta-analyses and we describe the arguments why pre-post SMDs can result in biased outcomes.

RESULTS

One important reason why pre-post SMDs should be avoided is that the scores on baseline and post-test are not independent of each other. The value for the correlation should be used in the calculation of the SMD, while this value is typically not known. We used data from an 'individual patient data' meta-analysis of trials comparing cognitive behaviour therapy and anti-depressive medication, to show that this problem can lead to considerable errors in the estimation of the SMDs. Another even more important reason why pre-post SMDs should be avoided in meta-analyses is that they are influenced by natural processes and characteristics of the patients and settings, and these cannot be discerned from the effects of the intervention. Between-group SMDs are much better because they control for such variables and these variables only affect the between group SMD when they are related to the effects of the intervention.

CONCLUSIONS

We conclude that pre-post SMDs should be avoided in meta-analyses as using them probably results in biased outcomes.

Trial participant representativeness compared to ordinary service users in a work rehabilitation setting

Background

Study representativeness is a major concern for generalizations from trials. The extent of the problem varies with study design and context. There is a strong emphasis on developing interventions to help people remain in the work force despite mental illness. We need to know if results from upcoming trials in this area are valid for those that later might receive the services.

Method

The AWaC trial was a multicenter RCT conducted at six different treatment centers (n = 1193). After the trial was over, the centers were upheld and run as ordinary services. At that time, we surveyed 80 ordinary service users with the same baseline questionnaire as used in the trial, and compared them with those who participated in the trial.

Results

There were a higher proportion of people with the highest level of education (4 years or more at university/college) in the post-trial comparison sample. This sample also reported to be “dissatisfied” with their job more often, but rated their chances for return to work as “bad” less often than the ordinary trial participants. No further significant differences between the two samples in any of the other education categories, or for any of the other demographic, health or work related comparisons were found.

Discussion

Participation bias is likely to depend on study context, but in the setting of a trial to help improve work participation among people who struggle with common mental disorders, the trial participants were overall very similar to those who sought the same services as ordinary practice.

Using a matrix-analytical approach to synthesizing evidence solved incompatibility problem in the hierarchy of evidence

OBJECTIVES

The hierarchy of evidence presupposes linearity and additivity of effects, as well as commutativity of knowledge structures. It thereby implicitly assumes a classical theoretical model.

STUDY DESIGN AND SETTING

This is an argumentative article that uses theoretical analysis based on pertinent literature and known facts to examine the standard view of methodology.

RESULTS

We show that the assumptions of the hierarchical model are wrong. The knowledge structures gained by various types of studies are not sequentially indifferent, that is, do not commute. External validity and internal validity are at least partially incompatible concepts. Therefore, one needs a different theoretical structure, typical of quantum-type theories, to model this situation. The consequence of this situation is that the implicit assumptions of the hierarchical model are wrong, if generalized to the concept of evidence in total.

CONCLUSION

The problem can be solved by using a matrix-analytical approach to synthesizing evidence. Here, research methods that produce different types of evidence that complement each other are synthesized to yield the full knowledge. We show by an example how this might work. We conclude that the hierarchical model should be complemented by a broader reasoning in methodology.

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.

Influence of sociodemographic and socioeconomic features on treatment outcome in RCTs versus daily psychiatric practice

PURPOSE

Sociodemographic and socioeconomic characteristics of participants in antidepressant and psychotherapy efficacy trials (AETs and PETs) for major depressive disorder (MDD) may limit the generalizability of the results. We compared trial participants with daily practice patients. We subsequently assessed the influence of socio-demographic and socioeconomic status on treatment outcome in daily practice.

METHODS

Data on daily practice patients were derived through routine outcome monitoring (ROM). We included 626 patients with MDD according to the MINIplus. Distributions of age, gender, race, marital status and employment status were compared with participants in 63 selected AETs and PETs. Influence of these features on treatment outcome was explored through multivariate regression analysis.

RESULTS

Trial participants were older, more often male (diff. 4 %, p = 0.05), white (diff. 4 %, p < 0.001) and not married (diff. 7 %, p = 0.003). Although significant, most differences were relatively small. However, the difference in employment status was striking: 34 % of the ROM patients were currently working versus 68 % of the trial participants (diff. 34 %, p < 0.001). Being employed contributed to a positive treatment outcome: OR 1.8 for response [50 % reduction of Montgomery Asberg Rating Scale for Depression (MADRS)], OR 1.9 for remission (MADRS ≤10).

CONCLUSIONS

Employment status should be taken into account while interpreting results from randomized controlled trials and as predictor of treatment success in daily practice.