The effects of once- versus twice-weekly sessions on psychotherapy outcomes in depressed patients

Amount and frequency of psychotherapy as predictors of treatment outcome for adult depression: A meta-regression analysis

BACKGROUND

It is not clear whether the amount and frequency of psychotherapy is associated with treatment effects for adult depression. We investigated whether a number of indicators of the amount and frequency of psychotherapy were related to the treatment effects in randomized controlled trials (RCTs) comparing individual, face-to-face psychotherapy to a control group (e.g., care-as-usual [CAU] or waitlist condition [WL]).

METHODS

Four databases were systematically searched, and meta-regression analyses conducted to assess the relationship between the effect size (Hedges' g) of the treatment and number of sessions, duration of psychotherapy, total contact time with the therapist, and number of sessions per week.

RESULTS

We included 176 studies (210 comparisons) with 15,158 participants. We did not find a relationship between the effect size, and number of sessions, or total contact time. There was a small negative association between duration of treatment and the effect size, an additional week of treatment was related to a 0.014 decrease in the effect size. In addition, there was a strong association between number of sessions per week and the effect size, an increase from one to two sessions per week was related to an effect size higher by 0.596. Both associations were no longer significant when controlling for characteristics of studies.

LIMITATIONS

The current findings are correlational, future research should thus address this question in an RCT.

CONCLUSIONS

We should deliver brief therapies, and thus shorten waiting lists. More sessions, if necessary, should be delivered with higher frequency and over a shorter period of time.

Web-Based, Human-Guided, or Computer-Guided Transdiagnostic Cognitive Behavioral Therapy in University Students With Anxiety and Depression: Randomized Controlled Trial

BACKGROUND

Internet-based cognitive behavioral interventions (iCBTs) are efficacious treatments for depression and anxiety. However, it is unknown whether adding human guidance is feasible and beneficial within a large educational setting.

OBJECTIVE

This study aims to potentially demonstrate the superiority of 2 variants of a transdiagnostic iCBT program (human-guided and computer-guided iCBT) over care as usual (CAU) in a large sample of university students and the superiority of human-guided iCBT over computer-guided iCBT.

METHODS

A total of 801 students with elevated levels of anxiety, depression, or both from a large university in the Netherlands were recruited as participants and randomized to 1 of 3 conditions: human-guided iCBT, computer-guided iCBT, and CAU. The primary outcome measures were depression (Patient Health Questionnaire) and anxiety (Generalized Anxiety Disorder scale). Secondary outcomes included substance use-related problems (Alcohol Use Disorder Identification Test and Drug Abuse Screening Test-10 items). Linear mixed models were used to estimate the effects of time, treatment group, and their interactions (slopes). The primary research question was whether the 3 conditions differed in improvement over 3 time points (baseline, midtreatment, and after treatment) in terms of depression and anxiety symptoms. Results were analyzed according to the intention-to-treat principle using multiple imputation. Patients were followed exploratively from baseline to 6 and 12 months.

RESULTS

In both short-term and long-term analyses, the slopes for the 3 conditions did not differ significantly in terms of depression and anxiety, although both web-based interventions were marginally more efficacious than CAU over 6 months (P values between .02 and .03). All groups showed significant improvement over time (P<.001). For the secondary outcomes, only significant improvements over time (across and not between groups) were found for drug use (P<.001). Significant differences were found in terms of adherence, indicating that participants in the human-guided condition did more sessions than those in the computer-guided condition (P=.002).

CONCLUSIONS

The transdiagnostic iCBT program offers a practical, feasible, and efficacious alternative to usual care to tackle mental health problems in a large university setting. There is no indication that human guidance should be preferred over technological guidance. The potential preference of human support also depends on the scale of implementation and cost-effectiveness, which need to be addressed in future trials.

TRIAL REGISTRATION

International Clinical Trials Registry Platform NL7328/NTR7544; https://trialsearch.who.int/Trial2.aspx?TrialID=NL-OMON26795.

Psychotherapy duration and work disability: A prospective Finnish register study

INTRODUCTION

The influence of psychotherapy duration on common mental disorder (CMD) outcomes remains a topic of ongoing debate. Whereas most research has focused on CMD symptom change, the evidence on the psychotherapy duration of subsequent CMD-related work disability and the change in psychotropic drug purchases is scarce.

METHODS

We used a register-based cohort representing 33% of the Finnish population. The participants included working-age individuals (N = 12,047, 76% women, mean age = 36) who initiated long-term psychotherapy, between 2014 and 2017. They were followed from 2011 to 2021 and psychotherapy duration ranged from less than a year to over 3 years. We used an interrupted time series design to analyze the psychotherapy duration-dependent changes in CMD-related work disability (primary outcome, operationalized as depression or anxiety-related sickness absence, SA, days) and the annual number of psychotropic drug purchases or distinct drugs purchased (secondary outcomes).

RESULTS

There were no differences in the levels of work disability or drug purchases before the psychotherapy. We observed a decreasing level and trend in all outcomes across all psychotherapy duration groups. The largest decline in level was observed in the <1-year duration group (88% decline for SA and 43%-44% for drug purchases) while the smallest decline was in the 3+ years duration group (73% for SA and 27% for drug purchases).

CONCLUSION

Work disability outcomes and duration varied among individuals, even with similar initial mental health-related work disability or use of auxiliary psychotropic treatments. Compared to longer psychotherapy, shorter psychotherapy was associated with sharper improvements.

Dosage effects of psychodynamic and schema therapy in people with comorbid depression and personality disorder: four-arm pragmatic randomised controlled trial

BACKGROUND

Higher intensity of psychotherapy might improve treatment outcome in depression, especially in those with comorbid personality disorder.

AIMS

To compare the effects of 25 individual sessions (weekly) of two forms of psychotherapy - short-term psychoanalytic supportive psychotherapy (SPSP) and schema therapy - with the same treatments given for 50 sessions (twice weekly) in people with depression and personality disorder. Trial registration: NTR5941.

METHOD

We conducted a pragmatic, double-randomised clinical trial and, over 37 months, recruited 246 adult out-patients with comorbid depression/dysthymia and personality disorder. A 2 × 2 factorial design randomised participants to 25 or 50 sessions of SPSP or schema therapy. The primary outcome was change in depression severity over 1 year on the Beck Depression Inventory II (BDI-II). Secondary outcomes were remission both of depression and personality disorder.

RESULTS

Compared with 25 sessions, participants who received 50 sessions showed a significantly greater decrease in depressive symptoms over time (time × session dosage, P < 0.001), with a mean difference of 5.6 BDI points after 1 year (d = -0.53, 95% CI -0.18 to 0.882, P = 0.003). Remission from depression was also greater in the 50-session group (74% v. 58%, P = 0.025), as was remission of personality disorder (74% v. 56%, P = 0.010).

CONCLUSIONS

Greater intensity of psychotherapy leads to better outcomes of both depression and personality status in people with comorbid depression and personality disorder.

What to do when the unwanted happens? Negative event management in studies on internet- and mobile-based interventions for youths and adults with two case reports

Background

Despite severely burdened individuals, often being excluded from research studies on internet- and mobile-based interventions (IMIs), negative events (NEs) including suicidal thoughts and behaviors (STBs) can still occur during a trial. NEs require monitoring and adequate safety measures. However, study protocols frequently lack comprehensive descriptions of procedures for managing NEs.

Aims

This study aimed to illustrate the assessment, monitoring, and procedures for addressing NEs in two studies on IMIs in adults and youth using case reports, to identify strengths and weaknesses of the NE management approaches, and to derive key learnings and recommendations.

Methods

Two case reports were drawn from two distinct IMI studies. The first study, PSYCHOnlineTHERAPY, evaluates the combination of an IMI with on-site psychotherapy for anxiety and depressive disorders in adults (adult blended study). The second study evaluates a standalone, therapist-guided IMI for post-traumatic stress disorder (PTSD) in youth (youth standalone study). Potential NEs were predefined depending on the study sample. The case studies thoroughly document the systematic recording and ongoing monitoring of NEs through self-report and observer-based assessments during the interventions. The cases illustrate a variety of NE management strategies, including automated and personalized approaches, adapted to the specific nature and severity of the NEs. The NE management approaches are visualized using decision trees.

Results

In the adult blended case study, online questionnaires detected STBs and triggered automated support information. As on-site therapy had already ended, a telephone consultation session allowed for the identification and discussion of the heightened intensity of suicidal thoughts, along with the development of specific additional help options. In the youth standalone case study, heightened tension in an adolescent with PTSD during trauma processing could be addressed in a telephone therapeutic session focusing on resource activation and emotion regulation. The referral to on-site treatment was supported. Overall, advantages of the NE management included automated procedures, multimodal assessment of a wide range of NEs, and standardized procedures tailored to different severity levels. Weaknesses included the use of single-item assessments for STBs and lack of procedures in case of deterioration or nonresponse to treatment.

Conclusion

This study provides practical insights and derives key learnings and recommendations regarding the management of NEs in different IMI contexts for both adults and youth.

Long-term outcomes of once weekly v. twice weekly sessions of cognitive behavioral therapy and interpersonal psychotherapy for depression

BACKGROUND

Twice weekly sessions of cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) for major depressive disorder (MDD) lead to less drop-out and quicker and better response compared to once weekly sessions at posttreatment, but it is unclear whether these effects hold over the long run.

AIMS

Compare the effects of twice weekly v. weekly sessions of CBT and IPT for depression up to 24 months since the start of treatment.

METHODS

Using a 2 × 2 factorial design, this multicentre study randomized 200 adults with MDD to once or twice weekly sessions of CBT or IPT over 16-24 weeks, up to a maximum of 20 sessions. Main outcome measures were depression severity, measured with the Beck Depression Inventory-II and the Longitudinal Interval Follow-up Evaluation. Intention-to-treat analyses were conducted.

RESULTS

Compared with patients who received once weekly sessions, patients who received twice weekly sessions showed a significant decrease in depressive symptoms up through month 9, but this effect was no longer apparent at month 24. Patients who received CBT showed a significantly larger decrease in depressive symptoms up to month 24 compared to patients who received IPT, but the between-group effect size at month 24 was small. No differential effects between session frequencies or treatment modalities were found in response or relapse rates.

CONCLUSIONS

Although a higher session frequency leads to better outcomes in the acute phase of treatment, the difference in depression severity dissipated over time and there was no significant difference in relapse.

Efficacy and safety of zuranolone co-initiated with an antidepressant in adults with major depressive disorder: results from the phase 3 CORAL study

Major depressive disorder (MDD) is a mental health disorder that can cause disability and functional impairment that standard-of-care (SOC) antidepressant therapies (ADTs) can take weeks to treat. Zuranolone is a neuroactive steroid and positive allosteric modulator of synaptic and extrasynaptic γ-aminobutyric acid (GABA) type A receptors approved as an oral, once-daily, 14-day treatment course in adults with postpartum depression and under investigation in adults with MDD. The phase 3 CORAL Study (NCT04476030) evaluated the efficacy and safety of zuranolone 50 mg co-initiated with SOC ADT (zuranolone+ADT) vs placebo co-initiated with SOC ADT (placebo+ADT) in adults with MDD. Patients were randomized 1:1 to once-daily, blinded zuranolone+ADT or placebo+ADT for 14 days, then continued open-label SOC ADT for 28 more days. The primary endpoint was change from baseline (CFB) in the 17-item Hamilton Rating Scale for Depression (HAMD-17) total score at Day 3. Among 425 patients in the full analysis set, CFB in HAMD-17 total score at Day 3 was significantly improved with zuranolone+ADT vs placebo+ADT (least squares mean [standard error], -8.9 [0.39] vs -7.0 [0.38]; p = 0.0004). The majority of patients receiving zuranolone+ADT that experienced treatment-emergent adverse events (TEAEs) reported mild or moderate events. The most common TEAEs present in ≥10% of patients in either zuranolone+ADT or placebo+ADT groups were somnolence, dizziness, headache, and nausea. These results demonstrate that zuranolone+ADT provided more rapid improvement in depressive symptoms compared with placebo+ADT in patients with MDD, with a safety profile consistent with previous studies. Clinical trial registration: ClinicalTrials.gov identifier: NCT04476030.

Cost-effectiveness of twice-weekly versus once-weekly sessions of cognitive-behavioural therapy and interpersonal psychotherapy for depression at 12 months after start of treatment: randomised controlled trial

BACKGROUND

Cost-effective treatments are needed to reduce the burden of depression. One way to improve the cost-effectiveness of psychotherapy might be to increase session frequency, but keep the total number of sessions constant.

AIM

To evaluate the cost-effectiveness of twice-weekly compared with once-weekly psychotherapy sessions after 12 months, from a societal perspective.

METHOD

An economic evaluation was conducted alongside a randomised controlled trial comparing twice-weekly versus once-weekly sessions of psychotherapy (cognitive-behavioural therapy or interpersonal psychotherapy) for depression. Missing data were handled by multiple imputation. Statistical uncertainty was estimated with bootstrapping and presented with cost-effectiveness acceptability curves.

RESULTS

Differences between the two groups in depressive symptoms, physical and social functioning, and quality-adjusted life-years (QALY) at 12-month follow-up were small and not statistically significant. Total societal costs in the twice-weekly session group were higher, albeit not statistically significantly so, than in the once-weekly session group (mean difference €2065, 95% CI -686 to 5146). The probability that twice-weekly sessions are cost-effective compared with once-weekly sessions was 0.40 at a ceiling ratio of €1000 per point improvement in Beck Depression Inventory-II score, 0.32 at a ceiling ratio of €50 000 per QALY gained, 0.23 at a ceiling ratio of €1000 per point improvement in physical functioning score and 0.62 at a ceiling ratio of €1000 per point improvement in social functioning score.

CONCLUSIONS

Based on the current results, twice-weekly sessions of psychotherapy for depression are not cost-effective over the long term compared with once-weekly sessions.

Preliminary Effectiveness of a Therapist-Supported Digital Mental Health Intervention in Reducing Suicidal Ideation

Suicidal ideation (SI) is a significant public health concern with increasing prevalence. Therapist-supported digital mental health interventions (DMHI) are an emergent modality to address common mental health problems like depression and anxiety, although less is known about SI. This study examined SI trajectories among 778 patients who participated in a therapist-supported DMHI using multilevel models during and up to 6-months post-treatment. Estimates of associated suicide attempts and deaths by suicide were calculated using published data linking PHQ-9-assessed SI to records of suicide attempts and deaths by suicide. The proportion of participants reporting no SI significantly increased between baseline and end-of-treatment (78.02% to 91.00%). Effect sizes of SI changes between baseline and end-of-treatment, 3-month, and 6-month follow-ups were 0.33 (95%CI = 0.27-0.38), 0.32 (95%CI = 0.27-0.38), and 0.32 (95%CI = 0.27-0.38), respectively. Results also indicated an estimated 30.49% reduction (95%CI = 25.15%-35.13%) in suicide attempts and death by suicide across treatment. This study provides preliminary evidence of the effectiveness of a therapist-supported DMHI in reducing SI.

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.

Identifying active ingredients in cognitive-behavioral therapies: What if we didn't?

Identifying active ingredients of psychological interventions is a major goal of psychotherapy researchers that is often justified by the promise that it will lead to improved patient outcomes. Much of this "active ingredients" research is conducted within randomized controlled trials (RCTs) with patient populations, putting it in Phase T2 of the clinical-translational spectrum. I argue that RCTs in patient populations are very "messy laboratories" in which to conduct active ingredient work and that T0 and T1 research provide more controlled contexts. However, I call attention to the long road from identifying active ingredients of CBTs, whether in T0, T1, or T2 research, to improving outcomes. Dissemination and implementation research (T3 and T4 approaches) may be conceptually closer to improving outcomes. Given how common and disabling mental health symptoms are, I argue that if researchers want to improve patient outcomes, these research programs must receive more attention including work on the uptake of psychological interventions as well as work on optimal ordering of existing interventions.

Psychological treatment of depression: A systematic overview of a 'Meta-Analytic Research Domain'

BACKGROUND

Over the past 16 years, we have developed a 'Meta-analytic Research Domain' (MARD) of all randomized trials of psychological treatments of depression. A MARD is a living systematic review of a research field, that cannot be otherwise covered by one (network) meta-analysis and includes multiple PICOs. In this paper we give an overview of the findings of this MARD.

METHODS

A narrative review of the results of the 118 meta-analyses on psychotherapies for depression that were published within our MARD.

RESULTS

Most research has been conducted on cognitive-behavioral therapy (CBT), but several other psychotherapies are also effective, with few differences between therapies. They can be effectively delivered in individual, group, telephone and guided self-help format and are effective in many different target groups and across different age groups, although the effects are significantly smaller in children and adolescents. Psychotherapies have comparable effects as pharmacotherapy at the short term but are probably more effective at the longer term. Combined treatment is more effective than either psychotherapy or pharmacotherapy alone at the short, but also at the longer term.

LIMITATIONS

We did not summarize all published meta-analyses (protocols, methodological studies) and have not compared our results to those found in other meta-analyses on comparable subjects.

CONCLUSION

Psychotherapies can contribute considerably to a reduction of the disease burden of depression. MARDs are an important next step in the aggregation of knowledge from randomized controlled trials in psychological treatments of depression as well as in other healthcare sectors.

Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial

INTRODUCTION

Effective non-pharmacological treatment options for depression in older adults are lacking.

OBJECTIVE

The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated.

METHODS

In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up.

RESULTS

Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24).

CONCLUSIONS

BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

The difference between shorter- versus longer-term psychotherapy for adult mental health disorders: a systematic review with meta-analysis

BACKGROUND

The optimal psychotherapy duration for mental health disorders is unclear. Our aim was to assess the beneficial and harmful effects of shorter- versus longer-term psychotherapy for adult mental health disorders.

METHOD

We searched relevant databases and websites for published and unpublished randomised clinical trials assessing different durations of the same psychotherapy type before June 27, 2022. Our methodology was based on Cochrane and an eight-step procedure. Primary outcomes were quality of life, serious adverse events, and symptom severity. Secondary outcomes were suicide or suicide-attempts, self-harm, and level of functioning.

RESULTS

We included 19 trials randomising 3,447 participants. All trials were at high risk of bias. Three single trials met the required information size needed to confirm or reject realistic intervention effects. One single trial showed no evidence of a difference between 6 versus 12 months dialectical behavioral therapy for borderline personality when assessing quality of life, symptom severity, and level of functioning. One single trial showed evidence of a beneficial effect of adding booster sessions to 8 and 12 weeks of internet-based cognitive behavioral therapy for depression and anxiety when assessing symptom severity and level of functioning. One single trial showed no evidence of a difference between 20 weeks versus 3 years of psychodynamic psychotherapy for mood- or anxiety disorders when assessing symptom severity and level of functioning. It was only possible to conduct two pre-planned meta-analyses. Meta-analysis showed no evidence of a difference between shorter- and longer-term cognitive behavioural therapy for anxiety disorders on anxiety symptoms at end of treatment (SMD: 0.08; 95% CI: -0.47 to 0.63; p = 0.77; I2 = 73%; four trials; very low certainty). Meta-analysis showed no evidence of a difference between shorter and longer-term psychodynamic psychotherapy for mood- and anxiety disorders on level of functioning (SMD 0.16; 95% CI -0.08 to 0.40; p = 0.20; I2 = 21%; two trials; very low certainty).

CONCLUSIONS

The evidence for shorter versus longer-term psychotherapy for adult mental health disorders is currently unclear. We only identified 19 randomised clinical trials. More trials at low risk of bias and at low risk of random errors assessing participants at different levels of psychopathological severity are urgently needed.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42019128535.

Barriers and enablers for young people, parents and therapists undertaking behavioural activation for depression: A qualitative evaluation within a randomised controlled trial

BACKGROUND

Adolescent depression is common, long-lasting and debilitating. Behavioural Activation (BA) is a brief, evidence-based therapy for depression in adults with promising outcomes for young people.

OBJECTIVES

We sought to understand how young people, their parents and therapists experienced manualised BA for depression within Child and Adolescent Mental Health Services.

DESIGN

Participants in a randomised controlled trial aged 12 to17 with depression, their parents and therapists were invited to a semi-structured interview with a researcher to explore their experiences of receiving, supporting or delivering BA.

METHODS

Six young people, five parents and five therapists were interviewed. Verbatim interview transcripts were coded using thematic analysis.

RESULTS

Factors that may optimise delivery of BA were: boosting the young person's motivation, tailoring parental input to the young person's needs/wishes and developing a positive collaboration between the young person and therapist. Engagement with treatment may be hindered by a mismatch between BA delivery and young person's preferences, concurrent mental health comorbidities that are not addressed within a wider care package, lack of parental support and therapist preconceptions against manualised therapy or BA.

CONCLUSIONS

Manualised BA for young people requires flexibility and adjustment to meet individual and family needs. Therapist preparation could dispel hindering preconceptions about the suitability and potential value of this brief and simple intervention for young people with complex needs and different learning styles.

Depression roundtable: Is there a role for BoNT?

Depression can occur in the context of major depressive disorder or bipolar disorder. There are many effective and well-tolerated treatment options for most patients experiencing major depressive episodes, but for patients with treatment-resistant major depressive disorder or bipolar depression, current pharmacologic and non-pharmacologic options can be less efficacious, well tolerated, or accessible. Botulinum neurotoxin (BoNT) offers a novel approach to treating depression that is both safe and well-tolerated. Several potential mechanisms of action in depression are theorized, and studies support the efficacy of BoNT in major depression. Early data suggests that BoNT may be efficacious in bipolar depression and further study is warranted.

Individual psychotherapy for cluster-C personality disorders: protocol of a pragmatic RCT comparing short-term psychodynamic supportive psychotherapy, affect phobia therapy and schema therapy (I-FORCE)

BACKGROUND

Cluster-C personality disorders (PDs) are highly prevalent in clinical practice and are associated with unfavourable outcome and chronicity of all common mental health disorders (e.g. depression and anxiety disorders). Although several forms of individual psychotherapy are commonly offered in clinical practice for this population, evidence for differential effectiveness of different forms of psychotherapy is lacking. Also, very little is known about the underlying working mechanisms of these psychotherapies. Finding evidence on the differential (cost)-effectiveness for this group of patients and the working mechanisms of change is important to improve the quality of care for this vulnerable group of patients.

OBJECTIVE

In this study, we will compare the differential (cost)-effectiveness of three individual psychotherapies: short-term psychodynamic supportive psychotherapy (SPSP), affect phobia therapy (APT) and schema therapy (ST). Although these psychotherapies are commonly used in clinical practice, evidence for the Cluster-C PDs is limited. Additionally, we will investigate predictive factors, non-specific and therapy-specific mediators.

METHODS

This is a mono-centre randomized clinical trial with three parallel groups: (1) SPSP, (2) APT, (3) ST. Randomization on patient level will be pre-stratified according to type of PD. The total study population to be included consists of 264 patients with Cluster-C PDs or other specified PD with mainly Cluster-C traits, aged 18-65 years, seeking treatment at NPI, a Dutch mental health care institute specialized in PDs. SPSP, APT and ST (50 sessions per treatment) are offered twice a week in sessions of 50 min for the first 4 to 5 months. After that, session frequency decreases to once a week. All treatments have a maximum duration of 1 year. Change in the severity of the PD (ADP-IV) will be the primary outcome measure. Secondary outcome measures are personality functioning, psychiatric symptoms and quality of life. Several potential mediators, predictors and moderators of outcome are also assessed. The effectiveness study is complemented with a cost-effectiveness/utility study, using both clinical effects and quality-adjusted life-years, and primarily based on a societal approach. Assessments will take place at baseline, start of treatment and at 1, 3, 6, 9, 12, 18, 24 and 36 months.

DISCUSSION

This is the first study comparing psychodynamic treatment to schema therapy for Cluster-C PDs. The naturalistic design enhances the clinical validity of the outcome. A limitation is the lack of a control group for ethical reasons.

TRIAL REGISTRATION

NL72823.029.20 [Registry ID: CCMO]. Registered on 31 August 2020. First participant included on 23 October 2020.

Expectation focused and frequency enhanced cognitive behavioural therapy for patients with major depression (EFFECT): a study protocol of a randomised active-control trial

INTRODUCTION

The effectiveness of psychotherapy in depression is subject of an ongoing debate. The mechanisms of change are still underexplored. Research tries to find influencing factors fostering the effect of psychotherapy. In that context, the dose-response relationship should receive more attention. Increasing the frequency from one to two sessions per week seems to be a promising start. Moreover, the concept of expectations and its influence in depression can be another auspicious approach. Dysfunctional expectations and the lack of their modification are central in symptom maintenance. Expectation focused psychological interventions (EFPI) have been investigated, primarily in the field of depression. The aim of this study is to compare cognitive behavioural therapy (CBT) once a week with an intensified version of CBT (two times a week) in depression as well as to include a third proof-of-principle intervention group receiving a condensed expectation focused CBT.

METHODS AND ANALYSIS

Participants are recruited through an outpatient clinic in Germany. A current major depressive episode, diagnosed via structured clinical interviews should present as the main diagnosis. The planned randomised-controlled trial will allow comparisons between the following treatment conditions: CBT (one session/week), condensed CBT (two sessions/week) and EFPI (two sessions/week). All treatment arms include a total dose of 24 sessions. Depression severity applies as the outcome variable (Beck Depression Inventory II, Montgomery Asberg Depression Rating Scale). A sample size of n=150 is intended.

ETHICS AND DISSEMINATION

The local ethics committee of the Department of Psychology, Philipps-University Marburg approved the study (reference number 2020-68 v). The final research article including the study results is intended to be published in international peer-reviewed journals.

TRIAL REGISTRATION NUMBER

German Clinical Trials Registry (DRKS00023203).

Are psychological interventions for adult PTSD more efficacious and acceptable when treatment is delivered in higher frequency? A meta-analysis of randomized controlled trials

BACKGROUND

Two systematic reviews indicated that higher treatment frequency of psychological interventions for adult PTSD may lead to higher efficacy and less dropout. Yet, a quantitative review is missing.

METHODS

We conducted a thorough systematic literature search and included trials meeting the following criteria: a) random allocation, 2) PTSD was primary treatment focus, 3) ≥ 70% interview-based PTSD rate 4) mean age ≥ 18 years, and 5) N ≥ 20. Treatment session frequency was analyzed dichotomously (< 1.5 vs. ≥ 1.5 sessions/week) and continuously (sessions per week & minutes per week).

RESULTS

A total of 160 RCTs with data from 10,556 patients were included. Analyses yielded similar treatment efficacy irrespective of treatment frequency definitions and whether differential efficacy was estimated directly via head-to-head trials or indirectly via comparisons to the same comparison group. Intense (≥ 1.5 sessions/week) vs. standard (< 1.5 sessions/week) delivery was, however, associated with significantly lower dropout rates (as a proxy for acceptability) for trauma-focused interventions (18.64% vs 11.54%, respectively, p = .024), but not for non-trauma-focused interventions.

CONCLUSIONS

We found no evidence for differential treatment efficacy of intense vs. standard psychotherapies for adult PTSD. Evidence for increased acceptability was found for intense vs. standard trauma-focused interventions.

Acceptability and Outcomes of Transdiagnostic Guided Self-help Bibliotherapy for Internalizing Disorder Symptoms in Adults: A Fully Remote Nationwide Open Trial

Introduction

Doing What Matters in Times of Stress (DWM) is a five-module transdiagnostic guided self-help (GSH) intervention developed by the World Health Organization, originally in a group-based format. In a sample of individuals recruited from across the United States, we conducted an open trial to study the feasibility and acceptability of an adaptation of DWM in which guidance was provided individually and remotely via phone and videoconferencing.

Methods

We assessed internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation over the course of 6 weeks.

Results

A total of 263 individuals completed our screening. Of those, 75.29% (n = 198) qualified for the intervention. We reached most participants who qualified (71.21%, n = 141) via phone to schedule a GSH session. Most of those scheduled attended a study session (84.4%, n = 119), and most of those who attended a session completed more than half the treatment (84.03%, n = 100). Retention rates were comparable to meta-analytic estimates of dropout rates in GSH. Participants showed improvement on internalizing symptoms, psychological well-being, work and social functioning, usability of the intervention, and emotion regulation.

Conclusion

DWM is a freely available, seemingly efficacious transdiagnostic intervention for internalizing disorder symptoms.

Supplementary Information

The online version contains supplementary material available at 10.1007/s10608-022-10338-5.

The Effectiveness of an Intensive Inpatient Psychotherapy Program for Chronic Depression: A naturalistic comparison with wait list

BACKGROUND

Patients with chronic depression (CD) typically have an early symptom onset, more psychiatric comorbidities, more treatment attempts, and more frequent and longer inpatient hospitalizations than patients with major depressive disorders. The main purpose of this study was to investigate the effectiveness of an intensive inpatient psychotherapy program for patients with chronic depression (CD). The primary research question was whether two intensive psychodynamic inpatient treatments, affect phobia therapy (APT) and VITA, were superior to an outpatient wait list condition, receiving treatment as usual (TAU), at completion of treatment. To investigate if a potential difference between the intensive treatment and the wait list control group was dependent on a specific psychotherapeutic model, the study contrasted two therapies with similar intensity, but different theoretical rationales.

METHODS

Two hundred eighty patients with CD were included in a naturalistic study. Patients were assessed at four time points; assessment, start of therapy, end of therapy and 1-year follow-up. Three comparisons were performed with patients matched across groups; Intensive inpatient treatment program (APT + VITA) vs wait list during treatment, APT vs VITA during treatment and APT vs VITA during follow-up. The outcome measure was the BDI-II.

RESULTS

Intensive inpatient treatment program vs. wait list showed a significant difference in favor of the intensive treatment. No significant differences were found between APT and VITA during therapy or follow-up; but both groups had large effect sizes during treatment, which were maintained during follow-up.

CONCLUSIONS

The intensive inpatient psychotherapy program showed superior effect on chronic depression over an outpatient wait list condition receiving treatment as usual (TAU), but no significant differences were found between the two intensive inpatient psychodynamic treatments. The results provide support for the effectiveness of an intensive inpatient psychotherapy program in treatment of chronic and severe disorders, such as CD, which could be of benefit for policymakers and the health care sector as they are allocating recourses efficiently.

TRIAL REGISTRATION

This study has been retrospectively registered on ClinicalTrials.gov (NCT05221567) on February 3rd, 2022.

Twelve-month follow-up of a randomised clinical trial of a brief group psychological intervention for common mental disorders in Syrian refugees in Jordan

AIMS

There is increasing evidence that brief psychological interventions delivered by lay providers can reduce common mental disorders in the short-term. This study evaluates the longer-term impact of a brief, lay provider delivered group psychological intervention (Group Problem Management Plus; gPM+) on the mental health of refugees and their children's mental health.

METHODS

This single-blind, parallel, controlled trial randomised 410 adult Syrians in Azraq Refugee Camp in Jordan who screened positive for distress and impaired functioning to either five sessions of gPM+ or enhanced usual care (EUC). Primary outcomes were scores on the Hopkins Symptom Checklist-25 (HSCL-25; depression and anxiety scales) assessed at baseline, 6 weeks, 3 months and 12 months Secondary outcomes included disability, posttraumatic stress, personally identified problems, prolonged grief, prodromal psychotic symptoms, parenting behaviour and children's mental health.

RESULTS

Between 15 October 2019 and 2 March 2020, 204 participants were assigned to gPM + and 206 to EUC, and 307 (74.9%) were retained at 12 months. Intent-to-treat analyses indicated that although participants in gPM + had greater reductions in depression at 3 months, at 12 months there were no significant differences between treatment arms on depression (mean difference -0.9, 95% CI -3.2 to 1.3; p = 0.39) or anxiety (mean difference -1.7, 95% CI -4.8 to -1.3; p = 0.06). There were no significant differences between conditions for secondary outcomes except that participants in gPM + had greater increases in positive parenting.

CONCLUSIONS

The short-term benefits of a brief, psychological programme delivered by lay providers may not be sustained over longer time periods, and there is a need for sustainable programmes that can prolong benefits gained through gPM + .

Treatment efficacy and effectiveness in adults with major depressive disorder and childhood trauma history: a systematic review and meta-analysis

BACKGROUND

Childhood trauma is a common and potent risk factor for developing major depressive disorder in adulthood, associated with earlier onset, more chronic or recurrent symptoms, and greater probability of having comorbidities. Some studies indicate that evidence-based pharmacotherapies and psychotherapies for adult depression might be less efficacious in patients with a history of childhood trauma than patients without childhood trauma, but findings are inconsistent. Therefore, we examined whether individuals with major depressive disorder, including chronic forms of depression, and a reported history of childhood trauma, had more severe depressive symptoms before treatment, had more unfavourable treatment outcomes following active treatments, and were less likely to benefit from active treatments relative to a control condition, compared with individuals with depression without childhood trauma.

METHODS

We did a comprehensive meta-analysis (PROSPERO CRD42020220139). Study selection combined the search of bibliographical databases (PubMed, PsycINFO, and Embase) from Nov 21, 2013, to March 16, 2020, and full-text randomised clinical trials (RCTs) identified from several sources (1966 up to 2016-19) to identify articles in English. RCTs and open trials comparing the efficacy or effectiveness of evidence-based pharmacotherapy, psychotherapy, or combination intervention for adult patients with depressive disorders and the presence or absence of childhood trauma were included. Two independent researchers extracted study characteristics. Group data for effect-size calculations were requested from study authors. The primary outcome was depression severity change from baseline to the end of the acute treatment phase, expressed as standardised effect size (Hedges' g). Meta-analyses were done using random-effects models.

FINDINGS

From 10 505 publications, 54 trials met the inclusion criteria, of which 29 (20 RCTs and nine open trials) contributed data of a maximum of 6830 participants (age range 18-85 years, male and female individuals and specific ethnicity data unavailable). More than half (4268 [62%] of 6830) of patients with major depressive disorder reported a history of childhood trauma. Despite having more severe depression at baseline (g=0·202, 95% CI 0·145 to 0·258, I2=0%), patients with childhood trauma benefitted from active treatment similarly to patients without childhood trauma history (treatment effect difference between groups g=0·016, -0·094 to 0·125, I2=44·3%), with no significant difference in active treatment effects (vs control condition) between individuals with and without childhood trauma (childhood trauma g=0·605, 0·294 to 0·916, I2=58·0%; no childhood trauma g=0·178, -0·195 to 0·552, I2=67·5%; between-group difference p=0·051), and similar dropout rates (risk ratio 1·063, 0·945 to 1·195, I2=0%). Findings did not significantly differ by childhood trauma type, study design, depression diagnosis, assessment method of childhood trauma, study quality, year, or treatment type or length, but differed by country (North American studies showed larger treatment effects for patients with childhood trauma; false discovery rate corrected p=0·0080). Most studies had a moderate to high risk of bias (21 [72%] of 29), but the sensitivity analysis in low-bias studies yielded similar findings to when all studies were included.

INTERPRETATION

Contrary to previous studies, we found evidence that the symptoms of patients with major depressive disorder and childhood trauma significantly improve after pharmacological and psychotherapeutic treatments, notwithstanding their higher severity of depressive symptoms. Evidence-based psychotherapy and pharmacotherapy should be offered to patients with major depressive disorder regardless of childhood trauma status.

FUNDING

None.

Less dropout from prolonged exposure sessions prescribed at least twice weekly: A meta-analysis and systematic review of randomized controlled trials

Trauma-focused psychotherapies, such as prolonged exposure (PE), are strongly recommended to treat posttraumatic stress disorder due to their effects in reducing symptoms. However, such therapies may also suffer from high dropout rates. To investigate how clients might benefit from trauma-focused therapy while minimizing dropout, we conducted a meta-analysis of 1,508 adults from 35 randomized controlled trials (RCTs) of outpatient PE programs to evaluate treatment frequency as a predictor of dropout. When an RCT prescribed PE sessions at least twice weekly compared to less frequently, the dropout rate was significantly lower at 21.0%, 95% CI [13.9%, 30.4%], compared to 34.0%, 95% CI [28.9%, 39.4%], OR = 0.52, 95% CI [0.30, 0.89], p = .018. It was not possible to draw causal conclusions, as only one RCT compared two PE treatment frequencies head-to-head. Nonetheless, the findings remained significant after controlling for study characteristics. These data invite reconsideration of the common practice of weekly psychotherapy in favor of twice-weekly sessions in standard outpatient treatment.

Sequential Interventions for Major Depression and Heart Failure Self-Care: A Randomized Clinical Trial

BACKGROUND

Major depression and inadequate self-care are common in patients with heart failure (HF). Little is known about how to intervene when both problems are present. This study examined the efficacy of a sequential approach to treating these problems.

METHODS

Stepped Care for Depression in HF was a single-site, single-blind, randomized controlled trial of cognitive behavior therapy (CBT) versus usual care (UC) for major depression in patients with HF. The intensive phase of the CBT intervention lasted between 8 and 16 weeks, depending upon the rate of improvement in depression. All participants received a tailored HF self-care intervention that began 8 weeks after randomization. The intensive phase of the self-care intervention ended at 16 weeks post-randomization. The coprimary outcome measures were the Beck Depression Inventory (version 2) and the Maintenance scale of the Self-Care of HF Index (v6.2) at week 16.

RESULTS

One hundred thirty-nine patients with HF and major depression were enrolled; 70 were randomized to UC and 69 to CBT. At week 16, the patients in the CBT arm scored 4.0 points ([95% CI, -7.3 to -0.8]; P=0.02) lower on the Beck Depression Inventory, version 2 than those in the usual care arm. Mean scores on the Self-Care of HF Index Maintenance scale were not significantly different between the groups ([95% CI, -6.5 to 1.5]; P=0.22).

CONCLUSIONS

CBT is more effective than usual care for major depression in patients with HF. However, initiating CBT before starting a tailored HF self-care intervention does not increase the benefit of the self-care intervention.

REGISTRATION

URL: https://www.

CLINICALTRIALS

gov; Unique identifier: NCT02997865.

Predictors of Disengagement and Symptom Improvement Among Adults With Depression Enrolled in Talkspace, a Technology-Mediated Psychotherapy Platform: Naturalistic Observational Study

BACKGROUND

Depression is a common psychiatric condition with an estimated lifetime prevalence for major depression of 16.6% in the US adult population and is effectively treated through psychotherapy. The widespread availability of the internet and personal devices such as smartphones are changing the landscape of delivery of psychotherapy; however, little is known about whether and for whom this type of therapy is beneficial, and whether having synchronous video-based sessions provides additional benefits to clients above and beyond messaging-based therapy.

OBJECTIVE

This study examined the outcomes associated with the use of a digital platform (Talkspace) for technology-mediated psychotherapy. We examined the duration of client engagement in therapy and client depression score trajectories over 16 weeks. We explored the association of client characteristics, therapist characteristics, and service plan type with time-to-disengagement and trajectories of change in depression scores.

METHODS

This naturalistic observational study assessed data collected routinely by the platform between January 2016 and January 2018 and examined psychotherapy outcomes among a large representative sample of adult clients with clinically significant depression. Treatment disengagement was defined as a lack of client-initiated communication for more than 4 weeks. Clients completed the Patient Health Questionnaire-8 item (PHQ-8) at intake and every 3 weeks via an in-app survey. Cox regression analysis was used to examine the time until and predictors of disengagement. Changes in depression scores and predictors of change over time were examined using mixed-effects regression.

RESULTS

The study included 5890 clients and 1271 therapists. Client scores on the PHQ-8 declined over time, with the average client improving from a score of 15 to below the clinical cutoff of 10 by week 6. At the same time point, 37% of clients had disengaged from the therapy. When combined into a final Cox regression model, those who were more likely to disengage were clients aged 18 to 25 years versus those aged ≥50 years (odds ratio [OR] 0.82, 95% CI 0.74-0.9; P<.001), had higher education (OR 1.14, 95% CI 1.06-1.22; P<.001), had been in therapy before (OR 1.09, 95% CI 1.02-1.17; P=.01), and were living with a partner but unmarried versus single (OR 1.14, 95% CI 1.02-1.27; P=.02). Having a therapist with >10 years of experience was related to lower odds of disengagement (OR 0.87, 95% CI 0.8-0.94; P=.01). When combined into a final regression model predicting improvement in depression scores over time, clients showing more improvement were those with an associate's degree or higher (linear estimate=-0.07, P=.002) and higher intake PHQ-8 scores (estimate=3.73, P<.001). There were no differences based on the plan type.

CONCLUSIONS

Our findings add to the growing literature showing the benefits of technology-mediated psychotherapy over a relatively brief period (16 weeks).

Metacognitive Short-Term Intervention in Patients With Mental Disorders Following Cardiovascular Events

Background

Mental disorders are common among patients with severe cardiovascular diseases (CVD). Yet, there is a lack of easily accessible evidence-based treatments. Recent research indicates elevated prevalence of dysfunctional metacognitions in patients with mental disorders following cardiovascular events. As metacognitive therapy (MCT) is an established treatment to modify metacognitions, we tested if a brief metacognitive intervention via videotelephony is effective in this patient group.

Methods

A brief MCT treatment was tailored to CVD patients and designed as a face-to-face internet-based intervention. Five patients with CVDs and comorbid mental disorders underwent a psychocardiological examination and diagnostic approach. Each patient participated in eight 50 min sessions via encrypted video messenger service. Metacognitions, depression and anxiety symptoms and quality of life were assessed by self-report measures pre- and post-treatment. Patients rated dysfunctional thought processes, current psychological impairment, and treatment satisfaction after each session. Intended follow-up measures were not reported due to missing data.

Results

For most patients, the brief metacognitive intervention was associated with a decrease in dysfunctional metacognitions and a reduction of symptoms of anxiety and depression post-treatment. Psychological and physiological quality of life improved. Patients reported high satisfaction with the tailored treatment.

Conclusion

Our results suggest that a brief internet-based metacognitive treatment may be a promising tool for patients with CVDs and comorbid mental disorders. Feasibility and acceptance of the intervention was rated high by the patients. Further research is necessary to support the preliminary findings and to adapt and evaluate the intervention in a controlled clinical trial setting.

Message-based psychotherapy for older adults: A cohort comparison study

OBJECTIVE

Digital Mental Health Interventions (DMHI) can diminish inequities in mental health care provision. As DMHIs increase in popularity, however, older adults may be unintentionally excluded due to barriers such as lack of awareness, internet access, digital tools, technological socialization and education, physiological accessibility, and communication technology infrastructure. The aim of this study was to examine longitudinal treatment engagement patterns and 15-week clinical outcomes of depressed and anxious older adults compared to a matched cohort of younger adults seeking treatment from a large asynchronous telemedicine provider.

METHODS

The 2,470 older adults (55+ years) and a matched cohort of younger adults (26-35 years) diagnosed with depression or anxiety were treated by licensed therapists via messaging 5 days a week. Patterns of treatment engagement on the platform were compared across groups by examining total number of days in treatment, days actively messaging on the platform, and average words and messages per week sent by patients over the entire period they remained in treatment. Symptoms were assessed every 3 weeks using the Patient Health Questionnaire (PHQ-9) and the Generalized Anxiety Disorder Scale (GAD-7), and changes were compared across age groups over 15 weeks.

RESULTS

Older patients attended more days in treatment than younger patients, but there were no differences in number of days actively messaging on the platform, number of messages per week, or word count per week. The two age groups did not differ in their final anxiety or depressive symptoms when controlling for total number of weeks attended. Patients in the younger age group experienced a quicker rate of reduction than older adults in their anxiety, but not depressive symptoms.

CONCLUSIONS

Among individuals willing to initiate care through a DMHI, older adults had overall similar engagement as younger adults and they showed similar improvement in symptoms of depression and anxiety. Given the advantages of message-based care for aiding a mental health workforce in serving larger numbers of individuals in need and the expected growth of the aging population, these findings could help healthcare systems in evaluating a variety of treatment options and delivery media for meeting the healthcare needs of the future.

Intensive outpatient treatment for PTSD: an open trial combining prolonged exposure therapy, EMDR, and physical activity

Background: Intensive outpatient treatment could be a promising option for patients with post-traumatic stress disorder (PTSD). Objective: The aim of the study was to test the effectiveness of an eight-day (two-week) intensive treatment for PTSD within a public health care setting (open trial design). Method: Eighty-nine patients were offered the choice between intensive treatment and spaced individual treatment, of which 34 (38.2%) chose the intensive format. Patients were assessed with self-report batteries and interviews at pre-treatment, start of treatment, post-treatment and three-month follow-up. Each day consisted of individual Prolonged Exposure therapy, Eye Movement Desensitization and Reprocessing therapy, group psychoeducation, and physical activity. Therapists rotated between patients. Results: Between 55 and 62% of the patients showed a clinically significant change (recovery) in symptoms of PTSD, and the effect sizes were large (d = 1.38-1.52). Patients also showed reduction in symptoms of depression and anxiety, along with improved well-being and interpersonal functioning. Changes in social and work functioning were more ambiguous. There were no dropouts, attendance was high, and patients were highly satisfied with the treatment. Conclusions: The intensive programme was an attractive and effective treatment option for patients with PTSD.

Intensive outpatient treatment for post-traumatic stress disorder: a thematic analysis of patient experience

BACKGROUND

Intensive treatments have shown encouraging results in the treatment of several psychological disorders, including post-traumatic stress disorder (PTSD). However, qualitative studies on patient experiences with intensive treatment for PTSD remain scarce.

OBJECTIVE

The aim of this study was to explore patient experiences with an intensive, outpatient treatment for PTSD and to discover important factors behind treatment feasibility.

METHOD

Eight participants were recruited from two groups of patients having completed the intensive treatment programme. Semi-structured qualitative interviews were conducted, and data sets were analysed using thematic analysis.

RESULTS

The main result indicated that patients experienced the treatment as very demanding, but still worth the effort in terms of reducing symptoms. The intensity was valued as useful. Participants emphasized the sense of unity with other participants as well as physical activity as important factors for completion of the treatment programme. The rotation of therapists was also highlighted as important for treatment efficacy.

CONCLUSIONS

This study provides insights into what the patients experienced and emphasized as important aspects of treatment and essential factors for completing treatment. The main conclusions were that all of the patients evaluated the treatment as demanding, but the reward of reduced symptoms made it worthwhile. The high frequency of therapy sessions and the therapist rotation were reported to counteract avoidance and increase the patients' commitment to therapy. Physical activity and unity in the group were highlighted as essential for treatment feasibility.

HIGHLIGHTS

• High treatment intensity enabled increased focus and adherence, and reduced avoidance.  Therapist rotation led to heightened intensity and new learning experiences.• Physical activity and sense of unity through group elements were reported as important factors for treatment feasibility.

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 Counseling for College Students: Pilot Feasibility and Acceptability Study

OBJECTIVE

University counseling centers struggle to meet the growing demand for mental health treatment by students in distress. More acutely distressed students typically receive priority, whereas those with mild to moderate depression often face longer wait times and fewer available therapy sessions. For this reason, interpersonal counseling for college students (IPC-C) was created as a brief manualized psychotherapy, suitable for students with mild to moderate depression, that maintains the core components of interpersonal counseling and integrates components from interpersonal psychotherapy for adolescents and other developmentally appropriate techniques. This article describes a pilot trial of IPC-C.

METHODS

IPC-C is delivered in three to six psychotherapy sessions focused on alleviating depressive symptoms and increasing social support. Ten participants from two university counseling centers were recruited to receive IPC-C. The inclusion criterion was a Patient Health Questionnaire-9 (PHQ-9) score of 5-14, indicating mild to moderate depression. Participants completed the PHQ-9 at each session, the College Adjustment Test at baseline and termination, and the IPC Satisfaction Scale at termination.

RESULTS

Nine of the 10 participants completed the study, attending an average of five therapy sessions each. Participants agreed that the number of sessions was appropriate and indicated satisfaction with the IPC-C intervention. Participants exhibited significantly reduced depression severity (Cohen's d=2.45) and significantly improved college adjustment (d=0.92).

CONCLUSIONS

In this pilot trial, IPC-C was found to be a feasible and acceptable intervention for university-based treatment of young adults with mild to moderate depressive symptoms. IPC-C holds promise as a potentially effective intervention for this population and warrants further study in a randomized trial.

The effect of twice-weekly versus once-weekly sessions of either imagery rescripting or eye movement desensitization and reprocessing for adults with PTSD from childhood trauma (IREM-Freq): a study protocol for an international randomized clinical trial

Background

Trauma-focused treatments for posttraumatic stress disorder (PTSD) are commonly delivered either once or twice a week. Initial evidence suggests that session frequency affects treatment response, but very few trials have investigated the effect of session frequency. The present study’s aim is to compare treatment outcomes of twice-weekly versus once-weekly sessions of two treatments for PTSD related to childhood trauma, imagery rescripting (ImRs) and eye movement desensitization and reprocessing (EMDR). We hypothesize that both treatments will be more effective when delivered twice than once a week. How session frequency impacts treatment response, whether treatment type moderates the frequency effect, and which treatment type and frequency works best for whom will also be investigated.

Methods

The IREM-Freq trial is an international multicenter randomized clinical trial conducted in mental healthcare centers across Australia, Germany, and the Netherlands. We aim to recruit 220 participants, who will be randomized to one of four conditions: (1) EMDR once a week, (2) EMDR twice a week, (3) ImRs once a week, or (4) ImRs twice a week. Treatment consists of 12 sessions. Data are collected at baseline until one-year follow-up. The primary outcome measure is clinician-rated PTSD symptom severity. Secondary outcome measures include self-reported PTSD symptom severity, complex PTSD symptoms, trauma-related cognitions and emotions, depressive symptoms, dissociation, quality of life, and functioning. Process measures include memory, learning, therapeutic alliance, motivation, reluctance, and avoidance. Additional investigations will focus on predictors of treatment outcome and PTSD severity, change mechanisms of EMDR and ImRs, the role of emotions, cognitions, and memory, the optimization of treatment selection, learned helplessness, perspectives of patients and therapists, the network structure of PTSD symptoms, and sudden treatment gains.

Discussion

This study will extend our knowledge on trauma-focused treatments for PTSD related to childhood trauma and, more specifically, the importance of session frequency. More insight into the optimal session frequency could lead to improved treatment outcomes and less dropout, and in turn, to a reduction of healthcare costs. Moreover, the additional investigations will broaden our understanding of how the treatments work and variables that affect treatment outcome.

Trial registration

Netherlands Trial Register NL6965, registered 25/04/2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13063-021-05712-9.

Evaluation of the Effect of Comprehensive Nursing in Psychotherapy of Patients with Depression

The purpose of this study is to understand the emotional experience and psychological intervention of patients with depression and to explore the intervention effect of nursing intervention in the psychological treatment of patients with depression, so as to provide clinical nursing work recommendations and provide reference for the implementation of intervention methods for patients with depression. In addition, through case analysis, this paper combines controlled trials to study the effect of comprehensive nursing in the psychotherapy of patients with depression and combines mathematical statistics to process data. Through the analysis of controlled trials, it can be known that on the basis of conventional medication, interventional guidance for patients with depression through comprehensive nursing programs can play an ideal effect in improving the depression of patients. Moreover, it can effectively improve the patient's quality of life after intervention and enhance the patient's nursing satisfaction.

Protocol for a sequential, multiple assignment, randomised trial to test the effectiveness of message-based psychotherapy for depression compared with telepsychotherapy

INTRODUCTION

Digital mental health tools have become popular alternatives to traditional psychotherapy. One emerging form of digital mental health is message-based care, the use of text messages or asynchronous voice or video messaging to provide psychotherapy. There has been no research into whether this is an effective method of psychotherapy as a stand-alone treatment or in combination with traditional psychotherapy.

METHODS AND ANALYSIS

This is a sequential, multiple assignment randomised trial to compare message-based care, videoconference-psychotherapy and a combination of the two treatments in 1000 depressed adults. Participants will be recruited through Talkspace, a digital mental health company, and randomised to receive 6 weeks of either message-based care only or videoconference-psychotherapy only. At 6 weeks, participants will be evaluated for their response to treatment. Those with a 50% or more response to treatment will continue with their assigned condition. Those who do not respond will be randomised to either monthly videoconference-psychotherapy or weekly videoconference-psychotherapy plus message-based care. Primary outcomes will be depression and social functioning. We will also explore moderators of treatment outcome.

ETHICS AND DISSEMINATION

The study received ethics approval from the University of Washington Institutional Review Board. Results of this study will be presented in peer-reviewed journals and at professional conferences.

TRIAL REGISTRATION NUMBER

NCT04513080; Pre-results.

The effects of psychological treatment of perinatal depression: an overview

Perinatal depression is an important public health problem. Psychological interventions play an essential role in the treatment of depression. In the current paper, we will present the results of a series of meta-analyses on psychological treatments of perinatal depression. We report the results of a series of meta-analyses on psychological treatments of depression, including perinatal depression. The meta-analyses are based on a database of randomized trials on psychotherapies for depression that has been systematically developed and updated every year. Psychological interventions are effective in the treatment of perinatal depression with a moderate effect size of g = 0.67, corresponding with a NNT of about 4. These effects were still significant at 12 months after the start of the treatment. These interventions also have significant effects on social support, anxiety, functional impairment, parental stress, and marital stress. Possibly the effects are overestimated because of the use of waiting list control groups, the low quality of the majority of trials and publication bias. Research on psychotherapies for depression in general has shown that there are no significant differences between the major types of therapy, except for non-directive counseling that may have somewhat smaller effects. CBT can also be delivered in individual, group, telephone, and guided self-help format. Interventions in subthreshold depression are also effective and may prevent the onset of a full-blown depressive disorder, while therapies may be less effective in chronic depression. Psychological interventions are effective and deserve their place as first-line treatment of perinatal depression.

Interpersonal Counseling for College Students: Pilot Feasibility and Acceptability Study

OBJECTIVE

University counseling centers struggle to meet the growing demand for mental health treatment by students in distress. More acutely distressed students typically receive priority, whereas those with mild to moderate depression often face longer wait times and fewer available therapy sessions. For this reason, interpersonal counseling for college students (IPC-C) was created as a brief manualized psychotherapy, suitable for students with mild to moderate depression, that maintains the core components of interpersonal counseling and integrates components from interpersonal psychotherapy for adolescents and other developmentally appropriate techniques. This article describes a pilot trial of IPC-C.

METHODS

IPC-C is delivered in three to six psychotherapy sessions focused on alleviating depressive symptoms and increasing social support. Ten participants from two university counseling centers were recruited to receive IPC-C. The inclusion criterion was a Patient Health Questionnaire-9 (PHQ-9) score of 5-14, indicating mild to moderate depression. Participants completed the PHQ-9 at each session, the College Adjustment Test at baseline and termination, and the IPC Satisfaction Scale at termination.

RESULTS

Nine of the 10 participants completed the study, attending an average of five therapy sessions each. Participants agreed that the number of sessions was appropriate and indicated satisfaction with the IPC-C intervention. Participants exhibited significantly reduced depression severity (Cohen's d=2.45) and significantly improved college adjustment (d=0.92).

CONCLUSIONS

In this pilot trial, IPC-C was found to be a feasible and acceptable intervention for university-based treatment of young adults with mild to moderate depressive symptoms. IPC-C holds promise as a potentially effective intervention for this population and warrants further study in a randomized trial.

Evaluation of the effect of cognitive behavioral therapy on tocophobia: A systematic review and meta-analysis

Non-medical approaches including cognitive behavioral therapy (CBT) have been proposed for the management of tocophobia. A new method of performing CBT is through internet. The aim of this systematic review and meta-analysis was to evaluate the effect of internet-based and traditional CBT on tocophobia. A literature search was conducted on qualitative and quantitative articles from 2000 to 2019 in Pubmed, Scopus, Web of Science and Cochrane databases using search terms referring to tocophobia and CBT. Identified articles were screened in two steps; 1) title and abstract and 2) full text screening. The quality of the quantitative and qualitative studies was assessed using the quality criteria proposed by the Cochrane Collaboration and Jonna Briggs Institute (JBI) checklist respectively. Out of the 382 relevant studies, 9 studies were eligible for the review. A high level of heterogeneity was observed in the studies (I² = 94%, P < 0.001). The meta-analysis showed that both internet-based, and traditional CBT were effective in reducing tocophobia. CBT was more effective in interventions in the Middle Eastern compared to European countries. More than five CBT sessions could significantly reduce tocophobia. Healthcare providers and midwives should have basic knowledge on physiological interventions to reduce tocophobia.

Intensive outpatient treatment for PTSD: a pilot feasibility study combining prolonged exposure therapy, EMDR, physical activity, and psychoeducation

Background: Intensive treatment could be effective for patients with post-traumatic stress disorder (PTSD). Objective: The aim of the study was to test the feasibility of an 8-day (2-week) intensive outpatient treatment for PTSD. Method: Treatment each day consisted of individual Prolonged Exposure (PE), Eye Movement Desensitization and Reprocessing (EMDR), and psychoeducation and physical activity in groups. Patients met different therapists from session to session. Results: Six patients started and completed treatment. Levels of attendance of sessions was high. Patients reported that they were satisfied with the treatment, describing it as emotionally taxing, but meaningful. Therapists also described several positive aspects of the treatment format. There were large reductions in PTSD symptoms. Conclusions: Given these promising, but preliminary findings on the programme's feasibility, future research should investigate this treatment format using larger samples and controlled designs.

The relation between therapy quality, therapy processes and outcomes and identifying for whom therapy quality matters in CBT and IPT for depression

BACKGROUND

Research on which therapy processes are crucial for whom is necessary to optimize treatment outcomes for major depressive disorder (MDD) but may be impeded by a lack of variation in therapy quality and because of individual differences in therapy response. The present study used a dataset with large variation in therapy quality to investigate the impact of therapy quality on change in therapy processes and outcome. Machine-learning techniques were used to explore individual differences in these relationships.

METHOD

Data come from a multicenter trial that randomized patients with MDD into weekly versus twice weekly sessions of cognitive behavioral therapy (CBT) or interpersonal psychotherapy (IPT). Correlations between quality of therapy, change in therapy processes and depressive symptoms were calculated. Using elastic net regression, a prognostic model was developed that investigated individual differences.

RESULTS

There were no significant correlations between therapy quality and change in therapy process variables or between therapy quality and therapy outcome, except between therapy quality and dysfunctional thinking and IPT skills. Improvement in therapy processes played a larger role in patients whose therapy outcome was poorly predicted by their baseline characteristics.

CONCLUSIONS

In this study, in which therapy quality varied considerably, we found that therapy quality was not related to change in therapy processes or outcome. In addition, this study provides a first demonstration of proposed methods to identify individual responses to change in therapy processes. Results suggested that the importance of certain therapy processes might differ between patients. Future research into the relation between therapy quality, change in therapy processes and outcome should take into account the variation of therapy quality, focus on improved measurement of therapy quality and use a combination of machine learning techniques and experimental lab studies to determine to which extent and for whom therapy quality and change in therapy processes matter.

Delivering Imagery Rescripting via Telehealth: Clinical Concerns, Benefits, and Recommendations

PURPOSE OF THE REVIEW

Delivery of psychological therapies via telehealth has increased with the emergence of the COVID-19 pandemic. Therapists may be hesitant in moving to telehealth when delivering therapies targeting memories of traumatic experiences. This paper collates the clinical experiences of clinicians and clients who have delivered or received imagery rescripting, respectively, via telehealth across a range of clinical presentations, and describes key clinical considerations and recommendations.

RECENT FINDINGS

It is important to consider perceived and real safety; practical and technological issues; therapeutic alliance; depth of emotional processing; and dissociation. There was support for the delivery of imagery rescripting via telehealth being no less effective than face-to-face delivery; however, telehealth delivery was not a viable option for many clients during COVID-19 lockdowns who were living in high density housing, old houses with thin walls, or with some complex disorders.

Alliance ruptures in cognitive-behavioral therapy: A cognitive conceptualization

The therapeutic relationship is crucial to the ethical and effective practice of any psychotherapy. In Cognitive Behavior Therapy (CBT) as formulated by Aaron T. Beck, the generic elements of the relationship including expressed empathy, expressions of positive regard, agreement on goals, and agreement on tasks within a therapeutic bond were considered a necessary condition for change. Alliance ruptures can therefore have a detrimental effect on therapy if left unrepaired. This article contributes to the In-Session issue on rupture repairs by outlining the role of the alliance as a component of the therapeutic relationship in CBT and illustrates how ruptures can be identified and effectively resolved through detailed case examples. Given the central importance of using collaborative empiricism and Socratic dialogue for the therapeutic relationship in CBT, we demonstrate the distinctive role of these elements in repairing ruptures.

A pragmatic factorial randomized controlled trial of transdiagnostic internet-delivered cognitive behavioural therapy: Exploring benefits of homework reflection questionnaires and twice-weekly therapist support

With the growing demand for internet-delivered cognitive behavioural therapy (iCBT), this pragmatic factorial (2 × 2 × 2) randomized controlled trial evaluated strategies for facilitating iCBT engagement and outcomes in routine care. Specifically, the benefits to patients and therapists of using homework reflection questionnaires and offering patients twice-weekly therapist support were examined. Patients (n = 632) accepted into iCBT for depression and/or anxiety were randomly assigned to complete homework reflection questionnaires or not (factor 1), receive once- or twice-weekly support (factor 2), and to receive care from therapists employed in one of two settings (iCBT clinic or a community mental health clinic; factor 3). Outcomes were measured at pre-treatment, and 8, 12, and 24-weeks post-enrollment. Therapist time was tracked and a focus group was conducted to examine therapist experiences. No differences in patient outcomes were found between therapists employed in the two settings; as such, these two groups were combined for further analyses. In terms of engagement, homework reflection questionnaires were associated with fewer website log-ins and days accessing iCBT; twice-weekly support was associated with more patient emails sent to therapists. Despite engagement differences, homework reflection questionnaires and twice-weekly support did not significantly impact primary outcomes; all groups showed large improvements in depression and anxiety that were maintained at 24-week follow-up. Therapists perceived a number of benefits and challenges associated with responding to homework reflection questionnaires and offering twice-weekly support; most notably the strategies did not benefit all patients. Twice-weekly support was associated with increased therapist time and organizational challenges. It is concluded that neither completion of homework questionnaires nor offering twice-weekly support significantly improve iCBT in routine care.