Using Progress Feedback to Enhance Treatment Outcomes: A Narrative Review

We face increasing demand for greater access to effective routine mental health services, including telehealth. However, treatment outcomes in routine clinical practice are only about half the size of those reported in controlled trials. Progress feedback, defined as the ongoing monitoring of patients' treatment response with standardized measures, is an evidence-based practice that continues to be under-utilized in routine care. The aim of the current review is to provide a summary of the current evidence base for the use of progress feedback, its mechanisms of action and considerations for successful implementation. We reviewed ten available meta-analyses, which report small to medium overall effect sizes. The results suggest that adding feedback to a wide range of psychological and psychiatric interventions (ranging from primary care to hospitalization and crisis care) tends to enhance the effectiveness of these interventions. The strongest evidence is for patients with common mental health problems compared to those with very severe disorders. Effect sizes for not-on-track cases, a subgroup of cases that are not progressing well, are found to be somewhat stronger, especially when clinical support tools are added to the feedback. Systematic reviews and recent studies suggest potential mechanisms of action for progress feedback include focusing the clinician's attention, altering clinician expectations, providing new information, and enhancing patient-centered communication. Promising approaches to strengthen progress feedback interventions include advanced systems with signaling technology, clinical problem-solving tools, and a broader spectrum of outcome and progress measures. An overview of methodological and implementation challenges is provided, as well as suggestions for addressing these issues in future studies. We conclude that while feedback has modest effects, it is a small and affordable intervention that can potentially improve outcomes in psychological interventions. Further research into mechanisms of action and effective implementation strategies is needed.

Inpatient psychotherapy for depression in a large routine clinical care sample: A Bayesian approach to examining clinical outcomes and predictors of change

BACKGROUND

A routinely collected dataset was analyzed (1) to determine the naturalistic effectiveness of inpatient psychotherapy for depression in routine psychotherapeutic care, and (2) to identify potential predictors of change.

METHODS

In a sample of 22,681 inpatients with depression, pre-post and pre-follow-up effect sizes were computed for various outcome variables. To build a probabilistic model of predictors of change, an independent component analysis generated components from demographic and clinical data, and Bayesian EFA extracted factors from the available pre-test, post-test and follow-up questionnaires in a subsample (N = 6377). To select the best-fitted model, the BIC of different path models were compared. A Bayesian path analysis was performed to identify the most important factors to predict changes.

RESULTS

Effect sizes were large for the primary outcome and moderate for various secondary outcomes. Almost all pretreatment factors exerted significant influences on different baseline factors. Several factors were found to be resistant to change during treatment: suicidality, agoraphobia, life dissatisfaction, physical disability and pain. The strongest cross-loadings were observed from suicidality on negative cognitions, from agoraphobia on anxiety, and from physical disability on perceived disability.

LIMITATIONS

No causal conclusions can be drawn directly from our results as we only used cross-lagged panel data without control group.

CONCLUSIONS

The results indicate large effects of inpatient psychotherapy for depression in routine clinical care. The direct influence of pretreatment factors decreased over the course of treatment. However, some factors appeared stable and difficult to treat, which might hinder treatment outcome. Findings of different predictors of change are discussed.

Praxisorientierte Forschung in der Psychotherapie

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

Acceptability and Efficacy of Group Behavioral Activation for Depression Among Adults: A Meta-Analysis

The evidence base for behavioral activation (BA) as a front-line treatment for depression is grounded in individual delivery. No valid previous meta-analytic reviews of BA delivered in groups have been conducted. This study therefore examined the efficacy and acceptability of group BA drawn from clinical trial evidence. Randomized controlled trials of group BA were identified using a comprehensive literature search. Depression outcomes at posttreatment/follow-up, recovery and dropout rates were extracted and analyzed using a random-effects meta-analysis. Treatment moderators were analyzed using meta-regression and subgroup analyses. Nineteen trials were quantitatively synthesized. Depression outcomes postgroup BA treatment were superior to controls (SMD 0.72, CI 0.34 to 1.10, k=13, N=461) and were equivalent to other active therapies (SMD 0.14, CI -0.18 to 0.46, k=15, N=526). Outcomes were maintained at follow-up for group BA and moderators of treatment outcome were limited. The dropout rate for group BA (14%) was no different from other active treatments for depression (17%). Further research is required to refine the conditions for optimum delivery of group BA and define robust moderators and mediators of outcome. However, BA delivered in groups produces a moderate to large effect on depressive symptoms and should be considered an appropriate front-line treatment option.

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.

Effectiveness of routine psychotherapy: Method matters

OBJECTIVE

Though many studies have shown that psychotherapy can be effective, psychotherapy available in routine practice may not be adequate. Several methods have been proposed to evaluate routine psychological treatments. The aim of this paper is to demonstrate the combined utility of complementary methods, change-based benchmarking, and end-state normative comparisons, across a range of self-reported psychological symptoms.

METHOD

Benchmarks derived from randomized controlled trials (RCTs) and normative comparisons were used to evaluate the effectiveness of psychotherapy in a large (N = 9895) sample of clients in university counseling centers (UCCs).

RESULTS

Overall, routine psychotherapy was associated with significant improvement across all symptoms examined. For clients whose initial severity was similar to RCT participants, the observed pre-post effect sizes were equivalent to those in RCTs. However, treatment tended to lead to normative end-state functioning only for those clients who were moderately, but not severely, distressed at the start of psychotherapy.

CONCLUSIONS

This suggests that although psychotherapy is associated with an effective magnitude of symptom improvement in routine practice, additional services for highly distressed individuals may be necessary. The methods described here comprise a comprehensive analysis of the quality of routine care, and we recommend using both methods in concert. Clinical or methodological significance of this article: This study examines the effectiveness of routine psychotherapy provided in a large network of counseling centers. By comparing multiple established methods to define outcomes in this sample we provide a detailed understanding of typical outcomes. The findings show that, across several different problem areas, routine psychotherapy provided substantial benefit, particularly to clients in the most distress. However, there is room to improve, especially by increasing the number of clients who return to normal functioning by the end of treatment. Using distinct methods provides complementary answers to the question: How effective is routine psychotherapy?

Psychological advocacy towards healing (PATH): A randomized controlled trial of a psychological intervention in a domestic violence service setting

BACKGROUND

Experience of domestic violence and abuse (DVA) is associated with mental illness. Advocacy has little effect on mental health outcomes of female DVA survivors and there is uncertainty about the effectiveness of psychological interventions for this population.

OBJECTIVE

To test effectiveness of a psychological intervention delivered by advocates to DVA survivors.

DESIGN, MASKING, SETTING, PARTICIPANTS

Pragmatic parallel group individually randomized controlled trial of normal DVA advocacy vs. advocacy + psychological intervention. Statistician and researchers blinded to group assignment. Setting: specialist DVA agencies; two UK cities. Participants: Women aged 16 years and older accessing DVA services.

INTERVENTION

Eight specialist psychological advocacy (SPA) sessions with two follow up sessions.

MEASUREMENTS

Primary outcomes at 12 months: depression symptoms (PHQ-9) and psychological distress (CORE-OM). Primary analysis: intention to treat linear (logistic) regression model for continuous (binary) outcomes.

RESULTS

263 women recruited (78 in shelter/refuge, 185 in community), 2 withdrew (1 community, control group; 1 intervention, refuge group), 1 was excluded from the study for protocol violation (community, control group), 130 in intervention and 130 in control groups. Recruitment ended June 2013. 12-month follow up: 64%. At 12-month follow up greater improvement in mental health of women in the intervention group. Difference in average CORE-OM score between intervention and control groups: -3.3 points (95% CI -5.5 to -1.2). Difference in average PHQ-9 score between intervention and control group: -2.2 (95% CI -4.1 to -0.3). At 12 months, 35% of the intervention group and 55% of the control group were above the CORE-OM -2clinical threshold (OR 0.32, 95% CI 0.16 to 0.64); 29% of the intervention group and 46% of the control group were above the PHQ-9 clinical threshold (OR 0.41, 95% CI 0.21 to 0.81).

LIMITATIONS

64% retention at 12 months.

CONCLUSIONS

An eight-session psychological intervention delivered by DVA advocates produced clinically relevant improvement in mental health outcomes compared with normal advocacy care.

TRIAL REGISTRATION

ISRCTN registry ISRCTN58561170 Original Research 3675/3750.

The Role of Practice Research Networks (PRN) in the Development and Implementation of Evidence: The Northern Improving Access to Psychological Therapies PRN Case Study

Practice research networks (PRNs) can support the implementation of evidence based practice in routine services and generate practice based evidence. This paper describes the structure, processes and learning from a new PRN in the Improving Access to Psychological Therapies programme in England, in relation to an implementation framework and using one study as a case example. Challenges related to: ethics and governance processes; communications with multiple stakeholders; competing time pressures and linking outcome data. Enablers included: early tangible outputs and impact; a collaborative approach; engaging with local research leads; clarity of processes; effective dissemination; and committed leadership.

Death anxiety interventions in patients with advanced cancer: A systematic review

BACKGROUND

Death anxiety is a common issue in adult patients with advanced cancer and can have a large impact on quality of life and end-of-life care. Interventions are available to assist but are scarcely used in everyday practice.

AIM

To assess quantitative studies on interventions for adult patients with advanced cancer suffering from death anxiety.

DATA SOURCES

MEDLINE, PsycINFO, Embase and CINAHL were searched to identify quantitative or mixed studies on death anxiety or relatable existential intervention studies in advanced cancer patients published from 1990 to December 2016. Two reviewers independently screened titles and abstracts and assessed relevant studies for eligibility. Data were then extracted from included studies for analysis.

RESULTS

Nine unique quantitative studies were identified, including five randomised controlled trials, involving a total overall of 1179 advanced cancer patients. All studies were psychotherapeutic in nature and centred on existential themes such as meaning, dignity, relationships and spiritual well-being. The therapies investigated shared overlapping themes but varied in duration, therapist experience, training required and burden on patient. Heterogeneity of studies and measures prevented determination of an overall effect size.

CONCLUSION

Interventions were identified for this clinical scenario of death anxiety in patients with advanced cancer. Therapies of short duration incorporating spiritual well-being and those evoking a sense of meaning were claimed to be the most beneficial, despite lacking rigorous statistical analysis. More high-quality studies with tailored outcome measures are required to fully evaluate the most effective interventions for death anxiety in patients with advanced cancer.

Acceptance and commitment therapy (ACT) for clinically distressed health care workers: Waitlist-controlled evaluation of an ACT workshop in a routine practice setting

OBJECTIVES

To examine the effects of a 1-day acceptance and commitment therapy (ACT) workshop on the mental health of clinically distressed health care employees, and to explore ACT's processes of change in a routine practice setting.

DESIGN

A quasi-controlled design, with participants block allocated to an ACT intervention or waiting list control group based on self-referral date.

METHODS

Participants were 35 health care workers who had self-referred for the ACT workshop via a clinical support service for staff. Measures were completed by ACT and control group participants at pre-intervention and 3 months post-intervention. Participants allocated to the waitlist condition went on to receive the ACT intervention and were also assessed 3 months later.

RESULTS

At 3 months post-intervention, participants in the ACT group reported a significantly lower level of psychological distress compared to the control group (d = 1.41). Across the 3-month evaluation period, clinically significant change was exhibited by 50% of ACT participants, compared to 0% in the control group. When the control group received the same ACT intervention, 69% went on to exhibit clinically significant change. The ACT intervention also resulted in significant improvements in psychological flexibility, defusion, and mindfulness skills, but did not significantly reduce the frequency of negative cognitions. Bootstrapped mediation analyses indicated that the reduction in distress in the ACT condition was primarily associated with an increase in mindfulness skills, especially observing and non-reactivity.

CONCLUSIONS

These findings provide preliminary support for providing brief ACT interventions as part of routine clinical support services for distressed workers.

PRACTITIONER POINTS

A 1-day ACT workshop delivered in the context of a routine staff support service was effective for reducing psychological distress among health care workers. The brief nature of this group intervention means it may be particularly suitable for staff support and primary care mental health service settings. The findings indicate that the beneficial effects of an ACT workshop on distressed employees' mental health were linked to improvements in specific mindfulness skills. Study limitations include non-random allocation of participants to the ACT and control groups, and measurement of mediators and outcome at the same time point (3 months post-intervention).

Randomized Trial of Interpersonal Psychotherapy and Cognitive Behavioral Therapy for Major Depressive Disorder in a Community-Based Psychiatric Outpatient Clinic

BACKGROUND

Interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) are both evidence-based treatments for major depressive disorder (MDD). Several head-to-head comparisons have been made, mostly in the United States. In this trial, we compared the two treatments in a small-town outpatient psychiatric clinic in Sweden. The patients had failed previous primary care treatment and had extensive Axis-II comorbidity. Outcome measures were reduction of depressive symptoms and attrition rate.

METHODS

Ninety-six psychiatric patients with MDD (DSM-IV) were randomized to 14 sessions of CBT (n = 48) or IPT (n = 48). A noninferiority design was used with the hypothesis that IPT would be noninferior to CBT. A three-point difference on the Beck Depression Inventory-II (BDI-II) was used as noninferiority margin.

RESULTS

IPT passed the noninferiority test. In the ITT group, 53.5% (23/43) of the IPT patients and 51.0% (24/47) of the CBT patients were reliably improved, and 20.9% (9/43) and 19.1% (9/47), respectively, were recovered (last BDI score <10). The dropout rate was significantly higher in CBT (40%; 19/47) compared to IPT (19%; 8/43). Statistically controlling for antidepressant medication use did not change the results.

CONCLUSIONS

IPT was noninferior to CBT in a sample of depressed psychiatric patients in a community-based outpatient clinic. CBT had significantly more dropouts than IPT, indicating that CBT may be experienced as too demanding. Since about half the patients did not recover, there is a need for further treatment development for these patients. The study should be considered an effectiveness trial, with strong external validity but some limitations in internal validity.

Prospective cohort feasibility study of a transdiagnostic group intervention for common mental health problems: The Take Control Course

OBJECTIVES

While transdiagnostic psychological treatments appear to be promising, they require greater empirical support. Further, a number of available transdiagnostic treatments are targeted at clients with a specific category of disorder, such as clients with anxiety disorders. This study is a preliminary examination of the effectiveness, feasibility, and acceptability of a new transdiagnostic six-session group-based intervention (Take Control Course; TCC) predominantly aimed at clients within primary care. The group is aimed at a broad range of clients; it is derived from an integrative transdiagnostic theory, which specifies mechanisms of psychopathology across disorders. Briefer interventions are gaining an increasing evidence base, and this study seeks to compare the TCC to an established brief intervention within primary care.

DESIGN

Prospective cohort study comparing two active psychological treatments.

METHODS

Take Control Course group (n = 66) was compared to a non-randomized control group of clients accessing individual low-intensity interventions (n = 43) using random-effect regression models. Primary outcomes were depression and anxiety scores; additional outcomes included social and other functioning.

RESULTS

For the TCC group, changes on all pre-post outcomes were significant with moderate effect sizes. The between-group differences were not significant.

CONCLUSIONS

Results show potential for TCC to be an effective intervention, but further work is required to validate these findings in a more rigorous, randomized study.

PRACTITIONER POINTS

Transdiagnostic understandings of psychological distress may inform pragmatic and effective treatments that can be offered to a broad range of clients. This study describes a transdiagnostic intervention (TCC) that targets maintenance processes common across disorders, and presents initial outcome data. The TCC was found to reduce pre-post scores on measures of anxiety and depression.

Treatment progress in medium security hospital settings for women: changes in symptoms, personality and service need from admission to discharge

BACKGROUND

Service evaluations of medium secure hospital facilities for women are underrepresented in the extant literature.

HYPOTHESIS

That positive changes in symptoms, personality traits and service need would be evident between admission and discharge among women in a medium security hospital service.

METHODS

A pre-test/post-test design was used, with comparisons made between admission and pre-discharge points on a variety of measures of psychiatric symptoms and personality traits.

RESULTS

There were significant improvements in mood according to Beck Depression Inventory scores, mood and other symptoms of mental disorder and distress as measured by the Brief Psychiatric Rating Scale and the Modified Post Traumatic Stress Disorder Symptom Scale, personality traits recorded using the Millon Clinical Multiaxial Inventory III and service need as measured by the Camberwell Assessment of Need, Forensic Version.

CONCLUSIONS/IMPLICATIONS FOR PRACTICE

Significant positive change during treatment, in all clinical areas, is encouraging given poor outcomes for women reported in other research. Findings cannot, however, be unequivocally attributed to the treatments given. Further work is needed to improve early engagement and tailor treatment more specifically to the needs of a heterogeneous population.

Intensive case management for high-risk patients with first-episode psychosis: service model and outcomes

BACKGROUND

The first episode of psychosis is a crucial period when early intervention can alter the trajectory of the young person's ongoing mental health and general functioning. After an investigation into completed suicides in the Early Psychosis Prevention and Intervention Centre (EPPIC) programme, the intensive case management subprogramme was developed in 2003 to provide assertive outreach to young people having a first episode of psychosis who are at high risk owing to risk to self or others, disengagement, or suboptimal recovery. We report intensive case management model development, characterise the target cohort, and report on outcomes compared with EPPIC treatment as usual.

METHODS

Inclusion criteria, staff support, referral pathways, clinical review processes, models of engagement and care, and risk management protocols are described. We compared 120 consecutive referrals with 50 EPPIC treatment as usual patients (age 15-24 years) in a naturalistic stratified quasi-experimental real-world design. Key performance indicators of service use plus engagement and suicide attempts were compared between EPPIC treatment as usual and intensive case management, and psychosocial and clinical measures were compared between intensive case management referral and discharge.

FINDINGS

Referrals were predominately unemployed males with low levels of functioning and educational attainment. They were characterised by a family history of mental illness, migration and early separation, with substantial trauma, history of violence, and forensic attention. Intensive case management improved psychopathology and psychosocial outcomes in high-risk patients and reduced risk ratings, admissions, bed days, and crisis contacts.

INTERPRETATION

Characterisation of intensive case management patients validated the clinical research focus and identified a first episode of psychosis high-risk subgroup. In a real-world study, implementation of an intensive case management stream within a well-established first episode of psychosis service showed significant improvement in key service outcomes. Further analysis is needed to determine cost savings and effects on psychosocial outcomes. Targeting intensive case management services to high-risk patients with unmet needs should reduce the distress associated with pathways to care for patients, their families, and the community.

FUNDING

National Health & Medical Research Council and the Colonial Foundation.

Do evidence-based interventions work when tested in the "real world?" A systematic review and meta-analysis of parent management training for the treatment of child disruptive behavior

Evidence-based interventions are often unavailable in everyday clinical settings. This may partly reflect practitioners' assumptions that research evidence does not reflect "real-world" conditions. To examine this further, we systematically assessed the clinical effectiveness of parent management training (PMT) for the treatment of child disruptive behavior across different real-world practice contexts. We identified 28 relevant randomized controlled trials from a systematic search of electronic bibliographic databases and conducted a meta-analysis of child outcomes across trials. Planned subgroup analyses involved comparisons between studies grouped according to individual real-world practice criteria and total real-world practice criteria scores, reflecting the extent to which PMT was delivered by non-specialist therapists, to a clinic-referred population, in a routine setting, and as part of a routine service. Meta-analysis revealed a significant overall advantage for PMT compared with waitlist control conditions. Subgroup analyses did not demonstrate significant differences in effect size estimates according to the total number of real-world practice criteria met by studies. Moreover, no consistent relationships were found between specific practice criteria and effect size estimates. In conclusion, PMT appears to be an effective treatment for children with disruptive behavior problems. There was no clear evidence that conducting PMT in real-world practice contexts is a deterrent to achieving effective child behavior outcomes, although relative advantage to "usual care" was not directly examined and the power of the analysis was limited as a result of significant heterogeneity. More research is needed to investigate whether this finding is generalizable to other psychological interventions. Suggestions are also made for developing more differentiated criteria to assist with evaluating the specific applicability of research evidence to different care providers.

Psychological advocacy toward healing (PATH): study protocol for a randomized controlled trial

Background

Domestic violence and abuse (DVA), defined as threatening behavior or abuse by adults who are intimate partners or family members, is a key public health and clinical priority. The prevalence of DVA in the United Kingdom and worldwide is high, and its impact on physical and mental health is detrimental and persistent. There is currently little support within healthcare settings for women experiencing DVA. Psychological problems in particular may be difficult to manage outside specialist services, as conventional forms of therapy such as counseling that do not address the violence may be ineffective or even harmful. The aim of this study is to assess the overall effectiveness and cost-effectiveness of a novel psychological intervention tailored specifically for survivors of DVA and delivered by domestic violence advocates based in third-sector organizations.

Methods and study design

This study is an open, pragmatic, parallel group, individually randomized controlled trial. Women ages 16 years and older experiencing domestic violence are being enrolled and randomly allocated to receive usual DVA agency advocacy support (control) or usual DVA agency support plus psychological intervention (intervention). Those in the intervention group will receive eight specialist psychological advocacy (SPA) sessions weekly or fortnightly, with two follow-up sessions, 1 month and then 3 months later. This will be in addition to any advocacy support sessions each woman receives. Women in the control group will receive usual DVA agency support but no additional SPA sessions. The aim is to recruit 250 women to reach the target sample size. The primary outcomes are psychological well-being and depression severity at 1 yr from baseline, as measured by the Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) and the Patient Health Questionnaire (PHQ-9), respectively. Secondary outcome measures include anxiety, posttraumatic stress, severity and frequency of abuse, quality of life and cost-effectiveness of the intervention. Data from a subsample of women in both groups will contribute to a nested qualitative study with repeat interviews during the year of follow-up.

Discussion

This study will contribute to the evidence base for management of the psychological needs of women experiencing DVA. The findings will have important implications for healthcare commissioners and providers, as well as third sector specialist DVA agencies providing services to this client group.

Trial registration

ISRCTN58561170

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

BACKGROUND

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

METHODS

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

RESULTS

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

LIMITATIONS

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

CONCLUSIONS

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

Taming the green-eyed monster: temporal responsivity to cognitive behavioural and cognitive analytic therapy for morbid jealousy

OBJECTIVES

Credible evaluations of the psychological treatment of morbid jealousy are rare. The aim of this study was to evaluate temporal responsivity to cognitive behavioural therapy (CBT) and cognitive analytic therapy (CAT) for morbid jealousy.

DESIGN

The methodology involved matched A/B single-case experimental designs (SCED) with extended follow-up, in which two patients and their partners completed daily jealousy target symptom items across the phases of the study. Patients also completed traditional psychometric outcome measures at assessment, post-therapy, and at final follow-up.

METHODS

Both patients received the same number of assessment (n = 3), treatment (n = 13), and follow-up (n = 1) sessions.

RESULTS

 Autoregressive Integrated Moving Average (ARIMA) models of the patients' daily target symptom jealousy SCED data indicate the effectiveness of the CAT intervention and the ineffectiveness of the CBT intervention, but both therapies produced large effect sizes. The partner of the CBT patient felt less controlled following therapy, whilst the partner of CAT patient did not perceive any change to his partner.

CONCLUSION

The discussion calls for a stronger evidence base for the psychological treatment of morbid jealousy to be constructed and debates the routine measurement of outcomes for partners of morbidly jealous patients.

PRACTITIONER POINTS

Measuring outcomes for partners of jealous patients is indicated.   CAT shows promise as an intervention for morbid jealousy. The evidence base for the treatment of morbid jealousy requires further development.

Estimating a preference-based index from the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM): valuation of CORE-6D

Background. The Clinical Outcomes in Routine Evaluation–Outcome Measure (CORE-OM) is used to evaluate the effectiveness of psychological therapies in people with common mental disorders. The objective of this study was to estimate a preference-based index for this population using CORE-6D, a health state classification system derived from the CORE-OM consisting of a 5-item emotional component and a physical item, and to demonstrate a novel method for generating states that are not orthogonal. Methods. Rasch analysis was used to identify 11 emotional health states from CORE-6D that were frequently observed in the study population and are, thus, plausible (in contrast, conventional statistical design might generate implausible states). Combined with the 3 response levels of the physical item of CORE-6D, they generate 33 plausible health states, 18 of which were selected for valuation. A valuation survey of 220 members of the public in South Yorkshire, United Kingdom, was undertaken using the time tradeoff (TTO) method. Regression analysis was subsequently used to predict values for all possible states described by CORE-6D. Results. A number of multivariate regression models were built to predict values for the 33 health states of CORE-6D, using the Rasch logit value of the emotional state and the response level of the physical item as independent variables. A cubic model with high predictive value (adjusted R² = 0.990) was selected to predict TTO values for all 729 CORE-6D health states. Conclusion. The CORE-6D preference-based index will enable the assessment of cost-effectiveness of interventions for people with common mental disorders using existing and prospective CORE-OM data sets. The new method for generating states may be useful for other instruments with highly correlated dimensions.

Efficacy versus effectiveness: a direct comparison of the outcome of treatment for mild to moderate depression in randomized controlled trials and daily practice

BACKGROUND

Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D.

METHODS

Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size.

RESULTS

From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40-74%). Differences were less explicit for antidepressants (21 vs. 34-47%) than for individual psychotherapy (27 vs. 34-58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45-63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively).

CONCLUSIONS

Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.

Assessing the Sensitivity of Treatment Effect Estimates to Differential Follow-Up Rates: Implications for Translational Research

We develop a new tool for assessing the sensitivity of findings on treatment effectiveness to differential follow-up rates in the two treatment conditions being compared. The method censors the group with the higher response rate to create a synthetic respondent group that is then compared with the observed cases in the other condition to estimate a treatment effect. Censoring is done under various assumptions about the strength of the relationship between follow-up and outcomes to determine how informative differential dropout can alter inferences relative to estimates from models that assume the data are missing at random. The method provides an intuitive measure for understanding the strength of the association between outcomes and dropout that would be required to alter inferences about treatment effects. Our approach is motivated by translational research in which treatments found to be effective under experimental conditions are tested in standard treatment conditions. In such applications, follow-up rates in the experimental setting are likely to be substantially higher than in the standard setting, especially when observational data are used in the evaluation. We test the method on a case study evaluation of the effectiveness of an evidence-supported adolescent substance abuse treatment program (Motivational Enhancement Therapy/Cognitive Behavioral Therapy-5 [MET/CBT-5]) delivered by community-based treatment providers relative to its performance in a controlled research trial. In this case study, follow-up rates in the community based settings were extremely low (54%) compared to the experimental setting (95%) giving raise to concerns about non-ignorable drop-out.

Psychological treatment outcomes in routine NHS services: what do we mean by treatment effectiveness?

OBJECTIVES

The question of how effective therapies are in routine practice is crucial. The answer depends on how we define effectiveness. Both the definition of who was treated and the index chosen to represent outcome can affect estimates dramatically.

DESIGN

We used data from the Clinical Outcomes in Routine Evaluation (CORE) Primary Care National Practice-Based Evidence database-2005 on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) from 33,587 patients and examined rates of improvement in psychological therapies in UK National Health Service (NHS) primary care services using various definitions of effectiveness.

METHODS

We constructed successively more restrictive sub-samples of patients, including practice-based analogues of several types of intent-to-treat (ITT) groups and completer groups. We focussed on patients scoring above clinical cut-off at intake, but we also considered samples that included sub-clinical patients. We assessed two types of recovery rates, improvement rates, mean pre-post change, and pre-post effect sizes for each sub-sample.

RESULTS

There was wide variation in the overall effectiveness of treatments as a function of which subset of data was considered and which specific criterion of recovery rate was adopted. Recovery rates and pre-post effect sizes ranged from 19% to 65% and 0.60 to 1.95, respectively.

CONCLUSIONS

Because estimates of effectiveness could have significant policy implications, clarity on the meanings of the differing constructions is essential.

Therapist effects in routine psychotherapy practice: an account from chronic fatigue syndrome

The effect of therapists in psychotherapy is a much debated topic, with a number of studies showing therapist variance being large while other studies show little or no variability in outcomes due to therapists. The aim of this study was to investigate therapist effects in a well-defined sample of patients and therapists from an outpatient service which specializes in providing cognitive behaviour therapy (CBT) for patients with chronic fatigue syndrome (CFS). Therapy was provided in a highly specialized clinical setting for CFS and was delivered by qualified CBT therapists with at least 2 years experience with this client group. Three hundred and seventy-four patients with CFS and 12 cognitive behavioural psychotherapists took part. Therapist effects on the primary outcomes of fatigue and disability were investigated with multilevel random effects models and variance component analysis. Different models were computed and compared. Results showed a reduction in fatigue and disability scores after therapy. Variance explained by therapists, when demographic covariates were accounted for, was 0% for fatigue and under 2% for disability. A number of important factors may have played a significant role in minimizing therapist effects in our study. These are: specialist setting, single centre, patients with the same primary diagnosis, therapists of the same orientation and training, shared environment and supervision. Future studies may stress the importance of these factors in the investigation of the therapist effect in psychotherapy.

Management of depression in patients with coronary heart disease: association, mechanisms, and treatment implications for depressed cardiac patients

IMPORTANCE OF THE FIELD

Coronary heart disease (CHD) and depression are two leading causes of death and disability in the United States and worldwide. Depression is especially common in cardiac patients, and there is growing evidence that depression is a risk factor for fatal and nonfatal events in CHD patients.

AREAS COVERED IN THIS REVIEW

This paper reviews current literature of depression as a risk factor for CHD along with pharmacologic and non-pharmacologic treatments for depression in cardiac patients.

WHAT THE READER WILL GAIN

Readers will gain knowledge about the importance of depression as a CHD risk factor and learn the results of efforts to treat depressed CHD patients.

TAKE HOME MESSAGE

Although randomized clinical trials (RCTs) of medication and non-pharmacologic therapies have not demonstrated that treating depression improves survival, there is evidence that treating depressed patients can reduce depressive symptoms and improve quality of life. Additional RCTs are needed, including evaluation of non-pharmacologic therapies such as exercise, to examine the effects of treatment of depression on medical and psychosocial outcomes.

The psychology of fear of flying (part II): a critical evaluation of current perspectives on approaches to treatment

This is the second of a two part review which critically evaluates research published in disparate sources into the psychological treatment of fear of flying. Part I established fear of flying as a complex heterogeneous clinical phenomenon. This paper discusses the way in which evidence from clinical trials translates to best practice in treating fear of flying. Published research on psychological interventions uses terminology which bears a close resemblance to cognitive behavioural therapy. It is, however, questionable whether some treatment approaches reflect the implementation of the cognitive behavioural model as it is described in the wider literature on the treatment of anxiety disorders. This review evaluates a synthesis of published research which considers fear of flying and related anxiety disorders with the aim of deriving best practice. It concludes that the most effective psychological interventions will be those based on an accurate functional assessment of an individual and their social context relevant to fear of flying and not merely a set of standard and invariant protocols. Most published research has been carried out on participants who self refer or volunteer for treatment and it is probable that this is a biased clinical group which may distort reported efficacy and treatment outcomes. It concludes by highlighting directions for future research and the development of psychological treatments for fear of flying.

Using Rasch analysis to form plausible health states amenable to valuation: the development of CORE-6D from a measure of common mental health problems (CORE-OM)

PURPOSE

To describe a new approach for deriving a preference-based index from a condition specific measure that uses Rasch analysis to develop health states.

METHODS

The CORE-OM is a 34-item instrument monitoring clinical outcomes of people with common mental health problems. The CORE-OM is characterised by high correlation across its domains. Rasch analysis was used to reduce the number of items and response levels in order to produce a unidimensional measure and to generate a credible set of health states corresponding to different levels of symptom severity using the Rasch item threshold map.

RESULTS

The proposed methodology resulted in the development of CORE-6D, a 2-dimensional health state descriptive system consisting of a unidimensional 5-item emotional component (derived from Rasch analysis) and a physical symptom item. Inspection of the Rasch item threshold map of the emotional component helped identify a set of 11 plausible health states, which, combined with 3 physical symptom item levels, form 33 plausible health states that can be used for the valuation of the instrument, resulting in the development of a preference-based index.

CONCLUSIONS

This is a useful new approach to develop preference-based measures from existing instruments with high correlations across domains. The CORE-6D preference-based index will enable calculation of Quality-Adjusted Life Years in people with common mental health problems.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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