The effectiveness of psychodynamic-interpersonal therapy (PIT) in routine clinical practice: a benchmarking comparison

Patient-reported outcome measures in depression

AIM

Patient-reported outcome measures (PROMs) are increasingly important as a mean for quality assurance. Feasible estimates of recovery can be achieved through the application of Jacobson plots, which is a simple demonstration of the outcome of each case, recommended for clinical use. We applied this approach with PROMs collected regarding group psychotherapy in a mental health service (MHS) setting. We hypothesized a recovery rate of above 50% of all cases, expecting a lower recovery rate amongst patients with severe depression.

METHODS

We made a secondary sub-sample analysis of data from patients with unipolar depression (N = 171) within a pragmatic, non-inferiority, randomized controlled clinical trial comparing two cognitive behavior therapy (CBT) group interventions. The treatment consisted of 14 2-hours weekly group CBT sessions. We collected depression PROMs with the Becks Depression Inventory-II and functional levels PROMs with the Work and Social Adjustment Scale at baseline, end-of-treatment, and at a 6-months follow-up.

RESULTS

At follow-up, 35% (N = 43/123) of cases with moderate or severe depression (BDI > 19) at baseline reached scores below the cut-off for moderate depression. Recovery rates in severe cases were significantly lower (26.5 vs 52.5%; p = 0.0004). We observed severe functional impairment in 36% of the patients at baseline (52/144) and observed no changes or worsening in scores at a 6-months follow-up in 44% of the patients (64/144).

CONCLUSION

We achieved satisfactory remission rates for patients with moderate depression. Patients with severe depression and patients with functional impairment reached recovery rates below the standard of comparable MHSs. Improved MHSs for these patients are needed.

Video gaming and gaming addiction in transgender people: An exploratory study

Background There is anecdotal clinical evidence that transgender people use the online world - such as forums and online video gaming - for the purpose of experiencing their gender identity in a safe, non-threatening, non-alienating, non-stigmatizing, and non-critical environment. Aims To describe gaming behavior, degree of problematic gaming behavior and associated factors with problematic gaming in a comparatively large group of transgender people accessing transgender health services. Methods Every individual referred to a national transgender health service in the United Kingdom during a 12-month period was invited to complete a series of questionnaires to measure gaming behavior, interpersonal functioning, severity of autistic features, and anxiety and depressive symptoms. Results A total of 245 people agreed to participate in the study with 154 (62.9%) describing themselves as current gamers. Gaming behavior in the transgender population attending transgender health services was prevalent, but less than 1% of them presented with clinical scores for Internet Gaming Disorder, with no differences according to gender. Problematic gaming behavior was associated with general interpersonal problems, depression, and young age. Discussion and conclusions Transgender people who engage in problematic gaming behavior are younger, and present with high interpersonal problems, and depression, which can affect a successful transition. In view of the high levels of gaming activity in this population games that are designed to address these psychological problems may be well received by transgender people.

The Experience of Empathy

Empathy is fundamental for interpersonal relationships, and therapy. There is some theoretical dissensus about its underlying process. This study investigated the lived experience of understanding another person through an innovative combination of qualitative methods. The design involved making video recordings of interpersonal interactions between pairs of volunteers. The recordings were then used for a same-day cued-recall interview. During the interview, both volunteers were asked to discuss their interaction experiences. Four in-depth case studies, involving eight participants, were conducted using this technique. The interviews were then subjected to Interpretative Phenomenological Analysis. The results illuminate the multi-dimensional characteristics of interpersonal understanding. Namely, understanding another person was experienced as a phenomenon with three main aspects to it: 1) intuitive; 2) shared/sympathetic; and 3) imaginative/intellectual. Interestingly, shared/sympathetic and imaginative/intellectual understandings were more strongly connected with insights accessed via verbal communication, and with more self-based understandings. On the other hand, intuitive understandings were typically linked to the nonverbal communication domain, and with more other-based, intersubjective or pre-reflective forms of understanding. We argue that intuitive understandings have been under-represented in the empathy literature, and should be acknowledged as an important experiential component of this phenomenon, to be distinguished from intellectual and sympathetic understandings.

The efficacy of short-term psychodynamic psychotherapy for depression: A meta-analysis update

OBJECTIVES

The efficacy of short-term psychodynamic psychotherapy (STPP) for depression is debated. Recently, a number of large-scale and high-quality studies have been conducted. We examined the efficacy of STPP by updating our 2010 meta-analysis.

RESULTS

After a thorough literature search, 54 studies (33 randomized clinical trials) totaling 3946 subjects were included. STPP was significantly more effective than control conditions at post-treatment on depression, general psychopathology and quality of life measures (d=0.49 to 0.69). STPP pre-treatment to post-treatment changes (d=0.57 to 1.18) indicated significant improvements on all outcome measures, which either significantly improved further (d=0.20 to 1.04) or were maintained from post-treatment to follow-up. No significant differences were found between individual STPP and other psychotherapies at post-treatment (d=-0.14) and follow-up (d=-0.06) in analyses that were adequately powered to detect a clinically relevant difference. STPP was significantly more efficacious than other psychotherapies on anxiety measures at both post-treatment (d=0.35) and follow-up (d=0.76).

CONCLUSION

We found clear indications that STPP is effective in the treatment of depression in adults. Although more high-quality studies are needed, particularly to assess the efficacy of STPP compared to control conditions at follow-up and to antidepressants, these findings add to the evidence-base of STPP for depression.

Psychodynamic-interpersonal therapy: an overview of the treatment approach and evidence base

This article describes the development of Psychodynamic-Interpersonal Therapy or the Conversational Model of therapy, as it is also known. It includes a brief description of the approach to therapy, a review of the evidence base, and a brief description of qualitative and psychotherapy process research that has been conducted on the model.

What do patients find helpful in psychotherapy? Implications for the therapeutic relationship in mental health nursing

This study examined client perception of the therapeutic impact of two models of therapy delivered by mental health nurses and clinical psychologists respectively - psychodynamic interpersonal therapy (PIT) and cognitive behavioural therapy (CBT). A non-equivalent groups design was used in order to benchmark results against Llewelyn et al.: one group received PIT and the other received CBT. This design was utilized principally because the research was conducted across two practice settings where randomization was not feasible. We used two intact groups in practice research settings that received the therapies as reported in Llewelyn et al. Sixty-one clients receiving CBT or PIT in practice research settings completed a Helpful Aspects of Therapy form after each session in order to measure client perceptions of helpful and hindering events in therapy. Only two out of the 13 impacts were rated as significantly different. PIT clients reported higher levels of 'awareness' than CBT clients, whereas CBT clients reported higher levels of problem solution than PIT clients. The results replicate Llewelyn et al.'s findings in that clients experienced theoretically different models of therapy as broadly similar in their therapeutic impact. We argue that this provides some support for the influence of 'common' rather than 'specific' factors in psychotherapy effectiveness in mental health nursing.

Clinically representative research in the psychological therapies: an emerging paradigm

This paper considers the tension between the ‘biology’ and the ‘therapeutic relationship’ camps within mental health nursing, which is focussed on differing conceptualisations of what it is that constitutes evidence and appropriate lines of inquiry. I argue that the struggle that mental health nurses have experienced in delivering evidence-based practice also resides in the thorny issue of methodological inquiry and how it is written into nursing practice. I would suggest that what is alienating to practitioners is the way in which evidence and evidence-based enquiry is generated. This paper offers a line of methodological inquiry that is based in clinical representativeness, a way of conducting and evaluating research to produce an evidence base that is informed from the ‘bottom up’ by ‘practice’. This paper not only contributes to the knowledge base of clinically representative research (CRR) but examines the ways in which this knowledge base has been produced and is currently perpetuated. The following themes are addressed: Processes and outcomes in CRR: I identify key treatment outcomes and processes operating in practice settings and consider with what confidence we can make conclusions on observed outcomes in these settings. I also examine key moderating and mediating processes influencing such outcomes. Practice of CRR: I reflect on the paradigm of CRR giving particular attention to how the paradigm has developed and is maintained. I look at how the relationship of CRR to effifficacy research has influenced paradigm development. Future directions of CRR: I summarise the conclusions of CRR to date and identify points of consensus, disagreement and clarity suggesting in what areas the field has moved forward and whether there are instances where points of conflict have contributed to growth.

Balancing rigour and relevance in guideline development for depression: the case for comprehensive cohort studies

PURPOSE

Clinical guidelines for the treatment of depression have not yet realized their potential for improving the delivery of the psychological therapies within national healthcare systems. Current guidelines emphasize treatment efficacy and issues in service delivery are relatively neglected. Hence, there is a hierarchy of evidence in which randomized efficacy trials are given primacy over naturalistic (i.e. practice-based) data. Such a strategy is inadequate to address important questions about best delivery of safe and acceptable psychological therapies and exacerbates divisions between research and practice communities.

METHODS

Selected narrative review.

RESULTS

Both randomized controlled trials and practice-based studies have shortcomings that can be ameliorated by the adoption of practical clinical trials embedded within large cohort studies - that is, comprehensive cohort studies.

CONCLUSIONS

Comprehensive cohort studies have the potential to deliver an evidence base which is both rigorous and relevant. This could satisfy the scientific community as well as allowing practitioners and service users to be fully involved and committed to the process of collecting evidence and implementing guidance. We argue this would be a sound foundation upon which to build an evidence base upon which to develop future clinical guidelines for depression.