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.

Interpersonal psychotherapy for the prevention of binge-eating disorder and adult obesity in an African American adolescent military dependent boy

OBJECTIVE

Military adolescent boys report similar levels of disordered-eating as their female counterparts. Yet, interventions for the prevention of full-threshold eating disorders in adolescent boys are lacking. Interpersonal psychotherapy (IPT), an evidenced-based therapy adapted for the prevention of BED and adult obesity, has been studied in adolescent girls, but it is unclear whether IPT might resonate with adolescent boys.

METHOD

The current case study elucidates the use of a 12-week IPT group intervention for the prevention of BED and adult obesity in adulthood for an African American adolescent military dependent boy with reported loss-of-control (LOC)-eating, obesity, and elevated mood symptoms.

RESULTS

LOC-eating and body mass index metrics decreased immediately post-intervention and further decreased by one-year follow-up. Social functioning scores improved and anxiety and depression scores decreased from baseline to one-year follow-up. In contrast to previous observations among girls, these improvements were evidenced without the teen's explicit acknowledgement of the link between mood and eating behaviors.

DISCUSSION

Although the mechanism of change may manifest differently than for girls, adapted IPT may be an effective intervention strategy for adolescent boys with LOC-eating and obesity who endorse elevated mood symptoms.

Efficacy of interpersonal psychotherapy for post-traumatic stress disorder: A systematic review and meta-analysis

BACKGROUND

Evidence for the efficacy of treatments for post-traumatic stress disorder (PTSD) is urgently required. This systematic review and meta-analysis examines the efficacy of interpersonal psychotherapy (IPT) in reducing the symptoms of PTSD.

METHODS

Five databases were searched from inception until November 2018 to identify randomized controlled trials (RCTs) that assessed the efficacy of IPT in patients with PTSD symptoms. The reference lists of included studies were also hand searched. A random effects model was used to estimate changes in a clinician-administered PTSD scale, or self-reported symptoms.

RESULTS

Of 509 screened abstracts, ten clinical trials (11 study arms) involving 755 patients with PTSD symptoms were included. Nine studies (10 study arms) were included in the meta-analysis. The overall standardized mean difference was -0.44 (CI: -0.69, -0.19), p = 0.0005. This represents a change in the clinically administrated PTSD Scale (CAPS) of approximately 12 points. IPT was not superior to other active controls, such as medication and non-IPT psychotherapies, but was significantly superior to passive controls, such as waiting list and educational pamphlets.

LIMITATIONS

Most studies modified the IPT protocol and did not comprehensively assess clinician fidelity to the protocol. The included studies generally had small sample sizes and were of limited quality.

CONCLUSIONS

IPT may be an effective treatment for PTSD, but clinical trials with larger sample sizes and improved methodology are required to confirm effects.

Implementation research for public sector mental health care scale-up (SMART-DAPPER): a sequential multiple, assignment randomized trial (SMART) of non-specialist-delivered psychotherapy and/or medication for major depressive disorder and posttraumatic stress disorder (DAPPER) integrated with outpatient care clinics at a county hospital in Kenya

BACKGROUND

Mental disorders are a leading cause of global disability, driven primarily by depression and anxiety. Most of the disease burden is in Low and Middle Income Countries (LMICs), where 75% of adults with mental disorders have no service access. Our research team has worked in western Kenya for nearly ten years. Primary care populations in Kenya have high prevalence of Major Depressive Disorder (MDD) and Posttraumatic Stress Disorder (PTSD). To address these treatment needs with a sustainable, scalable mental health care strategy, we are partnering with local and national mental health stakeholders in Kenya and Uganda to identify 1) evidence-based strategies for first-line and second-line treatment delivered by non-specialists integrated with primary care, 2) investigate presumed mediators of treatment outcome and 3) determine patient-level moderators of treatment effect to inform personalized, resource-efficient, non-specialist treatments and sequencing, with costing analyses. Our implementation approach is guided by the Exploration, Preparation, Implementation, Sustainment (EPIS) framework.

METHODS/DESIGN

We will use a Sequential, Multiple Assignment Randomized Trial (SMART) to randomize 2710 patients from the outpatient clinics at Kisumu County Hospital (KCH) who have MDD, PTSD or both to either 12 weekly sessions of non-specialist-delivered Interpersonal Psychotherapy (IPT) or to 6 months of fluoxetine prescribed by a nurse or clinical officer. Participants who are not in remission at the conclusion of treatment will be re-randomized to receive the other treatment (IPT receives fluoxetine and vice versa) or to combination treatment (IPT and fluoxetine). The SMART-DAPPER Implementation Resource Team, (IRT) will drive the application of the EPIS model and adaptations during the course of the study to optimize the relevance of the data for generalizability and scale -up.

DISCUSSION

The results of this research will be significant in three ways: 1) they will determine the effectiveness of non-specialist delivered first- and second-line treatment for MDD and/or PTSD, 2) they will investigate key mechanisms of action for each treatment and 3) they will produce tailored adaptive treatment strategies essential for optimal sequencing of treatment for MDD and/or PTSD in low resource settings with associated cost information - a critical gap for addressing a leading global cause of disability.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03466346, registered March 15, 2018.

Mixed Methods Analysis of Implementation of Interpersonal Psychotherapy (IPT) for Major Depressive Disorder in Prisons in a Hybrid Type I Randomized Trial

This article describes a mixed methods evaluation of implementation of interpersonal psychotherapy (IPT) in the first fully-powered trial of any treatment for major depressive disorder in an incarcerated population. Assessments in this Hybrid Type I trial included surveys of prison providers and administrators (n = 71), measures of feasibility and acceptability to prison patients (n = 90), and a planned document review (n = 460) to assess potential determinants of implementation. Quantitative and qualitative results indicated that IPT was a good fit for prisoners, and that prisoners and providers were enthusiastic about IPT. Providers were open to feedback, open to learning evidence-based practices, and committed to helping their clients. Limited treatment staff and variable supervision and collegial support may pose implementation challenges. For widespread prison implementation, scalable models for ongoing IPT training and supervision are needed.

Interpersonal Psychotherapy and the Treatment of Eating Disorders

Interpersonal psychotherapy (IPT) for the treatment of eating disorders is a brief treatment that addresses the social and interpersonal context in which the disorder begins and is maintained. IPT is classified as a strongly supported evidence-based treatment of bulimia nervosa and binge-eating disorder, and more research is needed to understand the effectiveness of IPT for anorexia nervosa and IPT for preventing excess weight gain. This article describes the core components and elements of IPT, the empirical evidence that supports its effectiveness, efforts to increase the dissemination and implementation of IPT, and future directions.

A randomized trial of interpersonal psychotherapy, problem solving therapy, and supportive therapy for major depressive disorder in women with breast cancer

PURPOSE

Breast cancer (BC) is a risk factor for major depressive disorder (MDD), yet little research has tested the efficacy of different psychotherapies for depressed women with BC. This study, the largest to date, compared outcomes of three evidence-based, 12-week therapies in treating major depressive disorder among women with breast cancer.

METHODS

This randomized trial compared interpersonal psychotherapy (IPT), problem solving therapy (PST), and brief supportive psychotherapy (BSP). Conducted at the outpatient clinic of the New York State Psychiatric Institute/Columbia University, the trial offered bilingual treatment by treatment-specific psychotherapists supervised by treatment experts. The primary outcome was change in the Hamilton Depression Rating Scale (HAM-D) at 12 weeks. Secondary outcomes included other validated patient-reported outcomes for depression and quality of life.

RESULTS

Of 179 women with breast cancer screening positive for depression at the Columbia Cancer Center, 134 eligible patients signed informed treatment consent. Half of patients were Hispanic and economically disadvantaged. Most women had stage I (35.2%) or II (36.9%) BC; 9% had stage IV. The three brief psychotherapies showed similar improvements on the HAM-D, with large pre-post effect sizes (d ~ 1.0); a priori defined response rates were 35% for IPT, 50% for PST and 31% for BSP, and remission rates 25%, 30% and 27%, respectively. The three treatments also showed similar improvements in the Quality of Life Enjoyment and Satisfaction Questionnaire. Dropout was high, ranging from 37 to 52% across treatments. Predictors of dropout included having < 16 years of education and annual family income < $20,000.

CONCLUSIONS

Among patients who completed treatment, all three psychotherapies were associated with similar, meaningful improvements in depression. Physical distance between the oncology and psychiatric treatment sites might have contributed to high dropout. This study suggests various psychotherapy approaches may benefit patients with breast cancer and major depression.