Gender, Race/Ethnicity, and Patient-Therapist Matching on Gender and Race/Ethnicity: Predictors/Moderators of the Effectiveness of Trust/Respect Feedback

A plethora of studies has exhibited the effectiveness of using measurement-based care feedback systems within mental health services to improve treatment outcomes; however, patient gender/race and patient-therapist matching on gender and race remain relatively unexplored as predictors/moderators in feedback studies. We conducted predictor/moderator analyses focusing on the relation of gender, race/ethnicity, and patient-therapist gender and race/ethnicity matching on two outcomes: patient self-reported levels of (1) functioning and (2) trust/respect within the therapeutic relationship. We used data from a randomized controlled trial studying the effectiveness of a feedback system comparing patient-reported levels of trust and respect towards their provider (together with symptom feedback) in comparison to symptom only feedback. We found that men improved in functioning more than women when their therapists received trust/respect feedback compared to symptom only feedback (F[1, 902] = 9.79, p = .002, d = 0.21). We also found that dyads matched on race/ethnicity but not gender, and those matched on gender but not race/ethnicity, improved in functioning over time more than dyads mismatched on both gender and race/ethnicity and those matched on both gender and race/ethnicity (F[1, 897] = 8.63, p = .0034, d = 0.20). On trust/respect outcomes, we found a gender difference over time (F[1, 759] = 6.61, p = .01, d = 0.19), a gender matching difference by feedback condition interaction (F[1, 757] = 5.25, p = .02, d = 0.17), and a racial/ethnic matching difference on trust/respect scores over time (F[1, 785] = 3.89, p = .049, d = 0.14). Male patients showed an initial decrease followed by a steady increase in trust/respect over time while female patients showed an initial increase followed by a steady decrease. Gender-matched therapeutic dyads showed higher levels of trust/respect compared to mismatched dyads when therapists received symptom only feedback, but this difference was not apparent when trust/respect feedback was provided. Dyads mismatched on race/ethnicity improved steadily in trust/respect over time, but matched dyads decreased in trust/respect after an initial increase. Future research should focus on the use of feedback systems to enhance outcomes for patients with specific gender and racial/ethnic identities.

Adapting psychotherapy in collaborative care for treating opioid use disorder and co-occurring psychiatric conditions in primary care

INTRODUCTION

Opioid use disorder (OUD) and psychiatric conditions commonly co-occur yet are infrequently treated with evidence-based therapeutic approaches, resulting in poor outcomes. These conditions, separately, present challenges to treatment initiation, retention, and success. These challenges are compounded when individuals have OUD and psychiatric conditions.

METHOD

Recognizing the complex needs of these individuals, gaps in care, and the potential for primary care to bridge these gaps, we developed a psychotherapy program that integrates brief, evidence-based psychotherapies for substance use, depression, and anxiety, building on traditional elements of the Collaborative Care Model (CoCM). In this article, we describe this psychotherapy program in a primary care setting as part of a compendium of collaborative services.

RESULTS

Patients receive up to 12 sessions of evidence-based psychotherapy and case management based on a structured treatment manual that guides treatment via Motivational Enhancement; Cognitive Behavioral Therapies for depression, anxiety, and/or substance use disorder; and/or Behavioral Activation components.

DISCUSSION

Novel, integrated treatments are needed to advance service delivery for individuals with OUD and psychiatric conditions and these programs must be rigorously evaluated. We describe our team's efforts to test our psychotherapy program in a large primary care network as part of an ongoing three-arm randomized controlled trial. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The development of a comprehensive coding system for evaluating insight based on a clinical interview: The SUIP-I coding system

Gaining insight is considered a cornerstone of psychodynamic psychotherapy. Existing tools used to measure insight mainly include patients' self-report questionnaires and external coding of therapy sessions. To expand on the available tools, the present study developed a comprehensive coding system for the Self-Understanding of Interpersonal Patterns Scales-Interview (SUIP-I; Gibbons & Crits-Christoph, 2017). A total of 55 patients enrolled in a randomized controlled trial received psychodynamic psychotherapy for depression and were interviewed using the SUIP-I at baseline. A comprehensive coding system was developed for rating the interviews, based on a Likert scale for each of the six levels of insight. The content validity, psychometric properties, and the reliability and validity of the coding system were examined. The new SUIP-I coding system demonstrated interrater reliability in the "excellent" range, ICC (1, 1) = .91-.97, for all the six levels, and adequate internal consistency (Cronbach's α = .81). Support for convergent validity was gained, as manifested in a significant positive association of the SUIP-I with alliance expectation and affiliation, and a significant negative association with avoidance attachment. Support for discriminant validity was also gained, as manifested in a weak, nonsignificant association between the SUIP-I and self-esteem. The proposed comprehensive coding system shows good initial reliability and validity. Research is needed to further establish the psychometric properties of the new SUIP-I coding system. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

The association between trauma and interpersonal problems in a United States community mental health setting

OBJECTIVE

Previous research has documented associations between trauma and interpersonal problems. We examined the impact of trauma on interpersonal problems among depressed patients seeking treatment in a community mental health setting.

METHODS

A total of 453 patients seeking treatment and screened for a comparative effectiveness study of therapies for depression were included. We conducted analyses relating the 32-item inventory of interpersonal problems (IIP-32) to trauma measures.

RESULTS

99.1% of the sample experienced a traumatic event. There were significant associations between the total number of traumas, the number of sexually and physically assaultive traumas, and both gender and race. The number of sexually assaultive traumas was significantly related to the IIP-32 "too caring" subscale (simple r = 0.167, p < 0.001). Controlling for demographics and other IIP-32 subscales, the total number of traumas remained significantly related to the IIP-32 "too caring" domain (partial r = 0.163, p < 0.001).

CONCLUSIONS

Traumatic events are prevalent among community populations and these experiences are associated with certain interpersonal problems. Trauma and interpersonal problems are key issues for the treatment of patients in the community mental health setting.

Efficacy and moderators of short-term psychodynamic psychotherapy for depression: A systematic review and meta-analysis of individual participant data

BACKGROUND

Short-term psychodynamic psychotherapy (STPP) is frequently used to treat depression, but it is unclear which patients might benefit specifically. Individual participant data (IPD) meta-analyses can provide more precise effect estimates than conventional meta-analyses and identify patient-level moderators. This IPD meta-analysis examined the efficacy and moderators of STPP for depression compared to control conditions.

METHODS

PubMed, PsycInfo, Embase, and Cochrane Library were searched September 1st, 2022, to identify randomized trials comparing STPP to control conditions for adults with depression. IPD were requested and analyzed using mixed-effects models.

RESULTS

IPD were obtained from 11 of the 13 (84.6%) studies identified (n = 771/837, 92.1%; mean age = 40.8, SD = 13.3; 79.3% female). STPP resulted in significantly lower depressive symptom levels than control conditions at post-treatment (d = -0.62, 95%CI [-0.76, -0.47], p < .001). At post-treatment, STPP was more efficacious for participants with longer rather than shorter current depressive episode durations.

CONCLUSIONS

These results support the evidence base of STPP for depression and indicate episode duration as an effect modifier. This moderator finding, however, is observational and requires prospective validation in future large-scale trials.

Randomized controlled trial evaluating feedback to community-based therapists based on patient reports of trust and respect

OBJECTIVE

Patient trust/respect toward their therapists may be an important component of patient-therapist relationships. This randomized controlled trial evaluated the impact of providing weekly feedback to therapists regarding patient ratings of trust/respect toward their therapist.

METHOD

Adult patients seeking mental health treatment at four community clinics (two community mental health centers and two community-based intensive treatment programs) were randomized to either having their primary therapist receive weekly symptom feedback-only or symptoms plus trust/respect feedback. Data were collected both prior to and during COVID-19. The primary outcome measure was a measure of functioning obtained weekly at baseline and the subsequent 11 weeks, with the primary analysis focusing on patients who received any treatment. Secondary outcomes included measures of symptoms and trust/respect.

RESULTS

Among 233 consented patients, 185 had a postbaseline assessment and were analyzed for the primary and secondary outcomes (median age of 30 years; 5.4% Asian, 12.4% Hispanic, 17.8% Black, 67.0% White, 4.3% more than 1 race, and 5.4% unknown; 64.4% female). On the Patient-Reported Outcomes Measurement Information System Social Roles and Activities scale (primary outcome), the trust/respect plus symptom feedback group had significantly greater improvements over time than the symptom alone feedback group (p = .0006, effect size d = .22). Secondary outcome measures of symptoms and trust/respect also showed statistically significant greater improvement for the trust/respect feedback group.

CONCLUSIONS

In this trial, trust/respect feedback to therapists was associated with significantly greater improvements in treatment outcomes. Evaluation of the mechanisms of such improvements is needed. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Repeated assessments of depressive symptoms in randomized psychosocial intervention trials: best practice for analyzing symptom change over time

OBJECTIVE

Psychotherapy randomized trials rarely have tested for the best fitting model for time effects. We examined the fit of different statistical models for examining time when repeated assessments of depressive symptoms are the primary outcome.

METHOD

We used data from three studies comparing psychotherapy treatments for major depressive disorder. Outcome measures were self-report ratings for Study 1 (N = 237) and Study 2 (N = 100) and clinician ratings for Study 3 (N = 120) of depressive symptoms measured at every session (Studies 1 and 2) or monthly (Study 3). We examined the fit of the following time patterns: linear, quadratic, cubic, log transformation of time, piece-wise linear, and unstructured.

RESULTS

In Study 1, a log-linear model had the best fit (Δ Akaike information criterion [AICc] = 7.5). In Study 2, all models had essentially no support (Δ AICcs > 10) in comparison to the best fitting model, which was the unstructured model. In Study 3, the cubic model had the best fit, but it was not significantly better than a log-linear (Δ AICc = 3.5) or unstructured model (Δ AICc = 2.5).

CONCLUSIONS

Trials should routinely compare different time models, including an unstructured model, when repeated measures of depressive symptoms are the primary outcome.

The association between medical comorbidity and psychotherapy processes and outcomes for major depressive disorder in a community mental health setting

Many individuals seeking mental health services for depression often suffer from a comorbid medical condition. The goal of the present study was to assess the presence of medical comorbidity in a community mental health center setting that primarily serves a Medicare and Medicaid population, characterize the types of comorbid medical conditions experienced in this setting, and explore the association between medical conditions on the alliance, attrition from services, and outcome. Medical diagnoses were collected from patient charts and structured clinical interviews from 353 participants who had a baseline assessment as part of a comparative effectiveness study of cognitive and dynamic therapies for major depressive disorder. We calculated the Charlson Comorbidity Index and the number of total medical diagnoses for each patient. Results from this study revealed that a high percentage of patients in this setting experienced a comorbid medical condition. No significant associations were found between the number of medical conditions or the Charlson Comorbidity Index and the alliance. No significant relationship was found between the number of medical conditions or the Charlson Comorbidity Index and early attrition from treatment or treatment outcome. However, exploratory analyses found that presence of a nervous system disorder was associated with relatively poorer treatment outcomes after initial engagement. Implications of these findings are discussed. Treatments for major depressive disorder may benefit from addressing the impact of medical disorders on physical functioning. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Insight as a mechanism of change in dynamic therapy for major depressive disorder

This study aimed to investigate change in insight into maladaptive interpersonal patterns over the course of psychotherapy, as well as the specificity of insight as a change mechanism in dynamic treatments. A total of 100 patients received up to 16 sessions of either cognitive or dynamic therapy for major depressive disorder in a randomized clinical trial. Assessments of insight (Insight into Conflictual Relationship Patterns scale) and depression severity (Hamilton Depression Inventory) took place at the beginning of treatment, at month 2, and month 5. Patient insight significantly improved over the course of dynamic treatments. Gains in insight from the beginning to month 2 of treatment were a significant predictor of decreases of depressive symptoms from month 2 to month 5 of treatment in the dynamic, but not in the cognitive treatment group, despite a nonsignificant interaction. Results provide support for insight as a change factor in dynamic therapies. Better self-understanding of dysfunctional interaction patterns could help patients to find more adaptive ways of behaving, to form more satisfying relationships, and to improve their depression. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

EMBRACE: An EM-based bias reduction approach through Copas-model estimation for quantifying the evidence of selective publishing in network meta-analysis

Systematic reviews and meta-analyses synthesize results from well-conducted studies to optimize healthcare decision-making. Network meta-analysis (NMA) is particularly useful for improving precision, drawing new comparisons, and ranking multiple interventions. However, recommendations can be misled if published results are a selective sample of what has been collected by trialists, particularly when publication status is related to the significance of the findings. Unfortunately, the missing-not-at-random nature of this problem and the numerous parameters involved in modeling NMAs pose unique computational challenges to quantifying and correcting for publication bias, such that sensitivity analysis is used in practice. Motivated by this important methodological gap, we developed a novel and stable expectation-maximization (EM) algorithm to correct for publication bias in the network setting. We validate the method through simulation studies and show that it achieves substantial bias reduction in small to moderately sized NMAs. We also calibrate the method against a Bayesian analysis of a published NMA on antiplatlet therapies for maintaining vascular patency.

A Feasibility Study of Behavioral Activation for Major Depressive Disorder in a Community Mental Health Setting

Behavioral activation (BA) is a well-supported treatment approach, but little research has been conducted on the effectiveness of this treatment within publicly funded community mental health settings. We examined the feasibility of conducting a randomized trial examining the effectiveness of nine sessions of BA as a treatment for major depressive disorder (MDD) in a community mental health clinic (CMHC) setting. Following adaptation of a BA manual and training of BA therapists, 80 patients seeking treatment at a CMHC were randomized, with a 3:1 randomization rate of BA to nine sessions of treatment as usual (TAU). Feasibility assessments indicated that only one eligible patient refused randomization and, of patients who attended at least one session, the median number of sessions was six for the BA group and eight for the TAU group. Of three postbaseline monthly assessments, 71.3% (171/240) were successfully obtained. On average, patients in the BA condition completed homework assignments 83.9% of the time. Treatment fidelity ratings indicated that substantially more BA techniques were delivered in the BA group compared to the TAU group (d = 2.11). Measures of BA mechanisms improved significantly over time and these changes were significantly associated with change in depressive symptoms. These results indicate that it is feasible to conduct a randomized study of BA for MDD in a CMHC setting. In addition, the study reconfirmed the potential importance of theory-relevant BA mechanism variables. Following these findings, further investigation into the effectiveness of BA in this setting is needed.

Use of cognitive techniques is associated with change in positive compensatory skills in the treatment of major depressive disorder in a community mental health setting

To examine the association between adherence and competence in cognitive therapy (CT) techniques and change in positive compensatory skills and depressive symptoms within a community mental health setting.

Adherence ratings were available for 97 individuals receiving CT for major depressive disorder. Assessments of adherence and competence were rated on one early session of CT. Compensatory skills were measured using the Ways of Responding Community Version at baseline and months 1, 2, and 5. Symptom severity was evaluated using the Hamilton Rating Scale for Depression at baseline and months 1, 2, 4, and 5.

In mixed effects models, adherence was significantly associated with linear change in positive compensatory skills from baseline to month 5 (F [1, 76] = 8.05, p=.006, r=.31). Competence was also significantly associated with change in positive compensatory skills from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25). High adherence was associated with improvements in HAM-D scores from baseline to month 5 (F [1, 78] = 5.1, p=.027, r=.25).

Results support the hypothesis that use of CT techniques is associated with change in compensatory skills in a community mental health setting.

Trust and respect in the patient-clinician relationship: preliminary development of a new scale

BACKGROUND

Trust and respect may be an important component of client-provider relationships. This study aimed to develop and report preliminary psychometric analyses of a new brief measure to evaluate a patient's level of trust and respect for their clinician. The scale was designed to be applicable in multiple healthcare contexts, with a particular focus on mental healthcare.

METHODS

Adult patients completed the study survey in an academic outpatient psychiatric clinic waiting room. Classical and Item Response Theory (IRT) analyses were utilized to examine the adequacy of scale items. Validity was examined in relation to the patient-therapist alliance and to willingness to share private information (social media content) with one's clinician.

RESULTS

Beginning with 10 items, a final 8-item version of the measure was created with an internal consistency reliability of .91. Principal components analysis indicated that the scale was best viewed as capturing one overall dimension. A Graded Response Model IRT model indicated that all items contributed information on the latent dimension, and all item curves were not flat at any region. The correlation of the trust/respect total score with the alliance was .53 when respect-related items were deleted from the alliance score. The trust/respect scale was significantly associated with patient willingness to share social media posts with their clinician but the alliance was not.

CONCLUSIONS

The brief measure of patient trust and respect towards their clinician was unidimensional, showed good internal consistency, and was not redundant with existing measures of the alliance. The scale has the potential to be used in a wide variety of healthcare settings.

Insight into conflictual relationship patterns: Development and validation of an observer rating scale

Objective: This study aimed to develop an observer-rated measure of Insight into Conflictual Relationship Patterns (ICR) applicable to audio- or videotapes of psychotherapy sessions and conduct a first psychometric evaluation. Method: We investigated the item properties, principal components, reliability, and validity of the ICR in a naturalistic sample of N = 125 outpatients in psychodynamic psychotherapy. Results: The ICR consists of 12 items that showed adequate item discrimination and item difficulty indices. All items represent one principal component. Using item response theory, discrimination parameters and item characteristic curves revealed that the ability of all items to differentiate patients was adequate to very good. The scale demonstrated good interrater reliability (ICC(3,1) = .76-.93), adequate internal consistency (Cronbach's α = .84), and high retest reliability (r = .91). Regarding validity, the ICR was significantly associated with insight according to the Achievement of Therapeutic Objectives Scale and patient-perceived session depth. Insight at session five predicted a symptomatic increase from session five to session ten. Conclusion: The ICR is an observer-rated measure to assess insight from psychotherapy session recordings that has demonstrated several aspects of reliability and validity. Future studies are needed to clarify the impact of ICR-assessed insight for symptomatic outcome.

Psychiatry Outpatients' Willingness to Share Social Media Posts and Smartphone Data for Research and Clinical Purposes: Survey Study

BACKGROUND

Psychiatry research has begun to leverage data collected from patients' social media and smartphone use. However, information regarding the feasibility of utilizing such data in an outpatient setting and the acceptability of such data in research and practice is limited.

OBJECTIVE

This study aimed at understanding the outpatients' willingness to have information from their social media posts and their smartphones used for clinical or research purposes.

METHODS

In this survey study, we surveyed patients (N=238) in an outpatient clinic waiting room. Willingness to share social media and passive smartphone data was summarized for the sample as a whole and broken down by sex, age, and race.

RESULTS

Most patients who had a social media account and who were receiving talk therapy treatment (74.4%, 99/133) indicated that they would be willing to share their social media posts with their therapists. The percentage of patients willing to share passive smartphone data with researchers varied from 40.8% (82/201) to 60.7% (122/201) depending on the parameter, with sleep duration being the parameter with the highest percentage of patients willing to share. A total of 30.4% of patients indicated that media stories of social media privacy breaches made them more hesitant about sharing passive smartphone data with researchers. Sex and race were associated with willingness to share smartphone data, with men and whites being the most willing to share.

CONCLUSIONS

Our results indicate that most patients in a psychiatric outpatient setting would share social media and passive smartphone data and that further research elucidating patterns of willingness to share passive data is needed.

Predictors of treatment attendance in cognitive and dynamic therapies for major depressive disorder delivered in a community mental health setting

OBJECTIVE

Our goal was to evaluate treatment attendance patterns, including both treatment completion and premature termination from treatment, for 2 evidence-based psychotherapies for major depressive disorder (MDD) delivered in a community mental health setting. We explored rates of premature termination across the course of treatment as well as the factors that predicted and moderated premature termination and treatment completion.

METHOD

This investigation included 237 patients with MDD who participated in a noninferiority trial comparing short-term dynamic psychotherapy (DT) to cognitive therapy (CT). Patients in both conditions were offered 16 sessions of treatment and had up to 5 months to complete treatment. All patients completed an extensive self-report battery at treatment baseline as well as measures of the therapeutic alliance and opinions about treatment following Session 2.

RESULTS

Premature termination from both treatments was high with 27% of patients discontinuing treatment very early after only an intake session or a single treatment session. Patients in CT were significantly more likely to terminate treatment prematurely, χ²(3) = 14.35, p = .002. Baseline physical health functioning, subthreshold psychotic symptoms, Session 2 ratings of agreement on tasks, and Session 2 ratings of treatment sensibility all independently predicted premature termination of services. Trauma history significantly moderated very early termination of treatment, χ²(3) = 10.26, p = .017, with patients with high trauma histories more likely to complete DT but terminate prematurely from CT.

CONCLUSIONS

Very early termination from services was higher in CT compared with DT. Including techniques to improve engagement in both therapies and matching patients to treatment based on predictors/moderators may be effective ways to optimize treatment engagement. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Instrumental variable analyses for causal inference: Application to multilevel analyses of the alliance-outcome relation

Objective: To introduce readers to instrumental variable analyses for causal inferences using as an example a test of the hypothesis that the quality of the therapeutic alliance has a causal role in relation to the outcome of psychotherapy. Method: We used data from a recent non-inferiority trial of cognitive and dynamic therapies for major depressive disorder in a community mental health setting. The data (N = 161) were analyzed using standard approaches as well as a multilevel 2-stage instrumental variables approach that allows for causal interpretations by removing the influence of unmeasured confounds. Results: Instrumental variables were created at the patient and therapist level using baseline patient and therapist variables. These baseline variables predicted the alliance but were otherwise unrelated to treatment outcome other than through their effects on the alliance. Standard multilevel mixed effects analyses revealed statistically significant associations of the alliance with outcome at the therapist level of analysis. The therapist level effect remained statistically significant when using the instrumental variables approach. Conclusion: Our results support the hypothesis that, at least at the therapist level, the alliance plays a causal role in producing better outcomes. Instrumental variable analyses can be a useful tool to supplement standard analyses.

Symptoms of anhedonia, not depression, predict the outcome of treatment of cocaine dependence

The purpose of this paper is to reanalyze data from two studies to determine if anhedonia specifically, rather than depression overall, predicts treatment outcome for patients with cocaine use disorders. Measures of baseline anhedonia symptoms were created using anhedonia items from the Beck Depression Inventory (BDI) to re-examine National Institute on Drug Abuse Cocaine Collaborative Treatment study data (Crits-Christoph et al., 1999) and the contingency management group from the McKay et al. (2010) trial. Baseline anhedonia was used to predict cocaine abstinence rates across the treatment period in both studies. Anhedonia was a significant predictor of cocaine abstinence, even when overall depression scores excluding anhedonia were included in the models. The development of treatments to target individuals with cocaine use disorder who have symptoms of anhedonia has the potential to improve overall outcomes for those with this disorder.

Impact of a medical home model on costs and utilization among comorbid HIV-positive Medicaid patients

OBJECTIVES

The Pennsylvania Chronic Care Initiative (CCI) was a statewide patient-centered medical home (PCMH) initiative implemented from 2008 to 2011. This study examined whether the CCI affected utilization and costs for HIV-positive Medicaid patients with both medical and behavioral health comorbidities.

STUDY DESIGN

Nonrandomized comparison of 302 HIV-positive Medicaid patients treated in 137 CCI practices and 2577 HIV-positive Medicaid patients treated elsewhere.

METHODS

All patients had chronic medical conditions (diabetes, chronic obstructive pulmonary disease, asthma, or congestive heart failure) and a psychiatric and/or substance use disorder. Analyses used Medicaid claims data to examine changes in total per patient costs per month from 1 year prior to 1 year following an index episode. Propensity score weighting was used to adjust for potential sample differences. Secondary outcomes included costs and utilization of emergency department, inpatient, and outpatient/pharmacy services.

RESULTS

We identified an average total cost savings of $214.10 per patient per month (P = .002) for the CCI group relative to the non-CCI group. This was a function of decreased inpatient medical (-$415.69; P = .007) and outpatient substance abuse treatment (-$4.86; P = .001) costs, but increased non-HIV pharmacy costs ($158.43; P = .001). Utilization for the CCI group, relative to the non-CCI group, was correspondingly decreased for inpatient medical services (odds ratio [OR], 0.619; P = .002) and inpatient services overall (OR, 0.404; P = .001), but that group had greater numbers of outpatient medical service claims when they occurred (11.7%; P = .003) and increased non-HIV pharmacy claims (9.7%; P = .001).

CONCLUSIONS

There was increased outpatient service utilization, yet relative cost savings, for HIV-positive Medicaid patients with medical and behavioral health comorbidities who were treated in PCMHs.

Which patients benefit specifically from short-term psychodynamic psychotherapy (STPP) for depression? Study protocol of a systematic review and meta-analysis of individual participant data

INTRODUCTION

Short-term psychodynamic psychotherapy (STPP) is an empirically supported treatment that is often used to treat depression. However, it is largely unclear if certain subgroups of depressed patients can benefit specifically from this treatment method. We describe the protocol for a systematic review and meta-analysis of individual participant data (IPD) aimed at identifying predictors and moderators of STPP for depression efficacy.

METHOD AND ANALYSIS

We will conduct a systematic literature search in multiple bibliographic databases (PubMed, PsycINFO, Embase.com, Web of Science and Cochrane's Central Register of Controlled Trials), 'grey literature' databases (GLIN and UMI ProQuest) and a prospective trial register (http://www.controlled-trials.com). We will include studies reporting (a) outcomes on standardised measures of (b) depressed (c) adult patients (d) receiving STPP. We will next invite the authors of these studies to share the participant-level data of their trials and combine these data to conduct IPD meta-analyses. The primary outcome for this study is post-treatment efficacy as assessed by a continuous depression measure. Potential predictors and moderators include all sociodemographic variables, clinical variables and psychological patient characteristics that are measured before the start of treatment and are assessed consistently across studies. One-stage IPD meta-analyses will be conducted using mixed-effects models.

ETHICS AND DISSEMINATION

Institutional review board approval is not required for this study. We intend to submit reports of the outcomes of this study for publication to international peer-reviewed journals in the fields of psychiatry or clinical psychology. We also intend to present the outcomes at international scientific conferences aimed at psychotherapy researchers and clinicians. The findings of this study can have important clinical implications, as they can inform expectations of STPP efficacy for individual patients, and help to make an informed choice concerning the best treatment option for a given patient.

PROSPERO REGISTRATION NUMBER

CRD42017056029.

The Measurement of Cognitive Schemas: Validation of the Psychological Distance Scaling Task in a Community Mental Health Sample

Objective

The purpose of this study was to examine the validity of the Psychological Distance Scaling Task (PDST), a measure of cognitive schema organization, in a community mental health setting. We also compared validity among African Americans and Caucasians.

Method

In order to accommodate participants with low education levels, 26 out of 80 PDST word stimuli were replaced with similar words at a lower reading level. A sample of 466 (42% African American; 50% Caucasian; 8% other) community patients with major depressive disorder completed the PDST and a variety of depressive symptom measures.

Results

The modified PDST demonstrated acceptable validity within all subscales. Validity coefficients resembled those reported in prior studies and were similar within minority and non-minority subsamples.

Conclusions

The modified PDST appears to be a valid measure of schema organization in a low-income, racially diverse population seeking treatment for depression at community clinics.

Mechanisms of change in cognitive therapy for major depressive disorder in the community mental health setting

OBJECTIVE

This study examined the relation of change in theory-relevant cognitive variables to depressive symptom change over the course of cognitive therapy, as well as the specificity of change mechanisms to cognitive therapy as compared with dynamic therapy.

METHOD

There were 237 adult outpatients who were randomized to either cognitive (n = 119) or dynamic (n = 118) therapy for major depressive disorder in a community mental health setting. Assessments of compensatory skills (Ways of Responding Community Version and Self-Report Version), dysfunctional attitudes (Dysfunctional Attitudes Scale), and depressogenic schemas (Psychological Distance Scaling Task) were obtained at baseline and months 1, 2, and 5 following baseline. Primary outcome was measured using the Hamilton Rating Scale for Depression.

RESULTS

Across both therapy conditions, change in all 3 cognitive domains was associated with concurrent change in depressive symptoms. After controlling for other cognitive variables, increased interconnectedness of the positive achievement-related schema was significantly associated with concurrent symptom change in cognitive (rp = .26, p < .001) but not dynamic therapy (rp = .08, p = .29). Increases in positive compensatory skills were associated with subsequent change in depressive symptoms in cognitive therapy (rp = -.36, p = .003), but not in dynamic therapy (rp = .11, p = .386).

CONCLUSIONS

Results provide support for the compensatory skills model of cognitive therapy (CT) within a community mental health setting. Additional research is necessary to understand other possible mechanisms of change in CT in the community setting. (PsycINFO Database Record

A self-report version of the Ways of Responding: Reliability and validity in a clinical sample

OBJECTIVE

The Ways of Responding (WOR) instrument measures compensatory skills, a central construct in some theories of the mechanism of cognitive therapy for depression. However, the instrument is time-consuming and expensive to use in community settings, because it requires trained independent judges to rate subjects' open-ended written responses to depressogenic scenarios. The present study evaluated the reliability and validity of a self-report version of the WOR (WOR-SR) in a community mental health sample with depressive symptoms (N = 467).

METHOD

Subjects completed the WOR-SR, a modified version of the original WOR, and other measures of depressive symptoms, dysfunctional cognitions, functioning, quality of life, and interpersonal problems at multiple time points.

RESULTS

An exploratory factor analysis confirmed the two-factor structure of the WOR-SR. The positive and negative subscales both demonstrated excellent internal consistency (Cronbach's alphas = .91) and moderate convergent validity with other measures.

CONCLUSION

The WOR-SR is a reliable and valid measure of compensatory skills in patients receiving treatment for depression at community mental health centers.

Comparative Effectiveness of Cognitive Therapy and Dynamic Psychotherapy for Major Depressive Disorder in a Community Mental Health Setting: A Randomized Clinical Noninferiority Trial

IMPORTANCE

Dynamic psychotherapy (DT) is widely practiced in the community, but few trials have established its effectiveness for specific mental health disorders relative to control conditions or other evidence-based psychotherapies.

OBJECTIVE

To determine whether DT is not inferior to cognitive therapy (CT) in the treatment of major depressive disorder (MDD) in a community mental health setting.

DESIGN, SETTING, AND PARTICIPANTS

From October 28, 2010, to July 2, 2014, outpatients with MDD were randomized to treatment delivered by trained therapists. Twenty therapists employed at a community mental health center in Pennsylvania were trained by experts in CT or DT. A total of 237 adult outpatients with MDD seeking services at this site were randomized to 16 sessions of DT or CT delivered across 5 months. Final assessment was completed on December 9, 2014, and data were analyzed from December 10, 2014, to January 14, 2016.

INTERVENTIONS

Short-term DT or CT.

MAIN OUTCOMES AND MEASURES

Expert blind evaluations with the 17-item Hamilton Rating Scale for Depression.

RESULTS

Among the 237 patients (59 men [24.9%]; 178 women [75.1%]; mean [SD] age, 36.2 [12.1] years) treated by 20 therapists (19 women and 1 man; mean [SD] age, 40.0 [14.6] years), 118 were randomized to DT and 119 to CT. A mean (SD) difference between treatments was found in the change on the Hamilton Rating Scale for Depression of 0.86 (7.73) scale points (95% CI, -0.70 to 2.42; Cohen d, 0.11), indicating that DT was statistically not inferior to CT. A statistically significant main effect was found for time (F1,198 = 75.92; P = .001). No statistically significant differences were found between treatments on patient ratings of treatment credibility. Dynamic psychotherapy and CT were discriminated from each other on competence in supportive techniques (t120 = 2.48; P = .02), competence in expressive techniques (t120 = 4.78; P = .001), adherence to CT techniques (t115 = -7.07; P = .001), and competence in CT (t115 = -7.07; P = .001).

CONCLUSIONS AND RELEVANCE

This study suggests that DT is not inferior to CT on change in depression for the treatment of MDD in a community mental health setting. The 95% CI suggests that the effects of DT are equivalent to those of CT.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01207271.

A Naturalistic Evaluation of Extended-Release Naltrexone in Clinical Practice in Missouri

The purpose of this study was to compare the naturalistic outcomes of individuals with alcohol or opioid use problems who were treated with extended-release naltrexone (XR-NTX) to those treated with psychosocial treatment only and also to those treated with other medication-assisted therapies in Missouri during 2010 to 2011. We analyzed intake and discharge data collected as part of SAMHSA's Treatment Episode Data Set assessments. Patients who received XR-NTX during their treatment episode were compared, for those reporting alcohol (but not opioids) as their problem (N=21,137), to those who received oral naltrexone, acamprosate, and psychosocial treatment only, and for those who reported opioids as a problem (N=8996), to those receiving oral naltrexone, buprenorphine/naloxone, and psychosocial treatment only. Group differences were adjusted using propensity score weighting, with propensity scores derived from 18 intake variables. For the alcohol sample, patients who received XR-NTX vs. the oral naltrexone group had superior composite outcomes on a measure combining abstinence, self-help participation, employment, and arrests. For the opioid sample, XR-NTX was found to have significantly better outcomes than oral naltrexone on the composite outcome measure. For both the alcohol and opioid samples, the group that received XR-NTX stayed in treatment longer vs. psychosocial treatment only. In the opioid sample, those receiving buprenorphine/naloxone remained in treatment longer than those receiving XR-NTX.

Developing a prototype for short-term psychodynamic (supportive-expressive) therapy: An empirical study with the psychotherapy process Q-set

OBJECTIVE

A Psychotherapy Process Q-set (PQS) prototype characteristic of short-term psychodynamic therapy (STPP) does not yet exist.

METHOD

Experts in supportive-expressive (SE) therapy used the 100-Item PQS questionnaire to rate an ideal short-term SE therapy.

RESULTS

Agreement between raters was high (Cronbach's alpha = 0.94). The prototype for SE therapy showed a significant correlation with the psychoanalytic prototype, but with 28% of variance explained, the majority of variance of the former was not explained by the latter or vice versa. Furthermore, the SE prototype showed significant correlations with the cognitive-behavioral prototype and the prototype of interpersonal therapy by Ablon and Jones (r = 0.69, 0.43).

CONCLUSIONS

We recommend using the PQS prototype presented here for future process research on STPP.

The effectiveness of clinician feedback in the treatment of depression in the community mental health system

OBJECTIVE

We describe the development and evaluation of a clinician feedback intervention for use in community mental health settings. The Community Clinician Feedback System (CCFS) was developed in collaboration with a community partner to meet the needs of providers working in such community settings.

METHOD

The CCFS consists of weekly performance feedback to clinicians, as well as a clinical feedback report that assists clinicians with patients who are not progressing as expected. Patients in the randomized sample (N = 100) were predominantly female African Americans, with a mean age of 39 years.

RESULTS

Satisfaction ratings of the CCFS indicate that the system was widely accepted by clinicians and patients. A hierarchical linear models (HLM) analysis comparing rates of change across conditions controlling for baseline gender, age, and racial group indicated a moderate effect in favor of the feedback condition for symptom improvement, t(94) = 2.41, p = .017, d = .50. Thirty-six percent of feedback patients compared with only 13% of patients in the no-feedback condition demonstrated clinically significant change across treatment, χ2(1) = 6.13, p = .013.

CONCLUSIONS

These results indicate that our CCFS is acceptable to providers and patients of mental health services and has the potential to improve the effectiveness of services for clinically meaningful depression in the community mental health setting.

The relation of baseline skills to psychotherapy outcome across diverse psychotherapies

OBJECTIVE

We explored whether patients with varied levels of baseline deficits in compensatory skills and self-understanding had different outcomes across cognitive and dynamic therapies.

METHOD

The assessment battery was administered at intake and termination (N = 97; 66% female, 81% Caucasian). We conducted regression analyses predicting symptom change from baseline levels of self-understanding and compensatory skills. We also evaluated the interaction between baseline skill levels and treatment condition in the prediction of psychotherapy outcome.

RESULTS

There was a significant interaction between treatment group and baseline compensatory skills in the prediction of Hamilton Depression Rating Scale (HAMD) symptom change, F(1,76) = 4.59, p = .035. Baseline deficits in compensatory skills were significantly related to symptom change for patients who received cognitive treatment, ηρ = .40, p = .037, while baseline levels of self-understanding were not significantly predictive of treatment outcome in either condition. Baseline skill variables did not predict symptom change as measured by the HAMA.

CONCLUSIONS

The findings support a capitalization model of cognitive therapy, whereby patients with relative strengths in compensatory skills at baseline have better treatment outcomes.

Predicting outcome of substance abuse treatment in a feedback study: Can recovery curves be improved upon?

OBJECTIVE

The goal of the study was to evaluate whether enhanced normative feedback recovery curves are needed for treatment of substance use problems.

METHOD

Patient predictors of outcome were examined using data from four substance abuse treatment clinics.

RESULTS

Baseline severity of symptoms/functioning, employment, and craving were found to be associated with rate of change in symptoms/functioning. Several other variables were associated with rate of change in alcohol use, although in the opposite direction than found in efficacy trials.

CONCLUSIONS

The results point to the complexity of designing feedback systems using normative recovery curves for those with substance use problems and highlight the important differences between real-world treatment of those with substance use problems compared to data from efficacy trials.

Comparative effectiveness of cognitive and dynamic therapies for major depressive disorder in a community mental health setting: study protocol for a randomized non-inferiority trial

BACKGROUND

There is substantial evidence that cognitive therapy is an effective intervention for the treatment of major depressive disorder. Although dynamic psychotherapies have been widely studied and are commonly practiced worldwide, there are few randomized comparisons of cognitive therapy and dynamic therapy for major depressive disorder.

METHODS

We are completing data collection on a randomized non-inferiority trial comparing the effectiveness of cognitive therapy and short-term dynamic psychotherapy in the treatment of major depressive disorder in the community mental health setting. Therapists employed in the community setting have been recruited for training in either short-term dynamic psychotherapy or cognitive therapy. Patients seeking services at the community site who meet criteria for major depressive disorder based on a blind independent diagnostic interview are randomized to 16 sessions of treatment. All patients are assessed at baseline and months 1, 2, 4, and 5 utilizing a comprehensive battery.

DISCUSSION

This study adds to the growing literature evaluating the effectiveness of short-term dynamic psychotherapy for specific diagnostic groups. These results will have implications for the dissemination of effective interventions for major depressive disorder in community mental health settings.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov, a service of the United States National Institute of Health. NIH Identifier: NCT01207271. Registered 21 September 2010.

Combined medication and CBT for generalized anxiety disorder with African American participants: reliability and validity of assessments and preliminary outcomes

Using data from a study of combined cognitive behavioral therapy (CBT) and venlafaxine XR in the treatment of generalized anxiety disorder (GAD), the current article examines the reliability and convergent validity of scales, and preliminary outcomes, for African American compared with European American patients. Internal consistency and short-term stability coefficients for African Americans (n=42) were adequate and similar or higher compared with those found for European Americans (n=164) for standard scales used in GAD treatment research. Correlations among outcome measures among African Americans were in general not significantly different for African Americans compared with European Americans. A subset of patients with DSM-IV-diagnosed GAD (n=24 African Americans; n=52 European Americans) were randomly selected to be offered the option of adding 12 sessions of CBT to venlafaxine XR treatment. Of those offered CBT, 33.3% (n=8) of the African Americans and 32.6% (n=17) of the European Americans accepted and attended at least one CBT treatment session. The outcomes for African Americans receiving combined treatment were not significantly different from European Americans receiving combined treatment on primary or secondary efficacy measures.

Psychotherapy credibility ratings: patient predictors of credibility and the relation of credibility to therapy outcome

OBJECTIVE

The current investigation examined the relation between credibility ratings for adult psychotherapies and a variety of patient factors as well as the relation between credibility ratings and subsequent symptom change.

METHOD

A pooled study database that included studies evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders was used. For all studies, a three-item credibility scale was administered at session 2. Patient variables at baseline were used to predict early treatment credibility.

RESULTS

Early symptom improvement, age, education, and expectation of improvement were all significantly predictive of credibility scores at session 2. In one combined multiple regression model controlling for treatment, study, and early symptom change, age, education, and expectation of improvement remained significantly predictive of credibility scores. Credibility was predictive of subsequent symptom change even when controlling for age, education, expectation of improvement, and early symptom improvement.

CONCLUSIONS

These findings suggest that age and education, in addition to expectations of improvement and the amount of early symptom improvement, may influence the patient's perceptions of the credibility of a treatment rationale early in the treatment process and that credibility ratings predict subsequent symptom change.

Measuring Outcome in the Treatment of Cocaine Dependence

BACKGROUND

Little in known about the extent to which outcome measures used in studies of the treatment of cocaine dependence are associated with longer-term use and with broader measures of clinical improvement. The current study examined reductions in use, and abstinence-oriented measures, in relation to functioning and longer-term clinical benefits in the treatment of cocaine dependence.

METHODS

Overall drug use, cocaine use, and functioning in a number of addiction-related domains for 487 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions in the NIDA Cocaine Collaborative Treatment Study were assessed monthly during 6 months of treatment and at 9, 12, 15, and 18 month follow-up.

RESULTS

Measures of during-treatment reduction in use were moderately correlated with drug and cocaine use measures 12 months, but showed non-significant or small correlations with measures of functioning at 12 months. Highest correlations were evident for abstinence measures (maximum consecutive days abstinence and completely abstinent) during treatment in relation to sustained (3 month) abstinence at 12 months. Latent class analysis of patterns of change over time revealed that most patients initially (months 1 to 4 of treatment) either became abstinent immediately or continued to use every month. Over the couse of follow-up, patients either maintained abstinence or used regularly - intermittent use was less common.

CONCLUSIONS

There were generally small associations between various measures of cocaine use and longer-term clinical benefits, other than abstinence was associated with continued abstinence. No one method of measuring outcome of treatment of cocaine dependence appears superior to others.

Supportive-expressive dynamic psychotherapy in the community mental health system: a pilot effectiveness trial for the treatment of depression

The goal of the current article is to present the results of a randomized pilot investigation of a brief dynamic psychotherapy compared with treatment-as-usual (TAU) in the treatment of moderate-to-severe depression in the community mental health system. Forty patients seeking services for moderate-to-severe depression in the community mental health system were randomized to 12 weeks of psychotherapy, with either a community therapist trained in brief dynamic psychotherapy or a TAU therapist. Results indicated that blind judges could discriminate the dynamic sessions from the TAU sessions on adherence to dynamic interventions. The results indicate moderate-to-large effect sizes in favor of the dynamic psychotherapy over the TAU therapy in the treatment of depression. The Behavior and Symptom Identification Scale-24 showed that 50% of patients treated with dynamic therapy moved into a normative range compared with only 29% of patients treated with TAU.

Process predictors of the outcome of group drug counseling

OBJECTIVE

This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatment, for cocaine dependence.

METHOD

Videotaped group drug counseling sessions from 440 adult patients (23% female, 41% minority) were rated for member alliance, group cohesion, participation, self-disclosure, as well as positive and non-positive feedback and advice during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse.

RESULTS

More positive alliances (with counselor) were associated with reductions in days using cocaine per month and next-session cocaine use and increases in endorsement of 12-step philosophy. Patient self-disclosure about the past and degree of participation in the group were generally not predictive of group drug counseling outcomes. More advice from counselor and other group members were consistently associated with poorer outcomes in all categories. Individual differences in changes in process variables over time (linear slopes) were generally not predictive of treatment outcomes.

CONCLUSIONS

Some group behaviors widely believed to be associated with outcome, such as self-disclosure and participation, were not generally predictive of outcomes of group drug counseling, but alliance with the group counselor was positively associated, and advice giving was negatively associated, with the outcome of treatments for cocaine dependence.

Does the alliance cause good outcome? Recommendations for future research on the alliance

Research has consistently documented that the quality of the therapeutic alliance is related to the outcome of diverse psychotherapies. Insufficient attention, however, has been directed at identifying the nature and magnitude of the causal relationship between the alliance and outcome. In this commentary, we discuss the major threats to causal interpretation of alliance-outcome correlations and provide suggestions for future research that would help clarify the extent to which the alliance causes positive outcomes. Assuming the alliance is a causal factor in relation to outcome, we provide recommendations for research on the alliance that would attempt to improve patient care by enhancing the alliance. (PsycINFO Database Record (c) 2010 APA, all rights reserved).

Do supervisors and independent judges agree on evaluations of therapist adherence and competence in the treatment of cocaine dependence?

The current study examined the agreement between supervisors' and independent judges' evaluations of therapist adherence and competence in three treatments of cocaine dependence: supportive expressive therapy (SE), cognitive therapy CT), and individual drug counseling (IDC). We used data from The National Institute on Drug Abuse Collaborative Cocaine Treatment Study (n = 295). Trained and experienced supervisors and independent judges rated treatment fidelity. At the therapist level of analysis, the agreement between supervisors' and independent judges' ratings was weak for SE competence, CT adherence, and CT competence. Moderate relations were found for IDC adherence and competence. Supervisors consistently rated adherence and competence more positively than judges in CT and IDC. The potential bias in supervisors' ratings is discussed.

How many treatment sessions and patients are needed to create a stable score of adherence and competence in the treatment of cocaine dependence?

The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges' ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.

The dependability of alliance assessments: the alliance-outcome correlation is larger than you might think

OBJECTIVE

To examine the dependability of alliance scores at the patient and therapist level, to evaluate the potential causal direction of session-to-session changes in alliance and depressive symptoms, and to investigate the impact of aggregating the alliance over progressively more sessions on the size of the alliance-outcome relationship.

METHOD

We used data from a study (N = 45 patients; N = 9 therapists) of psychotherapy for major depressive disorder in which the alliance was measured at every treatment session to calculate generalizability coefficients and to predict change in depressive symptoms from alliance scores. Two replication samples were also used.

RESULTS

At the therapist level, a large number of patients (about 60) per therapist is needed to provide a dependable therapist-level alliance score. At the patient level, generalizability coefficients revealed that a single assessment of the alliance is only marginally acceptable. Very good (>.90) dependability at the patient level is only achieved through aggregating 4 or more assessments of the alliance. Session-to-session change in the alliance predicted subsequent session-to-session changes in symptoms. Evidence for reverse causation was found in later-in-treatment sessions, suggesting that only aggregates of early treatment alliance scores should be used to predict outcome. Session 3 alliance scores explained 4.7% of outcome variance, but the average of Sessions 3-9 explained 14.7% of outcome variance.

CONCLUSION

Adequate assessment of the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial for fully understanding the size of the alliance-outcome relationship.

Changes in psychotherapy utilization among consumers of services for major depressive disorder in the community mental health system

The goal of this investigation was to explore changes in psychotherapy utilization for patients with major depressive disorder (MDD) treated in community mental health agencies across two cohorts. We used a Medicaid claims database including approximately 300,000 public sector clients. Although the use of psychotherapy alone showed a small decrease, there was a large increase in the use of combined medication and psychotherapy as a treatment for MDD. Race was a significant predictor of both treatment type received and length of treatment. African American consumers were more likely to receive psychotherapy alone than combined treatment and attended significantly fewer psychotherapy sessions.

Gender, race, and group behavior in group drug treatment

BACKGROUND

Group drug counseling is the primary treatment modality used to treat drug dependence in community settings in the United States. Findings from the social psychology literature suggest that gender may influence how individuals participate in groups, and that race may moderate the effects of gender on group behavior. This study examined gender, race, and their interaction as predictors of alliance, participation, self-disclosure, and receipt of advice and feedback in drug counseling groups, and explored how gender and racial differences in drug counseling group behavior related to outcome of cocaine dependence treatment.

METHOD

Ratings of group behavior were made from videotaped sessions of group drug counseling drawn from a randomized trial of treatment for cocaine-dependent individuals (n=438). Analyses examined the effects of race (African American or non-Hispanic White), gender, and the race by gender interaction on group behavior. Additional analyses examined race, gender, and group behavior, and interactions among these variables in predicting monthly cocaine use.

RESULTS

Race and the race by gender interaction, but not gender alone, predicted many group behaviors. Non-Hispanic White women had the highest rates of self-disclosure and receipt of advice and non-positive feedback, followed by men of both races, with African American women having the lowest levels. These differences were unrelated to cross-sectional cocaine outcome.

CONCLUSIONS

Women, but not men, of different races acted differently in mixed-race, mixed-gender cocaine treatment groups, with African American women exhibiting less of several behaviors. Additional research on causes and consequences of these differences could inform interventions for drug-dependent women.

Combined medication and cognitive therapy for generalized anxiety disorder

The current study assessed efficacy of combined cognitive behavioral therapy (CBT) and venlafaxine XR compared to venlafaxine XR alone in the treatment of generalized anxiety disorder (GAD) within settings where medication is typically offered as the treatment for this disorder. Patients with DSM-IV-diagnosed GAD who were recently enrolled in a long-term venlafaxine XR study were randomly offered (n=77), or not offered (n=40), the option of adding 12 sessions of CBT. Of those offered CBT, 33% (n=26) accepted and attended at least one treatment session. There were no differences between the combined treatment group and the medication only group on primary or secondary efficacy measures in any of the sample comparisons. Many patients who present in medical/psychopharmacology settings seeking treatment for GAD decline the opportunity to receive adjunctive treatment. Of those that receive CBT, there appears to be no additional benefit of combined treatment compared to venlafaxine XR alone.

A generalizability theory analysis of group process ratings in the treatment of cocaine dependence

Videotaped group drug counseling sessions were rated for alliance, self-disclosure, positive and negative feedback, group cohesion, and degree of participation of each group member. Interrater reliability was good to excellent for most measures. However, generalizability coefficients based on statistical models that included terms for patient, counselor, session, group, and rater revealed that some measures had inadequate dependability at the patient level if only two raters and two sessions were used to create patient-level scores. In contrast, good generalizability coefficients based on two raters and two sessions were obtained for alliance, non-positive learning statements received from counselor, participation variables, and self-disclosures about the past. The implications of the findings for the design of process-outcome studies are discussed.

Outcome assessment via handheld computer in community mental health: consumer satisfaction and reliability

Computerized administration of mental health-related questionnaires has become relatively common, but little research has explored this mode of assessment in "real-world" settings. In the current study, 200 consumers at a community mental health center completed the BASIS-24 via handheld computer as well as paper and pen. Scores on the computerized BASIS-24 were compared with scores on the paper BASIS-24. Consumers also completed a questionnaire which assessed their level of satisfaction with the computerized BASIS-24. Results indicated that the BASIS-24 administered via handheld computer was highly correlated with pen and paper administration of the measure and was generally acceptable to consumers. Administration of the BASIS-24 via handheld computer may allow for efficient and sustainable outcomes assessment, adaptable research infrastructure, and maximization of clinical impact in community mental health agencies.

Developing research and recruitment while fostering stakeholder engagement in a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs grant for depression

BACKGROUND

In the context of a National Institutes of Mental Health-funded Interventions and Practice Research Infrastructure Programs (IP-RISP) grant for the treatment of depression, a partnership was developed between a community mental health organization and a team of researchers.

OBJECTIVES

This paper describes the collaborative process, key challenges, and strategies employed to meet the goals of the first phase of the grant, which included development of a working and sustainable partnership and building capacity for recruitment and research.

METHODS

This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners.

LESSONS LEARNED

Communication with multiple stakeholders through varied channels, feedback from stakeholders on research procedures, and employing a research liaison at the clinic have been key strategies in the first phase of the grant.

CONCLUSION

The strategies we employed allowed multiple stakeholders to contribute to the larger mission of the IP-RISP and helped to establish an ongoing research program within the mental health organization.

Interpersonal accuracy of interventions and the outcome of cognitive and interpersonal therapies for depression

OBJECTIVE

The purpose of the current investigation was to examine the interpersonal accuracy of interventions in cognitive therapy and interpersonal therapy as a predictor of the outcome of treatment for patients with major depressive disorder.

METHOD

The interpersonal accuracy of interventions was rated using transcripts of treatment sessions for 72 patients who were being treated with cognitive or interpersonal therapy for major depressive disorder through the National Institute of Mental Health Treatment of Depression Collaborative Research Program (Elkin et al., 1989). Interpersonal accuracy of interventions was assessed by first identifying core conflictual relationship themes for each patient and then by having judges rate therapist intervention statements for the extent to which each statement addressed each component of the patient-specific interpersonal theme.

RESULTS

Using early-in-treatment sessions, statistically significant interactions of interpersonal accuracy of interventions and treatment group in relation to outcome were evident. These findings included significant interactions of treatment group with accuracy of interventions in the prediction of subsequent change of depressive symptoms and social adjustment from Week 4 to Week 16, with higher levels of interpersonal accuracy associated with relatively poorer outcomes for patients receiving cognitive therapy but relatively better outcomes for patients in interpersonal therapy.

CONCLUSION

The process of interpersonal and cognitive therapies may differ in important ways. Accurately addressing interpersonal themes may be particularly important to the process of interpersonal therapy but not cognitive therapy.

Unique and common mechanisms of change across cognitive and dynamic psychotherapies

The goal of this article was to examine theoretically important mechanisms of change in psychotherapy outcome across different types of treatment. Specifically, the role of gains in self-understanding, acquisition of compensatory skills, and improvements in views of the self were examined. A pooled study database collected at the University of Pennsylvania Center for Psychotherapy Research, which includes studies conducted from 1995 to 2002 evaluating the efficacy of cognitive and psychodynamic therapies for a variety of disorders, was used. Patient samples included major depressive disorder, generalized anxiety disorder, panic disorder, borderline personality disorder, and adolescent anxiety disorders. A common assessment battery of mechanism and outcome measures was given at treatment intake, termination, and 6-month follow-up for all 184 patients. Improvements in self-understanding, compensatory skills, and views of the self were all associated with symptom change across the diverse psychotherapies. Changes in self-understanding and compensatory skills across treatment were predictive of follow-up symptom course. Changes in self-understanding demonstrated specificity of change to dynamic psychotherapy.

A pilot study of community-friendly manual-guided drug counseling

Therapist training manuals that are more "community friendly" are needed to facilitate effectiveness testing and dissemination of treatments to community based setting. The aim of the current project was to create revised versions of individual drug counseling (IDC) and group drug counseling (GDC) treatment manuals for cocaine dependence and to conduct a preliminary study of their effectiveness. After changing the format and context of existing drug counseling manuals to have greater ease of use in the community, draft manuals were given to 23 community-based counselors for their feedback. Final versions were then used in a pilot randomized clinical trial involving 41 cocaine-dependent patients who received 3 months of either IDC + GDC or GDC-alone treatment. Counselors implemented the new treatment manuals with acceptable levels of adherence and competence. Outcome results indicated that substantial change in drug use was evident, but the amount of abstinence obtained was limited.

Dopamine transporter levels in cocaine dependent subjects

Cocaine use is a significant problem in the US and it is well established that cocaine binds to the dopamine transporter (DAT) in the brain. This study was designed to determine if the DAT levels measured by 99mTc TRODAT SPECT (single photon emission computed tomography) brain scans are altered in cocaine dependent subjects and to explore clinical correlates of such alterations. SPECT brain scans were acquired on 21 cocaine dependent subjects and 21 healthy matched controls. There were significantly higher DAT levels in cocaine dependent subjects compared to controls for the anterior putamen (p=0.003; Cohen's d effect size=0.98), posterior putamen (p<0.001; effect size=1.32), and caudate (p=0.003; effect size=0.97). DAT levels in these regions were 10%, 17%, and 8% higher in the cocaine dependent subjects compared to controls. DAT levels were unrelated to craving, severity of cocaine use, or duration of cocaine use, but DAT levels in the caudate and anterior putamen were significantly (p<0.05) negatively correlated with days since last use of cocaine.

The Relation of Rigidity Across Relationships With Symptoms and Functioning: An Investigation With the Revised Central Relationship Questionnaire

The belief that rigidity across relationships is related to greater symptoms and poorer functioning commonly informs the practice of many psychodynamic and interpersonal therapists. Using a profile correlation approach, we tested this hypothesis in a sample of 250 clients and 90 undergraduate control participants. Symptoms and functioning were assessed with the Inventory of Interpersonal Problems (IIP), Global Assessment of Functioning scale, and Brief Symptom Inventory. A revised version of the empirically-derived Central Relationship Questionnaire (CRQ) was used to measure interpersonal patterns. Revisions were made to the CRQ to increase the interpersonal dimensions it captured, reduce its length, and model a higher-order factor structure. The psychometric properties of the revised CRQ were found to be adequate. Rigidity as measured with the CRQ was not related to rigidity measured with the IIP (amplitude) and did not differ significantly among individuals with different interpersonal problems or DSM-IV diagnoses. Contrary to theory, however, greater rigidity across relationships was related to fewer symptoms and interpersonal problems. These relations did not appear due to the valence or the extremeness of the interpersonal patterns used in the estimation of rigidity.