"It takes time to see the whole picture": patients' views on improvement in cognitive behavioral therapy and psychodynamic therapy after three years

Introduction

There is a lack of qualitative research that retrospectively explores how patients with major depressive disorder view their improvement in psychotherapy.

Methods

Fifteen patients who received short-term cognitive behavioral therapy and psychodynamic therapy were individually interviewed approximately three years after completing therapy.

Results

Some patients had altered their views on therapy, especially those who initially were uncertain of how helpful therapy had been. They said they did not realize the extent and importance of their improvement in therapy before some time had passed, which can be explained by the surprising cumulative effects of seemingly small changes.

Discussion

This should make retrospective qualitative research an important part of future psychotherapy research.

Mediators of Outcome in Trauma-Focused Psychotherapy with Youth: A Systematic Review

This article aimed to provide a systematic narrative synthesis of existing studies on the mediators of change in psychotherapy with adolescents (10-19 years) and transition age youth (TAY) (20-29 years) who have experienced trauma-related symptoms or posttraumatic disorder. Additionally, we were interested in identifying psychotherapy-, trauma type-, and clients' age- and gender-specific mediators of treatment outcome. Following the preferred reporting items for systematic reviews and meta-analyses, a total of 3,723 studies published in PubMed and PsycINFO databases were screened against inclusion criteria, revealing 15 eligible studies. No studies with only TAY were found; therefore, all results were limited to therapy with adolescents. Cognitive mediators were tested in 66% of selected studies, followed by parents/family-related, mental-health-related, therapy-related, and behavioral mediators. Moderate evidence was found for posttraumatic cognitions, whereas therapeutic alliance seemed to be a promising candidate for future research. Striking absence of non-cognitive-behavioral therapy interventions, emotional and adolescent-specific mediators, as well as studies with males and in non-Western societies was evident. Future original studies would benefit from applying methodological rigor in respect to mediation testing.

Examining Psychotherapeutic Processes with Depressed Adolescents: A Comparative Study of Two Psychodynamic Therapies

To understand processes associated with better or poorer psychotherapy outcomes is vital. This study examined and contrasted interaction patterns between one therapist and two depressed 17-year-old girls, Johanna (good outcome) and Sonja (poor outcome), in short-term psychoanalytic therapies selected from an RCT. Outcome data were collected regarding level of inter- and intra-personal functioning and symptoms of depression. Process data were obtained using the Adolescent Psychotherapy Q-Set on all available sessions. Analyses yielded five relational patterns or "interaction structures" in the two therapy processes; Three explained most of the variance in sessions with Johanna (i.e., 'positive working alliance', 'therapist's active use of psychodynamic techniques', and 'a receptive patient') and two explained more of the variance in sessions with Sonja (i.e., 'therapist using a more problem-solving and symptom-oriented approach' and 'patient displaying limited capacity for mentalization'). The processes in the two cases presented differences related to mentalization, psychological mindedness, and attachment style of the patients. The therapist used different therapeutic approaches, favouring more psychodynamic interventions in the good outcome case and a more problem-solving and symptom-oriented approach with the poor outcome case. In the latter case, the relationship seemed to be more of a struggle.

Inter-Rater Reliability of the Structured Interview of DSM-IV Personality (SIDP-IV) in an Adolescent Outpatient Population

Personality disorders (PDs) are a class of mental disorders which are associated with subjective distress, decreased quality of life and broad functional impairment. The presence of one or several PDs may also complicate the course and treatment of symptom disorders such as anxiety and depression. Accurate and reliable means of diagnosing personality disorders are thus crucial to ensuring efficient treatment planning and resource allocation, a fact which is widely acknowledged within the adult mental health field. In adolescents, on the other hand, the consensus view has been that the rapid and discontinuous processes of normal personality development render the construct of PD in adolescents clinically unhelpful and conceptually dubious. However, recent research has established the reliability and validity of the construct, heralding an increased interest in the field, with important conceptual and clinical implications. The present article presents reliability data for the Structured Interview of DSM-IV Personality (SIDP-IV) in an adolescent outpatient population. For this study, 25 interviews conducted by experienced clinicians were blindly re-scored based on sound recordings, which allowed for the calculation of intra-class correlation metrics. The intra-class correlation coefficient for categorical diagnosis of specific personality disorders was found to be 0.876 (95% CI 0.718-0.945); Cohen's kappa for presence/absence of personality diagnosis was found to be 0.896. The present study found excellent intra-rater reliability for the sample, which suggests that the SIDP-IV is a suitable instrument for assessing personality pathology in adolescent populations.

Personality Disorders as a Possible Moderator of the Effects of Relational Interventions in Short-Term Psychoanalytic Psychotherapy with Depressed Adolescents

A significant proportion of adolescents suffering from major depressive disorder (MDD) are likely to have a co-morbid personality disorder (PD). Short-term psychoanalytic psychotherapy (STPP) was found to be one treatment of choice for adolescents suffering from MDD.

BACKGROUND

The first experimental study of transference work-in teenagers (FEST-IT) demonstrated the efficaciousness of transference work in STPP with adolescents suffering from MDD. The usefulness of STPP may be enhanced by exploring possible moderators.

METHODS

Depressed adolescents (N = 69), aged 16-18 years, were diagnosed with the structured interview for DSM-IV PDs and randomized to 28 weeks of STPP with or without transference work. A mixed linear model was applied. The moderator effect was investigated by a three-way interaction including "time", "treatment group" and "number of PD criteria".

RESULTS

A small but significant moderator effect was found for cluster B personality pathology. Patients with a higher number of cluster B PD criteria at baseline did better up to one-year post-treatment where therapists encouraged patients to explore the patient-therapist relationship in the here and now.

CONCLUSION

When treated with psychoanalytic psychotherapy for MDD, adolescents with cluster B PD symptoms seem to profit more from transference work than adolescents without such pathology.

Therapists’ Emotional Responses in Individual Therapy with Depressed Adolescents: An Evaluation of the Data Structure of the Feeling-Word Checklist—28

Countertransference (CT) responses during therapy sessions can be understood as the therapist’s emotional reactions towards the patient. Within adolescents’ psychotherapy, little is known about the effects of the therapists’ feelings on treatment outcome. The Feeling-Word Checklist—28 (FWC-28) is a self-report questionnaire designed to evaluate the therapist’s in-session feelings during therapy with younger patients. The aim of the study was to evaluate the psychometric properties of the clinician-rated FWC-28 and explore the associations between the CT-subscales and therapeutic alliance. Data were collected from a randomized controlled trial in which 11 therapists specialized in child and adolescent psychotherapy treated 16- to 18-year-old patients (n = 62) with major depressive disorder in outpatient clinics. The patients received psychodynamic psychotherapy treatment over 28 sessions. Therapists rated their emotional responses towards their patients on FWC-28 after sessions 3, 12, 20, and 28. Principal component analysis (PCA) with oblique rotation was performed to find clinically meaningful subscales of the FWC-28. PCA revealed four clinically meaningful components termed as follows: inadequate, confident, motherly, and disengaged. The psychometric properties of the FWC and the reliability of the CT subscales measured with Cronbach’s alpha were acceptable. The therapist-reported alliance showed significant and clinically meaningful correlations with all CT-subscales. Our findings indicate that the checklist is adequate for clinical practice and countertransference research in adolescents’ psychotherapy.

How therapists in cognitive behavioral and psychodynamic therapy reflect upon the use of metaphors in therapy: a qualitative study

BACKGROUND

Research suggests that metaphors are integral to psychotherapeutic practice. We wanted to explore how 10 therapists reflect upon the use of metaphors in therapy, and how they react to some metaphors expressed by patients treated for of major depressive disorder (MDD).

METHODS

Five therapists practicing psychodynamic therapy (PDT) and five practicing cognitive behavioral therapy (CBT) were interviewed with a semi-structured qualitative interview. Transcripts were analyzed using a thematic analysis approach.

RESULTS

Our analysis resulted in two main themes: the therapeutic use of metaphors, and conflicting feelings towards metaphors used by depressed patients. Most therapists said that they do not actively listen for metaphors in therapy and many said that they seldom use metaphors deliberately. While PDT-therapists appeared more attentive to patient-generated metaphors, CBT-therapists seemed more focused on therapist-generated metaphors. Most therapists did not try to alter the patient-generated metaphors they evaluated as unhelpful or harmful. Some therapists expressed strong negative feelings towards some of the metaphors used by patients. PDT-therapists were the most critical towards the metaphor of tools and the metaphor of depression as an opponent. CBT-therapists were the most critical towards the metaphor of surface-and-depth.

CONCLUSIONS

These results remind us of the complexity of using metaphors in therapy, and can hopefully be an inspiration for therapists to reflect upon their own use of metaphors. Open therapeutic dialogue on the metaphor of tools, surface-depth and depression as an opponent may be necessary to avoid patient-therapist-conflicts.

TRIAL REGISTRATION

Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Parental Bonding and Relationships with Friends and Siblings in Adolescents with Depression

According to attachment theory, the quality of the early child-parent bond determines the child's interpersonal relationships later in life. Utilising data from The First Experimental Study of Transference Work-In Teenagers (FEST-IT), the current paper investigated the connection between the self-reported quality of bonding with mother and father and the self-reported importance of relationships with friends and siblings in adolescents with depression. The scales employed were the Parental Bonding Instrument (PBI) and the Adolescent Relationship scale (ARS). A Pearson's correlation tested the relationship between the reported levels of maternal and paternal care and control, and the reported importance of friendship and relationship with siblings. Results revealed a statistically significant negative correlation between high levels of maternal control and importance of friendship, and a statistically significant positive correlation between high levels of paternal care and importance of relationships with siblings. The results are in line with Bowlby's theory of attachment.

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BACKGROUND

Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).

METHODS

A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.

RESULTS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.

CONCLUSIONS

Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.

ETHICS AND DISSEMINATION

Ethical approval was not required. PROSPERO registration number: CRD42021231835.

Psychological Interventions for Young People With Psychotic Disorders: A Systematic Review

BACKGROUND

Psychotic disorders are commonly accompanied by intense psychological burden, and psychological interventions are usually needed in order to reduce the symptoms and help in maintaining or improving the level of psychological and social functioning after the onset of psychosis. The evidence-base for treating young people at risk for psychosis and adults with psychotic disorders is accumulating. Yet, pervasive systematic literature reviews that would include patients from the full age range being the most essential period for the risk of developing a psychotic disorder, a wide range of psychological interventions, and various types of clinical trials, have been lacking. The aim of this systematic review is to fill the gap by presenting the current research evidence from clinical trials on the effectiveness of psychological interventions for treating young people (12-30) with psychotic disorders.

METHODS

A systematic search was conducted in PubMed and PsycINFO followed by a 3-step screening process based on the PICOS strategy. Risk of bias of the included studies was assessed by the Mixed Methods Appraisal Tool (MMAT). Extracted data from the included studies is reported using a narrative synthesis.

RESULTS

Of the 1,449 publications screened, 40 from 25 studies were included in the review. Of these, 10 studies reported results from cognitive or behavioral therapy, nine from cognitive remediation therapy (CRT), and six from other types of therapies (i.e., integrative interventions combining psychoeducation and family/group interventions). All but one study found the target interventions to be effective, but the results mostly did not differ significantly from the control conditions in reducing symptoms and improving functioning, preventing relapses and hospitalization, or improving psychological or family variables. The most consistent findings were from CRT, showing more improvement in cognitive functioning compared to control conditions while not being superior in reducing symptom severity. Integrative interventions might be effective in treating young people suffering from psychotic disorders.

CONCLUSION

There is some evidence that psychological interventions are effective for young people with psychotic disorders. However, with regard to symptom severity, psychotherapy does not outperform control conditions, and the results do not strongly favor any specific type of treatment.

SYSTEMATIC REVIEW REGISTRATION

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020166756], identifier [CRD42020166756].

Patient and Public Involvement in Youth Mental Health Research: Protocol for a Systematic Review of Practices and Impact

Various health settings have advocated for involving patients and members of the public (PPI) in research as a means to increase quality and relevance of the produced knowledge. However, youth PPI has been an understudied area. This protocol paper describes a new project that aims to summarize what is known about PPI with young people in mental health research. In line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses Statement guidelines we will identify and appraise suitable articles and extract and synthesize relevant information including at least two reviewers at each stage of the process. Results will be presented in two systematic reviews that will describe (a) how youth PPI has been conducted (Review1) and (b) what impact youth PPI had on the subsequent research and on stakeholders (Review2). To our knowledge, this is the first set of reviews that uses a critical appraisal tool, which is co-developed with children and young people. Findings from this project will provide valuable insights and set out the key steps to adopting adequate PPI methods when involving children and young people in mental health research.

Digging down or scratching the surface: how patients use metaphors to describe their experiences of psychotherapy

BACKGROUND

In the present study, we wanted to explore which metaphors patients suffering from major depressive disorder (MDD) use to explain their experience of being in therapy and their improvement from depression.

METHODS

Patients with MDD (N = 22) received either psychodynamic therapy (PDT) or cognitive behavioral therapy (CBT). They were interviewed with semi-structured qualitative interviews after ending therapy. The transcripts were analyzed using a method based on metaphor-led discourse analysis.

RESULTS

Metaphors were organized into three different categories concerning the process of therapy, the therapeutic relationship and of improvement from depression. Most frequent were the metaphorical concepts of surface and depth, being open and closed, chemistry, tools, improvement as a journey from darkness to light and depression as a disease or opponent.

CONCLUSIONS

Patient metaphors concerning the therapeutic experience may provide clinicians and researchers valuable information about the process of therapy. Metaphors offer an opportunity for patients to communicate nuances about their therapeutic experience that are difficult to express in literal language. However, if not sufficiently explored and understood, metaphors may be misinterpreted and become a barrier for therapeutic change.

TRIAL REGISTRATION

Clinical Trial gov. Identifier: NCT03022071 . Date of registration: 16/01/2017.

Psychotherapy Dropout: Using the Adolescent Psychotherapy Q-Set to Explore the Early In-Session Process of Short-Term Psychodynamic Psychotherapy

Research suggests that short-term psychodynamic psychotherapy (STPP) is an effective treatment for depression in adolescence, yet treatment dropout is a major concern and what leads to dropout is poorly understood. Whilst studies have begun to explore the role of patient and therapist variables, there is a dearth of research on the actual therapy process and investigation of the interaction between patient and therapist. This study aims to address this paucity through the utilisation of the Adolescent Psychotherapy Q-set (APQ) to examine the early treatment period. The sample includes 69 adolescents aged 16-18 years with major depressive disorder receiving STPP as part of the First Experimental Study of Transference Work-in Teenagers (FEST-IT) trial. Of these, 21 were identified as dropouts and were compared to completers on pre-treatment patient characteristics, symptomatology, functioning, and working alliance. APQ ratings available for an early session from 16 of these drop out cases were analysed to explore the patient-therapist interaction structure. Results from the Q-factor analysis revealed three distinct interaction structures that explained 54.3% of the total variance. The first described a process of mutual trust and collaboration, the second was characterised by patient resistance and emotional detachment, the third by a mismatch and incongruence between therapist and adolescent. Comparison between the three revealed interesting differences which taken together provide further evidence that the reasons why adolescents drop out of therapy vary and are multidimensional in nature.

Mediators and Theories of Change in Psychotherapy for Young People With Personality Disorders: A Systematic Review Protocol

Background: Personality disorders (PDs) are a severe health issue already prevalent among adolescents and young adults. Early detection and intervention offer the opportunity to reduce disease burden and chronicity of symptoms and to enhance long-term functional outcomes. While psychological treatments for PDs have been shown to be effective for young people, the mediators and specific change mechanisms of treatment are still unclear.

Aim: As part of the “European Network of Individualized Psychotherapy Treatment of Young People with Mental Disorders” (TREATme), funded by the European Cooperation in Science and Technology (COST), we will conduct a systematic review to summarize the existing knowledge on mediators of treatment outcome and theories of change in psychotherapy for young people with personality disorders. In particular, we will evaluate whether mediators appear to be common or specific to particular age groups, treatment models, or outcome domains (e.g., psychosocial functioning, life quality, and adverse treatment effects).

Method: We will follow the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched for prospective, longitudinal, and case–control designs of psychological treatment studies, which examine mediators published in English. Participants will be young people between 10 and 30years of age who suffer from subclinical personality symptoms or have a personality disorder diagnosis and receive an intervention that aims at preventing, ameliorating, and/or treating psychological problems.

Results: The results will be published in a peer-reviewed journal and at conference presentations and will be shared with relevant stakeholder groups. The data set will be made available to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives. The review has been registered in PROSPERO (evaluation is pending, registration number ID 248959).

Implications: This review will deliver a comprehensive overview on the empirical basis to contribute to the further development of psychological treatments for young people with personality disorders.

Predictors and moderators of outcome of psychotherapeutic interventions for mental disorders in adolescents and young adults: protocol for systematic reviews

BACKGROUND

Adolescence and young adulthood is a risk period for the emergence of mental disorders. There is strong evidence that psychotherapeutic interventions are effective for most mental disorders. However, very little is known about which of the different psychotherapeutic treatment modalities are effective for whom. This large systematic review aims to address this critical gap within the literature on non-specific predictors and moderators of the outcomes of psychotherapeutic interventions among adolescents and young adults with mental disorders.

METHODS

The protocol is being reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analysis Protocols (PRISMA-P) Statement. PubMed and PsycINFO databases will be searched for randomized controlled and quasi-experimental/naturalistic clinical trials. Risk of bias of all included studies will be assessed by the Mixed Methods Appraisal Tool. The quality of predictor and moderator variables will be also assessed. A narrative synthesis will be conducted for all included studies.

DISCUSSION

This systematic review will strengthen the evidence base on effective mental health interventions for young people, being the first to explore predictors and moderators of outcome of psychotherapeutic interventions for a wide range of mental disorders in young people.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42020166756 .

Mediators in Psychological Treatments for Anxiety and Depression in Adolescents and Young People: A Protocol of a Systematic Review

Introduction

Anxiety and depressive disorders are a significant problem that starts in childhood or adolescence and should be addressed early to avoid chronic mental conditions. There is strong evidence to demonstrate that psychological treatments are effective for these disorders, however, little is known on mediators and mechanisms of change of psychological treatment in adolescents and young adults. Understanding the pathways through which psychological treatments operate will facilitate more effective treatments.

Aim

We aim to conduct a systematic review, exploring the available evidence on mediators of psychological treatments for anxiety and depression in adolescents and young adults.

Methods

A systematic search has been performed on PubMed and PsycINFO databases to identify studies from inception to 23rd February 2020. Eligible studies include randomized controlled trials and trials (quasi-experimental) designs that have enrolled adolescents and young adults presenting with depression and/or anxiety and that have examined mediators of psychological treatments. A group of 20 reviewers from the COST-Action TREATme (CA16102) divided into 10 pairs independently screen studies for inclusion, extract information from the included studies, and assess the methodological quality of the included studies and the requirements for mediators. The methodological quality will be assessed by The Mixed Methods Appraisal Tool. Extracted data from the included studies will be collected and presented using a narrative approach.

Discussion

This systematic review will summarize and provide a comprehensive overview of the current evidence on mediators of psychological treatments for anxiety and depression for adolescents and young adults. Results will allow the identification of strategies to optimize intervention to enhance clinical outcomes.

Ethics and dissemination

Ethics approval is not required. Findings from this systematic review will be published in a peer-reviewed journal and disseminated at conferences and meetings. PROSPERO registration number: CRD42021234641.

Psychological Impact of the COVID-19 Outbreak on Mental Health Outcomes among Youth: A Rapid Narrative Review

The coronavirus disease (COVID-19) outbreak has affected not only physical health but also mental health and psychological wellbeing. This narrative review aimed to map the literature on the psychological impact on the young generation of the COVID-19 pandemic, social restrictions, and extraordinary measures to curb the spread of coronavirus. We performed a systematic search of MEDLINE through PubMed and Web of Science [Science Citation Index Expanded, SCI-EXPANDED), Social Sciences Citation Index (SSCI), and Emerging Sources Citation Index (ESCI)] of all scientific literature published from May 2020 until 15 March 2021. Based on inclusion and exclusion criteria, a total of 15 articles were included. We conducted a narrative review. The reviewed articles suggested the impact of the pandemic and lockdown measures on young persons for several mental symptoms as well as anxiety, stress, depression, event-specific distress, decrease in psychological wellbeing, and changes in sleep habits. Psychological symptoms were related to the experience of several stressors, such as risk for reduction of academic perspectives, massive e-learning adoption, economic issues, social restrictions, and implications for daily life related to the COVID-19 outbreak. This narrative review points out the negative psychological impact of the pandemic outbreak and the high vulnerability of the young in the development of psychological distress, highlighting the relevant focus on the mental health of young people during the pandemic and the need for structured and tailored psychological support and interventions focused to the improvement of Quality of Life of university students after the pandemic experience.

Young People Who Meaningfully Improve Are More Likely to Mutually Agree to End Treatment

Objective: Symptom improvement is often examined as an indicator of a good outcome of accessing mental health services. However, there is little evidence of whether symptom improvement is associated with other indicators of a good outcome, such as a mutual agreement to end treatment. The aim of this study was to examine whether young people accessing mental health services who meaningfully improved were more likely to mutually agree to end treatment.

Methods: Multilevel multinomial regression analysis controlling for age, gender, ethnicity, and referral source was conducted on N = 8,995 episodes of care [Female = 5,469, 61%; meanAge = 13.66 (SD = 2.87) years] using anonymised administrative data from young people's mental health services.

Results: Compared to young people with no change in mental health difficulties, those showing positive meaningful changes in mental health difficulties were less likely to have case closure due to non-mutual agreement (Odds Ratio or OR = 0.58, 95% Confidence Interval or CI = 0.50–0.61). Similarly, they were less likely to transfer (OR = 0.61, 95% CI = 0.49–0.74) or end treatment for other reasons (OR = 0.59, 95% CI = 0.50–0.70) than by case closure due to mutual agreement.

Conclusion: The findings suggest that young people accessing mental health services whose symptoms meaningfully improve are more likely to mutually agree to end treatment, adding to the evidence that symptom improvement may be appropriate to examine as an indicator of a good outcome of accessing mental health services.

Mediators and theories of change in psychotherapy with adolescents: a systematic review protocol

INTRODUCTION

Approximately 75% of mental disorders emerge before the age of 25 years but less than half receive appropriate treatment. Little is known about the mechanisms underlying the therapeutic change of adolescents in psychotherapy. The 'European Network of Individualised Psychotherapy Treatment of Young People with Mental Disorders', funded by the European Cooperation in Science and Technology, will conduct the first systematic review to summarise the existing knowledge on mediators and theories of change in psychotherapy for adolescents.

METHOD

A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched on 23 February 2020, for prospective, longitudinal and case-control designs which examine mediators of change. Participants will be adolescents between 10 and 19 years of age who suffer from a mental disorder or psychological difficulties and receive an intervention that aims at preventing, ameliorating and/or treating psychological problems.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review as no primary data will be collected. The results will be published in a peer-reviewed journals and at conference presentations and will be shared with stakeholder groups. The whole data set will be offered to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives.

PROSPERO REGISTRATION NUMBER

CRD42020177535.

The first experimental study of transference work-in teenagers (FEST-IT): a multicentre, observer- and patient-blind, randomised controlled component study

BACKGROUND

Little is known about the influence on outcome of exploration of the patient-therapist relationship (that is, transference work) in psychoanalytic psychotherapy. We hypothesized that depressed adolescents would have better long-term effects from psychoanalytic psychotherapy with than without transference work.

METHODS

Depressed adolescent (16 to 18 years) were recruited in health authority funded out-patient clinics in Oslo and Vestfold County, Norway. They were randomized to 28 weeks of treatment with psychoanalytic psychotherapy with or without transference work. Change was assessed using linear-mixed models. The primary outcome measure was the Psychodynamic Functioning Scale (pre- post-, and 1-year post-treatment). Level of depression was measured at the same time points and during therapy (week 12, and 20).

RESULTS

69 adolescents were treated with (N = 39) or without (N = 31) transference work. The mean number of sessions was 18.6 (SD = 8,6) in the transference work group and 18.0 (SD = 10.9) in the non-transference work group. Both groups showed large and significant improvement on Psychodynamic Functioning Scale during the whole study period. The difference between the two groups was not significant during the treatment period (95% CI -.79 to 1.2, p = .674, F = .18), or from post-treatment to one-year follow-up (95% CI -.13 to .96; p = .134; F = 2.3). For the secondary outcome measures the transference work group had significantly better outcomes from 12 weeks in treatment to one-year follow-up (Beck Depression Inventory, 95% CI - 1.7 to -.14, p = .022; Montgomery and Åsberg Depression Rating Scale, 95% CI - 1.6 to -.23, p = .009).

CONCLUSION

The findings suggest that exploration of the adolescents' relations to the therapist amplify the effects of short-term psychoanalytic psychotherapy on their depressive symptoms for adolescents with a Major Depressive Disorder.

TRIAL REGISTRATION

ClinicalTrials.gov . Id: NCT01531101 . Registered 8 February 2012.

Mechanisms of change and heterogeneous treatment effects in psychodynamic and cognitive behavioural therapy for patients with depressive disorder: a randomized controlled trial

BACKGROUND

Major depressive disorder (MDD) is a prevalent psychiatric condition associated with significant disability, mortality and economic burden. Cognitive behavioral therapy (CBT) and psychodynamic psychotherapy (PDT) are found to be equally effective for patients with depression. However, many patients do not respond sufficiently to either treatment. To offer individualized treatment, we need to know if some patients benefit more from one of the two therapies. At present little is known about what patient characteristics (moderators) may be associated with differential outcomes of CBT and PDT, and through what therapeutic processes and mechanisms (mediators) improvements occur in each therapy mode. Presently only theoretical assumptions, sparsely supported by research findings, describe what potentially moderates and mediates the treatment effects of CBT and PDT. The overall aim of this study is to examine theoretically derived putative moderators and mediators in CBT and PDT and strengthen the evidence base about for whom and how these treatments works in a representative sample of patients with MDD.

METHODS

One hundred patients with a diagnosis of MDD will be randomized to either CBT or PDT. Patients will be treated over 28 weeks with either CBT (one weekly session over 16 weeks and three monthly booster sessions) or PDT (one weekly session over 28 weeks). The patients will be evaluated at baseline, during the course of therapy, at the end of therapy, and at follow-up investigations 1 and 3 years post treatment. A large range of patient and observer rated questionnaires (specific preselected putative moderators and mediators) are included.

DISCUSSION

The clinical outcome of this study may better guide clinicians when deciding what kind of treatment any individual patient should be offered. Moreover, the study aims to further our knowledge of what mechanisms lead to symptom improvement and increased psychosocial functioning.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03022071.

Improvement in Psychodynamic Psychotherapy for Depression: A Qualitative Study of the Patients' Perspective

The patient's perspective on improvement in psychotherapy is crucial for tailoring the therapy he or she is receiving. The present study aimed at exploring the factors aiding and the patients' experiences of improvement in time-limited psychodynamic psychotherapy for depression. Semi-structured, in-depth interviews were conducted with ten adult patients who received up to 28 sessions of manualized psychodynamic psychotherapy in the Norwegian study "Mechanisms of change in psychotherapy" (the MOP study). The post-therapy interviews addressed the participants' experiences from therapy. The data were analyzed with thematic content analysis and hermeneutic interpretation. The analysis identified four helpful dimensions: "Therapist activities" comprised supporting and acknowledging, advising and offering tips for everyday life, questioning and pressuring. "Patient activities" included opening up, caring for oneself and showing agency. "Facilitators" for improvement were learning from therapy, learning to receive therapy and agreed goals. "Achievements" comprised new perspectives and understandings, increased self-awareness and mastery and changed thinking and feeling. Improvements from psychodynamic therapy seemed reliant on the degree to which the therapy could activate and be relevant to the patients' everyday life. Tailoring therapy for patients with depression should link the focus on symptoms and ways of thinking and feeling with their life circumstances.

Erratum: Therapeutic Atmosphere in Psychotherapy Sessions. Int. J. Environ. Res. Public Health 2020, 17, 4105

The authors wish to make the following correction to their paper [...].

Internet-based psychodynamic versus cognitive behaviour therapy for adolescents with depression: study protocol for a non-inferiority randomized controlled trial (the ERiCA study)

Background

Adolescent depression is a common mental health problem and there is an urgent need for effective and accessible treatments. Internet-based interventions solve many obstacles for seeking and receiving treatment, thus increasing access to effective treatments. Internet-based cognitive behavioural therapy (ICBT) for adolescent depression has demonstrated efficacy in previous trials. In order to broaden the range of evidence-based treatments for young people, we evaluated a newly developed affect-focused Internet-based psychodynamic treatment (IPDT) in a previous study with promising results. The purpose of the planned study is to evaluate the efficacy of IPDT for adolescent depression in a non-inferiority trial, comparing it to ICBT.

Methods

The study will employ a parallel randomized non-inferiority design (ratio 1:1; n = 270). Eligible participants are adolescents 15–19 years suffering from depression. The primary hypothesis is that IPDT will be non-inferior to ICBT in reducing depressive symptoms from pre-treatment to end of treatment. Secondary research questions include comparing outcomes of IPDT and ICBT regarding anxiety symptoms, emotion regulation and self-compassion. Additional data will be collected to evaluate cost-effectiveness as well as investigating predictors, moderators and mediators of outcome. In addition, we will examine long-term outcome up to 1 year after end of treatment. Diagnostic interviews with MINI 7.0 will be used to establish primary diagnosis of depression as well as ruling out any exclusion criteria. Both treatments consist of eight modules over 10 weeks, complemented with therapist support through text messages and weekly chat sessions. Primary outcome measure is the Quick Inventory of Depressive Symptomatology in Adolescents Self-Rated (QIDS-A17-SR). Primary outcome will be analysed using data from all participants entering the study using a multilevel growth curve strategy based on the weekly measurements of QIDS-A17-SR. The non-inferiority margin is defined as d = 0.30.

Discussion

This trial will demonstrate whether IPDT is non-inferior to ICBT in the treatment of adolescent depression. The study might therefore broaden the range of evidence-based treatment alternatives for young people struggling with depression. Further analyses of data from this trial may increase our knowledge about “what works for whom” and the pathways of change for two distinct types of interventions.

Trial registration

ISRCTN12552584, Registered on 13 August 2019.

Therapists' Experiences of Psychodynamic Therapy with and without Transference Interventions for Adolescents with Depression

Psychodynamic therapy is an effective treatment for depression. However, a large number of adolescent patients with depression do not respond and/or drop out of therapy and little is known about what therapists actually do in therapy with adolescents. Thus, more research is needed to explore the various actions that therapists do in therapy, so that therapists can tailor their therapy more specifically to each individual adolescent. The present study aimed to investigate how the experience of psychotherapists differs between two treatment modes for adolescents with depression: psychodynamic psychotherapy with and without transference interventions. In-depth interviews were conducted with six therapists. The data, which were analyzed using thematic analysis, generated three key themes: (1) The therapists experienced that transference interventions are often useful in therapies with adolescents with depression, (2) therapies without transference interventions can be challenging for therapists, but still helpful for patients, and (3) the experience contributed to the deepening recognition of therapists that they always need to adapt their techniques to the particular patient. The results enhance our knowledge of the significance of therapists’ actions in therapy with adolescents. The therapists highlighted issues that are important for identifying barriers to incorporating new knowledge into clinical practice.

Engaging Children and Young People in Digital Mental Health Interventions: Systematic Review of Modes of Delivery, Facilitators, and Barriers

BACKGROUND

There is a high prevalence of children and young people (CYP) experiencing mental health (MH) problems. Owing to accessibility, affordability, and scalability, an increasing number of digital health interventions (DHIs) have been developed and incorporated into MH treatment. Studies have shown the potential of DHIs to improve MH outcomes. However, the modes of delivery used to engage CYP in digital MH interventions may differ, with implications for the extent to which findings pertain to the level of engagement with the DHI. Knowledge of the various modalities could aid in the development of interventions that are acceptable and feasible.

OBJECTIVE

This review aimed to (1) identify modes of delivery used in CYP digital MH interventions, (2) explore influencing factors to usage and implementation, and (3) investigate ways in which the interventions have been evaluated and whether CYP engage in DHIs.

METHODS

A literature search was performed in the Cochrane Library, Excerpta Medica dataBASE (EMBASE), Medical Literature Analysis and Retrieval System Online (MEDLINE), and PsycINFO databases using 3 key concepts "child and adolescent mental health," "digital intervention," and "engagement." Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed using rigorous inclusion criteria and screening by at least two reviewers. The selected articles were assessed for quality using the mixed methods appraisal tool, and data were extracted to address the review aims. Data aggregation and synthesis were conducted and presented as descriptive numerical summaries and a narrative synthesis, respectively.

RESULTS

This study identified 6 modes of delivery from 83 articles and 71 interventions for engaging CYP: (1) websites, (2) games and computer-assisted programs, (3) apps, (4) robots and digital devices, (5) virtual reality, and (6) mobile text messaging. Overall, 2 themes emerged highlighting intervention-specific and person-specific barriers and facilitators to CYP's engagement. These themes encompassed factors such as suitability, usability, and acceptability of the DHIs and motivation, capability, and opportunity for the CYP using DHIs. The literature highlighted that CYP prefer DHIs with features such as videos, limited text, ability to personalize, ability to connect with others, and options to receive text message reminders. The findings of this review suggest a high average retention rate of 79% in studies involving various DHIs.

CONCLUSIONS

The development of DHIs is increasing and may be of interest to CYP, particularly in the area of MH treatment. With continuous technological advancements, it is important to know which modalities may increase engagement and help CYP who are facing MH problems. This review identified the existing modalities and highlighted the influencing factors from the perspective of CYP. This knowledge provides information that can be used to design and evaluate new interventions and offers important theoretical insights into how and why CYP engage in DHIs.

Therapeutic Atmosphere in Psychotherapy Sessions

There is uncertainty concerning what the active ingredients in psychotherapy are. The First Experimental Study of Transference interpretations (FEST) was a randomized controlled trial of the effects of transference work (TW) in psychodynamic psychotherapy. Women with low quality of object relations (QOR) showed a large positive effect of transference work, while men with high QOR showed a slight negative effect. The present study aimed to expand the knowledge from the FEST by investigating the therapeutic atmosphere with Structural Analysis of Social Behavior (SASB). Two-way ANOVAs were conducted to investigate differences between SASB cluster scores between subgroups. The therapeutic atmosphere was characterized by Protect–Trust, Affirm–Disclose and Control–Submit. Multilevel modeling was used to assess the relationship between a therapist variable and outcomes for men and women. Contrary to expectations, no significant differences in therapeutic atmosphere between subgroups (with or without TW in women with low QOR and men with high QOR) were observed using the process measure SASB.

Core conflictual relationship theme: the reliability of a simplified scoring procedure

BACKGROUND

Creating a case formulation is an important and basic skill in psychotherapy meant to guide treatment. A patient's interpersonal pattern is an essential part of a case formulation. Core Conflictual Relationship Theme (CCRT) is a well-known structured method to describe interpersonal patterns. The CCRT method is based on the assumption that humans display a central relationship theme, which is shown in most relationships as well as in the patient-therapist relation. The CCRT scoring is based on how the patient describes interactions with others, in therapy sessions or in a specific interview. These descriptions are transcribed. Raters then score the identified relational episodes by choosing elements from the clustered categories of Wishes, Response from Others and Response from Self. The method has shown high validity and reliability. Inter rater reliability is generally good: Cohen's kappa ranging from 0.55 to 0.70. To decide CCRT pattern from transcribed material is time consuming and labour intensive This study investigates a labour- and timesaving version of the method.

METHODS

This study aimed to investigate rater agreement in a simplified method of scoring the CCRT, based directly on live semi-structured dynamic interviews without transcribing the material. Fifty-two patients referred for psychotherapy in a clinical trial, were scored for CCRT pattern. Based on information that came forth during the two-hour interview, raters scored the patients choosing elements from the clustered categories of Wishes, Response from Others and Response from Self. More than one category in each component could be chosen without ranking. Five raters compared two by two were investigated. Inter rater reliability was measured by Cohen's kappa.

RESULTS

Mean kappa for Wishes, Response from Others and Response from Self was .33, .41 and .45 respectively. Mean kappa for CCRT in total was .41 among 5 raters.

CONCLUSION

In this simplified method to score the CCRT based on oral dynamic interviews, fair to moderate IRR was obtained.

TRIAL REGISTRATION

First Experimental Study of Transference-interpretations (FEST307/95). Registration number: ClinicalTrials.gov Identifier: NCT00423462.

Affect-Focused Psychodynamic Internet-Based Therapy for Adolescent Depression: Randomized Controlled Trial

Background

Adolescent depression is one of the largest health issues in the world and there is a pressing need for effective and accessible treatments.

Objective

This trial examines whether affect-focused internet-based psychodynamic therapy (IPDT) with therapist support is more effective than an internet-based supportive control condition on reducing depression in adolescents.

Methods

The trial included 76 adolescents (61/76, 80% female; mean age 16.6 years), self-referred via an open access website and fulfilling criteria for major depressive disorder. Adolescents were randomized to 8 weeks of IPDT (38/76, 50%) or supportive control (38/76, 50%). The primary outcome was self-reported depressive symptoms, measured with the Quick Inventory of Depressive Symptomatology for Adolescents (QIDS-A17-SR). Secondary outcomes were anxiety severity, emotion regulation, self-compassion, and an additional depression measure. Assessments were made at baseline, postassessment, and at 6 months follow-up, in addition to weekly assessments of the primary outcome measure as well as emotion regulation during treatment.

Results

IPDT was significantly more effective than the control condition in reducing depression (d=0.82, P=.01), the result of which was corroborated by the second depression measure (d=0.80, P<.001). IPDT was also significantly more effective in reducing anxiety (d=0.78, P<.001) and increasing emotion regulation (d=0.97, P<.001) and self-compassion (d=0.65, P=.003). Significantly more patients in the IPDT group compared to the control group met criteria for response (56% vs 21%, respectively) and remission (35% vs 8%, respectively). Results on depression and anxiety symptoms were stable at 6 months follow-up. On average, participants completed 5.8 (SD 2.4) of the 8 modules.

Conclusions

IPDT may be an effective intervention to reduce adolescent depression. Further research is needed, including comparisons with other treatments.

Trial Registration

International Standard Randomised Controlled Trial Number (ISRCTN) 16206254; http://www.isrctn.com/ISRCTN16206254

Psychodynamic case formulations without technical language: a reliability study

Background

To bridge the gap between symptoms and treatment, constructing case formulations is essential for clinicians. Limited scientific value has been attributed to case formulations because of problems with quality, reliability, and validity. For understanding, communication, and treatment planning beyond each specific clinician-patient dyad, a case formulation must convey valid information concerning the patient, as well as being a reliable source of information regardless of the clinician’s theoretical orientation. The first aim of the present study is to explore the completeness of unstructured psychodynamic formulations, according to four components outlined in the Case Formulation Content Coding Method (CFCCM). The second aim is to estimate the reliability of independent formulations and their components, using similarity ratings of matched versus mismatched cases.

Methods

This study explores psychodynamic case formulations as made by two or more experienced clinicians after listening to an evaluation interview. The clinicians structured the formulations freely, with the sole constraint that technical, theory-laden terminology should be avoided. The formulations were decomposed into components after all formulations had been written.

Results

The results indicated that most formulations were adequately comprehensive, and that overall reliability of the formulations was high (> 0.70) for both experienced and inexperienced clinician raters, although the lower bound reliability estimate of the formulation component deemed most difficult to rate - inferred mechanisms - was marginal, 0.61.

Conclusions

These results were achieved on case formulations made by experienced clinicians using simple experience-near language and minimizing technical concepts, which indicate a communicative quality in the formulations that make them clinically sound.

Trial registration

linicalTrials.gov Identifier: NCT00423462. 10.1007/s00432-018-2781-7., January 18, 2007.

How do adolescents with depression experience improvement in psychodynamic psychotherapy? A qualitative study

BACKGROUND

There is emerging evidence for the effectiveness of psychodynamic psychotherapy for depressive disorders. However, we know less of how this relation-focused therapy mode is experienced and what the patients themselves identify as helpful. Hence, the purpose of this study is to explore adolescents' experiences of factors promoting improvement in psychodynamic therapy.

METHODS

Eight female patients participating in a Norwegian study on psychodynamic therapy, the First Experimental Study of Transference Work - In Teenagers (FEST-IT), were included. The participants were offered a total number of 28 sessions. Semi-structured qualitative interviews about experiences with therapy were then conducted and analysed with systematic text condensation and hermeneutic interpretation.

RESULTS

The analysis revealed four main themes. 'Exploring oneself' comprises autonomy and acknowledgment, openness, insight and acceptance of oneself. 'Therapist relation and characteristics' includes confidence and trust in and support from the therapist as well as having a trustworthy and experienced therapist. 'Focusing on everyday life' includes learning and practical orientation. 'Time factors' refers to duration and frequency.

CONCLUSIONS

Together with a supportive and listening therapist, the adolescents improve by exploring themselves within the frames of a time-limited treatment period. Improvement seems to be experienced through better relations to oneself and to others and by finding one's place in the family, or at school. Adolescents value problem solving and help with concrete challenges. Hence, therapy should be tailored to the needs of adolescents with depression and incorporate the challenges they face in their everyday life.

TRIAL REGISTRATION

ClinicalTrials.gov . Id: NCT01531101. Date of registry: 8 February 2012, retrospectively registered.

Recovery and Nonrecovery After Psychotherapy With Transference Interpretation: Two Case Studies

The First Experimental Study of Transference Interpretation (FEST), conducted in Norway, is a dismantling, randomized clinical trial of the long-term effects of transference interpretation (TI). This article examines two case studies of women with poor quality of object relations (QOR), one who was rated as recovered after psychotherapy and one who was rated as not recovered. Both received TI. In general, women with poor QOR needed TI to recover, but some members of this group did not recover, even with TI. The therapist's negative countertransference and tendency to use controlling interventions was more pronounced with the poor-outcome patient. In addition, the poor-outcome patient had three subthreshold personality disorders in addition to obsessive-compulsive personality disorder. In childhood she had experienced substantial emotional abuse and some physical abuse. She was less motivated before therapy and more evasive during therapy than the good-outcome patient. The good-outcome patient also had obsessive-compulsive personality disorder but no subthreshold personality disorders, and her childhood home environment was more secure, although her parents were distant. She was more open to the therapist than the poor-outcome patient was. This article illustrates that different people require different techniques even though they belong to the same group (low QOR) that, in the FEST study, did well with TI.

Assessment of dynamic change in psychotherapy with asdolescents

BACKGROUND

Diagnostic interviews and questionnaires are commonly used in the assessment of adolescents referred to child and adolescent mental health services. Many of these rating scales are constructed for adults and focus on symptoms related to diagnosis. Psychodynamic Functioning Scales (PFS) focus on relational aspects and how the patients handle affects and solve problems, rather than manifest symptoms. As these aspects are considered important for mental health, the PFS were developed to assess change in adults, consistent with the relational and intrapsychic concepts of dynamic psychotherapy. The scales describe internal predispositions and psychological resources that can be mobilized to achieve adaptive functioning and life satisfaction. PFS consist of six subscales; the relational subscales Family, Friends and Romantic/Sexual relationships and the dynamic subscales Tolerance for Affects, Insight and Problem-solving Capacity. PFS has been used for the first time as a measure of change in adolescent psychotherapy. This study examines the reliability of PFS when used to assess adolescents' level of relational functioning, affective tolerance, insight, and problem-solving capacities.

METHODS

Outpatient adolescents 16-18 years old with a major depressive disorder were included in the First Experimental Study of Transference work in Teenagers (FEST-IT). They were evaluated before and after time-limited psychodynamic psychotherapy with an audio-recorded semi-structured psychodynamic interview. Based on the audio-tapes, raters with different clinical background rated all the available interviews at pre-treatment (n = 66) and post-treatment (n = 30) using PFS. Interrater reliability, the reliability of change ratings and the discriminability from general symptoms were calculated in SPSS.

RESULTS

The interrater reliability was on average good on the relational subscales and fair to good on the dynamic subscales. All pre-post changes were significant, and the analyses indicated discriminability from general symptoms. The interrater reliability on PFS (mean) and Global Assessment of Functioning were good to excellent.

CONCLUSION

Based on the interrater reliability in our study, PFS could be recommended in psychotherapy with adolescents by experienced clinicians without extensive training. From the post-treatment evaluations available, the scales seem to capture statistically and clinically significant changes. However, the interrater reliability on dynamic subscales indicates that subscales of PFS might be considered revised or adjusted for adolescents.Trial registration First Experimental Study of Transference-Work-In Teenagers (2011/1424 FEST-IT). ClinicalTrials.gov Identifier: NCT01531101.

Relational interventions in psychotherapy: development of a therapy process rating scale

BACKGROUND

In psychodynamic psychotherapy, one of the therapists' techniques is to intervene on and encourage exploration of the patients' relationships with other people. The impact of these interventions and the response from the patient are probably dependent on certain characteristics of the context in which the interventions are given and the interventions themselves. To identify and analyze in-session effects of therapists' techniques, process scales are used. The aim of the present study was to develop a simple, not resource consuming rating tool for in-session process to be used when therapists' interventions focus on the patients' relationships outside therapy.

METHODS

The present study describes the development and use of a therapy process rating scale, the Relational Work Scale (RWS). The scale was constructed to identify, categorize and explore therapist interventions that focus on the patient's relationships to family, friends, and colleges Relational Interventions and explore the impact on the in-session process. RWS was developed with sub scales rating timing, content, and valence of the relational interventions, as well as response from the patient. For the inter-rater reliability analyzes, transcribed segments (10 min) from 20 different patients were scored with RWS by two independent raters. Two clinical vignettes of relational work are included in the paper as examples of how to rate transcripts from therapy sessions with RWS.

RESULTS

The inter-rater agreement on the RWS items was good to excellent.

CONCLUSION

Relational Work Scale might be a potentially useful tool to identify relational interventions as well as explore the interaction of timing, category, and valence of relational work in psychotherapies. The therapist's interventions on the patient's relationships with people outside therapy and the following patient-therapist interaction might be explored.

TRIAL REGISTRATION

First Experimental Study of Transference-interpretations (FEST307/95) REGISTRATION NUMBER: ClinicalTrials.gov Identifier: NCT00423462 .

Personality disorders and Axis I comorbidity in adolescent outpatients with ADHD

BACKGROUND

Attention deficit hyperactivity disorder (ADHD) is a lifelong condition which carries great cost to society and has an extensive comorbidity. It has been assumed that ADHD is 2 to 5 times more frequent in boys than in girls. Several studies have suggested developmental trajectories that link ADHD and certain personality disorders. The present study investigated the prevalence of ADHD, common Axis I disorders, and their gender differences in a sample of adolescent outpatients. We also wanted to investigate the relationship between ADHD and personality disorders (PDs), as well as how this relationship was influenced by adjustment for Axis I disorders, age and gender.

METHODS

We used a sample consisting of 153 adolescents, aged 14 to 17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. ADHD, conduct disorder (CD) and other Axis I conditions were assessed using the Mini International Neuropsychiatric Interview (MINI). PDs were assessed using the Structured Interview for DSM-IV Personality (SIDP-IV).

RESULTS

13.7 % of the adolescents met diagnostic criteria for ADHD, with no significant gender difference. 21.6 % had at least one PD, 17.6 % had CD, and 4.6 % had both ADHD and a PD. There was a significantly elevated number of PD symptoms in adolescents with an ADHD diagnosis (p = 0.001), and this relationship was not significantly weakened when adjusted for age, gender and other Axis I disorders (p = 0.026). Antisocial (χ (2) = 21.18, p = 0.002) and borderline (χ (2) = 6.15, p = 0.042) PDs were significantly more frequent in girls than in boys with ADHD.

CONCLUSIONS

We found no significant gender difference in the prevalence of ADHD in a sample of adolescents referred to a general mental health outpatient clinic. Adolescent girls with ADHD had more PDs than boys, with antisocial and borderline PDs significantly different. The present study suggests that ADHD in girls in a general outpatient population may be more prevalent than previously assumed. It especially highlights the importance of assessing antisocial and borderline personality pathology in adolescent girls presenting with ADHD symptoms.

Substance abuse and personality disorder comorbidity in adolescent outpatients: are girls more severely ill than boys?

BACKGROUND

Substance use disorders (SUDs) constitute a major health problem and are associated with an extensive psychiatric comorbidity. Personality disorders (PDs) and SUDs commonly co-occur. Comorbid PD is characterized by more severe addiction problems and by an unfavorable clinical outcome. The present study investigated the prevalence of SUDs, PDs and common Axis I disorders in a sample of adolescent outpatients. We also investigated the association between PDs and SUDs, and how this association was influenced by adjustment for other Axis I disorders, age and gender.

METHODS

The sample consisted of 153 adolescents, aged 14-17 years, who were referred to a non-specialized mental health outpatient clinic with a defined catchment area. SUDs and other Axis I conditions were assessed using the mini international neuropsychiatric interview. PDs were assessed using the structured interview for DSM-IV personality.

RESULTS

18.3 % of the adolescents screened positive for a SUD, with no significant gender difference. There was a highly significant association between number of PD symptoms and having one or more SUDs; this relationship was practically unchanged by adjustment for gender, age and presence of Axis I disorders. For boys, no significant associations between SUDs and specific PDs, conduct disorder (CD) or attention deficit hyperactivity disorder (ADHD) were found. For girls, there were significant associations between SUD and BPD, negativistic PD, more than one PD, CD and ADHD.

CONCLUSIONS

We found no significant gender difference in the prevalence of SUD in a sample of adolescents referred to a general mental health outpatient clinic. The association between number of PD symptoms and having one or more SUDs was practically unchanged by adjustment for gender, age and presence of one or more Axis I disorders, which suggested that having an increased number of PD symptoms in itself may constitute a risk factor for developing SUDs in adolescence. The association in girls between SUDs and PDs, CD and ADHD raises the question if adolescent girls suffering from these conditions may be especially at risk for developing SUDs. In clinical settings, they should therefore be monitored with particular diligence with regard to their use of psychoactive substances. Trial registration The regional committee for medical research ethics for eastern Norway approved the study protocol in October 2004 (REK: 11395). Address correspondence and reprint requests to: Hans Ole Korsgaard, The Nic Waal Institute, Lovisenberg Diakonale Hospital, P.O. Box 2970 Nydalen, N-0440 Oslo, Norway; E-mail hansole.korsgaard@tele5.no.

The Effectiveness of Short- and Long-Term Psychodynamic Group Psychotherapy on Self-Concept: Three Years Follow-Up of a Randomized Clinical Trial

We compared differences in self-concept change across three years after short-(STG) and long-term (LTG) psychodynamic group psychotherapy, in a mixed sample of outpatients. Self-concept was assessed at baseline and three years later, using the Structural Analysis of Social Behavior Questionnaire. Vector scores Affiliation and Autonomy were primary, and the eight cluster scores-self-free, self-affirm, self-love, self-protect, self-control, self-blame, self-attack, and self-neglect-were secondary outcome measures. Within group univariate analyses showed change in LTG across three years on the vector scores Affiliation and Autonomy, while STG only changed on Autonomy. Comparisons between STG and LTG demonstrated a significantly larger improvement in Affiliation in LTG than in STG. This difference was explained by a higher improvement in the cluster scores of self-blame, self-attack, and self-neglect in LTG, dimensions that weight negatively on the Affiliation score. Patients with more serious self-neglect and harsh, punitive self-attack/self-blame may profit more in long-term than in short-term groups.

Manual for Transference Work Scale; a micro-analytical tool for therapy process analyses

BACKGROUND

The present paper is a manual for the Transference Work Scale (TWS). The inter-rater agreement on the 26 TWS items was good to excellent and previously published. TWS is a therapy process rating scale focusing on Transference Work (TW) (i.e. analysis of the patient-therapist relationship). TW is considered a core active ingredient in dynamic psychotherapy. Adequate process scales are needed to identify and analyze in-session effects of therapist techniques in psychodynamic psychotherapy and empirically establish their links to outcome. TWS was constructed to identify and categorize relational (transference) interventions, and explore the in-session impact of analysis of the patient-therapist relationship (transference work). TWS has sub scales that rate timing, content, and valence of the transference interventions, as well as response from the patient.

METHODS

Descriptions and elaborations of the items in TWS are provided. Clinical examples of transference work from the First Experimental Study of Transference Interpretations (FEST) are included and followed by examples of how to rate transcripts from therapy sessions with TWS.

RESULTS

The present manual describes in detail the rating procedure when using Transference Work Scale. Ratings are illustrated with clinical examples from FEST.

CONCLUSION

TWS might be a potentially useful tool to explore the interaction of timing, category, and valence of transference work in predicting in-session patient response as well as treatment outcome. TWS might prove especially suitable for intensive case studies combining quantitative and narrative data.

TRIAL REGISTRY NAME

First Experimental Study of Transference-interpretations (FEST307/95).

REGISTRATION NUMBER

ClinicalTrials.gov Identifier: NCT00423462. URL: http://clinicaltrials.gov/ct2/show/NCT00423462?term=FEST&rank=2.

Transference interventions and the process between therapist and patient

Interpreting the transference has been considered a core ingredient in psychodynamic psychotherapy. The effects of analyzing the transference are probably dependent on certain characteristics of the interventions themselves and the context in which transference interventions are given. The present study describes the development and use of a therapy process rating scale (Transference Work Scale; TWS) constructed to identify, categorize, and explore work with the transference. TWS has subscales that rate timing, content, and valence of the transference interventions, as well as response from the patient. Transcribed segments (10 min) from 51 different patients were scored with TWS by 2 independent raters. The interrater agreement on the TWS items was good to excellent. Clinical examples of transference work were also rated using the Structural Analysis of Social Behavior (SASB). TWS and SASB supplement each other. TWS might be a potentially useful tool to explore the interaction of timing, category, and valence of transference work in predicting in-session patient response as well as treatment outcome.