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.
dynamic psychotherapy; effectiveness; adherence; depression
Policymakers are investing significant resources in large-scale training and implementation programs for evidence-based psychological treatments (EBPTs) in public mental health systems. However, relatively little research has been conducted to understand factors that may influence the success of efforts to implement EBPTs for adult consumers of mental health services. In a formative investigation during the development of a program to implement cognitive therapy (CT) in a community mental health system, we surveyed and interviewed clinicians and clinical administrators to identify potential influences on CT implementation within their agencies. Four primary themes were identified. Two related to attitudes towards CT: (1) ability to address client needs and issues that are perceived as most central to their presenting problems, and (2) reluctance to fully implement CT. Two themes were relevant to context: (1) agency-level barriers, specifically workload and productivity concerns and reactions to change, and (2) agency-level facilitators, specifically, treatment planning requirements and openness to training. These findings provide information that can be used to develop strategies to facilitate the implementation of CT interventions for clients being treated in public-sector settings.
Evidence-based psychosocial treatments; Cognitive therapy; Dissemination and implementation
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.
statistical methodology; generalizability theory; adherence; competence
The Clinical Trials Network (CTN) represents a major initiative intended to bridge the gap between research and practice in substance abuse treatment by implementing a range of studies evaluating behavioral, pharmacologic, and combined treatments in community-based drug abuse treatment programs across the country. This article describes the development of CTN protocols evaluating the effectiveness of Motivational Enhancement Therapy and Motivational Interviewing. Design, training, and implementation challenges associated with conducting a clinical trial of brief behavioral treatments in community programs are discussed. Issues requiring attention included the diversity in treatments offered across sites, heterogeneity in the study sample, and training of clinicians drawn from the staff of community programs to deliver the study treatments.
Substance abuse treatment; Randomized clinical trials; Behavioral therapies; Motivational interviewing
The purpose of the current study is to examine the effects of feedback provided to counselors on the outcomes of patients treated at community-based substance abuse treatment programs. A version of the Outcome Questionnaire (OQ-45), adapted to include drug and alcohol use, was administered to patients (N=304) in three substance abuse treatment clinics. Phase I of the study consisted only of administration of the assessment instruments. Phase II consisted of providing feedback reports to counselors based on the adapted OQ-45 at every treatment session up to session 12. Patients who were found to not be progressing at an expectable rate (i.e., “off-track”) were administered a questionnaire that was used as a second feedback report for counselors. For off-track patients, feedback compared to no feedback led to significant linear reductions in alcohol use throughout treatment and also in OQ-45 total scores and drug use from the point of the second feedback instrument to session 12. The effect for improving mental health functioning was evident at only one of the three clinics. These results suggest that a feedback system adapted to the treatment of substance use problems is a promising approach that should be tested in a larger randomized trial.
Substance abuse; feedback; Outcome Questionnaire-45; quality improvement
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.
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 vs. non-Hispanic White), gender, and race by gender on group behavior. Additional analyses examined race, gender, and group behavior, and interactions among these variables in predicting monthly cocaine use.
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.
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.
cocaine dependence; group drug counseling; race; gender; group process
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.
Generalized Anxiety Disorder; Cognitive-Behavioral Therapy; venlafaxine; combined treatment
Despite the mounting evidence of the benefits of cognitive therapy for depression and suicidal behaviors over usual care, like other evidence-based psychosocial treatments (EBTs), it has not been widely adopted in clinical practice. Studies have shown that training followed by intensive consultation is needed to prepare providers to an appropriate level of competency in complex, multisession treatment packages such as cognitive therapy. Given the critical role of training in EBT implementation, more information on factors associated with the success and challenges of training programs is needed. To identify potential reasons for variation in training outcomes across ten agencies in a large, urban community mental health system, we explored program evaluation data and examined provider, consultant, and training program administrator perspectives through follow-up interviews. Perceptions of cognitive therapy, contextual factors, and reactions to feedback on audio recordings emerged as broad categories of themes identified from interviews. These factors may interact and impact clinician efforts to learn cognitive therapy and deliver it skillfully in their practice. The findings highlight experiences and stakeholder perspectives that may contribute to more or less successful training outcomes.
We explored patient, therapist, and program variability in the alliance in relation to drug and alcohol use during treatment, and whether alliance mediates the relation of program characteristics to drug/alcohol use. Data (N=1613 patients) were drawn from a randomized clinical trial investigating the efficacy of an intervention that provided alliance and outcome feedback to 112 counselors across 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Program characteristics were measured using the Organization Readiness for Change scale. Using multilevel modeling, we found that alliance was related to both drug and alcohol use during the past week at the patient and program levels of analysis, but not the counselor level. Several program characteristics were related to average drug and alcohol use. The alliance was not a mediator of these relationships. Program variability in the alliance is important to the alliance-outcome relationship in the treatment of substance abuse. Better outcomes can be achieved by improving both organizational functioning and the patient-counselor alliance.
Substance Abuse; Alliance; Program; Counselor
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.
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.
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 four 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 to 9 explaining 14.7% of outcome variance.
Adequately assessing the alliance using multiple patients per therapist and at least 4 treatment sessions is crucial to fully understanding the size of the alliance-outcome relationship.
alliance; outcome; generalizability theory; therapist
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.
group psychotherapy; process research; alliance; substance abuse
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.
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.
This paper was developed through the use of qualitative interviews and discussion with a variety of IP-RISP partners.
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.
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.
Mental health; psychiatry and psychology; depression; research infrastructure; community health partnerships
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.
Depression; Psychotherapy; Racial disparities; Community mental health system
The objective of this study was to determine if there is evidence for a causative link between sex under the influence of drugs or alcohol and risky sex for men in substance abuse treatment. Men in treatment participating in a multi-site HIV prevention protocol who reported on baseline, 3 or 6-month computerized assessments the details of their most recent sexual events, and who reported having sexual events under the influence and not under the influence, and who reported most recent events that did and did not include condom use served as participants (n=37). Safe sex was not significantly more likely to happen when participants were under the influence of drugs or alcohol during their most recent sexual event (48.3%) than when they were not under the influence (49%, p=.82). In this high-risk in treatment sample, a causative link between sex under the influence of drugs or alcohol and sexual risk behavior was not supported.
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.
The association between cocaine use and depression has been frequently observed. However, less is known about the significance of depression in the treatment of cocaine use disorders. This study examined possible interrelations between drug use and depression severity among cocaine-dependent patients in psychosocial treatments for cocaine dependence.
Monthly assessed drug use and depression severity scores of N = 487 patients during 6-month psychosocial treatments for cocaine dependence were analyzed using hybrid latent growth models.
Results indicated a moderate but statistically significant (z = 3.13, p < .01) influence of depression severity on increased drug use in the upcoming month, whereas drug use did not affect future depression severity.
Findings suggest that depression symptoms are an important predictor of drug use outcomes during psychosocial treatments for cocaine dependence and, hence, underline the importance of adequately addressing depression symptoms to improve treatment outcomes.
Cocaine Dependence; Depression; Psychosocial Treatment; Interrelations; Hybrid Latent Growth Models
Cognitive therapy (CT) has been shown to be efficacious in the treatment of depression in numerous randomized controlled trials (RCTs). However, little evidence is available that speaks to the effectiveness of this treatment under routine clinical conditions.
This paper examines outcomes of depressed individuals seeking cognitive therapy at an outpatient clinic (N = 217, Center for Cognitive Therapy; CCT). Outcomes were then compared to those of participants in a large NIMH-funded RCT of cognitive therapy and medications as treatments for depression.
The CCT is shown to be a clinically representative setting, and 61% of participants experienced reliable change in symptoms over the course of treatment; of those, 45% (36% of the total sample) met criteria for recovery by the end of treatment. Participants at CCT had similar outcomes to participants treated in the RCT, but there was some evidence that those with more severe symptoms at intake demonstrated greater improvement in the RCT than their counterparts at CCT.
The CCT may not be representative of all outpatient settings, and the structure of treatment there was considerably different from that in the RCT. Treatment fidelity was not assessed at CCT.
Depressed individuals treated with cognitive therapy in a routine clinical care setting showed a significant improvement in symptoms. When compared with outcomes evidenced in RCTs, there was little evidence of superior outcomes in either setting. However, for more severe participants, outcomes were found to be superior when treatment was delivered within an RCT than in an outpatient setting. Clinicians treating such patients in non-research settings may thus benefit from making modifications to treatment protocols to more closely resemble research settings.
Cognitive therapy; depression; effectiveness; randomized controlled trials
The purpose of this study is to determine the incidence of depression, anxiety and suicidality in patients with psoriasis compared to the general population.
A population-based cohort study using data collected as part of patient's electronic medical record from 1987 to 2002.
General Practice Research Database
Up to 5 controls without psoriasis were selected from the same practices and cohort entry dates as psoriasis patients.
Main Outcome Measures
Clinical diagnosis of depression, anxiety and suicidality were compared among 146,042 mild psoriasis, 3,956 severe psoriasis, and 766,950 control patients.
The adjusted hazard ratios for receiving a diagnosis of depression, anxiety and suicidality in patients with psoriasis compared to controls, were 1.39 (95% CI 1.37, 1.41), 1.31 (95% CI 1.29, 1.34) and 1.44 (95% CI 1.32, 1.57), respectively. The adjusted relative risk of depression was higher in severe (HR 1.72, 95% CI 1.57, 1.88), compared to mild psoriasis (HR 1.38, 95% CI 1.35, 1.40). Younger psoriasis patients had elevated relative risks of outcomes compared to older psoriasis patients.
Psoriasis patients have an increased risk of depression, anxiety, and suicidality. We estimate that in the UK, in excess of 10,400 diagnoses of depression, 7,100 diagnoses of anxiety, and 350 diagnoses of suicidality are attributable to psoriasis annually. It is important for clinicians to evaluate patients with psoriasis for these conditions in order to improve outcomes. Future investigation should determine the mechanisms by which psoriasis is associated with psychiatric outcomes as well as approaches for prevention.
The purpose of the current investigation was to examine the interpersonal accuracy of interventions in cognitive and interpersonal therapy as a predictor of the outcome of treatment for patients with major depressive disorder.
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 NIMH Treatment of Depression Collaborative Research Program. Interpersonal accuracy of interventions was assessed by first identifying core conflictual relationship themes for each patient and then having judges rate therapist intervention statements for the extent to which each statement addressed each component of the patient-specific interpersonal theme.
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 accuracy by treatment group interactions 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.
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.
interpersonal therapy; cognitive therapy; depression; therapeutic process; outcome
The effectiveness of the Real Men Are Safe (REMAS) HIV prevention intervention was examined as a function of treatment program modality. REMAS was associated with significantly larger decreases in unprotected sexual occasions than an HIV Education control condition in both treatment modalities. REMAS had superior effectiveness for reducing unprotected sexual occasions in the psychosocial outpatient compared to methadone. At 6-month follow up, the adjusted mean change for REMAS completers in psychosocial outpatient (M=6.4, d=0.38) was greater than for REMAS completers in methadone programs (M=2.3, d=0.25). Reasons for why REMAS appears to be especially effective in psychosocial outpatient programs are explored.
HIV prevention; substance abuse treatment modality; behavioral intervention; sexual risk reduction
We report here on the results of a randomized, controlled trial evaluating the efficacy of a semi-automated performance improvement system (“Patient Feedback”) that enables real-time monitoring of patient outcomes in outpatient substance abuse treatment clinics. The study involved 118 clinicians working at 20 community-based outpatient substance abuse treatment clinics in the northeast United States. Ten clinics received 12 weeks of the Patient Feedback performance improvement intervention and ten clinics received no intervention during the 12 weeks. Over 1500 patients provided anonymous ratings of therapeutic alliance, treatment satisfaction, and drug/alcohol use. There was no evidence of an intervention effect on the primary drug and alcohol use scales. There was also no evidence of an intervention effect on secondary measures of therapeutic alliance. Clinician-rated measures of organizational functioning and job satisfaction also showed no intervention effect. Possible insights from these findings, and alternative methods of utilizing feedback reports to enhance clinical outcomes are proposed.
performance improvement; substance abuse; feedback; alliance; treatment satisfaction
The NIDA Collaborative Cocaine Treatment Study yielded different efficacies for different psychosocial treatments for cocaine dependence. However, substantial heterogeneity of patient outcomes was evident. Longitudinal data analysis techniques can be helpful in examining differential effects of psychosocial interventions on specific subpopulations of patients.
Overall drug and cocaine use of 346 patients diagnosed with DSM-IV cocaine dependence and treated with one of four psychosocial interventions were assessed monthly during 6-month treatment. Growth mixture models were used to identify patient subgroups based on typical patterns of change in substance use during treatment and to evaluate differential treatment effects within these subgroups.
Three patient subgroups following different change patterns in cocaine and overall drug use were identified irrespective of the treatment type: (a) those with moderate baseline severity of drug use and very rapid reduction of drug use during treatment, (b) those with moderate baseline severity of drug use and moderate reduction of drug use during treatment, and (c) those with severe levels of baseline drug use with moderate reduction of drug use during treatment. Patient baseline characteristics enabled discrimination between these subgroups. Individual drug counseling was most efficacious among those patients with moderate baseline severity and moderate treatment response. There were no differential treatment effects in the two other patient subgroups.
The population of treatment-seeking cocaine dependent individuals is heterogeneous. Research on patient subgroups with different change patterns revealed its potential to enable classifications of patients that indicate which treatment is most effective for which type of patient.
Cocaine Dependence; Psychosocial Treatment; Differential Treatment Effects; Patterns of Change; Growth Mixture Modeling
In a previous report, the effectiveness of the Real Men Are Safe (REMAS) intervention in reducing the number of unprotected sexual occasions among male drug abuse treatment patients was demonstrated. A secondary aim of REMAS was to reduce the frequency with which men engage in sex under the influence (SUI) of drugs or alcohol.
Men in methadone maintenance (n=173) or outpatient psychosocial treatment (n=104) completed assessments at baseline, 3- and 6-months post intervention. Participants were randomly assigned to attend either REMAS (five sessions containing information, motivational exercises and skills training, including one session specifically targeting reducing SUI), or HIV education (HIV-Ed; one session containing HIV prevention information). SUI during the most recent sexual event served as the primary outcome in a repeated measures logistic regression model.
Men assigned to the REMAS condition reporting SUI at the most recent sexual event decreased from 36.8% at baseline to 25.7% at 3 months compared to a increase from 36.9% to 38.3% in the HIV-Ed condition (tintervention=−2.16, p=.032). No difference between the treatment groups was evident at 6-month follow-up. At each assessment time point, sex with a casual partner versus a regular partner, and being in methadone maintenance versus psychosocial outpatient treatment, were associated with engaging in SUI.
Overall a motivational and skills training HIV prevention intervention designed for men was associated with greater reduction in SUI than standard HIV education at the 3-month follow-up.
HIV prevention; substance abuse treatment; behavioral intervention
Data from a community-based multicenter study of Motivational Enhancement Therapy (MET) and counseling as usual (CAU) for outpatient substance users were used to examine questions about the role of the alliance in MET and CAU. Most (94%) of the sample met diagnostic criteria for abuse or dependence (primarily alcohol and/or cocaine). Sixteen therapists for CAU and 14 for MET participated. No reliable differences in patient ratings (n = 319) on the Helping Alliance Questionnaire-II (HAq-II) were evident for MET compared to CAU, but significant differences between therapists were found within each condition in mean patient-rated HAq-II scores. Overall, average levels of alliance were high. The between-therapist component of the alliance, but not the within-therapist component, was significantly associated with self-reported days of primary substance use during the follow-up period from Weeks 4 to 16 (Cohen's d = 0 .39; n = 257). Therapists with either low or very high alliances had relatively poorer average outcomes (quadratic effect: d = 0.44). For therapists in both MET and CAU, increased use of MET fundamental techniques and MET advanced techniques during treatment sessions were associated with higher levels of alliance. Implications of the findings for conceptualization of the alliance and for training of therapists are discussed.
alliance; motivational enhancement; motivational interviewing; substance use
To discuss psychotherapies for depression and anxiety that have emerged in recent years and to evaluate their current level of empirical support.
An electronic and a manual literature search of psychotherapies for mood and anxiety disorders were conducted.
Five new therapies for mood disorders and 3 interventions for posttraumatic stress disorder with co-occurring substance abuse met criteria for inclusion in this review. Fewer psychotherapies have been developed for other anxiety disorders. Although research for some of the psychotherapies has demonstrated superiority to usual care, none have firmly established efficacy or specific benefits over other established psychotherapies.
A plurality of the new psychotherapies introduced and established in the past 5 years have been different assimilations of previously established cognitive-behavioural, interpersonal, or psychodynamic models. While initial results are promising for some, more rigorous efficacy trials and replications are necessary before conclusions can be drawn regarding their relative benefits.
new psychotherapies; depression; anxiety