Antidepressant medication (ADM) is efficacious in the treatment of depression, but not all patients achieve remission and fewer still achieve recovery with ADM alone.
To determine the effects of combining cognitive therapy (CT) with ADM vs ADM alone on remission and recovery in major depressive disorder (MDD).
DESIGN, SETTING, AND PARTICIPANTS
A total of 452 adult outpatients with chronic or recurrent MDD participated in a trial conducted in research clinics at 3 university medical centers in the United States. The patients were randomly assigned to ADM treatment alone or CT combined with ADM treatment. Treatment was continued for up to 42 months until recovery was achieved.
Antidepressant medication with or without CT.
MAIN OUTCOMES AND MEASURES
Blind evaluations of recovery with a modified version of the 17-item Hamilton Rating Scale for Depression and the Longitudinal Interval Follow-up Evaluation.
Combined treatment enhanced the rate of recovery vs treatment with ADM alone (72.6% vs 62.5%; t451 = 2.45; P = .01; hazard ratio [HR], 1.33; 95% CI, 1.06–1.68; number needed to treat [NNT], 10; 95% CI, 5–72). This effect was conditioned on interactions with severity (t451 = 1.97; P = .05; NNT, 5) and chronicity (χ2 = 7.46; P = .02; NNT, 6) such that the advantage for combined treatment was limited to patients with severe, nonchronic MDD (81.3% vs 51.7%; n = 146; t145 = 3.96; P = .001; HR, 2.34; 95% CI, 1.54–3.57; NNT, 3; 95% CI, 2–5). Fewer patients dropped out of combined treatment vs ADM treatment alone (18.9% vs 26.8%; t451 = −2.04; P = .04; HR, 0.66; 95% CI, 0.45–0.98). Remission rates did not differ significantly either as a main effect of treatment or as an interaction with severity or chronicity. Patients with comorbid Axis II disorders took longer to recover than did patients without comorbid Axis II disorders regardless of the condition (P = .01). Patients who received combined treatment reported fewer serious adverse events than did patients who received ADMs alone (49 vs 71; P = .02), largely because they experienced less time in an MDD episode.
CONCLUSIONS AND RELEVANCE
Cognitive therapy combined with ADM treatment enhances the rates of recovery from MDD relative to ADMs alone, with the effect limited to patients with severe, nonchronic depression.
clinicaltrials.gov Identifier: NCT00057577
There is substantial evidence that cognitive therapy is an effective intervention for the treatment of major depressive disorder. Although dynamic psychotherapies have been widely studied and are commonly practiced worldwide, there are few randomized comparisons of cognitive therapy and dynamic therapy for major depressive disorder.
We are completing data collection on a randomized non-inferiority trial comparing the effectiveness of cognitive therapy and short-term dynamic psychotherapy in the treatment of major depressive disorder in the community mental health setting. Therapists employed in the community setting have been recruited for training in either short-term dynamic psychotherapy or cognitive therapy. Patients seeking services at the community site who meet criteria for major depressive disorder based on a blind independent diagnostic interview are randomized to 16 sessions of treatment. All patients are assessed at baseline and months 1, 2, 4, and 5 utilizing a comprehensive battery.
This study adds to the growing literature evaluating the effectiveness of short-term dynamic psychotherapy for specific diagnostic groups. These results will have implications for the dissemination of effective interventions for major depressive disorder in community mental health settings.
This trial is registered at ClinicalTrials.gov, a service of the United States National Institute of Health. NIH Identifier: NCT01207271. Registered 21 September 2010.
Dynamic therapy; Cognitive therapy; Non-inferiority trial; Community mental health
Enhanced affiliation among members is thought to provide increased support for women in single-gender compared with mixed-gender group therapy for substance use disorders (SUDs) and to provide a potential mechanism of action for its efficacy. In a Stage I trial of single-gender versus mixed-gender group therapy for SUDs we examined affiliative statements made by members in two group treatments, single-gender Women's Recovery Group (WRG) and mixed-gender Group Drug Counseling (GDC). Twenty-eight WRG and 17 GDC group therapy tapes were coded and compared for five types of affiliative statements. Three types of affiliative statements (agreement, supportive, and completing a thought) were highly correlated and were more frequent in WRG than GDC (D=0.882, p=0.27). In GDC, women were more likely to provide an affiliative statement to a male group member than any other combination of directionality (p<0.01). Compared with mixed-gender, single-gender group therapy for SUDs may enhance support through greater frequency of affiliative statements.
Treatment for women; Women-only programs; Mixed-gender programs; Treatment outcomes; Group Therapy
Cognitive therapy and antidepressant medications are effective treatments for depression, but little is known about their relative efficacy in reducing individual depressive symptoms. Using data from a recent clinical trial comparing cognitive therapy, antidepressant medication, and placebo in the treatment of moderate-to-severe depression, we examined whether there was a relative advantage of any treatment in reducing the severity of specific depressive symptom clusters. The sample consisted of 231 depressed outpatients randomly assigned to: cognitive therapy for 16 weeks (n=58); paroxetine treatment for 16 weeks (n=116); or pill placebo for 8 weeks (n=57). Differential change in five subsets of depressive symptoms was examined: mood, cognitive/suicide, anxiety, typical-vegetative, and atypical-vegetative symptoms. Medication led to a greater reduction in cognitive/suicide symptoms relative to placebo by 4 weeks, and both active treatments reduced these symptoms more than did placebo by 8 weeks. Cognitive therapy reduced the atypical-vegetative symptoms more than placebo by 8 weeks and more than medications throughout the trial. These findings suggest that medications and cognitive therapy led to different patterns of response to specific symptoms of depression and that the general efficacy of these two well-validated treatments may be driven in large part by changes in cognitive or atypical-vegetative symptoms.
Cognitive Therapy; Antidepressant Medication; Paroxetine; Symptom Reduction; Treatment for Depression
Rationale: Acute respiratory distress syndrome (ARDS) behaves as a complex genetic trait, yet knowledge of genetic susceptibility factors remains incomplete.
Objectives: To identify genetic risk variants for ARDS using large scale genotyping.
Methods: A multistage genetic association study was conducted of three critically ill populations phenotyped for ARDS. Stage I, a trauma cohort study (n = 224), was genotyped with a 50K gene-centric single-nucleotide polymorphism (SNP) array. We tested SNPs associated with ARDS at P < 5 × 10−4 for replication in stage II, a trauma case–control population (n = 778). SNPs replicating their association in stage II (P < 0.005) were tested in a stage III nested case–control population of mixed subjects in the intensive care unit (n = 2,063). Logistic regression was used to adjust for potential clinical confounders. We performed ELISA to test for an association between ARDS-associated genotype and plasma protein levels.
Measurements and Main Results: A total of 12 SNPs met the stage I threshold for an association with ARDS. rs315952 in the IL1RN gene encoding IL-1 receptor antagonist (IL1RA) replicated its association with reduced ARDS risk in stages II (P < 0.004) and III (P < 0.02), and was robust to clinical adjustment (combined odds ratio = 0.81; P = 4.2 × 10−5). Plasma IL1RA level was associated with rs315952C in a subset of critically ill subjects. The effect of rs315952 was independent from the tandem repeat variant in IL1RN.
Conclusions: The IL1RN SNP rs315952C is associated with decreased risk of ARDS in three populations with heterogeneous ARDS risk factors, and with increased plasma IL1RA response. IL1RA may attenuate ARDS risk.
functional genetic polymorphism; acute lung injury; acute respiratory distress syndrome; IL-1 receptor antagonist; replication
Adolescent offspring of depressed parents are at high risk for experiencing depressive disorders themselves.
To determine whether the positive effects of a group cognitive-behavioral prevention (CBP) program extended to longer term (multi-year) follow-up.
Design, Setting, and Participants
A four-site, randomized, controlled trial enrolled 316 adolescent (ages 13-17 years) offspring of parents with current and/or prior depressive disorders; adolescents had histories of depression, current elevated depressive symptoms, or both.
The CBP program consisted of 8 weekly, 90-minute group sessions followed by 6 monthly continuation sessions. Adolescents were randomly assigned to either the CBP program or usual care (UC).
Main Outcome Measure
The primary outcome was a probable or definite episode of depression (Depression Symptom Rating score ≥; 4) for at least 2 weeks through the month 33 follow-up evaluation.
Over the 33-month follow-up period, youths in the CBP condition had significantly fewer onsets of depressive episodes compared to those in UC. Parental depression at baseline significantly moderated the intervention effect. When parents were not depressed at intake, CBP was superior to UC (NNT ratio=6), whereas when parents were actively depressed at baseline, average onset rates between CBP and UC were not significantly different. A three-way interaction among intervention, baseline parental depression, and site indicated that the impact of parental depression on intervention effectiveness varied across sites.
The CBP program showed significant sustained effects compared to usual care in preventing the onset of depressive episodes in at-risk youth over a nearly three-year period. Important next steps will be to strengthen the CBP intervention to further enhance its preventive effects, improve intervention outcomes when parents are currently depressed, and conduct larger implementation trials to test the broader public health impact of the CBP program for preventing depression in youth.
depression; prevention; children; adolescents
This study reports secondary outcome analyses from a past study of the Penn Resiliency Program (PRP), a cognitive-behavioral depression prevention program for middle-school aged children. Middle school students (N = 697) were randomly assigned to PRP, PEP (an alternate intervention), or control conditions. Gillham et al., (2007) reported analyses examining PRP’s effects on average and clinical levels of depression symptoms. We examine PRP’s effects on parent-, teacher-, and self-reports of adolescents’ externalizing and broader internalizing (depression/anxiety, somatic complaints, and social withdrawal) symptoms over three years of follow-up. Relative to no intervention control, PRP reduced parent-reports of adolescents’ internalizing symptoms beginning at the first assessment after the intervention and persisting for most of the follow-up assessments. PRP also reduced parent-reported conduct problems relative to no-intervention. There was no evidence that the PRP program produced an effect on teacher- or self-report of adolescents’ symptoms. Overall, PRP did not reduce symptoms relative to the alternate intervention, although there is a suggestion of a delayed effect for conduct problems. These findings are discussed with attention to developmental trajectories and the importance of interventions that address common risk factors for diverse forms of negative outcomes.
adolescence; prevention intervention; conduct problems; internalizing symptoms
Critical research questions in the study of addictive behaviors concern how these behaviors change over time - either as the result of intervention or in naturalistic settings. The combination of count outcomes that are often strongly skewed with many zeroes (e.g., days using, number of total drinks, number of drinking consequences) with repeated assessments (e.g., longitudinal follow-up after intervention or daily diary data) present challenges for data analyses. The current article provides a tutorial on methods for analyzing longitudinal substance use data, focusing on Poisson, zero-inflated, and hurdle mixed models, which are types of hierarchical or multilevel models. Two example datasets are used throughout, focusing on drinking-related consequences following an intervention and daily drinking over the past 30 days, respectively. Both datasets as well as R, SAS, Mplus, Stata, and SPSS code showing how to fit the models are available on a supplemental website.
Adolescent conduct problems exact serious social as well as personal costs, and effective treatments are essential. One of the most widely disseminated and effective programs for the treatment of serious conduct problems in adolescents is Multisystemic Therapy (MST). However, most evaluations of MST have involved the developers of MST. The purpose of the present study was to conduct an independent evaluation of MST, with non-court-referred adolescents with conduct problems.
Participants were 164 adolescents aged 11 to 18 years who were recruited from self-contained behavior intervention classrooms in public schools. Adolescents and their families were randomly assigned to receive MST or services as usual. Outcome measures assessed conduct problems, school functioning, and court records of criminal behavior. Participants were followed for 18 months after baseline using parent, adolescent, and teacher reports; arrest data were collected for 2.5 years post-baseline.
Two of four primary outcome measures focused on externalizing problems showed significant treatment effects favoring MST. Several secondary and intervention targets pertaining to family functioning and parent psychopathology showed positive effects of MST, and no negative effects were identified.
Results provide some further support for the effectiveness of MST, although smaller effect sizes than previous studies also suggest the complexity of successful dissemination, particularly to non-court-referred populations.
multisystemic therapy; MST; delinquency; antisocial behavior; non-court-referred
This study examined the relation of process variables to the outcome of group drug counseling, a commonly used community treatment, for cocaine dependence.
Videotaped group drug counseling sessions from 440 adult patients (23% female, 41% minority) were rated for member alliance, group cohesion, participation, self-disclosure, positive and non-positive feedback and advice, during the 6-month treatment of cocaine dependence. Average, session-level, and slopes of process scores were evaluated. Primary outcomes were monthly cocaine use (days using out of 30), next session cocaine use, and duration of sustained abstinence from cocaine. Secondary outcomes were endorsement of 12-step philosophy and beliefs about substance abuse.
More positive alliances (with counselor) were associated with reductions in days using cocaine per month and next-session cocaine use, and increases in endorsement of 12-step philosophy. Patient self-disclosure about the past and degree of participation in the group were generally not predictive of group drug counseling outcomes. More advice from counselor and other group members were consistently associated with poorer outcomes in all categories. Individual differences in changes in process variables over time (linear slopes) were generally not predictive of treatment outcomes.
Some group behaviors widely believed to be associated with outcome, such as self-disclosure and participation, were not generally predictive of outcomes of group drug counseling, but alliance with the group counselor was positively associated, and advice giving negatively associated, with the outcome of treatments for cocaine dependence.
group drug counseling; cocaine dependence; predictors; process ratings
The objective of the current study was to examine predictors and moderators of response to two HIV sexual risk interventions of different content and duration for individuals in substance abuse treatment programs.
Participants were recruited from community drug treatment programs participating in the National Institute on Drug Abuse Clinical Trials Network (CTN). Data were pooled from two parallel randomized controlled CTN studies (one with men and one with women) each examining the impact of a multi-session motivational and skills training program, in comparison to a single-session HIV education intervention, on the degree of reduction in unprotected sex from baseline to 3- and 6- month follow-ups. The findings were analyzed using a zero-inflated negative binomial (ZINB) model.
Severity of drug use (p < .01), gender (p < .001), and age (p < .001) were significant main effect predictors of number of unprotected sexual occasions (USOs) at follow-up in the non-zero portion of the ZINB model (men, younger participants, and those with greater severity of drug/alcohol abuse have more USOs). Monogamous relationship status (p < .001) and race/ethnicity (p < .001) were significant predictors of having at least one USO vs. none (monogamous individuals and African Americans were more likely to have at least one USO). Significant moderators of intervention effectiveness included recent sex under the influence of drugs/alcohol (p < .01 in non-zero portion of model), duration of abuse of primary drug (p < .05 in non-zero portion of model), and Hispanic ethnicity (p < .01 in the zero portion, p < .05 in the non-zero portion of model).
These predictor and moderator findings point to ways in which patients may be selected for the different HIV sexual risk reduction interventions and suggest potential avenues for further development of the interventions for increasing their effectiveness within certain subgroups.
HIV prevention intervention; Skills building; Randomized controlled trial; Predictors; Moderators
College counseling centers (CCCs) are increasingly being called upon to treat highly distressed students with complex clinical presentations. This study compared the effectiveness of Dialectical Behavior Therapy (DBT) for suicidal college students to an optimized control condition, and analyzed baseline global functioning as a moderator.
The intent-to-treat (ITT) sample included 63 college students between the ages of 18 and 25 who were suicidal at baseline, reported at least one lifetime non-suicidal self-injurious (NSSI) act or suicide attempt, and met three or more borderline personality disorder (BPD) diagnostic criteria. Participants were randomly assigned to DBT (n = 31) or an optimized Treatment as Usual (O-TAU) control condition (n = 32). Treatment was provided by trainees, supervised by experts in both treatments. Both treatments lasted 7–12 months and included both individual and group components. Assessments were conducted at pretreatment, 3-months, 6-months, 9-months, 12-months, and 18-months (follow-up).
Mixed effects analyses (ITT sample) revealed that DBT, compared to the control condition, showed significantly greater decreases in suicidality, depression, number of NSSI events (if participant had self-injured), BPD criteria, and psychotropic medication use, and significantly greater improvements in social adjustment. Most of these treatment effects were observed at follow-up. No treatment differences were found for treatment dropout. Moderation analyses showed that DBT was particularly effective for suicidal students who were lower functioning at pretreatment.
DBT is an effective treatment for suicidal, multi-problem college students. Future research should examine the implementation of DBT in CCCs in a stepped care approach.
Acute kidney injury (AKI) is a common source of morbidity after trauma. We sought to determine novel risk factors for AKI, by Acute Kidney Injury Network (AKIN) criteria, in critically ill trauma patients.
Materials and Methods
Prospective cohort study of 400 patients admitted to the ICU of a level one trauma center, followed for development of AKI over five days.
AKI developed in 147/400 (36.8%) patients. In multivariable regression analysis, independent risk factors for AKI included African American race (OR 1.86; 95% CI 1.08,3.18; p=0.024), body mass index ≥30 (OR 4.72 versus normal BMI, 95% CI 2.59, 8.61, p<0.001), diabetes mellitus (OR 3.26; 95% CI 1.30,8.20; p=0.012), abdominal Abbreviated Injury Scale score ≥4 (OR 3.78; 95% CI 1.79,7.96; p<0.001), and unmatched packed red blood cells administered during resuscitation (OR 1.13 per unit; 95% CI 1.04,1.23; p=0.004). AKIN stages 1, 2, and 3 were associated with hospital mortality rates of 9.8%, 13.7%, and 30.4%, respectively, compared with 3.8% for those without AKI (p<0.001).
AKI in critically ill trauma patients is associated with substantial mortality. The findings of African American race, obesity, and blood product administration as independent risk factors for AKI deserve further study to elucidate underlying mechanisms.
acute kidney injury; trauma; critical illness; race; obesity; transfusion; epidemiology; risk factors
Packed Red Blood Cell (PRBC) transfusion is associated with Acute Lung Injury (ALI) development after trauma, but this risk may not be constant through time after trauma. We hypothesized the relationship between PRBC delivery and ALI risk varies through time after injury.
Data were collected prospectively from 1999–2006. Inclusion criteria: age > 13 years, SICU admission, and injury severity score (ISS) ≥ 16. Exclusion criteria included discharge/death within 24 hours of admission. Patients were followed prospectively for ALI development for 5 days after trauma. Discrete time models were fit to test the association of timing of PRBC delivery with development of ALI while controlling for patient demographics, resuscitation variables, ISS, and APACHE III scores.
At total of 602 patients were included. Median age was 33 years, 77% were male, and 50% were African American. Using a discrete time-survival model, the relation between transfusion and ALI development was found to vary by transfusion time-window (p<0.0001). The major effect of PRBC delivery on ALI risk occurred in the first 24 hours after trauma; this finding persisted in multivariable modeling (adjusted OR = 1.07 per unit; 95%CI 1.02–1.11, p<0.001). Cumulative incidence of ALI approached 50% in patients receiving ≥ 6u PRBC in the first 24 hours.
The association between PRBC transfusion and ALI development in trauma patients is time-dependent, with PRBC delivery in the first 24 hours after injury driving the overall relation. Each PRBC unit during this time period increases odds of subsequent ALI development by 7%.
Given the frequent comorbidity of anxiety and depression, it is important to study the effects of depression interventions on anxiety and the impact of comorbid anxiety on depression outcomes.
This paper reports on pooled anxiety and depression data from two randomized trials of Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST), a depression prevention program. Ninety-eight adolescents were randomized to receive IPT-AST or school counseling (SC). Outcome and predictor analyses were performed utilizing hierarchical linear models.
IPT-AST adolescents had significantly greater reductions in anxiety and depressive symptoms than SC adolescents during the intervention. Baseline anxiety symptoms predicted change in depressive symptoms for adolescents in both intervention conditions, with adolescents low in baseline anxiety demonstrating more rapid change in depressive symptoms than adolescents high in baseline anxiety.
These findings indicate that IPT-AST is effective at decreasing both depressive and anxiety symptoms. For adolescents with comorbid symptoms of anxiety, there may be slower rates of change in depressive symptoms following prevention programs.
prevention; depression; anxiety; adolescents; interpersonal psychotherapy
Therapist treatment adherence has received a great deal of attention in recent years, in part because of its relation to treatment outcomes. Although certain therapist behaviors have been found to be associated with treatment outcomes, little is known about client factors impacting on therapists’ ability to adhere to treatment protocols. In this study, we evaluated effects of parental beliefs, psychopathology, and interaction styles on therapists’ adherence to Multi-systemic Therapy (MST) principles. Eighty-two parents participating in a clinical trial of MST completed baseline measures assessing psychopathology, family functioning, and treatment expectations. Analyses indicated that parental perceptions of therapist adherence were established within the first 4 weeks of treatment, and that parental psychopathology, motivation, expectations, and child rearing practices were related to parental ratings of therapist adherence. Results were essentially unchanged when controlling for parental positive response style. Clinical and research implications of the findings are discussed.
therapist adherence; multi-systemic therapy; disruptive behavior; parent
To estimate the prevalence and stability of social, emotional, and academic competence in a nationally representative sample of children involved with child protective services.
Children were assessed as part of the National Survey of Child and Adolescent Well-Being. Children (N = 2,065) ranged in age from 8 to 16 years and were assessed at baseline and at 18 and 36 months postbaseline. Caregivers, teachers, and youths provided information about children's problem behaviors, school achievement, and social competence. Children were considered resilient in a domain if they met or exceeded national norms.
Thirty-seven percent to 49% of children demonstrated resilience in mental health, academic, or social domains at any time point. Eleven percent to 14% of children were resilient across domains at any time point, and only 14% to 22% of children were consistently resilient within a given domain across all three time points.
Resilience, as defined by competence in mental health, academic, and social domains, was demonstrated by relatively few children. The conditions that promote stable resilience may be difficult to achieve among allegedly maltreated children who are likely to face residential and caretaker instability. Future research should identify processes that promote stability in resilience over time.
child abuse; maltreatment; resilience; National Survey of Child and Adolescent Well-Being
Although many studies suggest that family violence is associated with child psychopathology, multiple features of the home environment might account for this association, such as poverty and caregiver psychopathology. Studies are needed examining how change in psychopathology symptoms is affected by home violence, controlling for children's own developmental symptom histories and other predictors of psychopathology. This study used latent difference score structural equation modeling to test if witnessing home violence and/or experiencing harsh physical discipline predicted changes in psychopathology symptoms among 2,925 youth aged 5 – 16 years previously exposed to violence. Results demonstrated that harsh physical discipline predicted child-specific changes in externalizing symptoms, whereas witnessing violence predicted child-specific changes in internalizing symptoms across time. Implications for research and policy are discussed.
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 aim of this Stage I Behavioral Development Trial was to develop a manual-based 12-session Women’s Recovery Group (WRG) and to pilot test this new treatment in a randomized controlled trial against a mixed-gender Group Drug Counseling (GDC), an effective manual-based treatment for substance use disorders. After initial manual development, two pre-pilot groups of WRG were conducted to determine feasibility and initial acceptability of the treatment among subjects and therapists. In the pilot stage, women were randomized to either WRG or GDC. No significant differences in substance use outcomes were found between WRG and GDC during the 12-week group treatment. However, during the 6-month post-treatment follow-up, WRG members demonstrated a pattern of continued reductions in substance use while GDC women did not. In addition, pilot WRG women with alcohol dependence had significantly greater reductions in average drinks/drinking day than GDC women 6 months post-treatment (p < .03, effect size = 0.81). While satisfaction with both groups was high, women were significantly more satisfied with WRG than GDC (p < .009, effect size = 1.11). In this study, the newly developed 12-session women-focused WRG was feasible with high satisfaction among participants. It was equally effective as mixed-gender GDC in reducing substance use during the 12-week in-treatment phase, but demonstrated significantly greater improvement in reductions in drug and alcohol use over the post-treatment follow-up phase compared with GDC. A women-focused single-gender group treatment may enhance longer-term clinical outcomes among women with substance use disorders.
Gender differences; Women; Substance use disorders; Alcohol use disorders; Treatment outcomes; Group therapy
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
This paper reports on school and social functioning outcomes in a randomized depression prevention study that compared Interpersonal Psychotherapy-Adolescent Skills Training (IPT-AST) with usual school counseling (SC). Outcome analyses were performed utilizing hierarchical linear models and mixed model analysis of variance. IPT-AST adolescents had significantly greater improvements than SC adolescents in total social functioning and friend functioning during the intervention. IPT-AST adolescents also demonstrated improvements in school, dating, and family functioning and emotional engagement in school, although these improvements were not significantly greater than seen in SC adolescents. Finally, in the 18 months following the intervention, IPT-AST adolescents were less likely than SC adolescents to be asked to leave school for academic or behavioral reasons. These findings extend the potential range of impact of depression prevention programs such as IPT-AST and provide preliminary evidence of the benefits of these programs on school and social functioning.
Prevention; Depression; Adolescents; School mental health
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
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