The contribution of reliable and clinically significant change methods to evidence-based mental health

Trauma-Focused Treatment in PTSD Patients With Psychosis: Symptom Exacerbation, Adverse Events, and Revictimization

OBJECTIVES

Most clinicians refrain from trauma treatment for patients with psychosis because they fear symptom exacerbation and relapse. This study examined the negative side effects of trauma-focused (TF) treatment in patients with psychosis and posttraumatic stress disorder (PTSD).

METHODS

Analyses were conducted on data from a single-blind randomized controlled trial comparing TF treatment (N = 108; 8 sessions prolonged exposure or eye movement desensitization) and waiting list (WL; N = 47) among patients with a lifetime psychotic disorder and current chronic PTSD. Symptom exacerbation, adverse events, and revictimization were assessed posttreatment and at 6-month follow-up. Also investigated were symptom exacerbation after initiation of TF treatment and the relationship between symptom exacerbation and dropout.

RESULTS

Any symptom exacerbation (PTSD, paranoia, or depression) tended to occur more frequently in the WL condition. After the first TF treatment session, PTSD symptom exacerbation was uncommon. There was no increase of hallucinations, dissociation, or suicidality during the first 2 sessions. Paranoia decreased significantly during this period. Dropout was not associated with symptom exacerbation. Compared with the WL condition, fewer persons in the TF treatment condition reported an adverse event (OR = 0.48, P = .032). Surprisingly, participants receiving TF treatment were significantly less likely to be revictimized (OR = 0.40, P = .035).

CONCLUSIONS

In these participants, TF treatment did not result in symptom exacerbation or adverse events. Moreover, TF treatment was associated with significantly less exacerbation, less adverse events, and reduced revictimization compared with the WL condition. This suggests that conventional TF treatment protocols can be safely used in patients with psychosis without negative side effects.

Testing the Clinical Implications of Planned Missing Data Designs

Assessment is a core element of evidence-based practice, but thorough formal assessment can place a significant burden on clients. We evaluated the clinical viability of using planned missing data designs to reduce client burden. Data come from an archival dataset with 1342 participants. Although significant differences were found in scores with planned missing data versus real scores, the effect sizes for the differences were generally small. Scores with missing data had sensitivity and specificity scores generally above .90 when predicting real scores over clinical cutoffs and improvement in real scores. These findings offer useful information to agencies and researchers looking for ways to collect more data without losing its immediate clinical utility.

Challenging the understanding of significant improvement and outcome in schizophrenia - the concept of reliable and clinically significant change methods

Significant changes of schizophrenia patients during inpatient treatment were evalutaed and compared to established outcome criteria. The concept of reliable and clinically significant change methods was applied to three hundred and ninety-six patients suffering from a schizophrenia spectrum disorder. First, information on whether or not the change of the patient's condition is sufficient in order to declare that it is beyond a measurement error or random effect (= reliable change) was evaluated and in a second step it was observed if the reliable change was clinically meaningful (= clinically significant change). Different Positive and Negative Syndrome Scale for Schizophrenia (PANSS) thresholds were applied to define the clinically significant change (40, 45 and 50 points). These changes were then compared to established outcome criteria such as response and remission. Seventy-nine of the 396 patients (20%) showed a reliable improvement of symptoms, whereas 70% improved without achieving a reliable change of their condition. Of the 79 patients achieving a reliable change during treatment 8-15% concurrently showed a clinically significant change depending on the respective PANSS threshold. In contrast, 56% of the patients achieved response and 60% were in remission at discharge when applying established outcome criteria. Our results showed that a rather small number of schizophrenia patients were found to reliably change during inpatient treatment, with even less patients achieving a clinically significant change. The concept of reliable and clinically significant changes revealed to be a lot more stringent than today's established outcome criteria and should be critically evaluated regarding its use in schizophrenia patients.

Randomized controlled trial of group cognitive behavioral therapy compared to a discussion group for co-morbid anxiety and depression in older adults

BACKGROUND

Co-morbid anxiety and depression in older adults is associated with worse physical and mental health outcomes and poorer response to psychological and pharmacological treatments in older adults. However, there is a paucity of research focused on testing the efficacy of the co-morbid treatment of anxiety and depression in older adults using psychological interventions. Accordingly, the primary objective of the current study was to test the effects of a group cognitive behavior therapy (CBT) program in treating co-morbid anxiety and depression in a sample of older age adults.

METHOD

A total of 133 community-dwelling participants aged ⩾60 years (mean age = 67.35, s.d. = 5.44, male = 59) with both an anxiety disorder and unipolar mood disorder, as assessed on the Anxiety Disorder Interview Schedule (ADIS), were randomly allocated to an 11-week CBT group or discussion group. Participants with Mini-Mental State Examination scores <26 were excluded. Participants were assessed pre-treatment, post-treatment and at 6 months follow-up on the ADIS, a brief measure of well-being, Geriatric Anxiety Inventory and Geriatric Depression Scale.

RESULTS

Both conditions resulted in significant improvements over time on all diagnostic, symptom and wellbeing measures. Significant group × time interaction effects emerged at post-treatment only for diagnostic severity of the primary disorder, mean severity of all anxiety disorders, mood disorders, and all disorders, and recovery rates on primary disorder.

CONCLUSION

Group CBT produced faster and sustained improvements in anxiety and depression on diagnostic severity and recovery rates compared to an active control in older adults.

Effectiveness of a home-based cognitive behavioral program to manage concerns about falls in community-dwelling, frail older people: results of a randomized controlled trial

Background

Concerns about falls are common among older people. These concerns, also referred to as fear of falling, can have serious physical and psychosocial consequences, such as functional decline, increased risk of falls, activity restriction, and lower social participation. Although cognitive behavioral group programs to reduce concerns about falls are available, no home-based approaches for older people with health problems, who may not be able to attend such group programs are available yet. The aim of this study was to assess the effectiveness of a home-based cognitive behavioral program on concerns about falls, in frail, older people living in the community.

Methods

In a randomized controlled trial in the Netherlands, 389 people aged 70 years and older, in fair or poor perceived health, who reported at least some concerns about falls and related activity avoidance were allocated to a control (n = 195) or intervention group (n = 194). The intervention was a home-based, cognitive behavioral program consisting of seven sessions including three home visits and four telephone contacts. The program aims to instill adaptive and realistic views about fall risks via cognitive restructuring and to increase activity and safe behavior using goal setting and action planning and was facilitated by community nurses. Control group participants received usual care. Outcomes at 5 and 12 months follow-up were concerns about falls, activity avoidance due to concerns about falls, disability and falls.

Results

At 12 months, the intervention group showed significant lower levels of concerns about falls compared to the control group. Furthermore, significant reductions in activity avoidance, disability and indoor falls were identified in the intervention group compared with the control group. Effect sizes were small to medium. No significant difference in total number of falls was noted between the groups.

Conclusions

The home-based, cognitive behavioral program significantly reduces concerns about falls, related activity avoidance, disability and indoor falls in community-living, frail older people. The program may prolong independent living and provides an alternative for those people who are not able or willing to attend group programs.

Trial registration

ClinicalTrials.gov, NCT01358032. Registered 17 May 2011

Does Collaborative Case Conceptualisation enhance engagement and outcome in the treatment of anorexia nervosa? Rational, design and methods

BACKGROUND

Anorexia Nervosa (AN) is a severe and potentially chronic disorder characterised by low body weight and persistent behaviours that interfere with weight gain. Individuals with AN are often difficult to engage in treatment and display high rates of drop out. The Collaborative Case Conceptualisation (CCC) assessment approach was developed to target proposed AN maintaining factors with the aim of improving treatment motivation and engagement and consequently treatment outcomes in individuals with AN. The proposed study aims to examine the efficacy of CCC in improving a range of outcomes including Body Mass Index, eating disorder symptomatology, general psychopathology, quality of life and future treatment motivation and participation. Potential mediators will also be explored.

METHODS/DESIGN

Thirty-two participants will be recruited from Melbourne based specialist eating disorder services, community and university clinics, and health practitioner networks. Participants will be randomised to three individual sessions of either CCC or a standardised assessment condition (assessment as usual; AAU). The AAU assessment will include; a mental status examination, assessment of current disordered eating behaviours and cognitions, assessment of clinical history, and a physical examination. The CCC condition combines the AAU assessment components with shared collaborative formulation and tailored psychoeducation highlighting the consequences of the eating disorder on wellbeing and future goals in a supportive and motivating way.

IMPLICATIONS

This intervention may provide an effective and feasible method of improving treatment engagement and outcomes for individuals suffering from AN, with the ultimate outcome of reducing the negative biopsychosocial impacts of this potentially severe and chronic disorder.

Differential response to depression prevention among a sample of informal caregivers: Moderator analysis of longer-term follow-up trial data

Depression is one of the most common mental disorders in caregivers. Therefore, preventive interventions for this population are needed, especially for caregivers with subclinical symptoms of depression. However, no study to date has identified the characteristics of caregivers that help to predict who will or will not benefit from such a preventive intervention. This study aimed to identify moderators of response to intervention comparing problem solving and usual care in indicated prevention of depression among informal caregivers. A randomized controlled trial was conducted involving 173 participants who were allocated to the problem-solving intervention (n=89) or the usual-care control-group (n=84), with 12-months follow-up. Socio-demographic, care-related and clinical variables at baseline were analyzed as potential moderators of intervention response at 12-months follow-up. Age and emotional distress emerged as significant moderators. Those caregivers younger than 65 years and with higher emotional distress at baseline were more likely to benefit from the intervention than from usual care. Simultaneous consideration of multiple moderators found that intervention was indicated for 95.4% of the sample. Considering these moderators in clinical decision-making could contribute to matching treatments and health service users in a more personalized and effective way.

Using a Brief Parent-Report Measure to Track Outcomes for Children and Teens with Internalizing Disorders

The Pediatric Symptom Checklist (PSC) is a widely-used, parent-completed measure of children's emotional and behavioral functioning. Previous research has shown that the PSC and its subscales are generally responsive to patient progress over the course of psychiatric treatment. In this naturalistic study, we examined the performance and utility of the five-item PSC Internalizing Subscale (PSC-IS) as an assessment of routine treatment in outpatient pediatric psychiatry. Parents and clinicians of 1,593 patients aged 17 or younger completed standardized measures at intake and three-month follow-up appointments. Comparisons between PSC-IS scores and clinician-reported diagnoses, internalizing symptoms, and overall functioning showed acceptable levels of agreement. Change scores on the PSC-IS were also larger among patients with internalizing diagnoses than those with non-internalizing diagnoses. As a brief measure of internalizing symptoms, the PSC may be particularly useful to mental health clinicians treating youth with depression and anxiety as a quality assurance or treatment outcome measure.

The 15-item Systemic Clinical Outcome and Routine Evaluation (SCORE-15) Scale: Portuguese Validation Studies

This study reports on the validity of the 15-item Portuguese version of the Systemic Clinical Outcome Routine Evaluation (SCORE-15; Vilaça, Silva, & Relvas, 2014), a brief and comprehensive measure of family functioning. Previous studies with SCORE-15 show that this version replicates the three-factor solution found for the original English version: Family strengths, Family communication and Family difficulties. In addition to reviewing previous studies, this article analyses the discriminant, convergent and predictive validity of the Portuguese SCORE-15. To do so, the SCORE-15 was administered to family members attending systemic family or couple's therapy at the start of the first and fourth sessions and also to a group of non-clinical individuals. Overall, data are reported from 618 participants, including 136 from families attending systemic therapy and 482 community family members. Comparisons of community and clinical samples (discriminant validity) showed statistically significant differences for the total scale and subscales (p < .001), with the community participants presenting healthier family functioning than the clinical ones. Analyses using SCORE-15 and the Quality of Life - adult version, another family measure applied simultaneously (convergent validity), indicate that both scales are significantly (p < .01) and moderately (r = -.47) correlated. Mean score analysis of SCORE-15's therapeutic sensitivity to change (predictive validity) showed that only the Family communication subscale was sensitive to statistically significant improvement (p < .05) from session 1 to session 4, whereas the SCORE-15's reliability change index points to its ability to detect clinical improvements (RCI = 14%).

Evaluating the Responsiveness to Therapeutic Change with Routine Outcome Monitoring: A Comparison of the Symptom Questionnaire-48 (SQ-48) with the Brief Symptom Inventory (BSI) and the Outcome Questionnaire-45 (OQ-45)

Assessment of psychological distress is important, because it may help to monitor treatment effects and predict treatment outcomes. We previously developed the 48-item Symptom Questionnaire (SQ-48) as a public domain self-report psychological distress instrument and showed good internal consistency as well as good convergent and divergent validity among clinical and non-clinical samples. The present study, conducted among psychiatric outpatients in a routine clinical setting, describes additional psychometric properties of the SQ-48. The primary focus is on responsiveness to therapeutic change, which to date has been rarely examined within psychiatry or clinical psychology. Since a questionnaire should also be stable when no clinically important change occurs, we also examined test-retest reliability within a test-retest design before treatment (n = 43). A pre-treatment/post-treatment design was used for responsiveness to therapeutic change, comparing the SQ-48 with two internationally widely used instruments: the Brief Symptom Inventory (n = 97) and the Outcome Questionnaire-45 (n = 109). The results showed that the SQ-48 has excellent test-retest reliability and good responsiveness to therapeutic change, without significant differences between the questionnaires in terms of responsiveness. In sum, the SQ-48 is a psychometrically sound public domain self-report instrument that can be used for routine outcome monitoring, as a benchmark tool or for research purposes. Copyright © 2015 John Wiley & Sons, Ltd. Key Practitioner Message The SQ-48 is developed as a public domain self-report questionnaire, in line with growing efforts to develop clinical instruments that are free of charge. The SQ-48 has excellent test-retest reliability and good responsiveness to therapeutic change or patient progress. There were no significant differences in terms of responsiveness between the SQ-48 and BSI or OQ-45. The SQ-48 can be used as a routine evaluation outcome measure for quality assurance in clinical practice. Providing feedback on patient progress via outcome measures could contribute to the enhancement of treatment outcomes.

The HCR-20 as a measure of reliable and clinically significant change in violence risk among secure psychiatric inpatients

OBJECTIVE

Periodic structured violence risk assessment is the principle method underlying treatment planning for mentally disordered offenders but little is known about how risk changes over time. We aimed to determine whether hospitalised patients underwent reliable clinical change in assessed risk.

METHOD

We used a pseudo-prospective longitudinal study design. Demographic, clinical and risk assessment data of adult inpatients (N=480) who had been routinely assessed with the HCR-20 on two to four occasions over a mean period of 17 months (SD=2) were collated. Linear mixed models regression was conducted to determine change over time on total, subscale, and individual item scores, and relative change between clinical and demographic groups. The Reliable Change Index was calculated to examine whether change was greater than that expected by measurement error; clinically significant change was defined as the extent to which HCR-20 scores reduced below previously reported scores for patients not requiring hospitalisation.

RESULTS

HCR-20 total score (Estimate -0.42, 95% CI=-0.84, -0.01, p<.05; d=.20) and clinical score (Estimate=-0.42, 95% CI=-0.64, -0.20, p<.001; d=.36) reduced over assessments. Significant differences in change were evident between clinically and demographically defined groups. A maximum of 3% of individuals showed clinically significant reliable reductions in HCR-20 total scores. The scores of patients whose overall level of risk was judged to have decreased did not reduce between assessments.

CONCLUSION

Violence risk changes very little over the course of treatment although there is some variation between groups. Most change cannot be demonstrated to be reliable or clinically significant. Important clinical management decisions should not depend solely on evidence from changes in HCR-20 risk assessment.

“Stress Control” as a Large Group Psychoeducational Intervention at Step 2 of IAPT Services: Acceptability of the Approach and Moderators of Effectiveness

Background:“Stress Control” (SC) has been adopted as a core intervention in step 2 of Improving Access to Psychological Therapies (IAPT) services, but contemporary evidence of effectiveness has lagged behind service uptake.Aims:To investigate the acceptability and effectiveness of SC and to explore moderators of outcome.Method:Analysis of acceptability (via attendance rates) and effectiveness (via IAPT minimum dataset).Results:SC was well tolerated with 73.3% of all patients and 75.4% of “clinical cases” attending three or more sessions. Of the 546 “clinical cases” attending SC and not in receipt of other interventions, 37% moved to recovery. Attendance improved outcome; for those patients attending all SC sessions the recovery rate rose to 59.2%.Conclusion:SC appears a well-tolerated and effective intervention that enables large numbers to gain access to treatment in an organizationally efficient manner. Attendance is important in facilitating SC outcomes and research evaluating attendance interventions are needed.

Do Old Errors Always Lead to New Truths? A Randomized Controlled Trial of Errorless Goal Management Training in Brain-Injured Patients

Both errorless learning (EL) and Goal Management Training (GMT) have been shown effective cognitive rehabilitation methods aimed at optimizing the performance on everyday skills after brain injury. We examine whether a combination of EL and GMT is superior to traditional GMT for training complex daily tasks in brain-injured patients with executive dysfunction. This was an assessor-blinded randomized controlled trial conducted in 67 patients with executive impairments due to brain injury of non-progressive nature (minimal post-onset time: 3 months), referred for outpatient rehabilitation. Individually selected everyday tasks were trained using 8 sessions of an experimental combination of EL and GMT or via conventional GMT, which follows a trial-and-error approach. Primary outcome measure was everyday task performance assessed after treatment compared to baseline. Goal attainment scaling, rated by both trainers and patients, was used as secondary outcome measure. EL-GMT improved everyday task performance significantly more than conventional GMT (adjusted difference 15.43, 95% confidence interval [CI] [4.52, 26.35]; Cohen's d=0.74). Goal attainment, as scored by the trainers, was significantly higher after EL-GMT compared to conventional GMT (mean difference 7.34, 95% CI [2.99, 11.68]; Cohen's d=0.87). The patients' goal attainment scores did not differ between the two treatment arms (mean difference 3.51, 95% CI [-1.41, 8.44]). Our study is the first to show that preventing the occurrence of errors during executive strategy training enhances the acquisition of everyday activities. A combined EL-GMT intervention is a valuable contribution to cognitive rehabilitation in clinical practice.

"Am I Becoming a Serial Killer?" A Case Study of Cognitive Behavioral Therapy for Mental Illness Anxiety

BACKGROUND

Although mental illness anxiety is described in the literature, there is very little information on which to draw when treating individuals who present with fears and worries about mental health. In fact, we identified no previous case descriptions focused on this form of anxiety and treated from a cognitive behavioral perspective.

AIMS

The current case study aims to advance the understanding of the clinical picture of mental illness anxiety, and facilitate the understanding of how cognitive behavioral techniques for health anxiety can be effectively adapted and implemented for such a case.

METHOD

A case study approach was adopted in which a baseline condition and repeated assessments were conducted during an 8-week treatment and 2-month follow-up period. In the current case study, we discuss the assessment, conceptualization, and cognitive behavioral treatment of a 24-year old woman who presented with mental illness anxiety. Several common health anxiety assessment tools and cognitive behavioural techniques were adapted for her particular clinical presentation.

RESULTS

Consistent with research evidence for health anxiety, significant improvements in health anxiety and anxiety sensitivity were seen after eight sessions of therapy and maintained at 2-month follow-up.

CONCLUSIONS

The results provide preliminary evidence that cognitive behavioral techniques for health anxiety can be effectively and efficiently adapted for mental illness anxiety. However, the lack of available research pertaining to mental illness anxiety contributes to challenges in conceptualization, assessment and treatment.

Longitudinal Changes in Dental Fear and Coping Behavior in Children, Adolescents, and Young Adults with Cleft Lip and/or Cleft Palate

Objective

To determine changes in dental anxiety levels of cleft lip and/or palate (CL/P) children and to explore the role of coping strategies in the development of their dental anxiety.

Design

Prospective study.

Setting

Free University Medical Center Amsterdam.

Patients

A sample of CL/P children (at T1: n = 153, 4 to 18 years, 67 girls; at T2: n = 113, 7 to 21 years, 51 girls). Data were available at both time points for 102 children.

Measures

Dental anxiety and coping strategies were assessed at the start of the study (T1; mean age: 9.8 years, standard deviation 4.1) and 3 years later (T2; mean age: 13.4 years, standard deviation 3.8). These scores were compared to a normative group of Dutch children.

Main Outcome Measure(s)

The severity of dental anxiety was indexed using the Parental Version of the Dental Subscale of the Children's Fear Survey Schedule. Dental coping strategies were assessed with the Dental Cope Questionnaire.

Results

Overall, dental anxiety decreased to a level equal to normative scores of Dutch children. However, 5% of the children became more anxious. At T2, children used significantly fewer coping strategies. Children whose level of dental anxiety increased significantly used more destructive coping strategies than children whose level of dental anxiety decreased significantly or remained stable.

Conclusions

Results suggest that dental anxiety levels of most CL/P children gradually decline over time. Whereas some coping strategies have the potential to be protective, more destructive coping strategies may put children at greater risk for developing and maintaining their dental anxiety.

Frequency and change mechanisms of psychotherapy among depressed patients: study protocol for a multicenter randomized trial comparing twice-weekly versus once-weekly sessions of CBT and IPT

BACKGROUND

Cognitive behavioral therapy (CBT) and interpersonal therapy (IPT) are among the most well established therapies for the treatment of depression. However, some major questions remain unanswered. First, it is unknown what session frequency results in the most optimal (cost) effectiveness in psychotherapy. Second, the debate as to what mechanisms underlie the effect of psychotherapy has not yet been resolved. Enhancing knowledge about the optimal session frequency and mechanisms of change seems crucial in order to optimize the (cost) effectiveness of psychotherapy for depression. This study aims to compare treatment outcome of twice-weekly versus once-weekly sessions of CBT and IPT. We expect twice-weekly sessions to be more effective and lead to more rapid recovery of depressive symptoms in comparison to once-weekly sessions. Both therapy-specific and non-specific process measures will be included to unravel the mechanisms of change in psychotherapy for depression. Besides the use of self-reports and behavioral observations, this study will also examine underlying biological processes by collecting blood samples.

METHOD

In a multicenter randomized trial, two hundred depressed patients will be recruited from Dutch specialized mental healthcare centers and randomized into one of the following groups, all receiving a maximum of 20 sessions in different frequencies: a) twice-weekly sessions at the start of CBT, b) twice-weekly sessions at the start of IPT, c) once-weekly sessions at the start of CBT, d) once-weekly sessions at the start of IPT. Primary outcome measures are depression severity, cost-effectiveness and quality of life. Process measures include therapeutic alliance, recall, therapy-specific skills, motivation and compliance. Assessments will take place during baseline, monthly during treatment and follow-up at month 9, 12 and 24. In addition, at 12 and 24 months, the frequency of depressive episodes in the previous year will be assessed. Blood samples will be taken pre- and post-treatment. The study has been ethically approved and registered.

DISCUSSION

Finding that twice-weekly sessions are more effective or lead to more rapid recovery of depressive symptoms could lead to treatment adaptations that have the potential to reduce the personal and societal burden of depression. In addition, insight into the mechanisms of change and physiological processes in psychotherapy will enable us to optimize treatments and may help to understand human functioning beyond the context of treatment.

TRIAL REGISTRATION

The study has been registered on October 21th, 2014 at the Netherlands Trial Register, part of the Dutch Cochrane Centre ( NTR4856 ).

The development and implementation of a pilot CBT for early psychosis service: achievements and challenges

AIM

Cognitive behaviour therapy (CBT) is a clinically indicated treatment for first-episode psychosis. Despite this, CBT for early psychosis is not routinely available as part of standard mental health services in Australia. The aim of this pilot project was to develop a CBT for early psychosis service to be provided as an adjunct to existing community mental health services. This study examined the feasibility of this service model, delivered in a real-world setting. A secondary aim was to explore the effectiveness of this service, as measured by clinical and functional outcomes.

METHODS

Participants living in northern Sydney, Australia, and who had recently experienced a first episode of psychosis, were offered up to 20 sessions of individual CBT. Service feasibility was measured via attrition rates, therapy attendance and referrer feedback. Measures of psychosis, depression, anxiety and psychosocial functioning, were assessed pretreatment, after six and 12 sessions, and at 3 months post-treatment.

RESULTS

Nineteen clients attended treatment to completion. Survey feedback from referrers affirmed the positive impact of the service on clients' recovery. Additionally, clients showed improvements in symptoms of psychosis over the first three time points. Psychosocial functioning also shifted from the moderately to mildly impaired range by the end of treatment.

CONCLUSIONS

The CBT for early psychosis service has been successfully integrated into the mental health landscape of northern Sydney. Outcomes of this pilot project are discussed with reference to the achievements of the service, as well as the obstacles encountered, and how they were overcome.

Investigating the relationship between competence and patient outcome with CBT

Little is understood about the relationship between therapist competence and the outcome of patients treated for common mental health disorders. Understanding the relationship between competence and patient outcome is of fundamental importance to the dissemination and implementation of Cognitive Behavioural Therapy (CBT). The current study extends existing literature by exploring the relationship between CBT competence and patient outcome in routine clinical practice within the framework of the British Government's Improving Access to Psychological Therapies (IAPT) programme. Participants comprised 43 therapists treating 1247 patients over a training period of one year. Results found little support of a general association between CBT competence and patient outcome; however significantly more patients of the most competent therapists demonstrated a reliable improvement in their symptoms of anxiety than would be expected by chance alone, and fewer experienced no reliable change. Conversely, significantly more patients treated by the least competent therapists experienced a reliable deterioration in their symptoms than would be expected. The implications of these results for the dissemination and implementation of CBT are discussed.

Evaluation and applications of the clinically significant change method with the Violence Risk Scale-Sexual Offender version: implications for risk-change communication

We examined the use of the clinically significant change (CSC) method with the Violence Risk Scale-Sexual Offender version (VRS-SO), and its implications for risk communication, in a combined sample of 945 treated sexual offenders from three international settings, followed up for a minimum 5 years post-release. The reliable change (RC) index was used to identify thresholds of clinically meaningful change and to create four CSC groups (already okay, recovered, improved, unchanged) based on VRS-SO dynamic scores and amount of change made. Outcome analyses demonstrated important CSC-group differences in 5-year rates of sexual and violent recidivism. However, when baseline risk was controlled via Cox regression survival analysis, the pattern and magnitude of CSC-group differences in sexual and violent recidivism changed to suggest that observed variation in recidivism base rates could be at least partly explained by pre-existing group differences in risk level. Implications for communication of risk-change information and applications to clinical practice are discussed.

An implementation pilot of the MindBalance web-based intervention for depression in three IAPT services

Web-based interventions for depression have burgeoned over the past 10 years as researchers and health professionals aim to harness the reach and cost-effectiveness that the internet promises. Despite strong clinical evidence of their effectiveness and policy support, web-based interventions have not become widely used in practice. We explored this translation gap by conducting an implementation pilot of MindBalance, a web-based intervention for depression built on the SilverCloud platform, in three IAPT services. We posed three questions: (1) Who chooses to use MindBalance? (2) Is MindBalance effective for these clients? (3) How do clients use MindBalance? Our results for questions (1) and (2) are commensurate with the positive findings in the literature on patient acceptability and clinical effectiveness for such interventions. Client usage, captured in adherence data as well as usage case-studies, was diverse and differed markedly from face-to-face sessions. The most surprising result, however, concerned the small number of people who were offered the intervention. We reflect upon why this was and discuss implementation issues that primary mental health services should consider when adding a web-based intervention to their services.

Case-Series Evaluating a Transdiagnostic Cognitive-Behavioural Treatment for Co-occurring Anxiety Disorders

BACKGROUND

Patients with anxiety disorder diagnoses commonly have more than one anxiety diagnosis. While cognitive-behavioural interventions have proven efficacy in treating single anxiety disorder diagnoses, there has been little investigation of their efficacy in treating co-occurring anxiety disorders.

AIMS

To evaluate the efficacy of a transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders.

METHOD

An A-B single case study design (N = 6) was used to evaluate the efficacy of a 12 to 13-session modular transdiagnostic cognitive-behavioural intervention for treating co-occurring anxiety disorders across patients with at least two of the following diagnoses: GAD, Social Phobia, Panic Disorder and/or OCD.

RESULTS

Five of the six participants completed treatment. At posttreatment assessment the five treatment completers achieved diagnostic and symptomatic change, with three participants being diagnosis free. All participants who completed treatment no longer met criteria for any DSM-IV-TR Axis-I diagnosis at the 3-month follow-up assessment, and demonstrated reliable and clinically-significant improvements in symptoms. Across the participants, statistically significant improvements from pre to postintervention were found on measures of anxiety, depression and general well-being, and all improvements were maintained at 3-month follow-up.

CONCLUSIONS

Results suggest that transdiagnostic cognitive behavioural interventions can be of benefit to patients with co-occurring anxiety disorders.

Trajectories of quality of life in early-stage dementia: individual variations and predictors of change

BACKGROUND

Little evidence is available about how quality of life (QoL) changes as dementia progresses.

OBJECTIVES

We explored QoL trajectories over a 20-month period and examined what predicted change in QoL.

METHOD

Fifty-one individuals with a diagnosis of Alzheimer's, vascular or mixed dementia (people with dementia (PwD)) participating in the Memory Impairment and Dementia Awareness Study rated their QoL using the QoL-Alzheimer's Disease Scale at baseline and at 20-month follow-up. PwD also rated their mood and quality of relationship with the carer. In each case, the carer rated his or her level of stress and perceived quality of relationship with the PwD.

RESULTS

There was no change in mean QoL score. Nearly one-third of PwD rated QoL more positively at 20-month follow-up and nearly one-third rated QoL more negatively. These changes could be regarded as reliable in one-quarter of the sample. Participants taking acetylcholinesterase-inhibiting medication at baseline were more likely to show a decline in QoL score. There were no other significant differences between those whose scores increased, decreased or stayed the same on any demographic or disease-related variables, or in mood or perceived quality of relationship with the carer. Whereas baseline QoL score was the strongest predictor of QoL at 20 months, the quality of relationship with the carer as perceived by the PwD was also independently a significant predictor.

CONCLUSIONS

There is a degree of individual variation in QoL trajectories. Use of acetylcholinesterase-inhibiting medication appears linked to decline in QoL score, whereas positive relationships with carers play an important role in maintaining QoL in early-stage dementia.

The effectiveness of an Internet support forum for carers of people with dementia: a pre-post cohort study

Background

The well-being of informal carers of people with dementia is an important public health issue. Caring for an elderly relative with dementia may be burdensome and stressful, and can negatively affect the carer’s social, family, and professional life. The combination of loss, the physical demands of caregiving, prolonged distress, and biological vulnerabilities of older carers may compromise their physical health, increase social isolation, and increase the risk of anxiety and depressive disorders. Caregiver stress is also linked to negative outcomes for the recipient of care and costs to society, including increased nursing home and hospital admissions. Consequently, carer support interventions are an important component of dementia care. Computer-mediated carer support offers a range of potential advantages compared to traditional face-to-face support groups, including accessibility and the possibility of tailoring to meet individual needs, but there has been little research on its effectiveness so far.

Objective

This mixed-methods study examined the impact of a well-respected UK-based online support forum for carers of people with dementia.

Methods

A total of 61 new forum users completed measures of anxiety (7-item Generalized Anxiety Disorder scale, GAD-7), depression (9-item Patient Health Questionnaire, PHQ-9), and quality of relationship with the person with dementia (Scale for the Quality of the Current Relationship in Caregiving, SQCRC), at baseline and again after 12 weeks of forum usage, within a pre-post design. In addition, 8 participants were interviewed about their experiences with using the forum.

Results

There was an improvement in the quality of the relationship with the person with dementia (SQCRC: P=.003). There was no change in users’ depression (PHQ-9) or anxiety (GAD-7) over the 12-week study period. Interview participants reported a range of positive experiences and benefits from using the forum. Limited negative experiences were also reported.

Conclusions

Many of the reported experiences and benefits are unique to online peer support. Further research into online peer support for carers of people with dementia is needed to clarify who benefits under what conditions.

Mutuality of Rogers's therapeutic conditions and treatment progress in the first three psychotherapy sessions

OBJECTIVE

Research on the effects of Rogers's therapeutic relationship conditions has typically focused on the unilateral provision of empathy, unconditional positive regard, and congruence from therapist to client.

METHOD

This study looked at both client and therapist mutuality of the Rogerian therapeutic conditions and the association between mutuality and treatment progress in the first three psychotherapy sessions. Clients (N = 62; mean age = 24.32; 77% female, 23% male) and therapists (N = 12; mean age = 34.32; nine female and three male) rated one another using the Barrett-Lennard Relationship Inventory after the first and third session.

RESULTS

Both clients and therapists perceived the quality of the relationship as improved over time. Client rating of psychological distress (CORE-OM) was lower after session 3 than at session 1 (es = .85, [95% CIs: .67, 1.03]). Hierarchical multiple regression was used to test the predictive power of mutually high levels of the therapeutic conditions on treatment progress. The association between client rating of therapist-provided conditions and treatment progress at session 3 was higher when both clients and therapists rated each other as providing high levels of the therapeutic conditions (R(2) change = .073, p < .03).

CONCLUSIONS

The findings suggest mutuality of Rogers's therapeutic conditions is related to treatment progress.

Defining multiple criteria for meaningful outcome in routine outcome measurement using the Health of the Nation Outcome Scales

PURPOSE

Using the reliable and clinically significant change approach, we aimed to identify meaningful outcome indicators for the Health of the Nation Outcome Scales (HoNOS) and to combine them in a single model. We applied these indicators to the 1-year outcome of two large samples of people attending community mental health services in Italy (cohort 1) and the Netherlands (cohort 2).

METHODS

Data were drawn from two studies on routine outcome assessment. The criteria for meaningful outcome were defined on both study cohorts and both language versions of the scale. The model combined (a) two criteria for adequate change (at least 4 or 8 points change), (b) two cut-offs for clinically significant change (a total score of 10 was the threshold between mild and moderate illness, 13 between moderate and severe illness), and (c) a method for classifying stable subjects in three degrees of severity (stable in mild, moderate or severe illness). Results were compared with those given by the effect size (ES) and analysis of variance and covariance (ANOVA and ANCOVA).

RESULTS

For the proposed approach the outcome of cohort 1 was better than cohort 2, with 65-67% of its subjects showing a positive outcome compared to only 45-46%. The other reference methods (ES and ANOVA), however, showed a greater improvement for cohort 2. ANCOVA indicated that the differences were due to regression to the mean (RTM) which showed opposite effects across the two cohorts.

CONCLUSIONS

The proposed approach proved valuable and generalizable for interpreting outcome on HoNOS, scarcely influenced by the RTM effect. Its introduction could benefit outcome evaluation and management.

Effectiveness of a brief group cognitive behavioral therapy for auditory verbal hallucinations: a 6-month follow-up study

The current study investigated the effectiveness of a group cognitive behavioral therapy for auditory verbal hallucinations (AVHs), the Voices Group. This consists of seven specific sessions. Forty-one participants with schizophrenic or schizoaffective disorders completed a battery of questionnaires. The severity of psychiatric symptoms, beliefs about voices, quality of life, self-esteem, clinical global impression, and functioning were assessed at baseline, before and after intervention, and at the 6-month follow-up. After intervention, there was a statistically significant reduction in the severity of AVHs. This result remained stable at follow-up. The dropout rate was high. Some differences were found in subjective experience of AVHs between the patients who completed the intervention and those who dropped out. Altogether, these findings suggest that a brief intervention has some positive benefits in patients struggling with voices, which remain stable over time.

Psychosexual outcome after labiaplasty: a prospective case-comparison study

INTRODUCTION AND HYPOTHESIS

Our goal was to determine psychosexual outcome after labiaplasty in the long-term with specific measures of genital body image and sexual dysfunction.

METHOD

We conducted a prospective study with a matched-comparison group of women not wanting labiaplasty. Forty-nine women were compared against a group of 39 women matched for age, sexual orientation, ethnicity, and marital status. The labiaplasty group was assessed before, 3 months after and between 11 and 42 months after surgery. The comparison group was assessed at two time points 3 months apart to control for the passage of time. The primary outcome measure was the Genital Appearance Satisfaction (GAS) scale.

RESULTS

Of the 49 women receiving labiaplasty, 19 (38.8 %) were lost to follow-up but were reassessed clinically. Twenty-four of 25 (96 %) women in the labiaplasty group showed a reliable and clinically significant improvement on the GAS scale 3 months after the procedure; 21/23 (91.3 %) showed an improvement at the long-term follow-up. A large effect size was found for improvements on the GAS scale in the labiaplasty group. Small-effect sizes were found for improvements in sexual functioning. Nine women obtaining labiaplasty met diagnostic criteria for body dysmorphic disorder before the operation; eight lost that diagnosis at the 3-month follow-up; 26 % reported minor side effects.

CONCLUSIONS

Labiaplasty is effective in improving genital appearance and sexual satisfaction, but larger studies are required to determine the prevalence of potential side effects.

Changes in sexual functioning from 6 to 12 months following traumatic brain injury: a prospective TBI model system multicenter study

OBJECTIVE

To investigate longitudinal changes in sexual functioning during the first year following moderate to severe traumatic brain injury (TBI).

DESIGN

Prospective cohort study.

SETTING

Community.

PARTICIPANTS

182 persons (53 women and 129 men) with moderate to severe TBI who were admitted to 1 of 6 participating TBI Model System centers and followed in the community at 6 and 12 months after injury.

MAIN MEASURES

Derogatis Interview for Sexual Functioning-Self-Report (DISF-SR); Global Sexual Satisfaction Index (GSSI).

RESULTS

Mean T-scores on the DISF-SR Arousal subscale demonstrated marginal improvement over time, with a 2.59-point increase (P = .05) from 6 to 12 months after injury. There were no significant differences over this 6-month period on the remaining DISF-SR subscales, including sexual cognition/fantasy, sexual behavior/experience, and orgasm. There was no significant change in satisfaction with sexual functioning on the GSSI from 6 months (72% satisfied) to 12 months (71% satisfied).

CONCLUSIONS AND IMPLICATIONS

Sexual function and satisfaction appears to be stable in those with moderate to severe TBI from 6 to 12 months after injury, with the exception of minimal improvement in arousal. These findings, to our knowledge, reflect the first evidence regarding prospective changes in sexual functioning in this population. Future research can go far to assist clinicians in treatment planning and managing patient expectations of recovery of sexual functioning after TBI.

Preschool based JASPER intervention in minimally verbal children with autism: pilot RCT

In this pilot study, we tested the effects of a novel intervention (JASPER, Joint Attention Symbolic Play Engagement and Regulation) on 3 to 5 year old, minimally verbal children with autism who were attending a non-public preschool. Participants were randomized to a control group (treatment as usual, 30 h of ABA-based therapy per week) or a treatment group (substitution of 30 min of JASPER treatment, twice weekly during their regular program). A baseline of 12 weeks in which no changes were noted in core deficits was followed by 12 weeks of intervention for children randomized to the JASPER treatment. Participants in the treatment group demonstrated greater play diversity on a standardized assessment. Effects also generalized to the classroom, where participants in the treatment group initiated more gestures and spent less time unengaged. These results provide further support that even brief, targeted interventions on joint attention and play can improve core deficits in minimally verbal children with ASD.

Translating the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM) into Lithuanian

BACKGROUND

There are no standardized tools in Lithuanian feasible for ongoing routine use to measure the effectiveness of psychotherapeutic treatment. The CORE-OM is a widely used 34-item self-report measure for such purpose.

AIMS

To explore the reliability, validity and sensitivity of the Lithuanian translation of CORE-OM questionnaire.

METHODS

A validation study of the CORE-OM was conducted in the psychiatric clinic attached to Vilnius University. A Lithuanian translation of the English original CORE-OM was prepared by a team of translators. Then 39 psychotherapy outpatients and 187 students were asked to complete the Lithuanian version of the CORE-OM; 66 were tested twice to determine test-retest stability. Analysis included both internal and test-retest reliability, acceptability, influence of gender, principal component analysis and criteria for reliable and clinically significant change.

RESULTS

Internal and test-retest reliability were good (0.61-0.94), though somewhat lower for the risk domain (α: 0.57-0.79, Spearman's rho 0.25-0.60). Differences between scores of the clinical and non-clinical samples were large and significant (P < 0.001). Some of the Lithuanian criteria for clinically significant change were a bit lower than those of the original UK criteria (e.g. well-being) and others higher (symptoms, functioning, overall score), illustrating the need for local exploration.

CONCLUSIONS

In spite of small differences in psychometric properties from the original, the Lithuanian version of the CORE-OM was reliable and sensitive in both clinical and non-clinical settings. It has the potential to become a practical, sensitive and reliable tool for psychotherapists in Lithuania.

Effects of a physical therapy program on quality of life among community-dwelling elderly women: randomized-controlled trial

INTRODUCTION: Health promotion policies for encouraging elderly to remain active, independent and, effectively have a positive effect on their quality of life. OBJECTIVE: To verify the effects of a low-intensity group-based physical therapy program on quality of life among community-dwelling elderly women. MATERIALS AND METHODS: It was carried out a randomized controlled trial. Seventeen women (67.8 ± 4.9 years old) that completed 12-week training program and 10 women (68.9 ± 5.7 years old) that were included in control group answered the abbreviated version for World Health Organization Quality of life Questionnaire - WHOQOL-bref at baseline and after 12 weeks. Exercise group performed stretching, resistance and balance training. Intragroup and intergroup analysis was made using Wilcoxon and Mann-Whitney U tests, respectively. The level of significance used for all comparisons was 5%. Furthermore, it was determined the Reliable Change Index (RCI) as part of JT Method. RESULTS: Exercise group presented a significant improvement for Psychological domain (p = 0.047) after 12-week physical therapy program. Otherwise, control group presented a significant worsening for overall (p = 0.01), physical (p = 0.01) and psychological (p = 0.008) domains. Exercise group presented two participants with positive reliable change (PRC) for social domain, two participants with PRC for Environment domain. Overall and Physical domain presented three participants with PRC. Psychological domain presented four participants with PRC and one with negative reliable change. CONCLUSION: A low-intensity group-based physical therapy program may contribute in order to maintain quality of life and improve some psychological aspects among community-dwelling elderly women.

A randomized controlled trial of group Stepping Stones Triple P: a mixed-disability trial

Stepping Stones Triple P (SSTP) is a parenting program designed for families of a child with a disability. The current study involved a randomized controlled trial of Group Stepping Stones Triple P (GSSTP) for a mixed-disability group. Participants were 52 families of children diagnosed with an Autism Spectrum Disorder, Down syndrome, Cerebral Palsy, or an intellectual disability. The results demonstrated significant improvements in parent-reported child behavior, parenting styles, parental satisfaction, and conflict about parenting. Results among participants were similar despite children's differing impairments. The intervention effect was maintained at 6-month follow-up. The results indicate that GSSTP is a promising intervention for a mixed-disability group. Limitations of the study, along with areas for future research, are also discussed.

Efficacy of Stepping Stones Triple P Plus a Stress Management Adjunct for Parents of Children with an Acquired Brain Injury: The Protocol of a Randomised Controlled Trial

Paediatric acquired brain injury (ABI) is the most common cause of acquired disability in childhood. It frequently results in significant personality, cognitive, emotional and behavioural changes, and consequent impairment in independent functioning, education, employment and interpersonal relationships. Additionally, paediatric ABI impacts on the entire family system, with parents commonly reporting significant distress and adjustment difficulties. Despite this, there is currently limited research into effective programmes to support families following their child's ABI. This protocol describes a wait-list randomised controlled trial of a behavioural family intervention plus a parent stress management programme for paediatric ABI. Interventions will be conducted with parents in a group format, aiming to improve child outcomes by improving parenting behaviour and coping. Outcomes assessed will be: (i) child behaviour and emotional outcome as measured by parent and teacher reports; (ii) parental style and confidence; (iii) parental adjustment (stress, anxiety and depression symptoms); (iv) family functioning; (v) parent relationship; and (vi) parent psychological flexibility. Assessments will be via questionnaires conducted pre-, mid- and post- intervention, and at a 6-month follow-up. The theoretical basis, study hypotheses, methods and planned analyses are described.

Effectiveness of a cognitive behavioural group therapy (CBGT) for social anxiety disorder: immediate and long-term benefits

This study examines the effectiveness of a group CBT (CBGT) intervention in reducing a variety of symptoms and problem areas associated with social anxiety disorder. A longitudinal cohort design assessed changes in standardized psychological scales assessing general mood and specific aspects of social anxiety. Questionnaires were completed pre-programme (time 1, n = 252), post-programme (time 2, n = 202), and at 12 months follow-up (time 3, n = 93). A consistent significant pattern was found for all variables: pre-intervention scores were significantly higher than both post-intervention scores and 12-month follow-up scores. Large effect sizes were found and rates of clinical significant changes varied, with over half of the participants recording clinically significant changes in general mood. Individual CBT can be translated successfully into a group format for social anxiety. Given the high completion rate, the intervention is acceptable to participants, feasible, and effective in a routine clinical service.

A Validation and Replication Study of the Patient-Generated Measure PSYCHLOPS on an Icelandic Clinical Population

PSYCHLOPS (Psychological Outcome Profiles; Ashworth et al., 2004 ) is a patient-generated outcome measure developed to be a sensitive indicator of change after therapy. It requires the patient to choose which symptoms or problems are most important to measure over the course of therapy. The present study replicates previous findings for the original version and validates the Icelandic version. The psychometric properties of PSYCHLOPS were investigated by comparing it to an established nomothetic outcome measure, CORE-OM. Icelandic versions of both questionnaires were administered to patients attending cognitive behavior group therapy in a mental-health setting in Iceland. PSYCHLOPS was found to be considerably more sensitive to change over therapy than CORE-OM; convergent and concurrent validity was supported, and internal reliabilities were satisfactory. The acceptability of the instrument was demonstrated by the high completion rate. Overall, these findings suggest that the Icelandic version of PSYCHLOPS has good psychometric properties, and the findings compared very favorably to previous findings. It is concluded that PSYCHLOPS should be considered a desirable instrument for evaluating mental-health outcome and a valuable complement to conventional nomothetic outcome measures.