What treatment outcomes matter in adolescent depression? A Q-study of priority profiles among mental health practitioners in the UK and Chile

Evidence-based and person-centred care requires the measurement of treatment outcomes that matter to youth and mental health practitioners. Priorities, however, may vary not just between but also within stakeholder groups. This study used Q-methodology to explore differences in outcome priorities among mental health practitioners from two countries in relation to youth depression. Practitioners from the United Kingdom (UK) (n = 27) and Chile (n = 15) sorted 35 outcome descriptions by importance and completed brief semi-structured interviews about their sorting rationale. By-person principal component analysis (PCA) served to identify distinct priority profiles within each country sample; second-order PCA examined whether these profiles could be further reduced into cross-cultural "super profiles". We identified three UK outcome priority profiles (Reduced symptoms and enhanced well-being; improved individual coping and self-management; improved family coping and support), and two Chilean profiles (Strengthened identity and enhanced insight; symptom reduction and self-management). These could be further reduced into two cross-cultural super profiles: one prioritized outcomes related to reduced depressive symptoms and enhanced well-being; the other prioritized outcomes related to improved resilience resources within youth and families. A practitioner focus on symptom reduction aligns with a long-standing focus on symptomatic change in youth depression treatment studies, and with recent measurement recommendations. Less data and guidance are available to those practitioners who prioritize resilience outcomes. To raise the chances that such practitioners will engage in evidence-based practice and measurement-based care, measurement guidance for a broader set of outcomes may be needed.

The Effectiveness of 6 versus 12 Months of Dialectical Behavior Therapy for Borderline Personality Disorder: A Noninferiority Randomized Clinical Trial

INTRODUCTION

Evidence-based psychotherapies for borderline personality disorder (BPD) are lengthy, posing a barrier to their access. Brief psychotherapy may achieve comparable outcomes to long-term psychotherapy for BPD. Evidence is needed regarding the comparative effectiveness of short- versus long-term psychotherapy for BPD.

OBJECTIVE

The aim was to determine if 6 months of Dialectical Behavior Therapy (DBT) is noninferior to 12 months of DBT in terms of clinical effectiveness.

METHODS

This two-arm, single-blinded, randomized controlled noninferiority trial with suicidal or self-harming patients with BPD was conducted at two sites in Canada. Participants (N = 240, M (SD)age = 28.27 (8.62), 79% females) were randomized to receive either 6 (DBT-6) or 12 months (DBT-12) of comprehensive DBT. Masked assessors obtained measures of clinical effectiveness at baseline and every 3 months, ending at month 24. DBT-6 and DBT-12 were outpatient treatments consisting of weekly individual therapy sessions, weekly DBT skills training group sessions, telephone consultation as needed, and weekly therapist consultation team meetings.

RESULTS

The noninferiority hypothesis was supported for the primary outcome, total self-harm (6 months: margin = -1.94, Mdiff [95% CI] = 0.16 [-0.14, 0.46]; 12 months: margin = -1.47, Mdiff [95% CI] = 0.04 [-0.17, 0.23]; 24 months: margin = -1.25, Mdiff [95% CI] = 0.12 [-0.02, 0.36]). Results also supported noninferiority of DBT-6 for general psychopathology and coping skills at 24 months. Furthermore, DBT-6 participants showed more rapid reductions in BPD symptoms and general psychopathology. There were no between-group differences in dropout rates.

CONCLUSIONS

The noninferiority of a briefer yet comprehensive treatment for BPD has potential to reduce barriers to treatment access.

Group treatment for complex dissociative disorders: a randomized clinical trial

BACKGROUND

Patients with complex dissociative disorders (CDD) report high levels of childhood- abuse experiences, clinical comorbidity, functional impairment, and treatment utilization. Although a few naturalistic studies indicate that these patients can benefit from psychotherapy, no randomized controlled trials have been reported with this patient-group. The current study evaluates a structured protocolled group treatment delivered in a naturalistic clinical setting to patients with CDD, as an add-on to individual treatment.

METHODS

Fifty nine patients with CDD were randomized to 20 sessions of stabilizing group-treatment, conjoint with individual therapy, or individual therapy alone, in a delayed-treatment design. The treatment was based on the manual Coping with Trauma-Related Dissociation. The primary outcome was Global Assessment of Functioning (GAF), while secondary outcomes were PTSD and dissociative symptoms, general psychopathology, and interpersonal difficulties.

RESULTS

Mixed effect models showed no condition x time interaction during the delayed treatment period, indicating no immediate differences between conditions in the primary outcome. Similar results were observed for secondary outcomes. Within-group effects were non-significant in both conditions from baseline to end of treatment, but significant improvements in psychosocial function, PTSD symptoms, and general psychopathology were observed over a 6-months follow-up period.

CONCLUSION

In the first randomized controlled trial for the treatment of complex dissociative disorders, stabilizing group treatment did not produce immediate superior outcomes. Treatment was shown to be associated with improvements in psychological functioning.

TRIAL REGISTRATION

Clinical Trials ( NCT02450617 ).

Older adults respond better to psychological therapy than working-age adults: evidence from a large sample of mental health service attendees

BACKGROUND

Older adults commonly experience depression and anxiety, yet are under-represented in psychological treatment services. There is uncertainty about the outcomes from psychological therapies for older adults relative to working-age adults. This study explored: pre-treatment differences between older and working-age patients with depression or anxiety disorders; whether outcomes from psychological therapy differ between groups controlling for pre-treatment clinical severity, functioning, and socio-demographics; and whether the impact of a long-term health condition (LTC) on outcome differs by age.

METHODS

Data on >100,000 patients treated with psychological therapies in eight Improving Access to Psychological Therapies services were analyzed. We compared pre-treatment characteristics and therapy outcomes for older (≥65 years) and working-age (18-64 years) patients, and investigated associations between age and outcomes.

RESULTS

Older adults had less severe clinical presentations pre-treatment. In adjusted models older adults were more likely to reliably recover (OR=1.33(95%CI=1.24-1.43)), reliably improve (OR=1.34(95%CI =1.24-1.45)), and attrition was less likely (OR=0.48(95%CI =0.43-0.53)). Effects were more pronounced in patients with anxiety disorders compared to depression. Having an LTC was associated with a much lower likelihood of reliable recovery for working-age patients but had only a modest effect for older adults.

LIMITATIONS

There are potential selection biases affecting the characteristics of older people attending these services. Residual confounding cannot be ruled out due to limits on data available.

CONCLUSIONS

Older adults experienced better outcomes from psychological treatments than working-age adults. Given the deleterious effects if mental health conditions go untreated, increasing access to psychological therapies for older people should be an international priority.

Lifespan Integration Therapy with Trauma-Exposed Children: a Hermeneutic Single Case Efficacy Study

Childhood trauma is a devastating reality with immense psychological impact to a child. Outcome research of therapy with trauma-exposed children is scarce and mostly focuses on cognitive and behavioural changes. Anecdotal evidence suggests that Lifespan Integration (LI) therapy purports to integrate traumatic experiences into a cohesive autobiographical narrative. In this research study, we investigate the efficacy of LI with children through the careful examination of one participant. We applied Robert Elliott's Hermeneutic Single Case Efficacy Research Design (HSCED; 2002, 2014), which uses quantitative and qualitative data to argue for and against therapy efficacy. The 12-year-old research participant received nine sessions of LI over 3 months, and data was collected before, throughout, and after therapy. The extent of the client's change over the course of therapy was investigated, as well as LI's contribution to the change, and what parts of LI were most helpful in bringing about change. Findings indicate that the client changed significantly over the course of therapy with lasting effects at follow-up, and that LI was substantially responsible for this change. Conclusions: The results provide evidence for LI as an important tool that mental health professionals can use to help trauma-exposed children.

Interactive Motion-Assisted Exposure Therapy for Veterans with Treatment-Resistant Posttraumatic Stress Disorder: A Randomized Controlled Trial

BACKGROUND

Veterans with posttraumatic stress disorder (PTSD) tend to benefit less from evidence-based treatments than other PTSD populations. A novel virtual reality and motion-assisted exposure therapy, called 3MDR, provides treatment in an immersive, personalized and activating context.

OBJECTIVE

To study the efficacy of 3MDR for veterans with treatment-resistant PTSD.

METHOD

In a randomized controlled trial (n = 43) 3MDR was compared to a non-specific treatment component control group. Primary outcome was clinician-rated PTSD symptoms at baseline, after 3MDR, and at the 12-week and 16-week follow-up (primary end point). Intention-to-treat analyses of covariance and mixed models were applied to study differences between groups at the end point and over the course of intervention, controlling for baseline scores.

RESULTS

The decrease in PTSD symptom severity from baseline to end point was significantly greater for 3MDR as compared to the control group, with a large effect size (F[1, 37] = 6.43, p = 0.016, d = 0.83). No significant between-group difference was detected in the course of PTSD symptoms during treatment when including all time points. The dropout rate was low (7%), and 45% of the patients in the 3MDR group improved clinically. The number needed to treat was 2.86.

CONCLUSIONS

In this trial, 3MDR significantly decreased PTSD symptoms in veterans with, on average, a history of 4 unsuccessful treatments. The low dropout rate may be indicative of high engagement. However, a lack of significant differences on secondary outcomes limits conclusions that can be drawn on its efficacy and underlines the need for larger phase III trials. These data show emerging evidence for 3MDR and its potential to progress PTSD treatment for veterans (Dutch Trial Register Identifier: NL5126).

Effectiveness of EMDR in patients with substance use disorder and comorbid PTSD: study protocol for a randomized controlled trial

BACKGROUND

Eye Movement Desensitization and Reprocessing (EMDR) is an evidence-based treatment for PTSD. However, it is unclear whether EMDR shows the same effectiveness in patients with substance use disorders (SUD) and comorbid PTSD. In this trial, we examine the effectiveness of EMDR in reducing PTSD symptoms in patients with SUD and PTSD.

METHODS/DESIGN

We conduct a single-blinded RCT among 158 patients with SUD and comorbid PTSD admitted to a German addiction rehabilitation center specialized for the treatment of patients with SUD and comorbid PTSD. Patients are randomized to receive either EMDR, added to SUD rehabilitation and non-trauma-focused PTSD treatment (TAU), or TAU alone. The primary outcome is change from baseline in PTSD symptom severity as measured by the Clinician-Administered PTSD Scale at 6-month follow-up. Secondary outcomes are change from baseline in substance use, addiction-related problems, depressive symptoms, dissociative symptoms, emotion dysregulation and quality of life. Assessments are carried out by blinded raters at admission, at end of treatment, and at 3- and 6-month follow-up. We expect that EMDR plus TAU will be more effective in reducing PTSD symptoms than TAU alone. Mixed models will be conducted using an intention-to-treat and per-protocol approach.

DISCUSSION

This study aims to expand the knowledge about the effectiveness of EMDR in patients with SUD and comorbid PTSD. The expected finding of the superiority of EMDR in reducing PTSD symptoms compared to non-trauma-focused PTSD treatment may enhance the use of trauma-focused treatment approaches for patients with SUD and co-morbid PTSD.

TRIAL REGISTRATION

German Clinical Trials Register: DRKS00009007 ; U1111-1172-9213. Retrospectively registered 01 Juni 2016.