A. C. Del Re

How central is the alliance in psychotherapy? A multilevel longitudinal meta-analysis

Prior meta-analyses have found a moderate but robust relationship between alliance and outcome across a broad spectrum of treatments, presenting concerns, contexts, and measurements. However, there continues to be a lively debate about the therapeutic role of the alliance, particularly in treatments that are tested using randomized clinical trial (RCT) designs. The purpose of this present study was to examine whether research design, type of treatment, or authors allegiance variables, alone or in combination, moderate the relationship between alliance and outcome. Multilevel longitudinal analysis was used to investigate the following moderators of the alliance-outcome correlation: (a) research design (RCT or other), (b) use of disorder-specific manuals, (c) specificity of outcomes, (d) cognitive and/or behavioral therapy (CBT) or other types of treatments, (e) researcher allegiance, and (f) time of alliance assessment. RCT, disorder-specific manual use, specificity of primary and secondary outcomes, and CBT did not moderate the alliance-outcome correlation. Early alliance-outcome correlations were slightly higher in studies conducted by investigators with specific interest in alliance than were those in studies conducted by researchers without such an allegiance. Over the course of therapy, these initial differences disappeared. Apart from this trend, none of the variables previously proposed as potential moderators or mediators of the alliance-outcome relation, alone or in combination, were found to have a mediating impact.

Therapist effects in the therapeutic alliance–outcome relationship: A restricted-maximum likelihood meta-analysis☆

OBJECTIVE Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance-outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship. METHOD A random effects analysis examined several moderators of the alliance-outcome correlation. These included (a) patient-therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis. RESULTS The patient-therapist ratio (PTR) was a significant moderator of the alliance-outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance-outcome correlation. CONCLUSION Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.

Evidence-based treatments for depression and anxiety versus treatment-as-usual: A meta-analysis of direct comparisons☆

OBJECTIVE The aim of this study was to examine the relative efficacy of evidence-based treatments (EBTs) versus treatment-as-usual (TAU) in routine care for anxiety and depression in adults. METHOD A computerized search of studies that directly compared an EBT with a TAU was conducted. Meta-analytic methods were used to estimate effectiveness of EBTs relative to TAU and to model how various confounding variables impacted the results of this comparative research. RESULTS A total of 14 studies were included in the final meta-analysis. There was significant heterogeneity in the TAU conditions, which ranged from unknown and/or minimal mental health treatment to psychotherapeutic interventions provided by trained professionals. Although the effect for EBT vs. TAU was significantly greater than zero, the effect for EBT vs. TAUs that were psychotherapeutic interventions was not statistically different from zero. CONCLUSIONS Heterogeneity of TAU conditions in this meta-analysis highlight the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT-TAU comparisons. Researchers need to clarify if they are comparing an EBT to psychotherapeutic services in routine care or to minimal mental health services. Extant research on EBT versus TAU reveals that there is insufficient evidence to recommend the transportation of EBTs for anxiety and depression to routine care, particularly when the routine care involves psychotherapeutic services.

A meta-analysis of topiramate's effects for individuals with alcohol use disorders.

BACKGROUND Influenced by several trials and reviews highlighting positive outcomes, topiramate is increasingly prescribed as a treatment for alcohol use disorders (AUDs). The only previously published meta-analysis of topiramate for AUDs was limited by a sample of only 3 randomized, placebo-controlled trials (RCTs). METHODS A systematic search identified 7 RCTs (including a total of 1,125 participants) that compared topiramate to placebo for the treatment for AUDs. This meta-analysis estimated the overall effects of topiramate on abstinence, heavy drinking, craving, and γ-glutamyltranspeptidase (GGT) outcomes and included several sensitivity analyses to account for the small sample of studies. RESULTS Overall, the small to moderate effects favored topiramate, although the effect on craving was not quite significantly different from 0. The largest effect was found on abstinence (g = 0.468, p < 0.01), followed by heavy drinking (g = 0.406, p < 0.01), GGT (g = 0.324, p = 0.02), and craving (g = 0.312, p = 0.07) outcomes. Sensitivity analyses did not change the magnitude or direction of the results, and tests did not indicate significant publication bias. The small sample size did not allow for examination of specific moderators of the effects of topiramate. CONCLUSIONS Topiramate can be a useful tool in the treatment of AUDs. Its efficacy, based on the current sample of studies, seems to be of somewhat greater magnitude than that of the most commonly prescribed medications for AUDs (naltrexone and acamprosate). Further research will help to identify the contexts in which topiramate is most beneficial (e.g., dose, concurrent psychotherapy, patient characteristics).

Efficacy of new generation antidepressants: differences seem illusory.

Background Recently, Cipriani and colleagues examined the relative efficacy of 12 new-generation antidepressants on major depression using network meta-analytic methods. They found that some of these medications outperformed others in patient response to treatment. However, several methodological criticisms have been raised about network meta-analysis and Ciprianis analysis in particular which creates the concern that the stated superiority of some antidepressants relative to others may be unwarranted. Materials and Methods A Monte Carlo simulation was conducted which involved replicating Ciprianis network meta-analysis under the null hypothesis (i.e., no true differences between antidepressants). The following simulation strategy was implemented: (1) 1000 simulations were generated under the null hypothesis (i.e., under the assumption that there were no differences among the 12 antidepressants), (2) each of the 1000 simulations were network meta-analyzed, and (3) the total number of false positive results from the network meta-analyses were calculated. Findings Greater than 7 times out of 10, the network meta-analysis resulted in one or more comparisons that indicated the superiority of at least one antidepressant when no such true differences among them existed. Interpretation Based on our simulation study, the results indicated that under identical conditions to those of the 117 RCTs with 236 treatment arms contained in Cipriani et al.s meta-analysis, one or more false claims about the relative efficacy of antidepressants will be made over 70% of the time. As others have shown as well, there is little evidence in these trials that any antidepressant is more effective than another. The tendency of network meta-analyses to generate false positive results should be considered when conducting multiple comparison analyses.

The effectiveness of evidence-based treatments for personality disorders when comparing treatment-as-usual and bona fide treatments ☆

OBJECTIVE The purpose of Study 1 was to examine the relative efficacy of evidence-based treatments (EBTs) when compared to treatment-as-usual (TAU) for adults diagnosed with a personality disorder (PD). The purpose of Study 2 was to investigate the strength of the differences between bona fide psychotherapeutic treatments for PDs. METHOD Two separate computerized searches were conducted of: (a) studies that directly compared an EBT with a TAU for treatment of PDs, or (b) studies that compared at least two bona fide treatments for PDs. Meta-analytic methods were used to estimate the effectiveness of the treatments when compared to one another and to model how various confounding variables impacted the results of this comparative research. RESULTS A total of 30 studies (Study 1; N=1662) were included in the meta-analysis comparing EBTs to TAU. A total of 12 studies (Study 2; N=723) were included in the meta-analysis comparing bona fide treatments. Study 1 found that EBTs were superior to TAU, although the TAU conditions were not comparable in many respects (e.g., not psychotherapy, lacking supervision, lacking training, etc.) to the EBT and there was significant heterogeneity in the effects. Study 2 found that some bona fide treatments were superior to others.

In pursuit of truth: A critical examination of meta-analyses of cognitive behavior therapy

Abstract Objective: Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia). Method: The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments. Results: When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies. Conclusion: Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Monitoring mindfulness practice quality: An important consideration in mindfulness practice

Abstract Mindfulness-Based Stress Reduction (MBSR) is an experientially based group intervention empirically supported to reduce psychological symptomology. Although MBSR has shown to be an effective intervention, little is known about which facets of the intervention are important in producing positive outcomes. This study tested several aspects of mindfulness practice (total practice duration, practice frequency and practice quality) with the primary focus being on validating (i.e., predictive and convergent validity) a new measure of mindfulness practice quality (PQ-M). The PQ-M fit a two-factor solution via a Maximum Likelihood Exploratory Factor Analysis (n=99). Using longitudinal multilevel modeling on a smaller subsample (n=19), preliminary support was found for changes in practice quality over the course of the MBSR intervention. Further, change in practice quality was associated with improvements in psychological symptoms. While this study was exploratory, these findings suggest that practice quality is a relevant factor to promote positive outcomes and may guide mindfulness instructors in providing highly tailored interventions.

The impact of neurobehavioral features on medication adherence in HIV: Evidence from longitudinal models

Effective antiretroviral therapy has led to substantial improvements in health-related outcomes among individuals with HIV. Despite advances in HIV pharmacotherapy, suboptimal medication adherence remains a significant barrier to successful treatment. Although several factors have been associated with medication adherence in the extant literature, study assessing the effects of some of the neurobehavioral features specific to HIV has been limited. Moreover, although there is a growing body of literature measuring medication adherence in HIV prospectively, few employ advanced statistical methodologies suited to handle advanced models with multiple predictors that would strengthen our understanding of medication adherence trajectories in HIV. This study sought to integrate traditionally assessed predictors of medication adherence with neurobehavioral features of HIV in a longitudinal study of medication adherence to combined antiretroviral therapy (cART). The current study used multilevel modeling to examine a wide arrangement of categories of factors – demographic, medication related, psychosocial, and neurobehavioral – on medication adherence. The sample consisted of 235 HIV+ individuals whose medication adherence was monitored over the course of six months using electronic monitoring devices. After controlling for the effects of demographic, medication, and psychosocial factors, neurobehavioral features added predictive validity to the model. In the final model, simultaneously controlling for the effects of each of the predictors within all the categories, age, self-efficacy, executive functioning, apathy, and frequency of stimulant use emerged as unique individual predictors of average medication adherence across the 6-month study. Self-efficacy and irritability predicted changes in medication adherence over time. Adherence behavior is multidetermined. Adequate assessment of these factors, combined with timely intervention, appears to be warranted in order to boost adherence rates.

Prescription of topiramate to treat alcohol use disorders in the Veterans Health Administration

BackgroundAs a quality improvement metric, the US Veterans Health Administration (VHA) monitors the proportion of patients with alcohol use disorders (AUD) who receive FDA approved medications for alcohol dependence (naltrexone, acamprosate, and disulfiram). Evidence supporting the off-label use of the antiepileptic medication topiramate to treat alcohol dependence may be as strong as these approved medications. However, little is known about the extent to which topiramate is used in clinical practice. The goal of this study was to describe and examine the overall use, facility-level variation in use, and patient -level predictors of topiramate prescription for patients with AUD in the VHA.MethodsUsing national VHA administrative data in a retrospective cohort study, we examined time trends in topiramate use from fiscal years (FY) 2009–2012, and predictors of topiramate prescription in 375,777 patients identified with AUD (ICD-9-CM codes 303.9x or 305.0x) treated in 141 VHA facilities in FY 2011.ResultsAmong VHA patients with AUD, rates of topiramate prescription have increased from 0.99% in FY 2009 to 1.95% in FY 2012, although substantial variation across facilities exists. Predictors of topiramate prescription were female sex, young age, alcohol dependence diagnoses, engagement in both mental health and addiction specialty care, and psychiatric comorbidity.ConclusionsVeterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Not including topiramate in the metric, which is prescribed more often than acamprosate and disulfiram combined, may underestimate the extent to which VHA patients at specific facilities and overall are receiving pharmacotherapy for AUD.