Allan Zuckoff

Brief Interpersonal Psychotherapy for Depressed Mothers Whose Children Are Receiving Psychiatric Treatment

OBJECTIVE Depressed mothers of children with psychiatric illness struggle with both their own psychiatric disorder and the demands of caring for ill children. When maternal depression remains untreated, mothers suffer, and psychiatric illness in their offspring is less likely to improve. This randomized, controlled trial compared the interpersonal psychotherapy for depressed mothers (IPT-MOMS), a nine-session intervention based on standard interpersonal psychotherapy, to treatment as usual for depressed mothers with psychiatrically ill offspring. METHOD Forty-seven mothers meeting DSM-IV criteria for major depression were recruited from a pediatric mental health clinic where their school-age children were receiving psychiatric treatment and randomly assigned to IPT-MOMS (N=26) or treatment as usual (N=21). Mother-child pairs were assessed at three time points: baseline, 3-month follow-up, and 9-month follow-up. Child treatment was not determined by the study. RESULTS Compared to subjects assigned to treatment as usual, subjects assigned to IPT-MOMS showed significantly lower levels of depression symptoms, as measured by the Hamilton Depression Rating Scale, and higher levels of functioning, as measured by the Global Assessment of Functioning, at 3-month and 9-month follow-ups. Compared to the offspring of mothers receiving treatment as usual, the offspring of mothers assigned to IPT-MOMS showed significantly lower levels of depression as measured by the Childrens Depressive Inventory at the 9-month follow-up. CONCLUSIONS Assignment to IPT-MOMS was associated with reduced levels of maternal symptoms and improved functioning at the 3- and 9-month follow-ups compared to treatment as usual. Maternal improvement preceded improvement in offspring, suggesting that maternal changes may mediate child outcomes.

Challenges Using Motivational Interviewing as an Adjunct to Exposure Therapy for Obsessive-Compulsive Disorder

Exposure and response prevention (EX/RP) is an efficacious treatment for obsessive-compulsive disorder (OCD). However, patients often do not adhere fully to EX/RP procedures. Motivational interviewing (MI) has been shown to improve treatment adherence in other disorders. This pilot study used a randomized controlled design to examine whether MI can be successfully added to EX/RP and whether this intervention (EX/RP+MI) could improve patient adherence to between-session EX/RP procedures relative to EX/RP alone. Thirty adults with OCD were randomized to 18 sessions of EX/RP or EX/RP+MI. Therapists rated patient adherence at each exposure session. Independent evaluators assessed change in OCD and depressive symptoms, and patients completed self-report measures of readiness for change and quality of life. The two treatment conditions differed in degree of congruence with MI but not in conduct of EX/RP procedures. Both groups experienced clinically significant improvement in OCD symptoms, without significant group differences in patient adherence. There are several possible reasons why EX/RP+MI had no effect on patient adherence compared to standard EX/RP, each of which has important implications for the design of future MI studies in OCD. We recommend that MI be further evaluated in OCD by exploring alternative modes of delivery and by focusing on patients less ready for change than the current sample.

Adding motivational interviewing to exposure and ritual prevention for obsessive-compulsive disorder: an open pilot trial.

Exposure and ritual prevention (EX/RP) is an efficacious treatment for obsessive–compulsive disorder (OCD), but high dropout rates and variable treatment adherence limit its effectiveness. Motivational interviewing (MI) has shown promise as an adjunct to symptom‐focused treatments for improving treatment adherence and outcomes. The authors developed a manual integrating MI with EX/RP, consisting of three information‐gathering/motivational enhancement sessions and 15 EX/RP sessions with an optional MI module to be used as needed. Six patients with moderate to severe OCD symptoms (Yale‐Brown Obsessive Compulsive Scale [Y‐BOCS] score⩾16) underwent treatment. Five showed a decrease in their baseline Y‐BOCS scores and an increase in their quality of life, with three achieving an excellent response (i.e. Y‐BOCS⩽12 at Session 18). The authors briefly describe the motivational strategies used in the six cases and suggest that integrating MI with standard EX/RP is a promising method to increase and sustain patient engagement with EX/RP. Challenges in combining these treatments and maintaining the integrity of each as well as limitations of the study are discussed.

Preventive Intervention for Living Donor Psychosocial Outcomes: Feasibility and Efficacy in a Randomized Controlled Trial

There are no evidence‐based interventions to prevent adverse psychosocial consequences after living donation. We conducted a single‐site randomized controlled trial to examine the postdonation impact of a preventive intervention utilizing motivational interviewing (MI) to target a major risk factor for poor psychosocial outcomes, residual ambivalence (i.e. lingering hesitation and uncertainty) about donating. Of 184 prospective kidney or liver donors, 131 screened positive for ambivalence; 113 were randomized to (a) the MI intervention, (b) an active comparison condition (health education) or (c) standard care only before donation. Ambivalence was reassessed postintervention (before donation). Primary trial outcomes—psychosocial variables in somatic, psychological and family interpersonal relationship domains—were assessed at 6 weeks and 3 months postdonation. MI subjects showed the greatest decline in ambivalence (p = 0.050). On somatic outcomes, by 3 months postdonation MI subjects reported fewer physical symptoms (p = 0.038), lower rates of fatigue (p = 0.021) and pain (p = 0.016), shorter recovery times (p = 0.041) and fewer unexpected medical problems (p = 0.023). Among psychological and interpersonal outcomes, they had a lower rate of anxiety symptoms (p = 0.046) and fewer unexpected family‐related problems (p = 0.045). They did not differ on depression, feelings about donation or family relationship quality. The findings suggest that the intervention merits testing in a larger, multisite trial.

Enhancing Interpersonal Psychotherapy for Mothers and Expectant Mothers on Low Incomes: Adaptations and Additions

Intervening with depressed women during their childbearing years, especially with those on low incomes, is critically important. Not only do mothers and expectant mothers suffer unnecessarily, but their untreated depression has critical negative consequences for their families. Despite this, these women have proven especially difficult to engage in psychotherapy. In this paper we describe several adaptations and additions we have made to a brief form of Interpersonal Psychotherapy (IPT) to meet the needs of mothers and expectant mothers living on low incomes in the community who suffer from depression, but face significant practical, psychological, and cultural barriers to engaging in and staying in treatment. In addition, we present some preliminary data on the extent to which our enhanced, brief IPT approach promotes improvements in treatment engagement and retention relative to usual care for expectant mothers on low incomes.

Characterizing female bipolar alcoholic patients presenting for initial evaluation

This study examined gender differences of age and race-matched group of bipolar disorder (BPO) patients with comorbid alcohol dependence (AD; n = 65; males = 35, females = 30) to a group of BPO patients without comorbid AD (n = 61; males = 22, females = 39). The two groups were also similar on marital status and frequency of BPO subtypes. The results revealed that female bipolar alcoholic patients were more likely to report depressive symptoms as compared to either male bipolar alcoholics or both male and female non-alcoholic bipolar patients. When compared to male bipolar alcoholics, they had higher frequency of depressed mood, slow motor behavior, low self-esteem, decreased libido, decreased appetite, and higher general anxiety symptoms. On the other hand, female bipolar alcoholics differed from female non-alcoholic bipolar patients on reports of mood lability, depressed mood, low self-esteem, suicidal indicators, decreased libido, and general anxiety symptoms. These results raise the question of whether alcohol increases the frequency of depressive symptoms among female bipolar patients.

Predictors of patient adherence to cognitive-behavioral therapy for obsessive-compulsive disorder.

Cognitive-behavioral therapy consisting of exposure and response prevention (EX/RP) is an effective treatment for obsessive-compulsive disorder (OCD). However, only about half of patients achieve minimal or no symptoms by the end of treatment [1,2,3]. Identifying factors that lead to poor outcome and developing interventions to address them is one way to maximize the effects of EX/RP. Patient adherence to EX/RP is a strong predictor of EX/RP outcome [4,5]. Specifically, during EX/RP treatment, therapists teach patients to face feared situations and thoughts (exposures) and to refrain from compulsive behaviors (response prevention). However, no prior study has systematically examined what predicts patient adherence to EX/RP procedures. We examined potential predictors of patient adherence to EX/RP and whether patient adherence mediated the relationship between these predictors and post-treatment OCD severity. The sample consisted of 28 adults (18–70 years old) with OCD who received EX/RP as part of a clinical trial described in detail elsewhere [3]. In brief, patients participated in 8 weeks of EX/RP that included 3 introductory sessions and 15 twice-weekly 90-minute exposure sessions following the guidelines of Kozak and Foa. Patient adherence was measured at each exposure session using the Patient EX/RP Adherence Scale (PEAS) [7]; it assessed the quantity and quality of between-session exposures and the degree of response prevention practiced for homework. OCD symptoms were rated by independent evaluators using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) [8,9]. We examined four factors hypothesized to affect cognitive-behavioral therapy adherence in other patient groups [3,10,11,12]: treatment expectancy using the Expectancy Questionnaire [10], therapeutic alliance using the Working Alliance Inventory – Self Report (WAI-SR) [12], readiness for change using the University of Rhode Island Change Assessment (URICA) [13], and readiness for treatment using the Readiness Ruler [3]. These measures were completed after the 3 introductory sessions and before exposure sessions began. We also examined baseline characteristics that predicted EX/RP outcome in prior OCD studies [14]. These included depressive severity as measured by the 17-item Hamilton Depression Rating Scale [15], insight on the Brown Assessment of Beliefs Scale [16], quality of life as measured by the Quality of Life and Enjoyment Questionnaire [17], Axis I comorbidity using the SCID-I [18], total number of serotonin reuptake inhibitor trials, female gender, employment status, work impairment as measured by an item on the Sheehan Disability Scale [19], and hoarding subtype. Simple linear regression examined potential bivariate predictors of adherence. Significant predictors (p < 0.05) were then considered in subsequent mediation analyses (using Mplus 6.1) that involved simultaneous multiple regressions of adherence on all predictors and of treatment outcome (measured by post-treatment Y-BOCS adjusting for baseline Y-BOCS) on all predictors and adherence. Significant predictors (p < 0.05) of adherence and outcome in these multiple regressions were retained and their indirect effects (mediation effects) on treatment outcome through adherence were estimated and delta method standard errors were used for 95% confidence intervals and testing [20]. Data from all patients having a PEAS score were used (n = 28) and full information maximum likelihood was implemented in Mplus to account for missing post-treatment Y-BOCS scores (3 subjects dropped out from EX/RP treatment after session 9). Estimates were standardized to facilitate interpretation across predictors with different units. The relationship between potential predictors and patient adherence to between-session EX/RP assignments based on simple regressions is presented in table ​table1.1. The 6 significant (p < 0.05) bivariate predictors of patient adherence were entered into mediation analyses and their estimated indirect effects are presented in table ​table1.1. Therapeutic alliance (WAI-SR, beta = 0.53), treatment readiness (Readiness Ruler, beta = 0.38), and hoarding status (beta = −0.26) all had significant (p < 0.05) independent effects on patient adherence. Patient adherence also had a significant direct effect (beta = −0.57, p < 0.01) on outcome and significantly mediated the impact of these other predictors on post-treatment OCD severity (table ​(table1,1, indirect effects). The effects for treatment expectancy and readiness to change (URICA) were not significant in these mediation analyses. Work impairment (Sheehan Disability Scale) was not significantly associated with patient adherence, although it directly predicted post-treatment OCD severity (0.40, p < 0.01). Table 1 Individual predictors of patient adherence (between-session PEAS) and their indirect effects on treatment outcome through patient adherence (n = 28) Our findings have several implications. First, therapeutic alliance (measured by the WAI-SR) predicted treatment outcome through its impact on patient adherence. The WAI-SR assesses patient attitudes about EX/RP strategies and goals presented by the therapist, and patients’ trust in the therapist. This suggests that taking time to understand patients’ symptoms and to carefully explain treatment strategies and goals before conducting exposure can have a strong impact on adherence and outcome. Future studies should examine whether there are specific components of therapeutic alliance that predict patient adherence and how to bolster them to maximize EX/RP outcome. Second, readiness for treatment (measured by the Readiness Ruler) also predicted treatment outcome through patient adherence. The Readiness Ruler measures readiness to engage in specific EX/RP procedures, unlike the URICA, which measures readiness to change in general. If our findings are replicated, the simplicity of the Readiness Ruler makes it an attractive tool for identifying patients at risk for poor EX/RP adherence, which would permit early intervention to enhance readiness for EX/RP before a lengthy course of treatment is initiated. Third, hoarding status predicted poorer treatment outcome through patient adherence. This finding is consistent with prior observations that these patients often have low motivation for treatment and poor insight that makes exposure to discarding very difficult [21,22]. To improve treatment outcome for people who hoard, interventions are needed that enhance patient adherence to EX/RP procedures. Such interventions may need to focus first on addressing motivation for EX/RP treatment and insight into the need to discard. This study has several limitations. First, the sample was relatively small. Replication in larger samples is needed. Second, this sample was generally adherent to EX/RP treatment. Different factors might influence patient adherence in treatment-refractory patients. Finally, patients were relatively free of depression and had good insight, limiting inferences that can be made about the impact of either on patient adherence. If these findings are replicated, future research should develop interventions to enhance therapeutic alliance and treatment readiness, deliver these interventions to those who show poor alliance or treatment readiness, and test whether this leads to improved patient adherence and thereby outcome, as our findings suggest.

Measuring client perceptions of motivational interviewing: factor analysis of the Client Evaluation of Motivational Interviewing scale

Motivational interviewing (MI) is an intervention approach that has solid evidence of efficacy with substance use disorders. Research and training have benefitted from the development of observational measures to assess MI fidelity and competence. However, one untapped area of assessment is the client perception of the clinician use of MI. Client perceptions of MI have been found through qualitative interviews to relate to motivation to change, view of the therapist and safety of therapy. The Client Evaluation of MI (CEMI) scale was developed to assess client perception of clinician MI use. This study further evaluated the CEMI through exploratory and confirmatory factor analysis with a sample of 500 individuals with dual diagnosis pre-discharge from an inpatient unit. Participants completed an MI based session prior to completing CEMIs. A two factor (relational and technical) model explained 51.1% of the cumulative variance and was supported through confirmatory factor analysis. Suggestions for revisions are provided as well as potential uses of the CEMI and future directions for research.

Patient adherence to cognitive-behavioral therapy predicts long-term outcome in obsessive-compulsive disorder.

Our prior research demonstrated that patient adherence to homework during cognitive-behavioral therapy (CBT) strongly predicts acute outcome for patients with obsessive-compulsive disorder (OCD).1 To examine whether homework adherence also predicts outcome at 6 month follow-up, we capitalized on data from a clinical trial that provided CBT consisting of exposure and ritual prevention (EX/RP) to 30 adults with OCD, measured homework adherence during acute treatment using a reliable and validated scale, and re-evaluated severity of OCD 6 months later.

A Randomized Controlled Trial to Compare Computer-assisted Motivational Intervention with Didactic Educational Counseling to Reduce Unprotected Sex in Female Adolescents

STUDY OBJECTIVE To examine a computer-assisted, counselor-guided motivational intervention (CAMI) aimed at reducing the risk of unprotected sexual intercourse. DESIGN, SETTING, PARTICIPANTS, INTERVENTIONS, AND MAIN OUTCOME MEASURES: We conducted a 9-month, longitudinal randomized controlled trial with a multisite recruitment strategy including clinic, university, and social referrals, and compared the CAMI with didactic educational counseling in 572 female adolescents with a mean age of 17 years (SD = 2.2 years; range = 13-21 years; 59% African American) who were at risk for pregnancy and sexually transmitted diseases. The primary outcome was the acceptability of the CAMI according to self-reported rating scales. The secondary outcome was the reduction of pregnancy and sexually transmitted disease risk using a 9-month, self-report timeline follow-back calendar of unprotected sex. RESULTS The CAMI was rated easy to use. Compared with the didactic educational counseling, there was a significant effect of the intervention which suggested that the CAMI helped reduce unprotected sex among participants who completed the study. However, because of the high attrition rate, the intent to treat analysis did not demonstrate a significant effect of the CAMI on reducing the rate of unprotected sex. CONCLUSION Among those who completed the intervention, the CAMI reduced unprotected sex among an at-risk, predominantly minority sample of female adolescents. Modification of the CAMI to address methodological issues that contributed to a high drop-out rate are needed to make the intervention more acceptable and feasible for use among sexually active predominantly minority, at-risk, female adolescents.