Bernd Puschner

Effect of feedback of treatment outcome in specialist mental healthcare: meta-analysis

BACKGROUND Feedback of treatment outcome during the course of therapy (outcome management) is increasingly considered to be beneficial for improving the quality of mental healthcare. AIMS To review the impact of feedback of outcome to practitioners and/or patients in specialist mental health services. METHOD A systematic search and meta-analysis of controlled trials using outcome management in mental health services published in English or German language. RESULTS Twelve studies met inclusion criteria. Feeding back outcome showed a small, but significant (d = 0.10; 95% CI 0.01-0.19) positive short-term effect on the mental health of individuals that did not prevail in the long run. Subgroup analysis revealed no significant differences regarding feedback modalities. Outcome management did not contribute to a reduction of treatment duration. CONCLUSIONS Evidence on the effects of outcome management in mental healthcare is promising. More targeted research is needed in order to identify the effective ingredients of outcome feedback and to assess its cost-effectiveness.

Discharge planning in mental health care: a systematic review of the recent literature

Objective:  To determine and estimate the efficacy of discharge planning interventions in mental health care from in‐patient to out‐patient treatment on improving patient outcome, ensuring community tenure, and saving costs.

Assessment of medication adherence in patients with schizophrenia: the Achilles heel of adherence research

Measuring medication adherence in patients with schizophrenia is difficult and lacks a gold standard. Consequently, a great number of different methods and instruments have been proposed. Although it has been assumed that they all measure medication adherence, this study demonstrates that instruments differ significantly. Using data from an international multisite study (N = 329), we found that 3 questionnaires, designed to measure medication adherence and typical for instruments used in studies in patients with schizophrenia, do not agree in labeling patients as nonadherent. Further, they seem not to measure the same trait, are related to different established risk factors of nonadherence, and are only weakly related to these established risk factors of nonadherence. If these results are representative of the validity of other measures used in adherence research, this may have serious consequences for the interpretation of, and explanations for discrepancies found in the literature. Researchers should be aware of this problem and continue to combine objective and subjective methods in the hope of increasing the reliability and validity of measures of adherence.

Interpersonal problems and outcome in outpatient psychotherapy: findings from a long-term longitudinal study in Germany.

We used a comprehensive longitudinal data set from Germany to examine trajectories of symptom distress depending on interpersonal problems at study intake measured via the Inventory of Interpersonal Problems-64 (IIP-64; Horowitz, Strauβ, & Kordy, 1994). Participants (N = 622) underwent mid- or long-term outpatient psychotherapy (either psychodynamically oriented psychotherapy, cognitive behavioral therapy, or analytic psychotherapy). Data comprises up to 5 assessments during a 2-year period and was analyzed via hierarchical linear modeling. In the analytic psychotherapy subgroup, initial symptom level was higher in submissive patients. Initial interpersonal problems were not predictive of the rate of symptom change during therapy. Only in psychodynamic treatments, low affiliation positively affected treatment outcome. Interpersonal problems at intake were not related to the number of utilized sessions and utilization rate across treatment subgroups. We discuss the findings and outline future research topics.

Course of improvement over 2 years in psychoanalytic and psychodynamic outpatient psychotherapy.

OBJECTIVE To assess and predict the level and course of symptomatic improvement in psychoanalytic (PAP) and psychodynamic psychotherapy (PD). METHODS In a comprehensive longitudinal study, the course of improvement of 116 patients in PAP and of 357 patients in PD was tracked over a period of 2 years and analysed via hierarchical linear models. RESULTS At baseline, over 90% of the patients reported substantial psychological, physical or interpersonal distress. In both forms of treatment, the course of improvement could be adequately fitted by a linear model. Symptom distress decreased notably within 2 years, with an especially sharp decline before the first formally scheduled therapy session. No significant differences between forms of treatment as to level or pace of symptom improvement could be observed. Prediction of speed of improvement was poor, with initial symptom distress showing the strongest influence while initial helping alliance had no predictive value. When comparing patients who finished their treatment within the 2-year observation period with those with still ongoing treatments, the former showed quicker symptom improvement. DISCUSSION Strategies for the optimal allocation of valuable therapeutic resources should be reconsidered. An adaptive, outcome-oriented allocation strategy of therapeutic resources is proposed.

Adherence to medication and quality of life in people with schizophrenia: results of a European multicenter study.

Quality of life is often severely impaired in people with schizophrenia, and adherence to antipsychotic medication has been consistently found to be low in this population. Although there is a considerable amount of evidence on these two variables in schizophrenia research, there is only limited knowledge on how they relate to one another. The aim of this study is to develop a meaningful model of the relationship between quality of life and adherence that includes mediating variables. A multicenter randomized controlled trial recruited 409 subjects in London, Verona, Amsterdam, and Leipzig. Baseline interviews obtained data on adherence, quality of life, and other variables. We used graphical modeling to investigate the relationships between the variables. No direct relation could be discerned between subjective quality of life and adherence to medication. Mediating variables, most importantly symptomatic impairment, global functioning, and medication side effects, were identified by the model. It can be concluded that, when aiming at the improvement of quality of life in people with schizophrenia, variables other than adherence, i.e., symptomatic impairment, global functioning, and medication side effects, should be targeted.

Needs-oriented discharge planning for high utilisers of psychiatric services: multicentre randomised controlled trial.

AIMS Attempts to reduce high utilisation of mental health inpatient care by targeting the critical time of hospital discharge are rare. In this study, we test the effect of a needs-oriented discharge planning intervention on number and duration of psychiatric inpatient treatment episodes (primary), as well as on outpatient service use, needs, psychopathology, depression and quality of life (secondary). METHODS Four hundred and ninety-one adults with a defined high utilisation of mental health care gave informed consent to participate in a multicentre RCT carried out at five psychiatric hospitals in Germany (Düsseldorf, Greifswald, Regensburg, Ravensburg and Günzburg). Subjects allocated to the intervention group were offered a manualised needs-led discharge planning and monitoring intervention with two intertwined sessions administered at hospital discharge and 3 months thereafter. Outcomes were assessed at four measurement points during a period of 18 months following discharge. RESULTS Intention-to-treat analyses showed no effect of the intervention on primary or secondary outcomes. CONCLUSIONS Process evaluation pending, the intervention cannot be recommended for implementation in routine care. Other approaches, e.g. team-based community care, might be more beneficial for people with persistent and severe mental illness.

Development and psychometric properties of a five-language multiperspective instrument to assess clinical decision making style in the treatment of people with severe mental illness (CDMS)

BackgroundThe aim of this study was to develop and evaluate psychometric properties of the Clinical Decision Making Style (CDMS) scale which measures general preferences for decision making as well as preferences regarding the provision of information to the patient from the perspectives of people with severe mental illness and staff.MethodsA participatory approach was chosen for instrument development which followed 10 sequential steps proposed in a current guideline of good practice for the translation and cultural adaptation of measures. Following item analysis, reliability, validity, and long-term stability of the CDMS were examined using Spearman correlations in a sample of 588 people with severe mental illness and 213 mental health professionals in 6 European countries (Germany, UK, Italy, Denmark, Hungary, and Switzerland).ResultsIn both patient and staff versions, the two CDMS subscales “Participation in Decision Making” and “Information” reliably measure distinct characteristics of decision making. Validity could be demonstrated to some extent, but needs further investigation.ConclusionsTogether with two other five-language patient- and staff-rated measures developed in the CEDAR study (ISRCTN75841675) – “Clinical Decision Making in Routine Care” and “Clinical Decision Making Involvement and Satisfaction” – the CDMS allows empirical investigation of the complex relation between clinical decision making and outcome in the treatment of people with severe mental illness across Europe.

Helping alliance and outcome in psychotherapy: What predicts what in routine outpatient treatment?

Abstract This naturalistic longitudinal study analyzed the reciprocal dependency of the helping alliance and symptom outcome over the course of mid- and long-term outpatient psychotherapy as practiced in routine care in Germany. Patient-rated helping alliance and symptom distress were assessed repeatedly over a 2-year period in a sample of 259 outpatients in psychodynamic, cognitive–behavioral, and psychoanalytic psychotherapy. Hierarchical linear models showed that initial symptom distress negatively predicted subsequent quality of the helping alliance but not vice versa. Only initial symptom distress affected symptom status at the last treatment session. These results raise doubts about the helping alliance being a strong predictor of outcome and indicate that other patient and therapist variables might be more important for treatment success.

The Dose-Response Relationship at a College Counseling Center

Abstract Most college counseling centers have adopted session limits for their psychotherapy clients though little evidence exists to support such cutoff points. In the past eight years, a few studies have been published using survival analysis statistics for investigating the speed of recovery in psychotherapy. The outcome of clients at a university counseling center was studied to assess change across time, on a session-by-session basis. The analysis of these data showed that 14 sessions of psychotherapy were required for 51% of clients to meet criteria for clinically significant change. Results were interpreted as suggesting that limiting psychotherapy at college counseling centers may result in improvements that are not clinically meaningful for the majority of clients receiving services.