Karla Moras

Evaluation of Psychotherapy Efficacy, Effectiveness, and Patient Progress

Treatment-focused research is concerned with the establishment of the comparative efficacy and effectiveness of clinical interventions, aggregated over groups of patients. The authors introduce and illustrate a new paradigm-patient-focused research-that is concerned with the monitoring of an individuals progress over the course of treatment and the feedback of this information to the practitioner, supervisor, or case manager.

Distinguishing anxiety and depression: Reexamination of the reconstructed Hamilton scales.

The discriminant validities of the original and the reconstructed Hamilton anxiety and depression scales (Riskind et al., 1987) were compared in patients who had principal DSM-III-R anxiety disorders with or without one or more comorbid mood disorders. The reconstructed anxiety and depression scales that had better discriminant validity (scale intercorrelation=.61) than the original scales did (r=.78). However, the reconstructed scales shared considerable variance (about 37%), which was significantly higher than the shared variance (about 2%) reported by Risking et al. Discriminant analyses showed that the reconstructed scales did not distinguish anxiety patients with comorbid mood disorders from those without comorbid mood disorders better than the original scales did. However, the reconstructed scales eliminate item overlap, an obvious source of artifactual correlations between scores on the Hamilton anxiety and depression scales

Efficacy and specific effects data on new treatments: a case study strategy with mixed anxiety-depression.

The case study research strategy presented here can be used to develop new psychotherapeutic treatments, test theorized mechanisms of action, and obtain initial outcome data of the type needed to support treatment outcome grant applications. The strategy is illustrated by 2 case studies of a new psychotherapeutic intervention for patients with coexisting generalized anxiety disorder and major depression as described in the Diagnostic and Statistical Manual of Mental Disorders (3rd ed., rev; American Psychiatric Association, 1987). The treatment is a modification and integration of existing treatments for panic disorder (Barlow & Craske, 1989) and for major depression (Klerman, Weissman, Rounsaville, & Chevron, 1984).

Rater Selection for Psychotherapy Process Research: An Evaluation of the State of the Art

The main source of information on selecting raters for process research has been the practical knowledge of process researchers, not empirical data. Some of the practical knowledge that has been conveyed by word of mouth among process researchers is documented here. In addition, to elucidate rater selection practices in process research, we reviewed prominent psychotherapy process measures and compiled the rater selection information that is available for them. The information is summarized and used to describe and evaluate the state of the art in rater selection for psychotherapy process research. Recommendations are made about how current practices could be improved (e.g., by establishing guidelines for the field on what rater selection information should be provided for process rating instruments) and about needed research (e.g., the impact of rater personality features on the reliability and validity of ratings on different types of process measures).

Dimensional Approaches to Diagnosis and the Problem of Anxiety and Depression

For any field of scientific investigation to advance, a consensually agreed upon way to classify the phenomena of interest is required. In the United States, the prevailing way to classify the problems that bring people to mental health professionals is the Diagnostic and Statistical Manual, 3rd edition, revised (DSM-III-R, American Psychiatric Association, 1987). The DSM-III-R is primarily a categorical system, although it has dimensional components (e.g., the Axis V ratings of level of adaptive functioning). In a categorical nosology, sets of criteria are used to determine which diagnostic category best fits a person’s presenting problems. Categorical nosologies assume discontinuity and qualitative differences between categories.

Twenty-five years of psychological treatment research on unipolar depression in adult outpatients: Introduction to the special section

The studies in this special section illustrate key facets of the current era of research on psychological treatments for unipolar depression in adult outpatients. The era began circa 1980 with the publication of a substantially revised edition (3rd) of the Diagnostic and Statistical Manual of Mental Disorders (DSM III ; American Psychiatric Association, 1980). The DSM III marked a paradigm shift in psychotherapy research in the United States. One highly mutative force was the emergence of a de facto requirement that, to be fundable, grant applications for treatment outcome studies submitted to the U.S. National Institute of Mental Health had to target a specific disorder as defined in the DSM nomenclature. Unipolar (also called ‘‘major’’) depression as defined in the Diagnostic and Statistical Manual of Mental Disorders (DSM ; American Psychiatric Association, 1980, 2000) is prevalent. Estimates vary, with figures ranging between 14.5 and 19 million American adults affected at any time (e.g., National Institute of Mental Health [NIMH], 2002). Its lifetime prevalence in the United States is estimated to be 17.1%, a figure that is similar worldwide (Tamminga et al., 2002). Depression occurs across the entire life span and across races and ethnic groups. Data suggest that it occurs twice as often in women as men. Reasons for the disparity remain unknown, but gender differences in reporting could be one factor. It is estimated that 4% to 5% of women will have at least one episode of depression during their life compared with 2% to 4% of men (NIMH, 2002). Current evidence suggests that depression is likely to be a recurrent problem: A single episode of depression in one’s life is the exception. A study sponsored by the World Health Organization and World Bank concluded that unipolar depression is the leading cause of disability in the United States and other economically developed countries (NIMH, 2002). The prevalence and burdens associated with depression (e.g., suicide, disability, compromised quality of life for sufferers, stress for significant others) have prompted a relatively huge, often ad hoc, treatment armamentarium. Treatments commonly used or under investigation in the United States include pharmacotherapy, aggressive pharmacological augmentation strategies (i.e., prescribing several drugs concurrently), somatic therapies (e.g., electroconvulsive therapy, regional transcranial magnetic stimulation, deep brain stimulation, vagal nerve stimulation), combined pharmacotherapy and somatic therapies, psychological treatments, and combined pharmacological and psychological treatments. Unfortunately, the large number of treatments is not matched by their efficacy, even when only those that have been shown to be efficacious in randomized controlled clinical trials are considered (e.g., Chambless et al., 1998). Data presented by De Maat, Dekker, Schoevers, and De Jonghe (2006) in this special section illustrate the limited efficacy, in terms of enduring full remission and recovery, of existing treatments for depression. Increasing recognition of the unsatisfactory efficacy of all treatments for unipolar depression prompted research interest in ‘‘treatment-resistant’’ depression, particularly in the past 10 years (e.g., Fava & Davidson, 1996). (The general conclusion that existing treatments have limited efficacy is not unique to depression. For example, Kraemer, Wilson, Fairburn, & Agras, 2002, noted that ‘‘even the most potent of the available treatments are limited in their effects, helping many, but not all patients, regardless of clinical disorder’’ [p. 878].)

Might Relationship “Techniques” Extend the Reach, Efficacy, and Efficiency of the Psychotherapies? The Challenge of Treatment-Resistant Outpatients

Study-based clinical observations and two premises are presented as indications for a need to identify “therapeutic relationship techniques” or the like that can extend the reach and efficiency of the psychotherapies. The premises are: (1) advances in psychotherapy practice and research now highlight one of the fields most longstanding challenges, signified by terms like “treatment resistance”; and (2) some proportion of outpatients whose problems are resistant to the psychotherapies (and medications) have marked limitations in the capacity to relate positively and productively to others, including therapists. Thus, ironically, they cannot optimally utilize a treatment modality that largely has developed to ameliorate problems relating to others.

Cocaine‐Induced Mood Disorder: Prevalence Rates and Psychiatric Symptoms in an Outpatient Cocaine‐Dependent Sample

This paper attempts to examine and compare prevalence rates and symptom patterns of DSM substance-induced and other mood disorders. 243 cocaine-dependent outpatients with cocaine-induced mood disorder (CIMD), other mood disorders, or no mood disorder were compared on measures of psychiatric symptoms. The prevalence rate for CIMD was 12% at baseline. Introduction of the DSM-IV diagnosis of CIMD did not substantially affect rates of the other depressive disorders. Patients with CIMD had symptom severity levels between those of patients with and without a mood disorder. These findings suggest some validity for the new DSM-IV diagnosis of CIMD, but also suggest that it requires further specification and replication.