Paula Ravitz

Adult attachment measures: A 25-year review

OBJECTIVE Over the past 25 years, attachment research has extended beyond infant-parent bonds to examine dyadic relationships in children, adolescents, and adults. Attachment has been shown to influence a wide array of biopsychosocial phenomena, including social functioning, coping, stress response, psychological well-being, health behavior, and morbidity, and has thus emerged as an important focus of psychosomatic research. This article reviews the measurement of adult attachment, highlighting instruments of relevance to-or with potential use in-psychosomatic research. METHODS Following a literature search of articles that were related to the scales and measurement methods of attachment in adult populations, 29 instruments were examined with respect to their utility for psychosomatic researchers. RESULTS Validity, reliability, and feasibility were tabulated on 29 instruments. Eleven of the instruments with strong psychometric properties, wide use, or use in psychosomatic research are described. These include the following: Adult Attachment Interview (George, Kaplan, and Main); Adult Attachment Projective (George and West); Adult Attachment Questionnaire (Simpson, Rholes, and Phillips); Adult Attachment Scale (and Revised Adult Attachment Scale) (Collins and Read); Attachment Style Questionnaire (Feeney); Current Relationship Interview (Crowell and Owens); Experiences in Close Relationships (Brennan, Clark, and Shaver) and Revised Experiences in Close Relationships (Fraley, Waller, and Brennan); Parental Bonding Instrument (Parker, Tupling, and Brown); Reciprocal Attachment Questionnaire (West and Sheldon-Keller); Relationship Questionnaire (Bartholomew and Horowitz); and Relationship Scales Questionnaire (Grifiin and Bartholomew). CONCLUSION In addition to reliability and validity, investigators need to consider relationship focus, attachment constructs, dimensions or categories of interest, and the time required for training, administration, and scoring. Further considerations regarding attachment measurement in the context of psychosomatic research are discussed.

Psychiatric education and simulation: a review of the literature.

Objectives: Simulation methodologies are integral to health professional education at all levels of training and across all disciplines. This article reviews the literature on simulation in psychiatric education and explores recent innovations and emerging ethical considerations related to teaching and evaluation. Method: The authors searched the MEDLINE, ERIC, and PsycINFO databases from 1986 to 2006 using multiple search terms. A detailed manual search was conducted of Academic Psychiatry, Academic Medicine, and Medical Education. Literature indirectly relevant to the search parameter was also included. Results: Of the more than 5000 articles retrieved from the literature on simulation and health professional education, 72 articles and books used the terms simulation and standardized patients or role play and psychiatry education. Of the more than 900 articles on objective structured clinical examinations (OSCE), 24 articles related specifically to psychiatry OSCEs. Conclusions: Live simulation is used in teaching, assessment, and research at all levels of training in psychiatric education. Simulated and standardized patients are useful and appropriate for teaching and assessment and are well accepted at both undergraduate and post-graduate level. There is also an important place for role play. Further research is needed regarding the implications of different simulation technologies in psychiatry.

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments.

Background: The Canadian Network for Mood and Anxiety Treatments (CANMAT) has revised its 2009 guidelines for the management of major depressive disorder (MDD) in adults by updating the evidence and recommendations. The target audiences for these 2016 guidelines are psychiatrists and other mental health professionals. Methods: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. “Psychological Treatments” is the second of six sections of the 2016 guidelines. Results: Evidence-informed responses were developed for 25 questions under 5 broad categories: 1) patient characteristics relevant to using psychological interventions; 2) therapist and health system characteristics associated with optimizing outcomes; 3) descriptions of major psychotherapies and their efficacy; 4) additional psychological interventions, such as peer interventions and computer- and technology-delivered interventions; and 5) combining and/or sequencing psychological and pharmacological interventions. Conclusions: First-line psychological treatment recommendations for acute MDD include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephone-delivered psychotherapy. Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended because combined treatment is superior to either treatment alone. First-line psychological treatments for maintenance include CBT and mindfulness-based cognitive therapy (MBCT). Patient preference, in combination with evidence-based treatments and clinician/system capacity, will yield the optimal treatment strategies for improving individual outcomes in MDD.

Interpersonal psychotherapy for mental health problems: A comprehensive meta-analysis

OBJECTIVE Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted. METHOD Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem. RESULTS Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT. There was risk of bias as defined by the Cochrane Collaboration in the majority of studies. There was little indication that the presence of bias influenced outcome. CONCLUSIONS IPT is effective in the acute treatment of depression and may be effective in the prevention of new depressive disorders and in preventing relapse. IPT may also be effective in the treatment of eating disorders and anxiety disorders and has shown promising effects in some other mental health disorders.

Advances in Psychotherapy Education

Acquiring expertise in psychotherapy is central to the professional development of psychiatrists able to employ a broad therapeutic repertoire in their clinical practice. This article reviews how postgraduate psychiatry programs address this important aspect of training. We present the results of a national survey of psychotherapy education in Canadian psychiatry residency programs. The results highlight significant advances over the past decade in curriculum, in teaching methods, and in evaluation. These include training in evidence-based, manualized, time-limited therapies such as cognitive-behavioural and interpersonal therapy, greater attention to evaluating competence, and integrating electronic technology. Trends and advances in postgraduate and continuing medical psychotherapy education programs are considered in association with principles of adult learning. Health education research endorses the provision of longitudinal training programs that integrate learning and practice. We discuss issues related to the development of expertise, the importance of educational communities of practitioners, and the importance of attending to both educational process and outcomes, with a view to more effectively translating psychotherapy practice guidelines into sustained improvements in practice behaviours.

Autonomous and controlled motivation and interpersonal therapy for depression: moderating role of recurrent depression.

OBJECTIVES We examined the moderating role of depression recurrence on the relation between autonomous and controlled motivation and interpersonal therapy (IPT) treatment outcome. DESIGN The investigation was conducted in an out-patient mood disorders clinic of a large university-affiliated psychiatric hospital. The sample represents a subset of a larger naturalistic database of patients seen in the clinic. METHODS We examined 74 depressed out-patients who received 16 sessions of IPT. The Beck Depression Inventory-II, administered at pre-treatment and post-treatment, served as a measure of depressive severity. Measures of motivation and therapeutic alliance were collected at the third session. RESULTS In the entire sample, both the therapeutic alliance and autonomous motivation predicted higher probability of achieving remission; however, the relation differed for those with highly recurrent depression compared to those with less recurrent depression. For those with highly recurrent depression, the therapeutic alliance predicted remission whereas autonomous motivation had no effect on remission. For those with less recurrent depression, both autonomous motivation and the therapeutic alliance predicted better achieving remission. Controlled motivation emerged as a significant negative predictor of remission across both groups. CONCLUSION Taken together, these results highlight the possible use of motivation theory to inform and enrich therapeutic conceptualizations and interventions in clinical practice, but also point to the importance of modifying interventions based on the chronicity of a clients depression.

Improving Physician-Patient Communication Through Coaching of Simulated Encounters

ObjectiveEffective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees.MethodsTwenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with “difficult” standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention.ResultsImprovements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-upperiod.ConclusionsThis innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.

Failures in interpersonal psychotherapy (IPT): factors related to treatment resistances

Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan and across cultures. However, even when delivered with fidelity, some patients drop out and others do not improve sufficiently. Attention to IPT treatment attrition, dropout, nonresponse, or failure can elucidate its limitations and the opportunities to improve its effectiveness. Studies of factors known to moderate and negatively predict IPT depression treatment response are reviewed along with recommended modifications to improve outcomes. Although the risk of treatment failure always exists, it is possible to enhance treatment effectiveness by attending to the therapeutic alliance, strategically addressing depression, and adapting IPT to patient characteristics. These include adding pharmacotherapy, extending the course of treatment, and targeting specific symptoms or interpersonal vulnerabilities. Case examples illustrate several of these points.

Attachment style as a moderating influence on the efficacy of cognitive-behavioral and interpersonal psychotherapy for depression: A failure to replicate.

Research on aptitude-treatment interactions, or patient characteristics that are associated with better outcome in one treatment than another, can help assign patients to the treatments that will be most personally effective. Theory and one past study suggest that adult attachment style might influence whether depressed patients respond better to cognitive-behavioral therapy (CBT) or interpersonal psychotherapy (IPT). Spurred by inconsistency in past aptitude-treatment interaction research in general, as well as concerns about the reproducibility of psychological research, we sought to replicate and extend the previous study that showed that high attachment avoidance was associated with greater depression reduction in CBT than in IPT and to improve upon that study methodologically. Using longitudinal hierarchical linear modeling, the present study examined whether, among 69 adults randomly assigned to CBT or IPT, rate of change in severity of depression symptoms was predicted by treatment condition, attachment style, and their interaction. We also conducted regression analyses to determine whether posttreatment depression was predicted by the same variables. As expected, CBT and IPT were equivalent in efficacy; however, unlike in the previous trial, there were no moderation effects of attachment. Interestingly, in some analyses, anxious attachment was associated with more positive outcomes and avoidant attachment with more negative outcomes across both treatments. The findings highlight the need for researchers to attempt replications of past studies using methods that might elucidate the reasons for discrepancies in results, and they also suggest that alternative approaches to aptitude-treatment interaction research may be more fruitful.

Baseline patient characteristics as predictors of remission in interpersonal psychotherapy for depression

Abstract We examined patient characteristics as remission predictors in interpersonal psychotherapy (IPT) for depression (n=95). Four characteristic domains (sociodemographic, clinical/diagnostic, interpersonal, cognitive) were analyzed using receiver operating characteristic analysis. Remission was defined two ways: (a) posttreatment BDI-II beyond population-based cut-scores for reliable and clinically significant change, and (b) posttreatment BDI-II≤10. Across both definitions, patients most likely to remit had lower mean item ratings (<3.75 and<3.25, respectively) on the fearful attachment dimension of the Relationship Scales Questionnaire (χ 2 =7.172, p<.01 and χ 2 =7.792, p<.01, respectively). For the second definition only, more fearfully attached patients who were≤25 years of age at index depression onset were more likely to remit (χ 2 =7.617, p<.01) than those>25. The findings contribute to the scant literature on patient factors related to remission following IPT.