R. Kathryn McHugh

The dissemination and implementation of evidence-based psychological treatments: A review of current efforts.

Recognizing an urgent need for increased access to evidenced-based psychological treatments, public health authorities have recently allocated over

Patient Preference for Psychological vs Pharmacologic Treatment of Psychiatric Disorders: A Meta-Analytic Review

2 billion to better disseminate these interventions. In response, implementation of these programs has begun, some of it on a very large scale, with substantial implications for the science and profession of psychology. But methods to transport treatments to service delivery settings have developed independently without strong evidence for, or even a consensus on, best practices for accomplishing this task or for measuring successful outcomes of training. This article reviews current leading efforts at the national, state, and individual treatment developer levels to integrate evidence-based interventions into service delivery settings. Programs are reviewed in the context of the accumulated wisdom of dissemination and implementation science and of methods for assessment of outcomes for training efforts. Recommendations for future implementation strategies will derive from evaluating outcomes of training procedures and developing a consensus on necessary training elements to be used in these efforts.

Balancing fidelity and adaptation in the dissemination of empirically-supported treatments: The promise of transdiagnostic interventions.

OBJECTIVE Evidence-based practice involves the consideration of efficacy and effectiveness, clinical expertise, and patient preference in treatment selection. However, patient preference for psychiatric treatment has been understudied. The aim of this meta-analytic review was to provide an estimate of the proportion of patients preferring psychological treatment relative to medication for psychiatric disorders. DATA SOURCES A literature search was conducted using PubMed, PsycINFO, and the Cochrane Collaboration library through August 2011 for studies written in English that assessed adult patient preferences for the treatment of psychiatric disorders. The following search terms and subject headings were used in combination: patient preference, consumer preference, therapeutics, psychotherapy, drug therapy, mental disorders, depression, anxiety, insomnia, bipolar disorder, schizophrenia, substance-related disorder, eating disorder, and personality disorder. In addition, the reference sections of identified articles were examined to locate any additional articles not captured by this search. STUDY SELECTION Studies that assessed preferred type of treatment and included at least 1 psychological treatment and 1 pharmacologic treatment were included. Of the 644 articles identified, 34 met criteria for inclusion. DATA EXTRACTION Authors extracted relevant data including the proportion of participants reporting preference for psychological or pharmacologic treatment. RESULTS The proportion of adult patients preferring psychological treatment was 0.75 (95% CI, 0.69-0.80), which was significantly higher than equivalent preference (ie, higher than 0.50; P < .001). Sensitivity analyses suggested that younger patients (P = .05) and women (P < .01) were significantly more likely to choose psychological treatment. A preference for psychological treatment was consistently evident in both treatment-seeking and unselected (ie, non-treatment-seeking) samples (P < .001 for both) but was somewhat stronger for unselected samples. CONCLUSIONS Aggregation of patient preferences across diverse settings yielded a significant 3-fold preference for psychological treatment. Given evidence for enhanced outcomes among those receiving their preferred psychiatric treatment and the trends for decreasing utilization of psychotherapy, strategies to maximize the linkage of patients to preferred care are needed.

Cognitive Behavioral Therapy for Substance Use Disorders

Assessing treatment fidelity is a core methodological consideration in the study of treatment outcome; it influences both the degree to which changes can be attributed to the intervention and the ability to replicate and disseminate the intervention. Efforts to increase access to evidence-based psychological treatments are receiving unprecedented support; but pressures exist to adapt treatments to service settings, running the risk of compromising fidelity. However, little evidence is available to inform the necessary conditions for the transportation of interventions to service provision settings, and the degree to which fidelity is even evaluated or emphasized in dissemination and implementation programs varies dramatically. Moreover, adaptation is associated with several benefits for dissemination efforts and may address relevant barriers to adoption. A particularly promising strategy for maximizing the benefits of both fidelity and adaptation is the use of transdiagnostic interventions. Such treatments allow for greater flexibility of the pacing and content of treatment, while still providing structure to facilitate testing and replication. Preliminary evidence supports the efficacy of this strategy, which may be particularly conducive to dissemination into service provision settings. At this time, further research is needed to evaluate the relationships among fidelity, adaptation, and outcome, and to determine the potential for transdiagnostic treatments to facilitate dissemination.

Shared Variance Among Self-Report and Behavioral Measures of Distress Intolerance

Cognitive behavioral therapy (CBT) for substance use disorders has shown efficacy as a monotherapy and as part of combination treatment strategies. This article provides a review of the evidence supporting the use of CBT, clinical elements of its application, novel treatment strategies for improving treatment response, and dissemination efforts. Although CBT for substance abuse is characterized by heterogeneous treatment elements such as operant learning strategies, cognitive and motivational elements, and skills-building interventions, across protocols several core elements emerge that focus on overcoming the powerfully reinforcing effects of psychoactive substances. These elements, and support for their efficacy, are discussed.

A meta-analytic review of the association between anxiety sensitivity and pain.

Distress intolerance may be an important individual difference variable in understanding maladaptive coping responses across diagnostic categories. However, the measurement of distress intolerance remains inconsistent across studies and little evidence for convergent validity among existing measures is available. This study evaluated the overlap among self-report and behavioral measures of distress intolerance in four samples, including an unselected sample, a sample of patients with drug dependence, and two samples of cigarette smokers. Results suggested that the self-report measures were highly correlated, as were the behavioral measures; however, behavioral and self-report measures did not exhibit significant associations with each other. There was some evidence of domain specificity, with anxiety sensitivity demonstrating strong associations with somatic distress intolerance, and a lack of association between behavioral measures that elicit affective distress and those that elicit somatic distress. These findings highlight a potential divergence in the literature relative to the conceptualization of distress intolerance as either sensitivity to distress or as the inability to persist at a task when distressed. Further research is needed to elucidate the conceptualization and measurement of distress intolerance to facilitate future clinical and research applications of this construct.

The serotonin transporter gene and risk for alcohol dependence: A meta-analytic review

In recent years, anxiety sensitivity (AS) has demonstrated applicability across a wide range of conditions. An area of particular interest has been the association between AS and pain. This study aimed to provide an accounting of the magnitude of this effect across studies of both clinical and nonclinical pain. Forty‐one studies (14 clinical and 27 nonclinical pain) were evaluated in this meta‐analytic review and represented the study of 5,908 participants (2,093 for clinical and 3,815 for nonclinical pain studies). Results indicate that AS was strongly associated with fearful appraisals of pain, with more modest results for measures of pain tolerance/threshold and pain‐related disability. Implications of these results for the treatment of chronic pain are discussed. Depression and Anxiety, 2010.

Refining the Measurement of Distress Intolerance

Previous studies have implicated a relationship between particular allelic variations of the serotonin transporter gene (5HTTLPR) and alcohol dependence. To provide a current estimate of the strength of this association, particularly in light of inconsistent results for 5HTTLPR, we conducted a meta-analytic review of the association between 5HTTLPR and a clinical diagnosis of alcohol dependence. Of 145 studies initially identified, 22 (including 8050 participants) met inclusion criteria. Results indicated that there was a significant albeit modest association between alcohol dependence diagnosis and the presence of at least 1 short allele (OR=1.15, 95% CI=1.01, 1.30, p<.05). Slightly more robust results were observed for participants who were homogeneous for the short allele (OR=1.21, 95% CI=1.02, 1.44, p<.05). These results were unrelated to sex and race/ethnicity of participants; however, the effect size was moderated by study sample size and publication year. Additionally, the fail-safe N analysis indicated potential publication bias. Therefore, although our review indicates that there is a significant association between 5HTTLPR and alcohol dependence diagnosis, this result should be interpreted with caution.

Empirically supported treatments for panic disorder.

Distress intolerance is an important transdiagnostic variable that has long been implicated in the development and maintenance of psychological disorders. Self-report measurement strategies for distress intolerance (DI) have emerged from several different models of psychopathology and these measures have been applied inconsistently in the literature in the absence of a clear gold standard. The absence of a consistent assessment strategy has limited the ability to compare across studies and samples, thus hampering the advancement of this research agenda. This study evaluated the latent factor structure of existing measures of DI to examine the degree to which they are capturing the same construct. Results of confirmatory factor analysis in three samples totaling 400 participants provided support for a single-factor latent structure. Individual items of these four scales were then correlated with this factor to identify those that best capture the core construct. Results provided consistent support for 10 items that demonstrated the strongest concordance with this factor. The use of these 10 items as a unifying measure in the study of DI and future directions for the evaluation of its utility are discussed.

Domain-general and domain-specific strategies for the assessment of distress intolerance.

This article provides an empirical review of the elements and efficacy of both pharmacologic and psychosocial treatments for panic disorder. Both monotherapies and combination treatment strategies are considered. The available evidence suggests that both cognitive behavioral therapy (CBT) and pharmacotherapy (prominently, selective serotonin reuptake inhibitors or serotonin-norepinephrine reuptake inhibitors) are effective first-line agents and that CBT offers particular cost efficacy relative to both pharmacotherapy alone and combined pharmacotherapy and CBT. Predictors of non-response and mechanisms of action are considered, as are novel treatment strategies, including the use of memory enhancers to improve CBT outcome.