Shirley Reynolds

Effects of treatment duration and severity of depression on the effectiveness of cognitive-behavioral and psychodynamic-interpersonal psychotherapy

A total of 117 depressed clients, stratified for severity, completed 8 or 16 sessions of manualized treatment, either cognitive-behavioral psychotherapy (CB) or psychodynamic-interpersonal psychotherapy (PI). Each of 5 clinician-investigators treated clients in all 4 treatment conditions. On most measures, CB and PI were equally effective, irrespective of the severity of depression or the duration of treatment. However, there was evidence of some advantage to CB on the Beck Depression Inventory (Beck, Ward, Mendelson, Mock, & Erbaugh, 1961). There was no evidence that CBs effects were more rapid than those of PI, nor did the effects of each treatment method vary according to the severity of depression. There was no overall advantage to 16-session treatment over 8-session treatment. However, those presenting with relatively severe depression improved substantially more after 16 than after 8 sessions.

Effects of psychotherapy for anxiety in children and adolescents: A meta-analytic review

This paper provides a comprehensive quantitative review of high quality randomized controlled trials of psychological therapies for anxiety disorders in children and young people. Using a systematic search for randomized controlled trials which included a control condition and reported data suitable for meta-analysis, 55 studies were included. Eligible studies were rated for methodological quality and outcome data were extracted and analyzed using standard methods. Trial quality was variable, many studies were underpowered and adverse effects were rarely assessed; however, quality ratings were higher for more recently published studies. Most trials evaluated cognitive behavior therapy or behavior therapy and most recruited both children and adolescents. Psychological therapy for anxiety in children and young people was moderately effective overall, but effect sizes were small to medium when psychological therapy was compared to an active control condition. The effect size for non-CBT interventions was not significant. Parental involvement in therapy was not associated with differential effectiveness. Treatment targeted at specific anxiety disorders, individual psychotherapy, and psychotherapy with older children and adolescents had effect sizes which were larger than effect sizes for treatments targeting a range of anxiety disorders, group psychotherapy, and psychotherapy with younger children. Few studies included an effective follow-up. Future studies should follow CONSORT reporting standards, be adequately powered, and assess follow-up. Research trials are unlikely to address all important clinical questions around treatment delivery. Thus, careful assessment and formulation will remain an essential part of successful psychological treatment for anxiety in children and young people.

Debt, social disadvantage and maternal depression

Depression is common among women with young children, and is strongly associated with financial adversity. Debt is a common feature of such adversity, yet its relationship with depression has not been examined before. We have used longitudinal data, collected over six months, on 271 families with young children, to examine this relationship. Multiple regression was used to identify independent predictors of the total Edinburgh Post-natal Depression Scale score from a range of socioeconomic, demographic, social support and child health related variables. Worry about debt was the strongest independent socioeconomic predictor of the depression score at both initial and follow-up occasions. To account for the possibility of reverse causation, i.e. depression causing worry about debt, alternative regression models are reported which show that owing money by itself predicts depression and earlier debt worries predicts depression six months later. We were unable to show that earlier debt worries independently predicted subsequent depression scores after the initial depression score had been taken into account in the analysis. Although debt has not been shown to be an independent prospective predictor of depression, our results suggest it has a central place in the association between socioeconomic hardship and maternal depression. Evidence from qualitative studies on poverty and from studies on the causes of depression support this hypothesis. The implications for policy are that strategies to enable families to control debt should be an explicit part of wider antipoverty measures which are designed to reduce depression and psychological distress among mothers of young children.

The costs, benefits, and limitations of organizational level stress interventions

Models of organizational stress posit that a number of undesirable employee states and behaviors, such as lower levels of well-being and performance, and higher levels of absence and turnover are caused by organizational stress. It is often suggested that organizational level interventions which aim to reduce stress, such as job redesign, will therefore reduce or eliminate these states and behaviors. This suggestion is, however, based on two unsupportable assertions. The first is that these states and behaviors are caused by organizational stress. While there is some limited evidence for the role of stress, the quality of this evidence is severely compromised by numerous methodological and conceptual problems. The second assertion is that organizational level interventions aimed at changing some of these states and behaviors will actually have an effect, and that these effects will be uniformly positive. However, the available evidence suggests that these interventions often have little or no effect, and where they do have effects, these may be both positive and negative., The implications of this analysis for future work on organizational level stress interventions are discussed. Copyright

Time Frames for Mood: Relations between Momentary and Generalized Ratings of Affect

A computerized diary method was used to investigate relations between momentary and generalized affect reports. Thirty participants rated current mood at 2-hourly intervals and gave retrospective reports of daily and weekly mood for a 2-week period. Average momentary ratings provided a closer estimate of daily mood than either peak or most recent momentary ratings. Similarly, average daily mood indexes tended to give the best estimates of weekly mood. However, for positive (but not negative) mood, daily reports were consistently higher than average momentary ratings, and weekly reports were consistently higher than average daily ratings. Regression analyses suggested that daily ratings were influenced mainly by average momentary mood but that independent effects of peak and most recent momentary mood were detectable too. Retrospective reports of daily mood were also influenced by current mood. In general, however, memory for affect was rather better than previous research has implied.

Improving mood with psychoanalytic and cognitive therapies (IMPACT): a pragmatic effectiveness superiority trial to investigate whether specialised psychological treatment reduces the risk for relapse in adolescents with moderate to severe unipolar depression: study protocol for a randomised controlled trial

BackgroundUp to 70% of adolescents with moderate to severe unipolar major depression respond to psychological treatment plus Fluoxetine (20-50 mg) with symptom reduction and improved social function reported by 24 weeks after beginning treatment. Around 20% of non responders appear treatment resistant and 30% of responders relapse within 2 years. The specific efficacy of different psychological therapies and the moderators and mediators that influence risk for relapse are unclear. The cost-effectiveness and safety of psychological treatments remain poorly evaluated.Methods/DesignImproving Mood with Psychoanalytic and Cognitive Therapies, the IMPACT Study, will determine whether Cognitive Behavioural Therapy or Short Term Psychoanalytic Therapy is superior in reducing relapse compared with Specialist Clinical Care. The study is a multicentre pragmatic effectiveness superiority randomised clinical trial: Cognitive Behavioural Therapy consists of 20 sessions over 30 weeks, Short Term Psychoanalytic Psychotherapy 30 sessions over 30 weeks and Specialist Clinical Care 12 sessions over 20 weeks. We will recruit 540 patients with 180 randomised to each arm. Patients will be reassessed at 6, 12, 36, 52 and 86 weeks. Methodological aspects of the study are systematic recruitment, explicit inclusion criteria, reliability checks of assessments with control for rater shift, research assessors independent of treatment team and blind to randomization, analysis by intention to treat, data management using remote data entry, measures of quality assurance, advanced statistical analysis, manualised treatment protocols, checks of adherence and competence of therapists and assessment of cost-effectiveness. We will also determine whether time to recovery and/or relapse are moderated by variations in brain structure and function and selected genetic and hormone biomarkers taken at entry.DiscussionThe objective of this clinical trial is to determine whether there are specific effects of specialist psychotherapy that reduce relapse in unipolar major depression in adolescents and thereby costs of treatment to society. We also anticipate being able to utilise psychotherapy experience, neuroimaging, genetic and hormone measures to reveal what techniques and their protocols may work best for which patients.Trial RegistrationCurrent Controlled Trials ISRCTN83033550

Befriending carers of people with dementia: randomised controlled trial

Objective To evaluate the effectiveness of a voluntary sector based befriending scheme in improving psychological wellbeing and quality of life for family carers of people with dementia. Design Single blind randomised controlled trial. Setting Community settings in East Anglia and London. Participants 236 family carers of people with primary progressive dementia. Intervention Contact with a befriender facilitator and offer of match with a trained lay volunteer befriender compared with no befriender facilitator contact; all participants continued to receive “usual care.” Main outcome measures Carers’ mood (hospital anxiety and depression scale—depression) and health related quality of life (EuroQoL) at 15 months post-randomisation. Results The intention to treat analysis showed no benefit for the intervention “access to a befriender facilitator” on the primary outcome measure or on any of the secondary outcome measures. Conclusions In common with many carers’ services, befriending schemes are not taken up by all carers, and providing access to a befriending scheme is not effective in improving wellbeing. Trial registration Current Controlled Trials ISRCTN08130075.

Evidence based practice in mental health.

Why has it proved so difficult to narrow the gap between research and practice in psychiatry and mental health? The provision of mental health services is determined by many factors, including government policy, public demand, the behaviour of general practitioners and mental health professionals, and the financial pressures under which purchasers and providers of services work. These groups often have widely disparate views about the nature of mental disorder and the most appropriate services, and many forces exist to keep their views apart. Now is the time for a different approach based on the optimum application of the available evidence—heralded by the publication early next year of a new journal, Evidence- Based Mental Health . This approach will not provide easy answers and there will still be room for discussion about interpretation of even the very best evidence. Nevertheless, an approach that, firstly, acknowledges that mental health services should be fundamentally evidence based and, secondly, helps define what constitutes the best available evidence should clarify decision making. The …

Young Children's Ability to Engage in Cognitive Therapy Tasks: Associations With Age and Educational Experience

In two linked studies we examined childrens performance on tasks required for participation in cognitive therapy. In Study 1 we piloted some new tasks with children aged 5 to 11 years. In study 2 the effects of IQ, age and educational experience were examined in children aged 5 to 7 years. In study 1, 14 children aged 5 to 11 completed three tasks related to cognitive therapy; generating post-event attributions, naming emotions, and linking thoughts and feelings. Study 2 used a between-subjects design in which 72 children aged 5, 6, or 7 years from two primary schools completed the three tasks and the Block Design and Vocabulary sub-tests from the WISC III or WPPSI-R. Children were tested individually during the school day. All measures were administered on the same occasion. In study 2 administration order of the cognitive therapy task and the WISC III/WPPSI-R were randomized. The majority of children demonstrated some ability on each of the three tasks. In study 2, performance was associated with school and with IQ but not with age. There were no gender differences. Children attending a school with an integrated thinking skills programme and those with a higher 1Q were more successful on the cognitive therapy tasks. These results suggest that many young children could engage in cognitive therapy given age-appropriate materials. The effects of training in relevant meta-cognitive skills on childrens ability to use concepts in CBT may warrant further research.

Factors associated with competence in cognitive therapists

As a result of its expanding evidence base from randomized controlled trials, cognitive therapy is becoming increasingly widely practised in the treatment of many mental health problems. However, little is known about the extent to which it is carried out competently in practice, nor about what characteristics of therapists may be associated with competence. In therapists claiming to practice cognitive therapy, this study examined the relationship of a number of therapist factors, including training, profession, experience, supervision and accreditation, to competence. Therapists ( n = 24) taped a mid-treatment cognitive therapy session. An independent rater, blind to information about the therapist, assessed the competence shown by the therapist during this session using the Cognitive Therapy Scale (CTS). Five randomly selected tapes were rated by a second rater and the inter-rater correlations were high. Although all therapists had received some cognitive therapy training during basic professional qualification, therapists with formal post -qualification training in cognitive therapy showed significantly higher levels of competence than those without. Psychologists were rated as more competent than therapists from other professions on one of the CTS subscales (Interpersonal Effectiveness). Number of years of experience, frequency of supervision, and accreditation were unrelated to ratings of competence. A number of accredited cognitive therapists scored well below a widely used criterion of competence.