Susan Simpson

A meta-analysis of electroconvulsive therapy efficacy in depression

Recently published controlled studies comparing electroconvulsive therapy (ECT) with other treatments for depression offer the opportunity to perform a meta-analysis of ECT in depression. Fifteen studies were identified which fulfilled the inclusion criteria. From these controlled trials, 20 effect sizes of ECT were calculated. The speed of action during the course and the efficacy after a full course of ECT were explored. The efficacy of sine wave and brief pulse machines were compared. The comparison between ECT and four other comparative treatments was made. Predictive variables were explored using homogeneity tests. ECT was shown to be superior after a full course. The funnel plot showed the absence of publication bias. There was no exaggeration of effect size in the lower quality trials. No evidence was found for a superior speed of action of ECT or for a difference in efficacy between sine wave and brief pulse stimulation. ECT was shown to be superior to medication and simulated ECT. Some evidence was found that psychosis predicted better response to ECT.

A Systematic Review of the Evidence Base for Schema Therapy

Schema Therapy is becoming an increasingly popular psychological model for working with individuals who have a variety of mental health and personality difficulties. The aim of this review is to look at the current evidence base for Schema Therapy and highlight directions for further research. A systematic search of the literature was conducted up until January 2011. All studies that had clinically tested the efficacy of Schema Therapy as described by Jeffrey Young (1994 and 2003) were considered. These studies underwent detailed quality assessments based on Scottish Intercollegiate Guidelines Network (SIGN-50) culminating in 12 studies being included in the review. The culminative message (both from the popularity of this model and the medium-to-large effect sizes) is of a theory that has already demonstrated clinically effective outcomes in a small number of studies and that would benefit from ongoing research and development with complex client groups. It is imperative that psychological practice be guided by high-quality research that demonstrates efficacious, evidence-based interventions. It is therefore recommended that researchers and clinicians working with Schema Therapy seek to build on these positive outcomes and further demonstrate the clinical effectiveness of this model through ongoing research.

Group Schema Therapy for Eating Disorders: A Pilot Study

This paper describes the use of Group Schema Therapy for Eating Disorders (ST-E-g) in a case series of eight participants with chronic eating disorders and high levels of co-morbidity. Treatment was comprised of 20 sessions which included cognitive, experiential, and interpersonal strategies, with an emphasis on behavioral change. Specific schema-based strategies focused on bodily felt-sense and body-image, as well as emotional regulation skills. Six attended until end of treatment, two dropped-out at mid-treatment. Eating disorder severity, global schema severity, shame, and anxiety levels were reduced between pre- and post-therapy, with a large effect size at follow-up. Clinically significant improvement in eating severity was found in four out of six completers. Group completers showed a mean reduction in schema severity of 43% at post-treatment, and 59% at follow-up. By follow-up, all completers had achieved over 60% improvement in schema severity. Self-report feedback suggests that group factors may catalyze the change process in schema therapy by increasing perceptions of support and encouragement to take risks and try out new behaviors, whilst providing a de-stigmatizing and de-shaming therapeutic experience.

Therapeutic alliance in videoconferencing psychotherapy: A review

Psychotherapy services are limited in remote and rural areas in Australia and across the globe. Videoconferencing has become well established as a feasible and acceptable mode of psychological treatment delivery. Therapeutic alliance (TA) is an essential factor underlying successful therapy across therapeutic models. In order to determine the state of knowledge regarding TA in psychotherapy via videoconferencing, a literature review was conducted on research studies that formally measured TA as primary, secondary or tertiary outcome measures over the past 23 years. The databases searched were Medline, PsycArticles, PsycINFO, PsycEXTRA and EMBASE. Searching identified 9915 articles that measured satisfaction, acceptability or therapeutic rapport, of which 23 met criteria for the review. Three studies were carried out in Australia, 11 in USA, 4 in Canada, 3 in Scotland and 2 in England. Studies overwhelmingly supported the notion that TA can be developed in psychotherapy by videoconference, with clients rating bond and presence at least equally as strongly as in-person settings across a range of diagnostic groups. Therapists also rated high levels of TA, but often not quite as high as that of their clients early in treatment. The evidence was examined in the context of important aspects of TA, including bond, presence, therapist attitudes and abilities, and client attitudes and beliefs. Barriers and facilitators of alliance were identified. Future studies should include observational measures of bond and presence to supplement self-report.

Obesity and outpatient rehabilitation using mobile technologies: the potential mHealth approach

Obesity is currently an important public health problem of epidemic proportions (globesity). Inpatient rehabilitation interventions that aim at improving weight-loss, reducing obesity-related complications and changing dysfunctional behaviors, should ideally be carried out in a multidisciplinary context with a clinical team composed of psychologists, dieticians, psychiatrists, endocrinologists, nutritionists, physiotherapists, etc. Long-term outpatient multidisciplinary treatments are likely to constitute an essential aspect of rehabilitation. Internet-based technologies can improve long-term obesity rehabilitation within a collaborative approach by enhancing the steps specified by psychological and medical treatment protocols. These outcomes may be augmented further by the mHealth approach, through creating new treatment delivery methods to increase compliance and engagement. mHealth (m-health, mobile health) can be defined as the practice of medicine and public health, supported by mobile communication devices for health services and information. mHealth applications which can be implemented in weight loss protocols and obesity rehabilitation are discussed, taking into account future research directions in this promising area.

Psychological Treatments and Psychotherapies in the Neurorehabilitation of Pain: Evidences and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: It is increasingly recognized that treating pain is crucial for effective care within neurological rehabilitation in the setting of the neurological rehabilitation. The Italian Consensus Conference on Pain in Neurorehabilitation was constituted with the purpose identifying best practices for us in this context. Along with drug therapies and physical interventions, psychological treatments have been proven to be some of the most valuable tools that can be used within a multidisciplinary approach for fostering a reduction in pain intensity. However, there is a need to elucidate what forms of psychotherapy could be effectively matched with the specific pathologies that are typically addressed by neurorehabilitation teams. Objectives: To extensively assess the available evidence which supports the use of psychological therapies for pain reduction in neurological diseases. Methods: A systematic review of the studies evaluating the effect of psychotherapies on pain intensity in neurological disorders was performed through an electronic search using PUBMED, EMBASE, and the Cochrane Database of Systematic Reviews. Based on the level of evidence of the included studies, recommendations were outlined separately for the different conditions. Results: The literature search yielded 2352 results and the final database included 400 articles. The overall strength of the recommendations was medium/low. The different forms of psychological interventions, including Cognitive—Behavioral Therapy, cognitive or behavioral techniques, Mindfulness, hypnosis, Acceptance and Commitment Therapy (ACT), Brief Interpersonal Therapy, virtual reality interventions, various forms of biofeedback and mirror therapy were found to be effective for pain reduction in pathologies such as musculoskeletal pain, fibromyalgia, Complex Regional Pain Syndrome, Central Post—Stroke pain, Phantom Limb Pain, pain secondary to Spinal Cord Injury, multiple sclerosis and other debilitating syndromes, diabetic neuropathy, Medically Unexplained Symptoms, migraine and headache. Conclusions: Psychological interventions and psychotherapies are safe and effective treatments that can be used within an integrated approach for patients undergoing neurological rehabilitation for pain. The different interventions can be specifically selected depending on the disease being treated. A table of evidence and recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation is also provided in the final part of the paper.

Ebesity – E-Health for Obesity – New Technologies for the Treatment of Obesity In Clinical Psychology and Medicine

The spread of obesity (globesity) has been declared a worldwide epidemic by the World Health Organization (WHO). More than 1 billion adults are overweight and at least 315 million are clinically obese. This epidemic has generated an unlimited array of weight-loss strategies. Obesity is now one of the most important public and clinical problems: “it increases the risk of many health complications such as hypertension, coronary heart disease and type 2 diabetes, needs long-lasting treatment for effective results and involves high public and private costs” (p. 204, (Castelnuovo et al., 2010)). In the past few years, internet, mobile phone or computer based clinical protocols have shown promising long-term effects in the improvement of healthy lifestyle interventions for the treatment of obesity with or without complications (type 2 diabetes, eating disorders, etc.). These technologies (cd-rom software, internet websites, e-mail contacts, sms or mms based systems, telemedicine platforms etc.) have opened potential applications to revolutionize health care in different inpatient and outpatient settings. There is a significant interest in the employment of new technologies and devices in order to obtain better results in weight-reduction programs: this literature has grown strongly over recent years (Riva et al., 2001, Riva et al., 2002, Simpson et al., 2002, Jeffery et al., 2003, Riva et al., 2003, Simpson et al., 2003, Castelnuovo et al., 2004, Goulis et al., 2004, Sherwood et al., 2006, Haugen et al., 2007, Joo and Kim, 2007, Wister et al., 2007, Kim and Kim, 2008, Krukowski et al., 2008, Morak et al., 2008, Schiel et al., 2008, Shaikh et al., 2008, McTigue et al., 2009, Park et al., 2009, Castelnuovo, 2010, Castelnuovo et al., 2010). One of the main aims of the E-BESITY CPEMH special issue is to present new results concerning the use of advanced telehealth approaches. These innovations are designed to bring healthcare to where it is really needed, providing continuity between clinic settings and patients’ daily lives. Technology cannot replace medicine but it can improve the efficacy of traditional clinical and healthy lifestyle protocols. According to Scott and Wonderlich (2010), new technologies are continuously changing and providing new opportunities: “One final thought focuses on the ever-changing nature of technology – and therefore technology based interventions. Technology is always in flux; most cutting-edge technologies of today are typically nothing more than tomorrow’s outdated and obsolete methods (keep in mind that the sun dial, abacus, and eight-track cassette players were all “cutting edge” at one time). We have seen many of these changes in our work: for example, modems that we once used with PDAs have become obsolete due to the cellular phones and digital phone lines, the Internet has dramatically changed the way telehealth treatments are being delivered, and some of our older PDAs are not compatible with newer computer operating systems. Technologies will inevitably continue to change, and with these changes will come additional opportunities for new applications to…. treatment….” (p. 507, (Scott and Wonderlich, 2010)). Whereas some of these technologies have been the subject of extensive research to date, others are in their early stages of development and evaluation. This special issue presents a range of research studies, covering both ends of the spectrum. The STRATOB study by Castelnuovo and colleagues is a two-arm randomized controlled clinical trial comparing the effectiveness of BST (Brief Strategic Therapy) with the gold standard CBT (Cognitive Behavioral Therapy) in an inpatient and telephone based outpatient program for a sample of obese people with Binge Eating Disorder seeking treatment for weight reduction. This group also report on their progress to date with a separate RCT which is examining the efficacy of the TECNOB program whereby participants were instructed to use a weight-loss web-site, a web-based videoconference tool, dietary software installed into their cellular phones and an electronic armband measuring daily steps and energy expenditure to maintain weight-loss, following inpatient hospital treatment. A range of technologies are integrated into the program, showing the potential for multi-modal treatment delivery options. A range of exploratory projects and smaller pilot studies are also presented in this special edition, which are vital at this early stage of trialing new technologies in the treatment of obesity. These include the introduction of a new technological paradigm ‘Interreality’ by Riva and colleagues, that integrates assessment and treatment within a hybrid experiential environment, including both virtual and real worlds and provides targeted support and suggestions through the use of bio and activity sensors and smartphones. Several excellent recent studies have capitalized on the ubiquity of the internet and utilized this as a mode of treatment delivery for those with obesity and/or eating disorders. Funk and colleagues describe the development of a tailored self-assessment tool in an internet-based weight loss maintenance program, demonstrating the potential for technology in both replicating personal counseling and tailoring treatment strategies based on client feedback. Carrard et al. evaluated a self-help internet-based treatment program composed of eleven CBT based modules in a population of adult obese patients with Binge Eating Disorder, with encouraging results, both in terms of outcome and overall acceptability of the program. Lindenberg et al. describe an internet-based program, ‘Appetite for Life’, which was specifically designed to provide individualized support to students at-risk of developing an eating disorder. This stepped-care approach encourages users to make choices and seek support according to their personal preferences, thus utilising the technology to meet the needs of individuals and to enhance self-efficacy. The treatment and prevention of childhood obesity has also been targeted through the development of the ‘ETIOBE’ e-therapy platform. This system aims to improve long-term weight loss maintenance by specifically addressing treatment adherence and self-control in the context of teaching and reinforcing healthy lifestyle habits (Banos et al.). Videoconferencing has played an important role in the assessment and treatment of obesity and eating disorders; a critical development both for obesity sufferers located in remote and rural areas, and for those who are unable to travel to appointments due to disability or ill-health. Morrow and colleagues demonstrate the potential of videoconferencing as a means of providing multidisciplinary post surgical review of bariatric surgery patients and Simpson and Slowey examine the use of videoconferencing in a case study, exploring the provision of psychological treatment for co-morbid obesity and eating disorder. These preliminary studies are ideal for the examination of process issues, thus facilitating the exploration of interactions between technology and psychological treatment models. The studies described in this special edition on e-besity have gathered important data on the effectiveness, acceptability and feasibility of a range of technologies in treatment and weight-loss maintenance and will inform the development of large scale efficacy studies in the future. As Manzoni observes in his systematic review of internet-based treatment programs, there is a great need for improvement and standardization of the design of future studies in this area which will allow for the identification of factors which are critical to the success of weight loss and maintenance.

Psychological Considerations in the Assessment and Treatment of Pain in Neurorehabilitation and Psychological Factors Predictive of Therapeutic Response: Evidence and Recommendations from the Italian Consensus Conference on Pain in Neurorehabilitation

Background: In order to provide effective care to patients suffering from chronic pain secondary to neurological diseases, health professionals must appraise the role of the psychosocial factors in the genesis and maintenance of this condition whilst considering how emotions and cognitions influence the course of treatment. Furthermore, it is important not only to recognize the psychological reactions to pain that are common to the various conditions, but also to evaluate how these syndromes differ with regards to the psychological factors that may be involved. As an extensive evaluation of these factors is still lacking, the Italian Consensus Conference on Pain in Neurorehabilitation (ICCPN) aimed to collate the evidence available across these topics. Objectives: To determine the psychological factors which are associated with or predictive of pain secondary to neurological conditions and to assess the influence of these aspects on the outcome of neurorehabilitation. Methods: Two reviews were performed. In the first, a PUBMED search of the studies assessing the association between psychological factors and pain or the predictive value of these aspects with respect to chronic pain was conducted. The included papers were then rated with regards to their methodological quality and recommendations were made accordingly. In the second study, the same methodology was used to collect the available evidence on the predictive role of psychological factors on the therapeutic response to pain treatments in the setting of neurorehabilitation. Results: The first literature search identified 1170 results and the final database included 189 articles. Factors such as depression, anxiety, pain catastrophizing, coping strategies, and cognitive functions were found to be associated with pain across the various conditions. However, there are differences between chronic musculoskeletal pain, migraine, neuropathy, and conditions associated with complex disability with regards to the psychological aspects that are involved. The second PUBMED search yielded 252 studies, which were all evaluated. Anxiety, depression, pain catastrophizing, coping strategies, and pain beliefs were found to be associated to different degrees with the outcomes of multidisciplinary programs, surgery, physical therapies, and psychological interventions. Finally, sense of presence was found to be related to the effectiveness of virtual reality as a distraction tool. Conclusions: Several psychological factors are associated with pain secondary to neurological conditions and should be acknowledged and addressed in order to effectively treat this condition. These factors also predict the therapeutic response to the neurorehabilitative interventions.

Video Therapy for Atypical Eating Disorder and Obesity: A Case Study

Both eating and weight disorders are prevalent in our society but many sufferers do not have access to specialist treatments, especially those living in remote and rural areas. Video therapy is proposed as a potential solution, allowing therapists to deliver psychological treatments without the costs associated with travel. Furthermore, there is a gap in the evidence base for those with co-morbid obesity and atypical eating disorders, but it is likely that treatments which focus on linking past and present patterns of behaviour and emphasise cognitive, behavioural and emotional change will be most effective. A naturalistic single case design was used to pilot the feasibility of providing video therapy using the schema therapy mode model, which involves a range of ‘active’ techniques including chair work and imagery. Results suggest that videoconferencing may be well suited to the delivery of experiential psychotherapy, leading to change across several domains. Scores on the EDE-Q showed a 77% improvement and the client was abstinent from vomiting during the last 28 days of treatment. The findings from this study indicate that video therapy may be effective for this co-morbid diagnostic group and highlight the need for further larger scale research.

A meta‐analysis of the relation between therapeutic alliance and treatment outcome in eating disorders

The therapeutic alliance has demonstrated an association with favorable psychotherapeutic outcomes in the treatment of eating disorders (EDs). However, questions remain about the inter-relationships between early alliance, early symptom improvement, and treatment outcome. We conducted a meta-analysis on the relations among these constructs, and possible moderators of these relations, in psychosocial treatments for EDs. Twenty studies met inclusion criteria and supplied sufficient supplementary data. Results revealed small-to-moderate effect sizes, βs = 0.13 to 0.22 (p < .05), indicating that early symptom improvement was related to subsequent alliance quality and that alliance ratings also were related to subsequent symptom reduction. The relationship between early alliance and treatment outcome was partially accounted for by early symptom improvement. With regard to moderators, early alliance showed weaker associations with outcome in therapies with a strong behavioral component relative to nonbehavioral therapies. However, alliance showed stronger relations to outcome for younger (vs. older) patients, over and above the variance shared with early symptom improvement. In sum, early symptom reduction enhances therapeutic alliance and treatment outcome in EDs, but early alliance may require specific attention for younger patients and for those receiving nonbehaviorally oriented treatments.