Wolfgang Lutz

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.

Enhancing outcome for potential treatment failures: Therapist–client feedback and clinical support tools

Abstract Enhancing treatment outcomes for clients who are predicted to deteriorate before leaving treatment has important implications for quality of client care. The effects of three interventions aimed at reducing client deterioration were examined in a sample of 1,374 clients whose outcome was contrasted across experimental groups and with a no-feedback/archival control group consisting of data from 1,445 clients. Results indicated that feedback to therapists reduced deterioration rates and improved outcome across clients, especially those predicted to be treatment failures. Therapist feedback effects were enhanced by the use of prompts to action based on a clinical support tools manual but not by the provision of direct feedback to clients.

Therapist effects in outpatient psychotherapy: A three-level growth curve approach

Evidence suggests that a moderate amount of variance in patient outcomes is attributable to therapist differences. However, explained variance estimates vary widely, perhaps because some therapists achieve greater success with certain kinds of patients. This study assessed the amount of variance in across-session change in symptom intensity scores explained by therapist differences in a large naturalistic data set (1,198 patients and 60 therapists, who each treated 10–77 of the patients). Results indicated that approximately 8% of the total variance and approximately 17% of the variance in rates of patient improvement could be attributed to the therapists. Cross-validation and extreme group analyses validated the existence of these therapist effects.

Patterns of early change and their relationship to outcome and follow-up among patients with major depressive disorders

BACKGROUND While highlighting the efficacy of different treatments for major depressive disorders (MDD), findings of the National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP) often are interpreted as supporting the idea of treatment non-specificity for MDD. However, heterogeneity in treatment courses and outcomes might be undetected when focusing only on types of treatment in terms of sample means without taking into account early change in treatment. METHOD In this study, growth mixture models (GMM) were used in the completer sample of N=162 patients from the NIMH TDCRP to identify meaningful patterns of early change of depression severity that are shared by many individual patients. RESULTS Results revealed three typical patterns of early change over the first 8 weeks of treatment irrespective of the type of treatment protocol provided: (a) moderate to severe depression with moderate early improvement, (b) moderate to severe depression with rapid early improvement, and (c) mild to moderate depression with moderate early improvement. In contrast to the type of treatment, these differential patterns of early response (together with overall pre-treatment symptom severity) predicted outcomes (i.e. depression severity) at treatment termination and over the 1.5-year follow-up period. LIMITATIONS Due to the small sample size and the controlled setting of this study the degree to which these results can be generalized to clinical practice has to be further investigated. CONCLUSIONS The findings provide further support for the assumption that early change is an important factor for the prediction of short- and long-term outcome in psychotherapy.

Advancing psychotherapy and evidence-based psychological interventions

Psychological models of mental disorders guide research into psychological and environmental factors that elicit and maintain mental disorders as well as interventions to reduce them. This paper addresses four areas. (1) Psychological models of mental disorders have become increasingly transdiagnostic, focusing on core cognitive endophenotypes of psychopathology from an integrative cognitive psychology perspective rather than offering explanations for unitary mental disorders. It is argued that psychological interventions for mental disorders will increasingly target specific cognitive dysfunctions rather than symptom‐based mental disorders as a result. (2) Psychotherapy research still lacks a comprehensive conceptual framework that brings together the wide variety of findings, models and perspectives. Analysing the state‐of‐the‐art in psychotherapy treatment research, “component analyses” aiming at an optimal identification of core ingredients and the mechanisms of change is highlighted as the core need towards improved efficacy and effectiveness of psychotherapy, and improved translation to routine care. (3) In order to provide more effective psychological interventions to children and adolescents, there is a need to develop new and/or improved psychotherapeutic interventions on the basis of developmental psychopathology research taking into account knowledge of mediators and moderators. Developmental neuroscience research might be instrumental to uncover associated aberrant brain processes in children and adolescents with mental health problems and to better examine mechanisms of their correction by means of psychotherapy and psychological interventions. (4) Psychotherapy research needs to broaden in terms of adoption of large‐scale public health strategies and treatments that can be applied to more patients in a simpler and cost‐effective way. Increased research on efficacy and moderators of Internet‐based treatments and e‐mental health tools (e.g. to support “real time” clinical decision‐making to prevent treatment failure or relapse) might be one promising way forward. Copyright

Predicting Change for Individual Psychotherapy Clients on the Basis of their Nearest Neighbors.

This study extended client-focused research by using the nearest neighbor (NN) approach, a client-specific sampling and prediction strategy derived from research on alpine avalanches. Psychotherapy clients (N=203) seen in routine practice settings in the United Kingdom completed a battery of intake measures and then completed symptom intensity ratings before each session. Forecasts of each clients rate of change and session-by-session variability were computed on the basis of that clients NNs (n=10-50 in different comparisons). Alternative forecasts used linear or log-linear slopes and were compared with an alternative prediction strategy. Results showed that the NN approach was superior to the alternative model in predicting rate of change, though the advantage was less clear for predicting variability.

The ups and downs of psychotherapy: Sudden gains and sudden losses identified with session reports

Abstract Psychotherapy does not always follow a linear path. The present study explores the frequency of sudden gains and losses during the course of outpatient psychotherapy. The sample includes 1500 patients treated at three different outpatient centers. The patients were 57.4% female, and suffered primarily from anxiety and depressive disorders. Progress was measured by session reports. Significant sudden shifts in both directions were prevalent for 28.9% of the patients. Patients with early sudden gains showed the highest effect sizes and patients with sudden losses showed the smallest at the end of treatment. The therapeutic relationship was significantly better after the sudden gain sessions. Results suggest further investigation of the occurrence of sudden gains in relation to early response as well as further exploration of sudden losses during the course of treatment with respect to differential patterns of change and outcome.

Exploring individual change.

In the analysis of the impact of clinical interventions, the received wisdom has been that posttreatment scores, with pretreatment scores equated by random assignment or statistically partialed out, should be used to evaluate treatment outcomes. However, posttreatment scores are not generally more reliable than, nor equivalent to, change scores, even with pretreatment scores partialed out of both. Moreover, there are data-analytic methods that indicate how individual patients change, in terms of response curves over time, rather than indicate only how much groups change on the average. These methods take researchers back to the individual data that they ought to use for choosing the specific models of change to be used. To maximize relevance for clinical practice, the results of treatment research should always be reported at this most disaggregated or individual change level, as well as, when appropriate, at more aggregated statistical levels.

Effects of a Psychological Internet Intervention in the Treatment of Mild to Moderate Depressive Symptoms: Results of the EVIDENT Study, a Randomized Controlled Trial

Background: Mild to moderate depressive symptoms are common but often remain unrecognized and treated inadequately. We hypothesized that an Internet intervention in addition to usual care is superior to care as usual alone (CAU) in the treatment of mild to moderate depressive symptoms in adults. Methods: This trial was controlled, randomized and assessor-blinded. Participants with mild to moderate depressive symptoms (Patient Health Questionnaire, PHQ-9, score 5-14) were recruited from clinical and non-clinical settings and randomized to either CAU or a 12-week Internet intervention (Deprexis) adjunctive to usual care. Outcomes were assessed at baseline, 3 months (post-assessment) and 6 months (follow-up). The primary outcome measure was self-rated depression severity (PHQ-9). The main analysis was based on the intention-to-treat principle and used linear mixed models. Results: A total of 1,013 participants were randomized. Changes in PHQ-9 from baseline differed significantly between groups (t825 = 6.12, p < 0.001 for the main effect of group). The post-assessment between-group effect size in favour of the intervention was d = 0.39 (95% CI: 0.13-0.64). It was stable at follow-up, with d = 0.32 (95% CI: 0.06-0.69). The rate of participants experiencing at least minimally clinically important PHQ-9 change at the post-assessment was higher in the intervention group (35.6 vs. 20.2%) with a number needed to treat of 7 (95% CI: 5-10). Conclusions: The Internet intervention examined in this trial was superior to CAU alone in reducing mild to moderate depressive symptoms. The magnitude of the effect is clinically important and has public health implications.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patients response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.