A meta-analytic evaluation of the effectiveness and durability of psychotherapy for adults presenting with functional dissociative seizures.

BACKGROUND: Psychological interventions are the most recommended treatment for functional/dissociative seizures (FDS); however, there is ongoing uncertainty about their effectiveness on seizure outcomes. METHODS: This systematic review and meta-analysis synthesises the available data. In February 2023, we completed a systematic search of four electronic databases. We described the range of seizure-related outcomes captured, used meta-analytic methods to analyse data collected during treatment and follow-up; and explored sources of heterogeneity between outcomes. RESULTS: Overall, 44 relevant studies were identified involving 1,300 patients. Most were categorised as being at high (39.5 %) or medium (41.9 %) risk of bias. Seizure frequency was examined in all but one study; seizure intensity, severity or bothersomeness in ten; and seizure duration and cluster in one study each. Meta-analyses could be performed on seizure freedom and seizure reduction. A pooled estimate for seizure freedom at the end of treatment was 40 %, while for follow-up it was 36 %. Pooled rates for ≥50 % improvement in seizure frequency were 66 % and 75 %. None of the included moderator variables for seizure freedom were significant. At the group level, seizure frequency improved during the treatment phase with a moderate pooled effect size (d = 0.53). FDS frequency reduced by a median of 6.5 seizures per month. There was also evidence of improvement of the other (non-frequency) seizure-related measures with psychological therapy, but data were insufficient for meta-analysis. CONCLUSIONS: The findings of this study complement a previous meta-analysis describing psychological treatment-associated improvements in non-seizure-related outcomes. Further research on the most appropriate FDS-severity measure is needed.

Treating taboo thoughts on a psychiatric intensive care unit: a four-phase mixed methods single case experimental design.

BACKGROUND: Well-designed evaluations of psychological interventions on psychiatric intensive care units (PICUs) are a rarity. AIMS: To evaluate the effectiveness of cognitive behaviour therapy for intrusive taboo thoughts with a patient diagnosed with bipolar affective disorder admitted to a PICU due to significant ongoing risk of harm to self. METHOD: This was a four-phase ABC plus community follow-up (D) mixed methods n=1 single case experimental design. Four idiographic measures were collected daily across four phases; the baseline (A) was during PICU admission, the first treatment phase (B) was behavioural on the PICU, the second treatment phase (C) was cognitive on an acute ward and the follow-up phase (D) was conducted in the community. Four nomothetic measures were taken on admission, on discharge from the PICU, discharge from the acute ward and then at 4-week follow-up. The participant was also interviewed at follow-up using the Change Interview. RESULTS: Compared with baseline, the behavioural and the cognitive interventions appeared effective in terms of improving calmness, optimism and rumination, but the effects on sociability were poor. There was evidence across idiographic and nomothetic outcomes of a relapse during the follow-up phase in the community. Eleven idiographic changes were reported in the interview and these tended to be unexpected, related to the therapy and personally important. DISCUSSION: Single case methods can be responsive to tracking the progress of patients moving through in-patient pathways and differing modules of evidence-based interventions. There is a real need to implement robust outcome methodologies on PICUs to better evaluate the psychological aspects of care in this context.

Exploratory and confirmatory factor analysis of emPHasis-10: The health-related quality-of-life measure in pulmonary hypertension.

The emPHasis-10 is a health-related quality of life (HRQoL) unidimensional measure developed specifically for adults with pulmonary hypertension. The tool has excellent psychometric properties and is well used in research and clinical settings. Its factor structure has not been examined, which may help to identity a complimentary approach to using the measure to examine patient functioning. We performed an exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) on a data set collected from 263 adults with PH recruited from a community setting. The EFA suggested the emPHasis-10 consists of three underlying latent variables, which based on the loading of items, were termed "fatigue" (Items 3, 4, and 5), "independence" (Items 7, 8, 9, and 10), and "breathlessness" (Items 1, 2, and 6). All factors were found to have good internal consistency. "Independence" accounted for most of the variance (29%), followed by "breathlessness" (22%) and "fatigue" (19%). The CFA looked to confirm the fit of a three-factor model. A higher-order model was found to be the best fit consisting of HRQoL as a superordinate factor, for which the association between this factor and the 10 items was mediated through the three latent factors. Further analyses were performed testing the validity of the latent variables revealing all were significantly correlated with self-reported measures of depression, anxiety, health-anxiety, and dyspnea. Our analyses support the emPHasis-10 as a measure of HRQoL, while also proposing the clinical utility of examining the three emergent factors, which could be used to glean additional insight into the respondent's functioning and inform care.

A meta-analytic review of the effectiveness of psychological treatment of functional/dissociative seizures on non-seizure outcomes in adults.

Psychological therapies are considered the treatment of choice for functional/dissociative seizures (FDSs). Although most previous studies have focused on seizure persistence or frequency, it has been argued that well-being or health-related quality of life outcomes may actually be more meaningful. This study contributes by summarizing and meta-analyzing non-seizure outcomes to quantify the effectiveness of psychological treatment in this patient group. A pre-registered systematic search identified treatment studies (e.g., cohort studies, controlled trials) in FDSs. Data from these studies were synthesized using multi-variate random-effects meta-analysis. Moderators of treatment effect were examined using treatment characteristics, sample characteristics, and risk of bias. A total of 171 non-seizure outcomes across 32 studies with a pooled sample size of N = 898 yielded a pooled effect-size of d = .51 (moderate effect size). The outcome domain assessed and the type of psychological treatment were significant moderators of reported outcomes. Greater rates of improvement were demonstrated for outcomes assessing general functioning. Behavioral treatments emerged as particularly effective interventions. Psychological interventions are associated with clinical improvements across a broad array of non-seizure outcomes, over and above seizure frequency, in adults with FDSs.

Long-term psychotherapy in tertiary care: A practice-based benchmarking study.

OBJECTIVES: The literature regarding the effectiveness of long-term psychological interventions delivered in tertiary care is scarce. This study sought to quantify and evaluate outcomes delivered in a UK tertiary care psychotherapy service against equivalent service benchmarks. DESIGN: A retrospective analysis of outcomes on the Outcome Questionnaire-45 (OQ-45) over a 10-year period in a tertiary care psychotherapy service. The modalities evaluated were cognitive-behavioural, cognitive-analytic, and psychoanalytic psychotherapies. METHODS: Effectiveness was calculated at the service level and for each modality using pre-post-effect sizes and recovery rates. Benchmarking included a random-effects meta-analysis. Trajectories of change for each modality were examined using growth curve models. RESULTS: Baseline distress on the OQ-45 was higher than comparative norms (M = 102.57, SD = 22.79, N = 364). The average number of sessions was 48.68 (SD = 42.14, range = 5-335). There was a moderate pre-post-treatment effect (d = .46, 95% CI = .37-.55) which was lower than available benchmarks. The modalities differed in duration but were largely equivalent in terms of outcome. The reliable improvement rate was 29.95%, and the recovery rate was 10.16%, and change over time was best explained using a nonlinear (cubic) time trend. CONCLUSIONS: The elevated distress at baseline appears to create the conditions for relatively lengthy interventions and attenuated clinical outcomes. Suggestions are made regarding the clinical role, function, and evaluation of tertiary care psychotherapy services.

The Effectiveness of Psychological Interventions Delivered in Routine Practice: Systematic Review and Meta-analysis.

This review presents a comprehensive evaluation of the effectiveness of routinely delivered psychological therapies across inpatient, outpatient and University-based clinics. This was a pre-registered systematic-review of studies meeting pre-specified inclusion criteria (CRD42020175235). Eligible studies were searched in three databases: MEDLINE, CINAHL and PsycInfo. Pre-post treatment (uncontrolled) effect sizes were calculated and pooled using random effects meta-analysis to generate effectiveness benchmarks. Moderator analyses were used to examine sources of heterogeneity in effect sizes. Overall, 252 studies (k = 298 samples) were identified, of which 223 (k = 263 samples) provided sufficient data for inclusion in meta-analysis. Results showed large pre-post treatment effects for depression [d = 0.96, (CI 0.88-1.04), p ≤ 0.001, k = 122], anxiety [d = 0.8 (CI 0.71-0.9), p ≤ 0.001, k = 69], and other outcomes [d = 1.01 (CI 0.93-1.09), p ≤ 0.001, k = 158]. This review provides support for the effectiveness of routinely delivered psychological therapy. Effectiveness benchmarks are supplied to support service evaluations across multiple settings.

Effectiveness of cognitive analytic therapy for bipolar affective disorder: A co-produced single subject cumulative treatment design with extended follow-up (A1 /B/A2 /C-FU).

OBJECTIVES: Evidence for the treatment of bipolar affective disorder with cognitive analytic therapy (CAT) is limited, and so this study sought to intensively evaluate outcomes in a co-produced single-case experimental design (SCED). DESIGN: An A1 /B/A2 /C with extended follow-up SCED with a female patient meeting diagnostic criteria for bipolar disorder. METHODS: Following the 6-week baseline period 'A1 ', treatment occurred in two phases (18 'B' and 6 sessions 'C') sandwiching a 12-week treatment withdrawal phase ('A2 ') and a 24-week structured follow-up phase. Five idiographic daily measures were collected daily to create a 622-day timeline. The PHQ-9 and the Mania Rating Scale were completed after each treatment session. The participant held two roles: as the patient and provider of the idiographic/nomothetic outcomes and also as part of the research team through providing a commentary on the outcomes identified. RESULTS: CAT was a partially effective intervention. There were improvements to idiographic measures of self-criticism, self-acceptance, body dissatisfaction and worry. Nomothetic outcomes showed little change. CAT did not insulate from the occurrence of a hypermanic relapse during the follow-up phase. The change commentary mirrored the idiographic outcomes in noting that the 'exits' were harder to implement during the manic relapse. CONCLUSIONS: This co-produced SCED suggests a partially effective CAT intervention, but with exits much harder to sustain during manic relapse. Methodologically, it is possible to improve SCED methodology through widening the participant role further beyond that of data collection.

Effectiveness of the unified protocol for treating co-morbid health anxiety and depression: an empirical case study.

AIMS: The unified protocol (UP) is indicated when patients present with co-morbidity, but no studies have previously investigated the effectiveness of the UP with co-morbid health anxiety and depression. METHOD: An A/B single case design evaluated outcomes for a 27-year-old male presenting with health anxiety and co-morbid depression. Following a 21-day assessment-baseline period containing three sessions, the manualised UP was delivered across a 42-day period containing seven intervention sessions. Four idiographic measures (occurrence and duration of health checking, sleep duration and food intake satisfaction) were collected daily throughout, and two nomothetic measures were collected at four time points. RESULTS: All sessions were attended. Number of health checking episodes reduced from four per day to two per day. A 59 minute per day reduction in time spent health checking occurred, and sleep increased by 100 minutes per night. There was little apparent change in terms of food intake satisfaction. There was a reliable and clinically significant reduction in depression. DISCUSSION: Further testing of the effectiveness of the UP with co-morbid health anxiety and depression in true single case experimental designs is now indicated.

Effectiveness of transdiagnostic seminars to support patients with common mental disorders: a multi-service practice research network study.

BACKGROUND: This was a multi-site evaluation of psycho-educational transdiagnostic seminars (TDS) as a pre-treatment intervention to enhance the effectiveness and utilisation of high-intensity cognitive behavioural therapy (CBT). AIMS: To evaluate the effectiveness of TDS combined with high-intensity CBT (TDS+CBT) versus a matched sample receiving CBT only. Second, to determine the consistency of results across participating services which employed CBT+TDS. Finally, to determine the acceptability of TDS across patients with different psychological disorders. METHOD: 106 patients across three services voluntarily attended TDS while on a waiting list for CBT (TDS+CBT). Individual and pooled service pre-post treatment effect sizes were calculated using measures of depression, anxiety and functional impairment. Effectiveness and completion rates for TDS+CBT were compared with a propensity score matched sample from an archival dataset of cases who received high-intensity CBT only. RESULTS: Pre-post treatment effect sizes for TDS+CBT were comparable to the matched sample. Recovery rates were greater for the group receiving TDS; however, this was not statistically significant. Greater improvements were observed during the waiting-list period for patients who had received TDS for depression (d = 0.49 compared with d = 0.07) and anxiety (d = 0.36 compared with d = 0.04). CONCLUSIONS: Overall, this new evidence found a trend for TDS improving symptoms while awaiting CBT across three separate IAPT services. The effectiveness of TDS now warrants further exploration through an appropriately sized randomised control trial.

The effectiveness of cognitive analytic therapy for borderline personality disorder: Utilizing a withdrawal experimental design to improve sensitivity to abandonment.

OBJECTIVES: A primary methodological weakness of the single-case experimental design (SCED) outcome studies conducted of the treatment of personality disorder with cognitive analytic therapy (CAT) is that they have failed to employ a withdrawal phase or cross-over design and so are deemed quasi-experimental. This study sought to implement a withdrawal design, in order to improve the internal validity of the study to make it a true SCED, and also in order to enable the patient to explore abandonment dynamics. DESIGN: The study employed an A1 /B1 /A2 /B2 with extended follow-up SCED with a female patient treated with CAT meeting diagnostic criteria for borderline personality disorder (BPD). Following the 6-week baseline period 'A1 ', treatment occurred in two phases (21 sessions 'B1 ' and 24 sessions 'B2 ') sandwiching a 12-week treatment withdrawal phase ('A2 ') and a 24-week structured follow-up phase. Seven idiographic daily measures were collected that created a N = 698 day timeline. Nomothetic outcome measures were collected at baseline and at the end of each phase of the study, and the Session Impact Scale was completed after each treatment session. RESULTS: There was a significant increase in the task focus of treatment sessions. Ideographically, CAT was an effective treatment for improving the participant's self-to-self relationship, as their self-hate reduced and their sense-of-self increased. There was a broad pattern of deterioration during the second treatment phase (B2 ) and follow-up phase across the ideographic measures, and CAT was ineffective for BPD ideographic emotional or self-to-other measures. Reliable change occurred on the primary BPD nomothetic outcome measure from baseline to end of first treatment phase. CONCLUSIONS: The study suggests that the CAT intervention was partially successful and that it is possible to integrate good research practice with clinical innovation. The methodological strengths and limitations of the design and the clinical implications of the results are discussed. PRACTITIONER POINTS: Cognitive analytic therapy was partially effective in the treatment of BPD in a case that had been unresponsive to other psychological interventions. Therapists need to complete lengthy and structured follow-up to capture any emerging relapse. Therapists need to discuss the patient's thoughts and feelings about termination regularly in a relationally informed manner.

Treatment of compulsive buying disorder: comparing the effectiveness of cognitive behavioural therapy with person-centred experiential counselling.

BACKGROUND: Outcome studies of the treatment of compulsive buying disorder (CBD) have rarely compared the effectiveness of differing active treatments. AIMS: This study sought to compare the effectiveness of cognitive behavioural therapy (CBT) and person-centred experiential therapy (PCE) in a cross-over design. METHOD: This was an ABC single case experimental design with extended follow-up with a female patient meeting diagnostic criteria for CBD. Ideographic CBD outcomes were intensively measured over a continuous 350-day time series. Following a 1-month baseline assessment phase (A; 28 days; three sessions), CBT was delivered via 13 out-patient sessions (B: 160 days) and then PCE was delivered via six out-patient sessions (C: 63 days). There was a 99-day follow-up period. RESULTS: Frequency and duration of compulsive buying episodes decreased during active treatment. CBT and PCE were both highly effective compared with baseline for reducing shopping obsessions, excitement about shopping, compulsion to shop and improving self-esteem. When the PCE and CBT treatment phases were compared against each other, few differences were apparent in terms of outcome. There was no evidence of any relapse over the follow-up period. A reliable and clinically significant change on the primary nomothetic measure (i.e. Compulsive Buying Scale) was retained over time. CONCLUSIONS: The study suggests that both CBT and PCE can be effective for CBD. Methodological limitations and suggestions for future CBD outcome research are discussed.