The Importance of Conducting Practice-oriented Research with Underserved Populations.

There has been a growing emphasis on dissemination of empirically supported treatments. Dissemination, however, should not be restricted to treatment. It can and, in the spirit of the scientific-practitioner model, should also involve research. Because it focuses on the investigation of clinical routine as it takes place in local settings and because it can involve the collaboration of several stakeholders, practice-oriented research (POR) can be viewed as an optimal research method to be disseminated. POR has the potential of addressing particularly relevant gaps of knowledge and action when implemented in regions of the world that have limited resources for or experiences with empirical research, and/or in clinical settings that are serving clinical populations who are not typically receiving optimal mental care services - specifically, individuals in rural and inner cities that have limited economic and social resources. The establishment and maintenance of POR in such regions and/or settings, however, come with specific obstacles and challenges. Integrating the experiences acquired from research conducted in various continents (Africa, Europe, Latin America, and North America), the goal of this paper is to describe some of these challenges, strategies that have been implemented to address them, as well as new possible directions to facilitate the creation and growth of POR. It also describes how these challenges and ways to deal with them can provide helpful lessons for already existing POR infrastructures.

Socioeconomic Deprivation and Dropout from Contemporary Psychological Intervention for Common Mental Disorders: A Systematic Review.

Dropout during psychological intervention is a significant problem. Previous evidence for associations with socioeconomic deprivation is mixed. This study aimed to review the evidence for associations between deprivation and dropout from contemporary adult psychological interventions for common mental disorders (CMDs). Systematic review, narrative synthesis and random effects meta-analysis of peer-reviewed English language journal articles published June 2010-June 2020 was conducted. Data sources included medline, PsycInfo, databases indexed by web of science, ProQuest social science database and sociology collection, and the Cochrane Library, supplemented by forward and backward citation searching. Five studies were eligible for inclusion (mean N = 170, 68% female, 60% White Caucasian, 32% dropout rate, predominantly cognitive behaviour therapy/cognitive processing therapy). Narrative synthesis indicated an overall non-significant effect of deprivation on dropout. Meta-analytic significance of controlled (k = 3) and uncontrolled (k = 4) effects depended on the measure of deprivation included for those studies using more than one measure (controlled OR 1.21-1.32, p = 0.019-0.172, uncontrolled OR 1.28-1.76, p = 0.024-0.423). The low number of included studies meant sub-group comparisons were limited, despite some tentative indications of potential differential effects. A comparator set of excluded studies showed similar uncertainty. There was limited evidence that did not overall suggest a clear significant effect of deprivation on dropout from contemporary individual CMD interventions. However, more contemporary research is needed, as effects may vary according to clinical and methodological factors, and for dropout versus non-initiation.

An investigation of the competencies involved in the facilitation of CBT-based group psychoeducational interventions.

BACKGROUND: Whilst the delivery of low-intensity group psychoeducation is a key feature of the early steps of the Improving Access to Psychological Therapies (IAPT) programme, there is little consensus regarding the skills and competencies demanded. AIMS: To identify the competencies involved in facilitating CBT-based group psychoeducation in order to inform future measure development. METHOD: A Delphi study in which participants (n = 36) were relevant IAPT stakeholders and then an expert panel (n = 8) review of the competencies identified within the Delphi study to create a shortened, more practical list of competencies. RESULTS: After three consultation rounds, consensus was reached on 36 competencies. These competencies were assigned to four main categories: group set-up, content, process and closure. A further expert review produced a shortened 16-item set of psychoeducation group facilitation competencies. CONCLUSIONS: The current study has produced a promising framework for assessing facilitator competency in delivering CBT-based group psychoeducational interventions. Weaknesses in the Delphi approach are noted and directions for future measure development research are identified.

Therapist effects vary significantly across psychological treatment care sectors.

Psychological intervention outcomes depend in part on the therapist who provides the intervention (a therapist effect). However, recent reviews suggest that therapist effects may vary as a function of the context in which care is provided and therefore should not be generalized beyond that context. This study statistically analysed therapist effect differences between care sectors delivering psychological interventions. The sample comprised routine clinical data from 26,814 patients (69% female; mean age 38) and 466 therapists in five care sectors: primary care, secondary care, university, voluntary, and workplace. Therapist effects were analysed using multilevel models and Markov chain Monte Carlo credible intervals. The therapist effect was significantly larger in primary care (8.4%) than in any other sector (1.1%-2.3%) except secondary care (4.1%), after controlling for explanatory baseline and process variables as well as accounting for differences between clinics. There were no other significant differences detected between care sectors. These findings support the hypothesis that differences in effectiveness between therapists vary depending on the context in which psychological treatment is provided. Differences in relative therapist impact can vary by a factor of 4-8 across treatment sectors. This should be considered in the application of research evidence, treatment planning, and the design and delivery of psychological care provision.

Adverse impact of neighbourhood socioeconomic deprivation on psychological treatment outcomes: the role of area-level income and crime.

Aim: Socioeconomic deprivation is known to be associated with depression and anxiety symptoms. This study aimed to investigate the influence of several domains of neighbourhood deprivation on psychological treatment outcomes. Method: Healthcare records from 44805 patients who accessed psychological treatment were analyzed. Patient-level depression (PHQ-9) and anxiety (GAD-7) outcome measures were linked to their neighbourhood statistics, including area-level indices of income, unemployment, education, health and disability, crime, housing quality, and quality of the local environment. Linear regressions were applied to examine associations between these domains and post-treatment symptom severity after controlling for patient-level and service-level variables. Results: Neighbourhood income and crime rates were associated with depression and anxiety symptoms after controlling for covariates, explaining 4% to 5% of variability in treatment outcomes. Patients living in low-income areas required a higher number of treatment sessions to benefit from therapy. Conclusions: Patients living in economically deprived neighbourhoods tend to have poorer depression and anxiety treatment outcomes and require lengthier interventions.

The influence of socio-demographic similarity and difference on adequate attendance of group psychoeducational cognitive behavioural therapy.

Aim: The study aimed to investigate the impact of socio-demographic similarity on the probability of attending an adequate dose of a psychoeducational group intervention (≥4 of 6 sessions). Method: The sample comprised 2071 patients (63% female, 93% White, 15% unemployed, mean age 43) who received the Stress Control intervention in the UK's national Improving Access to Psychological Therapies (IAPT) programme. Similarity indices were constructed to measure each patient's similarity to the rest of their group on four characteristics: age, gender, ethnicity, and neighbourhood deprivation (Index of Multiple Deprivation; IMD). Results: Multilevel analysis found that patients with greater IMD similarity to their group had significantly higher probabilities of attending an adequate dose of intervention (p = .026, controlling for absolute IMD). A cumulative effect of age similarity, ethnic similarity, and group size was also found, such that patients who were similar in age and ethnicity to their group had higher probabilities of adequate attendance in larger groups (p = .006). Conclusions: These results suggest that socio-demographic comparison (a.k.a. relational demography) may consciously or unconsciously impact on patients' attendance at group psychoeducational interventions, particularly regarding indicators of socio-economic similarity. Clinical implications include structuring group composition and/or intervention content to maximise attendance and therefore clinical effectiveness.

Predictors of depression relapse and recurrence after cognitive behavioural therapy: a systematic review and meta-analysis.

BACKGROUND: Cognitive behavioural therapy (CBT) is an effective psychological treatment for major depressive disorder, although some patients experience a return of symptoms after finishing therapy. The ability to predict which individuals are more vulnerable to deterioration would allow for targeted interventions to prevent short-term relapse and longer-term recurrence. AIM: This systematic review and meta-analysis aimed to identify factors associated with an increased risk of relapse and/or recurrence (RR) after CBT for depression. METHOD: We reviewed 13 relevant papers, of which a small set of unique samples were eligible for meta-analysis (k = 5, N = 369). Twenty-six predictor variables were identified and grouped into seven categories: residual depressive symptoms; prior episodes of depression; cognitive reactivity; stressful life events; personality factors; clinical and diagnostic factors; demographics. RESULTS: Meta-analyses indicated that residual depressive symptoms (r = 0.34 [0.10, 0.54], p = .01) and prior episodes (r = 0.19 [0.07, 0.30], p = .002) were statistically significant predictors of RR, but cognitive reactivity was not (r = 0.18 [-0.02, 0.36], p = .08). Other variables lacked replicated findings. On average, 33.4% of patients experienced RR after CBT. CONCLUSIONS: Patients with the above risk factors could be offered evidence-based continuation-phase interventions to enhance the longer-term effectiveness of CBT.

Associations between socioeconomic status and psychological therapy outcomes: A systematic review and meta-analysis.

BACKGROUND: Socioeconomic deprivation is associated with higher prevalence of mental health problems; however, the influence of socioeconomic status (SES) on psychological therapy outcomes is as yet unclear. AIM: To review published evidence on the association between indicators of SES (income, education, employment, neighborhood deprivation, social position) and the outcomes of psychological interventions for depression and anxiety. METHODS: Systematic review and meta-analysis of outcomes research studies published in the last 10 years. RESULTS: Seventeen studies including 165,574 patients measured at least one indicator of SES and its relationship with psychological therapy outcomes. Twelve of these studies found significant relationships between SES measures and mental health outcomes. Six studies focusing on employment status offered sufficient quantitative information to conduct meta-analysis. The overall effect of employment was not significant (-0.66, confidence of interval (CI) -1.33, 0.02). A sensitivity analysis (k = 5) showed a small effect (-0.22, CI -0.36, -0.09) of employment on treatment outcomes. CONCLUSIONS: There is some evidence to indicate that socioeconomic deprivation is associated with poorer treatment outcomes, although limitations of the available data warrant treating this as a preliminary conclusion.

The Relationship Between Therapist Effects and Therapy Delivery Factors: Therapy Modality, Dosage, and Non-completion.

To consider the relationships between, therapist variability, therapy modality, therapeutic dose and therapy ending type and assess their effects on the variability of patient outcomes. Multilevel modeling was used to analyse a large sample of routinely collected data. Model residuals identified more and less effective therapists, controlling for case-mix. After controlling for case mix, 5.8 % of the variance in outcome was due to therapists. More sessions generally improved outcomes, by about half a point on the PHQ-9 for each additional session, while non-completion of therapy reduced the amount of pre-post change by six points. Therapy modality had little effect on outcome. Patient and service outcomes may be improved by greater focus on the variability between therapists and in keeping patients in therapy to completion.

The role of socioeconomic deprivation in explaining neighborhood and clinic effects in the effectiveness of psychological interventions.

OBJECTIVE: Treatment outcomes are known to vary according to therapist and clinic/organization (therapist effect, clinic effect). Outcomes may also vary according to the neighborhood where a person lives (neighborhood effect), but this has not previously been formally quantified. Evidence suggests that deprivation may contribute to explaining such cluster effects. This study aimed to (a) simultaneously quantify neighborhood, clinic, and therapist effects on intervention effectiveness and (b) determine the extent to which deprivation variables explain neighborhood and clinic effects. METHOD: The study used a retrospective, observational cohort design with a high intensity psychological intervention sample (N = 617,375), and a low intensity (LI) psychological intervention sample (N = 773,675). Samples each included 55 clinics, 9,000-10,000 therapists/practitioners, and over 18,000 neighborhoods in England. Outcomes were postintervention depression and anxiety scores and clinical recovery. Deprivation variables included individual employment status, domains of neighborhood deprivation, and clinic-level mean deprivation. Data were analyzed using cross-classified multilevel models. RESULTS: Unadjusted neighborhood effects of 1%-2% and unadjusted clinic effects of 2%-5% were detected, with proportionally larger effects for LI interventions. After controlling for predictors, adjusted neighborhood effects of 0.0%-0.1% and clinic effects of 1%-2% remained. Deprivation variables were able to explain a significant proportion of the neighborhood effect (80%-90% of neighborhood variance) but not clinic effect. The majority of neighborhood variance could only be explained by a shared effect of baseline severity and socioeconomic deprivation variables. CONCLUSIONS: People in different neighborhoods respond differently to psychological intervention, and this clustering effect was mainly explained by socioeconomic factors. People also respond differently according to the clinic they access, but this could not be completely explained by deprivation in the present study. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Associations between treatment adherence-competence-integrity (ACI) and adult psychotherapy outcomes: A systematic review and meta-analysis.

OBJECTIVE: To provide a comprehensive assessment of the association between psychological treatment adherence/competence/integrity (ACI) and clinical outcomes. METHOD: The review protocol was preregistered (CRD42020193889). Studies that assessed ACI-outcome relationships for adult psychotherapy were searched across three databases (Scopus, PsycINFO, MEDLINE). Random effects meta-analyses were conducted on adherence-outcome, competence-outcome, and integrity-outcome relationships. Separate analyses were performed for studies with hierarchical (i.e., patients nested within therapist) versus nonhierarchical study designs. Moderator analyses were performed according to predefined clinical and methodological features. GRADE assessments rated the quality of each meta-analytic comparison. RESULTS: The review identified 62 studies suitable for inclusion (45 adherence-outcome, 39 competence-outcome, and seven integrity-outcome effect sizes; N = 8,210 across all analyses). No significant adherence-outcome association was found. A small significant positive association was found only in nonhierarchical studies between competence and outcome, r = 0.17, 95% CI [0.07-0.26], p < .001, ∼d = .34, GRADE = moderate. Small-to-moderate significant positive associations between integrity and outcome were found for both nonhierarchical, r = 0.15, 95% CI [0.06-0.23], p < .001, ∼d = .30, GRADE = high, and hierarchical study designs, r = 0.23, 95% CI [0.01, 0.43], p < .044, ∼d = .47, GRADE = low. Diagnosis, treatment modality and year of publication significantly moderated the strength of ACI-outcome correlations. CONCLUSIONS: Competence and integrity are significantly associated with clinical outcome, with a magnitude comparable to wider common factors. Further research is required to study these process-outcome associations with greater precision in routine-care settings and to understand the role of moderating variables. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Health psychology attendance: A multilevel analysis of patient-level predictors and therapist effects.

The study investigated adult outpatient Health Psychology Services appointment attendance, cancellation, and missed appointments (A/C/M). The first objective was to determine which demographic and process factors predicted the probability of A/C/M. The second objective was to determine whether there remained residual significant differences in A/C/M between therapists (i.e., a "therapist effect"), after controlling for explanatory variables. We conducted a practice-based retrospective 2-year cohort study. Three-level multilevel models were constructed and tested to analyze the probability of A/C/M at (1) assessment appointments (N = 1,175) and (2) follow-up appointments (N = 5,441). After controlling for predictor variables, significant therapist effects were found for attendance (10.0% to 13.0%) and cancellation (4.4%) at follow-up appointments (but not assessments), indicating significantly different attendance rates at follow-up between therapists. Predictors of attendance at follow-up included patient age, pretherapy symptom severity scores (including risk and symptom scores), and completion of intake questionnaires. Early morning follow-up appointments were least likely to be canceled, followed by late afternoon and finally midday appointments. Treatment intensity predicted attendance, but among qualified therapists, qualification type and pay level were nonsignificant. No significant predictors of attendance at assessment were detected. Attendance at Health Psychology Services outpatient appointments varies significantly according to patient, therapist, and appointment factors. Key routinely collected variables are predictive of attendance at follow-up. Clinical implications include the potential to identify patients at risk of nonattendance and target engagement interventions to these patients. Research directions include closer examination of variability in follow-up attendance between therapists. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Therapist and clinic effects in psychotherapy: A three-level model of outcome variability.

OBJECTIVE: The study aimed to (a) investigate the effect of treatment location on clinical outcomes for patients receiving psychological therapy (a clinic effect, akin to the concept of a therapist effect) and (b) assess the impact of explanatory individual and aggregate demographic and process variables on the clinic and therapist effects. METHOD: The sample comprised 26,888 patients, seen by 462 therapists, across 30 clinics. Mean patient age was 38 years (69% female, 90% White, 92% planned ending). The dependent variable was patients' posttherapy score on the Clinical Outcomes in Routine Evaluation-Outcome Measure. An incremental 3-level multilevel model was constructed. Markov Chain Monte Carlo estimation created 95% probability intervals for the clinic and therapist effects. RESULTS: A 3-level model with no explanatory variables detected a clinic effect of 8.2%, significantly larger than the therapist effect of 3.2%. Adding explanatory variables significantly reduced the clinic effect to 1.9% but did not significantly alter the therapist effect (3.4%). Patient-level symptom severity and employment status, and clinic-level percentage of White patients and health care sector, explained the most clinic outcome variance and overall outcome variance. CONCLUSIONS: Substantial variability in clinical outcomes was found between clinics providing psychological therapy. Socioeconomic mix of patients explained significant proportions of variability at the clinic level but not the therapist level. Clinical implications include the need to go beyond the therapist-patient interaction to deliver effective psychological therapy. Future research is also needed to identify the mechanisms by which clinic and/or area-level factors impact on clinical outcomes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

The clinical effectiveness of stepped care systems for depression in working age adults: a systematic review.

BACKGROUND: Stepped care service delivery models involve treatments that become increasingly intense through successive steps, with patients re-assigned via pre-defined decision criteria. This article reviews the clinical effectiveness of stepped care systems for depression in working age adults. METHODS: Systematic literature review of quantitative clinical outcome evidence comprising 14 controlled and uncontrolled studies meeting specified criteria. Principal outcomes were (a) recovery rates, defined as patients no longer meeting clinical cut-off criteria for the specific outcome measure and (b) treatment response rates, defined as a 50% decrease in outcome measure score. RESULTS: Stepped care systems had recovery rates ranging predominantly between 40% and 60% and response rates approximating 60%. Studies comparing stepped care with usual/enhanced usual care tended to find significant differences favouring stepped care. The median recovery odds ratio was 1.31 (interquartile intervals of 1.05 and 1.66; k=7 studies). The median comparative Cohen's d effect size estimate was 0.41 (interquartile intervals 0.25 and 0.45; k=5 studies). LIMITATIONS: The inclusion of uncontrolled studies could be seen as reducing the overall quality of evidence and a meta-analysis was not included due to limitations with the available data. CONCLUSIONS: Evidence suggested that stepped care interventions for depression are at least as effective as usual care. However, the clinical and organisational superiority of stepped care is yet to be scientifically verified. Differential benefits of stepped care may ultimately depend on service quality. Further research investigating and comparing the specific components and configurations of stepped care interventions are indicated.

Therapist effects and moderators of effectiveness and efficiency in psychological wellbeing practitioners: A multilevel modelling analysis.

OBJECTIVES: The study investigated whether psychological wellbeing practitioners (PWPs) working within the UK government's Improving Access to Psychological Therapies (IAPT) initiative are differentially effective (i.e., therapist effect size) and differentially efficient (i.e., rate of clinical change), and the moderating effect of demographic and process factors on outcomes. DESIGN AND METHODS: Routine clinical outcome data (depression, anxiety, and functional impairment) were collected from a single IAPT service. A total of 6111 patients were treated by 56 PWPs. Multilevel modelling (MLM) determined the size of the therapist effect and examined significant moderators of clinical outcomes. PWPs were grouped according to below average, average, and above average patient outcomes and compared on clinical efficiency. RESULTS: Therapist effects accounted for 6-7% of outcome variance that was moderated by greater initial symptom severity, treatment duration, and non-completion of treatment. Clinically effective PWPs achieved almost double the change per treatment session. As treatment durations increased beyond protocol guidance, outcomes atrophied. Treatment non-completion was particularly detrimental to outcome. CONCLUSIONS: PWPs appear to be differentially effective and efficient despite ostensibly delivering protocol driven interventions. Implications for services, training, and supervision are outlined.

Effectiveness of psychologically focused group interventions for multiple sclerosis: a review of the experimental literature.

Psychologically focused group interventions for multiple sclerosis were reviewed. Studies reviewed (14) were quantitative, experimental and involved a comparison group (control or other intervention). Compared with controls, psychologically focused group interventions achieved considerable improvements in depression and moderate improvements in self-efficacy and quality of life but little change in anxiety. Psychologically focused group interventions compared well with other interventions, although evidence was limited. Psychologically focused group intervention was less effective short term for depression than individual cognitive behavioural therapy or medication but comparable long term. Intervention heterogeneity made comparisons difficult. Specificity of effect is unclear. Limited evidence suggests psychologically focused group intervention is effective in improving certain outcomes.