A model for streamlining psychotherapy in the RDoC era: the example of 'Engage'.

A critical task for psychotherapy research is to create treatments that can be used by community clinicians. Streamlining of psychotherapies is a necessary first step for this purpose. We suggest that neurobiological knowledge has reached the point of providing biologically meaningful behavioral targets, thus guiding the development of effective, simplified psychotherapies. This view is supported by the Research Domain Criteria (RDoC) Project, which reflects the field's consensus and recognizes the readiness of neurobiology to guide research in treatment development. 'Engage' is an example of such a streamlined therapy. It targets behavioral domains of late-life depression grounded on RDoC constructs using efficacious behavioral strategies selected for their simplicity. 'Reward exposure' targeting the behavioral expression of positive valence systems' dysfunction is the principal therapeutic vehicle of 'Engage'. Its first three sessions consist of direct 'reward exposure', but the therapists search for barriers in three behavioral domains, that is, 'negativity bias' (negative valence), 'apathy' (arousal) and 'emotional dysregulation' (cognitive control), and add strategies targeting these domains when needed. The end result is a structured, stepped approach using neurobiological constructs as targets and as a guide to personalization. We argue that the 'reduction' process needed in order to arrive to simplified effective therapies can be achieved in three steps: (1) identify RDoC constructs driving the syndrome's psychopathology; (2) create a structured intervention utilizing behavioral and ecosystem modification techniques targeting behaviors related to these constructs; (3) examine whether the efficacy of the new intervention is mediated by change in behaviors related to the targeted RDoC constructs.

Predicting diabetes distress in patients with Type 2 diabetes: a longitudinal study.

AIMS: Diabetes distress (DD) is a condition distinct from depression that is related to diabetes outcomes. In those without distress initially, little is known about what indicators place patients at risk for subsequent distress over time. METHODS: From a community-based, three-wave, 18-month study of Type 2 diabetic patients (n = 506), we identified patients with no DD at T1 who displayed DD at T2, T3 or both (n = 57). Using logistic regression with full and trimmed models, we compared them with patients with no DD at all three time points (n = 275) on three blocks of variables: patient characteristics (demographics, depression, extra-disease stress), biological (HbA(1c), body mass index, comorbidities, complications, blood pressure, non-high-density lipoprotein-cholesterol), and behavioural variables (diet, exercise). Selected interactions with stress and major depressive disorder (MDD) were explored. RESULTS: The odds of becoming distressed over time were higher for being female, previously having had MDD, experiencing more negative events or more chronic stress, having more complications, and having poor diet and low exercise. Negative life events increased the negative effects of both high HbA(1c) and high complications on the emergence of distress over time. CONCLUSIONS: We identified a list of significant, independent direct and interactive predictors of high DD that can be used for patient screening to identify this high-risk patient cohort. Given the impact of high DD on diabetes behavioural and biological indicators, the findings suggest the usefulness of regularly appraising both current life and disease-related stressors in clinical care.

A longitudinal study of affective and anxiety disorders, depressive affect and diabetes distress in adults with Type 2 diabetes.

AIMS: To report the prevalence and correlates of affective and anxiety disorders, depressive affect and diabetes distress over time. METHODS: In a non-interventional study, 506 patients with Type 2 diabetes were assessed three times over 18 months (9-month intervals) for: major depressive disorder (MDD), general anxiety disorder (GAD), panic disorder (PANIC), dysthymia (DYS) (Composite International Diagnostic Interview); depressive affect [Center for Epidemiological Studies-Depression (CES-D)]; Diabetes Distress Scale (DDS); HbA(1c); and demographic data. RESULTS: Diabetic patients displayed high rates of affective and anxiety disorders over time, relative to community adults: 60% higher for MDD, 123% for GAD, 85% for PANIC, 7% for DYS. The prevalence of depressive affect and distress was 60-737% higher than of affective and anxiety disorders. The prevalence of individual patients with an affective and anxiety disorder over 18 months was double the rate assessed at any single wave. The increase for CES-D and DDS was about 60%. Persistence of CES-D and DDS disorders over time was significantly greater than persistence of affective and anxiety disorders, which tended to be episodic. Younger age, female gender and high comorbidities were related to persistence of all conditions over time. HbA(1c) was positively related to CES-D and DDS, but not to affective and anxiety disorders over time. CONCLUSIONS: The high prevalence of comorbid disorders and the persistence of depressive affect and diabetes distress over time highlight the need for both repeated mental health and diabetes distress screening at each patient contact, not just periodically, particularly for younger adults, women and those with complications/comorbidities.

Physicians are less willing to treat suicidal ideation in older patients.

OBJECTIVE: Older adults have the highest rate of suicide of any age group, and reducing the number of late-life suicides has become a national priority. The objective of this study was to determine if an age bias exists among primary care physicians when they contemplate treating suicidal patients. DESIGN: Primary care providers were mailed one of two case vignettes of a suicidal, depressed patient. The only difference between the two vignettes was the age of the patient (38 or 78 years old) and employment status (employed vs retired as a factory worker). A questionnaire was included to determine provider recognition of suicidal ideation, and a scale was designed to detect willingness to treat the vignette patient. SETTING/PARTICIPANTS: Physicians were selected randomly from the University of California, San Francisco physician roster and invited to participate in the study. A total of 342 physicians (63% response rate), including specialists, responded to the mailings. For this study, the responses of 215 primary care physicians were analyzed. INTERVENTION: The randomly assigned experimental group received a vignette of a geriatric, retired patient who was depressed and suicidal (n = 100 participants). The control group received an identical but younger, employed patient (n = 115 participants). MEASUREMENTS: A 21-item Suicidal Patient Treatment Scale measured willingness to treat the suicidal patient. RESULTS: The physicians in this study recognized depression and suicidal risk in both the adult and the geriatric vignette, but they reported less willingness to treat the older suicidal patient compared with the younger patient. The physicians were more likely to feel that suicidal ideation on the part of the older patient was rational and normal. They were less willing to use therapeutic strategies to help the older patient, and they were not optimistic that psychiatrists or psychologists could help the suicidal patient. CONCLUSIONS: This study suggests that primary care physicians are capable of recognizing suicidal ideation but are less willing to treat it if the patient is older and retired. Future research needs to determine etiologic factors for this age bias.

Issues and recommendations for the recruitment and retention of older ethnic minority adults into clinical research.

A burgeoning literature indicates that treatment of mental disorders offsets mortality, morbidity, and poor quality of life in senior citizens. Unfortunately, ethnic minority senior citizens, who are in most need of mental health services, have not been well represented in psychosocial research. This lack of attention is due, in large part, to difficulties that may arise in recruitment and retention of older ethnic minority adults in research studies. The purpose of this article is to discuss successful methods for recruiting older ethnic minority adults into psychosocial research and to offer specific suggestions for keeping this population involved in longitudinal studies. Also included is a discussion of past research and present data from treatment studies that used the methods discussed in this article.

Comparative effectiveness of social problem-solving therapy and reminiscence therapy as treatments for depression in older adults.

Compared the effects of 2 psychotherapies based on divergent conceptualizations of depression in later life. Seventy-five older adults diagnosed with major depressive disorder were assigned randomly to problem-solving therapy (PST), reminiscence therapy (RT), or a waiting-list control (WLC) condition. Participants in PST and RT were provided with 12 weekly sessions of group treatment. Dependent measures, taken at baseline, posttreatment, and 3-month follow-up, included self-report and observer-based assessments of depressive symptomatology. At posttreatment, both the PST and the RT conditions produced significant reductions in depressive symptoms, compared with the WLC group, and PST participants experienced significantly less depression than RT subjects. Moreover, a significantly greater proportion of participants in PST versus RT demonstrated sufficient positive change to warrant classification of their depression as improved or in remission at the posttreatment and follow-up evaluations.

Do primary care patients accept psychological treatments?

Most individuals seeking care for psychological distress go to primary care physicians rather than to mental health professionals. Many have symptoms of distress that do not meet criteria for psychiatric disorders; pharmacotherapies are generally not available for these subsyndromal problems. Preliminary studies suggest that psychosocial therapies may be useful. The aim of this paper was to learn whether medical patients would accept psychological treatments for 1) depression, an explicit psychopathology; 2) stress, a nonpathological, but psychological, problem; and 3) medical problems, a nonpsychological issue. Respondents were 131 primary care patients at San Francisco General Hospital, a public sector hospital. The results show that most of the patients (107 of 131) found psychological interventions acceptable. In addition, the vast majority were willing to have the treatments focus on psychological issues such as depression and stress. This study demonstrates that primary care patients find psychological interventions acceptable.

Assertiveness and problem-solving training for mildly mentally retarded persons with dual diagnoses.

This study investigated the differential effectiveness of assertiveness and problem-solving training on dually diagnosed patients' adaptive social behavior, distress and psychiatric symptoms, anger control, and problem-solving coping skills using a counterbalanced design. Assessments were conducted at pretreatment, midphase, posttreatment, and a 3-month follow-up examination. A combined assertiveness and problem-solving training package was effective for treatment of individuals with mild mental retardation with dual psychiatric diagnoses. Specifically, improvements occurred regarding both self-report measures of distress and caregiver ratings of adaptive functioning; however, no essential differences were found between these two treatment protocols. The importance of using self-regulatory models of therapy with this population is highlighted, and recommendations were made for future research.

Treating depressive disorders: who responds, who does not respond, and who do we need to study?

Numerous studies show that pharmacotherapy and psychotherapy are efficacious and effective in treating depression. Even though that is true for many people, there are some who do not respond to these therapies, whether it is because they possess characteristics that make them resistant to treatment or because the treatment is not acceptable to them. Also, there are other populations for whom research has yet to determine if guideline-level treatment is effective. People with comorbid Axis I disorders, certain minority groups, and children have been under-represented in treatment research. Future research should focus on treatment-resistant depression and special populations that have been understudied.

Methods for studying course of illness with severely mentally ill adults.

This study examined methods for obtaining course of illness data on adults who are severely mentally ill. A convenience sample (N = 60) was recruited within 4 programs serving different subgroups of adults with severe mental illness. Forty-three participants were able to complete follow-up interviews, using a life chart format to report on personal history in the domains of housing, employment, finances, psychiatric service utilization, health problems, use of psychotropic medication, drug and alcohol use, social relationships, and other major life events. Corresponding information was abstracted from treatment records and examined for concordance with self-reports. Results showed distinct areas of concordance, including recent (1 year) life events, psychiatric care, psychotropic medications, and use of alcohol. Areas of disagreement included legal problems, illicit drug use, and general health. With multiple data sources, it is possible to involve a range of adults with severe mental illness in research and to incorporate their knowledge into course of illness studies.

The prevalence of psychiatric disorders and subsyndromal mental illness in low-income, medically ill elderly.

OBJECTIVE: This study estimated the past and current prevalence of psychiatric illness and subsyndromal mental illness (both pre-relapse and new onset) in a sample of low-income, medically ill older adults. METHOD: A convenience sample of 95 public sector medical patients aged 55 and older were assessed for the presence of psychiatric diagnosis and symptoms using the Geriatric Depression Scale, Beck Anxiety Inventory, the Short Michigan Alcohol Screening Test, and the Computerized Diagnostic Interview Schedule (DIS-C). RESULTS: Dysthymia and Major Depression were the most prevalent current disorders and Alcohol Dependence the most prevalent past disorder. Overall, 25 percent met criteria for at least one Axis I disorder. An additional 44 percent of patients had subsyndromal mental illness: 14 percent had subsyndromal depression, 17 percent were significantly anxious, and 30 percent were problem drinkers. A prior model predicting current Axis I disorder in younger people was found to be predictive of current Axis I but did not predict to subsyndromal disorder. CONCLUSIONS: The rates of psychiatric disorders and symptoms in this older, low-income population were similar to those in other samples of older medical patients. The findings from this research suggest the need for larger epidemiological studies of the prevalence of psychiatric disorders in this disadvantaged aging population. The complexities of this type of research are also discussed.

Psychosocial treatment research with ethnic minority populations: ethical considerations in conducting clinical trials.

Because of historical mistreatment of ethnic minorities by research and medical institutions, it is particularly important for researchers to be mindful of ethical issues that arise when conducting research with ethnic minority populations. In this article, we focus on the ethical issues related to the inclusion of ethnic minorities in clinical trials of psychosocial treatments. We highlight 2 factors, skepticism and mistrust by ethnic minorities about research and current inequities in the mental health care system, that researchers should consider when developing psychosocial interventions studies that include ethnic minorities.

Ethical considerations in psychotherapy effectiveness research: choosing the comparison group.

The primary purpose behind effectiveness research is to determine whether a treatment with demonstrated efficacy has utility when administered to the general population. The main questions these studies are meant to answer are these: Can the typical patient respond to treatment? Is the treatment acceptable to the typical patient? Can the treatment be administered safely and in its entirety in the typical treatment setting? Is the treatment under study significantly better than the community standard of care both from and a cost and outcome perspective? Answering these questions is meant to provide sufficient information to providers and policymakers so that effective interventions can be adopted and become the new community standard. For this research to make a meaningful impact on a provider and policymaker's decision to change the status quo, study interventions should be compared to the existing community standard of treatment, often referred to as treatment as usual (TAU). From an ethical perspective, this decision may not always be the safest choice. In some populations, TAU may mean no treatment at all, and in others TAU may be worse than withholding treatment. The effectiveness researcher is then caught between the pull to do no harm and the need for research to have an impact on change. The purpose of this article is to highlight certain conditions when TAU is ethically acceptable and to discuss alternatives when TAU may be an unethical treatment condition. For purposes of precision, we focus exclusively on psychotherapy effectiveness research rather than system-intervention research or medication-intervention research.

Differential item functioning in a Spanish translation of the Beck Depression Inventory.

Brief and culturally compatible measures of depression are necessary, yet most depression scales are translated without regard for cultural biases. In this study, 292 medical outpatients completed an English or a Spanish-translated and back-translated version of the Beck Depression Inventory (BDI). The BDI items were analyzed for bias between Spanish and English-speaking patients to determine the equivalence of the scale. A Differential Item Function (DIF) using a Mantel Haenszel Approach for Ordered Response Categories was used to analyze how likely subjects in the two ethnic groups were to endorse each response category. The results suggest that regardless of level of depression, Latinos are more likely to endorse items reflecting tearfulness and punishment, and less likely to endorse inability to work. Cultural interpretations and recommendations for use of the BDI are discussed.

Symptom differences between older depressed primary care patients with and without history of trauma.

OBJECTIVE: The current study explored the relationship between past traumatic experiences and current depression in a sample of depressed older adult primary care patients. METHOD: Sixty-six patients were referred from primary care to a psychogeriatric clinic that specialized in the treatment of unipolar depressive disorders. All patients received an extensive psychological assessment. RESULTS: Twenty-one percent had a history of trauma reported in their medical charts. Despite no differences found on a clinician-rated measure of depression, those with a trauma history had more depressive symptoms on a self-report measure. CONCLUSIONS: Although older patients with a history of trauma may not appear more depressed than a non-trauma comparison group, they may be in more psychological distress. The clinical implications of these findings and recommendations for mental health professionals are discussed.

Improving primary care for depression in late life: the design of a multicenter randomized trial.

BACKGROUND: Late life depression can be successfully treated with antidepressant medications or psychotherapy, but few depressed older adults receive effective treatment. RESEARCH DESIGN: A randomized controlled trial of a disease management program for late life depression. SUBJECTS: Approximately 1,750 older adults with major depression or dysthymia are recruited from seven national study sites. INTERVENTION: Half of the subjects are randomly assigned to a collaborative care program where a depression clinical specialist supervised by a psychiatrist and a primary care expert supports the patient's regular primary care provider to treat depression. Intervention services are provided for 12 months using antidepressant medications and Problem Solving Treatment in Primary Care according to a stepped care protocol that varies intervention intensity according to clinical needs. The other half of the subjects are assigned to care as usual. EVALUATION: Subjects are independently assessed at baseline, 3 months, 6 months, 12 months, 18 months, and 24 months. The evaluation assesses the incremental cost-effectiveness of the intervention compared with care as usual. Specific outcomes examined include care for depression, depressive symptoms, health-related quality of life, satisfaction with depression care, health care costs, patient time costs, market and nonmarket productivity, and household income. CONCLUSIONS: The study blends methods from health services and clinical research in an effort to protect internal validity while maximizing the generalizability of results to diverse health care systems. We hope that this study will show the cost-effectiveness of a new model of care for late life depression that can be applied in a range of primary care settings.