Assessing treatment progress of individual patients using expected treatment response models.

The dosage model provides a normative estimate of the overall pattern of patient improvement in psychotherapy. The phase model further specifies patterns of change in the domains of subjective well-being, symptom remediation, and functioning. The expected treatment response (ETR) approach uses patient characteristics to predict an expected path of progress for each patient. With repeated measures of mental health status, the treatment progress of an individual patient can be assessed against the patient's ETR to support decisions that would enhance the quality of a clinical service while it is being delivered.

Syzygy, science, and psychotherapy: the Consumer Reports study.

Results from a Consumer Reports (CR) survey indicated that psychotherapy has proven to be quite effective and that longer-term therapy has been more effective than shorter-term therapy. Critiques of the methodology of this study have included the claim that (a) the self-selected sample was biased in favor of people who felt that they had benefited from psychotherapy, (b) the use of retrospective accounts led to a further positive bias, and (c) the validity of the outcome assessment was questionable. Supplemental data from other sources, including prospective data from a large sample of psychotherapy patients, are presented to augment the interpretation of the results of the CR study and to illustrate how some critiques of research results can be evaluated systematically.

Prediction of dose-response relations based on patient characteristics.

The recent discussion of evidence-based, adaptive treatment planning highlights the need for models for the prediction of courses of treatment response. We combine a dose-response model with growth curve modeling to determine dose-response relations for well-being, symptoms, and functioning. Hierarchical linear modeling was used to model each patient's expected course of improvement. The resulting predictions were cross-validated on two samples of psychotherapy outpatients. The results give further empirical support for the dose-response model and the phase model of psychotherapy as well as for the usefulness of patient treatment response profiling for individual treatment management.

The altering of reported experiences.

OBJECTIVES: The unreliability of human memory is well documented in the literature, yet psychiatrists and other mental health care professionals rely on patient self-report in history-taking. This study provides new evidence from a longitudinal study of autobiographical memory and discusses implications for the development and implementation of appropriate treatment plans and goals. METHOD: Seventy-three mentally healthy 14-year-old males were studied in 1962. Sixty-seven of these subjects were reinterviewed face-to-face at age 48. Questions concerning areas of family relationships, home environment, dating, sexuality, religion, parental discipline, and general activities were asked in both interviews. RESULTS: Significant differences were found between adult memories of adolescence and what was actually reported during adolescence. Accurate memory was generally no better than expected by chance. CONCLUSIONS: If the accurate memory of one's past is not better than chance in the mentally healthy individual, even more care probably should be taken in obtaining accurate historical information in the medically, psychologically, or otherwise health-compromised individual. It would be more constructive to treat recollections as existential reconstructions.

The predicted and observed course of psychotherapy for anxiety and mood disorders.

By applying hierarchical linear modeling (HLM) techniques, patient clinical characteristics at the beginning of treatment were used to predict individual patient responses (N = 160) to psychotherapy. Four diagnostic groups (mood, anxiety, other, and no diagnosis) were formed among the patients based on intake-administered Structured Diagnostic Interview for the Diagnosis of DSM-III-R axis I Disorders. Patients with mood and anxiety disorders had predicted courses of response to psychotherapy that were similar but different from patients with other disorders and no diagnosis. Predicted and observed courses of response to psychotherapy in a subsample (N = 75) who had provided enough data to model the actual course of treatment showed high levels of congruence, thus supporting the validity of predicting course of response. HLM predictive profiling offers a new approach for assessing treatment effectiveness of psychotherapy with patients having axis I diagnostic conditions by considering an individual patient's clinical characteristics.

Clinical trials versus mental health services research: contributions and connections.

The growing emphasis on using empirical data to guide mental health policy decision making has contributed, in part, to a developing dichotomy along the continuum of research on mental health interventions. At one end of the continuum is research on the efficacy of mental health interventions, traditionally referred to as clinical trials research. The goal of clinical trials research is to determine whether or not a specific intervention can be shown to be efficacious for a specific problem. At the other end of the continuum is research on the implementation and evaluation of mental health interventions, traditionally referred to as mental health services research. The goals of mental health services research are to understand the access to, organization and financing of, and outcomes of mental health interventions. The conceptual, methodological, and measurement features of both types of research are presented and suggestions are offered to bridge the gap between the two paradigms. The purpose of this article is to highlight each discipline's unique contributions to mental health research and, in so doing, facilitate a discussion that fosters scientific integration and collaboration between clinical trials and mental health services investigators.

Predicting patients' responses to psychotherapy: are some more predictable than others?

Patient profiling predicts improvement across psychotherapy sessions on the basis of intake clinical characteristics. Patients completed questionnaires before their 1st session and at other points during treatment. After using hierarchical linear modeling to calculate expected courses of improvement, 1/2 of the sample was divided into 1 of 2 groups: those whose treatment responses across sessions matched or exceeded their expected courses (75% of the sample) and those whose responses failed to match expectations. A discriminant function analysis indicated that the groups could be differentiated on the basis of intake characteristics; that is, patients with higher discriminant scores were more likely than those with low discriminant scores to have responded to psychotherapy as predicted. Successful cross-validation of the predictor weights was performed with the other 1/2 of the sample.

Patient profiling: an application of random coefficient regression models to depicting the response of a patient to outpatient psychotherapy.

Adaptive treatment planning is a dynamic process that is dependent on valid, systematic assessments. The dosage and phase models provide theoretical bases for the development of such "patient-focused" information. Given an underlying mathematical regularity to the recovery process, growth modeling techniques can be used to determine an expected treatment response for every patient. By mapping the patient's actual status against such an expected change trajectory, it is possible to address the most clinically relevant question, "Is this treatment working?"

"Between-group psychotherapy outcome research and basic science" revisited.

Case studies involving the measurement of every plausibly causal variable and every important outcome variable and covering the widest possible range of cases in terms of these variables are the highest priority for psychotherapy research. Such case studies looked at together will give us the best initial understanding of what variables are probably causal and what treatments yield the best results for particular kinds of patients, therapists, and settings. The accumulation of such case studies will show us where we would benefit by doing comparative controlled experiments of distinct therapies or by employing optimum-seeking designs for a particular therapy. Collaboration by the practitioner community will be needed to do this. The truly difficult and necessary work of applied psychotherapy research still lies ahead of us, hardly touched.

Individual psychotherapy outcome and process research: challenges leading to greater turmoil or a positive transition?

Psychotherapy is facing challenges that relate to the emergence of managed health care, the possibility of a national health care system, and advances in biological psychiatry. These situations have created pressure to achieve a more accurate assessment of psychotherapeutic effectiveness. Psychotherapy has been proven to be generally effective; however, there is uncertainty as to why. The field is currently experiencing apparent turmoil in three areas: (a) theory development for psychotherapeutic effectiveness, (b) research design, and (c) treatment technique. This chapter reviews the dynamics within each of the areas and highlights the progress made in treating mental disorders. We conclude that recent advances in research design may provide a transition that will bring psychotherapy closer to becoming a unified paradigm with an acceptable theory of effectiveness.

Are advanced psychiatry residents more skillful than beginning residents in the conduct of psychodynamic psychotherapy?

The psychotherapy skills of psychiatry residents were assessed by using a structured-response supervisor inventory, the Supervisor Report (SR). Longitudinal data on the same resident across time showed a small but positive trend toward the acquisition of skill in doing psychodynamic psychotherapy. Mixed cross-sectional and longitudinal comparisons between ratings of the beginning residents and advanced residents demonstrated a significant, but small, increase in skill over the course of outpatient training. SR score changes also corroborated observational data on individual residents. While these findings suggest the utility of the SR in measuring changes in psychotherapy skill, the results must be considered in light of the relatively poor interrater reliability and only somewhat better test-retest reliability.

The acquisition of psychotherapeutic skill: an empirical study.

The acquisition of psychotherapy skillfulness is an important aspect of training programs in psychiatry and clinical psychology. Psychotherapy supervision is employed to teach and monitor the development of these clinical skills. The Supervisor Report (SR) is a questionnaire designed to systematically assess therapeutic behaviors and global psychotherapeutic skillfulness of therapists conducting psychodynamic psychotherapy. SRs were employed to examine changes in trainees' skillfulness over the course of training. T-tests were applied to evaluate differences between the average scores of trainees in the first half of their training compared to the last half of their training. Comparisons of the scores for Psychotherapeutic Techniques and assessments of Global Skillfulness were in the predicted direction: Trainees in the advanced portion of their training were rated as more skillful than at the beginning. This study provides some evidence that psychotherapy skillfulness is acquired over time in training.

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.

Clinical utility research: an introduction.

Clinical utility research is concerned with how one develops knowledge that can be directly used for improving clinical practice. Some have referred to this domain as "effectiveness" research, but clinical utility implies much more than clinical effectiveness. It also addresses issues of access, transferability, sample specificity, and the uniqueness of each human condition. This special series of papers describe several research programs that have been conducted in applied settings and that illustrate research on clinical utility. These descriptions are modestly representative of the wide applicability of research methods that address the uniqueness of each setting and population and the nature of findings that can be used to guide clinical practice. The papers bridge cultures, countries, settings, and problems. They illustrate some of the advantages of, and some of the knowledge to be gained from conducting controlled research in settings that are devoted to clinical service.

Serotonin reuptake inhibitors and the adequacy of antidepressant treatment.

OBJECTIVE: To determine whether the use of serotonin reuptake inhibitors (SSRIs) improves antidepressant medication prescribing patterns for both psychiatric and non-psychiatric physicians. DATA SOURCES/SETTING: Drug utilization review of 4,103 prescriptions for antidepressant medications with patients diagnosed with depressive disorders over an eighteen-month period from the formulary records of a large insurance company. DESIGN: Using standards developed for clinical guidelines, variation in trial and treatment adequacy between drug types and physician specialty was studied. PRINCIPAL FINDINGS: Thirty-five percent of initial antidepressant trials were not prescribed for an adequate duration or at an adequate dosage level. SSRIs were more likely to be prescribed adequately than any other antidepressant reviewed. Psychiatrists were more likely to prescribe antidepressants at an adequate dosage level, whereas non-psychiatric physicians were more likely to attain adequate duration of treatment. CONCLUSIONS: A greater reliance on SSRIs may increase the likelihood of maintaining adequacy in antidepressant treatments. Although higher in cost than other treatment choices, their lower side effect profile is likely to maximize patient satisfaction and physician and patient adherence to guidelines. In order to ensure effective and efficient antidepressant usage, such patterns must be identified and appropriate performance improvement strategies (e.g., Total Quality Improvement, critical pathways) may be employed.

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 individual's progress over the course of treatment and the feedback of this information to the practitioner, supervisor, or case manager.

Patterns of mental health service utilization.

How many and which individuals, with which psychiatric disorders, receive (and do not receive) mental health services from which professionals in what settings? This question falls within the purview of mental health services research, which is a multidisciplinary field that brings together the methodologies of epidemiology, econometrics, and clinical research. First, in this article, we present an explication of what is known about those individuals in need of psychotherapy and how they access services. Next, we describe the numbers, professional affiliations, and service sites of professionals who are engaged in the practice of psychotherapy. We summarize our current knowledge about the actual utilization of psychotherapy services relative to the needs of patients and the professional background of therapists. Finally, we identify aspects of psychotherapy service utilization that are, as yet, unaddressed.