Defining the Assessment and Treatment Competencies to Deliver Low-Intensity Cognitive Behavior Therapy: A Multi-Center Validation Study.

Despite the vastly increased dissemination of the low-intensity (LI) version of cognitive behavior therapy (CBT) for the treatment of anxiety and depression, no valid and reliable indices of the LI-CBT clinical competencies currently exist. This research therefore sought to develop and evaluate two measures: the low-intensity assessment competency scale (LIAC) and the low-intensity treatment competency scale (LITC). Inductive and deductive methods were used to construct the competency scales and detailed rating manuals were prepared. Two studies were then completed. The first study used a quantitative, fully-crossed design and the second a multi-center, quantitative longitudinal design. In study one, novice, qualified, and expert LI-CBT practitioners rated an LI-CBT assessment session (using the LIAC) and an LI-CBT treatment session (using the LITC). Study two used the LIAC and LITC across four training sites to analyze the competencies of LI-CBT practitioners over time, across raters, and in relation to the actor/patients' feedback concerning helpfulness, the alliance, and willingness to return. Both the LIAC and LITC were found to be single factor scales with good internal, test-retest reliability and reasonable inter-rater reliability. Both measures were sensitive to measuring change in clinical competence. The LIAC had good concurrent, criterion, discriminant, and predictive validity, while the LITC had good concurrent, criterion, and predictive validity, but limited discriminant validity. A score of 18 accurately delineated a minimum level of competence in LI-CBT assessment and treatment practice, with incompetent practice associated with patient disengagement. These observational ratings scales can contribute to the clinical governance of the burgeoning use of LI-CBT interventions for anxiety and depression in routine services and also in the methods of controlled studies.

Efficacy and cost-effectiveness of intensive short-term dynamic psychotherapy for treatment resistant depression: 18-Month follow-up of the Halifax depression trial.

BACKGROUND: Depressed patients with chronic and complex health issues commonly relapse; therefore, examining longer-term outcomes is an important consideration. For treatment resistant depression (TRD), the post-treatment efficacy of time-limited Intensive Short-Term Dynamic Psychotherapy (ISTDP) has been demonstrated but longer-term outcomes and cost-effectiveness are unclear. METHOD: In this superiority trial, 60 patients referred to Community Mental Health Teams (CMHT) were randomised to 2 groups (ISTDP=30 and CMHT=30). The primary outcome was Hamilton Depression Rating scale (HAM-D) scores at 18 months. Secondary outcomes included Patient Health Questionnaire (PHQ-9) depression scores and dichotomous measure remission. A health economic evaluation examined mental health costs with quality-adjusted life years (QALYs). RESULTS: Statistically significant treatment differences in depression previously found at 6 months favouring ISTDP were maintained at 18-month follow-up. Group differences in depression were in the moderate to large range on both the observer rated (Cohen's d = .64) and self-report measures (Cohen's d = .70). At 18 months follow-up the remission rate in ISTDP patients was 40.0%, and 23.4% had discontinued antidepressants. Health economic analysis suggests that ISTDP was more cost-effective than CMHT at 18 months. Probabilistic analysis suggests that there is a 64.5% probability of ISTDP being cost-effective at a willingness to pay for a QALY of $25,000 compared to CMHT at 18 months. LIMITATIONS: Replication of these findings is necessary in larger samples and future cost analyses should also consider indirect costs. CONCLUSIONS: ISTDP demonstrates long-term efficacy and cost-effectiveness in TRD.

Demands, control, supportive relationships and well-being amongst British mental health workers.

PURPOSE: Staff well-being is considered to be a potential problem within mental health occupations, and its variability is in need of investigation. Our starting point is to assess the role of demands, control and supportive relationships that are at the core of Karasek's model. The study aims to assess the relationship amongst mental health workers of job demands, control and support (from peers and superiors) with multiple measures of well-being. METHOD: Data were obtained through a self-completion questionnaire from mental health staff in 100 inpatient wards, 18 crisis resolution/home treatment teams and 18 community mental health teams. The data was analysed using multilevel regression analysis. RESULTS: Job demands (negatively), control (positively) and supportive relationships (positively) are each uniquely associated with the five measures of well-being included in the study: namely intrinsic satisfaction, anxiety, depression, emotional exhaustion and personal accomplishment. Non-linear and interaction effects involving these demands, control and supportive relationships are found, but vary in type and strength across well-being measures. CONCLUSIONS: The combination of low levels of demands and high levels of control and supportive relationships is good for the well-being of mental health staff. Our results suggest that management initiatives in mental health services should be targeted at creating this combination within the working environment, and particularly at increasing levels of job control.

Comparing perceived injustices from supervisors and romantic partners as predictors of aggression.

To examine the predictive effects of perceived injustice in two different interpersonal relationships (i.e., working relationship with a supervisor, romantic relationship with a partner) on aggression enacted in those relationships, we computed a series of multilevel regressions on 62 heterosexual couples with all 124 partners employed part-time and working for different supervisors. Higher levels of perceived supervisor injustice predicted higher supervisor-directed aggression, whereas higher levels of perceived partner injustice predicted lower supervisor-directed aggression. An interaction between perceived partner injustice and anger predicted higher levels of partner-directed aggression. Implications and recommendations for future research on the relationship specificity of perceived injustice are discussed.