The impact of accommodating client preference in psychotherapy: A meta-analysis.

Client preferences in psychotherapy reflect specific conditions and activities that clients desire in their treatment, with increasing evidence pointing to preference accommodation as facilitating psychotherapy outcomes. This updated meta-analysis establishes the magnitude of the effect of client preference accommodation in psychotherapy. Based on data from 53 studies and over 16,000 clients, preference accommodation was associated with fewer treatment dropouts (OR = 1.79) and more positive treatment outcomes (d = 0.28) than providing client with a nonpreferred treatment or psychotherapy condition. The preference effect was moderated by study design, timing and type of outcome measurement, and client diagnosis. It was not moderated by year of publication, treatment duration, preference type, treatment options, client age, client gender, client ethnicity, or client years of education. The authors provide a case example of preference accommodation and practice recommendations for working with client preferences.

Understanding the client's perspective of helpful and hindering events in psychotherapy sessions: A micro-process approach.

The purpose of this study was to bridge the methodologies of significant events and micro-process research to gain a better understanding of clients' perceptions of helpful and hindering events in psychotherapy. A total of 16 clients were asked to review a recent psychotherapy session and, while watching, complete a moment-by-moment rating of helpful/hindrance using a dial rating system. They were also asked to describe the most helpful and hindering segments that were rated as such. The moment-by-moment ratings suggest that clients perceive a significant amount of variability within a single session. The qualitative results suggest that clients perceive both specific treatment and common factors techniques as being helpful. Further, some of the same therapist actions were rated as both helpful and hindering, but they differed in the timing and the client's experience of feeling heard and understood versus judged or given advice that was not perceived as relevant to them. These results have important implications for clinical practice.

The client as the expert in psychotherapy: What clinicians and researchers can learn about treatment processes and outcomes from psychotherapy clients.

Clients are frequently recognized as perhaps having the largest impact on the eventual success or failure of treatment; however, researchers and clinicians alike often give inadequate attention to clients' perspectives on psychotherapy processes and outcomes. Researchers who do examine client variables in psychotherapy often conduct research about the client rather than from the client. The purpose of this article is to introduce a special issue focused on the client's perspective in psychotherapy. Specifically, the articles in this issue present case studies and quantitative and qualitative research that seek to (a) demonstrate how to tailor interventions according to the client's perspective and (b) identify common themes in clients' perspectives about their experiences in psychotherapy.

Treatment refusal and premature termination in psychotherapy, pharmacotherapy, and their combination: A meta-analysis of head-to-head comparisons.

The purpose of this meta-analysis was to examine rates of treatment refusal and premature termination for pharmacotherapy alone, psychotherapy alone, pharmacotherapy plus psychotherapy, and psychotherapy plus pill placebo treatments. A systematic review of the literature resulted in 186 comparative trials that included a report of treatment refusal and/or premature termination for at least 2 of the 4 treatment conditions. The data from these studies were pooled using a random-effects analysis. Odds Ratio effect sizes were then calculated to compare the rates between treatment conditions, once across all studies and then again for specific client disorder categories. An average treatment refusal rate of 8.2% was found across studies. Clients who were assigned to pharmacotherapy were 1.76 times more likely to refuse treatment compared with clients who were assigned psychotherapy. Differences in refusal rates for pharmacotherapy and psychotherapy were particularly evident for depressive disorders, panic disorder, and social anxiety disorder. On average, 21.9% of clients prematurely terminated their treatment. Across studies, clients who were assigned to pharmacotherapy were 1.20 times more likely to drop out compared with clients who were assigned to psychotherapy. Pharmacotherapy clients with anorexia/bulimia and depressive disorders dropped out at higher rates compared with psychotherapy clients with these disorders. Treatment refusal and dropout are significant problems in both psychotherapy and pharmacotherapy and providers of these treatments should seek to employ strategies to reduce their occurrence. (PsycINFO Database Record

Relationship between placebo response rate and clinical trial outcome in bipolar depression.

The aim of this work is to investigate the impact of placebo response rates on the relative risk of response to drug versus placebo in randomized, double-blind, placebo-controlled clinical trials of pharmacological therapy in Bipolar Depression (BPD). Medline/PubMed publication databases were searched for randomized, double-blind, placebo-controlled trials of oral drugs used as monotherapy for the treatment of BPD. The search was limited to articles published between January 1980 and September 2015. Data extracted from 12 manuscripts and one poster with yet unpublished results, representing a total of 17 clinical trials were pooled (n = 6578). Pooled response rates for drug and placebo were 55.1% and 39.2%, corresponding to a risk ratio (RR) for responding to active treatment versus placebo of 1.29 (p < 0.001). Clinical response was defined as a 50% or greater reduction in depression scores, baseline to endpoint. A higher placebo response rate correlated with a significantly lower RR of responding to pharmacotherapy versus placebo (p = 0.002). The pooled drug and placebo response rates for studies with a placebo response rate ≤ 30% were 50.5% versus 26.6%, while corresponding values from studies with a placebo response rate >30 were 55.0% versus 41.6%. These results suggest that the relative efficacy of the active drug compared to placebo in clinical trials for BPD is highly heterogeneous across studies with different placebo response rates, with a worse performance in showing a superiority of the drug versus placebo for studies with placebo response rates >30%. It is important to maintain placebo response rates below this critical threshold, since this is one of the most challenging obstacles for new treatment development in BPD.

Efficacy and safety of a form of cranial electrical stimulation (CES) as an add-on intervention for treatment-resistant major depressive disorder: A three week double blind pilot study.

We examined efficacy and safety of one specific cranial electrical stimulator (CES) device at a fixed setting in subjects with treatment-resistant major depressive disorder (MDD). Thirty subjects (57% female, mean age 48.1 ± 12.3 years) with MDD and inadequate response to standard antidepressants were randomized to 3 weeks of treatment with CES (15/500/15,000 Hz, symmetrical rectangular biphasic current of 1-4 mAmp, 40 V) or sham CES (device off) for 20 min, 5 days per week. The primary outcome measure was improvement in the 17-item Hamilton Depression Rating Scale (HAM-D-17). Adverse effects (AEs) were assessed using the Patient Related Inventory of Side Effects (PRISE). Completion rates were 88% for CES, 100% for sham. Both treatment groups demonstrated improvement of about 3-5 points in HAM-D-17 scores (p < 0.05 for both), and no significant differences were observed between groups. Remission rates were 12% for CES, and 15% for sham, a nonsignificant difference. CES was deemed safe, with good tolerability; poor concentration and malaise were the only distressing AEs that differed significantly between CES and sham (p = 0.019 and p = 0.043, respectively). Limitations include a small sample and lack of an active comparator therapy. Although both treatment groups improved significantly, this CES at the setting chosen did not separate from sham in this sample. Thus we cannot rule out that the benefit from this setting used in this particular form of CES was due to placebo effects. Since this form of CES has other settings, future studies should test these settings and compare it against other CES devices. Clinicaltrials.gov ID: NCT01325532.

A double-blind placebo-controlled trial of maca root as treatment for antidepressant-induced sexual dysfunction in women.

Objective. We sought to demonstrate that maca root may be an effective treatment for antidepressant-induced sexual dysfunction (AISD) in women. Method. We conducted a 12-week, double-blind, placebo-controlled trial of maca root (3.0 g/day) in 45 female outpatients (mean age of 41.5 ± 12.5 years) with SSRI/SNRI-induced sexual dysfunction whose depression remitted. Endpoints were improvement in sexual functioning as per the Arizona Sexual Experience Scale (ASEX) and the Massachusetts General Hospital Sexual Function Questionnaire (MGH-SFQ). Results. 45 of 57 consented females were randomized, and 42 (30 premenopausal and 12 postmenopausal women) were eligible for a modified intent-to-treat analysis based on having had at least one postmedication visit. Remission rates by the end of treatment were higher for the maca than the placebo group, based on attainment of an ASEX total score ≤ 10 (9.5% for maca versus 4.8% for placebo), attaining an MGH-SFQ score ≤ 12 (30.0% for maca versus 20.0% for placebo) and reaching an MGH-SFQ score ≤ 8 (9.5% for maca versus 5.0% for placebo). Higher remission rates for the maca versus placebo group were associated with postmenopausal status. Maca was well tolerated. Conclusion. Maca root may alleviate SSRI-induced sexual dysfunction in postmenopausal women. This trial is registered with NCT00568126.

Association between physician beliefs regarding assigned treatment and clinical response: re-analysis of data from the Hypericum Depression Trial Study Group.

BACKGROUND: We have previously shown an association between patient belief and treatment response in the Hypericum Depression Trial Study Group's 2002 study. We re-examined these data to determine whether clinical improvement was associated with physician belief about assigned therapy. METHODS: Three hundred and forty adults with major depression and baseline scores ≥20 on the 17-item Hamilton Depression Scale (HDRS-17) were randomized to Hypericum 900-1500mg/day, sertraline 50-100mg/day, or placebo for 8 weeks. At week 8, physicians guessed their patients' treatment. We analyzed 277 subjects with at least one post-baseline visit and physician guess data. We examined association between guess and improvement in HDRS-17 and whether treatment assignment moderated the effect of belief on remission (final HDRS-17 score <8). RESULTS: Patient and doctor guesses agreed at 53% for sertraline, 68% for Hypericum, and 52% for placebo (kappa=0.37). Doctors guessed placebo correctly (38%) more than sertraline (18%) or Hypericum (19%) (p=0.001). Adverse event scores were significantly greater among subjects for which the clinicians guessed Hypericum (p<0.001) or sertraline (p=0.005) compared to placebo. Significant improvements in HDRS-17 score were found when comparing the Hypericum-guess (p<0.001) or the sertraline-guess group (p<0.001) against the placebo-guess group. Remission rates were significantly greater for subjects whose clinicians guessed sertraline (p<0.001) or Hypericum (p<0.001) versus placebo. CONCLUSION: Doctors tended to guess placebo more easily than Hypericum or sertraline, and their guesses tended to favor active therapies when improvement was more robust. Results show association but not causation, and merit more careful investigation.