Psychotherapies at a Glance: Consensus Guideline-Recommended Psychotherapies for Adults With Psychiatric Disorders.

Clinical decision making by psychiatrists and informed consent by patients require knowledge of evidence-based psychotherapies (EBPs) and their indications. However, many mental health professionals are not versed in the empirical literature on EBPs or the consensus guideline recommendations derived from this literature. The authors compared rigorous national consensus guidelines for EBP treatment of DSM-defined adult psychiatric disorders-derived from well-conducted randomized controlled trials and meta-analyses and from expert opinions from the United States, United Kingdom, and Canada-to create the Psychotherapies-at-a-Glance tool. Recommended EBPs are cognitive-behavioral therapy, family therapy, contingency management, dialectical behavior therapy, eye movement desensitization reprocessing, interpersonal psychotherapy, mentalization-based treatment, motivational interviewing, peer support, problem-solving therapy, psychoeducation, short-term psychodynamic psychotherapy, and 12-step facilitation. The Psychotherapies-at-a-Glance tool summarizes the indications, rationales, and therapeutic tasks that characterize these differing psychotherapies and psychosocial treatments. The tool is intended for use in clinical teaching, treatment planning, and patient communications.

Interpersonal Psychotherapy and Mentalizing-Synergies in Clinical Practice.

Interpersonal psychotherapy (IPT) is an evidence-supported, relationally focused treatment for people living with depression and other psychiatric disorders in the context of stressful life events. Mentalizing, also relationally focused, promotes the ability to perceive, understand, and interpret human behavior in terms of intentional mental states of others or oneself, in order to support social leaning. IPT and mentalization-based treatments (MBT) both seek to improve interpersonal effectiveness, albeit with different emphases in the therapeutic process, with IPT promoting interpersonal problem solving and MBT promoting understanding of the obstacles to this outcome. In this article, the authors propose that the central intentions of IPT and mentalizing are essentially linked and complementary; understanding others and oneself in relationships facilitates interpersonal problem resolution and symptomatic recovery and enhances resilience. The clinical synergies of IPT and mentalizing are elaborated and illustrated through a case example of treatment for a socially isolated woman with depression and interpersonal sensitivities.

Treatment-resistant major depressive disorder: Canadian expert consensus on definition and assessment.

BACKGROUND: Treatment-resistant depression (TRD) is a debilitating chronic mental illness that confers increased morbidity and mortality, decreases the quality of life, impairs occupational, social, and offspring development, and translates into increased costs on the healthcare system. The goal of this study is to reach an agreement on the concept, definition, staging model, and assessment of TRD. METHODS: This study involved a review of the literature and a modified Delphi process for consensus agreement. The Appraisal of Guidelines for Research & Evaluation II guidelines were followed for the literature appraisal. Literature was assessed for quality and strength of evidence using the grading, assessment, development, and evaluations system. Canadian national experts in depression were invited for the modified Delphi process based on their prior clinical and research expertize. Survey items were considered to have reached a consensus if 80% or more of the experts supported the statement. RESULTS: Fourteen Canadian experts were recruited for three rounds of surveys to reach a consensus on a total of 27 items. Experts agreed that a dimensional definition for treatment resistance was a useful concept to describe the heterogeneity of this illness. The use of staging models and clinical scales was recommended in evaluating depression. Risk factors and comorbidities were identified as potential predictors for treatment resistance. CONCLUSIONS: TRD is a meaningful concept both for clinical practice and research. An operational definition for TRD will allow for opportunities to improve the validity of predictors and therapeutic options for these patients.

Telephone-based nurse-delivered interpersonal psychotherapy for postpartum depression: nationwide randomised controlled trial.

BACKGROUND: Postpartum depression and anxiety are under-addressed public health problems with numerous treatment access barriers, including insufficiently available mental health specialist providers. AIMS: To examine the effectiveness of nurse-delivered telephone interpersonal psychotherapy (IPT) for postpartum depression. Trial registration ISRCTN88987377. METHOD: Postpartum women (n = 241) with major depression (on the Structured Clinical Interview for DSM-IV (SCID-I)) from 36 Canadian public health regions in rural and urban settings were randomly assigned to 12 weekly 60 min nurse-delivered telephone-IPT sessions or standard locally available care. The primary outcome was the proportion of women clinically depressed at 12 weeks post-randomisation, with masked intention-to-treat analysis. Secondary outcomes examined included comorbid anxiety, self-reported attachment and partner relationship quality. RESULTS: At 12 weeks, 10.6% of women in the IPT group (11/104) and 35% in the control group (35/100) remained depressed (OR = 0.22, 95% CI 0.10-0.46), with the IPT group 4.5 times less likely to be clinically depressed (SCID); 21.2% in the IPT group and 51% in the control group had an Edinburgh Postnatal Depression Scale (EPDS) score >12 (OR = 0.26, 95% CI 0.14-0.48), and attachment avoidance decreased more in the IPT group than in the control group (P = 0.02). Significant differences favoured the IPT group for comorbid anxiety and partner relationship quality at all time points, with no differences in health service or antidepressant use. None of the IPT responders relapsed by 36 weeks. Between-group SCID differences were sustained at 24 weeks, but not at 36 weeks. CONCLUSIONS: Nurse-delivered telephone IPT is an effective treatment for diverse urban and rural women with postpartum depression and anxiety that can improve treatment access disparities.

Psychotherapy Patients of Psychiatry Residents: A Descriptive Study.

OBJECTIVE: Psychiatry residents learn psychodynamic psychotherapy for generalizable skills and as a transdiagnostic, long-term treatment indicated for patients with chronic mood, anxiety, or personality disorders. It is unknown how these indications align with actual patients of trainees. The aim of this descriptive study was to define characteristics of outpatients receiving psychodynamic psychotherapy from psychiatry residents. METHODS: Case reports (N=204) from 184 psychiatry residents were analyzed for patients' diagnoses and past treatments. RESULTS: Eighty-six percent of patients had prior psychiatric medication or treatment, 31% had three or more past courses of psychotherapy, and 48% had two or more diagnoses, including depression (62%), anxiety (46%), and personality disorders or traits (27%). CONCLUSIONS: Patients receiving psychodynamic psychotherapy from psychiatry residents had multiple psychiatric illnesses and a history of prior treatments that had not achieved or sustained recovery, suggesting complex and chronic illness. Consistent with community-based findings, these patient characteristics correspond with psychodynamic psychotherapy treatment indications.

Integrating Evidence-Supported Psychotherapy Principles in Mental Health Case Management: A Capacity-Building Pilot.

OBJECTIVES: Mental health case managers comprise a large workforce who help patients who struggle with complex mental illnesses and unmet needs with respect to the social determinants of health. This mixed-methods capacity-building pilot examined the feasibility, experiences, and outcomes of training community-based mental health case managers to integrate evidence-based psychotherapy principles into their case conceptualization and management practices. METHODS: Case-based, once-weekly, group consultations and training in applied therapeutic principles from mentalizing, interpersonal psychotherapy, motivational interviewing, and other evidence-based psychotherapies were provided to case managers over 8 months. A trauma-informed and culturally sensitive approach was emphasized to improve therapeutic alliances and to foster adaptive expertise and an appreciation of individual patient differences. RESULTS: Qualitative analyses of focus groups and individualized interviews identified a shift toward being more reflective rather than reactive, with improved empathy, patient engagement, morale, and confidence resulting from the training (N = 16). Self-reported pre-post counseling self-efficacy changes revealed significant improvements overall, driven by improved microskills and an ability to deal with challenging client behaviors (N = 10; P < 0.05). CONCLUSIONS: This pilot demonstrated that case-based consultations and training of mental health case managers within a community-of-practice in trauma-informed, culturally sensitive application of evidence-supported psychotherapy principles were feasible and acceptable with scalable potential to improve case managers' counseling self-efficacy, reflective capacity, empathy, and morale. Further research in this area is needed with a larger sample, and patient and health systems outcomes.

Psychotherapy Competency Milestones: an Exploratory Pilot of CBT and Psychodynamic Psychotherapy Skills Acquisition in Junior Psychiatry Residents.

OBJECTIVE: Psychiatry residents train in Psychodynamic Psychotherapy and Cognitive Behavioral Therapy (CBT), evidence-supported treatments used in mental health care that can facilitate clinical reasoning, foster therapeutic alliances, and improve clinical outcomes. However, empirically derived milestones are needed to evaluate competency. This exploratory pilot examined changes over 1 year of training in junior psychiatry residents' competency milestone elements in Psychodynamic Psychotherapy and CBT. METHODS: Seventy-nine randomly selected audio-recorded sessions from differing phases of Psychodynamic Psychotherapy and CBT with five junior residents and ten patients were rated using the Psychotherapy Process Q-sort (PQS). RESULTS: In both treatments, patient engagement with attention to in-session emotions improved. In CBT, residents were directive, supported patients' self-efficacy, emphasized patients' accepting responsibility for their problems, discussed homework such as thought records, and focused on termination in the concluding sessions. In Psychodynamic Psychotherapy, residents attended to emotional arousal and linked patients' feelings or perceptions to past situations or behavior. Growth and hierarchical linear modeling differentiated these treatments, with CBT v. Psychodynamic adherence to PQS modality-specific ideal elements being 52% v.19%. CONCLUSION: Teaching and observation using empirically derived observable psychotherapy practice behaviors is feasible and can be used to assess milestone elements for competency-based education of psychiatry trainees.

Autonomous and controlled motivation for interpersonal therapy for depression: Between-therapists and within-therapist effects.

Differences between therapists in the average outcomes their patients achieve are well documented, and researchers have begun to try to explain such differences (Baldwin & Imel, 2013). Guided by Self-Determination Theory (Deci & Ryan, 2000), we examined the effects on outcome of differences between therapists in their patients' average levels of autonomous and controlled motivation for treatment, as well as the effects of differences among the patients within each therapist's caseload. Between and within-therapist differences in the SDT construct of perceived relational support were explored as predictors of patients' motivation. Nineteen therapists treated 63 patients in an outpatient clinic providing manualized interpersonal therapy (IPT) for depression. Patients completed the BDI-II at pretreatment, posttreatment, and each treatment session. The Impact Message Inventory was administered at the third session and scored for perceived therapist friendliness, a core element of relational support. We created between-therapists (therapist-level) scores by averaging over the patients in each therapist's caseload; within-therapist (patient-level) scores were computed by centering within each therapist's caseload. As expected, better outcome was predicted by higher levels of therapist-level and patient-level autonomous motivation and by lower levels of therapist-level and patient-level controlled motivation. In turn, autonomous motivation was predicted by therapist-level and patient-level relational support (friendliness). Controlled motivation was predicted solely by patient self-critical perfectionism. The results extend past work by demonstrating that both between-therapists and within-therapist differences in motivation predict outcome. As well, the results suggest that therapists should monitor their interpersonal impact so as to provide relational support. (PsycINFO Database Record

Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 Clinical Guidelines for the Management of Adults with Major Depressive Disorder: Section 2. Psychological Treatments.

BACKGROUND: The Canadian Network for Mood and Anxiety Treatments (CANMAT) has revised its 2009 guidelines for the management of major depressive disorder (MDD) in adults by updating the evidence and recommendations. The target audiences for these 2016 guidelines are psychiatrists and other mental health professionals. METHODS: Using the question-answer format, we conducted a systematic literature search focusing on systematic reviews and meta-analyses. Evidence was graded using CANMAT-defined criteria for level of evidence. Recommendations for lines of treatment were based on the quality of evidence and clinical expert consensus. "Psychological Treatments" is the second of six sections of the 2016 guidelines. RESULTS: Evidence-informed responses were developed for 25 questions under 5 broad categories: 1) patient characteristics relevant to using psychological interventions; 2) therapist and health system characteristics associated with optimizing outcomes; 3) descriptions of major psychotherapies and their efficacy; 4) additional psychological interventions, such as peer interventions and computer- and technology-delivered interventions; and 5) combining and/or sequencing psychological and pharmacological interventions. CONCLUSIONS: First-line psychological treatment recommendations for acute MDD include cognitive-behavioural therapy (CBT), interpersonal therapy (IPT), and behavioural activation (BA). Second-line recommendations include computer-based and telephone-delivered psychotherapy. Where feasible, combining psychological treatment (CBT or IPT) with antidepressant treatment is recommended because combined treatment is superior to either treatment alone. First-line psychological treatments for maintenance include CBT and mindfulness-based cognitive therapy (MBCT). Patient preference, in combination with evidence-based treatments and clinician/system capacity, will yield the optimal treatment strategies for improving individual outcomes in MDD.

Lost in Transition: Examining Transitions in Psychotherapy Training.

OBJECTIVE: Disruptions are inevitable during psychiatry residency training and can affect resident learning and patient care. This exploratory study examined the nature and impact of transitions in psychotherapy training. METHODS: PGY2-5 residents (45/150; 30% response rate) and psychotherapy supervisors (46/247; 18.6% response rate) were surveyed about transitional events during residency training in psychotherapy. RESULTS: Supervisors and residents ranked the frequency of occurrence of transitional events and their impact very similarly, as well as the "feed forward" items when transitioning to a new supervisor. Residents feeling confused or overwhelmed with the balancing of learning differing models with differing levels of comfort or knowledge was ranked as the issue that occurred most frequently by both supervisors and residents. CONCLUSIONS: This study highlights issues that arise at transitions during psychotherapy training in psychiatry residency. Strategies for managing these periods are discussed, with a focus on resident learning and improved continuity of patient care.

Twelve tips for asking and responding to difficult questions during a challenging clinical encounter.

BACKGROUND: Teaching healthcare providers (HCPs) effective communication skills can be challenging, but is crucial for managing complex patient encounters. AIM: To provide medical trainees strategies for recognizing and understanding problematic interactions. METHODS: The Twelve Tips are based on a study of communication skills teaching with family medicine trainees (n = 26) who received controlled exposure to common clinical difficulties simulated by standardized patients (SPs). The following tips were derived from a thematic analysis of a subset of the transcribed coaching sessions. RESULTS: These tips demonstrate that doctor-patient communication difficulties can arise from any of three sources: the patient's issues, the HCP's misunderstanding or inaccurate responsiveness to an issue, and/or the interaction between the HCP and the patient. These tips are heuristically grouped into two themes: (1) guiding principles to hold in mind and (2) behaviors that can be used to apply these principles. CONCLUSION: We believe that these strategies will help trainees to remain attentive to the patient, the interaction, and their own reactions, to improve the overall clinical encounter.

Patient interpersonal and cognitive changes and their relation to outcome in interpersonal psychotherapy for depression.

OBJECTIVE: Despite interpersonal psychotherapy's (IPT) efficacy for depression, little is known about its change-promoting ingredients. This exploratory study examined candidate change mechanisms by identifying whether patients' interpersonal and cognitive characteristics change during IPT and whether such changes relate to outcomes. METHOD: Patients were 95 depressed adults receiving manualized IPT. We used multilevel modeling to assess the relation between change in each interpersonal and cognitive domain and outcome. RESULTS: Across all interpersonal and cognitive variables measured, patients showed significant improvement. Unexpectedly, reduced romantic relationship adjustment was related to posttreatment depression reduction (ß = 2.028, p = .008, self-rated; ß = 1.474, p = .022, clinician-rated). For the other measured domains, change was not significantly associated with outcome (though changes in some interpersonal variables evidenced a trend-level relation to outcome). CONCLUSIONS: Possible reciprocal influences among IPT, depression, and romantic relationship functioning are discussed, as are implications for future research.

Psychotherapy Knowledge Translation and Interpersonal Psychotherapy: Using Best-Education Practices to Transform Mental Health Care in Canada and Ethiopia.

Psychotherapies, such as Interpersonal Psychotherapy (IPT), that have proven effective for treating mental disorders mostly lie dormant in consensus-treatment guidelines. Broadly disseminating these psychotherapies by training trainers and front-line health workers could close the gap between mental health needs and access to care. Research in continuing medical education and knowledge translation can inform the design of educational interventions to build capacity for providing psychotherapy to those who need it. This paper summarizes psychotherapy training recommendations that: adapt treatments to cultural and health organizational contexts; consider implementation barriers, including opportunity costs and mental health stigma; and engage local opinion leaders to use longitudinal, interactive, case-based teaching with reflection, skills-coaching, simulations, auditing and feedback. Community-based training projects in Northern Ontario, Canada and Ethiopia illustrate how best-education practices can be implemented to disseminate evidence-supported psychotherapies, such as IPT, to expand the therapeutic repertoire of health care workers and improve their patients' clinical outcomes.

Novel Web-Based Drop-In Mindfulness Sessions (Pause-4-Providers) to Enhance Well-Being Among Health Care Workers During the COVID-19 Pandemic: Descriptive and Qualitative Study.

BACKGROUND: The COVID-19 pandemic exerted extraordinary pressure on health care workers (HCWs), imperiling their well-being and mental health. In response to the urgent demand to provide barrier-free support for the health care workforce, Pause-4-Providers implemented 30-minute live web-based drop-in mindfulness sessions for HCWs. OBJECTIVE: This study aims to evaluate the use, feasibility, satisfaction, and acceptability of a novel mindfulness program aimed at enhancing the well-being of HCWs during the COVID-19 pandemic. METHODS: Accrual for the study continued throughout the first 3 pandemic waves, and attendees of ≥1 session were invited to participate. The evaluation framework included descriptive characteristics, including participant demographics, resilience at work, and single-item burnout scores; feedback questionnaires on reasons attended, benefits, and satisfaction; qualitative interviews to further understand participant experience, satisfaction, benefits, enablers, and barriers; and the number of participants in each session summarized according to the pandemic wave. RESULTS: We collected descriptive statistics from 50 consenting HCWs. Approximately half of the participants (24/50, 48%) attended >1 session. The study participants were predominantly female individuals (40/50, 80%) and comprised physicians (17/50, 34%), nurses (9/50, 18%), and other HCWs (24/50, 48%), who were largely from Ontario (41/50, 82%). Of 50 attendees, 26 (52%) endorsed feeling burned out. The highest attendance was in May 2020 and January 2021, corresponding to the first and second pandemic waves. The participants endorsed high levels of satisfaction (43/47, 92%). The most cited reasons for attending the program were to relax (38/48, 79%), manage stress or anxiety (36/48, 75%), wish for loving kindness or self-compassion (30/48, 64%), learn mindfulness (30/48, 64%), and seek help with emotional reactivity (25/48, 53%). Qualitative interviews with 15 out of 50 (30%) participants identified positive personal and professional impacts. Personal impacts revealed that participation helped HCWs to relax, manage stress, care for themselves, sleep better, reduce isolation, and feel recognized. Professional impacts included having a toolbox of mindfulness techniques, using mindfulness moments, and being calmer at work. Some participants noted that they shared techniques with their colleagues. The reported barriers included participants' needing time to prioritize themselves, fatigue, forgetting to apply skills on the job, and finding a private place to participate. CONCLUSIONS: The Pause-4-Providers participants reported that the web-based groups were accessible; appreciated the format, content, and faculty; and had high levels of satisfaction with the program. Both novel format (eg, drop-in, live, web-based, anonymous, brief, and shared activity with other HCWs) and content (eg, themed mindfulness practices including micropractices, with workplace applications) were enablers to participation. This study of HCW support sessions was limited by the low number of consenting participants and the rolling enrollment project design; however, the findings suggest that a drop-in web-based mindfulness program has the potential to support the well-being of HCWs.

Improving physician-patient communication through coaching of simulated encounters.

OBJECTIVE: Effective communication between physicians and their patients is important in optimizing patient care. This project tested a brief, intensive, interactive medical education intervention using coaching and standardized psychiatric patients to teach physician-patient communication to family medicine trainees. METHODS: Twenty-six family medicine trainees (9 PGY1, 11 PGY2, 6 fellows) from five university-affiliated hospitals conducted four once-weekly, 30-minute videotaped interviews with "difficult" standardized patients. After each interview, trainees received 1 hour of individual coaching that incorporated self-assessment and skills-teaching from experienced psychiatrists. Two follow-up interviews with standardized patients occurred 1 week and an average of 6 months post-intervention. Trainee self-reported physician-patient communication efficacy was measured as a control 1 month before the intervention; during the month of the intervention; and an average of 6 months after the intervention. Coach-rated physician-patient communication competence was measured each week of the intervention. RESULTS: Improvements in physician-patient communication were demonstrated. Self-efficacy for physician-patient communication improved significantly during the intervention, in contrast to no improvement during the control period (i.e., training-as-usual). This improvement was sustained during the follow-up period. CONCLUSIONS: This innovative educational intervention was shown to be highly effective in improving trainee communication competence and self-efficacy. Future applications of this brief model of physician training have potential to improve communication competence and, in turn, can improve patient care.

Baseline patient characteristics as predictors of remission in interpersonal psychotherapy for depression.

We examined patient characteristics as remission predictors in interpersonal psychotherapy (IPT) for depression (n=95). Four characteristic domains (sociodemographic, clinical/diagnostic, interpersonal, cognitive) were analyzed using receiver operating characteristic analysis. Remission was defined two ways: (a) posttreatment BDI-II beyond population-based cut-scores for reliable and clinically significant change, and (b) posttreatment BDI-II≤10. Across both definitions, patients most likely to remit had lower mean item ratings (<3.75 and<3.25, respectively) on the fearful attachment dimension of the Relationship Scales Questionnaire (χ2 =7.172, p<.01 and χ2 =7.792, p<.01, respectively). For the second definition only, more fearfully attached patients who were ≤25 years of age at index depression onset were more likely to remit (χ2 =7.617, p<.01) than those >25. The findings contribute to the scant literature on patient factors related to remission following IPT.

Training community-based psychotherapists to maintain a therapeutic alliance: A psychotherapy practice research network study.

The goal of this study was to test the efficacy of training community-based psychotherapists who were part of a practice research network to be more attuned to their patients' experiences of the therapeutic relationship. We were particularly interested in the effect of therapist training on the congruence of alliance ratings with their patients. Forty psychotherapists who treated 117 patients were randomly assigned to receive either no training or training, whose learning objectives were to help therapists to develop and maintain a therapeutic alliance. The training included workshops and ongoing consultations to help the clinician to strengthen the therapeutic relationship with the use of mentalizing, attachment theory, countertransference management, and metacommunication. Therapeutic alliance and well-being outcomes were measured at each of six consecutive early psychotherapy sessions. We used the truth and bias model and response surface analysis within a multilevel modeling context to test hypotheses. There was a significantly faster rate of alliance growth in the training versus the no training condition when the alliance was rated by therapists, but not when rated by patients. Trained therapists experienced greater temporal congruence in alliance ratings with their patients compared to untrained therapists. Patient well-being outcomes improved in a session when trained therapists and their patients agreed in their positive alliance ratings in a previous session. This association not significant among untrained therapists. Training therapists in key interpersonally focused skills may lead them to be better attuned to their patients' experiences of the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Scaling up quality-assured psychotherapy: The role of therapist competence on perinatal depression and anxiety outcomes.

OBJECTIVES: To examine: (1) the psychometric properties of two therapist competence measures-multiple choice questionnaire (MCQ) and standardized role-plays; (2) whether therapist competence differed between non-specialist (NSPs) and specialist (SPs) providers; and (3) the relations between therapist competence and patient outcomes among perinatal patients receiving brief psychotherapy. METHODS: This study is embedded within the SUMMIT Trial-a large, ongoing psychotherapy trial for perinatal women with depressive and anxiety symptoms. We assessed the: (1) psychometric properties of therapist competence measures using Cronbach's alpha and inter-class correlation; (2) differences in therapist competence scores between n = 23 NSPs and n = 22 SPs using a two-sample t-test; and (3) relations between therapist competence measures and perinatal patient outcomes through a linear regression model. RESULTS: Internal consistency for role-play was acceptable (α = 0.71), whereas MCQ was excellent (α = 0.97). Role-play showed good inter-rater reliability (ICC = 0.80) and scores were higher for SPs compared with NSPs (t(2,38) = -2.86, p = 0.0069) and associated with outcomes of anxiety (B = 1.52, SE = 0.60, p = 0.01) and depressive (B = 0.96, SE = 0.55, p = 0.08) symptom scores. CONCLUSIONS: Our study highlights the importance of demonstrating psychological treatment skills through standardized role-plays over knowledge-based competence to predict perinatal patient outcomes. Using well-defined evidence-based tools is critical for deploying NSPs to provide high-quality psychotherapy and increase accessibility to psychological treatments for perinatal populations worldwide.