Efficacy and tolerability of serotonin transport inhibitors in obsessive-compulsive disorder. A meta-analysis.

BACKGROUND: Questions have been raised regarding the relative efficacy and tolerability of the different serotonin transport inhibitors in the treatment of obsessive-compulsive disorder. We compared the results from four large multicenter placebo-controlled trials of the serotonin transport inhibitors clomipramine hydrochloride (N = 520), fluoxetine hydrochloride (N = 355), fluvoxamine maleate (N = 320), and sertraline hydrochloride (N = 325) for the treatment of obsessive-compulsive disorder. METHODS: Effect size was calculated by subtracting the end-point drug treatment mean change from the end-point placebo mean change and dividing by the end-point pooled change standard deviation. A test for overall differences between effect sizes was conducted, followed by all possible pairwise comparisons. The Yale-Brown Obsessive Compulsive Scale was the primary outcome measure for all four studies. RESULTS: All four agents were significantly more effective than placebo, with clomipramine significantly more effective than the other three treatments, which did not differ in effect size. A significantly greater percentage of patients treated with clomipramine were rated much or very much improved than were patients treated with fluoxetine, fluvoxamine, or sertraline. CONCLUSION: While the results of this meta-analysis support the superiority of clomipramine, head-to-head, double-blind comparisons of these compounds would be the best test of comparative efficacy and tolerability.

Sertraline for social phobia: a double-blind, placebo-controlled crossover study.

OBJECTIVE: The authors examined the efficacy of sertraline in the treatment of social phobia. METHOD: In a double-blind crossover study, 12 outpatients were randomly assigned to 10 weeks of sertraline (50-200 mg/day, flexible dosing) and 10 weeks of placebo. RESULTS: A statistically significant improvement in scores on the Liebowitz Social Anxiety Scale was found with sertraline but not with placebo. There was no significant difference between scores obtained with computer- and clinician-administered versions of the Liebowitz Social Anxiety Scale, and the majority of patients preferred to be interviewed by the computer. CONCLUSIONS: Sertraline seems a safe and effective treatment for social phobia, and computer administration may be a preferable mode of assessment with socially phobic patients.

Dimensions of the impact of cancer pain in a four country sample: new information from multidimensional scaling.

We investigated the question of how cultural and linguistic backgrounds affect relationships among ratings (reported by patients with metastatic cancer) of pain's interference with such functions as activity, mood, and sleep. Multidimensional scaling (MDS) was used to analyze ratings of pain interference from a sample consisting of four culturally and linguistically different groups from the US (n = 1106), France (n = 324), the Philippines (n = 267), and China (n = 146). Patients all completed the Brief Pain Inventory, a self-report measure of pain and its interference with function. For each of these samples, MDS solutions consistently revealed two interpretable dimensions. In all samples, one dimension represented affect and the other dimension represented activity. The dimensions were consistently interpretable across all four samples and across three levels of pain severity ('mild', 'moderate', and 'severe'). The dimensions were most prominent when pain was moderate, rather than mild (when little interference was produced) or severe (when all domains were highly interfered with). These dimensions may have utility in the study of the epidemiology of pain and of the effectiveness of pain treatment. They may also be useful in clinical assessment to describe different patterns of pain interference.

Misuse of statistical test in three decades of psychotherapy research.

This article reviews the misuse of statistical tests in psychotherapy research studies published in the Journal of Consulting and Clinical Psychology in the years 1967-1968, 1977-1978, and 1987-1988. It focuses on 3 major problems in statistical practice: inappropriate uses of null hypothesis tests and p values, neglect of effect size, and inflation of Type I error rate. The impressive frequency of these problems is documented, and changes in statistical practices over the past 3 decades are interpreted in light of trends in psychotherapy research. The article concludes with practical suggestions for rational application of statistical tests.

Testing for robustness in Monte Carlo studies.

Monte Carlo studies provide the information needed to help researchers select appropriate analytical procedures under design conditions in which the underlying assumptions of the procedures are not met. In Monte Carlo studies, the 2 errors that one could commit involve (a) concluding that a statistical procedure is robust when it is not or (b) concluding that it is not robust when it is. In previous attempts to apply standard statistical design principles to Monte Carlo studies, the less severe of these errors has been wrongly designated the Type I error. In this article, a method is presented for controlling the appropriate Type I error rate; the determination of the number of iterations required in a Monte Carlo study to achieve desired power is described; and a confidence interval for a test's true Type I error rate is derived. A robustness criterion is also proposed that is a compromise between W. G. Cochran's (1952) and J. V. Bradley's (1978) criteria.

The consequence of ignoring a nested factor on measures of effect size in analysis of variance.

Although the consequences of ignoring a nested factor on decisions to reject the null hypothesis of no treatment effects have been discussed in the literature, typically researchers in applied psychology and education ignore treatment providers (often a nested factor) when comparing the efficacy of treatments. The incorrect analysis, however, not only invalidates tests of hypotheses, but it also overestimates the treatment effect. Formulas were derived and a Monte Carlo study was conducted to estimate the degree to which the F statistic and treatment effect size measures are inflated by ignoring the effects due to providers of treatments. These untoward effects are illustrated with examples from psychotherapeutic treatments.

Answering two criticisms of hypothesis testing: a comment.

In a recent article, Leventhal (1999) responds to two criticisms of hypothesis testing by showing that the one-tailed test and the directional two-tailed test are valid, even if all point null hypotheses are false and that hypothesis tests can provide the probability of decisions being correct which are based on the tests. Unfortunately, the falseness of all point null hypotheses affects the operating characteristics of the directional two-tailed test, seeming to weaken certain of Leventhal's arguments in favor of this procedure.

Patient education in pain control.

Patients' concerns about reporting pain and using analgesics have been cited as major contributors to the problem of inadequate pain management. The purpose of this paper is to describe a program of research in which we have focused on these patient concerns, or as we refer to them, "patient-related barriers to pain management." We present a summary of descriptive studies on this topic, describe educational interventions that have been tested, and suggest future avenues of research and practice.

Modifiability of figural relations performance among elderly adults.

This study examined the relative efficacy of two figural relations training strategies in improving cognitive performance in healthy, well-functioning elderly individuals (N = 69; aged 62 to 92). Participants were randomly assigned to a no-contact control group (n = 24), a training group that received formal instructions in principles underlying figural relations problem solution (n = 24), or a self-instructed interactive group that received practice with the figural relations training materials but no formal instruction (n = 21). All participants took a pretest battery and posttests on two occasions following training that tapped a variety of cognitive abilities. Planned comparisons indicated that the experimental groups differed significantly from the control group at the first posttest as well as across both posttest occasions on near versus far transfer tasks. However, self-generated strategies for task solution were found to be more durable over time as compared to specific rule training on near versus far transfer.

Effect of computer support on younger women with breast cancer.

OBJECTIVE: Assess impact of a computer-based patient support system on quality of life in younger women with breast cancer, with particular emphasis on assisting the underserved. DESIGN: Randomized controlled trial conducted between 1995 and 1998. SETTING: Five sites: two teaching hospitals (Madison, Wis, and Chicago, Ill), two nonteaching hospitals (Chicago), and a cancer resource center (Indianapolis, Ill). The latter three sites treat many underserved patients. PARTICIPANTS: Newly diagnosed breast cancer patients (N = 246) under age 60. INTERVENTIONS: Experimental group received Comprehensive Health Enhancement Support System (CHESS), a home-based computer system providing information, decision-making, and emotional support. MEASUREMENTS AND MAIN RESULTS: Pretest and two post-test surveys (at two- and five-month follow-up) measured aspects of participation in care, social/information support, and quality of life. At two-month follow-up, the CHESS group was significantly more competent at seeking information, more comfortable participating in care, and had greater confidence in doctor(s). At five-month follow-up, the CHESS group had significantly better social support and also greater information competence. In addition, experimental assignment interacted with several indicators of medical underservice (race, education, and lack of insurance), such that CHESS benefits were greater for the disadvantaged than the advantaged group. CONCLUSIONS: Computer-based patient support systems such as CHESS may benefit patients by providing information and social support, and increasing their participation in health care. These benefits may be largest for currently underserved populations.

A computer-administered telephone interview to identify mental disorders.

CONTEXT: Common mental disorders are often not identified in primary care settings. OBJECTIVE: To evaluate the validity and clinical utility of a telephone-assisted computer-administered version of Primary Care Evaluation of Mental Disorders (PRIME-MD), a brief questionnaire and interview instrument designed to identify psychiatric disorders in primary care patients. DESIGN: Comparison of diagnoses obtained by computer over the telephone using interactive voice response (IVR) technology vs those obtained by a trained clinician over the telephone using the Structured Clinical Interview for DSM-IV [Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition] Diagnosis (SCID). A subsample also received the clinician-administered version of PRIME-MD. PATIENTS: Outpatients (N=200) from 4 primary care clinics, an eating disorders clinic, an alcohol treatment facility, psychiatric outpatients, and community controls. SETTING: Interviews conducted by telephone, except for face-to-face administration of PRIME-MD, which was conducted at either the primary care clinic or a research clinic. MEASUREMENTS AND MAIN RESULTS: Prevalence rates for any psychiatric disorder were similar between diagnoses made by the computer and those made by a mental health professional using the SCID (60.0% vs 58.5%). Prevalence rates for individual diagnoses were generally similar across versions. However, primary care patients reported twice as much alcohol abuse on the computer (15.0%) as on either the SCID (7.5%) or the clinician-administered PRIME-MD (7.5%). Using the SCID as the criterion, both the computer- and clinician-administered versions of PRIME-MD demonstrated high and roughly equivalent levels of sensitivity and specificity. Overall agreement (K) for any diagnosis was 0.67 for the computer-administered PRIME-MD and 0.70 for the clinician-administered PRIME-MD. CONCLUSIONS: The computer-administered PRIME-MD appears to be a valid instrument for assessing psychopathology in primary care patients. Interactive voice response technology allows for increased availability, and provides primary care physicians with information that will increase the quality of patient care without additional physician time and at minimal expense.