The impact of patients' pre-treatment expectations on immunosuppressive treatment outcomes in myasthenia gravis: A pilot correlational study.

INTRODUCTION/AIMS: The impact of treatment expectations on active treatment outcomes has not been specifically investigated in neuromuscular disorders. We thus explored in myasthenia gravis (MG) the contribution of patients' pre-treatment expectations combined with an immunosuppressant drug on treatment outcomes. METHODS: This pilot correlational study involved 17 patients with generalized MG, scheduled to start immunosuppressant azathioprine. At baseline, a healthcare professional administered: (i) the Stanford Expectations of Treatment Scale; (ii) a structured checklist paper form asking patients which side-effects they expected to develop after starting azathioprine, coupled with a standardized framing of statements. Quantitative Myasthenia Gravis (QMG) score and daily dose of concomitant drugs were assessed by neurologists as clinical outcomes. Clinical outcomes and side-effects were re-assessed at 3 and 6 months, and clinical outcomes were monitored at 18 months. RESULTS: Clinically significant improvement in the QMG scores was achieved at 3 or 6 months. The level of state anxiety appeared to act as moderator of pre-treatment negative expectations (strong, positive, indicative correlation, rs = .733, p = .001). The latter were, in turn, associated with the fulfillment of side-effects that patients expected to develop with the new treatment (moderate, positive, indicative correlation, rs = .699, p = .002). No significant correlation emerged between positive and negative expectations. DISCUSSION: Our findings show a very quick clinical response and also suggest that patients' expectations and anxiety contributed to treatment outcomes, highlighting the importance of promoting safety messages and education strategies around newly introduced treatments. Future goals include evaluating a larger cohort that includes a matched control group.

Patient and therapist change process expectations: Independent and dyadic associations with psychotherapy outcomes.

Objective: Patients and therapists possess psychotherapy-related expectations, such as their forecast of what processes will promote improvement. Yet, there remains limited research on such change process expectations, including their independent and dyadic associations with psychotherapy outcome. In this study, we explored the predictive influence of participants' change process expectations, and their level of congruence, on therapeutic outcomes. METHODS: Patients (N = 75) and therapists (N = 17) rated their change process expectations at baseline, and patients rated their psychological distress at baseline and three months into treatment. RESULTS: Multilevel models indicated that patients' expectations for therapy to work through sharing sensitive contents openly and securely were positively related to subsequent improvement (B = -1.097; p = .007). On the other hand, patients' expectations for therapy to work through the exploration of unexpressed contents were negatively related to improvement (B = 1.388; p = .049). When patients rated the sharing of sensitive contents openly and securely higher than their therapists, they reported better outcomes (B = -16.528; p = .035). CONCLUSION: These findings suggest that patients' expectations produce diverse effects during early stages of treatment, and that patients' belief in their ability to share sensitive contents may constitute a potential target to improve therapy effectiveness.

Informed consent for psychotherapy: Ethical illusion or clinical reality? A survey about psychotherapists' attitudes and practices in Germany.

OBJECTIVE: This study aimed to assess clinicians' attitudes and their current clinical practices regarding informed consent for psychotherapy. METHOD: A convenience sample of N = 530 clinicians in Germany (n = 418 licensed psychotherapists and n = 112 postgraduate psychotherapy trainees) took part in an online survey. RESULTS: Most clinicians (84%) reported obtaining informed consent for psychotherapy in their daily routine. However, many psychotherapists felt unsure about satisfactorily fulfilling the legal (63%) and ethical obligations (52%). The two most frequently reported components of information disclosure related to explaining the terms and conditions of psychotherapy (96%) and the psychotherapeutic approach (91%). Providing information about mechanisms of psychotherapy (33%) and the role of expectations (30%) were least practiced. One in five psychotherapists reported not informing clients about potential risks and side effects. A considerable proportion reported concern about inducing anxiety in patients by disclosing information about risks and side effects (52%). CONCLUSIONS: Although obtaining informed consent for psychotherapy seems to be the rule rather than the exception in clinical practice, the quality of its implementation in terms of legal, ethical and clinical demands remains questionable. Training psychotherapists in providing comprehensive informed consent enables informed decision-making and might have a positive influence on treatment expectations and outcomes.

[Treatment expectations for postoperative pain]. / Behandlungserwartungen bei postoperativen Schmerzen.

BACKGROUND: Preoperative treatment expectations have a significant influence on postoperative pain and treatment outcomes. Positive expectations are an important mechanism of the placebo effect and negative expectations are an important mechanism of the nocebo effect. OBJECTIVES: What is the influence of treatment expectations, how are they assessed in the clinical setting, and how can the findings be implemented in clinical practice? METHODS: A literature search was performed using the keywords "expectation" AND ("postoperative" OR "surgery"). All English and German articles were selected. In addition, the bibliographies of the articles found were examined and incorporated. RESULTS: A total of 158 articles were found, 49 of which investigate expectations and include postoperative treatment outcomes. Most articles investigate expectations only at baseline to ensure that groups do not differ preoperatively. The studies that prospectively examine the influence of expectations apply very different measurement methods to investigate expectancy constructs. Thus, comparison across studies is difficult. There are few studies examining whether and how expectations can be influenced perioperatively, and who developed practice-relevant interventions to change them. CONCLUSION: Valid and reliable measurement tools should be applied in clinical trials for a more robust investigation of treatment expectations. Further studies should address possible intervention options so that treatment expectations can also be incorporated into standard clinical care.

Treatment expectations and perception of therapy in adult patients with spinal muscular atrophy receiving nusinersen.

BACKGROUND AND PURPOSE: This was an investigation of treatment expectations and of the perception of therapy in adult patients with 5q-associated spinal muscular atrophy (5q-SMA) receiving nusinersen. METHODS: A prospective, non-interventional observational study of nusinersen treatment in adult 5q-SMA patients was conducted at nine SMA centers in Germany. The functional status, treatment expectations and perceived outcomes were assessed using the Amyotrophic Lateral Sclerosis Functional Rating Scale-extended (ALS-FRS-ex), the Measure Yourself Medical Outcome Profile (MYMOP2), the Treatment Satisfaction Questionnaire for Medication (TSQM-9) and the Net Promoter Score (NPS). RESULTS: In all, 151 patients were included with a median age of 36 years (15-69 years). SMA type 3 (n = 90, 59.6%) prevailed, followed by type 2 (33.8%) and type 1 (6.6%). In SMA types 1-3, median ALS-FRS-ex scores were 25, 33 and 46 (of 60 scale points), respectively. MYMOP2 identified distinct treatment expectations: head verticalization (n = 13), bulbar function (n = 16), arm function (n = 65), respiration (n = 15), trunk function (n = 34), leg function (n = 76) and generalized symptoms (n = 77). Median symptom severity decreased during nusinersen treatment (median observational period 6.1 months, 0.5-16 months) from 3.7 to 3.3 MYMOP2 score points (p < 0.001). The convenience of drug administration was critical (49.7 of 100 TSQM-9 points, SD 22); however, the overall treatment satisfaction was high (74.3, SD 18) and the recommendation rating very positive (NPS +66). CONCLUSIONS: Nusinersen was administered across a broad range of ages, disease durations and motor function deficits. Treatment expectations were highly differentiated and related to SMA type and functional status. Patient-reported outcomes demonstrated a positive perception of nusinersen therapy in adult patients with 5q-SMA.

Fear of compassion is associated with treatment ambivalence and negative expectations for treatment in people with anxiety.

OBJECTIVES: Fears of compassion are hypothesized to be associated with treatment attitudes, but this relationship has not yet been explored. METHODS: Measures of fear of compassion and treatment expectations and ambivalence were administered to those with above-average anxiety (N = 302) and those who met criteria for an anxiety or related disorder (N = 40). RESULTS: In those with anxiety disorders, fear of receiving compassion and fear of self-compassion were strongly correlated with treatment ambivalence. In both samples, higher fear of receiving compassion was associated with more negative expectations for treatment. CONCLUSIONS: Fear of compassion is associated with treatment ambivalence and treatment expectations and may be an important target early in treatment. PRACTITIONER POINTS: Fears of receiving compassion and self-compassion were related to treatment ambivalence and negative treatment expectations There may be benefit in targeting fear of compassion early in treatment.

[Placebo effects in pain therapy]. / Placeboeffekte in der Schmerztherapie.

In the past few decades, research on pain and placebo analgesia has gained importance both scientifically and clinically. In this article, the current findings and focus of research as well as the significance of placebo research for assessing the effectiveness of pain medication are illustrated. The underlying mechanisms of placebo analgesia not only have implications for theoretical models but also offer clinically relevant guidelines for everyday interventions in pain treatment. However, many placebo phenomena are not fully understood and have to be investigated further in order to exploit the full potential of placebo effects. Interindividual differences and their inclusion in treatment will play a major role in this aspect.

[The effect of medical and psychotherapeutic treatment models for schizophrenia on stigma and recovery expectations]. / Die Wirkung medizinischer und psychotherapeutischer Behandlungskonzepte für Schizophrenie auf Stigma und Genesungserwartungen.

BACKGROUND: It is common practice to inform patients about causes and treatment models when starting psychiatric treatment or psychotherapy for schizophrenia. However, previous research indicates that focusing on etiological models increases stigmatizing beliefs. This raises the question of whether contemporary, medical or cognitive behavioral therapy (CBT)-based treatment models share this negative side effect. AIM: This experiment tested whether providing information about medical vs. CBT-based vs. combined treatment models affects stigmatizing attitudes towards schizophrenia and the expected efficacy of these treatments. METHODS: Participants received a case vignette of a person with schizophrenia including either: (1) no treatment details, or a description of treatment with (2) medication, (3) CBT, or (4) medication and CBT. Next, stigmatizing attitudes (stereotypes, affective reactions, and desired social distance) were assessed and participants rated the perceived effectiveness of different treatment methods. RESULTS: No treatment model showed an effect on stigmatizing attitudes. Medical and CBT treatment information (alone or in combination) had a positive effect on subjective efficacy ratings for the respective treatment. CONCLUSION: There appear to be no negative side effects of (biogenetic) models when presented in a context emphasizing recovery. Moreover, medication and CBT treatment information showed additive positive effects on the rating of treatment strategies. A combined treatment model integrating various evidence-based methods appears to be most useful in clinical practice.

Does involving patients in treatment decisions affect perceptions of treatments and therapists?

Psychotherapists may offer patients more or less involvement when deciding on a treatment. The aim of the present research was to examine whether perceptions of the treatment and therapist differ when a therapist uses a paternalistic style in making treatment decisions or a more collaborative approach, in which the patient helps in selecting treatment. In the study, 172 participants, recruited from a university setting and a national sample, listened to a simulated conversation representing either a paternalism or informed-choice model of a therapist-patient interaction. The participants then rated their expectation the treatment would help the patient, their perception of the therapist's trustworthiness, and their own preference for relying on clinicians for knowledge and decisions. Analysis indicated that among participants preferring to rely on clinicians, perceptions did not differ reliably based on the type of interaction they heard. However, participants wanting more involvement in treatment choices perceived greater treatment effectiveness and clinician trustworthiness for the interaction in which the patient was offered treatment choices. These results suggest that if therapists adopt a collaborative approach, it has the potential to enhance perceptions of individuals preferring the collaborative style without negatively affecting those who prefer less involvement in treatment decisions.

Can orthognathic surgery be expected to improve patients' psychological well-being? The challenge of hedonic adaptation.

In addition to improved oral health and function, many people are motivated to undergo orthognathic surgery to improve their facial aesthetics and overall psychological well-being (daily affect and satisfaction with life). This article explains the phenomenon of hedonic adaptation, which challenges the notion that patients treated with orthognathic surgery can expect to experience improvements in psychological well-being following surgery. We review evidence for hedonic adaptation across a variety of life circumstances and explain the psychological processes which account for the relative stability of people's well-being over their life course despite significant positive (and negative) changes in their circumstances. We examine the conditions that assist and inhibit hedonic adaptation to positive life events, and argue that if patients are made aware of these processes, they are more likely to achieve sustained improvements in psychological well-being following orthognathic surgery. Based on our narrative review of evidence for hedonic adaptation, we conclude that orthognathic surgery should not be expected to improve patients' psychological well-being in the long term and suggest that patients be advised to take intentional steps to preserve any improvements in their day-to-day affect and satisfaction with life that arise as a result of their surgery.

Preventing adverse events of chemotherapy by educating patients about the nocebo effect (RENNO study) - study protocol of a randomized controlled trial with gastrointestinal cancer patients.

BACKGROUND: Patients undergoing chemotherapy are highly burdened by side effects. These may be caused by the pharmacodynamics of the drug or be driven by psychological factors such as negative expectations or pre-conditioning, which reflect nocebo effects. As such, negative pre-treatment expectations or prior experiences might exacerbate the burden of chemotherapy side effects. Educating patients about this nocebo effect has been put forward as a potential strategy to optimize patients' pre-treatment expectations. In this study, we evaluate whether a briefing about the nocebo effect is efficacious in reducing side effects. METHODS: In this exploratory study, a total number of n = 100 outpatients with newly diagnosed gastrointestinal cancers are randomized 1:1 to an information session about the nocebo effect (nocebo-education) or an attention control group (ACG) with matching interaction time. Assessments take place before the intervention (T1 pre), post-intervention (T1 post), and 10 days (T2) and 12 weeks (T3) after the initial chemotherapy. The primary outcomes are the patient-rated number and intensity of side effects at 10-days and at 12-weeks follow-up. Secondary outcomes include coping with side effects, tendency to misattribute symptoms, compliance intention, attitude towards the chemotherapy, co-medication to treat side effects and the clinician-rated severity of toxicity. Further analyses are conducted to investigate whether a potential beneficial effect is mediated by a change of expectations before and after the intervention. DISCUSSION: Informing patients about the nocebo effect might be an innovative and feasible intervention to reduce the burden of side effects and strengthen patients' perceived control over adverse symptoms. TRIAL REGISTRATION: The trial is registered at the German Clinical Trials Register (ID: DRKS00009501 ; retrospectively registered on March 27, 2018). The first patient was enrolled on September 29, 2015.

Entertaining accurate treatment expectations while suffering from chronic pain: an exploration of treatment expectations and the relationship with patient- provider communication.

BACKGROUND: Accurate patient expectations are important to optimise treatment success, especially for complex conditions such as chronic pain. Communication may be the key to managing patient expectations. This study aimed to explore whether health care provider communication influences patient expectations and which communication aspects are most important. METHODS: We conducted secondary analyses on data that had been collected between September and November 2012. 2603 patients suffering from chronic pain were invited to complete a survey. RESULTS: Although 69.9% of patients achieved or surpassed their treatment goal, 30.2% of patients were unsatisfied. Even though overall health care provider communication and shared decision making were unrelated to patient expectations, several affective communication aspects were related. These aspects were attentive listening, taking enough time, building patient's trust in the physician's competence and giving patients the feeling that the physician is doing all he or she can (p's < 0.05). CONCLUSIONS: Even though treatment goals are not always explicitly discussed, patients still form expectations regarding treatment outcomes. Affective communication may be more important for managing patient expectations than sharing information. Building a good therapeutic relationship by showing affective communication may be important to increase the accuracy of patient expectations.

Do patients prefer optimistic or cautious psychiatrists? An experimental study with new and long-term patients.

BACKGROUND: Patients seeking treatment may be assumed to prefer a psychiatrist who suggests a new treatment with confidence and optimism. Yet, this might not apply uniformly to all patients. In this study, we tested the hypothesis that new patients prefer psychiatrists who present treatments optimistically, whilst patients with longer-term experience of mental health care may rather prefer more cautious psychiatrists. METHODS: In an experimental study, we produced video-clips of four psychiatrists, each suggesting a pharmacological and a psychological treatment once with optimism and once with caution. 100 'new' patients with less than 3 months experience of mental health care and 100 'long-term' patients with more than one year of experience were shown a random selection of one video-clip from each psychiatrist, always including an optimistic and a cautious suggestion of each treatment. Patients rated their preferences for psychiatrists on Likert type scales. Differences in subgroups with different age (18-40 vs. 41-65 years), gender, school leaving age (≤16 vs. >16 years), and diagnosis (ICD 10 F2 vs. others) were explored. RESULTS: New patients preferred more optimistic treatment suggestions, whilst there was no preference among long-term patients. The interaction effect between preference for treatment presentations and experience of patients was significant (interaction p-value = 0.003). Findings in subgroups were similar. CONCLUSION: In line with the hypothesis, psychiatrists should suggest treatments with optimism to patients with little experience of mental health care. However, this rule does not apply to longer-term patients, who may have experienced treatment failures in the past.

Measuring nonspecific factors in treatment: item banks that assess the healthcare experience and attitudes from the patient's perspective.

PURPOSE: Nonspecific factors that accompany healthcare treatments, such as patients' attitudes and expectations, are important parts of the experience of care and can influence outcomes. However, no precise, concise, and generalizable instruments to measure these factors exist. We report on the development and calibration of new item banks, titled the Healing Encounters and Attitudes Lists (HEAL), that assess nonspecific factors across a broad range of treatments and conditions. METHODS: The instrument development methodology of the Patient-Reported Outcomes Measurement Information System (PROMIS(®)) was used. Patient focus groups and clinician interviews informed our HEAL conceptual model. Literature searches of eight databases yielded over 500 instruments and resulted in an initial item pool of several thousand items. After qualitative item analysis, including cognitive interviewing, 296 items were included in field testing. The calibration sample included 1657 respondents, 1400 obtained through an Internet panel and 257 from conventional and integrative medicine clinics. Following exploratory and confirmatory factor analyses, the HEAL item banks were calibrated using item response theory. RESULTS: The final HEAL item banks were Patient-Provider Connection (57 items), Healthcare Environment (25 items), Treatment Expectancy (27 items), Positive Outlook (27 items), and Spirituality (26 items). Short forms were also developed from each item bank. A six-item short form, Attitudes toward Complementary and Alternative Medicine (CAM), was also created. CONCLUSIONS: HEAL item banks provided substantial information across a broad range of each construct. HEAL item banks showed initial evidence of predictive and concurrent validity, suggesting that they are suitable for measuring nonspecific factors in treatment.

Patient Pre-Treatment Expectations Do Not Predict Cocaine Use Outcomes: Data From Four Clinical Trials.

BACKGROUND: There are very few data regarding the extent to which patients' initial expectations regarding treatment are associated with substance use treatment outcomes. OBJECTIVE: This study sought to determine how patients' treatment expectations were associated with treatment outcomes. METHODS: This study explored patient pre-treatment expectations and substance use treatment outcomes for 387 individuals participating in treatment for cocaine use within the United States (68.2% male, mean age 36 years old, 54.8% Caucasian). RESULTS: Participants' expectations regarding abstinence were not strongly associated with post-treatment or follow-up cocaine use outcome measures. There was a significant association between the expected timeframe of receiving a positive treatment effect (i.e., outcome efficiency expectations) and days of cocaine use at the 1-month follow-up point (F = 3.45, p =.009). Post-hoc comparisons revealed that participants that expected positive effects of treatment within 0-1 week reported fewer days of cocaine use than those that expected results in 1-2 months. Also, those that expected positive effects of treatment in 1-2 months reported more cocaine use than those who expected positive results within two weeks to one month. Further, there was a significant effect of outcome efficiency expectations on a proxy measure of achieving a good treatment outcome at the three-month follow-up point (F = 11.13, p =.025). CONCLUSIONS/IMPORTANCE: Results suggest that treatment outcomes are not associated with patients' treatment outcome expectations, but that some outcomes are associated with treatment outcome efficiency expectations.

Monitoring treatment expectations in patients with an implantable cardioverter-defibrillator using the EXPECT-ICD scale.

AIMS: Patient treatment expectations may affect cardiac outcomes; however, till date, no validated instruments have been developed to monitor treatment expectations in patients with an implantable cardioverter-defibrillator (ICD). This study evaluates the predictive value of the newly developed 10-item EXPECtations Towards ICD therapy (EXPECT-ICD) in relation to anxiety, depression, and ICD related concerns 3 months post-implant. METHODS AND RESULTS: Consecutive implanted ICD patients were included as part of the WEB-based distress management programme for ICD patients (WEBCARE) trial from six Dutch referral hospitals. The patients completed the baseline questionnaires briefly after ICD implantation. Information on clinical variables was captured from the patients' medical records. Patients' treatment expectations as assessed with the EXPECT-ICD questionnaire could best be represented with a two-factor model involving both negative (α = 0.84) and positive expectations (α = 0.77) with a score range of 0-20 for each factor. Negative treatment expectations were associated with higher levels of anxiety (ß = 0.443; P < 0.001), depression (ß = 0.506; P < 0.001), and ICD concerns (ß = 0.428; P < 0.001) 3 months post-implant after controlling for demographic and clinical factors. Positive expectations were not related to any of the distress outcomes. CONCLUSION: Negative expectations were associated with anxiety, depression, and ICD concerns 3 months post-implant. The current findings indicate that the EXPECT-ICD scale is a reliable, valid, and disease-specific measure of the treatment expectations in ICD patients. Future research needs to investigate whether addressing the patients' expectations might improve the outcome and the subjective well-being of ICD patients.

Pre-treatment expectations and their influence on subjective symptom change in Crohn's disease.

BACKGROUND: Treatment expectations reportedly shape treatment outcomes, but have not been studied in the context of multimodal therapy in Crohn's disease (CD). Therefore, the current study investigated the role of treatment expectations for subjective symptom changes in CD patients who have undergone an integrative multimodal therapy program. METHODS: Validated questionnaires were completed at the start of the treatment program and post intervention. Pre-treatment expectations and experienced symptom change were assessed with the Generic Rating Scale for Previous Treatment Experiences, Treatment Expectations, and Treatment Effects (GEEE); stress levels were quantified with the Perceived Stress Scale (PSS-10) and disease specific quality of life was quantified with the disease-specific Inflammatory Bowel Disease Questionnaire (IBDQ). We performed multiple linear and Bayesian regression to determine how expectations related to symptom change. RESULTS: N = 71 CD patients (66.2% female) were included. Stronger expectations regarding symptom improvement (b = 0.422, t = 3.70, p < .001) were associated with higher experienced symptom improvement. Additionally, Bayesian analysis provided strong evidence for including improvement expectations as a predictor of improvement experience (BFinclusion = 13.78). CONCLUSIONS: In line with research in other disorders, we found that positive treatment expectations were associated with experienced symptom improvement. In contrast, we found no indication that an experience of symptom worsening was associated with positive or negative baseline treatment expectations. Induction of positive expectations might be a potential avenue for improving treatment outcomes in CD therapy.

Treatment expectations and clinical outcomes following repetitive transcranial magnetic stimulation for treatment-resistant depression.

BACKGROUND: Patient expectations, including both positive (placebo) and negative (nocebo) effects, influence treatment outcomes, yet their impact on acute repetitive transcranial magnetic stimulation (rTMS) for treatment-resistant depression (TRD) is unclear. METHODS: In this single-center retrospective chart review, 208 TRD patients completed the Stanford Expectation of Treatment Scale (SETS) before starting open-label rTMS treatment. Patients were offered two excitatory rTMS protocols (deep TMS or intermittent theta-burst stimulation), which stimulated the left dorsolateral prefrontal cortex. A minimum of 20 once daily treatments were provided, delivered over 4-6 weeks. Primary outcomes were 1) remission, measured by a post-treatment score of <8 on the Hamilton Depression Rating Scale (HAMD-17), and 2) premature discontinuation. The change in HAMD-17 scores over time was used as a secondary outcome. Physicians were blinded to SETS scores. Logistic and linear regression, adjusting for covariates, assessed SETS and HAMD-17 relationships. RESULTS: Of 208 patients, 177 had baseline and covariate data available. The mean positivity bias score (positive expectancy minus negative expectancy subscale averages) was 0.48 ± 2.21, indicating the cohort was neutral regarding the expectations of their treatment on average. Higher positive expectancy scores were significantly associated with greater odds of remission (OR = 1.90, p = 0.003) and greater reduction in HAMD-17 scores (ß = 1.30, p = 0.005) at the end of acute treatment, after adjusting for covariates. Negative expectancy was not associated with decreased odds of remission (p = 0.2) or treatment discontinuation (p = 0.8). CONCLUSIONS: Higher pre-treatment positive expectations were associated with greater remission rates with open-label rTMS in a naturalistic cohort of patients with TRD.

Treatment Expectations-You Get What You Expect-and Depression Plays a Role.

Positive treatment expectations demonstrably shape treatment outcomes regarding pain and disability in patients with chronic low back pain. However, knowledge about positive and negative treatment expectations as putative predictors of interindividual variability in treatment outcomes is sparse, and the role of other psychological variables of interest, especially of depression as a known predictor of long-term disability, is lacking. We present results of the first prospective study considering expectations in concert with depression in a sample of 200 patients with chronic low back pain undergoing an inpatient interdisciplinary multimodal pain therapy. We analyzed the characteristics of pain and disability, treatment expectation, and depression assessed at the beginning (T0), at the end of (T1), and at 3-month follow-up (T2) of interdisciplinary multimodal pain therapy. Treatment expectations did emerge as a significant predictor of changes in pain intensity and disability, respectively, showing that positive expectations were associated with better treatment outcomes. Mediation analyses revealed a partially mediating effect of treatment expectations on the relation between depression and pain outcomes. PERSPECTIVE: These results expand knowledge regarding the role of treatment expectations in individual treatment outcome trajectories in chronic pain patients, paving the way for much-needed efforts toward optimizing patient expectations and personalized approaches in clinical settings.

Parental Cognitions, Treatment Engagement, and Child Outcomes of ADHD Behavioral Treatment among Asian American Families.

Asian American (AA) families remain critically underrepresented in clinical trials for ADHD interventions. Little is known about AA families' engagement in and outcomes of behavioral treatment (BT). Comparing AA families to other minoritized (OM) families and White families, this study examined parental cognitions, treatment engagement, and child outcomes of BT for ADHD inattentive type (ADHD-I). Path analyses were conducted utilizing data from a randomized controlled trial of BT for ADHD-I (N = 199 children, ages 7-11). Racial/ethnic differences in pretreatment parental self-competence and treatment expectations were examined for AA (n = 29) compared to OM (n = 35) and White (n = 135) parents. Two additional path models were conducted to examine the relations among race/ethnicity, pretreatment parental cognitions, treatment engagement, and posttreatment child outcomes. Direct effects of race/ethnicity and parental cognitions on posttreatment child outcomes as well as their indirect effects via treatment engagement were estimated. At pretreatment, AA parents endorsed lower parental self-competence and treatment expectations compared to OM and White parents. At posttreatment, AA parents reported fewer improvements in ADHD symptoms than White parents and lower global psychosocial improvement than OM parents. For all parents, treatment expectations positively predicted parent- and observer-rated treatment engagement, which in turn predicted child global psychosocial improvement. Path analyses indicated that the relationship between treatment expectations and posttreatment child global improvement was fully mediated by treatment engagement. These findings suggest that treatment expectations impede AA parents' engagement and success in BT. Implications for cultural adaptations of BT to improve AA families' treatment experience are discussed.