Low Treatment Expectations Research Articles

Depression symptom outcomes and re-engagement among VA patients who discontinue care while symptomatic

ObjectiveEvaluate outcomes of Veterans who discontinued treatment with at least moderate ongoing depressive symptoms. MethodVeterans with elevated depression symptoms from 29 Department of Veterans Affairs facilities completed baseline surveys and follow-up assessments for one year. Analyses examined rates and predictors of treatment discontinuation, treatment re-engagement, and subsequent symptoms among patients who remained out of care. ResultsA total of 242 (17.8%; n = 1359) participants discontinued treatment while symptomatic, with Black participants, participants with less severe depression, and participants receiving only psychotherapy (versus combined psychotherapy and antidepressant medications) discontinuing at higher rates. Among all participants who discontinued treatment (n = 445), 45.8% re-engaged within the following six months with participants receiving combined treatment re-engaging at higher rates. Of participants who discontinued while symptomatic within the first 6 months of the study and did not return to care (n = 112), 68.8% remained symptomatic at 12 months. Lower baseline treatment expectancy and greater depression symptom severity were associated with remaining symptomatic while untreated. ConclusionsBlack race, lower symptom severity, and treatment modality may help identify patients at higher risk for discontinuing care while symptomatic, whereas patients with lower treatment expectations may be at greater risk for remaining out of care despite continuing symptoms.

Agency affects pain inference through prior shift as opposed to likelihood precision modulation in a Bayesian pain model

Agency and expectations play a crucial role in pain perception and treatment. In the Bayesian pain model, somatosensation (likelihood) and expectations (prior) are weighted by their precision and integrated to form a pain percept (posterior). Combining pain treatment with stimulus-related expectations allows the mechanistic assessment of whether agency enters this model as a shift of the prior or a relaxation of the likelihood precision. In two experiments, heat pain was sham treated either externally or by the subject, while a predictive cue was utilized to create high or low treatment expectations. Both experiments revealed additive effects and greater pain relief under self-treatment and high treatment expectations. Formal model comparisons favored a prior shift rather than a modulation of likelihood precision. Electroencephalography revealed a theta-to-alpha effect, temporally associated with expectations, which was correlated with trial-by-trial pain ratings, further supporting a prior shift through which agency exerts its influence in the Bayesian pain model.

The self-critical patient in clinical supervision: a qualitative study of therapists’ alliance struggles and emotional reactions in short-term psychodynamic psychotherapy for depression

ABSTRACT Self-critical perfectionism has been linked to alliance impairments due to patients’ distancing attitudes. However, systematic research on therapists’ emotional experiencing when working with self-critical patients is scarce. This qualitative study explores how therapists perceive, emotionally experience, and react to self-critical patients’ interpersonal dynamics. We studied narrative data from clinical supervisions where psychodynamic psychotherapists discussed self-critical patients (N = 7) within the context of an RCT on Major Depressive Disorder. Consensual Qualitative Research was applied to identify recurrent patterns in the data. As a global impediment to treatment, therapists observed a pattern of non-engagement. Patients’ superficial and avoidant way of communicating, hostility or aggressiveness in the alliance, and low or inaccurate treatment expectations emerged as main obstacles to the therapeutic process, evoking negative affect in therapists. More vulnerable aspects of the patient and case formulation emerged as having a mitigating effect on unfavorable therapist reactions. Our findings confirm longstanding clinical and theoretical accounts associating therapeutic work with self-critical patients with negative affect in therapists. Our study suggests that negative responses may be enacted in therapy which can reinforce poor alliance. We discuss the role of supervision in helping therapists to become aware of and manage negative responses, engage in case conceptualization, and advance clinical work.

Comparing treatment outcomes and patient satisfaction among individuals presenting to psychiatric care with and without recent suicidal ideation.

To compare pre- and posttreatment psychological functioning and patient satisfaction among patients with and without recent suicidal ideation receiving care at a partial hospital program. Patients (N = 1295) completed (1) self-report measures of clinical severity, treatment beliefs, and patient satisfaction and (2) a clinician-administered suicidal ideation measure. At admission, patients with past-month ideation reported more severe psychopathology and functional impairment than those without past-month ideation; however, at discharge, both groups reported comparable psychological functioning. Additionally, although patients with past-month ideation reported lower expectations that treatment would be helpful, both groups ultimately reported comparable satisfaction with services. Individuals with recent suicidal ideation may present to care with more severe psychopathology and lower treatment expectations yet may experience comparable treatment benefits and report similar satisfaction with services as patients without recent ideation. Research is needed to identify treatment components that drive perceived benefits and symptom reduction among at-risk individuals.

Impact of Preoperative Opioid Use on 2-Year Patient-Reported Outcomes in Knee Surgery Patients.

The objectives of this study are to assess perioperative opioid use in patients undergoing knee surgery and to examine the relationship between preoperative opioid use and 2-year postoperative patient-reported outcomes (PROs). We hypothesized that preoperative opioid use and, more specifically, higher quantities of preoperative opioid use would be associated with worse PROs in knee surgery patients. We studied 192 patients undergoing knee surgery at a single urban institution. Patients completed multiple PRO measures preoperatively and 2-year postoperatively, including six patient-reported outcomes measurement information system (PROMIS) domains; the International Knee Documentation Committee (IKDC) questionnaire, numeric pain scale (NPS) scores for the operative knee and the rest of the body, Marx's knee activity rating scale, Tegner's activity scale, International Physical Activity Questionnaire, as well as measures of met expectations, overall improvement, and overall satisfaction. Total morphine equivalents (TMEs) were calculated from a regional prescription monitoring program. Eighty patients (41.7%) filled an opioid prescription preoperatively, and refill TMEs were significantly higher in this subpopulation. Opioid use was associated with unemployment, government insurance, smoking, depression, history of prior surgery, higher body mass index, greater comorbidities, and lower treatment expectations. Preoperative opioid use was associated with significantly worse 2-year scores on most PROs, including PROMIS physical function, pain interference, fatigue, social satisfaction, IKDC, NPS for the knee and rest of the body, and Marx's and Tegner's scales. There was a significant dose-dependent association between greater preoperative TMEs and worse scores for PROMIS physical function, pain interference, fatigue, social satisfaction, NPS body, and Marx's and Tegner's scales. Multivariable analysis confirmed that any preoperative opioid use, but not quantity of TMEs, was an independent predictor of worse 2-year scores for function, activity, and knee pain. Preoperative opioid use and TMEs were neither independent predictors of met expectations, satisfaction, patient-perceived improvement, nor improvement on any PROs. Our findings demonstrate that preoperative opioid use is associated with clinically relevant worse patient-reported knee function and pain after knee surgery.

Stressors and chemical imbalances: Beliefs about the causes of depression in an acute psychiatric treatment sample

BackgroundPublic perceptions of mental illness are increasingly construed in neurobiological and genetic terms. Accumulating evidence suggests there are some unintended consequences of these explanations, including reduced optimism for recovery among individuals with depression. However, little is known about how these beliefs relate to treatment process and outcomes in a psychiatric treatment setting, a gap this study aimed to fill. MethodsWe examined etiological beliefs about depression in a sample of patients (N = 279) seeking acute treatment in a behaviorally-based therapy program at a psychiatric hospital and examined relations with treatment expectations and outcomes. ResultsWe found that although psychosocial explanations of depression were most popular, biogenetic beliefs, particularly the belief that depression is caused by a chemical imbalance, were prevalent in this sample. Further, the chemical imbalance belief related to poorer treatment expectations. This relationship was moderated by symptoms of depression, with more depressed individuals showing a stronger relationship between chemical imbalance beliefs and lower treatment expectations. Finally, the chemical imbalance belief predicted more depressive symptoms after the treatment program ended for a 2-week measure of depression (but not for a 24-hour measure of depression), controlling for psychiatric symptoms at admission, inpatient hospitalizations, and treatment expectations. LimitationsThe sample was homogenous in terms of race and ethnicity and we did not assess how patients came to their beliefs. ConclusionsTogether, the results illustrate the correlates and possible impacts of etiological beliefs in a real-world clinical setting and invite a critical discussion about predominant messages about the etiology of depression.

Treatment Expectations Towards Different Pain Management Approaches: Two Perspectives.

PurposeAccumulating evidence suggests an association between patient expectations and treatment success across various types of pain treatments. Expectations among treatment caregivers, however, are often neglected. Despite international treatment guidelines, only a small minority of chronic pain patients undergo psychological interventions. Therefore, our aim was to explore expectations among treatment receivers and caregivers especially concerning their attitudes towards psychological pain treatments.MethodsTwo hundred ten (potential) treatment receivers (n=85 individuals suffering from chronic low back pain (CLBP); n=125 healthy controls) and 237 caregivers (n=75 physicians; n=64 psychotherapists; n=98 physiotherapists) provided ratings of expected treatment success for standardized vignettes describing patients suffering from CLBP and undergoing a pharmacological, psychological, or multimodal pain management program.ResultsIndividuals suffering from CLBP generally had lower treatment expectations than healthy controls. Both psychotherapists and physicians had higher treatment expectations from their own individual treatment approach. All participants expected the multimodal approach to be most effective. The psychological approach was expected to be more effective than the pharmacological approach – except for the physicians, who expected both treatment approaches to be equally effective.ConclusionThere is an urgent need to clarify, under which circumstances and how patient expectations can be altered among individuals suffering from CLBP. Our results appear to encourage the implementation of multimodal and psychological pain management approaches across various settings. We invite clinicians to reflect whether their own expectations are in line with the recommendations in international treatment guidelines.

Treatment expectations seem to affect bowel health when using acupuncture during radiotherapy for cancer: Secondary outcomes from a clinical randomized sham-controlled trial

ObjectiveTo investigate if frequent stools (“diarrhoea”), infrequent stools (“constipation”), capacity in daily activities and Quality of Life (QoL) differed between patients treated with verum or sham acupuncture, and if patients with more positive treatment expectations differed regarding frequent stools and infrequent stools from patients with less positive treatment expectations. MethodsIn this randomized sham controlled trial, 200 patients received verum traditional penetrating acupuncture or sham acupuncture using a telescopic non-penetrating sham-needle 2–3 times a week during abdominal-pelvic radiotherapy (12 needling sessions during median 5 radiotherapy weeks). The patients registered stool frequency once a week, and registered capacity in daily activities and QoL at the start and end of radiotherapy, and at a one-month follow-up. ResultsIn the verum acupuncture group, 29 of 96 answering patients (30 %) experienced frequent stools and 7 (7 %) experienced infrequent stools at least one week of radiotherapy. In the sham acupuncture group, 21 of 97 (22 %) experienced frequent stools (p = 0.175) and 10 (10 %) experienced infrequent stools (p = 0.613). Patients with low treatment expectancy were more likely than other patients to experience frequent stools (60 % versus 26 %, p = 0.014) but not to experience infrequent stools (25 % versus 12 %, p = 0.334). ConclusionPenetrating acupuncture was not effective for frequent stools or for infrequent stools and did not improve capacity in daily activities or QoL in patients undergoing pelvic-abdominal irradiation for cancer more than non-penetrating acupuncture. Since patients with low acupuncture treatment expectations were more likely to experience frequent stools compared to other patients, non-specific treatment effects warrant further studies.

A moderately extended time interval between hCG administration and oocyte retrieval is good for most patients with oocyte retrieval scheduled on the same day: a retrospective cohort study

Evidence is limited regarding the time intervals between human chorionic gonadotropin (hCG) administration and oocyte retrieval in controlled ovarian hyperstimulation cycles, and it is difficult to determine proper schedules to optimise outcomes for patients undergoing oocyte retrieval on the same day. We aimed to identify correlations between factors pertaining to treatment outcomes and time intervals to facilitate working schedules of ART centres. Our study included 2509 patients who underwent ICSI cycles. Based on different time intervals between hCG administration and oocyte retrieval, all cycles were divided into four groups: group 1 (34.00–35.99 hours), group 2 (36.00–36.99 hours), group 3 (37.00–37.99 hours) and group 4 (38.00–39.32 hours). Female age, basal FSH level, Gn starting stimulation dosage and total Gn dosage of group 1 were significantly higher than those of other groups. E2 level on hCG day and number of follicles aspirated were significantly higher in group 4 than in the other groups. Number of oocytes retrieved, oocyte retrieval rate, cleavage rate and number of usable embryos were positively correlated with the time interval, even after adjusting for female age, basal FSH level, E2 on hCG day and number of follicles aspirated. A fixed hCG administration time matching arranged oocyte retrieval is good enough for most patients to achieve maximal treatment outcomes. For patients with lower treatment expectations (expected no. of oocyte retrieval ≤3), moderately delayed oocyte retrieval would be more appropriate. Impact Statement What is already known on this subject? The time interval between hCG administration and OPU during COH is essential for ART treatment outcomes, but different intervals were reported in previous studies. What the results of this study add? Fixed hCG administration time matching arranged OPU is good enough for most patients to achieve maximal outcomes. For patients with lower treatment expectations (expected no. of oocyte retrieval ≤3), moderately delayed oocyte retrieval would be required. What the implications are of these findings for clinical practice and/or further research? We studied whether the oocytes and pregnancy outcomes changed along with extended time intervals, and there is no need to adhere to an exact interval for every patient. Therefore, it would help clinicians develop more reasonable time schedules for fertility centres and patients undergoing oocyte recovery on the same day.

Therapist Effects on and Predictors of Non-Consensual Dropout in Psychotherapy.

Whereas therapist effects on outcome have been a research topic for several years, the influence of therapists on premature treatment termination (dropout) has hardly been investigated. Since dropout is common during psychological treatment, and its occurrence has important implications for both the individual patient and the healthcare system, it is important to identify the factors associated with it. Participants included 707 patients in outpatient psychotherapy treated by 66 therapists. Multilevel logistic regression models for dichotomous data were used to estimate the impact of therapists on patient dropout. Additionally, sociodemographic variables, symptoms, personality style and treatment expectations were investigated as potential predictors. It was found that 5.7% of variance in dropout could be attributed to therapists. The therapist's effect remained significant after controlling for patient's initial impairment. Furthermore, initial impairment was a predictor of premature termination. Other significant predictors of dropout on a patient level were male sex, lower education status, more histrionic and less compulsive personality style and negative treatment expectations. The findings indicate that differences between therapists influence the likelihood of dropout in outpatient psychotherapy. Further research should focus on variables, which have the potential to explain these inter-individual differences between therapists (e.g., therapist's experience or self-efficacy). Copyright © 2016 John Wiley & Sons, Ltd. There are substantial differences between therapists concerning their average dropout rates. At the patient level, higher initial impairment, male sex, lower education, less compulsive personality style, more histrionic personality style and low treatment expectations seem to be risk factors of non-consensual treatment termination. Psychometric feedback during the course of treatment should be used to identify patients who are at risk for dropout.

If I am not for myself, who is for me? The experiences of older migrant home care recipients during their hospitalization

Objective: Hospitalization is a major risk for older adults; therefore, it is crucial to provide the appropriate treatment during hospitalization. This study examined hospitalized older adults’ perceptions regarding three groups of treatment providers: nursing staff, family members, migrant home care workers.Method: Qualitative interviews were conducted with 17 hospitalized older adults. Data were gathered by in-depth interviews. Content analysis included open coding, axial coding and integration of the main findings using constant comparisons.Results: Three themes emerged: (1) ‘What is my worth?’ This theme was focused on the participants’ perceptions of themselves as helpless and dependent on others. (2) ‘What would I do without them?’ This theme referred to the perception of the migrant home care workers and nursing staff as essential. It meant immense gratitude, but also a sense of dependency on paid caregivers. (3) ‘They have their own busy life.’ This theme concerned participants’ low treatment expectations from their family members due to their perception of their family members as having multiple obligations.Conclusion: Hospitalized older adults prefer to turn to paid caregivers rather than to their families. Findings are discussed in light of the tension between formal and informal care in countries that are transitioning from traditional family values to modern values, placing the care of older adults by paid caregivers.

Pain in patients attending outpatient rehabilitation: results of a pilot study

The aim of the study was to investigate pain occurrence, characteristics and correlations in an outpatient rehabilitation setting. This was an observational pilot study. The setting was an outpatient rehabilitation facility. The subjects included all patients attending physiotherapy in the week 25th to 29th September 2010 and the interventions were made using self-administered questionnaire. Ongoing pain was assessed by a yes-no question, pain intensity by a numeric rating scale (NRS) ranging 0-10. Pain-related medication was investigated, along with pain characteristics, patient treatment expectations, life satisfaction, and catastrophism. Of the 201 patients, 12 were excluded and 189 enrolled (age 63.6 ± 15.6; 70.4% women). Pain (mean NRS = 5.6 ± 2.4) was reported by 60.9% patients (66% orthopedic and 40% neurological). In 87.8% cases, pain was chronic (>6 months). According to patients reporting pain, the main objectives of treatment were both pain relief and functional recovery for 51%; pain relief for 24.9%; functional recovery for 22.8%. Low treatment expectations were reported by 15.3% patients; catastrophism by 40.7%; 28.6% patients were on pain medication: use of drugs was related to age (p = 0.005), pain intensity (p = 0.009) and catastrophism (p = 0.0003). In a multivariate analysis, pain was independently correlated with an orthopedic versus neurological diagnosis (p = 0.000), and with reduced treatment expectations (p = 0.020), while independent of age (p = 0.74) gender (p = 0.22), and catastrophism (0.17). A high prevalence of pain was observed in outpatients undergoing rehabilitation. Pain was chronic in most cases. Pain relief was the most desired treatment outcome by patients reporting pain. Pain complaint was independently correlated to orthopedic vs neurological diagnosis and to reduced treatment expectations.

A Treatment-Refractory Case of Social Anxiety Disorder: Lessons Learned From a Failed Course of Cognitive-Behavioral Therapy

Over the past 25 years researchers have made enormous strides in the implementation of cognitive-behavioral therapy (CBT) for social anxiety disorder (SAD), although considerable work remains to be done. The present paper discusses a treatment refractory case seen in our clinic. The young man presented numerous interrelated obstacles, such as low treatment expectations, poor homework compliance, and comorbid depression and alcohol dependence. We highlight the challenges presented by this complex presentation, as well as issues that arose over the course of treatment. We then elaborate on techniques that could have improved his outcome. The promise of motivational interviewing and behavioral activation techniques for these complex clients is discussed. Future research and treatment directions for refractory cases are considered.

The Psychosocial Treatment Expectations Questionnaire (PTEQ) for Alcohol Problems

High dropout rates from treatment for alcohol-related problems are a problem for treatment delivery. Outcome expectations of treatment attendance are motivational aspects of treatment adherence. Since no method to put such expectations into operation has been found, we developed the Psychosocial Treatment Expectations Questionnaire (PTEQ) to assess the expectations of people receiving such psychosocial treatments. PTEQ development and early validation relied on data from 151 clients. A two-dimensional questionnaire assessing treatment purpose and atmosphere, and impact on daily life was developed, showing acceptable levels of reliability (α = 0.85 for the overall score, and 0.80 and 0.77 for the two scales, respectively). The PTEQ overall score significantly detected differences in expectations between those who remained in, and those who dropped out of treatment. On average, the dropouts had lower treatment expectations than those who remained in treatment. Validity for populations other than alcohol misusers and for treatments delivered exclusively through individual sessions, needs to be further examined.

Psychosocial treatment refusal in personality disorder: a comparative study

AbstractThere is a paucity of research concerning the identification of features implicated in treatment refusal by personality disorder. This study aims to identify clinical factors that may affect treatment uptake to a specialist psychosocial programme for personality disorder. Following a lengthy assessment, 39 patients (out of a total of 60 referrals) were offered entry to the programme. Fourteen patients who did not take up the offer of treatment and 25 patients who started the programme are compared on a number of demographic, diagnostic and clinical variables, including severity of presentation and subjective experience of the assessment process. The results show that, relative to non‐refusers, refusers were significantly younger, single, had a higher frequency of borderline personality disorder (BPD), experienced a less satisfactory relationship with the assessing clinician and had lower treatment expectations. Several dimensions measuring severity of presentation did not make a significant contribution to treatment uptake. A logistic regression analysis showed that assessment‐related variables total score and BPD were significant predictors of treatment refusal. The low sample size and the specialist nature of the service are important limitations with regard to the generalizability of the findings. Copyright © 2010 John Wiley & Sons, Ltd.

Predictors of Poor Outcome in Patients With Neck Pain Treated by Physical Therapy

This study evaluated predictors of poor outcome in patients with neck pain treated by physical therapy, and sought to compare the findings of empirical data with physical therapy practitioners' subjective perceptions about predictors of outcome. This study was a secondary analysis of data from a randomized controlled trial assessing physical therapy treatments for neck pain (n=346). A baseline questionnaire provided data on a number of potential risk factors of poor outcome at follow-up. Follow-up was conducted at 6 weeks and 6 months by postal questionnaire with outcome defined separately by perceived (global) change and minimal clinically important differences in the Northwick Park Neck Pain Questionnaire (MCID-NPQ). Therapists' perceptions of predictors for treatment outcome were captured using a separate questionnaire, and the ratings compared with ranks derived from the 6-month trial data. Baseline characteristics accounted for a much greater proportion of explained variance for global change compared with MCID-NPQ at 6 months. Independent biopsychosocial characteristics included manual social class, catastrophizing, anxiety and depression, low treatment expectations, severity of baseline neck pain/disability, presence of comorbid back pain, and older age. Physical therapist ranks correlated highly with those derived from the trial data. Significant predictors of outcome were identified, particularly at 6 months, including psychosocial, functional, and demographic indicators. Our findings suggest that physical therapists are collectively aware of the relative importance of physical and psychosocial factors in predicting clinical outcome. However, a significant amount of variability in outcomes in our prognostic models remained largely unexplained, indicating that we need to explore further underlying factors to inform clinical decision-making.

Patient Expectations and Therapeutic Alliance as Predictors of Outcome in Group Cognitive-Behavioral Therapy for Insomnia

Despite growing evidence for the efficacy of cognitive-behavioral therapy for insomnia (CBT–I), few data exist on the relation between process and outcome for this treatment. Drawing on interpersonal theory and the broader psychotherapy literature, this study examined the contribution of patient expectations and the therapeutic alliance to outcomes in group CBT–I. For patients with low early treatment expectations for improvement, those perceiving the therapist as higher in affiliation had greater reduction in sleep problems. Perceiving the therapist as critically confrontive was generally associated with less treatment satisfaction, and particularly so for those individuals who came to treatment with high expectations for improvement. Critical confrontation also differentiated dropouts from continuers, with dropouts experiencing their therapist as more critically confrontive.

Managing asthma in the real world.

Asthma treatment is suboptimal in many patients, with impacts on morbidity and mortality, healthcare resource utilisation and patients' quality of life. The reasons for this include the inherent variability of asthma and the unpredictability of exacerbations, which can range from mild to fatal. In addition, asthma can be difficult to diagnose, particularly in the very young and old. Although treatment guidelines are widely available and well publicised, surveys have identified a significant gap between treatment aims and current levels of asthma control. Patient adherence to inhaled corticosteroids is poor, and many patients rely on short-acting beta2-agonists. The reasons for this are complex but are believed to include poor perception by patients of their asthma severity, concerns about the safety and efficacy of medication and low treatment expectations. Patients appear to be unaware of the extent to which airway inflammation can be controlled and are therefore satisfied with poor asthma control, accepting a high level of symptoms. Increasing patient understanding of asthma and its treatment, allowing patients greater involvement in treatment decisions, increasing the role of asthma nurses and improved communication between physicians and patients may improve outcomes in patients with asthma.