Psychotherapy In Primary Care Research Articles

Personalised psychotherapy in primary care: evaluation of data-driven treatment allocation to cognitive-behavioural therapy versus counselling for depression.

Various effective psychotherapies exist for the treatment of depression; however, only approximately half of patients recover after treatment. In efforts to improve clinical outcomes, research has focused on personalised psychotherapy - an attempt to match patients to treatments they are most likely to respond to. The present research aimed to evaluate the benefit of a data-driven model to support clinical decision-making in differential treatment allocation to cognitive-behavioural therapy versus counselling for depression. The present analysis used electronic healthcare records from primary care psychological therapy services for patients receiving cognitive-behavioural therapy (n = 14 544) and counselling for depression (n = 4725). A linear regression with baseline sociodemographic and clinical characteristics was used to differentially predict post-treatment Patient Health Questionnaire (PHQ-9) scores between the two treatments. The benefit of differential prescription was evaluated in a held-out validation sample. On average, patients who received their model-indicated optimal treatment saw a greater improvement (by 1.78 PHQ-9 points). This translated into 4-10% more patients achieving clinically meaningful changes. However, for individual patients, the estimated differences in benefits of treatments were small and rarely met the threshold for minimal clinically important differences. Precision prescription of psychotherapy based on sociodemographic and clinical characteristics is unlikely to produce large benefits for individual patients. However, the benefits may be meaningful from an aggregate public health perspective when applied at scale.

Study What You Do: Developing a Psychotherapy Tracking Database in a Large-Scale Integrated Behavioral Health Service.

Many individuals with behavioral health challenges receive services in primary care, and integrated behavioral health (IBH) programs can help increase access to evidence-based interventions. IBH programs can benefit substantially from integrating standardized tracking databases that allow for the implementation of measurement-based care to evaluate patient-, clinician-, and practice-level outcomes. We describe the development and integration of Mayo Clinic's pediatric and adult primary care psychotherapy tracking database. IBH practice leaders directed the development of a large psychotherapy tracking database that continuously populates from Mayo Clinic's electronic health record system. The database captures numerous patient variables including demographics, behavioral health and substance use issues, psychotherapy principles used, and self-reported symptoms. We retrieved current data for patients empaneled in Mayo Clinic's pediatric and adult primary care psychotherapy programs from June 2014 to June 2022. The tracking database contained data for 16,923 adult patients and 6,298 pediatric patients. The mean age of adult patients was 43.2 years (SD 18.3), 88.1% were non-Latine White, and 66.7% identified as female. The mean age of pediatric patients was 11.6 years (SD 4.2), 82.5% were non-Latine White, and 56.9% identified as female. We provide examples of practical applications of the database across clinical, educational, research, and administrative domains. The development and integration of a psychotherapy tracking database supports clinician communication, examination of patient outcomes, practice quality improvement efforts, and clinically relevant research. Our description of Mayo Clinic's IBH database may serve as a model for other IBH practices.

Implementation of Group Interpersonal Psychotherapy in primary care.

ABSTRACTOBJECTIVE To show the implementation process of IPT-G in primary care, including facilitating and obstructing factors, implementation strategies, and training and supervision of primary care professionals.METHODS Quantitative (cross-sectional and longitudinal) analysis of pre and post-knowledge tests; qualitative analyses of the training courses; patient recruitment; conduction of IPT-G sessions; supervision of IPT-G therapists; application of a semi-structured questionnaire to assess, investigate, and develop strategies against the identified barriers.RESULTS About 120 clinicians answered the pre-test; 84 completed the post-test. Pre- and post-test scores of IPT-G knowledge were significantly different. Twenty initially trained clinicians completed additional supervision in IPT-G. Qualitative analysis identified twelve barriers and six facilitators to IPT-G implementation in individual, organizational, and systemic contexts.CONCLUSIONS Implementation of IPT-G in primary care is a complex process with several steps. In the first step, health professionals were successfully trained in IPT-G. However, subsequent steps were more complex. Therefore, careful planning of IPT-G implementation is essential to maximize the success of this innovation.

Psychotherapy in a resource-constrained setting: Understanding context for adapting and integrating a brief psychological intervention into primary care.

Low- and middle-income countries have few mental health professionals, and efforts to increase access to treatment are a global priority. A key gap is the lack of integration of psychotherapy interventions as a part of accessible evidence-based care. Current recommendations suggest that the integration of mental health treatments, including psychotherapy, into existing primary care pathways may serve as a means to address this disparity. Understanding the cultural and contextual factors that affect this process is a critical step in identifying necessary adaptations. The aim of this qualitative study was to identify contextual factors associated with integrating psychotherapy in primary care in a predominantly rural district in south-central Ethiopia. Purposive sampling was used to recruit 48 mental health service users, caregivers, health care providers, and community leaders. Semistructured interviews were conducted, recorded, and transcribed in Amharic and translated into English. Although challenges (e.g., stigma, job strain, lack of belief in formal treatments) are present, other existing strengths (e.g., openness to seeking treatment, increasing knowledge about mental health treatment, familiarity with practices similar to therapy) support subsequent psychotherapy adaptation and implementation. These findings suggest possible mechanisms to improve delivery and adaptation in the effort to lower the existing global treatment gap. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

A Turkish-Speaking Community Program in A Primary Care Psychotherapy Setting: How to Support and Engage A Complex Patient Population

ABSTRACT This paper presents a description of a multigroup-based psychotherapy program for Turkish-speaking individuals provided by an innovative primary care mental health service in London. As of 2021, the project offers two types of therapy: a year-long horticultural group, which is a blend between talking therapy and gardening, and a 20-week psychotherapy group. Both were designed to engage the particularly complex Turkish-speaking patient population in the London Borough of Hackney. The project is grounded in group psychotherapy and borrows elements from different theoretical orientations and therapeutic modalities including community psychology, group analytic therapy, horticultural therapy, attachment theory, and dynamic therapies. Here, we present how the program was created and developed and the specifics of the groups, together with the main themes and dynamics that emerged in the therapeutic process. The program evaluation and outcomes are illustrated by several clinical case vignettes throughout the paper.

A national evaluation of the Irish public health counselling in primary care service\u2013 examination of initial effectiveness data

BackgroundThe Counselling in Primary Care service (CIPC) is the first and only nationally available public counselling service in the Republic of Ireland. This study provides initial data for the effectiveness of short-term psychotherapy delivered in a primary care setting in Ireland for the first time.MethodA practice-based observational research approach was employed to examine outcome data from 2806 clients receiving therapy from 130 therapists spread over 150 primary care locations throughout Ireland. Pre-post outcomes were assessed using the CORE-OM and reliable and clinically significant change proportions. Binary logistic regression examined the effect of pre therapy symptom severity on the log odds of recovering. Six and 12 month follow up data from a subsample of 276 clients were also analysed using growth curve analysis.ResultsOf 14,156 referred clients, 5356 presented for assessment and 52.3% (N = 2806) consented to participate. Between assessment and post-therapy a large reduction in severity of symptoms was observed- Cohen’s d = 0.98. Furthermore, 47% of clients achieved recovery,a further 15.5% reliably improved, 2.7% reliably deteriorated and34.7% showed no reliable improvement. Higher initial severity was associated with less chance of recovering at post-therapy. Significant gains were maintained between assessment and12 months after therapy- Cohen’s d = 0.50.ConclusionsOutcomes for clients in the CIPC service compared favourably with large scale counselling and psychotherapy services in jurisdictions in the U.K., the U.S.A., Norway and Sweden. This study expands the international primary care psychotherapy research base to include the entire Republic of Ireland jurisdiction.

Activité des psychologues libéraux : modalités d’exercice, orientations et outils psychothérapeutiques

IntroductionDespite their wide differences in practices, psychologists are among the qualified professionals able to provide psychotherapy in primary care. Along with psychiatrists, they are (after GPs) the professionals most consulted for psychological disorders, and their demographics mean they are readily accessible. They are the first actors that patients would choose to see for psychotherapy in France. Patients consider that psychologists have more time than their GP and are better trained to handle their psychological problems. While the French National Authority for Health has just issued inventory and recommendations to improve coordination between the various care providers in the management of adult patients with mental disorders, published data on the activity of psychologists in France remain scarce. ObjectiveTo describe the professional activity of private psychologists in the Midi-Pyrénées region of southwest France (demography, work-related information, professional environment, number of patients, fees, psychotherapeutic tools used and practice specificities, patients’ referrals and reasons for consultations, interactions with GPs). MethodsThis was a cross-sectional descriptive study. A self-administered questionnaire, based on relevant elements from a narrative review of the literature, was sent by post in February 2017 to all 1128 private psychologists of the Midi-Pyrénées region of southwest France. Questionnaire replies were collected by post between February and April, 2017, anonymously. A descriptive analysis was carried out. ResultsThe response rate was 38% (n=434 out of 1128). Among the 434 respondents, psychologists used on average between 3 and 4 psychotherapeutic tools, among which their main approach was: psychoanalysis and psychodynamic therapies for 42.2% of psychologists, cognitive-behavioural therapies (16.8%), humanist therapies (10.1%), integrative or holistic therapies (9.7%), EMDR (6.7%), systemic therapies (4.6%), hypnosis (2.3%), other (7.6%). Psychologists received an average of 17 patients per week and the average fee for a session was 44 (±8) euros; 67% (n=289) of the psychologists provided care for children, 71% (n=309) for adolescents, 38% (n=163) for couples, and 23% (n=99) for groups. The most frequent reasons for a consultation with a psychologist were depression, anxiety or stress disorders, and their social and professional impacts. 62% (n=267) of psychologists were in a group setting in at least one of their practice; 18% (n=80) worked in group practice with one or more physicians. Psychologists reported poor professional interactions/communication and exchange of information with GPs. Out of 10 new patients, 2 were referred by a GP, 2 by another health care professional, and 6 came of their own initiative. Our study sample was comparable to the reference population of psychologists of the same region regarding sex (P=0.61), age group (P=0.39) and type of activity (P=0.07). ConclusionA large sociodemographically representative sample of 434 psychologists is the main strength of this study; limitations are a possible selection bias and a probable influence on the responses of the university's regional anchoring of the psychoanalytical approach. We did not find any publication describing the modalities of the psychologists’ professional activities. Psychologists are a large and accessible resource of mental health professionals, despite the diversity of their training and practices; they could provide better access to and use of psychotherapy for the benefit of patients, and better collaborative practice in mental health care. This reflection and the framework of a collaboration to be defined are particularly justified in the context of current medical demographics, the appetite for pluriprofessional work, and the experiments and research work abroad that encourage these proposals.

Measurement equivalence of the Four-Dimensional Symptom Questionnaire (4DSQ) in adolescents and emerging adults.

The Four-Dimensional Symptom Questionnaire (4DSQ) is a self-report instrument measuring distress, depression, anxiety and somatization. The questionnaire has been developed and validated in adult samples. It is unknown whether adolescents and emerging adults respond to the 4DSQ items in the same way as adults do. The objective of the study was to examine measurement equivalence of the 4DSQ across adolescents, emerging adults and adults. 4DSQ data were collected in a primary care psychotherapy practice (N = 1349). Measurement equivalence was assessed using differential item and test functioning (DIF and DTF) analysis in an item response theory framework. DIF was compared across the following groups: adolescents (age 10–17), emerging adults (age 18–25), and adults (age 26–40). DIF was found in 9 items (out of 50) across adolescents and adults, and in 4 items across emerging adults and adults. The item with the largest DIF was ‘difficulty getting to sleep’, which was less severe for adolescents compared to adults. A likely explanation is that adolescents have a high base rate for problems with sleep initiation. The effect of DIF on the scale scores (DTF) was negligible. Adolescents and emerging adults score some 4DSQ items differently compared to adults but this had practically no effect on 4DSQ scale scores. 4DSQ scale scores from adolescents and emerging adults can be interpreted in the same way as 4DSQ scores from adults.

A relational perspective on the association between working alliance and treatment outcome

Objective: Evidence is inconclusive on whether variability in alliance ratings within or between therapists is a better predictor of treatment outcome. The objective of the present study was to explore between and within patient and therapist variability in alliance ratings, reciprocity among them, and their significance for treatment outcome. Method: A large primary care psychotherapy sample was used. Patient and therapist ratings of the working alliance at session three and patient ratings of psychological distress pre–post were used for analyses. A one-with-many analytical design was used in order to address problems associated with nonindependence. Results: Within-therapist variation in alliance ratings accounted for larger shares of the total variance than between-therapist variation in both therapist and patient ratings. Associations between averaged patient and therapist ratings of the alliance for the individual therapists and their average treatment outcome were weak but the associations between specific alliance ratings and treatment outcome within therapies were strong. Conclusions: The results indicated a substantial dyadic reciprocity in alliance ratings. Within-therapist variation in alliance was a better predictor of treatment outcome than between-therapist variation in alliance ratings.

Factors That Predict the Use of Psychotropics Among Children and Adolescents With PTSD: Evidence From Private Insurance Claims.

This study aimed to determine which characteristics of youths with posttraumatic stress disorder (PTSD) were associated with receiving prescriptions for antidepressants, antipsychotics, or benzodiazepines. A 2011-2012 retrospective cohort of children and adolescents with a new episode of PTSD was extracted from medical and pharmacy claims from a nationally representative sample of privately insured persons. Multivariate logistic regression assessed attributes (demographic characteristics, mental and general medical comorbidities, insurance arrangements, specialty type, and geographic location) associated with utilization of antidepressants, antipsychotics, and benzodiazepines. Among 7,726 youths with a new episode of PTSD in 2012, just less than 60% received psychotherapy alone, about 6% received pharmacotherapy, and about 35% received neither psychotherapy nor pharmacotherapy. Among utilizers of medications, 71.3% used antidepressants and 21.6% used antipsychotics. Youths prescribed medication tended to be older and have more general medical and mental comorbidities. Provider specialty, capitated insurance arrangements, and more comorbidities predicted being prescribed antidepressants. History of hospitalization, noncapitated insurance arrangements, nonuse of psychotherapy, and more comorbidities predicted being prescribed antipsychotics. Antidepressants and antipsychotics were more likely to be used in the South. Only three-fifths of youths with PTSD received first-line treatment (psychotherapy). More than one in 20 received pharmacotherapy, which appeared to be associated with the most severe and complex presentations. More than one-third of youths with PTSD received neither therapy nor medication, signaling compromised quality of care. Future research should confirm the factors associated with pharmacotherapy prescription and explore ways to increase the use of psychotherapy in primary care.

Initial outcomes of a real-world multi-site primary care psychotherapy program.

Although anxiety, mood, and adjustment disorders are commonly treated in primary care, little evidence exists regarding psychotherapy outcomes within this setting. The primary objective of this study was to describe outcomes of a large-scale primary care psychotherapy program. Patients (N = 2772) participated in cognitive behavioral therapy (CBT) as part of a multi-site primary care program. A tracking system was utilized to collect data on demographics, diagnoses, course of care, anxiety and depressive symptoms, and frequencies of psychotherapy principles used over the course of primary care CBT. Anxiety disorders were most frequent, often comorbid with depression. Over two-thirds of the sample participated in at least one CBT session. Case formulation, cognitive interventions, exposure, and behavioral activation were frequently utilized approaches. Significant improvements on the GAD-7 and PHQ-9 occurred for all groups, yielding medium effect sizes (d = 0.50-0.68). Rates of reliable change (48-80%), response (35-53%), and remission (21-36%) were noted for those scoring in the moderate range of severity. Patients suffering from anxiety, depression, and adjustment disorders can be effectively treated in primary care with CBT. Future efforts are needed to match patient characteristics with the types and timing of therapy interventions to improve clinical and functional outcomes.

Evidence-Based Psychotherapy in Primary Care.

The functional and financial effects of untreated psychiatric disorders within primary care have led to the development of novel service delivery models to improve access to high-quality, evidence-based mental health treatments. Cognitive-behavioral therapy (CBT) is an efficacious and effective psychotherapeutic approach for treating a broad range of mental health conditions. CBT is a practical, skill-building approach that emphasizes self-efficacy and self-management of symptoms while working toward defined and measurable treatment goals. Although significant barriers to the full dissemination of CBT remain, collaborative care and integrated behavioral health programs embedded within primary care clinics can enhance treatment outcomes by using CBT. Identifying core CBT principles used in the treatment of anxiety (e.g., exposure), depression (e.g., behavioral activation), and insomnia (e.g., stimulus control) is an important step toward improving the quality of care for these conditions. High-impact, low-intensity CBT programs hold promise in improving access to this evidence-based treatment across a broader population.

Effectiveness of Short-Term Dynamic Group Psychotherapy in Primary Care for Patients with Depressive Symptoms.

An open prospective controlled study was designed to compare the efficacy of short‐term dynamic group psychotherapy with the standard treatment in patients with depressive symptoms attended in the primary care setting. A total of 115 patients with depressive symptoms were assigned to receive psychotherapy (75 min) over 9 months (37 to 39 sessions) (n = 70) or the standard care (n = 45). Outcome measures were the differences between baseline and post‐treatment in the 17‐item Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HAM‐A) and the Short‐Form Health Survey (SF‐12) questionnaire in the two study groups. At the end of dynamic group psychotherapy, statistically significant improvements in the mean scores of all questionnaires were observed, whereas in control patients, significant improvements were only observed in the HDRS‐17 scale and in the Mental Component Summary score of the SF‐12. The mean changes after treatment were also higher in the psychotherapy group than in controls in all outcome measures, with statistically significant differences in the mean differences in favour of the psychotherapy group. In summary, implementation of short‐term dynamic group psychotherapy run by experienced psychotherapists for patients with depressive symptoms attended in routine primary care centres is feasible and effective. © 2016 The Authors. Clinical Psychology & Psychotherapy published by John Wiley & Sons Ltd.Key Practitioner Message Short‐term dynamic group psychotherapy was delivered as a non‐pharmacological intervention to improve depressive symptoms.Statistically significant differences as compared with a control group were observed in 17‐item Hamilton Depression Rating Scale (HDRS), Hamilton Anxiety Rating Scale (HAM‐A) and the Short‐Form Health Survey (SF‐12) questionnaire.Implementation of short‐term dynamic group psychotherapy run by experienced psychotherapists for patients with depressive symptoms attended in routine primary care centres is feasible and effective.

Alliance ruptures and repairs in psychotherapy in primary care

Objective: The association between alliance level and outcome in psychotherapy has been extensively studied. One way to expand this knowledge is to study alliance patterns. The main aims of this study were to examine how frequent alliance patterns with ruptures or rupture-repair episodes were in a naturalistic sample of psychotherapies in primary care, and if three alliance patterns (a Rupture pattern, a Repair pattern, and a No Rupture pattern) were differentially associated with treatment outcome. Method: The psychotherapies (N = 605) included a wide range of different treatment orientations and patient diagnoses. Alliance patterns were studied at session-to-session level, using patient-rated alliance scores. Outcome data were analyzed using longitudinal multilevel modeling with a slopes-as-outcomes model. Results: The Repair pattern accounted for 14.7% (n = 89) of the treatments, 10.7% (n = 65) exhibited a Rupture pattern, and 74.5% (n = 451) contained no ruptures. The Rupture pattern was associated with inferior treatment outcomes. The Repair pattern was, in longer treatments, associated with better outcomes than the No Rupture pattern. Conclusions: The results support theory about the importance of ruptures in the therapeutic alliance and suggest that identification of alliance ruptures is important in alliance-outcome research, for feedback purposes in clinical practice, and in training of therapists.

Access to Psychotherapy in the Era of Web 2.0 – New Media, Old Inequalities? / Zugang zur Psychotherapie in der Ära des Web 2.0 – Neue Medien, Alte Ungleichheiten?

Abstract Background: Currently, the debate on regional and socio-structurally related treatment gaps in psychotherapeutic care increases the interest in e-mental health interventions such as the Internet-based psychotherapy, online self-help and new approaches for self-empowerment. Thus, health professionals could support informed decision-making by knowing the latest developments. However, if the ‘digital revolution’ fails to reach patients not familiar with Web 2.0, access to psychotherapies is unlikely to improve. Therefore, the objective of this review is to clarify whether online therapies should be recommended as an effective alternative to conventional psychotherapy in primary care. Methods: To investigate the research evidence of online therapies in adults within the last decade (2004-2014), a rapid review of literature was conducted by using electronic databases (i.e. Medline/PubMed, PubMed Central, Cochrane Library) to find systematic reviews, meta-analysis and clinical trials. Furthermore, a hand search in journals and grey literature was undertaken. Results: A search in PubMed for clinical trials on ‘online psychotherapy’ resulted in a total number of 245 publications. So, eight reviews and several clinical trials were chosen. Overall, mostly positive findings on the effectiveness and acceptance of online psychotherapy, primarily in the treatment of depression and anxiety disorders, were identified. Discussion: In sum, Internet-based psychotherapies have been effective in reducing symptoms of mood and anxiety disorders in clinical trials. However, due to the limited range of treatable disorders and non-representative samples (young female college graduates), external validity remains insufficient. Thus, further research is needed to determine if online therapies will be capable of improving access to psychotherapy.

One size does not fit all: Examining heterogeneity and identifying moderators of the alliance-outcome association.

Although the alliance-outcome association is one of the most consistent findings in psychotherapy research, it is also highly heterogeneous. Little is known about the factors explaining this variability, and consequently there is a lack of adequate knowledge about how to utilize this association to improve treatment. The present study had the following objectives: (a) to examine the associations between within- and between-individual variability in alliance and outcome, controlling for previous symptomatic levels; (b) to examine the duration of the alliance-outcome association; and (c) to examine potential moderators of the alliance-outcome association. A total of 547 patients treated in a primary care psychotherapy setting in Chile were randomly assigned to 5 feedback conditions. The alliance-outcome association was analyzed using multilevel models, disentangling changes in alliance within-individuals from alliance between-individuals. Patient and therapist characteristics were examined as potential moderators. Findings suggest that patients who reported a better early alliance also reported a better outcome. Furthermore, patients reporting time-specific improvement in alliance also reported a greater reduction in symptoms. The unique effect of alliance on outcome at one point in time is maintained for a period of 2 weeks. Patients with more severe symptoms and longer treatments benefited more from a good alliance. Therapists identifying themselves as more integrative in their treatment orientation were able to better utilize good alliances for treatment success. Finally, the size of the alliance-outcome association can be manipulated by feedback to therapists.

Paradigms, politics and pragmatics: psychotherapy in primary care in City and Hackney – a new model for the NHS

The City and Hackney Primary Care Psychotherapy Consultation Service is an innovative, public sector service designed to support GPs in meeting the needs of patients with complex psychological/physical health issues throughout the London Boroughs of Hackney and the City. This paper provides an account of how this new model for the National Health Service (NHS) developed in the context of psychotherapy provision within the NHS, within the national and local context in the UK and gives an overview of some the service's key features and how it differs from other services operating in primary and secondary care. A linked paper, in this journal, explores the reality within which the service functions and describes clinical outcomes, health economic data, the modifications to the original model and prospects for the future.

Paradigms, politics and pragmatics: psychotherapy in primary care in City and Hackney – a new model for the NHS

Whilst an earlier paper (Part 1) in this journal describes the historical, political and economic drivers behind the creation of the City and Hackney Primary Care Psychotherapy Consultation Service (PCPCS), this paper (Part 2) focuses on exploring the context within which the service functions. The paper provides an overview of its operational model and is organised into 10 sections. The first section outlines the service's clinical practice, whilst the second addresses the value of GP consultations as a core part of the PCPCS's provision. The third section addresses how the service, as departure from a more ‘pure’ psychoanalytic tradition of providing longer-term therapy, has managed its provision of brief treatments. There is a description of how the service manages its team of multi-disciplinary clinicians and their work in a variety of micro-cultures, conveying some of the challenges faced by the service and the team since its inception. Thereafter, the quantitative and qualitative evidence for the service's clinical and cost effectiveness is assessed, including outcome results and findings from a health economic evaluation. To illustrate some of the service's work in practice, some disguised clinical vignettes are presented. The paper also summarises the service's recent clinical innovations, as well as its contribution to the field of research, audit and training. Finally, the way forward for the service is considered in the context of current and emerging trends in psychological provision in primary care.

Short-Term Existential Psychotherapy in Primary Care

Existential Experimentation is a short-term integrative psychological therapy intervention. It is based on the recent government initiative focusing on recovery and thus integrates central ideas from existential theory, utilizes a phenomenological methodology, and applies considerations of human potential from humanistic psychology to support recovery and aim for well-being. This work explores the outcomes of a systematic application of this approach to working-age adults referred for a psychological intervention for depression and/or anxiety in terms of (a) reducing depression and/or anxiety symptomatology, (b) reducing the level of perceived psychological distress, and (c) reducing the need for psychological services. The sample consisted of working-age adults referred to primary care by their general practitioner. The patients’ relevant symptomatology was assessed at every contact using Patient Health Questionnaire-9 and Generalized Anxiety Disorder–7, and the level of psychological distress was monitored using CORE-OM. Pre–post effect sizes were evaluated using Cohen’s d. Patients’ access to psychological services was monitored at 6 and 12 months after discharge. The large effect sizes expressed show that this therapeutic approach operates effectively in reducing the symptomatology of depression and/or anxiety, while promoting significantly low relapse and dropout rates.

Heterogeneity in patient-reported outcomes following low-intensity mental health interventions: a multilevel analysis.

BackgroundVariability in patient-reported outcomes of psychological treatments has been partly attributed to therapists – a phenomenon commonly known as therapist effects. Meta-analytic reviews reveal wide variation in therapist-attributable variability in psychotherapy outcomes, with most studies reporting therapist effects in the region of 5% to 10% and some finding minimal to no therapist effects. However, all except one study to date have been conducted in high-intensity or mixed intervention groups; therefore, there is scarcity of evidence on therapist effects in brief low-intensity psychological interventions.ObjectiveTo examine therapist effects in low-intensity interventions for depression and anxiety in a naturalistic setting.Data and AnalysisSession-by-session data on patient-reported outcome measures were available for a cohort of 1,376 primary care psychotherapy patients treated by 38 therapists. Outcome measures included PHQ-9 (sensitive to depression) and GAD-7 (sensitive to general anxiety disorder) measures. Three-level hierarchical linear modelling was employed to estimate therapist-attributable proportion of variance in clinical outcomes. Therapist effects were evaluated using the intra-cluster correlation coefficient (ICC) and Bayesian empirical predictions of therapist random effects. Three sensitivity analyses were conducted: 1) using both treatment completers and non-completers; 2) a sub-sample of cases with baseline scores above the conventional clinical thresholds for PHQ-9 and GAD-7; and 3) a two-level model (using patient-level pre- and post-treatment scores nested within therapists).ResultsThe ICC estimates for all outcome measures were very small, ranging between 0% and 1.3%, although most were statistically significant. The Bayesian empirical predictions showed that therapist random effects were not statistically significantly different from each other. Between patient variability explained most of the variance in outcomes.ConclusionConsistent with the only other study to date in low intensity interventions, evidence was found to suggest minimal to no therapist effects in patient-reported outcomes. This draws attention to the more prominent source of variability which is found at the between-patient level.