Time-limited Treatments Research Articles

Extending Child and Adolescent Psychoanalysis to Special Populations: Regulation-Focused Psychotherapy for Children (RFP-C) and Transference-Focused Psychotherapy for Adolescents (TFP-A)

ABSTRACT In the last decade clinicians and researchers have developed Regulation-Focused Psychotherapy for Children (RFP-C) and Transference-Focused Psychotherapy for Adolescents (TFP-A), two manualized, evidence-based, time-limited treatments derived from child and adolescent psychoanalysis. These therapies are designed to treat special, complex patient populations including children with severe externalizing behaviors and adolescents with nascent or actual severe personality disorders, youth thought to be beyond the reach of traditional psychoanalysis or thought to benefit from modifications of standard psychoanalytic technique to maximize the effectiveness and efficiency of psychoanalytic treatment. Despite the effectiveness of psychoanalysis, manualized cognitive-behavioral approaches like parent management training and dialectical behavior therapy are currently the most popular treatments for these patients, partially because there are too few child and adolescent psychoanalysts to meet demand. The authors describe RFP-C and TFP-A and illustrate their effectiveness using clinical material. The authors advocate for wider acceptance and utilization of these two broadly teachable manualized treatments by the psychoanalytic and psychotherapeutic communities to extend the reach of psychoanalysis to severely suffering patients who can reap the unique benefits of these essentially psychoanalytic approaches.

A Scoping Review of Potential Biological Mechanisms and Predictors of Interpersonal Psychotherapy

Social dysfunction plays a critical role in the development and maintenance of depression in both adolescents and adults. Interpersonal psychotherapy (IPT) and interpersonal psychotherapy for depressed adolescents (IPT-A) are effective, evidence-based, and time-limited treatments for depression that aim to mitigate depressive symptoms by strengthening an individual’s interpersonal relationships and skills. Though the efficacy of IPT/IPT-A has been well established, we are just beginning to know how biological systems are implicated in its success. In this scoping review, we examine the extant literature on biological mechanisms and predictors of IPT/IPT-A treatment efficacy. Overall, seven studies were identified that consider biological processes in the context of evaluating IPT/IPTA, and the studies that were conducted are typically preliminary in nature. Notably, there is some evidence showing that the hypothalamic–pituitary–adrenal axis, various frontal and limbic brain regions, and behavioral indexes that represent brain functioning are associated with changes in IPT/IPT-A or predictive of IPT/IPT-A outcomes. We also consider consequences for treatment and future research. The hope is that a better understanding of how and for whom IPT/IPT-A works can optimize the success of the treatment in reducing an individual’s depressive symptoms.

Using Peripheral Blood (PB) Measurable Residual Disease (MRD) Levels to Predict

CONCLUSIONS Time-limited treatments for CLL are under investigation but the optimal target for treatment cessation is not fully clear. Bone marrow (BM) measurable residual disease (MRD) is usually the most sensitive measure but would be too invasive to guide treatment in a routine setting. The iwCLL threshold of BM uMRD4 (<0.01%) has been demonstrated to be a powerful indicator of improved outcomes across multiple different trials and the aim of this analysis is to determine the feasibility of using PB MRD analysis to identify patients who have attained BM uMRD4. FLAIR (ISRCTN01844152) is an open-label, randomised, controlled, phase 3 trial comparing ibrutinib plus rituximab (IR) with fludarabine, cyclophosphamide and rituximab (FCR), subsequently amended to compare ibrutinib plus venetoclax (I+V) and ibrutinib alone (I) with FCR. Paired PB & BM samples were scheduled at: (1) response assessment 9 months after randomization in all arms (n=1086); (2) end of treatment after 72 months in the ibrutinib-containing arms (n=137, most I/I+V participants have not reached this timepoint yet); and (3) confirmation of BM uMRD4 for initiation of planned stopping rules in participants with sustained PB uMRD4 defined as <0.01% PB MRD at 3 timepoints over 6 months (n=188 in the I+V arm). MRD analysis was performed using an ERIC-compliant 8-colour flow cytometry assay targeting acquisition of 2.2 million events (detection limit MRD5/0.001%). As the target could not always be met due to sample/laboratory limitations, stringent uMRD4 assessing 500 thousand leucocytes (detection limit 0.005%) was also evaluated. Table 1 shows the BM vs. PB MRD levels for different treatment arms and timepoints. The greatest discrepancy was observed in participants receiving FCR with a median 0.8log higher disease in the BM vs. PB. Participants receiving ibrutinib monotherapy had similar PB and BM MRD levels while the addition of either rituximab or venetoclax was associated with slightly higher (median <0.1 log) BM vs. PB MRD levels for both IR and I+V arms. The difference did not persist in the IR arm but remained during I+V treatment in some cases, with median >0.59 log higher BM vs. PB MRD levels in 29/182 participants achieving PB uMRD4 but with detectable BM MRD. Table 1 also shows the proportion of cases that attain BM uMRD4 according to different PB MRD thresholds. For participants with rituximab exposure in the past 3 months, BM uMRD4 was attained in 75-88% of participants with PB uMRD5, and only 43-76% of participants with stringent uMRD4. For participants with PB dMRD5 (0.001-0.01% MRD), only 14-52% achieved BM uMRD4. However, participants on I+V with either PB uMRD5 or stringent uMRD4 attained BM uMRD4 in 94-96% of cases. Planned cessation of treatment in the FLAIR trial was guided by sustained PB uMRD4, defined as 3 successive results with <0.01% PB disease over six months with confirmation of BM uMRD4 at the final time point. This strategy in the I+V arm is highly effective in achieving improved progression-free and overall survival compared to FCR [see related abstract]. Sustained PB uMRD4 led to BM assessments in 188 participants of which 173/188 (92%) attained BM uMRD4. High sensitivity PB MRD gave concordant results to BM MRD4 analysis in 91% of participants (172/188), while 9/188 (5%) had PB dMRD5 / BM uMRD4 (7/9 had detectable BM MRD in the range 0.002-0.007% and 2/9 had BM uMRD5/<0.001%) and 7/188 (4%) had PB uMRD5/stringent uMRD4 but with persistent BM dMRD4 (median 0.02% BM MRD, range 0.01-0.055%). PB MRD level correlates closely with BM MRD level but there is lower concordance at the 0.01%/MRD4 threshold after recent cessation of therapeutic antibody. PB uMRD4 is not a suitable target for treatment cessation as the majority of patients with 0.001%-0.01% PB MRD have >0.01% BM disease. For the identification of people attaining BM uMRD4 (<0.01%) on I+V treatment, sustained PB uMRD4 was >90% effective. For translation into MRD-guided treatment in future routine clinical practice, BM assessment may be replaced with PB MRD monitoring if the 0.001%/MRD5 threshold is applied.

Time-Limited Maintenance with Ibrutinib after First-Line Therapy and the Incremental Impact on Minimal Residual Disease (MRD) for Patients with Chronic Lymphocytic Leukemia (CLL)

Background: Inhibitors of Bruton's tyrosine kinase (BTKi) are approved and clinically used as indefinite treatments (until disease progression) irrespective of the depth of response in patients (pts) with CLL. Despite impressive, sustained efficacy, their ability (as single agent) to target residual disease clone post induction treatment in CLL is not well established. As indefinite treatment is associated not only with cumulative toxicity but also high cost and compromised quality of life, we investigated the benefit of time-limited maintenance treatment (3 years) with ibrutinib to assess the ability of a BTKi to further deepen antitumor response achieved post induction treatment. Methods: CLL pts (n=35) who had residual disease (by clinical or molecular assessment) after primary induction treatment were enrolled on a prospective phase 2 trial (NCT02649387). MRD assessed in blood (PB)/bone marrow (BM), was determined by 8-color flowcytometry (1x10-4) and defined as ≥1 CLL cell per 10,000 leukocytes or ≥0.01%. Patient were eligible if they had detectable residual (non-progressive) disease within 1 year of completing induction and no prior ibrutinib (or other BTKi) treatment. Ibrutinib 420mg PO QD was given on days 1-28 of a 28-day cycle for up to 36 cycles. Clinical (iwCLL 2008 response criteria) and molecule response MRD (on PB) was done at baseline and then every 3 cycles while on treatment. BM-MRD evaluation was conducted only if PB-MRD was negative (on two separate timepoints 3 months apart). Monitoring of the PB-MRD was continued for 24 months after completing time-limited maintenance with ibrutinib. Cumulative toxicity was assessed using the CTCAE v4.0 and iwCLL criteria. Results: Patient characteristics are summarized in Table 1. In 34 out of 35 (97%) patients, obinutuzumab alone was used as induction therapy. The median follow up is 38.6 months (range 0.9-73.2) and the median number of maintenance cycles completed is 34 (range 1-36). Of the 33 patients assessed for PB-MRD, 8 (24.2%) pts became MRD- on at one assessment. Five patients had BM-MRD assessment with 1 (2.8%) converting to MRD-. The median time to achievement of MRD- was 4.4 months (range 2.7-34.7). We noted that single agent ibrutinib was unable to deliver stringent MRD-negativity (defined as achievement of MRD- status both in PB and BM sustained over 2 consecutive evaluations at least 3 months apart).To assess if pre-maintenance response could impact MRD post-treatment; we note that out of the 8 pts that achieved MRD-, 2 (25%) started with CR and 6 (75%) with nPR/PR at registration. Deepening of response was noted in 5 pts (14.3%) after a median of 14 cycles [3 (8.6%) pts improved nPR to CR and 1(2.9%) went from nPR to CRi and 1 (2.9%) went from a CRi to a CR]. Nine patients proceeded to subsequent treatment with the median time to next treatment (mTTNT) of 32.5 m (range: 12.1 - 61.0). One patient died due to a failure to thrive and acute kidney injury on dialysis and six pts have progressed. The median PFS for the entire cohort was 41.1 m (95% CI: 39.8 - NE). The most commonly reported adverse events (AEs) (seen in >10% pts) regardless of attributions were thrombocytopenia (24 pts; 68.6%), anemia (12 pts; 34.3%), neutropenia (9 pts; 25.7%), lymphopenia (9 pts; 25.7%), hypertension (9 pts; 25.7%), leucopenia (6 pts; 17.1%), fatigue (5 pts; 14.3%), headache (4 pts; 11.4%), and skin infections (4 pts; 11.4%). Atrial fibrillation (AFib) was noted in 3 pts (8.6%). Conclusion: We conclude that BTK targeting with ibrutinib alone although able to clear PB-MRD (24.2%), had limited efficacy to eradicate BM-MRD (2.8%) demonstrating a differential impact in these two disease compartments. While the rate of complete MRD eradication was not necessarily high (when compared to recent data with BTKi/BCL2i combination regimens) MRD-kinetics over time demonstrated progressive decrease in disease burden and response improvement with maintenance treatment. The sequential single agent treatment approach was well tolerated, and the time-limited therapy aimed at minimizing cumulative toxicity seemed to be effective in lowering rate of Afib (compared to historical control ~16%). This data warrants further investigation of time-limited maintenance therapy with newer, more favorably tolerated BTKi and/or Bcl2i post induction treatment(s) to optimize response vs. cumulative toxicity. Further evaluation of sequential time-limited treatments in CLL is warranted. Figure 1View largeDownload PPTFigure 1View largeDownload PPT Close modal

Association Between Clinical Value and Financial Cost of Cancer Treatments: A Cross-Sectional Analysis.

The cost of cancer treatment has increased significantly in recent decades, but it is unclear whether these costs have been associated with commensurate improvement in clinical value. This study aimed to assess the association between the cost of cancer treatment and 4 of the 5 NCCN Evidence Blocks (EB) measures of clinical value: efficacy of regimen/agent, safety of regimen/agent, quality of evidence, and consistency of evidence. This is a cross-sectional, observational study. We obtained NCCN EB ratings for all recommended, first-line, and/or maintenance treatments for the 30 most prevalent cancers in the United States and calculated direct pharmacologic treatment costs (drug acquisition, administration fees, guideline-concordant supportive care medications) using Medicare reimbursement rates in January 2019. We used generalized estimating equations to estimate the association between NCCN EB measures and treatment cost with clustering at the level of the treatment indication. A total of 1,386 treatments were included. Among time-unlimited treatments (those administered on an ongoing basis without a predetermined stopping point), monthly cost was positively associated with efficacy ($3,036; 95% CI, $1,782 to $4,289) and quality of evidence ($1,509; 95% CI, $171 to $2,847) but negatively associated with safety (-$1,470; 95% CI, -$2,790 to -$151) and consistency of evidence (-$2,003; 95% CI, -$3,420 to -$586). Among time-limited treatments (those administered for a predetermined interval or number of cycles), no NCCN EB measure was significantly associated with treatment cost. An association between NCCN EB measures and treatment cost was inconsistent, and the magnitude of the association was small compared with the degree of cost variation among treatments with the same EB scores. The clinical value of cancer treatments does not seem to be a primary determinant of treatment cost.

The correlation between clinical benefit and financial cost of cancer drugs.

7071 Background: The cost of many cancer drugs is very high, but it is unclear if these costs are associated with commensurate improvement in outcomes. We aimed to assess the association between the cost of cancer treatments and their clinical benefit, using the NCCN Evidence Blocks value assessment framework. Methods: The NCCN Evidence Blocks include 4 measures of clinical benefit: Efficacy, Safety, Quality of Evidence, and Consistency of Evidence. The NCCN assigns scores on each measure ranging from 1 (least favorable) to 5 (most favorable). We obtained the NCCN Evidence Blocks scores as of December 31, 2018 for all recommended cancer treatments for the 30 most prevalent cancers in the US. For each treatment, we calculated total treatment costs (including drugs, administration fees, and supportive care medications) using Medicare reimbursement rates. We categorized treatments as either “time-limited” or “time-unlimited” according to whether their costs are best reflected as per full treatment course (often, adjuvant/neoadjuvant treatments) (time-limited) or per month of therapy (often, treatments for advanced disease) (time-unlimited). We used generalized estimating equations, with clustering within treatment indications, to estimate the association between Evidence Blocks scores and treatment costs, modeling the expected change in cost associated with a one-unit increase in the score on an Evidence Blocks measure. Results: There were 541 time-unlimited and 845 time-limited treatments. Among time-unlimited treatments, monthly treatment cost ranged from $4 to $64,630. Monthly treatment cost was positively associated with Efficacy ($3,036, 95%CI: $1,782, $4,289) and Quality of Evidence ($1,509, 95%CI: $171, $2,847) but negatively associated with Safety (-$1,470, 95%CI: -$2,790, -$151) and Consistency of Evidence (-$2,003, 95%CI -$3,420, -$586). Among time-limited treatments, cost per course of therapy ranged from $0 to $775,559, and no measure was significantly associated with cost. Evidence Blocks scores accounted for little of the variation in treatment cost (linear model R-squared = 0.10 for time-unlimited, and < 0.01 for time-unlimited). Conclusions: The association between NCCN Evidence Blocks measures and treatment cost was inconsistent, and accounted for little of the cost variation among treatments for the same indication. The clinical benefit of cancer treatments does not appear to be a primary determinant of treatment cost, suggesting that current pricing models may be inadequate to incentivize the development and utilization of high-value treatments.

Mixed results of a pilot RCT of time-limited schema mindfulness-based cognitive therapy and competitive memory therapy plus treatment as usual for personality disorders.

Waiting lists for psychotherapy for patients with personality disorders are increasing; there is an imbalance between the number of patients seeking help and the amount of therapy available. Thus, there is a need for time-limited treatments that are effective for specific patients and their specific problems. This pilot randomized controlled trial aimed to investigate the effectiveness of two 8-week group modules + treatment as usual (TAU): schema mindfulness-based cognitive therapy (SMBCT) and competitive memory therapy (COMET) with special attention to predictors and mediators of change. Patients (N = 58) were randomized to either SMBCT + TAU or COMET + TAU. The dropout rate was 34%. Time effects were found for both treatments, but neither was more effective than the other, and around 23% showed deterioration after treatment. Explorative analyses suggested that predictors for change were severity of psychological distress and a demanding and/or punitive attitude toward oneself at baseline. Global severity index change in the beginning of the treatment mediated schema changes later on in treatment. SMBCT + TAU and COMET + TAU might be mostly suitable for patients with high levels of symptom severity followed by high scores on parent modes. More research is needed to tailor these time-limited therapies to specific personality problems. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

“We have to put the fire out first before we start rebuilding the house”: practitioners’ experiences of supporting women with histories of substance use, interpersonal abuse and symptoms of post-traumatic stress disorder

Introduction and aims: The high prevalence of women experiencing co-occurring substance use, interpersonal abuse, and symptoms of post-traumatic stress disorder (PTSD) has led to international calls for trauma-specific substance use treatments and wider trauma-informed practice. The aim of this study was to explore how services in England have developed practice responses with limited historical precedence for this work.Design and Methods: A purposive sample of 14 practitioners from substance use, interpersonal violence and criminal justice services were chosen for their integrated practice. Semi-structured interviews exploring their understanding of the co-occurring issues, staged treatment models and wider trauma-informed practice, and the challenges associated with this. Thematic analysis was employed.Results: Three key interlinking themes were identified: practitioners’ philosophical approach; tailored clinical practice, and system responsiveness. Analyses identified the importance of relational, non-pathologising practice, extensive focus on physical and emotional safety, and cautionary approaches towards using trauma-specific treatments involving trauma disclosure. Challenges included poor service integration, time-limited treatments and tokenistic trauma informed practice.Discussion: Practitioners from across disciplines emulated important components of trauma-informed practice and promoted a ‘safety-first’ approach reliant on multi-agency working and wider system responses. Trauma-specific interventions required skilled and experienced practitioners, and longer treatment programmes comprising first stage work.Conclusions: In the context of limited gender-responsive substance use treatment in the UK, practitioners demonstrated integrated practice that supported the recommended staged PTSD model and trauma-informed practice. Organisational leadership and support from service commissioners and funders are recommended to promote growth of this approach across the UK.

Systematic client feedback to brief therapy in basic mental healthcare: study protocol for a four-centre clinical trial

IntroductionThe Partners for Change Outcome Management System (PCOMS) is a client feedback-system built on two brief visual analogue self-report scales. Prior studies of PCOMS have found effects varying from significant...

An Old Treatment for an Even Older Problem: Does Psychoanalysis Have a Role in the Treatment of Addictive Disorders? A Review of the Literature.

The fact that addictive disorders have a significant negative impact on the health of the global population is well documented in contemporary health literature. What is less well documented is the uncomfortable realization that the tools in our armament to help individuals who struggle with addictive disorders are limited. Many individuals will spend their lives "cycling" through the addiction treatment continuum only to again be met with relapse. Third-party reimbursement for addiction treatment has focused on time-limited treatments and "brief" therapies with an additional emphasis on support group attendance (aka "free" services) with minimal focus on the fact that brief therapies have poor evidence for efficacy. In this article, we explore an alternative to brief therapies by reaching back to the earliest and most comprehensive treatment we have for behavioral change-psychoanalysis. This article engages in a literature review to determine whether sufficient evidence exists for the use of psychoanalysis as a treatment for addictive disorders. Implications for advanced practice psychiatric nurses are discussed.

Metacognitive Interpersonal Therapy in group (MIT-G) for young adults with personality disorders: A pilot randomized controlled trial.

Young adults with personality disorders (PD) other than borderline are in urgent need of validated treatments to help them in managing important life transitions. Therapeutic interventions focused upon social and interpersonal difficulties may facilitate these individuals in maximizing opportunities for employment, forming stable romantic relationships, and belong to social groups. It is also important that they are offered evidence-based, first-line time-limited treatments in order to maximize effectiveness and reduce costs. We developed a 16-session programme of group-based Metacognitive Interpersonal Therapy (MIT-G) including psychoeducation on the main interpersonal motives, an experiential component enabling practice of awareness of mental states; and use of mentalistic knowledge for purposeful problem-solving. We report a feasibility, acceptability, and clinical significance randomized clinical trial. Participants meeting inclusion criteria were randomized to receive MIT-G (n=10) or waiting list+TAU (n=10). Dropout rate was low and session attendance high (92.19%). Participants in the MIT-G arm had symptomatic and functional improvements consistent with large effect sizes. In the MIT-G arm similarly large effects were noted for increased capacity to understand mental states and regulate social interactions using mentalistic knowledge. Results were sustained at follow-up. Our findings suggest potential for applying MIT-G in larger samples to further test its effectiveness in reducing PD-related symptoms and problematic social functioning.

A Chronic Care Approach to the Prevention, Treatment, and Management of Addiction

Addiction is a chronic health condition that affects 40 percent of the American public. It costs society more than $400 billion annually (excluding nicotine), is responsible for up to 45% of all hospital emergency room admissions and is implicated in 66% of incarcerations [1,2]. Of the estimated 23-25 million people who need addiction treatment, about 2.5 million (10%) receive it [3]. Stigma, insurance barriers, and the perception by many that they don’t have a problem have limited access to care. Efforts to reduce stigma through awareness programs, the 2008 Mental Health and Addiction Parity Act, and the influx of newly insured patients through the ACA have sparked investor interest and led to rapid growth of inpatient rehabilitation programs. However, despite wider acceptance of addiction as a chronic brain disorder, treatment systems continue to be developed and defined by an emphasis on acute, time-limited treatments. For more than forty years, addiction treatment has been defined and judged by this misplaced perception that a fixed duration of treatment will “fix the problem”. Patients and families have been led to believe that a month in rehab would “take care of the problem”. This fragmented approach fails to provide the life-long management necessary to ensure sustained remission. The greatly underemphasized problem is the absence of substantial and comprehensive community based continuing care and the paucity of prevention, early identification and intervention efforts. Relegating follow-up care, prevention and early intervention to the sidelines contradicts the standard treatment of chronic disease. New ideas, innovative service delivery methods, alternative clinical interventions, and technological supports are not robustly developed, tested, and integrated. It is time for a new vision that addresses addiction as the chronic disease it is. This paper will describe an approach that incorporates prevention, early intervention, and extended engagement with traditional models of care to create a seamless, integrated system of care that addresses addiction as a chronic condition that can produce more favorable long term outcomes.

New Frontiers in Empirically Grounded Treatment Generation for Insomnia, Depression, and Bipolar Disorder: Translational Research With Transdiagnostic Implications

Progress toward developing psychosocial treatments for mental illness has been excellent. Yet, there remains a pressing need to further optimize these treatments and ensure they are accessible to the patients who need them. Four examples of treatment development processes are presented. All but one seeks to improve sleep. Improving sleep is important because sleep problems are among the most common health problems. The fourth example was generated by the observation that patients have difficulty remembering the content of a treatment session. A line of research is described to determine whether there is potential to improve outcome if memory for treatment can be improved. In sum, several studies are presented that add to the considerable evidence indicating that time-limited psychosocial treatments are powerful approaches to improving outcomes for patients with a mental illness. These results also demonstrate the power of deriving new treatments through the process of science.

The elephant tied up with string: a clinical case study showing the importance of NHS provision of intensive, time-limited psychoanalytic psychotherapy treatments

Prof. Richard Layard's influential advocacy for greater provision of ‘evidence-based’ psychological therapies, based in part on an economic rationale, has lead to greatly increased provision of cognitive behavioural therapy (CBT) and short-term therapies for depression, through the Increasing Access to Psychological Therapies (IAPT) initiative, whilst longer-term psychodynamic treatments are under threat, criticised as lacking an evidence base. This paper argues for the continuing provision of intensive thrice-weekly psychoanalytic psychotherapy treatments, time-limited to two years. It does so by describing such a treatment within an NHS psychotherapy department with a patient with a long history of severe personality pathology, including significant levels of perversity. The paper describes the patient's difficulties and his movement through the treatment, focussing on his difficulties making genuine emotional contact, his destructiveness of such contact, his acting out in the treatment, his perversity and the vital working through of the ending. The shifts the patient made are described, and follow-up information on the patient is given. The paper discusses the unique benefits of time-limited treatment and intensive psychoanalytic treatments for this ‘hard-to-help’ group of patients, and the economic rationale that can be made for such treatments.

Evaluating Compassion–Mindfulness Therapy for Recurrent Anxiety and Depression

Objective: To evaluate the effects of compassion–mindfulness therapy (C-MT), an adapted version of mindfulness-based cognitive therapy that integrates compassion training. Method: Individuals aged 17–69 with recurrent depressive and anxiety symptoms were recruited from a community mental health service unit. Half of the participants were randomized to an 8-week C-MT program ( n = 41) and the other half to a wait-list control condition ( n = 41). Results: Intent-to-treat analyses showed significant improvements in all measures in the treatment group. The effect sizes for depression and anxiety were 1.11 and 1.10, respectively, and those for physical distress, daily functioning, positive affect, and negative affect ranged from 0.71 to 1.04. All improvements were sustained at the 3-month follow-up. Conclusions: The results provide preliminary support for C-MT as a viable treatment option for individuals with recurrent depression and anxiety symptoms. Time-limited treatments such as C-MT should be promoted in social work practice.

Introduction to the Special Issue: An Analysis of a Short Term Dynamic Psychotherapy

-

Naturalistic study on the effectiveness of psycho-oncological interventions in cancer patients and their partners

There is evidence for the efficacy of psycho-oncological interventions (POI) in randomized controlled trials for cancer patients. Our objective was to explore, under naturalistic conditions (using propensity score matching), whether POI are effective to decrease anxiety, depression, distress and overall psychopathological symptoms within cancer patients and their partners. This study was conducted in the Oncology and Hematology Center of a University clinic in Switzerland with a group of 186 patients and 117 partners. Outcome measures of mental health were the Hospital Anxiety and Depression Scale and the Symptom Checklist (SCL-9-K). Repeated-measures ANOVAs were used to analyze change over time and group effects between individuals with POI vs. without POI. Highly distressed patients and their partners participating in POI reported better mental health over time. Among moderately distressed patients, a decrease over time emerged in depression and distress independent of POI. No effectiveness of POI could be demonstrated in moderately distressed patients and partners. Most of the highly distressed patients receive additional POI and therefore conclusions about the efficacy of POI are difficult. For moderately distressed individuals, POI as implemented in Switzerland does not improve mental health in such patients and their partners, which may be caused by very time limited POI treatments. Studies with more intense POI treatments are needed.

Winter Depression Recurrence One Year After Cognitive-Behavioral Therapy, Light Therapy, or Combination Treatment

The central public health challenge in the management of seasonal affective disorder (SAD) is prevention of depression recurrence each fall/winter season. The need for time-limited treatments with enduring effects is underscored by questionable long-term compliance with clinical practice guidelines recommending daily light therapy during the symptomatic months each year. We previously developed a SAD-tailored group cognitive-behavioral therapy (CBT) and tested its acute efficacy in 2 pilot studies. Here, we report an intent-to-treat (ITT) analysis of outcomes during the subsequent winter season (i.e., approximately 1 year after acute treatment) using participants randomized to CBT, light therapy, and combination treatment across our pilot studies ( N = 69). We used multiple imputation to estimate next winter outcomes for the 17 individuals who dropped out during treatment, were withdrawn from protocol, or were lost to follow-up. The CBT (7.0%) and combination treatment (5.5%) groups had significantly smaller proportions of winter depression recurrences than the light therapy group (36.7%). CBT alone, but not combination treatment, was also associated with significantly lower interviewer- and patient-rated depression severity at 1 year as compared to light therapy alone. Among completers who provided 1-year data, all statistically significant differences between the CBT and light therapy groups persisted after adjustment for ongoing treatment with light therapy, antidepressants, and psychotherapy. If these findings are replicated, CBT could represent a more effective, practical, and palatable approach to long-term SAD management than light therapy.

Therapist responsiveness to client interpersonal styles during time-limited treatments for depression.

Effective treatment involves therapists responding appropriately to their clients' varying requirements, including clients' predominant interpersonal styles. In 2 manualized time-limited treatments for depression, psychodynamic-interpersonal (PI) and cognitive-behavioral (CB) clients were assigned to 1 of 3 interpersonal style groups. Therapists, who were not told their clients' interpersonal style, nevertheless responded with systematically different interventions depending on clients' interpersonal style. Consistent with predictions, therapists tended to use more affective and relationship-oriented interventions with overinvolved clients, particularly in PI therapy. Therapists tended to use more cognitive treatment methods with underinvolved clients, particularly in CB therapy. Outcomes of the interpersonal style groups were approximately equivalent, consistent with a view that the differences in treatment implementation reflected appropriate responsiveness to clients' interpersonal styles.

Aptitude–treatment interactions based on clients' assimilation of their presenting problems.

Assigning clients to treatments on the basis of their differential aptitudes for those treatments may reduce variability and improve the mean outcomes of psychotherapy. The assimilation model suggests that in time-limited treatments, clients with well-assimilated problems would do better in cognitive or behavioral therapies than in psychodynamic, experiential, or interpersonal therapies, whereas the reverse should be the case for clients with poorly assimilated problems. Results for high-, moderate-, and low-assimilation subgroups (based on rating the level of assimilation of problems presented in the first 20 min of first sessions) of clients (N = 112) randomly assigned to time-limited cognitive-behavioral or psychodynamic-interpersonal treatment supported the first suggestion but not the second (clients with poorly assimilated problems did equally well in both treatments).