ArticleLiterature Review

Dropout from interpersonal psychotherapy for mental health disorders: A systematic review and meta-analysis

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Abstract

Objective: Dropout is one factor that might limit the effectiveness of interpersonal psychotherapy (IPT). Improved understanding of IPT dropout is an important research priority. This meta-analysis examined dropout rates from IPT in randomized controlled trials. Method: Seventy-two trials met inclusion criteria. Results: The weighted mean dropout rate from IPT was 20.6% (95% CI = 17.4-24.2). Dropout rates were similar for depressive (20.9%; 95% CI = 17.2-25.2), anxiety (16.1%; 95% CI = 11.1-22.9), and eating disorders (18.7%; 95% CI = 11.6-28.8). Dropout was highest when more stringent definitions of dropout were applied (e.g., failure to complete the entire IPT protocol versus failure to complete at least 50% of sessions) and was lowest when adolescent patients were sampled. There was some evidence that IPT was associated with significantly lower rates of dropout than both CBT and non-specific supportive therapies. These effects were generally replicated when analysing trials that provided a clear definition of treatment (rather than study) dropout. Conclusions: Overall, findings provide preliminary evidence to suggest that IPT may be an accepted and tolerated treatment option for patients with common mental health disorders. This review also highlights the need for future trials to rigorously report detail pertaining to patient dropout.

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... Meta-analytic research publications have addressed discontinuation in specific contemporary therapeutic orientations, including dialectical behaviour therapy (DBT) (Dixon & Linardon, 2019), acceptance and commitment therapy (ACT) (Ong, Lee, & Twohig, 2018), mindfulness-based therapy (Swift & Greenberg, 2012), interpersonal therapy (Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2018), and cognitive-behavioural psychotherapy (CBT) (Fernandez, Salem, Swift, & Ramtahal, 2015;Linardon et al., 2018). However, fewer research efforts address discontinuation rates in psychoanalytic or psychodynamic psychotherapy (Gold & Stricker, 2011;Hill, 2010;Ingenhoven, Duivenvoorden, Passchier, & Van Den Brink, 2012;Nuetzel & Larsen, 2012;Perry, Bond, & Roy, 2007;Wilson & Sperlinger, 2004). ...
... Meta-analytic research publications have addressed discontinuation in specific contemporary therapeutic orientations, including dialectical behaviour therapy (DBT) (Dixon & Linardon, 2019), acceptance and commitment therapy (ACT) (Ong, Lee, & Twohig, 2018), mindfulness-based therapy (Swift & Greenberg, 2012), interpersonal therapy (Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2018), and cognitive-behavioural psychotherapy (CBT) (Fernandez, Salem, Swift, & Ramtahal, 2015;Linardon et al., 2018). However, fewer research efforts address discontinuation rates in psychoanalytic or psychodynamic psychotherapy (Gold & Stricker, 2011;Hill, 2010;Ingenhoven, Duivenvoorden, Passchier, & Van Den Brink, 2012;Nuetzel & Larsen, 2012;Perry, Bond, & Roy, 2007;Wilson & Sperlinger, 2004). ...
... Noteworthy, too, was the latter study's findings that psychodynamic psychotherapy was not substantially elevated when compared to other treatment orientations, having a 20% discontinuation rate. Instructive in this regard is comparison with recently reported psychotherapy orientation-specific discontinuation rates: 20.6% in interpersonal psychotherapy (Linardon et al., 2018), 26% in CBT (Fernandez, Salem, Swift, & Ramtahal, 2015), 16% in ACT (Ong et al., 2018) and 28% in DBT (Dixon & Linardon, 2019). The GNC discontinuation rate was thus more than three times higher than the 20% psychodynamic discontinuation reported in Swift and Greenberg's (2012) meta-analysis, and higher than any of the discontinuation rates in the other therapeutic approaches noted above. ...
Article
Using data from an outcome study of adult individual psychoanalytic psychotherapy, conducted in a low‐cost Australian clinic, a mixed‐methods approach was employed to investigate patient discontinuation. This paper addresses the qualitative component of the discontinuation study, which explored patients’ reasons for leaving the clinic service upon assessment or in treatment proper. Of 205 patients commencing clinic contact, 41% discontinued during or shortly after the four‐week assessment period, while 40.5% of patients beginning psychotherapy withdrew before reaching the two‐year treatment limit. Across these two groups, former patients were interviewed about their therapy experience and decision to discontinue. Thematic analysis of 20 interview transcripts generated five descriptive categories of discomfort or dissatisfaction prompting discontinuation: clinic factors, therapist factors, patient factors, therapist–patient relationship factors and therapy factors. Findings suggest that experience of the clinic setting itself, together with negative patient perceptions of therapists and therapist interactional style, weres significant influences and that dissatisfaction with the psychotherapy process and outcome was more relevant than problematic patient factors in treatment withdrawal. A number of patients, mainly late discontinuers, reported positive experiences of psychotherapy and significant treatment gains. Implications of the findings, with specific emphasis on psychoanalytic treatment settings, are discussed.
... For example, estimating average attrition rates would assist investigators of future RCTs to factor in these expected attrition rates into a power analysis and recruitment planning (Swift & Greenberg, 2012). Studying differential attrition or adherence rates may help in understanding whether certain types of treatment modalities pose particular difficulties in terms of participant engagement and satisfaction (Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2018). Identifying participant-and trial-related factors predictive of study attrition and adherence would allow for (a) identification of participants sufficiently motivated and therefore most able to complete the research trial and benefit from the intervention, and (b) the offering of more targeted interventions for those at highest risk of discontinuing the study or not adhering to an intervention (Cooper & Conklin, 2015). ...
... Our findings suggested that, on average, approximately one quarter of participants drop out of the research trial by short-term follow up, and up to one third by longer-term follow up. These estimates are slightly higher than the attrition estimates reported in some previous meta-analytic reviews of face-to-face treatments, including individual psychotherapy for depressive (19.9% attrition rate; Cooper & Conklin, 2015) and anxiety disorders (16.9% attrition rate; Gersh et al., 2017), acceptance and commitment therapy for mental health problems (16% attrition rate; Ong et al., 2018), CBT for eating disorders (22% attrition rate; Linardon, Hindle, et al., 2018), and interpersonal psychopathology for mental health problems (20.6% attrition rate; Linardon, Fitzsimmons-Craft, et al., 2018). This could indirectly suggest that the mode of treatment delivery may be an important determinant of study attrition. ...
Article
Objectives: Although the efficacy of smartphone-delivered interventions for mental health problems is emerging, randomized controlled trials (RCTs) of smartphone interventions are characterized by high rates of attrition and low adherence. High attrition and low adherence may threaten the validity of RCT findings, so a better understanding of these phenomena is needed. We examined attrition and adherence in 70 RCTs of smartphone interventions. Method: Four online databases were searched for RCTs of mental health interventions delivered via smartphones. Results: The mean meta-analytic study attrition rate was 24.1% (95% CI [19.3, 29.6]) at short-term follow up and 35.5% (95% CI [26.7, 45.3]) at longer-term follow up. These rates varied according to target mental health condition. Attrition rates were significantly lower in trials that delivered an acceptance-based intervention, offered participants monetary compensation, and reminded participants to engage in the intervention, and were significantly higher in trials that used an online enrollment method (relative to telephone or in-person enrollment). No participant-level baseline characteristic reliably predicted attrition. Evidence of attrition bias came from many RCTs not conducting intention-to-treat analyses. However, the mean difference in the between-groups effect size on primary outcomes in trials that reported both per protocol an intention-to-treat analyses was only Δd = 0.18. Adherence rates were also suboptimal based on our qualitative synthesis; several participants failed to download the intervention, and intervention usage consistently declined over the course of the trial. Conclusion: Study attrition and low adherence are common, problematic, and may undermine the validity of findings in RCTs of smartphone-delivered interventions for mental health problems. (PsycINFO Database Record (c) 2019 APA, all rights reserved).
... En las últimas décadas, clínicos e investigadores han resaltado necesidades vigentes para el campo psicodinámico, vinculadas con: a) combinarjuicio clínico, teoría e investigación empírica (Levy et al., 2012), b) operacionalizar, registrar y evaluar procesos y resultados (Dagnino, 2013;Dagnino et al., 2014;Grupo de Trabajo OPD, 2006/2008Juan & Pozzi, 2016), y c) acumular evidencia a favor de postulados y procedimientos (Barber & Sharpless, 2015). Por una parte, algunos estudios han sugerido que el registro sistemático de casos psicodinámicos puede constituir una respuesta orgánica a este tipo de desafíos (Gottdiener & Suh, 2012;Tillman et al., 2011). ...
... Por otra parte, los estándares actuales sobre estudios empíricos de casos únicos (American Psychiatric Association, s.f.; Kazdin, 2002) plantean la necesidad de vincular diferentes perspectivas del proceso terapéutico, combinando, por ejemplo, la visión del terapeuta con la visión de jueces externos. A su vez, la temática del abandono terapéutico conforma otro conjunto de problemas para la clínica y la investigación (Linardon et al., 2018;Roos & Werbart, 2013;Swift et al., 2017) que requiere un estudio hacia el interior de la experiencia de abandono, las diferentes categorías posibles de este fenómeno, y cómo el no completamiento del proceso puede hacernos comprender, en retrospectiva, la evolución del paciente (Rodríguez Quiroga de Pereira et al., 2018). ...
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Introducción: es necesario mayor estudio de la experiencia de abandono terapéutico temprano. Indagar sistemáticamente casos únicos puede conformar una respuesta orgánica a este desafío. Objetivos y métodos: se analizó y comparó la evolución de focos terapéuticos, planteados por el terapeuta tratante y por dos juezas externas, para un caso de abandono temprano de psicoterapia psicodinámica focalizada de un trastorno emocional. Ciegos a la codificación de la contraparte, terapeuta y juezas utilizaron el Diagnóstico Psicodinámico Operacionalizado-2 (OPD-2) para generar un perfil psicodinámico y establecer focos de tratamiento. Para cada foco, aplicaron la Escala de Presencia de Foco y la Escala de Cambio Estructural de Heidelberg. Resultados y discusión: se observaron puntos de convergencia y divergencia entre las perspectivas de terapeuta y juezas externas. Se discute la utilidad de dichos puntos para la comprensión del abandono temprano del paciente, así como las implicancias del OPD-2 como herramienta de investigación orientada a la práctica. Palabras clave: OPD-2, Terapia psicodinámica, Abandono temprano, Caso único, Investigación orientada a la práctica.
... Interpersonal psychotherapy was shown to produce the highest abstinence rates. This reinforces recent calls to offer interpersonal psychotherapy as one of the front-running treatments for BED (Kazdin, Fitzsimmons-Craft, & Wilfley, 2017), particularly because interpersonal psychotherapy is not only effective in reducing BED symptoms, but also because it is well-tolerated by patients (Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2018), is cost-effective, and can effectively address more than one type of problem (e.g., co-occurring depressive and anxiety symptoms). However, more head-to-head trials of interpersonal psychotherapy with other treatments are required to make firmer conclusions about the relative effectiveness of BED treatments. ...
Article
Objective Standardized effect sizes reported in previous meta‐analyses of binge‐eating disorder (BED) treatment are sometimes difficult to interpret and are criticized for not being a useful indicator of the clinical importance of a treatment. Abstinence from binge eating is a clinically relevant component of a definition of a successful treatment outcome. This meta‐analysis estimated the prevalence of patients with BED who achieved binge eating abstinence following psychological or behavioral treatments. Method This meta‐analysis included 39 randomized controlled trials, with 65 treatment conditions and 2,349 patients. Most conditions comprised cognitive‐behavioral therapy (n = 40). Pooled event rates were calculated at posttreatment and follow‐up using random effects models. Results The total weighted percentage of treatment‐completers who achieved abstinence at posttreatment was 50.9% (95% CI = 43.9, 57.8); this estimate was almost identical at follow‐up (50.3%; 95% CI = 43.6, 56.9). The total weighted percentage of patients who achieved abstinence at posttreatment in the intention‐to‐treat analysis (all randomized patients) was 45.1% (95% CI =40.7, 49.5), and at follow‐up it was 42.3% (95% CI =37.5, 47.2). Interpersonal psychotherapy (IPT) produced the highest abstinence rates. Clinician‐led group treatments produced significantly higher posttreatment (but not follow‐up) abstinence estimates than guided self‐help treatments. Neither timeframe for achieving abstinence, assessment type (interview/questionnaire), number of treatment sessions, patient demographics, nor trial quality, moderated the abstinence estimates. Discussion The present findings demonstrate that 50% of patients with BED do not fully respond to treatment. Continued efforts toward improving eating disorder treatments are needed.
... Similarly, a recent systematic review and Table 1 Summary of the characteristics of the included studies . Orphans with PTSD and depression IPT vs NE meta-analysis by Linardon et al. concluded that IPT was associated with significantly lower rates of withdrawal from treatment than both CBT and non-specific supportive therapies in patients with common mental disorders (Linardon et al., 2018). Comparison with the outcomes of meta-analyses on the effectiveness of other interventions for PTSD reveals interesting insights. ...
Article
Background: Evidence for the efficacy of treatments for post-traumatic stress disorder (PTSD) is urgently required. This systematic review and meta-analysis examines the efficacy of interpersonal psychotherapy (IPT) in reducing the symptoms of PTSD. Methods: Five databases were searched from inception until November 2018 to identify randomized controlled trials (RCTs) that assessed the efficacy of IPT in patients with PTSD symptoms. The reference lists of included studies were also hand searched. A random effects model was used to estimate changes in a clinician-administered PTSD scale, or self-reported symptoms. Results: Of 509 screened abstracts, ten clinical trials (11 study arms) involving 755 patients with PTSD symptoms were included. Nine studies (10 study arms) were included in the meta-analysis. The overall standardized mean difference was -0.44 (CI: -0.69, -0.19), p = 0.0005. This represents a change in the clinically administrated PTSD Scale (CAPS) of approximately 12 points. IPT was not superior to other active controls, such as medication and non-IPT psychotherapies, but was significantly superior to passive controls, such as waiting list and educational pamphlets. Limitations: Most studies modified the IPT protocol and did not comprehensively assess clinician fidelity to the protocol. The included studies generally had small sample sizes and were of limited quality. Conclusions: IPT may be an effective treatment for PTSD, but clinical trials with larger sample sizes and improved methodology are required to confirm effects.
... IC: 17.6%, 43.8%) se asociaron con una mayor deserción que los psicólogos (media ponderada = 12.4%, IC 95%: 6.7%, 19.4%) (Ong, Lee y Twohig, 2018). Linardon, Fitzsimmons-Craft, Brennan, Barillaro y Wilfley (2018) en un metaanálisis de setenta y dos ensayos aleatorizados de psicoterapia interpersonal (TIP) encontraron una tasa de abandono promedio del 20.6% (IC 95% = 17.4-24.2). Las tasas de deserción fueron similares para la depresión (20.9%; ...
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La psicoterapia es un recurso efectivo y eficaz, pero no lo es para todas las personas. Uno de los problemas clínicos con el que nos encontramos en este campo es la terminación prematura por parte del paciente sin acuerdo con el psicoterapeuta. El problema mencionado deriva en dos problemas, uno conceptual y otro operacional, existiendo distintas definiciones del término como así diferentes maneras de medirlo. El objetivo general de este trabajo es realizar una revisión no sistemática sobre el tema, teniendo como ejes las distintas maneras en que se ha definido el concepto, las diversas formas de medirla, los resultados de meta-análisis realizados sobre la temática y las variables que pueden modularla.
... Our dropout rate is, however, high when compared to psychotherapy. Meta-analyses have reported dropout rates of 24% for cognitive behaviour therapy in people eating disorders (49), 18.7% for interpersonal therapy in eating disorders (50) and 19.9% for individual psychotherapy in unipolar depression (51). Of interest, personal choices and factors associated with individual trials are the main reasons for dropout, not metabolic effects such as weight gain as initially hypothesised. ...
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Background Second-generation antipsychotics are often used off-label in the treatment of anorexia nervosa (AN) across the clinical spectrum. Patients with anorexia nervosa often cite concerns about metabolic effects, such as weight gain, as reasons for their reluctance to start or continue second-generation antipsychotics. Improving our understanding of the metabolic effect patients experience and reasons underlying their disinclination will enable us to build rapport and guide our clinical decisions. We therefore aimed to conduct a comprehensive review of dropouts, metabolic effects, and patient-reported outcomes associated with second-generation antipsychotic in people with AN.MethodEMBASE, Medline, and PsycINFO were searched for all relevant studies published until 2019, and retrieved studies were assessed for eligibility as per predefined inclusion criteria. A random-effects meta-analysis was conducted to assess overall dropout rates.ResultsOf 983 citations retrieved, 21 studies met the inclusion criteria for the systematic review and 10 studies had appropriate data for meta-analysis. Using the random effects model, the pooled dropout rate in the intervention arm (95% confidence interval) from psychopharmacological trials was 28% (19 to 38%) in people with AN. Personal reasons or factors associated with study were commonest reason for dropout, not adverse events or metabolic effects as hypothesized.Conclusion Compared to personal reasons, drug-related factors such as side effects seem to play a lesser role for the discontinuation of antipsychotic treatment under trial conditions. This suggests an urgent need to consider and fully examine potential individual and patient-related factors that influence dropout rates in psychopharmacological trials and treatment compliance in clinical settings.
... Recent reviews of digital treatment and prevention programs for mental health problems (e.g., depression, anxiety, etc.) have reported adherence rates to be low as 35% and dropout rates to be as high as 40% . These figures are considerably higher than attrition rates observed for established face-to-face mental health treatments like CBT (ϳ26% drop-out; Fernandez, Salem, Swift, & Ramtahal, 2015), interpersonal psychotherapy (ϳ20% drop-out; Linardon, Fitzsimmons-Craft, Brennan, Barillaro, & Wilfley, 2018), and dialectical behavior therapy (ϳ28% drop-out; Dixon & Linardon, 2019), as well as face-to-face ED-specific treatment and prevention programs, including CBT-E (ϳ18% drop-out; Linardon, Hindle, & Brennan, 2018), the Body Project (ϳ8% drop-out and Ͼ50% completely adhere; Stice, Rohde, Shaw, & Gau, 2017), and Healthy Weight Intervention (ϳ5% drop-out and more than 90% have been shown to fully adhere; Stice, Shaw, Burton, & Wade, 2006). Issues with attrition in digital interventions for EDs have also been noted, with both treatment-and prevention-focused trials reporting dropout rates that range from 5% (Neumayr, Voderholzer, Tregarthen, & Schlegl, 2019) to 50% (Saekow et al., 2015) and adherence rates that range from 15% (Jacobi et al., 2018) to 75% (Ruwaard et al., 2013). ...
Article
Objectives: E-mental health (digital) interventions can help overcome existing barriers that stand in the way of people receiving help for an eating disorder (ED). Although e-mental health interventions for treating and preventing EDs have been met with enthusiasm, earlier reviews brought attention to poor quality of evidence, and offered solutions to enhance their evidence base. To assess developments in the field, we conducted an updated meta-analysis on the efficacy of e-mental health interventions for treating and preventing EDs, paying attention to whether trial quality and outcomes have improved in recent trials. We also assessed whether user-centered design principles have been implemented in existing digital interventions. Method: Four databases were searched for RCTs of digital interventions for treating and preventing EDs. Thirty-six RCTs (28 prevention- and 8 treatment-focused) were included. Results: Some evidence that study quality improved in recent prevention-focused trials was found. Few trials involved the end-user in the design or development stage of the intervention. Issues with intervention engagement were noted, and 1 in 4 participants dropped out from prevention- and treatment-focused trials. Digital interventions were more effective than control conditions in reducing established risk factors and symptoms in prevention- (g's = 0.19 to 0.43) and treatment-focused trials (g's = 0.29 to 0.69), respectively. Effect sizes have not increased in recent trials. Few trials compared a digital intervention with a face-to-face intervention. Whether digital interventions can prevent ED onset is unclear. Conclusion: Digital interventions are a promising approach to ED treatment and prevention, but improvements are still needed. Three key recommendations are provided. (PsycInfo Database Record (c) 2020 APA, all rights reserved).
... In addition, current guidelines for empirical single case studies 9, 10 highlight the importance of including different views of the therapeutic process, combining, for instance, therapist's and external judges' perspectives. At the same time, the problem of psychotherapy dropout conforms a challenging field for both research and practice [11][12][13] . ...
Article
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Introduction: contemporary psychodynamic therapy research supports combining clinical judgment with empirical evidences. Recent studies suggest that systematically analyzing single cases may contribute to such efforts. Also, current criteria for evidence-based case studies recommend different perspectives on therapeutic process and outcome, such as therapist’s and external judges’ ratings. Finally, client’s dropout conforms a challenge for psychotherapy research. Aims & Methods: as part of a SPR Small Research Grant, this study analyzed and compared the psychodynamic profile proposed both by therapist and two external judges, for the same case of early dropout from focused psychodynamic psychotherapy, consisting of two diagnostic interviews and five subsequent sessions, in a patient with an emotional disorder. Being blind to the rating process of the counterpart, Operationalized Psychodynamic Diagnosis (OPD-2) was used by therapist and judges to generate a psychodynamic profile including five therapeutic foci. External judges rating was achieved through consensus, following CQR’s guidelines. Results & Discussion: similarities and differences among therapist’s and judges’ psychodynamic profiles were found. Result’s contributions to the understanding of case’s early dropout are discussed, along with OPD-2’s usefulness for psychodynamic practice-oriented research. Keywords: Focused Psychodynamic Therapy; OPD-2; Change Mechanisms; Dropout; Single Case Research; Practice Oriented Research
... Further evidence suggests that IPT-A is well suited and acceptable to young people. Meta-analyses show that IPT-A is associated with significantly fewer dropouts than IPT for adults (13.0 vs. 22.6%) 73 , and is either superior or noninferior to active and non-active controls in terms of its all-cause discontinuation rate 67,70,71 . Although IPT-A trials have been predominantly conducted in the United States (k = 14), efficacy is also supported in low socioeconomic groups 74 , and in samples from Australia (k = 1), Canada (k = 1), Puerto Rico (k = 2), Uganda (k = 1) and Taiwan (k = 1) 67 . ...
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Interpersonal difficulties are often implicated in the onset of depressive disorders, and typically exacerbate depressive symptoms. This is particularly true for young people, given rapid changes in, and the increased importance of, their social relationships. The purpose of this narrative review was to identify empirically supported interventions that aim to prevent or treat depression in young people by facilitating improvements in their social environment. We conducted a search of controlled trials, systematic reviews and meta-analyses of such interventions, published between 1980 and June 2020. Our literature search and interpretation of results was informed by consultations with clinical experts and youth consumers and advocates. A number of promising approaches were identified with respect to prevention and treatment. Preliminary evidence was identified suggesting that school- and Internet-based approaches present a viable means to prevent the worsening of depressive symptoms in young people. Notably, delivering interpersonal psychotherapy-adolescent skills training (IPT-AST) in schools appears to be a promising early intervention strategy for young people at risk of full-threshold depressive disorder. In terms of treating depressive disorders in young people, there is strong evidence for the efficacy of interpersonal psychotherapy for adolescents (IPT-A), and preliminary evidence in favour of attachment-based family therapy (ABFT). Results are discussed with respect to recommendations for future research and practice.
... While specific risk factors for dropout among men are poorly understood, specific client characteristics are consistently discussed as predictors of dropout, albeit with small effect sizes (Hans & Hiller, 2013). Younger age, unemployment, low income, ethnic minority status, lower educational attainment, more severe symptoms, and doubt regarding the effectiveness of therapy have consistently been linked to greater risk of dropout among mixed-gender samples (Edlund et al., 2002;Egan & Kenny, 2005;Henzen et al., 2016;Linardon et al., 2019;Seidler, Rice, Dhillon, et al., 2020;Wang, 2007). Whilst commonly framed as barriers to entry into mental health services, clients' lack of motivation, pessimism as to the likely outcome of attending therapy, and experiential shame in attending therapy could serve as barriers to engagement and also predict dropout (Edlund et al., 2002). ...
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While increasing numbers of Australian men are accessing mental health services, the sustainability of their therapy engagement varies significantly, with many men being lost to follow-up. The current study investigated dropout rates in a large community-based male sample to highlight the reasons for, and potential predictors of, men dropping out of mental health care services. Data were drawn from an online survey of 1907 Australian men (aged 16–85; M = 44.1 years) reflecting on their broad experiences in mental health therapy. Participants responded to bespoke items assessing their past dropout experience and reasons for dropping out, the odds of which were modeled in relation to demographics and predictors (e.g., therapist engagement strategies, alignment to traditional masculinity and pretherapy feelings of optimism, shame, and emasculation). The overall dropout rate from therapy was 44.8% (n = 855), of which 26.6% (n = 120) accessed therapy once and did not return. The most common reasons for dropout were lack of connection with the therapist (54.9%) and the sense that therapy lacked progress (20.2%). Younger age, unemployment, self-reported identification with traditional masculinity, the presence of specific therapist engagement strategies, and whether therapy made participants feel emasculated all predicted dropout. Current depressive symptoms and suicidality were also higher amongst dropouts. Therapists should aim to have an honest discussion with all clients about the importance of therapy fit, including the real likelihood of dropout, in order to ensure this does not deter future engagement with professional services.
... Approximately 20% of clients in psychological treatments unilaterally decide to discontinue therapy (Cooper & Conklin, 2015;Fernandez et al., 2015;Linardon et al., 2019;Swift & Greenberg, 2012), an outcome referred to as premature termination or therapy dropout (Hatchett & Park, 2003). ...
Article
In an often-cited study, Murdock et al. (2010) found that therapists are more likely to attribute premature treatment termination to client characteristics than to themselves, a finding that the authors interpreted in terms of a self-serving bias (SSB). We replicated and extended the study of Murdock et al. (2010, study 2). Psychologists and psychotherapists (N = 91) read two case vignettes about premature treatment terminations of clients that, in a between-subjects set-up, were either described as own clients or other therapists' clients. Next, participants used three attribution subscales (blaming therapist, client and situation) to evaluate potential causes for the premature terminations. This way, we tested whether participants would manifest SSB. We also investigated whether therapists' scores on self-confidence and need for closure were linked to SSB tendencies. Unlike Murdock et al. (2010), we found no overall SSB. However, a stronger need for closure was related to more SSB tendencies (i.e., less endorsement of ‘blame therapist’ attributions) in the own-client condition (r = −.35, p < .05, r2 = .12), but not in the other-therapist's-client condition (r = .17, p = .27). Our results suggest that SSB is not a ubiquitous phenomenon when therapists evaluate premature termination problems and that their willingness to attend to their own role depends to some extent on their need for closure.
... Several tCBT studies reported that adolescents or young adults are generally interested in trying various platforms, but many discontinued early in treatment citing lack of interest, engagement, and perceived utility. [61][62][63] The high acceptability score of MYTH is likely due to the enhanced engagement and tailoring (for utility), which directly targets known risk factors for dropout. It is also reasonable to believe that MYTH's strong acceptability contributed to its low dropout rate, especially considering 6 out of 8 participants who did not drop out completed all 8 sessions. ...
Article
Objectives Technology-assisted Cognitive Behavioral Therapy (tCBT) has significant potentials to provide engaging and accessible depression treatment for adolescents and young adults (AYAs) coping with cancer. This study evaluated the feasibility and preliminary efficacy of an engaging and tailorable tCBT – Mind Your Total Health (MYTH) – for AYA cancer survivors’ depression. Methods Seventeen AYAs diagnosed with cancer were randomly assigned to either the intervention (MYTH) or control group. The intervention group (n = 10) received eight weekly 30-35 minutes coach-assisted tCBT (MYTH), while the control group (n = 7) received active control, BeatingtheBlues (BtB). Results Eight out of ten participants in the MYTH group completed at least six out of eight sessions, suggesting strong feasibility (80% completion rate) among AYAs with cancer. Efficacy outcomes indicated that participants in the MYTH group reported significant pre- and post-treatment reduction in depression, t(9) = 5.25, p < 0.001, and anxiety, t(9)=5.07, p < 0.001. Notably, participants in the MYTH group reported significantly lower post-treatment depression than participants in the BtB group, t(15) = 2.40, p < 0.05. The between-group difference reflected a significant between-group treatment effect size, d = 1.12, p < 0.05. Discussion This engaging, tailorable, and coach-assisted tCBT intervention is promising in alleviating depression and anxiety among AYA cancer survivors. Future research needs to include larger sample size and a more diverse patient population.
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Sustentada por cerca de oitocentas referências científicas, sobretudo nos domínios da biologia, psicologia, psiquiatria e sociologia, esta obra biblioterápica salienta informações surpreendentes sobre o primeiro estágio da existência humana: in utero. É direcionada à população em geral, visando ampliar a sensibilização sobre a vida psíquica intrauterina, bem como aos profissionais de saúde, sugerindo-lhes a inclusão da Projeção Idealizada de Sexo (PIS) nos seus racionais teóricos, para práticas mais incisivas e efetivas. Fruto de cerca de vinte anos de trabalho, nesta obra os autores dissertam sobre a preferência parental pelo sexo dos filhos, ilustrando cinquenta casos clínicos trabalhados com Constelações Familiares (CF) como psicoterapia clássica. Dessa prática fenomenológica sistémica sobressaem múltiplas reflexões, como as sobre o patriarcado, o aborto sexo-seletivo, o feticídio feminino, a feminigligência, o feminicídio, o efeito fraterno na ordem do nascimento, a não-heterossexualidade e o incesto intrafamiliar. São também aqui facultadas informações sobre temas mais raros na literatura sobre CF, tais como a atitude fenomenológica, os esquemas sobre o «estar com o outro», os tipos de vinculação, as criptas psíquicas, os fantasmas sistémicos, as lealdades invisíveis e as heurísticas cognitivas. Os autores propõem ainda a adição de vários novos conceitos à literatura científica sobre psicoterapia, como o de frases homeostaticamente orientadas, protoesquema psíquico, falha arcaica, vinculação fictiva e o tema central desta obra, a PIS.
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Dropout is an important factor that may compromise the validity of findings from randomized controlled trials (RCTs) of dialectical behaviour therapy (DBT). We conducted a targeted meta-analytic review of dropout from RCTs of DBT, with the aims of (1) calculating average rates of dropout from DBT; (2) investigating factors that moderate dropout; (3) examining whether dropout rates from DBT differ to control interventions; (4) synthesising reasons for dropout. Forty RCTs of DBT met full inclusion criteria. The weighted mean dropout rate was 28.0% (95% CI = 23.6, 32.9). Dropout rates were not related to target disorder, dropout definition, delivery format, therapist experience, and therapist adherence. Unexpectedly, dropout rates were significantly higher in trials that offered telephone coaching and utilized a therapist consultation team. DBT dropout rates did not significantly differ to dropout rates from control interventions. Few trials reported reasons for dropout, and there was little consistency in the reported reasons. Findings suggest that over one in four patients drop out from DBT in RCTs. This review highlights the urgency for future trials to explicitly report detail pertaining to patient dropout, as this may assist in the development of strategies designed to prevent future dropouts in RCTs of DBT.
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Interpersonal Counseling (IPC) comes directly from interpersonal psychotherapy (IPT), an evidenced-based psychotherapy developed by Klerman and Weissman. It [IPC?] is a briefer, more structured version for use primarily in non-mental health settings, such as primary care clinics when treating patients with symptoms of depression. National health-care reform, which will bring previously uninsured persons into care and provide mechanisms to support mental health training of primary care providers, will increase interest in briefer psychotherapy. This paper describes the rationale, development, evidence for efficacy, and basic structure of IPC and also presents an illustrated clinical vignette. The evidence suggests that IPC is efficacious in reducing symptoms of depression; that it can be used by mental health personnel of different levels of training, and that the number of sessions is flexible depending on the context and resources. More clinical trials are needed, especially ones comparing IPC to other types of care used in the delivery of mental health services in primary care.
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Objective: Exposure to trauma reminders has been considered imperative in psychotherapy for posttraumatic stress disorder (PTSD). The authors tested interpersonal psychotherapy (IPT), which has demonstrated antidepressant efficacy and shown promise in pilot PTSD research as a non-exposure-based non-cognitive-behavioral PTSD treatment. Method: The authors conducted a randomized 14-week trial comparing IPT, prolonged exposure (an exposure-based exemplar), and relaxation therapy (an active control psychotherapy) in 110 unmedicated patients who had chronic PTSD and a score >50 on the Clinician-Administered PTSD Scale (CAPS). Randomization stratified for comorbid major depression. The authors hypothesized that IPT would be no more than minimally inferior (a difference <12.5 points in CAPS score) to prolonged exposure. Results: All therapies had large within-group effect sizes (d values, 1.32-1.88). Rates of response, defined as an improvement of >30% in CAPS score, were 63% for IPT, 47% for prolonged exposure, and 38% for relaxation therapy (not significantly different between groups). CAPS outcomes for IPT and prolonged exposure differed by 5.5 points (not significant), and the null hypothesis of more than minimal IPT inferiority was rejected (p=0.035). Patients with comorbid major depression were nine times more likely than nondepressed patients to drop out of prolonged exposure therapy. IPT and prolonged exposure improved quality of life and social functioning more than relaxation therapy. Conclusions: This study demonstrated noninferiority of individual IPT for PTSD compared with the gold-standard treatment. IPT had (nonsignificantly) lower attrition and higher response rates than prolonged exposure. Contrary to widespread clinical belief, PTSD treatment may not require cognitive-behavioral exposure to trauma reminders. Moreover, patients with comorbid major depression may fare better with IPT than with prolonged exposure.
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Previous reviews of premature termination have yet to examine whether disparate psychotherapy treatments differ in their dropout rates for specific disorders. Using data from 587 studies, a series of meta-analyses were conducted comparing dropout rates between treatment approaches for 12 separate disorder categories. Although, significant differences between treatment approaches were found for depression [Q(9) = 22.69, p <.01], eating disorders [Q(7) = 14.63, p <.05], and posttraumatic stress disorder (PTSD) [Q(7) = 20.20, p <.01], treatments did not differ in their dropout rates for the remaining 9 diagnostic categories. Although integrative treatments resulted in the lowest dropout rates for depression and PTSD, dialectical-behavior therapy resulted in the lowest average dropout rate for eating disorders. The similarity in dropout rates for the majority of the disorder categories suggests that clients' decisions to drop out may depend more on other therapy variables (e.g., common factors, client characteristics, and therapist characteristics) rather than the specific type of treatment that is used. Additionally, our findings highlight the particular usefulness of an integrationist approach to therapy-it showed to be the most robust model for retaining clients in that its dropout rate was equal to or better than all of the other therapy approaches for 11 out of the 12 disorders examined.
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Interpersonal psychotherapy (IPT) is a dynamically informed and present-focused psychotherapy originally conceived for patients with unipolar depression and subsequently modified for other disorders, including postpartum depression (PPD). The aim of this paper is to review the evidence on the efficacy of IPT for PPD. We conducted a systematic review of studies published between 1995 and April 2013 assessing the efficacy of IPT for PPD using PubMed and PsycINFO. We included the following: (i) articles that presented a combination of at least two of the established terms in the abstract, namely, interpersonal [all fields] and ("psychotherapy" [MeSH terms] or psychotherapy [all fields]) and (perinatal [all fields] or postpartum [all fields]) and ("depressive disorder" [MeSH terms] or ("depressive" [all fields] and "disorder" [all fields]) or depressive disorder [all fields] or "depression" [all fields] or depression [MeSH terms]); (ii) manuscripts in English; (iii) original articles; and (iv) prospective or retrospective observational studies (analytical or descriptive), experimental, or quasi-experimental. Exclusion criteria were as follows: (i) other study designs, such as case reports, case series, and reviews; (ii) non-original studies including editorials, book reviews, and letters to the editor; and (iii) studies not specifically designed and focused on IPT. We identified 11 clinical primary trials assessing the efficacy of IPT for PPD, including 3 trials with group interventions (G-IPT) and one that required the presence of the partner (PA-IPT). We also identified six studies interpersonal-psychotherapy-oriented preventive interventions for use in pregnancy. IPT studies showed overall clinical improvement in the most commonly used depression measures in postpartum depressed women (EPDS, HDRS, BDI) and often-full recovery in several cases of treated patients. Evidence from clinical trials indicates that, when administered in monotherapy (or in combination with antidepressants), IPT may shorten the time to recovery from PPD and prolong the time spent in clinical remission.
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Face-to-face cognitive behavioral therapy (CBT) and interpersonal psychotherapy (IPT) are both effective treatments for depressive disorders, but access is limited. Online CBT interventions have demonstrated efficacy in decreasing depressive symptoms and can facilitate the dissemination of therapies among the public. However, the efficacy of Internet-delivered IPT is as yet unknown. This study examines whether IPT is effective, noninferior to, and as feasible as CBT when delivered online to spontaneous visitors of an online therapy website. An automated, 3-arm, fully self-guided, online noninferiority trial compared 2 new treatments (IPT: n=620; CBT: n=610) to an active control treatment (MoodGYM: n=613) over a 4-week period in the general population. Outcomes were assessed using online self-report questionnaires, the Center for Epidemiological Studies Depression scale (CES-D) and the Client Satisfaction Questionnaire (CSQ-8) completed immediately following treatment (posttest) and at 6-month follow-up. Completers analyses showed a significant reduction in depressive symptoms at posttest and follow-up for both CBT and IPT, and were noninferior to MoodGYM. Within-group effect sizes were medium to large for all groups. There were no differences in clinical significant change between the programs. Reliable change was shown at posttest and follow-up for all programs, with consistently higher rates for CBT. Participants allocated to IPT showed significantly lower treatment satisfaction compared to CBT and MoodGYM. There was a dropout rate of 1294/1843 (70%) at posttest, highest for MoodGYM. Intention-to-treat analyses confirmed these findings. Despite a high dropout rate and lower satisfaction scores, this study suggests that Internet-delivered self-guided IPT is effective in reducing depressive symptoms, and may be noninferior to MoodGYM. The completion rates of IPT and CBT were higher than MoodGYM, indicating some progress in refining Internet-based self-help. Internet-delivered treatment options available for people suffering from depression now include IPT. International Standard Randomized Controlled Trial Number (ISRCTN): 69603913; http://www.controlled-trials.com/ISRCTN69603913 (Archived by WebCite at http://www.webcitation.org/6FjMhmE1o).
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Objective: Many patients drop out of treatments for posttraumatic stress disorder (PTSD); some clinicians believe that trauma-focused treatments increase dropout. Method: We conducted a meta-analysis of dropout among active treatments in clinical trials for PTSD (42 studies; 17 direct comparisons). Results: The average dropout rate was 18%, but it varied significantly across studies. Group modality and greater number of sessions, but not trauma focus, predicted increased dropout. When the meta-analysis was restricted to direct comparisons of active treatments, there were no differences in dropout. Differences in trauma focus between treatments in the same study did not predict dropout. However, trauma-focused treatments resulted in higher dropout compared with present-centered therapy (PCT), a treatment originally designed as a control but now listed as a research-supported intervention for PTSD. Conclusion: Dropout varies between active interventions for PTSD across studies, but variability is primarily driven by differences between studies. There do not appear to be systematic differences across active interventions when they are directly compared in the same study. The degree of clinical attention placed on the traumatic event does not appear to be a primary cause of dropout from active treatments. However, comparisons of PCT may be an exception to this general pattern, perhaps because of a restriction of variability in trauma focus among comparisons of active treatments. More research is needed comparing trauma-focused interventions to trauma-avoidant treatments such as PCT.
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Premature discontinuation from therapy is a widespread problem that impedes the delivery of otherwise effective psychological interventions. The most recent comprehensive review found an average dropout rate of 47% across 125 studies (Wierzbicki & Pekarik, 1993); however, given a number of changes in the field over the past 2 decades, an updated meta-analysis is needed to examine the current phenomenon of therapy dropout. A series of meta-analyses and meta-regressions were conducted in order to identify the rate at which treatment dropout occurs and predictors of its occurrence. This review included 669 studies representing 83,834 clients. Averaging across studies using a random effects model, the weighted dropout rate was 19.7%, 95% CI [18.7%, 20.7%]. Further analyses, also using random effects models, indicated that the overall dropout rate was moderated by client diagnosis and age, provider experience level, setting for the intervention, definition of dropout, type of study (efficacy vs. effectiveness), and other design variables. Dropout was not moderated by orientation of therapy, whether treatment was provided in an individual or group format, and a number of client demographic variables. Although premature discontinuation is occurring at a lower rate than what was estimated 20 years ago (Wierzbicki & Pekarik, 1993), it is still a significant problem, with about 1 in every 5 clients dropping out of therapy. Special efforts should be made to decrease premature discontinuation, particularly with clients who are younger, have a personality or eating disorder diagnosis, and are seen by trainee clinicians.
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The present study quantitatively reviewed the literature on sudden gains in psychological treatments for anxiety and depression. The authors examined the short- and long-term effects of sudden gains on treatment outcome as well as moderators of these effects. The authors conducted a literature search using PubMed, PsycINFO, the Cochrane Library, and manual searches. The meta-analysis was based on 16 studies and included 1,104 participants receiving psychological treatment for major depressive disorder or an anxiety disorder. Effect size estimates suggest that sudden gains had a moderate effect on primary outcome measures at posttreatment (Hedges's g = 0.62) and follow-up (Hedges's g = 0.56). These effect sizes were robust and unrelated to publication year or number of treatment sessions. The effect size of sudden gains in cognitive-behavioral therapy was higher (Hedges's g = 0.75) than in other treatments (Hedges's g = 0.23). These results suggest that sudden gains are associated with short-term and long-term improvements in depression and anxiety, especially in cognitive-behavioral therapy.
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Interpersonal psychotherapy (IPT), a structured and time-limited therapy, has been studied in many controlled trials. Numerous practice guidelines have recommended IPT as a treatment of choice for unipolar depressive disorders. The authors conducted a meta-analysis to integrate research on the effects of IPT. The authors searched bibliographical databases for randomized controlled trials comparing IPT with no treatment, usual care, other psychological treatments, and pharmacotherapy as well as studies comparing combination treatment using pharmacotherapy and IPT. Maintenance studies were also included. Thirty-eight studies including 4,356 patients met all inclusion criteria. The overall effect size (Cohen's d) of the 16 studies that compared IPT and a control group was 0.63 (95% confidence interval [CI]=0.36 to 0.90), corresponding to a number needed to treat of 2.91. Ten studies comparing IPT and other psychological treatments showed a nonsignificant differential effect size of 0.04 (95% CI=-0.14 to 0.21; number needed to treat=45.45) favoring IPT. Pharmacotherapy (after removal of one outlier) was more effective than IPT (d=-0.19, 95% CI=-0.38 to -0.01; number needed to treat=9.43), and combination treatment was not more effective than IPT alone, although the paucity of studies precluded drawing definite conclusions. Combination maintenance treatment with pharmacotherapy and IPT was more effective in preventing relapse than pharmacotherapy alone (odds ratio=0.37; 95% CI=0.19 to 0.73; number needed to treat=7.63). There is no doubt that IPT efficaciously treats depression, both as an independent treatment and in combination with pharmacotherapy. IPT deserves its place in treatment guidelines as one of the most empirically validated treatments for depression.
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This meta-analytic review of 11 studies examined the relationship between psychotherapy dropout and therapeutic alliance in adult individual psychotherapy. Results of the meta-analysis demonstrate a moderately strong relationship between psychotherapy dropout and therapeutic alliance (d = .55). Findings indicate that clients with weaker therapeutic alliance are more likely to drop out of psychotherapy. The meta-analysis included a total of 1,301 participants, with an average of 118 participants per study, a standard deviation of 115 participants, and a range from 20 to 451 participants per study. Exploratory analyses were conducted to determine the influence of variables moderating the relationship between alliance and dropout. Client educational history, treatment length, and treatment setting were found to moderate the relationship between alliance and dropout. Studies with a larger percentage of clients who completed high school or higher demonstrated weaker relationships between alliance and dropout. Studies with lengthier treatments demonstrated stronger relationships between alliance and dropout. Inpatient settings demonstrated significantly larger effects than both counseling centers and research clinics. No significant differences were found between client-rated, therapist-rated, and observer/staff-rated alliance. Recommendations for clinicians and researchers are discussed.
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The CONSORT statement is used worldwide to improve the reporting of randomised controlled trials. Kenneth Schulz and colleagues describe the latest version, CONSORT 2010, which updates the reporting guideline based on new methodological evidence and accumulating experience. To encourage dissemination of the CONSORT 2010 Statement, this article is freely accessible on bmj.com and will also be published in the Lancet, Obstetrics and Gynecology, PLoS Medicine, Annals of Internal Medicine, Open Medicine, Journal of Clinical Epidemiology, BMC Medicine, and Trials.
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Despite more than 50 years of research on client attrition from therapy, obstacles to the delivery and success of treatments remain poorly understood, and effective methods to engage and retain clients in therapy are lacking. This article offers a review of the literature on attrition, highlighting the methodological challenges in effectively addressing the complex nature of this problem. Current interventions for reducing attrition are reviewed, and recommendations for implementing these interventions into psychotherapy practice are discussed.
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No meta-analytical study has examined whether the quality of the studies examining psychotherapy for adult depression is associated with the effect sizes found. This study assesses this association. We used a database of 115 randomized controlled trials in which 178 psychotherapies for adult depression were compared to a control condition. Eight quality criteria were assessed by two independent coders: participants met diagnostic criteria for a depressive disorder, a treatment manual was used, the therapists were trained, treatment integrity was checked, intention-to-treat analyses were used, N >or= 50, randomization was conducted by an independent party, and assessors of outcome were blinded. Only 11 studies (16 comparisons) met the eight quality criteria. The standardized mean effect size found for the high-quality studies (d=0.22) was significantly smaller than in the other studies (d=0.74, p<0.001), even after restricting the sample to the subset of other studies that used the kind of care-as-usual or non-specific controls that tended to be used in the high-quality studies. Heterogeneity was zero in the group of high-quality studies. The numbers needed to be treated in the high-quality studies was 8, while it was 2 in the lower-quality studies. We found strong evidence that the effects of psychotherapy for adult depression have been overestimated in meta-analytical studies. Although the effects of psychotherapy are significant, they are much smaller than was assumed until now, even after controlling for the type of control condition used.
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Although the subject has been debated and examined for more than 3 decades, it is still not clear whether all psychotherapies are equally efficacious. The authors conducted 7 meta-analyses (with a total of 53 studies) in which 7 major types of psychological treatment for mild to moderate adult depression (cognitive-behavior therapy, nondirective supportive treatment, behavioral activation treatment, psychodynamic treatment, problem-solving therapy, interpersonal psychotherapy, and social skills training) were directly compared with other psychological treatments. Each major type of treatment had been examined in at least 5 randomized comparative trials. There was no indication that 1 of the treatments was more or less efficacious, with the exception of interpersonal psychotherapy (which was somewhat more efficacious; d = 0.20) and nondirective supportive treatment (which was somewhat less efficacious than the other treatments; d = -0.13). The drop-out rate was significantly higher in cognitive-behavior therapy than in the other therapies, whereas it was significantly lower in problem-solving therapy. This study suggests that there are no large differences in efficacy between the major psychotherapies for mild to moderate depression.
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We study recently developed nonparametric methods for estimating the number of missing studies that might exist in a meta-analysis and the effect that these studies might have had on its outcome. These are simple rank-based data augmentation techniques, which formalize the use of funnel plots. We show that they provide effective and relatively powerful tests for evaluating the existence of such publication bias. After adjusting for missing studies, we find that the point estimate of the overall effect size is approximately correct and coverage of the effect size confidence intervals is substantially improved, in many cases recovering the nominal confidence levels entirely. We illustrate the trim and fill method on existing meta-analyses of studies in clinical trials and psychometrics.
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Interpersonal psychotherapy (IPT) is a time-limited psychotherapy for major depression. The aim of this study is to summarize findings from controlled trials of the efficacy of IPT in the treatment of depressive spectrum disorders (DSD) using a meta-analytic approach. Studies of randomized clinical trials of IPT efficacy were located by searching all available data bases from 1974 to 2002. The searches employed the following MeSH categories: Depression/ Depressive Disorder; Interpersonal therapy; Outcome/Adverse Effects/Efficacy; in the identified studies. The efficacy outcomes were: remission; clinical improvement; the difference in depressive symptoms between the two arms of the trial at endpoint, and no recurrence. Drop out rates were used as an index of treatment acceptability. Thirteen studies fulfilled inclusion criteria and four meta-analyses were performed. IPT was superior in efficacy to placebo in nine studies (Weight Mean Difference (WMD) - 3.57 [-5.9, -1.16]). The combination of IPT and medication did not show an adjunctive effect compared to medication alone for acute treatment (RR 0.78 [0.30, 2.04]), for maintenance treatment (RR 1.01 [0.81, 1.25]), or for prophylactic treatment (RR 0.70 [0.30, 1.65]). IPT was significantly better than CBT (WMD -2.16 [-4.16,-0.15]). The efficacy of IPT proved to be superior to placebo, similar to medication and did not increase when combined with medication. Overall, IPT was more efficacious than CBT. Current evidence indicates that IPT is an efficacious psychotherapy for DSD and may be superior to some other manualized psychotherapies.
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Rates of patient-initiated premature termination in different forms of psychotherapy are consistently high. Patient-initiated premature termination is recognized as a significant obstacle to the effective and efficient use of psychotherapy. The literature describes many strategies for preventing premature termination, but lacks integration. This review attempts to provide a concise and comprehensive summary of the strategies that research or clinical experience have suggested may be useful for minimizing patient-initiated premature termination. A search was conducted on the MEDLINE, PsycINFO, and EMBASE databases for literature published between January 1970 and March 2004. Retrieved articles were published in English in peer-reviewed journals and focused on psychotherapy for adults. Thirty-nine publications that discussed strategies for preventing or reducing patient-initiated premature termination of psychotherapy were identified. Surprisingly, only 15 of these were research studies. Most of the retrieved literature consisted of clinical descriptions. The strategies can be assigned to nine categories: pretherapy preparation, patient selection, time-limited or short-term contracts, treatment negotiation, case management, appointment reminders, motivation enhancement, facilitation of a therapeutic alliance, and facilitation of affect expression. Research supports some of the strategies for reducing premature termination. However, methodologically sound studies of prevention strategies remain few in number.
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Objective: Cognitive-behavioral therapy (CBT) is efficacious for a range of eating disorder presentations, yet premature dropout is one factor that might limit CBTs effectiveness. Improved understanding of dropout from CBT for eating disorders is important. This meta-analysis aimed to study dropout from CBT for eating disorders in randomized controlled trials (RCTs), by (a) identifying the types of dropout definitions applied, (b) providing estimates of dropout, (c) comparing dropout rates from CBT to non-CBT interventions for eating disorders, and (d) testing moderators of dropout. Method: RCTs of CBT for eating disorders that reported rates of dropout were searched. Ninety-nine RCTs (131 CBT conditions) were included. Results: Dropout definitions varied widely across studies. The overall dropout estimate was 24% (95% CI = 22-27%). Diagnostic type, type of dropout definition, baseline symptom severity, study quality, and sample age did not moderate this estimate. Dropout was highest among studies that delivered internet-based CBT and was lowest in studies that delivered transdiagnostic enhanced CBT. There was some evidence that longer treatment protocols were associated with lower dropout. No significant differences in dropout rates were observed between CBT and non-CBT interventions for all eating disorder subtypes. Conclusion: Present study dropout estimates are hampered by the use of disparate dropout definitions applied. This meta-analysis highlights the urgency for RCTs to utilize a standardized dropout definition and to report as much information on patient dropout as possible, so that strategies designed to minimize dropout can be developed, and factors predictive of CBT dropout can be more easily identified.
Article
Many psychotherapies, including cognitive behavioral therapy and acceptance and commitment therapy (ACT), have been found to be effective interventions for a range of psychological and behavioral health concerns. Another aspect of treatment utility to consider is dropout, as interventions only work if clients are engaged in them. To date, no research has used meta-analytic methods to examine dropout in ACT. Thus, the objectives of the present meta-analysis were to (1) determine the aggregate dropout rate for ACT in randomized controlled trials, (2) compare dropout rates in ACT to those in other psychotherapies, and (3) identify potential moderators of dropout in ACT. Our literature search yielded 68 studies, representing 4,729 participants. The weighted mean dropout rates in ACT exclusive conditions and ACT inclusive conditions (i.e., those that included an ACT intervention) were 15.8% (95% CI: 11.9%, 20.1%) and 16.0% (95% CI: 12.5%, 19.8%), respectively. ACT dropout rates were not significantly different from those of established psychological treatments. In addition, dropout rates did not vary by client characteristics or study methodological quality. However, master's-level clinicians/therapists (weighted mean = 29.9%, CI: 17.6%, 43.8%) were associated with higher dropout than psychologists (weighted mean = 12.4%, 95% CI: 6.7%, 19.4%). More research on manipulable, process variables that influence dropout is needed.
Article
Psychotherapy meta-analyses sometimes generate heterogeneous results, partially due to key methodological characteristics which vary between studies (e.g., psychotherapy conditions are contrasted with structurally different control conditions). Examining these potential moderator variables can help explain heterogeneous results within and between psychotherapy meta-analyses. The present manuscript provides an overview of moderators that are highly relevant to test the generalizability of effects across psychotherapy trials. These moderators mainly fall into one of the following groups: (a) structural equivalence of interventions, (b) preferences/allegiances, (c) therapist effects, and (d) sample representativeness. Individual moderators include: Bona fide psychotherapy, proximity to psychological interventions, psychotherapy orientation, pre-training of therapists, supervision, caseload of therapists, dosage, homework, patient preferences, researcher and therapist allegiance, therapist effects in nested designs, aspects of sample representativeness, multiple outcomes, and time of assessment. Our analysis of 15 psychotherapy meta-analyses published in 2016 suggests that the structural equivalence of psychotherapeutic conditions, patient and therapist preferences/allegiances, therapist effects and nested data structures as well as sample representativeness were often neglected and little-discussed as potential moderators. The manuscript describes further conceptual and methodological challenges when conducting moderator analyses such as the categorization of psychological treatments and the importance of interrater coding. We encourage meta-analysts to consider moderators which have previously shown utility in explaining heterogeneous results in the psychotherapy literature.
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The Cochrane risk of bias tool (RoB) is a widely used measure for methodological quality of randomized controlled trials. This paper discusses RoB’s rationale and risk of bias domains, reports on its application in current psychotherapy meta-analyses, and offers comments regarding the application of RoB in the context of psychotherapy outcome research. Our suggestions include focusing on patient’s and therapist’s expectations when judging the domain “blinding of personnel and participants” and paying greater attention to the domain “selective outcome reporting” and to matters of “treatment implementation.” Clinical or methodological significance of this article: This paper discusses the rationale of a widely used tool to assess the methodological quality of primary studies for meta-analysis and provides suggestions for its use in the context of psychotherapy outcome research.
Article
Objective: This meta-analysis examined the efficacy of cognitive-behavioral therapy (CBT) for eating disorders. Method: Randomized controlled trials of CBT were searched. Seventy-nine trials were included. Results: Therapist-led CBT was more efficacious than inactive (wait-lists) and active (any psychotherapy) comparisons in individuals with bulimia nervosa and binge eating disorder. Therapist-led CBT was most efficacious when manualized CBT-BN or its enhanced version was delivered. No significant differences were observed between therapist-led CBT for bulimia nervosa and binge eating disorder and antidepressants at posttreatment. CBT was also directly compared to other specific psychological interventions, and therapist-led CBT resulted in greater reductions in behavioral and cognitive symptoms than interpersonal psychotherapy at posttreatment. At follow-up, CBT outperformed interpersonal psychotherapy only on cognitive symptoms. CBT for binge eating disorder also resulted in greater reductions in behavioral symptoms than behavioral weight loss interventions. There was no evidence that CBT was more efficacious than behavior therapy or nonspecific supportive therapies. Conclusions: CBT is efficacious for eating disorders. Although CBT was equally efficacious to certain psychological treatments, the fact that CBT outperformed all active psychological comparisons and interpersonal psychotherapy specifically, offers some support for the specificity of psychological treatments for eating disorders. Conclusions from this study are hampered by the fact that many trials were of poor quality. Higher quality RCTs are essential. (PsycINFO Database Record
Article
Although third-wave behaviour therapies are being increasingly used for the treatment of eating disorders, their efficacy is largely unknown. This systematic review and meta-analysis aimed to examine the empirical status of these therapies. Twenty-seven studies met full inclusion criteria. Only 13 randomized controlled trials (RCT) were identified, most on binge eating disorder (BED). Pooled within- (pre-post change) and between-groups effect sizes were calculated for the meta-analysis. Large pre-post symptom improvements were observed for all third-wave treatments, including dialectical behaviour therapy (DBT), schema therapy (ST), acceptance and commitment therapy (ACT), mindfulness-based interventions (MBI), and compassion-focused therapy (CFT). Third-wave therapies were not superior to active comparisons generally, or to cognitive-behaviour therapy (CBT) in RCTs. Based on our qualitative synthesis, none of the third-wave therapies meet established criteria for an empirically supported treatment for particular eating disorder subgroups. Until further RCTs demonstrate the efficacy of third-wave therapies for particular eating disorder subgroups, the available data suggest that CBT should retain its status as the recommended treatment approach for bulimia nervosa (BN) and BED, and the front running treatment for anorexia nervosa (AN) in adults, with interpersonal psychotherapy (IPT) considered a strong empirically-supported alternative.
Article
Background Despite being a relatively prevalent and debilitating disorder, Generalized Anxiety Disorder (GAD) is the second least studied anxiety disorder and among the most difficult to treat. Dropout from psychotherapy is concerning as it is associated with poorer outcomes, leads to service inefficiencies and can disproportionately affect disadvantaged populations. No study to date has calculated a weighted mean dropout rate for GAD and explored associated correlates. Methods A systematic review was conducted using PsycINFO, Medline and Embase databases, identifying studies investigating individual psychotherapies for adults with GAD. Forty-five studies, involving 2224 participants, were identified for meta-analysis. Results The weighted mean dropout rate was 16.99% (95% confidence interval 14.42%–19.91%). The Q-statistic indicated significant heterogeneity among studies. Moderator analysis and meta-regressions indicated no statistically significant effect of client age, sex, symptom severity, comorbidity, treatment type, study type (randomized trial or not), study quality, number of sessions or therapist experience. Conclusions In research investigating psychotherapy for GAD, approximately one in six clients can be expected to drop out of treatment. Dropout rate was not significantly moderated by the client, therapist or treatment variables investigated. Future research should specify the definition of dropout, reasons for dropout and associated correlates to assist the field’s progression.
Article
Objective: Rapid response to cognitive behavior therapy (CBT) for eating disorders (i.e., rapid and substantial change to key eating disorder behaviors in the initial weeks of treatment) robustly predicts good outcome at end-of-treatment and in follow up. The objective of this study was to determine whether rapid response to day hospital (DH) eating disorder treatment could be facilitated using a brief adjunctive CBT intervention focused on early change. Method: 44 women (average age 27.3 [8.4]; 75% White, 6.3% Black, 6.9% Asian) were randomly assigned to 1 of 2 4-session adjunctive interventions: CBT focused on early change, or motivational interviewing (MI). DH was administered as usual. Outcomes included binge/purge frequency, Eating Disorder Examination-Questionnaire and Difficulties in Emotion Regulation Scale. Intent-to-treat analyses were used. Results: The CBT group had a higher rate of rapid response (95.7%) compared to MI (71.4%; p = .04, V = .33). Those who received CBT also had fewer binge/purge episodes (p = .02) in the first 4 weeks of DH. By end-of-DH, CBT participants made greater improvements on overvaluation of weight and shape (p = .008), and emotion regulation (ps < .008). Across conditions, there were no significant baseline differences between rapid and nonrapid responders (ps > .05). Conclusions: The results of this study demonstrate that rapid response can be clinically facilitated using a CBT intervention that explicitly encourages early change. This provides the foundation for future research investigating whether enhancing rates of rapid response using such an intervention results in improved longer term outcomes. (PsycINFO Database Record
Article
Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.
Article
Objective: This review aimed to (a) examine the effects of rapid response on behavioral, cognitive, and weight-gain outcomes across the eating disorders, (b) determine whether diagnosis, treatment modality, the type of rapid response (changes in disordered eating cognitions or behaviors), or the type of behavioral outcome moderated this effect, and (c) identify factors that predict a rapid response. Method: Thirty-four articles met inclusion criteria from six databases. End of treatment and follow-up outcomes were divided into three categories: Behavioral (binge eating/purging), cognitive (EDE global scores), and weight gain. Average weighted effect sizes(r) were calculated. Results: Rapid response strongly predicted better end of treatment and follow-up cognitive and behavioral outcomes. Moderator analyses showed that the effect size for rapid response on behavioral outcomes was larger when studies included both binge eating and purging (as opposed to just binge eating) as a behavioral outcome. Diagnosis, treatment modality, and the type of rapid response experienced did not moderate the relationship between early response and outcome. The evidence for weight gain was mixed. None of the baseline variables analyzed (eating disorder psychopathology, demographics, BMI, and depression scores) predicted a rapid response. Discussion: As there is a solid evidence base supporting the prognostic importance of rapid response, the focus should shift toward identifying the within-treatment mechanisms that predict a rapid response so that the effectiveness of eating disorder treatment can be improved. There is a need for future research to use theories of eating disorders as a guide to assess within-treatment predictors of rapid response. © 2016 Wiley Periodicals, Inc.
Article
Objective: Interpersonal psychotherapy (IPT) has been developed for the treatment of depression but has been examined for several other mental disorders. A comprehensive meta-analysis of all randomized trials examining the effects of IPT for all mental health problems was conducted. Method: Searches in PubMed, PsycInfo, Embase, and Cochrane were conducted to identify all trials examining IPT for any mental health problem. Results: Ninety studies with 11,434 participants were included. IPT for acute-phase depression had moderate-to-large effects compared with control groups (g=0.60; 95% CI=0.45-0.75). No significant difference was found with other therapies (differential g=0.06) and pharmacotherapy (g=-0.13). Combined treatment was more effective than IPT alone (g=0.24). IPT in subthreshold depression significantly prevented the onset of major depression, and maintenance IPT significantly reduced relapse. IPT had significant effects on eating disorders, but the effects are probably slightly smaller than those of cognitive-behavioral therapy (CBT) in the acute phase of treatment. In anxiety disorders, IPT had large effects compared with control groups, and there is no evidence that IPT was less effective than CBT. There was risk of bias as defined by the Cochrane Collaboration in the majority of studies. There was little indication that the presence of bias influenced outcome. Conclusions: IPT is effective in the acute treatment of depression and may be effective in the prevention of new depressive disorders and in preventing relapse. IPT may also be effective in the treatment of eating disorders and anxiety disorders and has shown promising effects in some other mental health disorders.
Article
In this era of insistence on evidence-based treatments, cognitive behavioral therapy (CBT) has emerged as a highly preferred choice for a spectrum of psychological disorders. Yet, it is by no means immune to some of the vagaries of client participation. Special concerns arise when clients drop out from treatment. The aim of this study was to answer questions about the rate and timing of dropout from CBT, with specific reference to pretreatment versus during treatment phases. Also explored were several moderators of dropout. A meta-analysis was performed on dropout data from 115 primary empirical studies involving 20,995 participants receiving CBT for a range of mental health disorders. Average weighted dropout rate was 15.9% at pretreatment, and 26.2% during treatment. Dropout was significantly associated with (a) diagnosis, with depression having the highest attrition rate; (b) format of treatment delivery, with e-therapy having the highest rates; (c) treatment setting, with fewer inpatient than outpatient dropouts; and (d) number of sessions, with treatment starters showing significantly reduced dropout as number of sessions increased. Dropout was not significantly associated with client type (adults or adolescents), therapist licensure status, study design (randomized control trial [RCT] vs. non-RCT), or publication recency. Findings are interpreted with reference to other reviews. Possible clinical applications include careful choice and supplementing of treatment setting/delivery according to the diagnosis, and use of preparatory strategies. Suggestions for future research include standardization of operational definitions of dropout, specification of timing of dropout, and exploration of additional moderator variables. (PsycINFO Database Record (c) 2015 APA, all rights reserved).
Article
• A randomized, controlled trial compared the combination of amitriptyline hydrochloride and short-term interpersonal psychotherapy, either treatment alone, and a nonscheduled treatment control group in ambulatory acute, nonbipolar, nonpsychotic depressives. Results show the efficacy of both psychotherapy and amitriptyline in overall symptom reduction. Amitriptyline and psychotherapy were about equal, and the effects of both treatments in combination were additive. The additive effect of combined treatment was largely due to the differential effects of the two treatments. Amitriptyline had its effect mainly on the vegetative symptoms of depression such as sleep and appetite disturbance, these occurred early in treatment, often within the first week. Psychotherapy had its effect mainly on mood, suicidal ideation, work, and interests; these effects occurred slightly later, at four to eight weeks.
Article
This report examines a possible distortion in the results of comparative treatment studies due to the association of the researcher's therapy allegiances with outcomes of those treatments. In eight past reviews a trend appeared for significant associations between the researcher's allegiance and outcomes of treatments compared. In this review of 29 studies of treatment comparisons, a similar trend appeared. Allegiance ratings were based not only on the usual reprint method, but also on two new methods: ratings by colleagues who knew the researcher well, and self-ratings by the researchers themselves. The two new allegiance methods intercorrelated only moderately, but each allegiance measure correlated significantly with outcomes of the treatments compared, and when combined, the three measures explained 69% of the variance in outcomes. Such an association can distort comparative treatment results. This report concludes with how the researcher's allegiance may become associated with treatment outcomes and how studies should deal with these associations. (PsycINFO Database Record (c) 2008 APA, all rights reserved)
Article
IntroductionIndividual studiesThe summary effectHeterogeneity of effect sizesSummary points
Article
The high attrition rates in obesity interventions are associated with poorer weight loss and maintenance for the individual and poorer overall treatment effectiveness and cost-effectiveness for the treatment provider. Increased knowledge about factors associated with attrition can facilitate the identification of individuals at risk of drop-out and inform treatment program improvements with the aim of maximising treatment retention. To date, a relatively small body of literature has explored attrition from weight-loss interventions using two methods of attrition assessment: identification of pre-treatment predictors of attrition and eliciting post-treatment reasons for attrition. A range of attrition rates have been reported and no reliable or consistent predictors of attrition have been found. It is unknown whether the lack of consistent findings reflects population or treatment differences, or if the discrepant findings simply reflect differences in definition and measurement of attrition. Further research is required to address these limitations. There is a need for a recognised definition of obesity treatment attrition, the consideration of predictors that are theoretically and empirically associated with attrition, the development of a well-validated and standardised measure of barriers to attendance, and assessment of both treatment completers and drop-outs. Understanding the factors that influence attrition can be used to inform the modification of treatment programs and to target those most at risk of drop-out so as to maximise the success of obesity interventions.
Background and aims: Attrition is a long-standing problem in mental health centres serving youth. However, attempts to understand attrition have not consistently identified the same risk factors. The way in which attrition was defined across studies may have had a significant impact on findings. This study examines three definitions of attrition across a large sample of children and adolescents receiving outpatient mental health services, and considers the different relationships observed between the identified predictors and each definition. Method: This study examined data collected concurrently from 1098 families who received services at an urban outpatient mental health clinic (OMHC). Logistic regression was used to examine the association between identified predictor variables and attrition, using three distinct definitions of attrition based on clinician judgment, missed last appointment, and specified dose. The results of each regression analysis were qualitatively compared to assess the impact on findings observed when applying different definitions of attrition. Results: As anticipated, observed predictors of attrition varied by definition. Ethnicity predicted attrition across all definitions. Residing in a single-caregiver household predicted attrition across two of the three definitions, while living with a non-biological family, receiving state-funded, low-income insurance support, having low parent-reported youth functioning, routine intakes (as compared to urgent intakes), and longer wait predicted attrition within only one definition. Conclusions: Rates and factors associated with attrition may vary substantially depending on how treatment attrition is defined. In the evaluation of attrition in youth mental health settings, the definition used should be clearly stated and should reflect the research question posed.
Article
Key practitioner message: Analyses data from 296 patients at a private outpatient clinic in a routine practice setting (CBT). Completer/dropout definition: presence or absence of measurement battery at post-assessment. Focuses on change in therapy processes by investigating post-session reports. Finds that positive changes in self-esteem experiences is the most robust predictor of dropout, followed by ratings of clarification experiences and the global alliance. In line with recent dropout research, these process indicators might help to detect therapeutic situations that are connected with psychotherapy dropouts.
Article
In this study, a previously evaluated guided Internet-based cognitive behavior therapy for social anxiety disorder (SAD) was adapted for mobile phone administration (mCBT). The treatment was compared with a guided self-help treatment based on interpersonal psychotherapy (mIPT). The treatment platform could be accessed through smartphones, tablet computers, and standard computers. A total of 52 participants were diagnosed with SAD and randomized to either mCBT (n = 27) or mIPT (n = 25). Measures were collected at pre-treatment, during the treatment, post-treatment and 3 month follow-up. On the primary outcome measure, the Liebowitz Social Anxiety Scale–self rated, both groups showed statistically significant improvements. However, mCBT performed significantly better than mIPT (between group Cohen's d =0.64 in favor of mCBT). A larger proportion of the mCBT group was classified as responders at post-treatment (55.6% versus 8.0% in the mIPT group). We conclude that CBT for SAD can be delivered using modern information technology. IPT delivered as a guided self-help treatment may be less effective in this format.
Article
This report examines a possible distortion in the results of comparative treatment studies due to the association of the researcher's treatment allegiances with outcomes of those treatments. In eight past reviews a trend appeared for significant associations between the researcher's allegiance and outcomes of treatments compared. In a new review of 29 studies of treatment comparisons, a similar trend appeared. Allegiance ratings were based not only on the usual reprint method, but also on two new methods: ratings by colleagues who knew the researcher well, and self-ratings by the researchers themselves. The two new allegiance methods Interco related only moderately, but each allegiance measure correlated significantly with outcomes of the treatments compared, and when combined, the three measures explained 69% of the variance in outcomes Such an association can distort comparative treatment results. Our report concludes with how the researcher's allegiance may become associated with treatment outcomes and how studies should deal with these associations.
Article
Interpersonal psychotherapy (IPT) is an effective treatment for depression across the lifespan and across cultures. However, even when delivered with fidelity, some patients drop out and others do not improve sufficiently. Attention to IPT treatment attrition, dropout, nonresponse, or failure can elucidate its limitations and the opportunities to improve its effectiveness. Studies of factors known to moderate and negatively predict IPT depression treatment response are reviewed along with recommended modifications to improve outcomes. Although the risk of treatment failure always exists, it is possible to enhance treatment effectiveness by attending to the therapeutic alliance, strategically addressing depression, and adapting IPT to patient characteristics. These include adding pharmacotherapy, extending the course of treatment, and targeting specific symptoms or interpersonal vulnerabilities. Case examples illustrate several of these points.
Article
Interpersonal psychotherapy (IPT) is an effective specialty treatment for binge eating disorder (BED). Behavioral weight loss treatment (BWL) and guided self-help based on cognitive behavior therapy (CBTgsh) have both resulted in short-term reductions in binge eating in obese patients with BED. To test whether patients with BED require specialty therapy beyond BWL and whether IPT is more effective than either BWL or CBTgsh in patients with a high negative affect during a 2-year follow-up. Randomized, active control efficacy trial. University outpatient clinics. Two hundred five women and men with a body mass index between 27 and 45 who met DSM-IV criteria for BED. Intervention Twenty sessions of IPT or BWL or 10 sessions of CBTgsh during 6 months. Binge eating assessed by the Eating Disorder Examination. At 2-year follow-up, both IPT and CBTgsh resulted in greater remission from binge eating than BWL (P < .05; odds ratios: BWL vs CBTgsh, 2.3; BWL vs IPT, 2.6; and CBTgsh vs IPT, 1.2). Self-esteem (P < .05) and global Eating Disorder Examination (P < .05) scores were moderators of treatment outcome. The odds ratios for low and high global Eating Disorder Examination scores were 2.8 for BWL, 2.9 for CBTgsh, and 0.73 for IPT; for self-esteem, they were 2.4 for BWL, 1.9 for CBTgsh, and 0.9 for IPT. Interpersonal psychotherapy and CBTgsh are significantly more effective than BWL in eliminating binge eating after 2 years. Guided self-help based on cognitive behavior therapy is a first-line treatment option for most patients with BED, with IPT (or full cognitive behavior therapy) used for patients with low self-esteem and high eating disorder psychopathology. clinicaltrials.gov Identifier: NCT00060762.
Article
A randomized, controlled trial compared the combination of amitriptyline hydrochloride and short-term interpersonal psychotherapy, either treatment alone, and a nonscheduled treatment control group in ambulatory acute, nonbipolar, nonpsychotic depressives. Results show the efficacy of both psychotherapy and amitriptyline in overall symptom reduction. Amitriptyline and psychotherapy were about equal, and the effects of both treatments in combination were additive. The additive effect of combined treatment was largely due to the differential effects of the two treatments. Amitriptyline had its effect mainly on the vegetative symptoms of depression such as sleep and appetite disturbance, these occurred early in treatment, often within the first week. Psychotherapy had its effect mainly on mood, suicidal ideation, work, and interests; these effects occurred slightly later, at four to eight weeks.
Article
Despite the widespread use of psychotherapy as treatment for cocaine abuse, the effectiveness of psychotherapy has not been explored through clinical trials. Forty-two outpatients who met DSM-III criteria for cocaine abuse were randomly assigned to one of two forms of purely psychotherapeutic treatments of cocaine abuse, either relapse prevention (RPT) or interpersonal psychotherapy (IPT). Subjects assigned to relapse prevention were more likely than subjects in IPT to attain three or more continuous weeks of abstinence (57 versus 33%), be classified as recovered at the point of treatment termination (43 versus 19%), and complete treatment (67 versus 38%). Whereas these differences did not reach statistical significance, significant differences by treatment group did emerge when subjects were stratified by severity of substance use: Among the subgroup of more severe users, subjects who received RPT were significantly more likely to achieve abstinence (54 versus 9%) and be classified as recovered (54 versus 0%). Among the subgroups of subjects with lower severity of substance abuse, outcome was comparable for both treatment types. Comparison of results from this investigation with historical controls from a structurally similar pharmacotherapy trial suggests that purely psychotherapeutic treatments may be both viable and effective approaches for many ambulatory cocaine abusers.
Article
The present study examined child, parent, and family factors that predict dropping out from therapy among children (ages 4-13) referred for the treatment of oppositional, aggressive, and antisocial behavior. It was proposed that factors predicting attrition would vary as a function of whether families dropped out early or late in treatment. Several factors related to family (e.g., socioeconomic disadvantage, adverse child-rearing practices), parent (e.g., stress, life events, history of antisocial behavior), and child functioning (e.g., severity and chronicity of antisocial behavior, lower IQ, peer relations) predicted premature termination from treatment. A different pattern was evident in the factors predicting early and late termination from therapy. The findings have implications for conceptualizing the process of engaging and retaining families in treatment and for preventing premature termination.
Article
The extent of heterogeneity in a meta-analysis partly determines the difficulty in drawing overall conclusions. This extent may be measured by estimating a between-study variance, but interpretation is then specific to a particular treatment effect metric. A test for the existence of heterogeneity exists, but depends on the number of studies in the meta-analysis. We develop measures of the impact of heterogeneity on a meta-analysis, from mathematical criteria, that are independent of the number of studies and the treatment effect metric. We derive and propose three suitable statistics: H is the square root of the chi2 heterogeneity statistic divided by its degrees of freedom; R is the ratio of the standard error of the underlying mean from a random effects meta-analysis to the standard error of a fixed effect meta-analytic estimate, and I2 is a transformation of (H) that describes the proportion of total variation in study estimates that is due to heterogeneity. We discuss interpretation, interval estimates and other properties of these measures and examine them in five example data sets showing different amounts of heterogeneity. We conclude that H and I2, which can usually be calculated for published meta-analyses, are particularly useful summaries of the impact of heterogeneity. One or both should be presented in published meta-analyses in preference to the test for heterogeneity.