Preferences Regarding Targeted Education and Risk Assessment in People with a Family History of Major Depressive Disorder

Genetic testing for susceptibility to major depressive disorder (MDD) is not available for clinical use at present. Given this, family history remains the best predictor for development of MDD, and family-history-based risk assessment and information about familial aspects of MDD may be useful to clients at increased risk for MDD attending for genetic counseling. This study uses a mixed-methods design to assess the information needs and preferences of people at increased familial risk for MDD. Telephone interviews were conducted with 23 individuals, who had at least one first-degree relative with MDD and were recruited through advertisements placed on depression education websites. The most preferred way to access depression information was via the internet (87 % of participants), although this preference may have been due to the internet-based recruitment method. The second most preferred dissemination strategy (56 %) was face-to-face delivery through a health professional, including genetic counselors. Individuals reported a need for information about etiology and development of MDD, reproductive decision-making, early detection of symptoms and risk-reducing strategies. Nearly all participants expressed an interest in risk assessment. The present study found evidence of a high level of interest for information targeted to people at increased familial risk for MDD. Genetic counselors are likely to be called upon increasingly to provide supportive counseling to assist clients at increased familial risk in interpreting and contextualizing such information once it becomes available.     

The Influence of Retention,Turnover, and Alliance on Process and Outcomes in Rolling Group Psychotherapy for Cocaine Disorder

A longitudinal repeated measures design was used to investigate the influence of treatment retention, and membership turnover on individual outcomes, and the relationship between individual-level and group-level therapeutic alliance in rolling group psychotherapy for individuals with cocaine abuse disorder. Eighteen patients were studied; data were collected prior to therapy and then monthly for 24 months. Patient outcomes and process were assessed. Improvements in symptoms and psychological functioning were associated with retention in psychotherapy. Membership turnover had a negative influence on symptoms. Development of an individual alliance was affected by the development of group-level therapeutic alliance, but not by time spent in therapy.     

The Persistent Case of Major Depression: An Argument for Long-Term Treatment

According to psychotherapy outcome literature, treatments for major depressive disorder (MDD) yield impressive results. Study after study demonstrates the efficacy of brief, evidence-based interventions for depressed individuals. Nevertheless, MDD continues to exact a devastating toll on modern society. The World Health Organization has identified it as the leading cause of disability worldwide. This reality is surprising given the implications from the academic literature. A historical analysis of MDD treatment suggests that most people with MDD experienced complete remission and enhanced outcomes when long-term, psychodynamically influenced treatments prevailed. An analysis of the system that perpetuates the brief intervention model for MDD, managed care, is discussed. This analysis is followed by a case study that illustrates the harm managed care can do to patients with MDD who are not permitted treatment of longer duration. Implications and recommendations for psychologists to intervene at the micro and macro levels are discussed.     

Providing a treatment rationale for PTSD: Does what we say matter?

Little is understood about the factors that influence a woman's preference for a particular type of treatment after an assault. Furthermore, it remains unclear the extent to which providing detailed information such as the mechanism underlying a treatment or its side effects can affect a client's treatment preference for psychotherapy or pharmacotherapy. The current study of 324 women with varying degrees of trauma exposure and posttraumatic stress symptoms experimentally manipulated the content of treatment rationales for two common PTSD treatments: sertraline (SER) and prolonged exposure (PE). Specifically, both information regarding the hypothesized mechanism of the treatment and treatment side effects were manipulated. In general, personal reactions were more positive and credibility was stronger for psychotherapy than pharmacotherapy. This preference for the psychotherapy persisted regardless of specific information presented in the treatment rationale. For those reporting heightened hyperarousal and those of minority status, there was an increased likelihood of more positive reactions to sertraline. The results highlight assessment of treatment-related beliefs and preferences early on in the therapeutic process. Ultimately, understanding the factors that shape treatment preferences may contribute to the development of personalized treatment strategies that integrate preferences and attitudes about treatment as a way of bolstering adherence and outcome.     

The acceptability and preference for the psychological treatment of PTSD

The acceptability and preference of psychological treatments is important in understanding patient treatment seeking, choice, engagement and attrition and possibly treatment response in health care. The acceptability of, and preference for, 14 different types of psychological treatment for posttraumatic stress disorder (PTSD) were investigated in a student population through invitation to participate in a web-based survey. Respondents were asked to rate each treatment on 10 scales and to rank the treatments in order of preference. Respondents were also asked whether they would seek treatment themselves, recommend treatment to friends and family, feel stigmatised by suffering from PTSD, had any prior knowledge of the treatments and if this had been positive or negative and whether they had a history of psychological problems or treatment. A total of 330 respondents completed the survey. A past or current history of psychological problems and treatment was surprisingly high. Almost all respondents indicated that they would seek or recommend treatment in spite of high levels of stigmatisation. Factor analysis of the 10 scales indicated two factors: Endorsement and Discomfort. Rank ordering on preference and Endorsement scores was highly consistent. The highly preferred and endorsed treatments involved cognitive therapy, exposure or psycho-education in spite of high levels of discomfort anticipated with exposure. Treatments involving new technologies, EMDR and psychodynamic psychotherapy received the lowest Endorsement and preference. There was a modest influence of prior knowledge of a treatment.     

Relational dynamics between psychotherapy clients and clinic administrative staff: A pilot study

Extensive empirical research has established therapeutic alliance as one of the most stable predictors of psychotherapy outcomes. Nearly all the contemporary empirical literature on therapeutic alliance focuses on the therapist-client dyad without attending to the relational experiences many clients in outpatient clinics have with administrative staff. Literatures from the fields of social work, psychiatric nursing and milieu therapy suggest there are more systemic relational and environmental dynamics that impact treatment beyond the therapist-client dyad, although these issues have been considered primarily in inpatient settings. A relational ecology framework has been developed drawing upon relational psychoanalysis, attachment theory and symbolic anthropology to help conceptualise the broader relational dynamics beyond the therapist-client dyad that may impact a more systemic therapeutic alliance in certain outpatient contexts. In an initial cross-sectional pilot study with a sample of clients (N = 107) receiving psychotherapy at a community mental health clinic in the Northeastern United States, the present study found client ratings of both (a) the therapeutic alliance with their therapists and (b) their alliance with administrative staff each significantly positively predicted client ratings of treatment. Thus, ratings of administrative alliance predicted client ratings of treatment over and above the effects of the therapist-client therapeutic alliance. These findings provide preliminary support for further investigation of the relational ecology of outpatient psychotherapy and suggest that client experiences of relational and environmental dynamics with administrative staff may be important contributors to psychotherapy outcomes. Limitations of the present study and implications for future research and practice are discussed.     

Der ausreichend gute Therapeut

Psychotherapists show a great variation in their ability to achieve positive outcomes in therapy. Specifically, they vary in terms of their ability to identify and repair ruptures in the therapeutic alliance. Alliance ruptures are a frequent phenomenon but often go undetected; however, repairing alliance ruptures represents a great opportunity to improve the psychotherapy process and therapy outcome. Empirical research suggests that patient feedback should be included in the psychotherapy process to be able to detect alliance ruptures better. From a psychodynamic point of view, a “sufficiently good” therapist is a therapist who can acknowledge the countertransference-based limitations in evaluating the therapeutic alliance with patients and the need to use feedback in order to detect and repair inevitable alliance ruptures. The consequences for research, practice and psychotherapy training are considered.     

The Role of Dyadic Discord in Outcomes in Acute Phase Cognitive Therapy for Adults With Recurrent Major Depressive Disorder

Major depressive disorder (MDD) and relationship discord between cohabiting partners frequently co-occur, with bidirectional effects established. As relationship quality influences understanding and treatment of MDD, the current analyses clarified the relations of pretreatment dyadic discord with outcomes during and at the end of acute phase cognitive therapy (CT) for adults with recurrent MDD. Married or cohabiting patients (n = 219) completed the Dyadic Adjustment Scale (DYS) before and after a 16–20 session, 12–14 week CT protocol. Lower levels of dyadic adjustment indicated higher levels of dyadic discord. Response to CT was defined as the absence of a major depressive episode and ≤ 12 on the 17-item Hamilton Rating Scale for Depression. Pretreatment dyadic discord, whether defined as a continuous or categorical variable (using DYS cutoff score of 97), was not associated with treatment completion or response but was positively associated with levels of depressive symptoms at the end of acute phase CT. Furthermore, CT was associated with declines in dyadic discord, with 23.3% of initially discordant couples moving to nondiscordant status at the end of CT. Depressive symptoms did not significantly mediate changes in dyadic discord. Finally, pre- (but not mid-) treatment dyadic discord was associated with subsequent changes in depressive symptoms, suggesting limited mediation. These findings replicate prior research indicating that individual CT is associated with reductions in depressive symptoms and dyadic discord while clarifying that lower pre-treatment dyadic discord may predict initial improvement in depressive symptoms.     

Chatbot-Delivered Psychotherapy for Adults With Depressive and Anxiety Symptoms: A Systematic Review and Meta-Regression

Although psychotherapy is a well-established treatment for depression and anxiety, chatbot-delivered psychotherapy is an emerging field that has yet to be explored in depth. This review aims to (a) examine the effectiveness of chatbot-delivered psychotherapy in improving depressive symptoms among adults with depression or anxiety, and (b) evaluate the preferred features for the design of chatbot-delivered psychotherapy. Eight electronic databases were searched for relevant randomized controlled trials. Meta-analysis and random effects meta-regression was conducted using Comprehensive Meta-Analysis 3.0 software. Overall effect was measured using Hedges’s g and determined using z statistics at significance level p < .05. Assessment of heterogeneity was done using χ² and I² tests. A meta-analysis of 11 trials revealed that chatbot-delivered psychotherapy significantly improved depressive symptoms (g = 0.54, 95% confidence interval [−0.66, −0.42], p < .001). Although no significant subgroup differences were detected, results revealed larger effect sizes for samples of clinically diagnosed anxiety or depression, chatbots with an embodiment, a combination of types of input and output formats, less than 10 sessions, problem-solving therapy, off-line platforms, and in different regions of the United States than their counterparts. Meta-regression did not identify significant covariates that had an impact on depressive symptoms. Chatbot-delivered psychotherapy can be adopted in health care institutions as an alternative treatment for depression and anxiety. More high-quality trials are warranted to confirm the effectiveness of chatbot-delivered psychotherapy on depressive symptoms.PROSPERO registration number: CRD42020153332.     

Ambulatory emotional reactivity to negative daily life events predicts remission from major depressive disorder

Major depressive disorder (MDD) is often associated with altered emotional reactivity. However, the functional significance of altered emotional reactivity in MDD is uncertain. This study was the first to examine the predictive relationship between intensely sampled ambulatory emotional reactivity and the clinical course of MDD. Forty-six outpatients who met criteria for MDD underwent six days of experience sampling of their ambulatory reactivity to everyday negative and positive life events. After experience sampling, all outpatients received pharmacotherapy with supportive psychotherapy and were followed clinically for 18 months. At one month, less emotional reactivity to negative and positive daily events predicted higher depressive symptom severity. Importantly, patients who exhibited less negative emotional reactivity to daily negative life events were less likely to recover from MDD over the 18 month follow-up. Relationships between ambulatory emotional reactivity and MDD course were not accounted for by the duration or the severity of initial MDD symptoms. Diminished ambulatory emotional reactivity appears to be functionally significant in depression. Intensive sampling of ambulatory emotions may have utility for predicting the clinical course of MDD.     

Racial/ethnic matching of clients and therapists in mental health services: a meta-analytic review of preferences, perceptions, and outcomes

Across several decades the effects of matching clients with therapists of the same race/ethnicity have been explored using a variety of approaches. We conducted a meta-analysis of 3 variables frequently used in research on racial/ethnic matching: individuals' preferences for a therapist of their own race/ethnicity, clients' perceptions of therapists across racial/ethnic match, and therapeutic outcomes across racial/ethnic match. Across 52 studies of preferences, the average effect size (Cohen's d) was 0.63, indicating a moderately strong preference for a therapist of one's own race/ethnicity. Across 81 studies of individuals' perceptions of therapists, the average effect size was 0.32, indicating a tendency to perceive therapists of one's own race/ethnicity somewhat more positively than other therapists. Across 53 studies of client outcomes in mental health treatment, the average effect size was 0.09, indicating almost no benefit to treatment outcomes from racial/ethnic matching of clients with therapists. These 3 averaged effect sizes were characterized by substantial heterogeneity: The effects of racial/ethnic matching are highly variable. Studies involving African American participants demonstrated the highest effect sizes across all 3 types of evaluations: preferences, perceptions, and outcomes.     

Emotions within reason: Resolving conflicts in risk preference

This research focused on differential effects of emotional and rational preferences in decision making and how people resolve conflicting risk preferences caused by inconsistency between their emotional reactions to and rational assessment of a risk problem. In addition, effects of the framing of choice outcomes on emotional, rational, and overall risk preferences were examined. Adopting a within-subjects design, Study 1 showed that the emotional choice preference was often the opposite of the rational choice preference and was more risk-seeking than the rational preference. The overall favourability rating for a chosen option was significantly higher when the emotional choice and rational choice were the same than when they were opposed. Emotional preferences were significantly more susceptible than rational preferences to the hedonic tone of risky choice framing. The overall preference was a compromise of the conflicting emotional and rational preferences in some risk domains, and resembled either the emotional preference or the rational preference in other risk domains. Study 2, using a between-subjects manipulation, further confirmed that emotional preference and rational preference had differential effects on risky choice.     

Reinforcement uncertainty enhances preference for choice in humans

Under concurrent‐chains schedules of reinforcement, participants often prefer situations that allow selection among alternatives (free choice) to situations that do not (forced choice). The present experiment examined the effects of reinforcement probability on choice preferences. Preferences for free versus forced choice were measured under a condition in which participants' choices were always reinforced (reinforcement probability of 1.0) and a condition in which outcomes were uncertain (reinforcement probability of 0.5). Forty‐four college students participated and preferences were examined under a concurrent‐chains schedule of reinforcement. Participants preferred free choice under uncertain reinforcement, but a bias toward free choice was not observed when reinforcement was certain. These results align with previous findings of preference for free choice under conditions of uncertainty, but suggest that preference may be dependent upon probabilistic reinforcement contingencies in the terminal links of the concurrent‐chains arrangement. Thus, reinforcement probability is an important variable to consider when conducting similar studies on the value of choice.     

Cognitive vulnerability to depression in individuals with borderline personality disorder

The goal of the current study was to examine whether individuals with comorbid Major Depressive Disorder (MDD) and Borderline Personality Disorder (BPD) exhibit greater severity of depressive symptoms than (1) individuals with MDD without BPD and (2) individuals with neither MDD nor BPD. One hundred and forty-one individuals participated in a semi-structured clinical interview assessing MDD and BPD. They also completed measures assessing depressive symptoms, depressogenic attributional style, hopelessness, self-esteem, rumination, and dysfunctional attitudes. In line with hypotheses, individuals with BPD and MDD exhibited higher levels of depressive symptoms and cognitive vulnerability than individuals in the other two groups. In addition, after controlling for the effects of cognitive vulnerability, the effect of group membership on depressive symptoms was reduced, suggesting that the increased severity of depressive symptoms experienced by those with BPD is partially due to their possessing higher levels of cognitive vulnerability to depression.     

Do Cognitive Therapy Skills Neutralize Lifetime Stress to Improve Treatment Outcomes in Recurrent Depression?

Cognitive therapy (CT) is an efficacious treatment for major depressive disorder (MDD), but not all patients respond. Past research suggests that stressful life events (SLE; e.g., childhood maltreatment, emotional and physical abuse, relationship discord, physical illness) sometimes reduce the efficacy of depression treatment, whereas greater acquisition and use of CT skills may improve patient outcomes. In a sample of 276 outpatient participants with recurrent MDD, we tested the hypothesis that patients with more SLE benefit more from CT skills in attaining response and remaining free of relapse/recurrence. Patients with more pretreatment SLE did not develop weaker CT skills, on average, but were significantly less likely to respond to CT. However, SLE predicted non-response only for patients with relatively weak skills, and not for those with stronger CT skills. Similarly, among acute-phase responders, SLE increased risk for MDD relapse/recurrence among patients with weaker CT skills. Thus, the combination of more SLE and weaker CT skills forecasted negative outcomes. These novel findings are discussed in the context of improving CT for depression among patients with greater lifetime history of SLE and require replication before clinical application.     

The relationship between agreeableness and the development of the working alliance in patients with borderline personality disorder

The working alliance between therapist and patient is an important component of effective interventions for borderline personality disorder (BPD). The current study examines whether client personality affects the development of the working alliance during the treatment of BPD, and whether this influences treatment effectiveness. Data was based on 87 patients with BPD who were participants in a randomized controlled trial comparing Dialectical Behavior Therapy (DBT) and general psychiatric management. Higher levels of trait Agreeableness were associated with steeper increases in working alliance throughout treatment, but only in the DBT condition. Increases in working alliance were in turn associated with better clinical outcomes. Mediation models revealed a significant indirect path from Agreeableness to better clinical outcomes, mediated through larger improvements in working alliance over time. These results highlight the role that patient personality can play during the therapeutic process, with a specific focus on the importance of Agreeableness for alliance development.     

Videoconferencing versus face-to-face psychotherapy: Insights from patients and psychotherapists about comparability of therapeutic alliance,empathy and treatment characteristics

Objective

Videoconferencing psychotherapy (VCT) is an effective treatment option. Yet, it is unclear whether a similar therapeutic alliance as in conventional face-to-face psychotherapy (F2F) can be achieved, since previous studies yielded mixed results. Furthermore, surveys about the attitudes towards VCT amongst patients have been missing until now. The current study gathered opinions from patients and psychotherapists about the perceived comparability of VCT and F2F regarding contextual factors and treatment characteristics, focusing on therapeutic alliance and empathy.

Method

An online survey amongst patients (N = 189) and practitioners (N = 57) taking part in cognitive behavioural therapy was conducted after the first lockdown in Germany due to the COVID-19 pandemic and a resulting transition from F2F to VCT for most participants.

Results

While patients experienced therapeutic alliance and empathy as comparable, psychotherapists indicated advantages of F2F. Both groups indicated advantages of F2F for the therapy contents and expressed advantages of VCT for flexibility regarding location and time. More than half of the participants expressed a preference for a combination of analogue and digital therapy.

Conclusion

The perceived disadvantages of VCT can be addressed, for example, with training programmes for psychotherapists targeting communication in VCT and adapting established psychotherapy methods to a digital format to further improve VCT.     

Can Cognitive‐Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive‐behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n = 121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre‐ to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT + TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1‐year follow‐up. Regarding family outcomes, adolescents in CBT + TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT‐alone showed an increase. The implication of these findings is discussed.