A practice-based exploration of therapeutic change in a charitable,community-based person-centred counselling service using routine outcome measures of anxiety and depression. I: Statistical and clinically significant change

Background

Establishing the value of differing treatments for depression and anxiety is crucial in a climate of delimited spending and increased demand. Drawing from a well-founded, diverse evidence base is salient to constructive evaluation and any subsequent recommendations being fit for purpose.

Design

This study employed a practice-based quantitative design to explore therapeutic gains in adult counselling clients attending person-centred therapy (n = 301), delivered in a charitable, community-based UK service.

Measures

Outcome measures PHQ-9 and GAD-7 were used from three time points: initial assessment (IA), first ongoing session and last or 6th ongoing appointment (whichever occurred first; T1, T2 and T3).

Analysis

Repeated measures ANOVA, CSI, RI and RCSI calculations were used to consider significant change in clients.

Findings

Reductions in PHQ-9 and GAD-7 outcome measures were observed over time (between T2 & T3 and T1 & T3) and were all statistically significant (p = <0.001). By T3: CSI was achieved by 48.1% of clients on PHQ-9 and 50.8% of clients on GAD-7, RI was achieved by 47.8% of clients on PHQ-9 and 60.5% of clients on GAD-7, and RCSI was achieved by 32.6% of clients on PHQ-9 and 41.2% of clients on GAD-7.

Conclusions

The treatment observed resulted in effective outcomes equivalent to other therapies reviewed in the literature for clients' symptoms of anxiety and depression as measured by GAD-7 and PHQ-9.     

The role of goal adjustment in symptoms of depression,anxiety and fatigue in cancer patients receiving psychosocial care: A longitudinal study

Objective: This study examined whether cancer patients reported increases in their goal adjustment capacities while receiving psychosocial care and whether these increases were related to changes in symptoms of depression, anxiety and fatigue. Goal adjustment was conceptualised as two independent capacities: goal disengagement (i.e. disengage from unattainable goals) and goal reengagement (i.e. reengage into new goals).

Design: This naturalistic, longitudinal study focused on 241 cancer patients receiving psychosocial care at one of the seven psycho-oncology institutions in the Netherlands. Data was collected before the start of psychosocial care (T1) and nine months thereafter (T2). Hierarchical regression analysis was used to examine the research questions.

Main Outcome Measures: Goal adjustment, symptoms of depression, anxiety and fatigue.

Results: At group level, patients reported small increases in goal disengagement (d = .22) but no significant change in goal reengagement (d = .09). At an individual level, 34% of cancer patients reported an increase in goal disengagement and 30% reported an increase in goal reengagement. Increases in goal reengagement were significantly associated with decreases in both depressive and anxiety symptoms, but not to changes in fatigue.

Conclusion: Findings indicate that particularly improvements in goal reengagement are beneficial for cancer patients’ psychological functioning.     

Religion and anxiety treatments in primary care patients

Earlier data suggested that religious physicians are less likely to refer to a psychiatrist or psychologist. This follow-up study measures how religious beliefs affect anxiety treatments in primary care. We surveyed US primary care physicians and psychiatrists using a vignette of a patient with anxiety symptoms. Physicians were asked how likely they were to recommend antianxiety medication, see the patient for counseling, refer to a psychiatrist, refer to a psychologist or licensed counselor, encourage meaningful relationships and activities, and encourage involvement in religious community. We experimentally varied symptom severity, whether the patient was Christian or Jewish, and whether she attended religious services. Physician attendance at religious services was assessed in the survey. The response rate was 896 out of 1427 primary care physicians and 312 out of 487 psychiatrists. Religious physicians were more likely to promote religious resources. There was no statistically significant difference between physicians' recommendations for religious and nonreligious patients. There was no statistically significant difference in religious and nonreligious physicians' referrals to a psychologist, licensed counselor, or psychiatrist. Ultimately, we did not find a difference in religious and nonreligious physicians' support for mental health referrals, however, religious physicians were more likely to encourage using religious resources.     

Effects of decreasing intersession interval duration on graduated exposure treatment during simulated routine dental care

Reports suggest that individuals with developmental disabilities often engage in behavior during dental visits that precludes regular dental care. Graduated exposure therapies are an effective treatment for avoidant behavior in people with developmental delays, and some studies show that the duration of the intersession interval (ISI) can impact the effectiveness of graduated exposure treatments for typically developing individuals. The current study examined the effects of decreasing ISI on outcomes of a graduated exposure treatment during simulated routine dental care for 3 individuals diagnosed with autism. Treatment consisted of graduated exposure and extinction for disruptive behavior. Initially, sessions were conducted once per week. In subsequent conditions, treatment sessions were conducted 3‐5 times per week. A nonconcurrent multiple baseline across subjects design was used to demonstrate experimental control. Results suggest that decreasing ISI durations can produce improved treatment outcomes.     

Health care utilisation in patients with non-cardiac chest pain: A longitudinal analysis of chest pain,anxiety and interoceptive fear

Chest pain can be a frightening experience that leads many to seek medical evaluation. The symptom results in costly health care utilisation. Over half of patients referred for cardiac evaluations of chest pain do not obtain definitive medical explanations for their symptoms; these cases are described as non-cardiac chest pain (NCCP). Some patients with NCCP are not reassured after being informed their chest pain is non-cardiac in origin and seek repeated medical evaluation. Co-morbid anxiety and mood disorders often coexist with NCCP and are associated with health care utilisation. The current study examined chest pain, general anxiety, interoceptive fear and health care utilisation in a sample of 196 chest pain patients near the time of cardiac evaluation (Time 1), and 70 of these patients one year later (Time 2). Results indicate that anxiety and interoceptive fear were significantly associated with health care utilisation at Time 1, and only interoceptive fear (at Time 1) predicted health care utilisation at Time 2. This study develops research in this area by examining the relation of anxiety and health care utilisation longitudinally in patients with NCCP.     

Both early and late changes in psychological variables relate to treatment outcome for musculoskeletal pain patients at risk for disability

We know little about why some people get better after psychological treatments for pain disability, whereas other people do not. In order to understand differences in treatment response, we need to explore processes of change during treatment. It has been suggested that people with pain complaints who change early in treatment have better outcomes. Therefore, we aimed to investigate whether changes in psychological variables at different time points are related to outcome, and whether early or late changes are better predictors of outcome. We used the fear avoidance model as a theoretical framework. We followed 64 patients weekly over 6–7 weeks and then determined outcome. Our findings indicate that people who decrease in catastrophizing and function early in treatment as well as in depressive symptoms, worry, fear avoidance beliefs and function late in treatment have better outcomes. Early decreases in function, and late decreases in depressive symptoms and worry uniquely predict improvements in disability. While early and late changes covaried concurrently, there were no significant sequential relationships between early and late changes. Changes in the proposed process variables in the fear avoidance model, early as well as late in treatment, thus add valuable information to the explanation of outcome.     

Therapists’ and clients’ perceptions of routine outcome measurement in the NHS: A qualitative study

Primary objective: This is the first qualitative study that elicited the perceptions of both psychological therapists and their clients in the use of Clinical Outcomes in Routine Evaluation with computer software (CORE‐Net), where instant visual feedback for session tracking was given on a computer screen in the therapy room at each therapy session. The study also examined how therapists viewed its potential value in supervision and provides suggestions for improving training. Research design: The study adopted a convenience sample of four therapists in a primary care counselling setting (PCC – General Practitioner referrals) who were experienced in using CORE‐Net, and five therapists in an NHS employee/occupational support counselling service (OH) who had just begun to use CORE‐Net for session tracking with 10 of their clients. Method: A qualitative methodology was used and interview data were collected from the therapists via focus groups; the clients were interviewed individually face to face. All data was analysed inductively. Findings: The study identified six overarching themes: (i) therapists were initially anxious and resistant; (ii) therapists adapt ‘creatively’; (iii) outcome measures help the client/therapist relationship; (iv) clients perceive visual measures as helpful; (v) CORE scores inform supervision; and (vi) proper and ongoing training/support of therapists is necessary. The main limitations are comparability of data and the generalisabilty of results. Conclusions: The implementation of routine outcome measurement (ROM) is a challenge but can be made easier with proper training and supervision. Clients appear happier than their therapists when routine outcome measurement is used.     

Short-term memory impairment in vestibular patients can arise independently of psychiatric impairment,fatigue, and sleeplessness

Vestibular dysfunction is associated with visual short-term memory impairment; however, it remains unclear if this impairment arises as a direct result of the vestibular dysfunction or is a consequence of comorbid changes in mood, affect, fatigue, and/or sleep. To this end, we assessed the concurrence and interdependence of these comorbidities in 101 individuals recruited from a tertiary balance clinic with a neuro-otological diagnosis. Over fifty per cent of the sample showed reduced visuospatial short-term memory, 60% and 37% exceeded cut-off on the Beck Anxiety and Depression Inventories, respectively, 70% exceeded cut-off on the Fatigue Severity Scale, 44% reported daytime sleepiness on the Epworth Sleepiness Scale, and 78% scored above cut-off on the Pittsburgh Sleep Quality Index. The high concurrence of these symptoms gives reason to infer the existence of a vestibular cognitive affective syndrome. Structural equation modelling indicated that the significant statistical association between general unassisted posture (a marker of chronic vestibular dysfunction and strong predictor of falls risk) and short-term memory was not mediated by mood and wakefulness. Instead, the memory impairment related more directly to vestibular dysfunction. From a rehabilitation perspective, the implication is that if the vestibular disorder is treated successfully then the memory problem will likewise improve.     

Fear of routine dental treatment in adults: Its nature and management

Abstract

The fear of dental treatment in adults can be characterised in several ways, loosely related, such as anticipating being afraid, avoiding dental check-ups and seeking treatment only under general anaesthesia. Defined thus, at least a quarter of adults are highly afraid of dentistry. The feared experiences are many, including most frequently, pain. Several studies have shown that anxious patients experience less pain during treatment than they expect. It remains to be confirmed that these are typical experiences because other studies show that local anaesthesia can fail to protect patients from sudden pain in 13% of treatments on average. Expectations of pain are highly resistant to change, the result probably of several influences including distortion in recall of pain-free treatment, intermittent experience of sudden severe pain, expecting pain in order to reduce its impact, and uncertainty about treatment. It has yet to be shown that experience free of discomfort can reduce these expectations. However, relaxation instructions and information about pain management and stop signals can reduce pre-treatment fear. To prevent the onset and the maintenance of anxiety: the prevention of pain is essential; controlled behavioural studies of the treatment of pain and other experiences such as panics are needed. Finally, the need for new instruments to assess all aspects of fear of dentistry is described.     

帕罗西汀配合心理干预对术后焦虑情绪的影响

研究帕罗西汀配合心理干预对术后焦虑情绪的影响。90例手术患者随机分为三组:A组术后常规治疗,B组常规治疗+帕罗西汀,C组常规治疗+帕罗西汀+心理干预。1周末B、C两组SAS和HAMA得分显著下降(P0.01),HAMA得分比较差异显著(P0.01),与A组比较差异显著(P0.01);2周末A组HAMA评分显著改善(P0.01)。帕罗西汀配合心理干预对术后焦虑情绪有显著而快速的影响。     

Eating behaviors and emotional distress are predicted by treatment and adverse outcome in patients with type 2 diabetes

Depression and anxiety are hightly prevalent among patients with Type 2 Diabetes (T2D), however not commonly related to outcomes, treatment and comorbidities. Eating behaviors could also have an implication. To evaluate the relation between mood and eating behaviors with demographic, physical, treatment, biochemical profiles and chronic comorbidities in T2D we conducted this exploratory cross sectional study in a population from Mexico. Hospital Anxiety and Depression Scale and the Three Factor Eating Questionnaire Revised 21 (TFEQ-R21) were correlated with age, gender, blood pressure, treatment and comorbidities (nephropathy, neuropathy, retinopathy and cardiopathy). Multi-linear regression models and 2^k factorial analyses were conducted. Sixty-one patients (31 male) 55 years old (SD 13) with at least 5 years of T2D were included. Anxiety correlated with depression (r = 0.25, p < 0.05). Gender (women) (std B 0.026, p < 0.001), insulin therapy (std B 0.3, p = 0.11), systolic blood pressure (std B 0.263, p = 0.02) and cardiovascular disease (std B 0.232, p = 0.035) predicted depression. Insulin therapy had a positive effect in cognitive restraint. (std B 0.32, p = 0.001). Age (std B 0.37, p = 0.003) and systolic blood pressure (std B 0.237, p = 0.048) predicted positively emotional eating (not previously published). 2^k factorial analyses proved additive interaction between complications and insulin therapy with depression. This study supports the relation between mood disorders and eating behaviors with demographic, physical, treatment, biochemical profiles and chronic comorbidities in T2D and the additive interaction between factors and mood disorders.     

Patterns and correlates of personal,family, and prior placement variables in an interagency community based system of care

We examined interrelationships among personal, family, and prior service utilization data collected on young people selected to participate in a Chicago suburban area system of care, with a detailed consideration of a subset of 176 White participants aged 9–20 years. Data obtained through a review of archival information and then analyzed included WISC IQ grade retention, medication status, DSM diagnostic group, adjudication, marital status of parents, living situation before selection, maternal employment, public assistance status, family risk status, and placement history. Results showed that IQ and specific DSM diagnostic category were not important correlates of personal, family, or placement variables, although having a DSM diagnosis of any kind was. Family risk factors, including family history of mental illness, substance abuse, criminal conviction, and violence in the family, were related to other family variables, primarily. Adjudication and prescribed medication appeared to have been alternative responses to these young people's problems. A cluster analysis of these system of care participants' placement histories indicated five clusters characterized by varied personal and family correlates, as well as different patterns of placement usage.     

The psychometric properties of the Greek version of the State-Trait Anxiety Inventory in cancer patients receiving palliative care

Objectives: To validate the Greek version of the State-Trait Anxiety Inventory (STAI) in a sample of cancer patients. Design: The scale was administered twice, with a 3-day interval, to 99 eligible patients with cancer. Together with the Greek version of STAI scale, the patients also completed the anxiety subscale from the Hospital Anxiety and Depression scale (HAD). Observations: Factor analysis yielded a three-factor solution, explaining 47.143% of the variance. Cronbach α for three scales was between 0.729 and 0.852. Inter-scale correlations were moderate-to-high and ranged from 0.282 to 0.563 (p < 0.0005, p < 0.005). The assessment of the relationships among the Greek STAI scales and HAD-Anxiety showed statistically significant correlations between them (r ranged between 0.428 and 0.596, p < 0.0005). The test/retest reliability of scale (Pearson's ‘r’), showed that the coefficient agreement ranged between 0.85 and 0.90 (p < 0.0005). Univariate analysis revealed significant correlations between female gender, metastasis, performance status, chemotherapy, mild opioids and low education level with increased anxiety. Conclusions: These results support that the Greek version of STAI is an instrument with satisfactory psychometric properties, and is a valid research tool for Greek cancer patients.     

Latent growth curve analysis of fear during a speech task before and after treatment for social phobia

Models of social phobia highlight the importance of anticipatory anxiety in the experience of fear during a social situation. Anticipatory anxiety has been shown to be highly correlated with performance anxiety for a variety of social situations. A few studies show that average ratings of anxiety during the anticipation and performance phases of a social situation decline following treatment. Evidence also suggests that the point of confrontation with the feared stimulus is the peak level of fear. No study to date has evaluated the pattern of anxious responding across the anticipation, confrontation, and performance phases before and after treatment, which is the focus of the current study. Socially phobic individuals (N = 51) completed a behavioral avoidance task before and after two types of manualized cognitive behavioral therapy, and gave ratings of fear during the anticipation and performance phases.Results from latent growth curve analysis were the same for the two treatments and suggested that before treatment, anxiety sharply increased during the anticipation phase, was highly elevated at the confrontation, and gradually increased during the performance phase. After treatment, anxiety increased during the anticipation phase, although at a much slower rate than at pretreatment, peaked at confrontation, and declined during the performance phase. The findings suggest that anticipatory experiences are critical to the experience of fear for public speaking and should be incorporated into exposures.     

The interpretation of negative social events in social phobia: changes during treatment and relationship to outcome

Catastrophic interpretations of negative social events are considered to be an important factor underlying social phobia. This study investigated the extent to which these interpretative biases change during cognitive-behavioural treatment for social phobia, and examined whether within-treatment changes in different types of interpretations predict longer-term treatment outcome. Results showed that treatment was associated with decreases in various types of maladaptive interpretations of negative social events, but that social phobia symptoms 3 months after treatment were independently predicted only by within-treatment reductions in the degree to which individuals personally believed that negative social events were indicative of unfavourable self-characteristics. These findings are discussed in relation to cognitive models of the maintenance of social anxiety, and implications for treatment are considered.     

The implementation of routine outcome measures in a Tier 3 Psychological Therapies Service: The process of enhancing data quality and reflections of implementation challenges

Background: The Newham Psychological Therapies Service (PTS) has been using the CORE System of evaluation to demonstrate effectiveness since 2004. More recently there has been the national and local drive to improve outcomes as outlined by a number of Department of Health policies and the Improving Access to Psychological Therapies (IAPT) initiative. Aims: This paper describes how, as a secondary care complex mental health service, we have engaged with the process of outcome measurement through complementing the usage of the CORE System with additional measures forming the service pilot minimum dataset. The process of implementation is outlined along with reflections on the challenges which the service faced in introducing outcome measurement. Findings: Engagement with outcome measurement by a service requires attention to be paid to the organisational and professional aspects and personal resonances for clinicians if it is to become established as a meaningful enterprise within secondary care services. Despite success at this task, challenges remain to the further development of this area of work.     

Characteristics of residential care for adolescent offenders: A comparison of assumptions and practices in two models

Staff assumptions and program practices in two models of residential care for male adolescent offenders were compared. Group care settings had from 6 to 15 youths in residence and used peer-mediated treatments. Treatment Foster Care settings had one youngster placed in each home and treatments were adult-mediated. Results showed that group care and Treatment Foster Care program models differed on staff assumptions about therapeutic mechanisms of change, and different patterns of daily program practices were found.     

More than one way to change: a study of course heterogeneity during and after short-term psychiatric in-patient treatment

This study describes differences in course and outcome, defined by GSI (SCL-90) at admission, discharge, and one‐year follow‐up, in 458 patients receiving in‐patient treatment for long‐standing symptom and/or personality disorders.
A K-mean cluster analysis identified seven subgroups of patients, representing four clinical distinct, meaningful patterns of change: early improvement, late improvement, relapsing after discharge, and a severe chronic course.
Main findings: the subgroups had unique correlates among socio-demographic, diagnostic, and treatment-related characteristics. One of the relapsing groups had a high rate of Cluster C personality disorders, whereas the other had low participation in the anxiety programme. The group with severe chronic course showed occupational maladjustment and high number of both Axis I and II disorders.
Implications: anxiety patients should participate in anxiety-treatment programmes, Cluster C patients should be followed and monitored for relapse, and severe chronic patients should be offered specialised treatment for their co‐existing substance abuse and/or eating disorders.