Barriers to Implementation of a Technology-Based Mental Health Intervention in a Rural Setting

This study utilized qualitative focus groups with rural health providers and patients to explore barriers to implementation of a technology-based mental health intervention for the treatment of depression in a primary care setting. A randomized controlled trial (RCT) was implemented in both urban and rural primary care practices to test the feasibility and effectiveness of computerized cognitive behavioral therapy (CCBT) for depression. Early implementation identified lower rates of willingness to participate in the intervention by rural patients. Subsequently, focus groups were conducted with rural providers and patients to explore barriers to participation and strategies to overcome these barriers in future implementation efforts. Two focus groups of five to seven participants each were conducted to understand patient experiences. Groups lasted approximately one hour and were recorded and transcribed for coding purposes. Key themes identified about barriers to use of CCBT by rural patients emerged included: 1) technical barriers, 2) stigma, 3) distrust of outsiders, 4) effort/motivational barriers, and 5) staff resistance/frustration. Conversely, several positive themes related to supports for CCBT also emerged, including: 1) readiness to change/symptom severity, 2) program supports and incentives, 3) clinician support, 4) components of the intervention, and 5) individual patient characteristics

Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial

Importance Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. Objectives To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. Design, Setting, and Participants This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire–9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. Interventions CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master’s level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. Main Outcomes and Measures The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder–7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire–8. Results The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, −2.5; 95% CI, −4.5 to −0.8; P = .005) and 3 month (mean difference, −2.3; 95% CI, −4.5 to −0.8; P = .006) and 6 month (mean difference, −3.2; 95% CI, −4.5 to −0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). Conclusions and Relevance In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome

Improving cost-effectiveness and access to cognitive behavior therapy for depression: providing remote-ready, computer-assisted psychotherapy in times of crisis and beyond

Introduction. There is growing evidence that computer-delivered or –assisted forms of cognitive-behavior therapy (CCBT) are helpful, but cost-effectiveness versus standard therapies is not well established. Objective. To evaluate the cost-effectiveness of a therapist-supported method for CCBT in comparison to standard CBT. Method. 154 drug-free MDD outpatients were randomly assigned to either 16 weeks of standard CBT (up to twenty 50-minute sessions) or CCBT using the Good Days Ahead program (including up to 5.5 hours of therapist contact). Outcomes were assessed at baseline, weeks 8 and 16, and at 3 and 6 months post-treatment. Economic analyses took into account the costs of services received and work/social role impairment. Results. In the context of almost identical efficacy, a form of CCBT that used only about onethird the amount of therapist contact as conventional CBT was highly cost-effective compared to conventional therapy and reduced cost of treatment by $928 per patient. Conclusions. A method of CCBT that blended internet-delivered modules and abbreviated therapeutic contact reduced the cost of treatment substantially without adversely affecting outcomes. Results suggest that use of this approach can more than double the access to CBT. Because clinician support in CCBT can be provided by telephone, videoconference, and/or email, this highly efficient form of treatment could be a major advance in remote treatment delivery

What is an evidence-based case formulation?

This work posits and answers the question about 'What is an evidence-based case formulation?' It tries to shed some light on the topic by proposing three key criteria that any therapist could follow to assess a particular model of case formulation (CF), or when taking into consideration his or her own practice: The first criterion relates to the grounding of the CF's core hypothesis on a theory supported by a solid and relevant evidence; the second criterion relates to the features of the kind of reasoning, in which the clinical judgement that nurtures the formulation is based; and the third criterion, that relates to the extent in which a given formulation is founded on a structured model of CF. Furthermore, the background of evidence-based CF as a form of Evidence-Based Practice in Psychology (EBPP) is reviewed, as well as what constitutes appropriate evidence in CF. An evidence-based, systematic framework for CF is also provided and explained

Generating and Generalizing Knowledge about Psychotherapy from Pragmatic Case Studies

An epistemological case is made for how single subject psychotherapy research provides unique and untapped opportunities for generating and generalizing scientific knowledge about psychotherapy. The epistemological claim asserts that it is essential that problem and method be aligned in psychotherapy research. Examples of misalignment in experimental and correlational contexts are given and their consequences discussed. Both Molenaar and Valsiner's (2005) genetic metaphor of phenotypes and genotypes and Lewin's (1931) concept of Aristotelian and Galileian thinking provides further epistemological grounds for the value of single subject research. Several suggestions are made for how to reconcile the epistemological problems discussed. Finally, examples are given of how a database generated by the PCSP journal process might serve as a tool to generate and generalize psychotherapy knowledge

Why Do Some Psychotherapy Clients Get Better Than Others?

This commentary explores reasons why one clien

In Support of Evidence-Based Case Formulation in Psychotherapy (From the Perspective of a Clinician)

Persons (2013) has commented on my article (Eells, 2013) about  revisiting the case formulation approach to psychotherapy research. I elaborate on her ideas by advocating for an evidence-based case formulation (EBCF) model of psychotherapy practice. The latter encourages clinician freedom of choice to select a case conceptualization and treatment plan, as long as those choices are empirically defensible.  While the EBCF approach is intellectually challenging for clinicians, it has the advantage of being  flexible in accommodating evidence, including but not limited to that derived from randomized clinical trials. The EBCF approach is preferable to the untenable position of relying primarily on one’s personal experience as a therapist or primarily on intuition.  The EBCF approach is an empirically defensible alternative to the empirically supported treatment (EST) movement.  Clinical judgment is emphasized more in the EBCF approach than in ESTs.  Conditions are described under which intuition in context can be trusted as one of a number of components of evidence-based practice.  Finally, since therapists practicing ESTs tailor treatment to meet patient needs as they arise, a false dichotomy may exist between the EST and EBCF approaches when considering psychotherapy as it is actually practiced.  A mixed-methods research agenda that examines the case formulation hypothesis can help determine whether such a false dichotomy exists, while advancing knowledge of psychotherapy as it unfolds in practice

Case Studies Help Us Read Between the Lines of Manual-Driven Therapy

Edwards’ (2010) article illuminates the benefits of systematic case series analysis in exploring metacompetencies such as therapist responsiveness.  These benefits are unique contributions of systematic case analyses since the situational and temporal contexts provided by cases are  lost in group comparison research such as randomized clinical trials.  For this reason, the two approaches triangulate well with each other, in the sense described by Edwards.  Aggregation of findings from multiple cases facilitates generalization.  Edward’s systematic case series of PTSD treatments demonstrates one important and pragmatic way in which this generalization can be accomplished.  I discuss Edward’s approach to studying therapist responsiveness in light of methodology, theory-building, training, and case formulation

Can Therapy Affect Physical Health?

A n impressive amount of research has accumulated over past decades suggesting that psychological states can have a profound effect on physiological processes. Psychoimmunologists focusing on the effects of stress have demonstrated that the mind affects the body through the neuroendocrine system. Glaser et al. 1 found suppressed immune functioning in highly stressed medical students. Pennebaker and colleagues 2 demonstrated that healthy college students who write about traumatic events have stronger immune functioning, visit university health clinics less frequently, and experience greater subjective well-being compared with control subjects. Similarly, Cohen et al. 3 found that highly stressed subjects were more likely to contract the cold virus compared with low-stress counterparts. Expanding beyond a focus on stress, Peterson and Seligman 4 reviewed several studies suggesting that a psychological trait (pessimism) can affect long-term health outcomes. Luborsky 5 conducted a series of single-subject studies of psychotherapy patients and identified psychological antecedents to stomach ulcer pains, migraine-like headaches, absence epilepsy episodes, and premature ventricular contractions of the heart. With this background in mind, I was curious to find out whether any recent psychotherapy research has explicitly addressed physiological outcomes. Therefore, I conducted an online literature search of the PsycINFO database for articles published since 1998 identified by the search terms "psychotherapy and health" and "psychotherapy and physical illness." I found the following seven articles. Summary: This article reviews some of the most methodologically rigorous outcome research in four areas of health psychology and behavioral medicine: smoking cessation, chronic pain, cancer, and bulimia nervosa. The authors' goal was to determine whether psychological therapy for these conditions meets criteria for empirically supported treatments as outlined by Chambless and Hollon. ABSTRACTS 6 These conditions were selected because they represent the diversity and significance of psychotherapy in health psychology and behavioral medicine. Outcomes were aimed at alleviating subclinical symptoms of anxiety and depression (in response to pain or the diagnosis and treatment of cancer); treating symptoms that can dramatically interfere with daily functioning and quality of life (chronic pain); treating a psychiatric diagnosis that relates directly to physical functioning (bulimia nervosa); reducing or eliminating potentially life-threatening behaviors (smoking); and prolonging life (cancer). With regard to smoking cessation, the authors focused on research since 1990 that reported the percentage of subjects who had completely ceased smoking at a 1-year follow-up and in whom abstinence could be corroborated biochemically. The most successful treatments were behavioral or cognitive-behavioral, achieving complete abstinence rates of 32% to 44%. These treatments were short-term and included some or most of the following components: an educational focus, environmental management (e.g. removal of ashtrays), Research Abstract

The Case Formulation Approach to Psychotherapy Research Revisited

This article revisits the case formulation approach to psychotherapy outcome research, first proposed by Persons (1991).  Persons asserted that randomized clinical trials (RCTs) of psychotherapy do not test the theoretical underpinnings of psychotherapy models since these trials standardize rather than individualize patient problems, ignore the link between individualized assessment and treatment as described in these models, and employ standardized rather than individualized treatment.  This article assesses the current status of these claims, concluding that they remain valid today.  A reformulated case formulation approach is described and research strategies proposed.  Investigating the reformulated case formulation approach will require increased resources for case formulation training, the addition of treatment arms in effectiveness trials that include case-formulation-based interventions, and expanded RCTs that include systematic case studies