Post-Traumatic Stress Disorder Outcome Research: Why Moderators Should not be Neglected

Several psychotherapeutic treatments have been developed over the years for treating the symptoms of post-traumatic stress disorder (PTSD). But it remains still unclear which components of the complex treatment packages are necessary and most beneficial for PTSD symptom improvement. In PTSD outcome research, the randomized controlled trial (RCT) design has been applied in order to address this issue. However, meta-analyses repeatedly reported considerable variation between results from individual RCTs (i.e. between-study heterogeneity). Attempts to explain such heterogeneity led to the identification of relevant moderators of treatment effects in PTSD RCTs. This study presents meta-analytic findings, which show that factors, which are not part of the treatment (such as the investigators’ preferences for a particular treatment or the complexity of the patients’ clinical problems), impact on outcome in PTSD RCTs. We show that considering extra-therapeutic moderators in meta-analyses on PTSD RCTs may impact the conclusions and recommendations that may be deduced. The summarized findings confirm the notion that no PTSD treatment consistently outperforms the others and strengthen the position that even non-trauma-focused treatments may be beneficial PTSD treatments

Lay Perspectives on Empathy in Patient-Physician Communication: An Online Experimental Study

Research indicates that patients consider empathy as a key factor contributing to the quality-of-care. However, ambiguities in the definition of this multidimensional construct complicate definite conclusions to-date. Addressing the challenges in the literature, and using a hypothetical physician-patient interaction which explored patient-perceived differences between expressions of affective empathy, cognitive empathy, compassion and no empathy, this study aimed to test whether lay participants' evaluations of the quality-of-care depend on the type of empathic physician behavior, and on the physician's gender. We conducted a randomized web-based experiment using a 4 (type of empathy) by 2 (physician gender) between-subjects design. Empathy was subdivided into three concepts: first, affective empathy (i.e. feeling with someone); second, cognitive empathy (i.e. understanding); and third, compassion (i.e. feeling for someone and offering support). Perceived quality-of-care was the primary outcome. Compared with non-empathic interactions, quality-of-care was rated higher when physicians reacted cognitively empathic or compassionate (d = 0.71; 0.43 to 1.00 and d = 0.68; 0.38 to 0.98). No significant difference was found between affective empathy and no empathy (d = 0.13; -0.14 to 0.42). The physician's gender was not related with quality-of-care. Aspects of participants' personality but not their age, gender or the number of physician visits were associated with quality-of-care. No interactions were observed. In showing that patients rated quality-of-care higher when physician reactions were described as cognitively empathic and compassionate, as compared with affectively empathic or non-empathic, our findings refine views about the kinds of empathy that are important in patient care with implications for clinical practice, education and communication trainings

Does information structuring improve recall of discharge information? A cluster randomized clinical trial

The impact of the quality of discharge communication between physicians and their patients is critical on patients' health outcomes. Nevertheless, low recall of information given to patients at discharge from emergency departments (EDs) is a well-documented problem. Therefore, we investigated the outcomes and related benefits of two different communication strategies: Physicians were instructed to either use empathy (E) or information structuring (S) skills hypothesizing superior recall by patients in the S group.; For the direct comparison of two communication strategies at discharge, physicians were cluster-randomized to an E or a S skills training. Feasibility was measured by training completion rates. Outcomes were measured in patients immediately after discharge, after 7, and 30 days. Primary outcome was patients' immediate recall of discharge information. Secondary outcomes were feasibility of training implementation, patients' adherence to recommendations and satisfaction, as well as the patient-physician relationship.; Of 117 eligible physicians, 80 (68.4%) completed the training. Out of 256 patients randomized to one of the two training groups (E: 146 and S: 119) 196 completed the post-discharge assessment. Patients' immediate recall of discharge information was superior in patients in the S-group vs. E-group. Patients in the S-group adhered to more recommendations within 30 days (p = .002), and were more likely to recommend the physician to family and friends (p = .021). No differences were found on other assessed outcome domains.; Immediate recall and subsequent adherence to recommendations were higher in the S group. Feasibility was shown by a 69.6% completion rate of trainings. Thus, trainings of discharge information structuring are feasible and improve patients' recall, and may therefore improve quality of care in the ED

Greater than the sum of the parts: a qualitative content analysis of what constitutes a good treatment in the inpatient setting

Background The evaluation of psychotherapy is guided by established concepts, such as efficacy and effectiveness, and acceptability. Although these concepts serve as valid proxies, little is known about corresponding criteria for those directly involved in this treatment. This study aimed to explore inpatients’ and health professionals’ definitions of a good treatment in the inpatient setting. Methods Fifteen semi-structured interviews were conducted in a private psychiatric clinic in Switzerland and structured by qualitative content analysis. Different subsamples of the inpatient setting (patients N = 5; psychiatrists N = 5; other health professionals N = 5) were interviewed. Results In total, 546 text passages were grouped in 10 superordinate categories and identified as relevant for the concept of a good treatment. Participants stressed patient-specific (i.e., new insights; basic attitudes), treatment-specific (i.e., therapy methods and expertise; treatment success; therapy setting), and relationship-based (i.e., communication and feedback; relationships within the clinical setting; overcoming challenges and hurdles) components that are indispensable for a good therapeutic process. Components that are related to the clinical inpatient setting (i.e., setting and organization of the clinic; code of conduct) were also highlighted. Conclusions Patients’ and health professionals’ definitions of what constitutes a good treatment entails a wide array of aspects. The clinical setting is seen to offer unique components that are emphasized to have a healing effect

The effects of exercise on sleep in unipolar depression: A systematic review and network meta-analysis

Insomnia predicts the onset, course, and reoccurrence of unipolar depression. However, systematic reviews of treatment options for insomnia in unipolar depression are lacking. After screening 7725 records, 17 trials comprising 1645 patients randomized to 13 treatments were included for quantitative synthesis. Network meta-analysis showed that compared to a passive control condition, all exercise interventions except moderate aerobic exercise alone resulted in significantly better sleep outcomes. Compared with treatment as usual, mind-body exercise plus treatment as usual (SMD: −0.46; 95% CI: −0.80, −0.12) and vigorous strength exercise (SMD: −0.61; 95% CI: −1.12, −0.10) were significantly more effective. Pairwise meta-analyses showed that mind-body exercise (SMD: −0.54; 95% CI: −0.85, −0.23) had beneficial effects compared to passive control. The network meta-analysis is statistically very robust with low heterogeneity, incoherence, and indirectness. However, confidence in the findings was moderate to very low, primarily due to within-study bias. This is the first network meta-analysis to assess exercise's efficacy to improve sleep quality in patients with depression. The findings confirm the benefits of exercise as an add-on treatment for depression. This consolidation of the current state of evidence can help clinicians make evidence-based decisions

What are the Key Characteristics of a ‘Good’ Psychotherapy?

__Objective:__ The evidence-based practice movement clearly defines the relevant components of a good treatment. In the present article, we elaborate on how the active involvement of patients within psychotherapy can and should be increased in order to respect ethical considerations. Our arguments complement the requirements of evidence-based practice, and are independent of the actual psychotherapeutic treatment approach being used. __Method:__ Theoretical and ethical analysis. __Results:__ In order to respect patient autonomy, psychotherapy needs to be transparent and honest when it comes to disclosing the relevant factors for promoting therapeutic change. It has been argued that ethical informed consent needs to include empirically supported patient information. In this paper we go one step further: we outline that fully respecting ethical considerations in psychotherapeutic treatment necessarily calls for acknowledging and strengthening the active role of patients in the course of psychotherapy. Accordingly, patients need not only to be informed openly and transparently about the planned treatment, the treatment rationale, and the expected prognosis of improvement in the course of psychotherapy, but they also need to be actively involved in the decision-making process and during the entire process of psychotherapeutic treatment. __Conclusions:__ Our arguments support the tendency that can be observed in health care in recent years towards more active patient involvement across different health-care domains, but also in clinical research. This article offers an ethical perspective on the question what defines a ‘good psychotherapy', which, hopefully, will hel

Comparative efficacy of seven psychotherapeutic interventions for patients with depression: a network meta-analysis

BACKGROUND Previous meta-analyses comparing the efficacy of psychotherapeutic interventions for depression were clouded by a limited number of within-study treatment comparisons. This study used network meta-analysis, a novel methodological approach that integrates direct and indirect evidence from randomised controlled studies, to re-examine the comparative efficacy of seven psychotherapeutic interventions for adult depression. METHODS AND FINDINGS We conducted systematic literature searches in PubMed, PsycINFO, and Embase up to November 2012, and identified additional studies through earlier meta-analyses and the references of included studies. We identified 198 studies, including 15,118 adult patients with depression, and coded moderator variables. Each of the seven psychotherapeutic interventions was superior to a waitlist control condition with moderate to large effects (range d = -0.62 to d = -0.92). Relative effects of different psychotherapeutic interventions on depressive symptoms were absent to small (range d = 0.01 to d = -0.30). Interpersonal therapy was significantly more effective than supportive therapy (d = -0.30, 95% credibility interval [CrI] [-0.54 to -0.05]). Moderator analysis showed that patient characteristics had no influence on treatment effects, but identified aspects of study quality and sample size as effect modifiers. Smaller effects were found in studies of at least moderate (Δd = 0.29 [-0.01 to 0.58]; p = 0.063) and large size (Δd = 0.33 [0.08 to 0.61]; p = 0.012) and those that had adequate outcome assessment (Δd = 0.38 [-0.06 to 0.87]; p = 0.100). Stepwise restriction of analyses by sample size showed robust effects for cognitive-behavioural therapy, interpersonal therapy, and problem-solving therapy (all d>0.46) compared to waitlist. Empirical evidence from large studies was unavailable or limited for other psychotherapeutic interventions. CONCLUSIONS Overall our results are consistent with the notion that different psychotherapeutic interventions for depression have comparable benefits. However, the robustness of the evidence varies considerably between different psychotherapeutic treatments

Examining the reproducibility of meta-analyses in psychology:A preliminary report

Meta-analyses are an important tool to evaluate the literature. It is essential that meta-analyses can easily be reproduced to allow researchers to evaluate the impact of subjective choices on meta-analytic effect sizes, but also to update meta-analyses as new data comes in, or as novel statistical techniques (for example to correct for publication bias) are developed. Research in medicine has revealed meta-analyses often cannot be reproduced. In this project, we examined the reproducibility of meta-analyses in psychology by reproducing twenty published meta-analyses. Reproducing published meta-analyses was surprisingly difficult. 96% of meta-analyses published in 2013-2014 did not adhere to reporting guidelines. A third of these meta-analyses did not contain a table specifying all individual effect sizes. Five of the 20 randomly selected meta-analyses we attempted to reproduce could not be reproduced at all due to lack of access to raw data, no details about the effect sizes extracted from each study, or a lack of information about how effect sizes were coded. In the remaining meta-analyses, differences between the reported and reproduced effect size or sample size were common. We discuss a range of possible improvements, such as more clearly indicating which data were used to calculate an effect size, specifying all individual effect sizes, adding detailed information about equations that are used, and how multiple effect size estimates from the same study are combined, but also sharing raw data retrieved from original authors, or unpublished research reports. This project clearly illustrates there is a lot of room for improvement when it comes to the transparency and reproducibility of published meta-analyses

Researcher allegiance as hidden moderator in psychotherapy outcome research

Randomized controlled trials that compare 2 rival treatments are used as the standard design to identify those constituents of complex psychotherapeutic treatments that critically impact symptom improvement. This paper examines the impact of unbalanced researcher allegiance, i.e. the researchers' preference regarding a particular treatment, as an extra -therapeutic moderator of the treatment effect. As researcher allegiance can only be measured at study level, meta -analytic strategies are required to investigate the association between researcher allegiance and outcome. Our review shows that researcher allegiance has a considerable impact on outcome. Despite the finding that researcher allegiance may impact outcome particularly in studies of poorer quality, other causal pathways need to be considered when trying to understand the relationship between unbalanced researcher allegiance and outcome. Although the association between unbalanced researcher allegiance and outcome is well established, the causal pathways that mediate this association are not well understood to date. Accordingly, we conclude that explicit statements by researchers regarding their preferences in a comparative outcome trial (e.g. by stating clear hypotheses or by including a conflict of interest statement) appear to be the most straightforward response to our findings in order to protect the validity of conclusions from psychotherapy outcome research