A Comparison of Rational Versus Empirical Methods in the Prediction of Psychotherapy Outcome

Several systems have been designed to monitor psychotherapy outcome, in which feedback is generated based on how a client\u27s rate of progress compares to an expected level of progress. Clients who progress at a much lesser rate than the average client are referred to as signal-alarm cases. Recent studies have shown that providing feedback to therapists based on comparing their clients\u27 progress to a set of rational, clinically derived algorithms has enhanced outcomes for clients predicted to show poor treatment outcomes. Should another method of predicting psychotherapy outcome emerge as more accurate than the rational method, this method would likely be more useful than the rational method in enhancing psychotherapy outcomes. The present study compared the rational algorithms to those generated by an empirical prediction method generated through hierarchical linear modeling. The sample consisted of299 clients seen at a university counseling center and a psychology training clinic. The empirical method was significantly more accurate in predicting outcome than was the rational method. Clients predicted to show poor treatment outcome by the empirical method showed, on average, very little positive change. There was no difference between the methods in the ability to accurately forecast reliable worsening during treatment. The rational method resulted in a high percentage of false alarms, that is, clients who were predicted to show poor treatment response but in fact showed a positive treatment outcome. The empirical method generated significantly fewer false alarms than did the rational method. The empirical method was generally accurate in its predictions of treatment success, whereas the rational method was somewhat less accurate in predicting positive outcomes. Suggestions for future research in psychotherapy quality management are discussed

Attention-Deficit/Hyperactivity Disorder Knowledge and Practices: A Survey of Pediatricians and Family Practice Physicians

Attention-deficit/hyperactivity disorder (ADHD) is a common childhood disorder often treated by pediatricians or family practice physicians. ADHD knowledge held by treating physicians may be an important predictor in patient outcomes. This study examined ADHD knowledge and common assessment and treatment practices of pediatricians and family practice physicians via a national survey sent to members of the American Academy of Pediatrics and the American Academy of Family Physicians. Mailings included the Knowledge of Attention Deficit Disorders Scale--Revised (KADDS-R) arid a demographic/practice questionnaire. Although both physician types reported utilizing assessment and treatment methods consistent with current ADHD practice guidelines, findings suggested that pediatricians had greater ADHD knowledge than did family physicians. Physicians who had completed a behavioral pediatric rotation or training specific to ADHD had greater knowledge than physicians who had not done so. The number of new ADHD evaluations conducted monthly was also related to ADHD knowledge. Implications for future research examining ADHD knowledge, training, and outcomes are discussed

Inappropriate data and measures lead to questionable conclusions

Letter to the EditorGlen I. Spielmans, Jon Jureidini, David Healy, Robert Pursse

Adjunctive Atypical Antipsychotic Treatment for Major Depressive Disorder: A Meta-Analysis of Depression, Quality of Life, and Safety Outcomes

Atypical antipsychotic medications are widely prescribed for the adjunctive treatment of depression, yet their total risk-benefit profile is not well understood. We thus conducted a systematic review of the efficacy and safety profiles of atypical antipsychotic medications used for the adjunctive treatment of depression

Adjunctive Atypical Antipsychotic Treatment for Major Depressive Disorder: A Meta-Analysis of Depression, Quality of Life, and Safety Outcomes

Background: Atypical antipsychotic medications are widely prescribed for the adjunctive treatment of depression, yet their total risk–benefit profile is not well understood. We thus conducted a systematic review of the efficacy and safety profiles of atypical antipsychotic medications used for the adjunctive treatment of depression. Methods and Findings: We included randomized trials comparing adjunctive antipsychotic medication to placebo for treatment-resistant depression in adults. Our literature search (conducted in December 2011 and updated on December 14, 2012) identified 14 short-term trials of aripiprazole, olanzapine/fluoxetine combination (OFC), quetiapine, and risperidone. When possible, we supplemented published literature with data from manufacturers' clinical trial registries and US Food and Drug Administration New Drug Applications. Study duration ranged from 4 to 12 wk. All four drugs had statistically significant effects on remission, as follows: aripiprazole (odds ratio [OR], 2.01; 95% CI, 1.48–2.73), OFC (OR, 1.42; 95% CI, 1.01–2.0), quetiapine (OR, 1.79; 95% CI, 1.33–2.42), and risperidone (OR, 2.37; 95% CI, 1.31–4.30). The number needed to treat (NNT) was 19 for OFC and nine for each other drug. All drugs with the exception of OFC also had statistically significant effects on response rates, as follows: aripiprazole (OR, 2.07; 95% CI, 1.58–2.72; NNT, 7), OFC (OR, 1.30, 95% CI, 0.87–1.93), quetiapine (OR, 1.53, 95% CI, 1.17–2.0; NNT, 10), and risperidone (OR, 1.83, 95% CI, 1.16–2.88; NNT, 8). All four drugs showed statistically significant effects on clinician-rated depression severity measures (Hedges' g ranged from 0.26 to 0.48; mean difference of 2.69 points on the Montgomery–Asberg Depression Rating Scale across drugs). On measures of functioning and quality of life, these medications produced either no benefit or a very small benefit, except for risperidone, which had a small-to-moderate effect on quality of life (g = 0.49). Treatment was linked to several adverse events, including akathisia (aripiprazole), sedation (quetiapine, OFC, and aripiprazole), abnormal metabolic laboratory results (quetiapine and OFC), and weight gain (all four drugs, especially OFC). Shortcomings in study design and data reporting, as well as use of post hoc analyses, may have inflated the apparent benefits of treatment and reduced the apparent incidence of adverse events. Conclusions: Atypical antipsychotic medications for the adjunctive treatment of depression are efficacious in reducing observer-rated depressive symptoms, but clinicians should interpret these findings cautiously in light of (1) the small-to-moderate-sized benefits, (2) the lack of benefit with regards to quality of life or functional impairment, and (3) the abundant evidence of potential treatment-related harm

BRIDGE study warrants critique

David M. Allen, Peter I. Parry, Robert Purssey, Glen I. Spielmans, Jon Jureidini, Nicholas Z. Rosenlicht, David Healy, Irwin Feinber

Effects of Home Exercise on Immediate and Delayed Affect and Mood Among Rural Individuals at Risk for Type 2 Diabetes

Physical activity is important for reducing overweight and obesity and related health consequences. This study examined changes in mood following 16 weeks of exercise in a sample of 29 individuals residing in a rural area and at risk for developing Type 2 diabetes mellitus (T2DM). Significant positive mood changes were detected, with moderate to large effect sizes. Assessments also revealed significant delayed postexercise positive emotion changes. These findings extend research on the mood benefits of exercise to individuals residing in rural settings and at risk for T2DM and suggest that to gain a full understanding of the exercise-affect relation, investigators need to assess affect at delayed intervals following exercise

Strategies and Practices in Off-Label Marketing of Pharmaceuticals: A Retrospective Analysis of Whistleblower Complaints

Aaron Kesselheim and colleagues analyzed unsealed whistleblower complaints against pharmaceutical companies filed in US federal fraud cases that contained allegations of off-label marketing, and develop a taxonomy of the various off-label practices

Comparative effect of collaborative care, pain medication, and duloxetine in the treatment of depression and comorbid pain in outpatient care: results of a randomized, placebo-controlled, multi-center trial

Objective: Evidence exists for efficacy of collaborative care (CC) against MDD, for efficacy of consequent use of pain medication against pain, and for efficacy of duloxetine against both MDD and neuropathic pain. However, their relative effectiveness in comorbid major depression (MDD) and pain has never been established so far. This study evaluates the effectiveness of CC, pain medication and duloxetine, and CC, pain medication and placebo, compared to duloxetine alone, on depressive and pain outcomes. Methods: Three armed cluster randomized multi-centre placebo controlled trial in consecutive patients presented at three specialized mental health outpatient clinics who screened positive for MDD. All interventions lasted 12 weeks. In the CC groups duloxetine or placebo was prescribed. Pain medication was administered according to an algorithm that avoids opiate prescription as much as possible as an alternative to the current WHO pain ladder, with paracetamol, COX inhibitors and pregabalin as steps before opiates are considered. Patients who did not show up for three or more sessions were registered as noncompliant. Explorative, intention-to-treat and per protocol, multilevel regression analyses were performed. The trial is listed in the trial registration (http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=1089; NTR number: NTR1089). Results: This study was prematurely terminated because of massive reorganisations and reimbursement changes for mental health care during the study. 60 patients completed the study. Patients in all treatment groups reported significant less depressive and pain symptoms after 12 weeks. CC with placebo condition showed the fastest decrease of depressive symptoms compared to the duloxetine alone group (b = -.78; p = .01), Noncompliant patients did not improve over the 12 weeks period. Pain outcomes did not differ between the three groups. Conclusions: In MDD and pain, compliance of patients and placebo effects are more important than choice of one of the three treatments. Active pain management in CC with COX inhibitors and pregabalin as alternatives to Tramadol or other opiates might provide an attractive alternative to the current WHO pain ladder as it avoids opiate prescription as much as possible. The study was sufficiently powered to show an exploratory result, but the generalizability is limited due to the small sample size. Larger studies are needed