Faculty Bibliography

OBJECTIVE: To identify variables predicting psychotherapy outcome for panic disorder or indicating which of 2 very different forms of psychotherapy-panic-focused psychodynamic psychotherapy (PFPP) or cognitive-behavioral therapy (CBT)-would be more effective for particular patients. METHOD: Data were from 161 adults participating in a randomized controlled trial (RCT) including these psychotherapies. Patients included 104 women; 118 patients were White, 33 were Black, and 10 were of other races; 24 were Latino(a). Predictors/moderators measured at baseline or by Session 2 of treatment were used to predict change on the Panic Disorder Severity Scale (PDSS). RESULTS: Higher expectancy for treatment gains (Credibility/Expectancy Questionnaire d = -1.05, CI95% [-1.50, -0.60]), and later age of onset (d = -0.65, CI95% [-0.98, -0.32]) were predictive of greater change. Both variables were also significant moderators: patients with low expectancy of improvement improved significantly less in PFPP than their counterparts in CBT, whereas this was not the case for patients with average or high levels of expectancy. When patients had an onset of panic disorder later in life (>/=27.5 years old), they fared as well in PFPP as CBT. In contrast, at low and mean levels of onset age, CBT was the more effective treatment. CONCLUSIONS: Predictive variables suggest possibly fruitful foci for improvement of treatment outcome. In terms of moderation, CBT was the more consistently effective treatment, but moderators identified some patients who would do as well in PFPP as in CBT, thereby widening empirically supported options for treatment of this disorder. (PsycINFO Database Record

Although widely used, the Hamilton Rating Scale for Depression (HRSD) and Hamilton Anxiety Rating Scale (HARS) discriminate poorly between depression and anxiety. To address this problem, Riskind, Beck, Brown, and Steer (J Nerv Ment Dis. 175:474-479, 1987) created the Reconstructed Hamilton Scales by reconfiguring HRSD and HARS items into modified scales. To further analyze the reconstructed scales, we examined their factor structure and criterion-related validity in a sample of patients with major depressive disorder and no comorbid anxiety disorders (n = 215) or with panic disorder and no comorbid mood disorders (n = 149). Factor analysis results were largely consistent with those of Riskind et al. The correlation between the new reconstructed scales was small. Compared with the original scales, the new reconstructed scales correlated more strongly with diagnosis in the expected direction. The findings recommend the use of the reconstructed HRSD over the original HRSD but highlight problems with the criterion-related validity of the original and reconstructed HARS.

OBJECTIVE: Scholars increasingly recognize that therapeutic alliance and symptomatic change are associated with one another. A common assumption is that alliance predicts symptomatic change. However, the issue is far from settled. One challenge in determining the causality is the establishment of temporal precedence showing that alliance, as opposed to previous symptomatic change, drives subsequent symptomatic reduction. METHOD: To make further advances in untangling this chicken-and-egg question, we employed autoregressive cross-lagged modeling over 4 time points in a sample of 149 depressive patients receiving supportive-expressive psychotherapy or clinical management combined with pharmacotherapy or clinical management combined with placebo. RESULTS: Using this methodology, we found that both alliance and symptoms across treatment made significant and unique contributions in predicting subsequent symptomatic levels throughout treatment. Additionally, alliance, but not symptoms, predicted subsequent alliance levels. No differences were found between treatments. CONCLUSIONS: Our findings imply that alliance temporally precedes symptomatic levels throughout treatment.

Will patients project their representations of significant others onto the therapist in a way that influences the formation of the therapeutic alliance? To address this issue, the current study explored the following questions: (1) To what extent are pretreatment representations of others projected onto the therapist and thereby predict the development of alliance throughout the course of treatment? (2) To what extent are these projections affected by the real relationship? (3) Are there specific representations of others that are more prone to be projected onto the alliance? To this end, data on 134 patients from a randomized controlled trial for depression comparing dynamic supportive-expressive therapy with supportive clinical management combined with pharmacotherapy or placebo were used. Findings demonstrated that the patients' pretreatment representations of significant others predicted a substantial part of the alliance with the therapist throughout the course of treatment. However, the representations of others were not automatically projected onto the alliance but rather the projections were also influenced by the real relationship with the therapist. Throughout this process, the alliance evolves into a collage of significant others. A process of assimilation seemed to emerge during treatment, in which the most relevant representations of significant others were projected onto the alliance with the therapist.

Passing the Examination for Professional Practice in Psychology (EPPP) is a prerequisite to professional licensure throughout the United States and much of Canada. As such, the EPPP helps serve a gatekeeping function for the many subspecialties of professional psychology. After first reviewing the history, validation process, known associations with other variables, and criticisms of the EPPP, we summarize the most recent program-level data according to degree type and specialty. To assess the predictors of EPPP performance, these data (i.e., % correct and recently released EPPP pass rates) were combined with other sources of graduate program information. We hypothesized that EPPP performance would be associated with program prestige, program selectivity (e.g., admission rates), and student factors predating graduate training (e.g., intelligence, motivation, and standardized test-taking ability as approximated by GRE scores and GPA). As predicted, and in every case, the EPPP was significantly correlated with these three sets of variables. Specifically, the strongest associations were found with higher GRE scores, lower admission rates, better US News and World Report scores, and greater research emphasis. We also explored the influence of minority status, and found a negative correlation between EPPP performance and the percentage of minority students in programs. To determine the strongest predictors of EPPP performance, a series of simultaneous multiple regressions was conducted. The three consistent predictors across regressions were GRE scores, percentage of minorities in programs, and internship match rates. Suggestions for clarifying these findings as well as recommendations to assess the EPPP's validity further are provided.

Long-Term Psychoanalytic Treatments (LTPT) include both long-term psychoanalytic psychotherapy (LTPP) and psychoanalysis (PsAn). Current opinion seems to be that there is some evidence for the effectiveness of LTPP, but none for that of PsAn. This may be due in part to researchers not balancing the level of evidence of randomized controlled studies (RCTs), cohort studies, and pre-post studies with patients' acceptance of these various research designs used in studying the effectiveness of LTPT. After a review of the merits of eight possible control conditions for LTPT in RCTs and cohort studies, and a consideration of the limitations and merits of pre-post studies, it was found that RCTs pair high levels of evidence with limited degrees of patient acceptance, especially where PsAn is concerned. Cohort studies appear to provide at most a moderate level of evidence. Their acceptability is hardly better than that of RCTs, as it depends on the acceptability of control conditions similar to those of RCTs. The acceptability of pre-post studies is much better, but they can provide, at most, a moderate level of evidence. Apart from randomization, they can meet all methodological criteria for high-quality research (often they do not, but there are ways to correct this). In summary, in the long-term treatment of complex mental disorders with LTPT, RCTs often pair a high level of evidence with limited patient acceptance of the method. Compared to RCTs, cohort studies show a lower level of evidence without much gain in acceptability. Pre-post studies pair the highest level of acceptability with the lowest level of evidence of the three designs. Limited acceptability is not to be confused with no acceptability, nor moderate level of evidence with none.

OBJECTIVE: To determine whether supportive-expressive psychotherapy (SET), a form of dynamic psychotherapy, and pharmacotherapy + clinical management (MED) for major depressive disorder (MDD) are more effective than pill-placebo + clinical management (PBO). METHOD: This National Institute of Mental Health (NIMH)-sponsored randomized controlled trial was conducted (from November 2001 through June 2007) at the University of Pennsylvania Medical School. The sample included 156 patients diagnosed with MDD (DSM-IV) and having a 17-item Hamilton Rating Scale for Depression (HRSD(17)) score >/= 14 for at least 2 consecutive weeks. This was an underserved sample in which 41% were male, 52% were self-designated minorities, and 76% had an annual income under $30,000. Treatment lasted 16 weeks. Medication patients not responsive by week 8 (maximum dose 200 mg/d of sertraline) were switched to venlafaxine (maximum dose 375 mg/d). Nonresponsive placebo patients at week 8 were switched to a different placebo. RESULTS: Patients' depression improved over the 16 weeks (P < .0001), with no between-group differences (P = .95), even among severely (HRSD(17) score >/= 20) depressed patients (P = .45). Response rates did not differ between groups (P = .73). Gender and minority status moderated outcome (P = .014), with psychotherapy more efficacious for minority men than MED (P = .027, Cohen d = 1.02) and PBO (P = .019, d = 1.09). PBO was more efficacious for white men than MED (P = .03, d = 0.62) and SET (P = .003, d = 1.07). For white women, MED (P = .005, d = 0.77) and SET (P = .033, d = 0.71) were more efficacious than placebo. No differences among treatments were found for minority women. CONCLUSIONS: This trial of urban MDD patients failed to confirm that either active treatment was better than placebo. Minority status and gender had significant and differential effects on outcome that warrant replication in future studies. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00043550.

Abstract The study utilized a generalizability theory analysis of adherence and competence ratings to evaluate the number of sessions and patients needed to yield dependable scores at the patient and therapist levels. Independent judges' ratings of supportive expressive therapy (n = 94), cognitive therapy (n = 103), and individual drug counseling (n = 98) were obtained on tapes of sessions from the NIDA Collaborative Cocaine Treatment Study. Generalizability coefficients revealed that, for all three treatments, ratings made on approximately five to 10 sessions per patient are needed to achieve sufficient dependability at the patient level. At the therapist level, four to 14 patients need to be evaluated (depending on the modality), to yield dependable scores. Many studies today use fewer numbers.