ABSTRACT
Studies of the primary care treatment of depressed elderly patients are constrained by limited time and space and by subject burden. Research assessments must balance these constraints with the need for obtaining clinically meaningful information. Due to the wide-ranging impact of depression, assessments should also focus on suicidality, hopelessness, substance abuse, anxiety, cognitive functioning, medical comorbidity, functional disability, social support, personality, service use and satisfaction with services. This paper describes considerations concerning the assessment selection process for primary care studies, using the PROSPECT (Prevention of Suicide in Primary Care Elderly: Collaborative Trial) study as an example. Strategies are discussed for ensuring that data are complete, valid and reliable.
Subject(s)
Depressive Disorder/diagnosis , Geriatric Assessment , Primary Health Care , Suicide Prevention , Activities of Daily Living , Aged , Aging , Disabled Persons , Health Services for the Aged/statistics & numerical data , Humans , Personality , Social Support , Suicide/psychologySubject(s)
Depressive Disorder/nursing , Depressive Disorder/therapy , Geriatric Psychiatry/statistics & numerical data , Psychiatric Nursing/methods , Referral and Consultation/statistics & numerical data , Aged , Aged, 80 and over , Depressive Disorder/diagnosis , Female , Geriatric Assessment , Humans , Incidence , Male , Quality of Health Care , Risk Assessment , Severity of Illness Index , United StatesABSTRACT
This study measured distinctions made by a sample of clergy and mental health professionals in response to three categories of presenting problems with religious content: mental disorder, religious or spiritual problem, and "pure" religious problem. A national, random sample of rabbis (N = 111) and clinical psychologists (N = 90) provided evaluations of three vignettes: schizophrenia, mystical experience, and mourning. The participants evaluated the religious etiology, helpfulness of psychiatric medication, and seriousness of the presenting problems. The rabbis and psychologists distinguished between the three diverse categories of presenting problems and concurred in their distinctions. The results provide empirical evidence for the construct validity of the new DSM-IV category religious or spiritual problem (V62.89). Use of the V code allows for more subtle distinctions among the variety of problems that persons bring to clergy and mental health professionals. These distinctions may also provide a foundation for the initiation of co-professional consultation.
Subject(s)
Clergy/psychology , Mental Disorders/diagnosis , Psychology, Clinical , Religion and Psychology , Attitude of Health Personnel , Clergy/statistics & numerical data , Diagnosis, Differential , Grief , Humans , Interprofessional Relations , Mental Disorders/classification , Mental Disorders/drug therapy , Mysticism/psychology , Professional Competence , Psychology, Clinical/statistics & numerical data , Psychotropic Drugs/therapeutic use , Referral and Consultation , Reproducibility of Results , Sampling Studies , Schizophrenia/diagnosis , Schizophrenia/drug therapy , Schizophrenic Psychology , Surveys and Questionnaires , Terminology as TopicABSTRACT
Using the Coding System of Therapeutic Focus, this exploratory study was a comparative process analysis of clinically significant sessions obtained from 22 master cognitive-behavior and 14 master psychodynamic-interpersonal therapists. Therapists were nominated by experts in each of these orientations, and clients were seen in a naturalistic setting for problems with anxiety, depression, or both. Relatively few between-groups differences emerged with this master therapist sample. However, regardless of theoretical orientation, several differences were found between those portions of the session labeled by therapists as being clinically significant and those viewed as less significant. As these findings are different from those obtained in a previous study of the therapeutic focus in interventions carried out within the context of a controlled clinical trial, some of the possible factors contributing to these differences are noted.
Subject(s)
Psychotherapy , Adult , Analysis of Variance , Female , Humans , Male , Middle Aged , Process Assessment, Health Care , Psychotherapy/methods , Psychotherapy/standardsABSTRACT
The quality of the therapeutic alliance was compared in sessions of psychodynamic-interpersonal and cognitive-behavioral therapy, and the alliance's relationship to various session impacts was investigated. As part of the Sheffield Psychotherapy Project 2 (D. A. Shapiro, M. Barkham, A. Rees, G. E. Hardy, S. Reynolds, & M. Startup, 1994), 57 clients diagnosed with major depression received 16 sessions of either psychodynamic-interpersonal or cognitive-behavioral therapy. Coders used the Working Alliance Inventory to rate 1 high-impact and 1 low-impact session from each client. Results indicated significantly greater alliance scores for cognitive-behavioral therapy sessions on the whole. Also, for the samples as a whole, high-impact sessions were characterized by higher alliance scores than those for low-impact sessions, and alliance was positively related to therapists' ratings of session depth and smoothness and to clients' ratings of mood.
Subject(s)
Cognitive Behavioral Therapy , Cooperative Behavior , Depressive Disorder/therapy , Object Attachment , Professional-Patient Relations , Psychoanalytic Therapy , Adult , Analysis of Variance , Cognitive Behavioral Therapy/standards , Female , Humans , Male , Observation , Process Assessment, Health Care , Psychoanalytic Therapy/standards , Regression Analysis , Retrospective StudiesABSTRACT
Psychiatric distress is substantially prevalent among elderly individuals, particularly in the primary care and institutional settings, where most older persons receive mental health care. Barriers to care from providers include negative attitudes and stigmatization and poor recognition by general health care professionals. When psychiatric disorders are recognized, the intensity and duration of treatment provided is generally below standards for adequacy. Further research can determine the impact of patient, caregiver, and provider factors on treatment provision and on patient adherence to treatment. Assessment of factors influencing the treatment process are needed to ensure that treatments provided in the real world approximate the efficacy established in controlled clinical trials.
Subject(s)
Aged/psychology , Mental Health Services/statistics & numerical data , Mental Health Services/standards , Humans , Mental Disorders/diagnosis , Mental Disorders/psychologyABSTRACT
The ability of several process variables to predict therapy outcome was tested with 30 depressed clients who received cognitive therapy with or without medication. Two types of process variables were studied: 1 variable that is unique to cognitive therapy and 2 variables that this approach is assumed to share with other forms of treatment. The client's improvement was found to be predicted by the 2 common factors measured: the therapeutic alliance and the client's emotional involvement (experiencing). The results also indicated, however, that a unique aspect of cognitive therapy (i.e., therapist's focus on the impact of distorted cognitions on depressive symptoms) correlated negatively with outcome at the end of treatment. Descriptive analyses that were conducted to understand this negative correlation suggest that therapists sometimes increased their adherence to cognitive rationales and techniques to correct problems in the therapeutic alliance. Such increased focus, however, seems to worsen alliance strains, thereby interfering with therapeutic change.
Subject(s)
Cognitive Behavioral Therapy/methods , Depressive Disorder/therapy , Adult , Antidepressive Agents, Tricyclic/therapeutic use , Combined Modality Therapy , Depressive Disorder/psychology , Female , Humans , Imipramine/therapeutic use , Male , Outcome and Process Assessment, Health Care , Personality Inventory , Professional-Patient Relations , PrognosisABSTRACT
The prospect of using psychotherapy integration to enhance therapeutic efficacy increases as clinical discussion and empirical inquiry mount. The authors review briefly the historical origins of integrative thought, discuss the new receptivity with which it is being met, and examine the clinical use of an integrative framework, using progress in the treatment of panic disorder as an example of the potential of integrative treatment strategies.
