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Fichier Détails
| Cartes-fiches | 298 |
|---|---|
| Langue | Deutsch |
| Catégorie | Devinettes |
| Niveau | Université |
| Crée / Actualisé | 28.02.2023 / 12.09.2023 |
| Lien de web |
https://card2brain.ch/box/20230228_evaluation_of_psychotherapeutic_interventions_
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Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); response(es verändert sich was) vs. remission(kein klin. relevanter score mehr); was kann man bei severely patients in den HRSD bzw. in den BDI socres am ende beobachten?
ADM + CT waren bei beiden mehoden ähnlich(50 response, 40 remission), bei BDi war ADM allerdings sogar noch schlechter als CT
BA war im HRSD besser bzgl. Remission--> 56%
BA war im BDI besser bzgl. response--> 76%
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); welche gruppe wurde wann + wie oft im follow up assessed? was war die beonderheit bei den adm leuten?
besonderheit: alle gruppen bis auf placebo haben grundlegend teilgenommen, es wurden nur respondeer eingeladen, adm responder wurden wurden nun in der follow up phase random in placebo oder medi aufgeteilt-->
1. year follow up--> 3,6,12 monate --> alle amigos(placebo, medication, BA, CT) an bord
2. year follow up--> 13,14,18,24 months--> placebo nicht, sonst alle --> in den zweiten 12 monaten haben die medi leute allerdings keine mediaktion bmehr bekommen sondern wurden nur noch befragt(CT + BA haben durchgängig keine therapie bekommen)
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); wie waren unterschiede bei treatment respondern in der follow up phase (erste 12monate) ausgeprägt?
placebo--> nur noch 40%, die anderen 55-65%--> CT the best!
nur CT + BA signi besser als placebo
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); wie waren unterschiede bei treatment respondern in der follow up phase (zweite 12monate) ausgeprägt?
placebo leute wurden ja nicht mehr assesssed; die adm leute welche keine medis mehr bekommen haben--> responder rate signi auf 0.15 abgesackt
BA +CT rate um die .50--> signi besser
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); was kann man also als fazit über die 3jährige post assessement phase sagen?
These results
indicate that brief
treatment with either
CT or BA is as
efficacious over the
long run as keeping
people on ADM
--> signi mehr leute in der CT responder gruppe waren nach einem bzw. 2 jahren relapsefree als die medi/placebo bzw. medi/medi condition; auch BA hat besser als die medi conditionen abgeschnitten
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); was kann man im summary sagen wenn man nur die medi gruppe mit den anderen vergeleicht?
Replication of results of TDCRP (Elikin, 1994) and
dismanteling study of Jacobson et al. (1996) and Gortner et
al. (1998)
• After 8 weeks, ADM was only better than placebo among more
severely depressed patients
• Post Treatment (after 16 weeks)
− Among less severely depressed patients, BA was comparable to
antidepressant medication, and CT.
− Among more severely depressed patients, BA was comparable to
antidepressant medication
− Antidepressant medication and BA significantly outperformed CT
directly after treatment.
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); was ist finale fazit aus den langzeitwirkmechnaismen?
Longterm results
− Differences between BA and CT were small and not significant
− Psychotherapeutic treatments were at least as efficacious as the
continuation of medication
− CT and BA were more efficacious than continuation of initial ADM
treatment with placebo
− Continuation with ADM was less sustainable
– Not better than continuation with placebo
– Risk of relapse increased, when ADM was withdrawn
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008);; welche kritikpunkte gabs an der studie?
high dropout rates--> highest attrition in the medication group
Power was not sufficient
• too small to show equivalence between conditions, when realistic effect
sizes were assumed (rather small than medium).
• To have a strong test of equivalence power needs to be high (ideally .95)
• For oneway anova of post measures (completer analysis with adjustment
due to unequal sample size 215) power would be
− .87 to detect a medium effect (f = .25)
− .20 to detect a small effect (f = .10)
▪ For follow up comparisons power was low (only rather big effects could
be detected)
▪ Blinding of the medication was broken or can be questioned
• After 8 weeks blinding was broken for patients and therapists (only
evaluators were blind)
• During follow up, success of blinding was not assessed
• Patients and doctors might have become aware of placebo condition->
overestimation the effect of ADM
-allegiance/(loyalität) conflict possible: jacobson intruduced BA in a broad field, co-author got research funds by glaxo smith
-design favors ADM
wie viele leute nahmen in der schwyz im jahr 2020 täglich antidepressiva ein?
200k
Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the treatment of adults with major depression. Dimidjian et al. (2006); Dobson et al. (2008); was ist des finale fazit bzgl. der gabe von antidepressiva?
Antidepressant medication only works better than placebo in
more severely depressed patients and in the short run
• at the cost of attrition, side effects, and addiction to the drug
• In the long run it seems to be less sustainable
Results are in contrast to the fact that ADM treatment is
considered the standard of care for depression in current
psychiatric guidelines for moderately and severely depressed
patients.
• Critical meta analytic reviews (Kirsch et al., 2008; Kirsch, 2014)
show that compared to placebo ADM has only small effects
even in severely depressed patients.
• Although effects of antidepressants vs. placebo might be
statistically significant in published studies, effects are not of
clinical importance (change of 2 units on HRSD that ranges from
0 to 52) (Munkholm et al., 2019)
• -> “Antidepressants can be considered as active placebos”
(Kirsch, 2014)
wer hat in der schweiz % am meisten antidepressiva im jahr 2020 verschriben?
-hausärzte 46%
-psychiatrie 35%
-andere fachärzte 16%
-kinder jugendpsychiatrie 1,4%
unter welchen umständen isses möglich, valid conclusions aus single case studies zu ziehen?
Yes, if we use an apropriate single case experimental design
• Controlled variation of the independent variable and measurement of the effects
of this variation is sufficient
was sind schwachstellen von Evidence based treatments, und in welcher art von treatment können schwachstellen ausgemerzt werden?
limited variability in patients
• limited variability in treatment method
--> varivability komponente kann bei evidence specified treatments gewährleistet werden-> Monitor patient’s response -> make additional modifications as needed
Treatment of a boy with panic disorder
Background (Nock, Goldman, Wang, & Albano, 2004); warum wurde dei study überhaupt durchgeführt?
single case; ging drum dasscbt zu dem zeitpunkt für adults bereits etabliert war, allerdings noch ned für kids mit panic disorder
Treatment of a boy with panic disorder
Background (Nock, Goldman, Wang, & Albano, 2004); welche cbt komponenten wurden bei dem dude angewendet?
-Psychoeducation and cognitive restructuring--> p. auf fehlannhmen hinweisen
-Somatic control exercises--> PMR, breathing techniques; weaken somatic arousal
-Interoceptive exposure--> graduell(ansteigend)
-Exposure to previously avoided situations
ums altersgerecht zu gestallten war die mum teiweise bei den sessions dabei
Treatment of a boy with panic disorder
Background (Nock, Goldman, Wang, & Albano, 2004); was waren ergebnisse der studie?
attacken haben signi abgenommen--> nach 11 wochen so gut wie keine mehr
Reduction in panic attacks and anxious symptoms
▪ Changes in social and academic functioning
• return to school on time
• only 6 days missing within one year
(because of mild physical complaints e.g., a cold)
• Active participation in classroom and after-school activities
• Sleepovers with his friends
▪ 6-month follow-up
• Mother and boy did not report panic attacks -> maintenance of
positive therapeutic change
Treatment of a boy with panic disorder
Background (Nock, Goldman, Wang, & Albano, 2004); nach welchem design wurde die sudie designed? und was waren vor- bzw. nachteile in dieser single case study?
-->quasi-experimentelles design
Advantages
▪ Repeated structured assessment and well specified treatment components
▪ Information about how interventions are related to process of change over time
Problems
▪ No control condition -> possible that other factors could have caused the observed behavior
change
• Maturation--> vllt. wars einfach kein seveerer fall
• History
• External factors
welche verschiedenen arten von sigle case experiments gibt es?
-Reversal Designs--> bestimmte zeiteinheit intervention, dann bestimmte einheit keine, dann bestimmte einehit wieder intervention
▪ Multiple Baseline Designs--> besipiel mit dem arvid kind; baseline 1: ich geb dem nur fluids, baseline 2: ich tu soft food dazu baseline 3: ich tue hard food dazu--> dadurch wird vermieden dass man Does not require the withdrawal of an effective interventions
--> avoids clinical and ethical concerns of reversal designs
▪ Changing Criterion Designs--> des criterion wird immer schwieriger, e.g. bei nem adhd kind immer höhere hürden, damit des criterion übersrpungen wird
Case experiment with an ABAB design:
Decreasing the frequency of non-suicidal self-injury with
physical exercise (Wallenstein & Nock, 2007); zeig an diesem bsp. warum ne adjustierung von nen reversal design sinn machen kann
hier abab design; erst baseline, dann intervention, dann abbruch intervention, dann nochmals intervention; kann nochmals dtl. zeigen, dass ne intervention was bringen kann
ablauf single case experi: obese patientin langjährig durch NSSV aufgefallen
Treatment: Twice a week
• Specific intervention: Physical work out exercise,
− 3 times per week
− and any time in response to self-injury urges
Initial baseline (A1) five weeks: 2.25(self injuries/week)
• Exercise (B1) for five weeks: 0.37
• Patient stopped exercise (A2) : 2.33
• Reintroduction of Exercise (B2): 0.00--> also richtig nice
trotzdem: Results suggest “to further investigate the effectiveness of exercise
as a treatment for nonsuicidal self-injury.” --> für ne generalisierung weitere vpn nötig
welche limitations gibts für nen reversal design bei ner single case study?
Sometimes it is undesirable and unethical to cause the behavior
to return back to baseline levels (A2 phase)
• E.g. Interventions that reduce self-injurious or aggressive behavior
toward others
▪ Sometimes Impossible
• When cognitive or behavior shifts due to learning processes occur
Multiple-Baseline Designs; welches bsp wurde in der vl. für ne single case study gebracht und, welche interventionen gabs und wie hat sich die multiple baseline hier ausgezeichnet?
4jähriger boy mit feeding problems; je fester das food umso belastender fand ers
interventionen via...
-Modeling-->vormachen
• Contingency management techniques − positive reinforcement: attention, praise, and material rewards in session and at home for the desired eating behavior − ignoring for behaviors that interfered with the desired eating behavior
therapie ging insgesamt über 2 monate; zu beginn nur fluids, nach 5 wochen kamen soft foods dazu(woche 7 mal kurz wieder gekotzt, da hat man dann kurz mit verstärkung aufgehört), woche 14 hard foods, woche 20 chewy food
Fazit-->The consumption of each group of food or liquid [soft to tough] increased when and only when the intervention was applied to that group; daraus haben die scientists geschlossen, dass es wirklich an den interventionen gelegne haben muss weil sonst e.g. die soft food quota auch im anshcluss wo hard food interveniert wurde hochgegängen wäre müssen, ist die aber ned; alternative facors wie maturation(reifeentwiclung), history oder relationship with therapist konnten so ausgeschlossen werden
was macht n multiple baseline design so stark? wo liegen die grenzen?
Demonstration of causality by replicating treatment effects across different behaviors different behaviors (as in the example of the boy) • different settings − e.g., school, home, and work • different individuals − e.g., different patients, classmates, or group members
Annahme fürs design--> Change does not occur across behaviors, settings, or individuals until the intervention is applied
Does not require the withdrawal of an effective interventions • avoids clinical and ethical concerns of reversal designs--> fluids konnten ja weitergegessen werden
Demonstration of causality requires that change does not occur across behaviors, settings, or individuals until the intervention is applied ▪ -> Not suited for interventions that lead to changes that generalize across areas --> des ist ja eig des ziel e.g. bei ner arcachnophobie, dass du fix ne generalisierung bestreibst damit die therapiefortschritte auch in verschied. settings an bord bleiben
single case studies; erzähl mal schnell was das changing criterions design ausmacht
After baseline, an intevention is directed at a behavior. Over time the criterion for reinforcement of this behavior is changed--> man verändert kontunierlich die defi von dem score, ab dem man ein responder ist
▪ "A causal relation between treatment and behavior change is demonstrated by showing that behavior changes when and only when the criterion for reinforcement is changed.“ (Nock et al., 2008, p. 343)
changing criterion design bei ner single case study; welches bsp. wurde für in der vl vorgestellt?
kind mit feeding problems, etablierung contingency/token management program; wenn der dude was gegessen hatte wurde er belohnt; mit der zeit wurde das criterion für ne belohnung(menge an essen) immer weiter erhöht, nachdem sich ne bstimmte essensmenge eingependelt hatte wurde das criterion anschlie0end wieder erhöht
was sind vorteile und grenzen eines changing criterion designs als konzeptualisierung einer single case study?
Changing criterion designs allow to gradually and systematically intervene to change the desired behavior
▪ Do not necessarily include a withdrawal of treatment (as in reversal designs)
▪ Do not necessarily include an isolated focus of treatment (as in multiple-baseline designs)
▪ -> Require the least amount of deviation from normal clinical practices
Not suited when the target behavior does change drastically and immediately.
was sind grundlegende vorteile einer single case study?
Highly efficient to demonstrate causal relations between intervention and behavior change.--> Facilitate more rapid clinical research advances than RCTs.
Highly flexible • Interventions can be tailored to individuals • Ongoing interventions can be changed -> more innovative treatments
▪ Capture change more precisely • Use of continuous assessment and multiple experimental phases -> detailed examinations of patterns of change and the temporal relations between manipulations and their effects over time
was gibts für grenzen bei ner single case study?
Lack of generalizability
• Demonstration that intervention is effective for a single individual under certain conditions, at a certain time − Intervention might not be effective with other individuals − Intervention may not even be replicated when readministered to the same individual at a later time. • However, generalizability is also a problem for large-sample studies that often use homogeneous samples of individuals
-Replication of intervention effects with multiple and heterogeneous individuals under different circumstances is necessary
unterschied efficacy vs. effectiveness?
efficacy: whether a treatment works is demonstrated in randomized controlled trails (RCTs)
effectiveness: whether a treatment works when applied under everyday praxis conditions
warum ist seligman vom paualus vom saulus geworden?
erst großer fan von rct; allerdings nach der consumer reports stuy zum schluss gekommen dass die wirkung von ner therapie in nem stand. verhfrahren(efficacy) ne ganz andere sein kann als im freuen feld(effectiveness)
warum sind efficacy studies nach seligman der falsche ansatz?
because it omits(auslassen) too many crucial elements of what is done in the field, nämlich im field gilt:
Treatments do not have a fixed duration -->Keeps going until patient is improved or quits
• Self correcting --> If one technique does not work another is tried
• Active shopping --> Patients choose treatment and therapist
• Patients often have multiple problems --> PTs deal with multiple problems
warum sind effectiveness studien schwierig zu generieren? wie istt des lt. seligmann aber trotzdem möglich?
- treatments do not have fixed duration
• are not manualized and have self correcting improvisations
• aim to improve general functioning
• patients are not randomized
• have multiple problems
lt. seligmann trotzdem mgl. via A survey of large numbers of people who have gone through such treatments.
wie war das design der consumer report study?
-100 questions about: • automobiles --> Männer • mental health services (26 questions)
- für die study relevante question; «If at any time over the past three years you experienced stress or other emotional problems for which you sought help from any of the following»: (Seligman, 1995, p. 967)
• friends • relatives • member of clergy • mental health specialist (psychologist, psychiatrist) • family doctor • support group
consumer report study; wie sah grob das sample aus? wen haben die leute ecounseld wenn sie stress erlebt haben, und wie sahs im smple bzgl. geschlecht und alter aus?
22 000 CR readers responded (13%) ▪ ca. 7 000 responded to mental health questions: •
3 000 talked to friends, relatives, or clergy
• 4100 contact with health professionals, family doctors, or support groups
• 2900 contact with specialists for mental health • 37% psychologists • 22% psychiatrists • 14% social workers • 9% marriage counselors • 18% others −
1 300 joined self help groups − 1 000 family doctors ▪ Respondents
• typical middle class • highly educated • 50% men, 50% women • Median Age 46 years
welche Skalen wurden zur Berechnung der Effectiveness in der consumer report study miteingebzogen, und welche ausprägung in den jeweiligen skalen konnten die vpn ankreuzen?
Specific Improvement “How much did treatment help with the specific problem that led you to therapy?--> range 0-4
Satisfaction “Overall how satisfied were you with the therapist’s treatment of your problem--> range 0-5
Global improvement • Overall emotional state at time of survey minus vs. Overall emotional state at outset Scale: 0 to 4
--> via multiplikation konnten in jedem bereich 100 punkte also insgesamt 300 punkte erreicht werden
consumer report studie; wie viel przent haben sich nach dem professionellen counseling wenigstens n bissl besser gefühlt, gabs unterschiede zw. pt + pt&medication + waren die psychologen erfolgreicher als marriage counselers?
No difference between PT alone and PT + medication
87% of the persons who were feeling very bad at outset (N = 426) were feeling at least so-so
Mental health professionals did better than marriage counselors:Psychologists (overall improvement score = 220) • Psychiatrists (226) • Social workers (225) • > marriage counselors (208)
consumer report studyy; welche ergebnisse gabs bzgl. der dauer von der behandlung?
Long-term treatments (PTs and medication) were more effective--> 201 one month vs. 241 2 years
consumer report study ergebnisse; vergleich family doctors vs. mental health ppl: was gabs da für ergebnisse?
Compared to mental health professionals family doctors were • equally effective in short term • but less effective in long term • Family doctors: − Treatment duration ≤ 6 months: 213; > 6 months: 212 • Mental health professionals: − Treatment duration ≤ 6 months: 211; > 6 months: 232
consumer report study: was gabs für nen einfluss von nem treatment eines spezifischen problems auf die generelle funktionsfähikeit?
Advantage of long term treatment by mental health professionals. Improvement of specific problems and general functioning: • Ability to relate to others • Coping with everyday stress • Enjoying live more • Self esteem and self-confidence
consumer report: wie schnitten mental health geegs ggüb. alcoholics anonymous ab?
Alcoholics Anonymous (AA) produced sig. better improvement (M = 251) than mental health professionals • People who went to Non-AA had less severe problems and did less well (215)
consumer report study; gabs unterschiede zw. verschied. disziplinen bzw. kurzzeit/langzeittherapie?
No specific PT did any better than any other for any problem • Conforms “dodo bird” hypothesis that all PTs do equally well
▪ Respondents whose choice of PT or duration was limited did worse
