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Objective The relationship between the therapeutic alliance and outcome has been supported consistently over time. More recently, studies have examined therapist effects in the alliance-outcome relationship and came up with somewhat mixed findings. The purpose of this study was to replicate and extend previous meta-analytic work using a much larger data set, permitting not only the verification of the overall impact of the therapists' contribution but, at the same time, controlling for several potential covariates effecting this relationship. Method We conducted two- and three-level mixed-effects meta-analyses (k = 152; 827 total effect sizes) to examine the significance of several potential moderators of the alliance-outcome correlation. These moderators included (a) Patient-Therapist Ratio (PTR; Patient N divided by therapist N to test therapist effects), (b) Alliance and Outcome Rater's contribution (patient, therapist, observer, and other), (c) Alliance Measures, (d) Research Design (RCT, Other) and (e) Personality Disorder. Results The PTR, an index of the therapist's contribution to the alliance, was a significant moderator of the alliance-outcome correlation in both the two- and three-level models. When several potential confounds were simultaneously tested in a three-level multipredictor metaregression, including rater of alliance and outcome, research design, alliance measure, and personality disorder, PTR remained a significant moderator of the alliance-outcome correlation. Conclusion Replicating and extending previous research, this study supported the significance of therapists' impact in the alliance-outcome relationship. These results remained significant even when, using three-level metaregressions, several potential covariates were simultaneously controlled. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

The alliance is widely recognized as a robust predictor of posttreatment outcomes. However, there is a debate regarding whether the alliance is an epiphenomenon of intake characteristics and/or treatment processes occurring over the course of treatment. This meta-analysis aimed to synthesize the evidence on this issue. We identified 125 effect sizes in 60 independent samples (6,061 participants) of studies that reported alliance-outcome correlations as well as parallel intake or process characteristics. We examined the impact of these potential confounds on the alliance-outcome correlations. We meta-analyzed the studies estimates by computing omnibus effects models as well as multivariate models. We identified 3 variable types that were used to adjust the alliance-outcome correlations: (a) intake characteristics (k = 35); (b) simultaneous processes, such as adherence or competence (k = 13); and (c) both intake and simultaneous processes (k = 24). We found moderate alliance-outcome correlations with or without adjustments for intake and simultaneous processes (range from r = .23 to r = .31). Our results provide robust empirical evidence for the assertion that the alliance-outcome association is an independent process-based factor. Findings suggest that alliance is positively related to outcome above and beyond the studied patient intake characteristics and treatment processes. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Caregivers of children with Special Healthcare Needs (SHN) are at an elevated risk for adverse health outcomes among the general population; research among military populations is lacking. Records ...

Objective Even though the early alliance has been shown to robustly predict posttreatment outcomes, the question whether alliance leads to symptom reduction or symptom reduction leads to a better alliance remains unresolved. To better understand the relation between alliance and symptoms early in therapy, we meta-analyzed the lagged session-by-session within-patient effects of alliance and symptoms from Sessions 1 to 7. Method We applied a 2-stage individual participant data meta-analytic approach. Based on the data sets of 17 primary studies from 9 countries that comprised 5,350 participants, we first calculated standardized session-by-session within-patient coefficients. Second, we meta-analyzed these coefficients by using random-effects models to calculate omnibus effects across the studies. Results In line with previous meta-analyses, we found that early alliance predicted posttreatment outcome. We identified significant reciprocal within-patient effects between alliance and symptoms within the first 7 sessions. Cross-level interactions indicated that higher alliances and lower symptoms positively impacted the relation between alliance and symptoms in the subsequent session. Conclusion The findings provide empirical evidence that in the early phase of therapy, symptoms and alliance were reciprocally related to one other, often resulting in a positive upward spiral of higher alliance/lower symptoms that predicted higher alliances/lower symptoms in the subsequent sessions. Two-stage individual participant data meta-analyses have the potential to move the field forward by generating and interlinking well-replicable process-based knowledge. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

In 2014, Macnamara, Hambrick, and Oswald published a meta-analysis of studies questioning the strength of the association between deliberate practice and performance. In this brief report, the corr...

We tested the predictive validity of the Progress Assessment (PA), a brief counselor administered tool for use in measurement-based care for substance use disorders. The PA includes 5 items assessing relapse risk and 5 items assessing factors protective against relapse. Data were drawn from a completed study of continuing care for cocaine dependence (McKay et al., 2013) and includes 12 months of follow-up on158 participants (76% male) who received brief telephone or face-to-face sessions. Each session began with the administration of the PA, followed by cognitive-behavioral counseling tied to the results of the PA and anticipated risky situations. Outcome was assessed via urine toxicology every 3 months. As administered in an effectiveness trial, average PA risk and protective scales within each 3-month segment of the study predicted urine toxicology results at the end of that period, with higher risk scores and lower protective scores predicting greater rates of cocaine positive urine drug screens. PA scores did not predict dropout from continuing care participation. The 10-item PA shows promise as a pragmatic clinical tool for ongoing monitoring during continuing care for substance dependence.

Clinical or methodological significance of this article: Meta-analysis is a powerful tool for resolving conflicting conjectures or findings while also providing a critical overview of a scientific area.

Introduction Recreational and adaptive sports programs are often provided to veterans with a variety of psychological and physical conditions; however, limited data exist regarding the outcomes of these programs. The current study evaluated the psychological outcomes of attendees of the 2017 and 2018 National Veterans Summer Sports Clinic (NVSSC) in San Diego, California. Method Seventy-four veteran participants completed self-report assessments before and after the week-long program, as well as 3 months following program completion. In addition, participants completed brief assessments before and after each of the daily recreational activities (cycling, surfing, sailing, kayaking, and archery/pickleball). Results Findings showed that depression, anxiety, social functioning, and positive and negative affect significantly improved from pre-to postprogram, but returned to baseline levels at 3-month follow-up. Within sessions, depression/anxiety and positive affect significantly improved each day, with no differences in the amount of change across days. Depression/anxiety and positive affect also significantly improved within each activity, regardless of order, with no differences in the magnitude of change across activities. Conclusions The NVSSC produced significant changes in psychological outcomes among veteran participants within immediate and short-term time periods; however, gains were not maintained longer-term. Follow-on engagement in exercise activities is likely necessary for continued benefit; future research, including studies with control groups, would provide greater clarity.

Purposes The objective of this study was to determine the percentage of veterans with active hepatitis C virus (HCV) infection who were deemed to be candidates for treatment and to identify factors associated with treatment ineligibility. Methods This was a multisite, retrospective cohort analysis of veterans with HCV infection within the Veteran Integrated Service Network 21. Patients evaluated between August and November 2015 who were viremic and not receiving HCV treatment were included in the analysis. Reasons for treatment exclusion were determined by an experienced clinician and recorded into a regional population management dashboard. Descriptive statistics were used to describe the population. The t test for normally distributed data, the Mann-Whitney rank sum test for data that failed normality testing, or the χ 2 test were used to examine differences between the treatment eligible and ineligible cohorts. Generalized linear mixed-effects models were conducted to estimate patient outcomes relevant to various disease states and characteristics while controlling for interfacility variability. Findings The cohort included 1,003 veterans within 5 medical centers; 988 (98.5%) were male, and 625 (62%) had a fibrosis 4 score >3.25, indicating the presence of ALD. According to clinician classification, 478 (48%) were considered HCV treatment candidates, whereas 525 (52%) were determined to be treatment ineligible. The most common reasons documented by clinicians for treatment ineligibility included unstable or uncontrolled comorbidities (n = 118 [22.4%]), excessive alcohol use (n = 116 [22.1%]), and treatment refusal by the patient (n = 69 [13%]). On the basis of statistical modeling and reporting odds ratios (ORs) and 95% CIs, diagnoses of active alcohol use disorder (OR = 0.68; 95% CI, 0.47–0.98; P = 0.038), hepatocellular carcinoma (OR = 0.24; 95% CI, 0.13–0.47; P P = 0.049) were statistically associated with treatment ineligibility, whereas posttraumatic stress disorder (OR = 1.48; 95% CI, 1.01–2.18; P = 0.046) was associated with treatment eligibility. There were no statistically significant differences found for other psychiatric diagnoses or an encounter for homelessness. Implications Results of this study indicate that a high percentage of patients may not be considered treatment eligible at initial clinical review. Within this veteran population, the presence of uncontrolled comorbidities and excessive alcohol use were the most commonly reported reasons for treatment ineligibility. On the basis of this analysis, processes could be established to address modifiable barriers to treatment, thus expanding the number of individuals receiving potentially curative therapy for HCV infection.

The alliance continues to be one of the most investigated variables related to success in psychotherapy. In this chapter, the authors define and illustrate the alliance (also conceptualized as therapeutic alliance or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients for face-to-face psychotherapy as well as Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using three-level meta-analysis with random-effects. The overall alliance–outcome association for face-to-face psychotherapy was r = .278 (equivalent of d = .579). The correlation for internet-based psychotherapy was approximately the same (r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The chapter concludes with research limitations, diversity considerations, and therapeutic practices.

The alliance continues to be one of the most investigated variables related to success in psychotherapy irrespective of theoretical orientation. We define and illustrate the alliance (also conceptualized as therapeutic alliance, helping alliance, or working alliance) and then present a meta-analysis of 295 independent studies that covered more than 30,000 patients (published between 1978 and 2017) for face-to-face and Internet-based psychotherapy. The relation of the alliance and treatment outcome was investigated using a three-level meta-analysis with random-effects restricted maximum-likelihood estimators. The overall alliance-outcome association for face-to-face psychotherapy was r = .278 (95% confidence intervals [.256, .299], p < .0001; equivalent of d = .579). There was heterogeneity among the effect sizes, and 2% of the 295 effect sizes indicated negative correlations. The correlation for Internet-based psychotherapy was approximately the same (viz., r = .275, k = 23). These results confirm the robustness of the positive relation between the alliance and outcome. This relation remains consistent across assessor perspectives, alliance and outcome measures, treatment approaches, patient characteristics, and countries. The article concludes with causality considerations, research limitations, diversity considerations, and therapeutic practices. (PsycINFO Database Record (c) 2018 APA, all rights reserved).

Zusammenfassung: Das pantheoretische Konzept der Arbeitsallianz stellt die kollaborative Qualität der an der Therapie beteiligten Personen (i.e. zumeist der Patient und der Therapeut) in den Mittelpunkt. Die Arbeitsallianz ist die weltweit am besten untersuchte Prozessvariable in der Psychotherapie. Die vorliegende Arbeit bietet einen Überblick über den aktuellen metaanalytischen Wissensstand. Basierend auf 200Primärstudien mit 14.000 teilnehmenden Patienten wurde der Zusammenhang zwischen Arbeitsallianz und Therapieerfolg metaanalytisch untersucht. Die Arbeitsallianz erweist sich als äußerst robuster Prädiktor, der moderate 8 % der Varianz des Therapieerfolgs erklärt. Der Zusammenhang über die verschiedenen Psychotherapietraditionen hinweg zeigte sich sowohl unter randomisierten kontrollierten, manualisierten Studienbedingungen als auch unter naturalistischen Voraussetzungen. Der Effekt fand sich zudem in den störungsspezifischen Erfolgseinschätzungen und den generelleren Erfolgsmaßen. Die moderaten Therapeuteneffekte in den Primärstudien konnten metaanalytisch bestätigt werden. Soziokulturelle Aspekte wie Substanzmissbrauch und ethnische Minoritäten moderieren den Einfluss zwischen Arbeitsallianz und Therapieerfolg. Die Nähe der Forscher zum Allianzkonzept ("allegiance") beeinflusst die Vorhersagekraft der frühen Allianz zwar statistisch bedeutsam, jedoch nicht substanziell.

Meta-analysis is a set of statistical procedures used for providing transparent, objective, and replicable summaries of research findings. This tutorial demonstrates the most common procedures on conducting a meta-analysis using the R statistical software program. It begins with an introduction to meta-analysis along with detailing the preliminary steps involved in completing a research synthesis. Then, a step-by-step tutorial for each of the quantitative componentsinvolved for meta-analysis is provided using a fictional set of psychotherapy treatment-control studies as a running example.

Three recent meta-analyses have made the claim, albeit with some caveats, that cognitive-behavioral treatments (CBT) are superior to other psychotherapies, in general or for specific disorders (e.g., social phobia).The purpose of the present article was to examine four issues in meta-analysis that mitigate claims of CBT superiority: (a) effect size, power, and statistical significance, (b) focusing on disorder-specific symptom measures and ignoring other important indicators of psychological functioning, (c) problems inherent in classifying treatments provided in primary studies into classes of treatments, and (d) the inclusion of problematic trials, which biases the results, and the exclusion of trials that fail to find differences among treatments.When these issues are examined, the effects demonstrating the superiority of CBT are small, nonsignificant for the most part, limited to targeted symptoms, or are due to flawed primary studies.Meta-analytic evidence for the superiority of CBT in the three meta-analysis are nonexistent or weak.

Objective Pharmacotherapy is an effective adjunct to behavioral interventions to treat obesity; although it is unclear how often medications are integrated into obesity treatment plans and for which patients in the Veterans Health Administration (VHA). Methods A retrospective cohort study was conducted that examined variation in and predictors of antiobesity medication receipt (orlistat) among > 2 million obese Veterans within 140 facilities nationwide. Results One-percent of all obese patients using VHA services filled a prescription for orlistat. Veterans were more likely to be treated with orlistat if they had a higher BMI, were female, unmarried, younger, a minority, had home instability, prescribed obesogenic psychiatric medications, had a psychiatric or obesity-related comorbidity, and used MOVE! weight management services. Among those who likely met the criteria for use, 2.5% had at least one orlistat prescription. Facility-level prescription rates varied from 0 to 1% of all obese patients in a VA facility receiving a prescription and 0 to 21% among those who met the criteria for use. Conclusions Consistent with guidelines recommending that obesity pharmacotherapy be prescribed in conjunction with behavioral therapy, the strongest predictor of receiving orlistat was being enrolled in the MOVE! weight-loss management program.

As mindfulness-based interventions become increasingly widespread, interest has grown in better understanding which features of these treatments produce beneficial effects. The present study examined the relative contribution of mindfulness practice time and practice quality in predicting psychological functioning (negative affect, emotion regulation, quality of life, mindfulness). Data were drawn from a randomized clinical trial of mindfulness training for smokers and assessed outcomes at posttreatment (n = 43) and 5-month follow-up (n = 38). The intervention included instruction in mindfulness techniques targeted to smoking cessation and relapse prevention and was composed of 10 group meetings over 8 weeks. Data from 8 treatment groups were used. Mindfulness practice quality was measured weekly over the course of treatment, and multilevel modeling was used to estimate trajectories of change in practice quality. The measure of practice quality was shown to be valid and reliable, with change in practice quality predicting change in psychological functioning at both posttreatment (β= .31, 95% CI =[0.04, 0.56], p = .022) and follow-up (β= .45 [0.16, 0.73], p = .002), even when controlling for practice time. Practice time predicted outcomes at posttreatment (β= .31 [0.05, 0.57], p = .019) but not at follow-up (β= .16 [[{"type":"entrez-nucleotide","attrs":{"text":"H11002","term_id":"875822"}}H11002]0.14, 0.47], p = .293). Neither practice time nor change in practice quality predicted smoking abstinence at 1 month or 6 months postquit. Results support the importance of practice quality as a relevant aspect of mindfulness interventions.

OBJECTIVE Placebo group improvement in pharmacotherapy trials has been increasing over time across several pharmacological treatment areas. However, it is unknown to what degree increasing improvement has occurred in pharmacotherapy trials for alcohol use disorders or what factors may account for placebo group improvement. This meta-analysis of 47 alcohol pharmacotherapy trials evaluated (1) the magnitude of placebo group improvement, (2) the extent to which placebo group improvement has been increasing over time, and (3) several potential moderators that might account for variation in placebo group improvement. METHOD Random-effects univariate and multivariate analyses were conducted that examined the magnitude of placebo group improvement in the 47 studies and several potential moderators of improvement: (a) publication year, (b) country in which the study was conducted, (c) outcome data source/type, (d) number of placebo administrations, (e) overall severity of study participants, and (f) additional psychosocial treatment. RESULTS Substantial placebo group improvement was found overall and improvement was larger in more recent studies. Greater improvement was found on moderately subjective outcomes, with more frequent administrations of the placebo, and in studies with greater participant severity of illness. However, even after controlling for these moderators, placebo group improvement remained significant, as did placebo group improvement over time. CONCLUSIONS Similar to previous pharmacotherapy placebo research, substantial pretest to posttest placebo group improvement has occurred in alcohol pharmacotherapy trials, an effect that has been increasing over time. However, several plausible moderator variables were not able to explain why placebo group improvement has been increasing over time.

Oral naltrexone, an opioid antagonist medication, is currently one of only four FDA-approved medications for treating alcohol use disorders (Harris et al., 2010). Although numerous studies and meta-analyses have supported its efficacy, a meta-analysis by Feinn and Kranzler (2005) found that, compared to earlier studies, more recent trials had smaller effects for relapse to heavy drinking and percent drinking days, although the trend for the latter outcome was not quite significant. In addition, multi-center trials (compared to single-site studies) had smaller medication effects on relapse to heavy drinking. Previous reviews of pharmacotherapy trials for depression and schizophrenia have come to similar conclusions (Kemp et al., 2010; Rief et al., 2009). That is, effect sizes in those trials both attenuated over time and were smaller in multi-center studies. Several factors have been pointed to that may account for these findings. The attenuation of effects in more recent pharmacotherapy trials may be attributed to (a) regression to the mean as a function of publication bias for earlier studies (Finney, 2008), (b) confounding of more recent studies with multi-center designs (Feinn and Kranzler, 2005), and (c) increasing placebo group improvement over time (Del Re et al., in submission). Multi-center studies are thought to have smaller effects due to variability in (a) study execution (e.g., varying fidelity to treatment protocol, recruitment procedures) among centers (Feinn and Kranzler, 2005) and (b) other contextual factors across sites (e.g., variation in participant and provider characteristics) which then attenuate the aggregated effect size (ES). The current review extends Feinn and Kranzler’s (2005) meta-analysis by using multivariate meta-analytic methods to examine the efficacy of naltrexone (vs. placebo) in a larger sample of single-site and multi-center studies over a longer time period. The additional studies provide more statistical power to detect the effects of potential moderators, such as time and multi- versus single-center trials. Utilizing multivariate procedures allows for simultaneous modeling of both percent days abstinent (the inverse of percent drinking days) and relapse to heavy drinking outcomes, and thus provides independent estimates for each outcome. This procedure is advantageous as it considers the correlation between the modeled outcome variables, instead of assuming independence as two separate univariate procedures do, thereby reducing the likelihood of Type I error (i.e., erroneously rejecting the null hypothesis). We hypothesize that naltrexone effect sizes continue to decrease after 2003 (the last year examined by Feinn and Kranzler), but eventually plateau (we expect that at no point in time will effect sizes average zero or less) and that multi-center trials continue to yield smaller effect sizes than single-site trials. Further extending the work of Feinn and Kranzler, we planned to examine whether placebo group improvement has been increasing over time, thus accounting for smaller medication effects over time. We also test whether the presence of a placebo run-in period moderates naltrexone effect sizes. Placebo run-in periods eliminate non-compliant participants or participants who exhibit a strong initial placebo response. Thus, studies with a placebo run-in period are expected to have stronger medication effects. Lastly, we examine the interaction between publication year and multi-center (vs. single site), to determine if there are differential effect sizes in multi-center sites versus single site studies on average (grand mean centered intercept) and over time (slope coefficient).

Meta-analysis has played a key role in psychotherapy research for nearly 40 years. There is now an opportunity for technology to assist with transparent and open meta-analyses. The authors describe an open-access database of effect sizes and a corresponding web application for performing meta-analyses, viewing the database, and downloading effect sizes. The initial databases provide effect sizes for family therapy for delinquency studies and for alliance-outcome correlations in individual psychotherapy. Disciplinary norms about data sharing and openness are shifting. Furthermore, meta-analyses of behavioral interventions have been criticized for lacking transparency and openness. The database and web application are aimed at facilitating data sharing and improving the transparency of meta-analyses. The authors conclude with a discussion of future directions for the database.

OBJECTIVE: Bell, Marcus, and Goodlad (2013) recently conducted a meta-analysis of randomized controlled additive trials and found that adding an additional component to an existing treatment vis-a-vis the existing treatment produced larger effect sizes on targeted outcomes at 6-months follow-up than at termination, an effect they labeled as a sleeper effect. One of the limitations with Bell et al.'s detection of the sleeper effect was that they did not conduct a statistical test of the size of the effect at follow-up versus termination. METHOD: To statistically test if the differences of effect sizes between the additive conditions and the control conditions at follow-up differed from those at termination, we used a restricted maximum-likelihood random-effect model with known variances to conduct a multilevel longitudinal meta-analysis (k = 30). RESULTS: Although the small effects at termination detected by Bell et al. were replicated (ds = 0.17-0.23), none of the analyses of growth from termination to follow-up produced statistically significant effects (ds .20), and when asymmetry was considered using trim-and-fill procedure or the studies after 2000 were analyzed, magnitude of the sleeper effect was negligible (d = 0.00). CONCLUSION: There is no empirical evidence to support the sleeper effect.

Influenced by several trials and reviews highlighting positive outcomes, topiramate is increasingly prescribed as a treatment for alcohol use disorders (AUDs). The only previously published meta-analysis of topiramate for AUDs was limited by a sample of only 3 randomized, placebo-controlled trials (RCTs).A systematic search identified 7 RCTs (including a total of 1,125 participants) that compared topiramate to placebo for the treatment for AUDs. This meta-analysis estimated the overall effects of topiramate on abstinence, heavy drinking, craving, and γ-glutamyltranspeptidase (GGT) outcomes and included several sensitivity analyses to account for the small sample of studies.Overall, the small to moderate effects favored topiramate, although the effect on craving was not quite significantly different from 0. The largest effect was found on abstinence (g = 0.468, p0.01), followed by heavy drinking (g = 0.406, p0.01), GGT (g = 0.324, p = 0.02), and craving (g = 0.312, p = 0.07) outcomes. Sensitivity analyses did not change the magnitude or direction of the results, and tests did not indicate significant publication bias. The small sample size did not allow for examination of specific moderators of the effects of topiramate.Topiramate can be a useful tool in the treatment of AUDs. Its efficacy, based on the current sample of studies, seems to be of somewhat greater magnitude than that of the most commonly prescribed medications for AUDs (naltrexone and acamprosate). Further research will help to identify the contexts in which topiramate is most beneficial (e.g., dose, concurrent psychotherapy, patient characteristics).

Objective This meta-analysis examined the enduring efficacy of evidence-based psychotherapies (EBP) in comparison to treatment as usual (TAU) by examining effects from termination to follow-up for acute anxiety and depression in an adult outpatient population. It was hypothesized that EBPs might extend their efficacy at follow-up assessment (Tolin, 2010). Method Longitudinal multilevel meta-analyses were conducted that examined the magnitude of difference between EBP and TAU. Targeted (disorder-specific) outcomes were examined, along with dropout rates at follow-up assessments. Results A total of 15 comparisons (including 30 repeated effect sizes [ES]) were included in this meta-analysis (average of 8.9 month follow-up). Small to moderate ES differences were found to be in favor of EBPs at 0–4 month assessments (Hedges' g = 0.40) and up to 12–18 month assessments (g = 0.20), indicating no extended efficacy at follow-up. However, the TAU-conditions were heterogeneous, ranging from absence of minimal mental health treatment to legitimate psychotherapeutic interventions provided by trained professionals, the latter of which resulted in smaller ES differences. Furthermore, samples where substance use comorbidities were not actively excluded indicated smaller ES differences. TAU-conditions produced slightly higher dropout rates than EBP-conditions. Conclusion Findings indicate small and no extended superiority of EBP for acute depression and anxiety disorders in comparison to TAU at follow-up assessment. There are a limited number of studies investigating the transportability and lasting efficacy of EBP compared to TAU, especially to TAU with equivalent conditions between treatment groups.

To determine the relations between obstructive sleep apnea (OSA) diagnosis, the likelihood of being diagnosed with a psychological condition, among obese veterans, after accounting for severity of obesity and the correlated nature of patients within facility. We hypothesized that (1) individuals with a diagnosis of OSA would be more likely to receive a diagnosis of a (a) mood disorder and (b) anxiety disorder, but not (c) substance use disorder.Cross-sectional retrospective database review of outpatient medical records between October 2009 and September 2010, conducted across all 140 Veterans Health Administration (VHA) facilities.The entire VA Health Care System.Population-based sample of veterans with obesity (N = 2,485,658).Physician- or psychologist-determined diagnosis of psychological conditions including mood, anxiety, and substance use disorders.Using generalized linear mixed modeling, after accounting for the correlated nature of patients within facility and the severity of obesity, individuals with a diagnosis of sleep apnea had increased odds of receiving a mood disorder diagnosis (OR = 1.85; CI = 1.71-1.72; p0.001), anxiety disorder diagnosis (OR = 1.82; CI = 1.77-1.84; p0.001), but not a diagnosis of substance use disorder.Among obese veterans within VA, OSA is associated with increased risk for having a mood and anxiety disorder, but not substance use disorder, with the strongest associations observed for posttraumatic stress disorder (PTSD) and major depressive disorder (MDD). In addition, this relation remained after accounting for severity of BMI.

Objectives: Intention to treat (ITT) is an analytic strategy for reducing potential bias in treatment effects arising from missing data in randomised controlled trials (RCTs). Currently, no universally accepted definition of ITT exists, although many researchers consider it to require either no attrition or a strategy to handle missing data. Using the reports of a large pool of RCTs, we examined discrepancies between the types of analyses that alcohol pharmacotherapy researchers stated they used versus those they actually used. We also examined the linkage between analytic strategy (ie, ITT or not) and how missing data on outcomes were handled (if at all), and whether data analytic and missing data strategies have changed over time. Design: Descriptive statistics were generated for reported and actual data analytic strategy and for missing data strategy. In addition, generalised linear models determined changes over time in the use of ITT analyses and missing data strategies. Participants: 165 RCTs of pharmacotherapy for alcohol use disorders. Results: Of the 165 studies, 74 reported using an ITT strategy. However, less than 40% of the studies actually conducted ITT according to the rigorous definition above. Whereas no change in the use of ITT analyses over time was found, censored (last follow-up completed) and imputed missing data strategies have increased over time, while analyses of data only for the sample actually followed have decreased. Conclusions: Discrepancies in reporting versus actually conducting ITT analyses were found in this body of RCTs. Lack of clarity regarding the missing data strategy used was common. Consensus on a definition of ITT is important for an adequate understanding of research findings. Clearer reporting standards for analyses and the handling of missing data in pharmacotherapy trials and other intervention studies are needed.

When mental health is monitored over the course of treatment, many clients report strong and stable changes, particularly early in psychotherapy. Such changes can occur both in singular events, such as sudden gains in particular symptoms, and more comprehensive ways across the World Health Organization definition of health (WHO, 1948), which includes well-being and psychosocial functioning. The present practical guideline illustrates a systematized sequence of tasks that explore rapid changes and sudden gains at a very early stage of therapy, as well as how such changes can be used in future therapeutic work. These tasks include (1) exploration of the change situation, (2) reinforcement of generalized self-efficacy and hope bonding, and (3) benefit for therapy.

Effective antiretroviral therapy has led to substantial improvements in health-related outcomes among individuals with HIV. Despite advances in HIV pharmacotherapy, suboptimal medication adherence remains a significant barrier to successful treatment. Although several factors have been associated with medication adherence in the extant literature, study assessing the effects of some of the neurobehavioral features specific to HIV has been limited. Moreover, although there is a growing body of literature measuring medication adherence in HIV prospectively, few employ advanced statistical methodologies suited to handle advanced models with multiple predictors that would strengthen our understanding of medication adherence trajectories in HIV. This study sought to integrate traditionally assessed predictors of medication adherence with neurobehavioral features of HIV in a longitudinal study of medication adherence to combined antiretroviral therapy (cART). The current study used multilevel modeling to examine a wide arrangement of categories of factors - demographic, medication related, psychosocial, and neurobehavioral - on medication adherence. The sample consisted of 235 HIV + individuals whose medication adherence was monitored over the course of six months using electronic monitoring devices. After controlling for the effects of demographic, medication, and psychosocial factors, neurobehavioral features added predictive validity to the model. In the final model, simultaneously controlling for the effects of each of the predictors within all the categories, age, self-efficacy, executive functioning, apathy, and frequency of stimulant use emerged as unique individual predictors of average medication adherence across the 6-month study. Self-efficacy and irritability predicted changes in medication adherence over time. Adherence behavior is multidetermined. Adequate assessment of these factors, combined with timely intervention, appears to be warranted in order to boost adherence rates.

Objective The purpose of Study 1 was to examine the relative efficacy of evidence-based treatments (EBTs) when compared to treatment-as-usual (TAU) for adults diagnosed with a personality disorder (PD). The purpose of Study 2 was to investigate the strength of the differences between bona fide psychotherapeutic treatments for PDs. Method Two separate computerized searches were conducted of: (a) studies that directly compared an EBT with a TAU for treatment of PDs, or (b) studies that compared at least two bona fide treatments for PDs. Meta-analytic methods were used to estimate the effectiveness of the treatments when compared to one another and to model how various confounding variables impacted the results of this comparative research. Results A total of 30 studies (Study 1; N = 1662) were included in the meta-analysis comparing EBTs to TAU. A total of 12 studies (Study 2; N = 723) were included in the meta-analysis comparing bona fide treatments. Study 1 found that EBTs were superior to TAU, although the TAU conditions were not comparable in many respects (e.g., not psychotherapy, lacking supervision, lacking training, etc.) to the EBT and there was significant heterogeneity in the effects. Study 2 found that some bona fide treatments were superior to others.

Stella E Panos,1,2 Charles H Hinkin,1,2 Elyse J Singer,3 April D Thames,1,2 Sapna M Patel,1,2 Janet S Sinsheimer,4 AC Del Re,5 Benjamin B Gelman,6 Susan Morgello,7 David J Moore,8 Andrew J Levine31Department of Psychiatry and Biobehavioral Sciences, University of California Los Angeles, David Geffen School of Medicine, 2VA Greater Los Angeles Healthcare System; 3National Neurological AIDS Bank, UCLA Department of Neurology, 4Departments of Biomathematics and Human Genetics, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, CA, 5Department of Psychiatry, Stanford University, Menlo Park, CA, 6Department of Pathology, University of Texas Medical Branch, Galveston, TX, 7Departments of Neurology, Neuroscience, and Pathology, The Mount Sinai School of Medicine, New York, NY, 8Department of Psychiatry, School of Medicine, University of California San Diego, La Jolla, CA, USABackground: The apolipoprotein-E (APOE) ε4 allele is a risk factor for vascular dementia and Alzheimer’s disease. Recent studies are equivocal with regards to whether or not the ε4 allele confers increased risk for the development of human immunodeficiency virus (HIV)-associated neurocognitive disorder (HAND), but suggest that age and/or disease severity may be modulating factors. The aim of this study was to assess the interactions and contributions of APOE genotype, age, and HIV disease severity as risk factors for HAND in HIV-infected adults.Methods: Participants were 259 HIV-positive individuals who underwent APOE genotyping, a standardized neurological evaluation, a comprehensive neuropsychological evaluation, and laboratory testing.Results: Older ε4 carriers showed a higher frequency of HAND compared with age-matched non-ε4 carriers. Analysis by discrete neurocognitive domain revealed that advanced age modulated the effect of the ε4 allele, such that older ε4 allele carriers showed reduced executive functioning and information processing speed. Exploratory analyses assessing the relationship between ε4 and disease severity in the overall sample revealed that disease severity modulated the effect of the ε4 allele on cognition. Lower absolute CD4+ cell count among ε4 allele carriers was associated with poorer working memory ability.Conclusion: Advancing age and degree of immunosuppression may influence the association between APOE ε4 allele status and HAND. These two factors need to be taken into account in future research.Keywords: apolipoprotein-E, human immunodeficiency virus, aging, neurocognition

The patterns of growth and development of the therapeutic alliance over the course of therapy have been of continued interest to psychotherapy researchers. The purpose of this study was to investigate whether a simple institutional metacommunication intervention with clients had an effect on the development of the alliance. This adjunctive instruction involved inviting therapy clients to take a proactive role in their treatment by encouraging feedback to their therapist about various aspects of the therapy process. In this randomized controlled study (N = 94) clients were assigned to 1 of 2 conditions: (a) an institutional adjunctive instruction condition in which patients were contacted by clinic personnel at the beginning of the remediation phase (Session 5) and encouraged to take a proactive role in their treatment and (b) a control condition that contained no institutional adjunctive instruction. Between condition differences in the alliance were tested controlling for baseline influences and the early therapeutic alliance. Clients' postsession reports from Sessions 1 to 24 indicated that the adjunctive instruction increased the alliance over the course of therapy vis à vis the control condition. The adjunctive instruction appeared to have fostered clients' evaluation of their therapists' interest in their welfare. The results indicate that interventions even brief or subtle can produce lasting benefits in the alliance when targeted at specific psychological processes. Systematic metacommunication from the institutional level appeared to reinforce clients' therapeutic alliance with their therapists in individual treatment. (PsycINFO Database Record (c) 2012 APA all rights reserved).

Objective Although the relationship between the therapeutic alliance and outcome has been supported consistently across several studies and meta-analyses, there is less known about how the patient and therapist contribute to this relationship. The purpose of this present meta-analysis was to (1) test for therapist effects in the alliance–outcome correlation and (2) extend the findings of previous research by examining several potential confounds/covariates of this relationship. Method A random effects analysis examined several moderators of the alliance–outcome correlation. These included (a) patient–therapist ratio (patient N divided by therapist N), (b) alliance and outcome rater (patient, therapist, and observer), (c) alliance measure, (d) research design and (e) DSM IV Axis II diagnosis. Results The patient–therapist ratio (PTR) was a significant moderator of the alliance–outcome correlation. Controlling for several potential confounds in a multi-predictor meta-regression, including rater of alliance, research design, percentage of patient Axis II diagnoses, rater of outcome and alliance measure, PTR remained a significant moderator of the alliance–outcome correlation. Conclusion Corroborating previous research, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes. This relationship remains significant even when simultaneously controlling for several potential covariates of this relationship.

Prior meta analyses have found a moderate but robust relationship between alliance and outcome across a broad spectrum of treatments presenting concerns contexts and measurements. However there continues to be a lively debate about the therapeutic role of the alliance particularly in treatments that are tested using randomized clinical trial (RCT) designs. The purpose of this present study was to examine whether research design type of treatment or author's allegiance variables alone or in combination moderate the relationship between alliance and outcome. Multilevel longitudinal analysis was used to investigate the following moderators of the alliance outcome correlation: (a) research design (RCT or other) (b) use of disorder specific manuals (c) specificity of outcomes (d) cognitive and/or behavioral therapy (CBT) or other types of treatments (e) researcher allegiance and (f) time of alliance assessment. RCT disorder specific manual use specificity of primary and secondary outcomes and CBT did not moderate the alliance outcome correlation. Early alliance outcome correlations were slightly higher in studies conducted by investigators with specific interest in alliance than were those in studies conducted by researchers without such an allegiance. Over the course of therapy these initial differences disappeared. Apart from this trend none of the variables previously proposed as potential moderators or mediators of the alliance outcome relation alone or in combination were found to have a mediating impact. (PsycINFO Database Record (c) 2012 APA all rights reserved).

This article reports on a research synthesis of the relation between alliance and the outcomes of individual psychotherapy. Included were over 200 research reports based on 190 independent data sources, covering more than 14,000 treatments. Research involving 5 or more adult participants receiving genuine (as opposed to analogue) treatments, where the author(s) referred to one of the independent variables as "alliance," "therapeutic alliance," "helping alliance," or "working alliance" were the inclusion criteria. All analyses were done using the assumptions of a random model. The overall aggregate relation between the alliance and treatment outcome (adjusted for sample size and non independence of outcome measures) was r = .275 (k = 190); the 95% confidence interval for this value was .25-.30. The statistical probability associated with the aggregated relation between alliance and outcome is p.0001. The data collected for this meta-analysis were quite variable (heterogeneous). Potential variables such as assessment perspectives (client, therapist, observer), publication source, types of assessment methods and time of assessment were explored.

Objective The aim of this study was to examine the relative efficacy of evidence-based treatments (EBTs) versus treatment-as-usual (TAU) in routine care for anxiety and depression in adults. Method A computerized search of studies that directly compared an EBT with a TAU was conducted. Meta-analytic methods were used to estimate effectiveness of EBTs relative to TAU and to model how various confounding variables impacted the results of this comparative research. Results A total of 14 studies were included in the final meta-analysis. There was significant heterogeneity in the TAU conditions, which ranged from unknown and/or minimal mental health treatment to psychotherapeutic interventions provided by trained professionals. Although the effect for EBT vs. TAU was significantly greater than zero, the effect for EBT vs. TAUs that were psychotherapeutic interventions was not statistically different from zero. Conclusions Heterogeneity of TAU conditions in this meta-analysis highlight the importance of clarifying the research questions being asked when investigating and drawing conclusions from EBT–TAU comparisons. Researchers need to clarify if they are comparing an EBT to psychotherapeutic services in routine care or to minimal mental health services. Extant research on EBT versus TAU reveals that there is insufficient evidence to recommend the transportation of EBTs for anxiety and depression to routine care, particularly when the routine care involves psychotherapeutic services.

Background As a quality improvement metric, the US Veterans Health Administration (VHA) monitors the proportion of patients with alcohol use disorders (AUD) who receive FDA approved medications for alcohol dependence (naltrexone, acamprosate, and disulfiram). Evidence supporting the off-label use of the antiepileptic medication topiramate to treat alcohol dependence may be as strong as these approved medications. However, little is known about the extent to which topiramate is used in clinical practice. The goal of this study was to describe and examine the overall use, facility-level variation in use, and patient -level predictors of topiramate prescription for patients with AUD in the VHA. Methods Using national VHA administrative data in a retrospective cohort study, we examined time trends in topiramate use from fiscal years (FY) 2009–2012, and predictors of topiramate prescription in 375,777 patients identified with AUD (ICD-9-CM codes 303.9x or 305.0x) treated in 141 VHA facilities in FY 2011. Results Among VHA patients with AUD, rates of topiramate prescription have increased from 0.99% in FY 2009 to 1.95% in FY 2012, although substantial variation across facilities exists. Predictors of topiramate prescription were female sex, young age, alcohol dependence diagnoses, engagement in both mental health and addiction specialty care, and psychiatric comorbidity. Conclusions Veterans Health Administration facilities are monitored regarding the extent to which patients with AUD are receiving FDA-approved pharmacotherapy. Not including topiramate in the metric, which is prescribed more often than acamprosate and disulfiram combined, may underestimate the extent to which VHA patients at specific facilities and overall are receiving pharmacotherapy for AUD.