PhD/PsyD Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models

[mdwpsyd]

Interesting research that rings pretty true for me. What do you think?

CITATION
Lee, A. A., Sripada, R. K., Hale, A. C., Ganoczy, D., Trivedi, R. B., Arnow, B., & Pfeiffer, P. N. (2021). Psychotherapy and depressive symptom trajectories among VA patients: Comparing dose-effect and good-enough level models. Journal of Consulting and Clinical Psychology, 89(5), 379–392. APA PsycNet

ABSTRACT
Objective: Psychotherapy for depression is effective for many veterans, but the relationship between number of treatment sessions and symptom outcomes is not well established. The Dose-Effect model predicts that greater psychotherapeutic dose (total sessions) yields greater symptom improvement with each additional session resulting in smaller session-to-session improvement. In contrast, the Good-Enough Level (GEL) model predicts that rate of symptom improvement varies by total psychotherapeutic dose with faster improvement associated with earlier termination. This study compared the dose-effect and GEL model among veterans receiving psychotherapy for depression within the Veterans Health Administration.

Method: The sample included 13,647 veterans with ≥2 sessions of psychotherapy for depression with associated Patient Health Questionnaire-9 (PHQ-9) scores in primary care (n = 7,502) and specialty mental health clinics (n = 6,145) between October 2014 and September 2018. Multilevel longitudinal modeling was used to compare the Dose-Effect and GEL models within each clinic type.

Results: The GEL model demonstrated greater fit for both clinic types relative to dose-effect models. In both treatment settings, veterans with fewer sessions improved faster than those with more sessions. In primary care clinics, veterans who received 4–8 total sessions achieved similar levels of symptom response. In specialty mental health clinics, increased psychotherapeutic dose was associated with greater treatment response up to 16 sessions. Veterans receiving 20 sessions demonstrated minimal treatment response.

Conclusions: These findings support the GEL model and suggest a flexible approach to determining length of psychotherapy for depression may be useful for optimizing treatment response and allocation of clinical resources.

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[WisNeuro]

Honestly, unless they controlled for validity and excluded those currently in the SC or appealing a SC status, hard to say. It was common for us to see someone going for multiple SC disabilities schedule as many MH appointments as they could and halo symptom questionnaires, and then drop off the face of the earth when they got it. Hard to control for that with these giant datasets.

 

[IWillSurvive]

Honestly, unless they controlled for validity and excluded those currently in the SC or appealing a SC status, hard to say. It was common for us to see someone going for multiple SC disabilities schedule as many MH appointments as they could and halo symptom questionnaires, and then drop off the face of the earth when they got it. Hard to control for that with these giant datasets.

Agreed with the SC comment. We could just be tapping into motivation here...I also feel like...in primary care, symptom severity should theoretically be lower so fewer sessions will naturally be needed there. In Gen MH, the EBP's we use tend to be 12-16 sessions so perhaps beyond 16 is reaching a point of diminishing returns...which makes sense. I generally consider the dose effect to be 12-16 so that seems consistent to me. I'd be curious if anyone tried the 4-8 sessions in Gen MH...I would expect that would be an insufficient 'dose' at that level of care but it could be surprising. I've definitely seen some clinicians doing that as they try to manage individual pt and overall access needs. Also curious if group vs. individual makes a difference because I see a lot of group happening in MH clinics too.

 

[R. Matey]

Also, the PHQ-9 shares variance with a lot of presenting concerns one would expect in primary care (eating, sleeping, attention, tiredness etc.) so it would be difficult to establish the change in scores is due to therapeutic dosage, clinical expertise, or another intervention.