The goal of the proposed research is to develop and evaluate the feasibility of a cost-efficient and easily disseminated intervention for improving psychotherapy outcomes for patients with major depressive disorder treated in the community mental health system. A number of studies have demonstrated promising results for feedback systems that identify potential treatment failures and provide outcome information that enables psychotherapists to alter the treatment process to maximize outcomes. Yet no investigations have evaluated the effects of feedback interventions in community mental health centers that are in dire need of cost-efficient and effective interventions to improve outcomes. Our goal is to develop a feedback system that provides information to therapists on the patient's early progress in treatment based on the BASIS-24 as well as important clinical information to guide treatment based on the Personality Assessment Inventory (PAI). We propose a two phase intervention development program in which we will 1) evaluate the feasibility of computerized assessment of the BASIS-24 and PAI, 2) conduct therapist focus groups to develop community friendly feedback reports, and 3) conduct a pilot randomized controlled trial of the feedback system in the community mental health center for the purpose of evaluating the feasibility of the research protocol and the acceptability of the feedback intervention to the community mental health system.. We will randomize therapists delivering services at two community mental health centers to either receive feedback or not receive feedback on the early progress of new patients entering treatment for major depressive disorder. All patients diagnosed with major depressive disorder at the mental health agency will complete the BASIS-24 at baseline and at each treatment session as part of regular clinic procedures. Therapists of patients in the feedback group will receive a brief report based on the BASIS-24 prior to the early sessions of treatment that indicates the patient's progress to date. The report will also include a color code system that indicates to the therapist whether the patient is on track to improve in treatment based on the estimated recovery curves. For patients who are predicted to do poorly, the report will indicate to the therapist that the patient should complete the PAI following the session. The patient will complete the PAI on a computer following his/her therapy session and a clinical report that includes useful clinical recommendations will be given to the therapist prior to the next session. This pilot trial will provide the necessary feasibility and acceptability data to support a future fully-powered trial and to justify the potential success of this feedback system clinically.
Major depressive disorder is a severe and disabling disorder afflicting 7% of individuals in the United States annually and approximately 17% of individuals across their lifetime (Kessler et al., 2005). Depression has been ranked as the fourth greatest public health problem by the World Health Organization (Murray &Lopez, 1996) and is considered the most likely illness to result in disability (Murray &Lopez, 1996). Despite multiple investigations demonstrating that both medications as well as psychotherapeutic interventions are effective in the treatment of major depressive disorder (APA, 2000), response rates in well-done efficacy trials still reach only 40 to 60% (DeRubeis et al., 2005;Bielski, Ventura, &Chang, 2004;Keller et al., 2000), and response rates for public sector clients are less than 30% (Rush, Trivedi, Carmody, et al., 2004). While many have suggested that outcomes in community-based settings could be improved through the dissemination of empirically-supported psychotherapies (Stirman, Crits-Christoph, &DeRubeis, 2004;Barlow et al., 1999;Chorpita et al., 2002;Henggler et al., 1995), such efforts have a variety of hurdles, including the cost of training therapists in new methods, and resistances of therapists to adopting new approaches that are discrepant from their own preferred style of therapy. The current research paradigm represents an alternative way to improve outpatient mental health outcomes, through performance feedback to the therapist that has the potential to improve mental health outcomes in community clinics in a feasible and sustainable way.