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Couple therapy has been shown to be effective in randomized clinical trials; however, results from naturalistic couple therapy have been less consistent. This study utilized a benchmarking approach to compare the effectiveness of couple therapy in a community-based setting with findings from efficacy treatments, such as treatment within randomized clinical trials. The current study is the largest couple therapy sample published to date (N = 3,347 couples). Clients in couple therapy were asked to provide initial and weekly ratings of symptomology on the Outcome Questionnaire (OQ-45.2). We found that treatment effect sizes found at community clinics were smaller than efficacy studies (i.e., the benchmark). However, when taking into account measurement reactivity, the effect sizes were comparable. This is the first benchmarking study for community-based couple therapy, allowing for meaningful comparisons and understanding of outcomes in real-world couple therapy. Implications for the field are offered in terms of evaluating community-based psychotherapy studies with benchmarking for couple therapy. Results of this study provide clinicians and researchers a way to meaningfully compare couple therapy outcomes, accounting for differences in community-based practices and randomized clinical trials. This benchmark also underscores the impact of measurement sensitivity, an issue commonly overlooked in psychotherapy research and practice.

Se ha demostrado que la terapia de pareja es eficaz en los ensayos clínicos aleatorizados, sin embargo, los resultados de la terapia de pareja naturalista han sido menos consecuentes. Este estudio utilizó un enfoque comparativo para comparar la eficacia de la terapia de pareja en un entorno basado en la comunidad con hallazgos de los tratamientos de eficacia, como los tratamientos dentro de los ensayos clínicos aleatorizados El presente estudio es la muestra más grande de terapia de pareja publicado hasta la fecha (N = 3347 parejas). Se pidió a los pacientes en terapia de pareja que proporcionen calificaciones iniciales y semanales de la sintomatología en el cuestionario para evaluación de resultados (OQ-45.2).Descubrimos que los tamaños del efecto de los tratamientos hallados en las clínicas comunitarias fueron más pequeños que los de los estudios de eficacia (p. ej.: el estudio comparativo). Sin embargo, cuando se tomó en cuenta la reactividad a la medición, los tamaños del efecto fueron comparables. Este es el primer estudio comparativo para la terapia de pareja basada en la comunidad, el cual permite comparaciones significativas y comprensión de los resultados en la terapia de pareja en el mundo real. Se ofrecen las implicancias para el área en cuanto a la evaluación de los estudios de la psicoterapia basada en la comunidad con evaluación comparativa de la terapia de pareja. Los resultados de este estudio proporcionan a los clínicos y a los investigadores una manera de comparar significativamente los resultados de la terapia de pareja, así como de explicar las diferencias en las prácticas basadas en la comunidad y en los ensayos clínicos aleatorizados. Esta evaluación comparativa también subraya el efecto de la sensibilidad a la medición, una cuestión comúnmente pasada por alto en la investigación y la práctica de la psicoterapia.

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Recent evidence suggests that psychotherapists may not increase in effectiveness over accrued experience in naturalistic settings, even settings that provide access to patients' outcomes. The current study examined changes in psychotherapists' effectiveness within an agency making a concerted effort to improve outcomes through the use of routine outcome monitoring coupled with ongoing consultation and the planful application of feedback including the use of deliberate practice. Data were available for 7 years of implementation from 5,128 patients seen by 153 psychotherapists. Results indicate that outcomes indeed improved across time within the agency, with increases of d = 0.035 (p = .003) per year. In contrast with previous reports, psychotherapists in the current sample showed improvements within their own caseloads across time (d = 0.034, p = .042). It did not appear that the observed agency-level improvement was due to the agency simply hiring higher-performing psychotherapists or losing lower-performing psychotherapists. Implications of these findings are discussed in relation to routine outcome monitoring, expertise in psychotherapy, and quality improvement within mental health care. (PsycINFO Database Record

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OBJECTIVE: Although supervision has long been considered as a means for helping trainees develop competencies in their clinical work, little empirical research has been conducted examining the influence of supervision on client treatment outcomes. Specifically, one might ask whether differences in supervisors can predict/explain whether clients will make a positive or negative change through psychotherapy. METHOD: In this naturalistic study, we used a large (6521 clients seen by 175 trainee therapists who were supervised by 23 supervisors) 5-year archival data-set of psychotherapy outcomes from a private nonprofit mental health center to test whether client treatment outcomes (as measured by the OQ-45.2) differed depending on who was providing the supervision. Hierarchical linear modeling was used with clients (Level 1) nested within therapists (Level 2) who were nested within supervisors (Level 3). RESULTS: In the main analysis, supervisors explained less than 1% of the variance in client psychotherapy outcomes. CONCLUSIONS: Possible reasons for the lack of variability between supervisors are discussed.

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BACKGROUND: Depression is a common comorbidity in multiple sclerosis (MS), but little is known about its long-term prognosis. Depression in the general population is usually episodic with relatively short-lasting depressive episodes. In this study we investigate the long-term prognosis of depression in MS. METHODS: Using data from a large longitudinal observational study and from the Calgary MS clinic database, we investigated changes in Center for Epidemiological Studies Depression Scale (CESD) scores in MS patients over four years of follow-up. We used logistic regression to investigate the association of the factors sex, age, disease duration, Expanded Disability Status Scale (EDSS), depression at baseline, and antidepressant use with depression at each year of follow-up. RESULTS: CESD scores remained largely stable, or decreased slightly over four years of follow-up, whereas EDSS scores steadily increased. Depression at baseline was the strongest predictor of depression at follow-up; the other factors were not or not consistently associated with depression at follow-up. As expected, antidepressant use was associated with a greater risk of depression at follow-up. Starting and stopping antidepressant treatment during follow-up was not associated with the risk of depression at follow-up or with significant change in CESD scores. CONCLUSION: In contrast to depression in the general population, depression in MS is largely chronic, which suggests a different pathophysiology.

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OBJECTIVE: Effective pandemic responses rely on frontline healthcare workers continuing to work despite increased risk to themselves. Our objective was to investigate Alberta family physicians willingness to work during an influenza pandemic. DESIGN: Cross-sectional survey. SETTING: Alberta prior to the fall wave of the H1N1 epidemic. PARTICIPANTS: 192 participants from a random sample of 1000 Alberta family physicians stratified by region. MAIN OUTCOME MEASURES: Willingness to work through difficult scenarios created by an influenza epidemic. RESULTS: The corrected response rate was 22%. The most physicians who responded were willing to continue working through some scenarios caused by a pandemic, but in other circumstances less than 50% would continue. Men were more willing to continue working than women. In some situations South African and British trained physicians were more willing to continue working than other groups. CONCLUSIONS: Although many physicians intend to maintain their practices in the event of a pandemic, in some circumstances fewer are willing to work. Pandemic preparation requires ensuring a workforce is available. Healthcare systems must provide frontline healthcare workers with the support and resources they need to enable them to continue providing care.

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BACKGROUND: Patients with multiple sclerosis (MS) have a high prevalence of depression, but there are concerns regarding assessment of possible depression status using rating scales, such as the 9-item Patient Health Questionnaire (PHQ-9). The idea has been proposed that PHQ-9 scores are contaminated by the MS symptoms of fatigue and impaired concentration, decreasing the validity of measurement. OBJECTIVES: To determine the extent to which scores on the PHQ-9 are contaminated by patients reporting symptoms attributable to MS. METHODS: Baseline PHQ-9 scores from an ongoing prospective cohort study of depression in patients with MS (N = 173) were compared with those of a general population sample (N = 3304). Depression prevalence estimates for the MS and general population samples were calculated using conventional algorithm and cutoff point scoring methods, as well as modified scoring methods, excluding fatigue and concentration deficits. Correlations between scores on adjusted scoring methods were analyzed. The proportion that each item contributed to total PHQ-9 scores was also calculated. A logistic regression model evaluated the relationship between symptom severity and MS status corrected for age, sex, and other depressive symptoms. RESULTS: Conventional PHQ-9 algorithm and cutoff point scoring yielded 2-week prevalence estimates of 9.8% and 21.4%, respectively, in patients with MS, and 3.3% and 8.4%, respectively, in the general population. In both samples, conventional and modified scoring methods were strongly correlated (Spearman rank correlation coefficient > 0.9). The proportion of total scores contributed by fatigue and concentration items was not different between samples. With adjustment for other depressive symptoms, the MS sample had greater odds of endorsement for guilt (odds ratio, 2.17; P = 0.025) and fatigue (odds ratio, 1.51; P = 0.046). CONCLUSION: Inclusion or exclusion of fatigue and concentration items on the PHQ-9 scale does not substantially alter the performance of the scale. With use of the PHQ-9 in MS populations, we find no evidence to suggest that modified approaches to scoring are necessary.

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OBJECTIVE: To assess the public's level of mental health literacy for psychosis. METHOD: A cross-sectional telephone survey using a random phone number selection procedure was conducted to identify a sample of 1685 participants comprised of youth at risk (aged 15 to 39 [corrected] years) and parents of youth at risk of psychosis (aged 35 to 59 years). The Canadian Journal of Psychiatry regrets the error and any inconvenience it might have caused. [corrected]. Participants were asked about their awareness of symptoms and causes of schizophrenia and psychosis, treatment options, and preferred channels for obtaining information about health and mental health. RESULTS: The response rate was 73%. There was a high reported knowledge of the term schizophrenia (76%), but a low reported knowledge of the term psychosis (23%). Ninety-one per cent of participants agreed that medications can control symptoms of schizophrenia. Significant barriers to getting help included not knowing the early signs of psychosis, concerns about being labelled mentally ill or psychotic, and not knowing where to go for help. Preferred communication elements to reach at-risk youth and their families were pamphlets at family physicians' and school counsellors' offices, posters on buses, television and radio advertisements, and information on websites. CONCLUSIONS: Whereas there is good knowledge about recognition and treatment of schizophrenia, there is less awareness of the broader concept of psychosis. Barriers to accessing care included recognition of early signs of psychosis and stigma. Public education programs aimed at promoting earlier intervention would need to address information about both psychosis and stigma.

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BACKGROUND: Community-based studies can describe health status and related variables in people with Multiple Sclerosis (MS) while avoiding biases introduced by help-seeking in specific clinical settings. OBJECTIVE: To describe general health status, stress perceptions and life satisfaction in people with MS, in comparison to those with other types of disabilities. MATERIALS & METHODS: The Participation and Activity Limitation Survey (PALS) was a post-censual survey conducted by Statistics Canada in association with the 2006 Canadian Census. PALS collected data from a random sample of n = 22,513 respondents identified as having health-related impairments. Frequencies and quartiles as well as mean values, along with associated 95% confidence intervals, were calculated in the analysis. RESULTS: PALS identified 245 individuals with MS. Health status, both perceived and when weighted for societal preference, was markedly lower than that of other disabled groups. No differences in self-perceived stress were seen. People with MS reported lower levels of satisfaction with their health but slightly higher levels of satisfaction with their family and friends. CONCLUSIONS: People with MS report lower levels of general health status and more impairment than those with other disabling conditions. Higher levels of satisfaction with friends and family may reflect psychological adaptation to the illness.

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Community-based studies are required to accurately describe the supportive services needed by people with multiple sclerosis (MS). Characteristics that influence (or result from) care-seeking may introduce bias into other types of studies. The Participation and Activity Limitation Survey (PALS) was a post-census survey conducted by Statistics Canada in association with a 2006 national census. The PALS collected data from a sample of 22,513 respondents having health-related impairments according to their census forms. The survey collected self-reported diagnostic data and obtained ratings for items assessing impairment as well as perceived met and unmet needs for care and support. It identified 245 individuals with MS, leading to an estimated (weighted) population prevalence of 0.2% (200 per 100,000). As expected, those with MS reported more-severe health problems than did those with other types of disability, particularly in the areas of mobility, dexterity, and cognition; they were also more likely to report having multiple caregivers. People with MS also reported more unmet health-care needs than did those with other forms of disability, particularly with respect to meal preparation, housework, shopping, and chores. Despite their more negative health status and greater reliance on caregivers, people with MS reported participation in society comparable to that of people without MS. Thus, people with MS report greater needs than do people with other forms of health-related disability and utilize supportive services more often. However, they also report higher levels of unmet needs. The substantial needs of people with MS are only partially addressed by existing services.

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BACKGROUND: Screening has frequently been proposed as a strategy for detection of depression in multiple sclerosis (MS). In a recent study, we found a minimal impact of screening, even when this was coupled with rapidly responsive and evidence-based depression care. METHODS: In order to explore the challenges involved in screening we analyzed prospective data from the Canadian Impact of MS (CIMS) database, which provides annual ratings on a self-report depression rating scale, the Center for Epidemiologic Studies Depression Rating Scale (CES-D). RESULTS: Approximately 30% of respondents screened positive at each visit. CES-D ratings correlated fairly strongly from year to year, Pearson's r ranged from 0.65 to 0.73. Approximately 10% of those below the CES-D cut-point at each assessment exceeded the cut-point when rated 1 year later, but only about half of these cases had large (≥10 points) increases in their scores. CONCLUSIONS: Screening interventions are generally oriented towards early detection, whereas the longitudinal pattern of depressive symptoms in MS appears to be characterized more prominently by a persistent burden of depressive symptoms in a substantial proportion of the population. Resources invested in screening efforts can probably be more effectively deployed in other areas, such as improved long-term clinical management.

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Efforts to reduce both costs and medical waste have led many health systems to start reusing single-use medical devices (SUDs) after cleaning and sterilizing (i.e. reprocessing). There is a currently a wide range of SUD types being reused in many health systems. The objective of this paper is to provide a brief summary of risk issues associated with critical SUDs, based on a rapid review of the available literature. The specific focus is on risk issues, but includes discussion of economic and legal/ethical issues as well. The evidence in the literature regarding the safety of reuse of SUDs indicates that for certain devices (e.g. heart catheters) reuse can be safe (in terms of patient infection) and cost-effective as long as stringent reprocessing protocols are followed. However, potential risks associated with reusing SUDs are not just limited to infection of patients. There are staff and environmental risks, plus important legal, ethical, and financial issues to consider in a reuse policy. There are currently no Canadian guidelines on reuse or reprocessing SUDs, although a national Scientific Advisory Panel on Reprocessing of Medical Devices has made recommendations. Additionally, reuse of SUDs is interwoven with the issue of infection control and reprocessing procedures in general and as applied to multiple-use devices. With limited healthcare resources, there will always be a trade-off between the human resources and costs required to clean and sterilize reused devices with costs associated with purchasing and disposing of non-reused SUDs. Evaluation of complete operational pathways, especially for more expensive and commonly used SUDs, will be useful to properly determine the balance of benefits, risks, and costs under a reuse policy.

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