Jacques P. Barber, Ph.D., ABPP - US grants

The goals of this proposal are: to develop further measures of adherence to treatment manuals and of the quality of delivery of treatment for the three modalities (Cognitive Therapy (CT), Drug Counseling (DC), and Supportive-Expressive Dynamic Psychotherapy (SE)) included in the Treatments for Cocaine Addiction Collaborative Study (TCACS); and to provide additional evidence for the reliability and validity of these measures. Reliability will be examined by calculating coefficients of interjudge reliability, internal consistency and test-retest reliability of the scales. Scales validity will be addressed by examining 1) face validity, 2) concurrent validity, and 3) predictive validity. Concurrent validity of the scales will be examined by evaluating a) whether the TCACS modalities as they are delivered indeed differ and b) by correlating the independent expert judges' ratings of therapists' actions with the ratings from the TCACS' supervisors. Predictive validity of the scales will be explored by examining the relations between therapists' behavior and patient outcome in a sample of the patients. The pilot reliability (interjudge and internal consistency) and developmental studies of the adherence measures will be performed in three initial samples. Each pilot sample will include 15 audiotapes from the training phase of the TCACS, each one of them will be rated by experts from all modalities. Further reliability and validity (discriminant, concurrent, and predictive)will be examined by having experts in the three modalities rate 2 tapes from a sample of patients who participated in the TCACS. Expert judges in SE, CT, and IDC will rate 2 tapes from 5 randomly selected patients for each therapist enrolled in each modality. In view of the fact that psychosocial approaches are the treatment of choice for cocaine abuse, the significance of the current research program is that: 1) it will provide the field with measures of adherence and quality of applying techniques for widely used forms of psychosocial treatments (cognitive, dynamic and drug counseling) for cocaine abuse; 2) it will examine whether TCACS therapists' actions, in each of these different psychosocial treatments for cocaine abuse, can be differentiated; and, 3) it will explore the complex relations among therapists' behavior and treatment outcome in a sample of TCACS patients.

Major Depressive Disorder (MDD) is one of the most prevalent psychiatric disorders. A number of psychosocial and pharmacological treatments have been developed which have proven to be efficacious for major depression. In general, different forms of psychotherapy for depression have been found efficacious. One of the most widely used forms of psychotherapy, dynamic therapy, however, has received very little research attention. For example, no study has yet compared the efficacy of dynamic therapy to serotonin selective reuptake inhibitor (SSRI) or to a placebo control condition among depressed patients. The primary aim of this proposal is to conduct a randomized clinical trial to examine the efficacy of a widely used form of manualized dynamic psychotherapy (supportive expressive psychodynamic therapy or SE) relative to an antidepressant medication condition (SSRI-Sertraline) replaced if clinically indicated by a serotonin-norepinephrine reuptake inhibitor (SNRI-venlafaxine) + Clinical Management (CM) and pill placebo + CM for patients with MDD. The secondary aims are: (a) to test whether SSRI/SNRI + CM is more effective than SE therapy among the more severely depressed outpatients in the sample; (b) to gather preliminary data on the relapse/recurrence rate of depression for patients who received SE versus SSRI/SNRI + CM; and (c) to examine predictors of outcome and mediators of change in these treatments. Steps toward effectiveness research have been taken by minimizing exclusion criteria, including a flexible medication switching condition, examining a wide range of outcome and functioning variables and assessing health care usage.

DESCRIPTION (provided by applicant): Panic disorder (PD) is a prevalent and debilitating condition. Efficacious treatments for this condition exist, including several classes of medication. Cognitive behavioral therapy, (CBT) has been shown to be efficacious for PD. However, over 30% of PD patients decline medication, and nearly one half do not remit from CBT, there is a pressing need for additional nonpharmacologic approaches. We have developed and tested a manualized psychodynamic psychotherapy for panic disorder, Panic Focused Psychodynamic Psychotherapy (PFPP). We have completed treatment development stages I and II and have demonstrated efficacy in 40 patients with DSM-IV primary PD in comparison with Applied Relaxation Training (ART). This application will investigate the indications, overall utility, and mechanisms of action of PFPP. We are conducting this study at two sites with broad inclusion criteria, to recruit sufficient patients, and to increase generalizability. The project has 3 aims: 1. Acute Efficacy. (Primary Aim) To conduct a 12-week randomized controlled trial of Panic-Focused Psychodynamic Psychotherapy (PFPP), and CBT, versus Applied Relaxation Training (ART) in a 2:2:1 ratio of randomization in 233 subjects with primary PD with or without Agoraphobia. 2. To compare the sustained effects of these two treatments in these patients at 12 months post-treatment termination, 3. To test specific mediator and moderator hypotheses for PFPP and CBT. We shall enroll 233 participants, ages 18 to 70, who meet DSM-IV criteria for PD with or without Agoraphobia as their primary diagnosis. All subjects will be randomly assigned to 19-24 sessions over 12 weeks of CBT, PFPP, or ART in a 2:2:1 ratio. Patients will be followed monthly with standard rating instruments for 12 months post treatment termination to compare durability of effects. Subjects in the ART condition will be given their choice of CBT or PFPP (nonrandomized) if they do not respond at treatment termination.