The implementation and adherence to evidence-based protocols for psychotherapy for depression: the perspective of therapists in Dutch specialized mental healthcare

Abstract

BackgroundAlthough psychotherapy is an effective treatment for depression, a large number of patients still do not receive care according to the protocols that are used in clinical trials. Instead, patients often receive a modified version of the original intervention. It is not clear how and when treatment protocols are used or modified in the Dutch specialized mental health care and whether these changes lead to suboptimal adherence to treatment protocols.MethodsIn the context of an ongoing multicenter trial that investigates whether twice-weekly sessions of protocolized interpersonal psychotherapy (IPT) and cognitive behavioral therapy (CBT) for depression lead to better treatment outcomes compared to once-weekly sessions, two focus groups using semi-structured interviews were organized. Aims were to increase insight in the adherence to and modifications of CBT and IPT protocols in the Dutch specialized mental health care for depression. Participants were fifteen therapists from seven mental health locations part of five mental health organizations. Verbatim transcripts were coded and analyzed using qualitative software.ResultsThree themes emerged: modification as the common practice, professional and patient factors influencing the adherence to protocols and organizational boundaries and flexibility. Treatment modification appeared to happen on a frequent basis, even in the context of a trial. Definitions of treatment modifications were multiple and varied from using intuition to flexible use of the same protocol. Therapist training and supervision, the years of work experience and individual characteristics of the therapist and the patient were mentioned to influence the adherence to protocols. Modifications of the therapists depended very much on the culture within the mental health locations, who differed in terms of the flexibility offered to therapists to choose and modify treatment protocols.ConclusionsNot all treatment modifications were in line with existing evidence or guidelines. Regular supervision, team meetings and a shared vision were identified as crucial factors to increase adherence to treatment protocols, whereas additional organizational factors, among which a change of mindset, may facilitate adequate implementation.

Costs, benefits, and cost-benefit of Collaborative Assessment and Management of Suicidality versus enhanced treatment as usual

“…Although this approach maximized fidelity to study treatment, it should be noted that CAMS therapists inadvertently had more than twice the years of practice experience since professional degree than ETAU therapists. This finding is consistent with research suggesting that less-experienced therapists may be more inclined to adhere to a specific treatment protocol or newly learned therapy whereas more seasoned providers may be more open to a variety of approaches [ 71 – 73 ]. Previous research suggests that years of practice experience is not necessarily correlated with therapist effectiveness [ 74 , 75 ] and statistical modeling in the current study did not suggest any therapist effects on clinical outcomes.…”

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“…Although this approach maximized fidelity to study treatment, it should be noted that CAMS therapists inadvertently had more than twice the years of practice experience since professional degree than ETAU therapists. This finding is consistent with research suggesting that less-experienced therapists may be more inclined to adhere to a specific treatment protocol or newly learned therapy whereas more seasoned providers may be more open to a variety of approaches [71][72][73]. Previous research suggests that years of practice experience is not necessarily correlated with therapist effectiveness [74,75] and statistical modeling in the current study did not suggest any therapist effects on clinical outcomes.…”

Effectiveness of late‐life depression interventions on functional limitations: A systematic review

“…First, it could be argued that the guideline cannot be regarded as a structured management plan, especially because implementation of depression guidelines in clinical practice is generally questionable (Bruijniks et al . 2018; Sinnema et al . 2013, 2015).…”