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Mental health problems are highly prevalent worldwide. Fortunately, psychotherapy has proven highly effective in the treatment of a number of mental health issues, such as depression and anxiety disorders. In contrast, psychotherapy training as is practised currently cannot be considered evidence-based. Thus, there is much room for improvement. The integration of simulated patients (SPs) into psychotherapy training and research is on the rise. SPs originate from the medical education and have, in a number of studies, been demonstrated to contribute to effective learning environments. Nevertheless, there has been voiced criticism regarding the authenticity of SP portrayals, but few studies have examined this to date.
Based on these considerations, this dissertation explores SPs’ authenticity while portraying a mental disorder, depression. Altogether, the present cumulative dissertation consists of three empirical papers. At the time of printing, Paper I and Paper III have been accepted for publication, and Paper II is under review after a minor revision.
First, Paper I develops and validates an observer-based rating-scale to assess SP authenticity in psychotherapeutic contexts. Based on the preliminary findings, it can be concluded that the Authenticity of Patient Demonstrations scale is a reliable and valid tool that can be used for recruiting, training, and evaluating the authenticity of SPs.
Second, Paper II tests whether student SPs are perceived as more authentic after they receive an in-depth role-script compared to those SPs who only receive basic information on the patient case. To test this assumption, a randomised controlled study design was implemented and the hypothesis could be confirmed. As a consequence, when engaging SPs, an in-depth role-script with details, e.g. on nonverbal behaviour and feelings of the patient, should be provided.
Third, Paper III demonstrates that psychotherapy trainees cannot distinguish between trained SPs and real patients and therefore suggests that, with proper training, SPs are a promising training method for psychotherapy.
Altogether, the dissertation shows that SPs can be trained to portray a depressive patient authentically and thus delivers promising evidence for the further dissemination of SPs.
Publication Bias in meta-analyses of the efficacy of psychotherapeutic interventions for depression
(2013)
Objective: The aim of this study was to assess whether systematic reviews investigating psychotherapeutic interventions for depression are affected by publication bias. Only homogeneous data sets were included, as heterogeneous data sets can distort statistical tests of publication bias. Method: We applied Begg and Mazumdar's adjusted rank correlation test, Egger's regression analysis, and the trim and fill procedure to assess the presence and magnitude of publication bias in all homogeneous data sets of systematic reviews published up to September 2010. Results: Thirty-one data sets reported in 19 meta-analyses fulfilled our inclusion criteria. Significant bias was detected in 5 (16.13%; rank correlation test) and 6 (19.35%; Egger's regression analysis) of these data sets. Applying the trim and fill procedure to amend presumably missing studies rarely changed the assessment of the efficacy of therapeutic interventions, with 2 exceptions. In 1 data set psychotherapy was no longer found to be significantly more efficacious than pharmacotherapy in reducing dropout at posttreatment when publication bias was taken into account. In the 2nd data set, after correcting for publication bias, there was no longer evidence that depressed patients without comorbid personality disorder profited more from psychotherapy and pharmacotherapy than patients with comorbid personality disorder. Conclusions: The results suggest that taken together, psychotherapy research for depression is only marginally affected by the selective reporting of positive outcomes. With 2 notable exceptions, correcting for publication bias did not change the evaluation of the efficacy of psychotherapeutic interventions.