Toward effective and efficient treatment adherence monitoring : development of the cognitive behavioral therapy adherence measure

Despite the large body of research demonstrating the efficacy of evidence-based practices (EBPs) for the most common youth mental health problems, EBPs are rarely used in usual care (UC). When EBPs are implemented in UC settings, there is a drop in adherence, and sometimes a drop in outcomes. Feasible and practical adherence monitoring tools may support high quality EBP delivery in UC. The current study examined the psychometric properties of the Cognitive-Behavioral Therapy Adherence Measure (CBTAM), a suite of therapist-, parent-, and youth-reported measures of adherence to the core components of cognitive-behavioral therapy (CBT) for youth anxiety, depression, and behavior problems. Therapists, parents, and youths completed the CBTAM after every session throughout a six-session treatment. Coders coded a subset of treatment sessions using the CBTAM and other established observational coding systems for CBT adherence and alliance. Therapists were consistent with coders on their ratings of individual CBTAM items. Therapist, parent, and youth CBTAM item ratings were correlated with similar items on established observational measures of CBT adherence and alliance, and these correlations were higher than correlations between CBTAM items and dissimilar items on observational measures. CBTAM adherence scores predicted faster symptom improvement on some therapist- and parent-rated outcomes. Therapist and parent end-of-treatment ratings were consistent with observational coding measures of adherence and alliance. Findings demonstrate the promise of the CBTAM as a feasible adherence monitoring tool for routine care.

The Case of Sharon Considered from the Vantage Point of Interpersonal Reconstructive Therapy

In Interpersonal Reconstructive Therapy (IRT: Benjamin, 2003/2006; 2018) a case formulation is used to tailor interventions to each patient’s unique patterns. Using the IRT lens, psychopathology is understood as reflecting attempts to adapt to current environments using maladaptive rules and values that were learned and internalized in the context of close attachment relationships. IRT identifies precise ways in which early learning shapes present experience. Additionally, the "gift of love" (GOL) hypothesis posits that motivation to repeat maladaptive ways is linked to the wish to receive love and acceptance from specific internalized attachment figures by repeating their ways and values for the patient. The IRT case formulation has been shown to be reliable and valid (Critchfield, Benjamin, Levenick, 2015). The therapy adherence measure is also reliable (Critchfield, Davis, Gunn, Benjamin, 2008) and correlates well with retention as well as reduced symptoms and rehospitalization rates (Karpiak, Critchfield, Benjamin, 2011) among "difficult to treat" patients characterized as having high levels of personality disorder, chronic and severe problems, and prior failed treatment attempts. To illustrate the case formulation process, an IRT formulation is applied to the case of a 28-year-old female patient for whom a poor outcome was documented.

Optimal cut-off points for adherence measure among patients with type 2 diabetes in primary care clinics: a retrospective analysis

Background: Medication adherence measures are often dichotomized to classify patients into those with good or poor adherence using a cut-off value ⩾80%, but this cut-off may not be universal across diseases or medication classes. This study aimed to examine the cut-off value that optimally distinguish good and poor adherence by using the medication possession ratio (MPR) and proportion of days covered (PDC) as adherence measures and glycated hemoglobin (HbA1c) as outcome measure among type 2 diabetes mellitus (T2DM) patients. Method: We used pharmacy dispensing data of 1461 eligible T2DM patients from public primary care clinics in Malaysia treated with oral antidiabetic drugs between January 2018 and May 2019. Adherence rates were calculated during the period preceding the HbA1c measurement. Adherence cut-off values for the following conditions were compared: adherence measure (MPR versus PDC), assessment period (90-day versus 180-day), and HbA1c target (⩽7.0% versus ⩽8.0%). Results: The optimal adherence cut-offs for MPR and PDC in predicting HbA1c ⩽7.0% ranged between 86.1% and 98.3% across the two assessment periods. In predicting HbA1c ⩽8.0%, the optimal adherence cut-offs ranged from 86.1% to 92.8%. The cut-off value was notably higher with PDC as the adherence measure, shorter assessment period, and a stricter HbA1c target (⩽7.0%) as outcome. Conclusion: We found that optimal adherence cut-off appeared to be slightly higher than the conventional value of 80%. The adherence thresholds may vary depending on the length of assessment period and outcome definition but a reasonably wise cut-off to distinguish good versus poor medication adherence to be clinically meaningful should be at 90%.

Factorial Structure of the Therapist Adherence Measure-Revised (TAM-R) Within Multisystemic Therapy

The Therapist Adherence Measure (TAM-R) is a central assessment within the quality-assurance system of Multisystemic Therapy (MST). Studies into the validity and reliability of the TAM in the US have found varying numbers of latent factors. The current study aimed to reexamine its factor structure using two independent samples of families participating in MST in the Netherlands. The factor structure was explored using an Exploratory Factor Analysis (EFA) in Sample 1 ( N = 580). This resulted in a two-factor solution. The factors were labeled “therapist adherence” and “client–therapist alliance.” Four cross-loading items were dropped. Reliability of the resulting factors was good. This two-factor model showed good model fit in a subsequent Confirmatory Factor Analysis (CFA) in Sample 2 ( N = 723). The current finding of an alliance component corroborates previous studies and fits with the focus of the MST treatment model on creating engagement.