From the Editor

When we speak of improving the quality of mental health care, we often think about cutting-edge innovation – wearables, virtual reality, genetics, to name a few things.

This week, there are two selections. Both discuss innovations aimed at improving care – but neither could be considered particularly “cutting edge.”

In the first selection, researchers sought to improve outpatient appointment attendance with a decidedly low-tech idea: appointment letters reminding patients of the importance of follow up. Spoiler alert: it worked.

In the second selection, drawn from The New York Times, reporter Andrea Petersen discusses clinics that use a short, intense version of CBT.

Thinking outside the box

Together, these two selections illustrate some thinking outside the box.



Letters and Follow-up 

“Message Framing and Engagement in Specialty Mental Health Care: A Follow-up Analysis”

Shahrzad Mavandadi, Erin Wright, Johanna Klaus, David Oslin

Psychiatric Services, 9 August 2018 Published Online

Attendance rates in specialty mental health treatment are suboptimal, with many individuals neither initiating treatment nor engaging in continued mental health care. A variety of strategies to improve attendance rates have been developed and examined. For example, multicomponent care management strategies that use tailored feedback, motivational techniques, and tracking of outcomes can lead to significant improvements in initial and sustained treatment engagement. However, these strategies are both time intensive and staff intensive, and not all clinical settings have adequate resources to track and manage all patients referred to specialty mental health care. Less intensive strategies, including delivering automated prompts and appointment reminders by means of telephone, text, or postal mail, also have been shown to improve attendance rates among patients, representing potentially brief, effective, and low-cost methods of improving engagement.

Similar to other health behaviors, seeking treatment for mental health concerns is guided by cognitive processes related to both motivation and decision making. Thus one cognitively centered approach that has the potential to motivate patients to engage in treatment involves manipulating the phrasing—or “framing”—of the health recommendation. For example, varying the extent to which a health appeal highlights the benefits of performing a specific behavior (that is, a gain-framed appeal; “by exercising, you increase your chances of keeping your blood pressure under control”) or the costs of not performing the behavior (that is, a loss-framed appeal; “by not exercising, you decrease your chances of keeping your blood pressure under control”) has been found to influence both intention to change and actual engagement in a range of health behaviors (for example, mammography and breast self-examination, sunscreen use, HIV testing, and smoking cessation).

Guided by empirical support for the impact of message framing on health behavior and the effectiveness of appointment reminder letters in improving treatment attendance rates among patients with mental illness, we conducted a randomized study to examine the relative effect of loss-framed, gain-framed, and neutral messages on mental health treatment initiation and engagement for up to six months following a positive result on a depression screen. Primary analyses revealed that patients who received a gain-framed appointment reminder letter prior to their first scheduled specialty care visit were significantly more likely to attend their appointment than those who were randomly assigned to receive a neutral, standard appointment reminder letter. There were no significant differences, however, in appointment attendance rates across patients receiving a loss-framed reminder letter and those receiving a gain-framed or a neutral letter. In this report, we examine the relative effect of message frame on the rate of engagement in specialty care appointments over a six-month period following the initial referral. According to prospect theory, individuals act to avoid risks when presented with potential gains or benefits but are more willing to take risks when presented with potential losses or costs associated with engaging in a behavior. Given that attending mental health care appointments can result in a variety of desirable outcomes, or gains (for example, maintenance of mental health, prevention of further, more severe impairment, and alleviation or remission of depressive symptoms), we hypothesized that patients who received gain-framed messages would be significantly more likely to attend their scheduled appointments than those receiving a loss-framed or neutral letter.

So begins a paper by Mavandadi et al.

Here’s what they did:

  • The sample consisted of veterans receiving care at the Corporal Michael J. Crescenz Veterans Affairs Medical Center (CMCVAMC), located in Philadelphia, and affiliated community-based outpatient clinics.
  • Participants completed a behavioural health assessment between March 30, 2015, and September 29, 2016.
  • Participants had major depression, based on PHQ-9 scores.
  • Exclusion criteria included PTSD, bipolar disorder, psychosis, or substance use disorder, as well as hearing problems.
  • “One-third of the patients were sent a routine clinical reminder letter with the name of the provider, date and time of the scheduled specialty mental health care visit, and directions to the hospital and clinic (neutral arm). The other two-thirds of the patients were randomly assigned to receive reminder letters that were modified to include a gain-framed or loss-framed message or appeal.”
  • Appointment and attendance data were extracted from the computerized system.
  • Statistical analyses were done, including chi-square tests.

Here’s what they found:

  • There were 360 people included.
  • Demographically: people in the sample were male (85%) and non-Hispanic black (54%). The mean depressive symptom score on the PHQ-9 was 19.3 (SD 3.8).
  • “Patients assigned to receive gain-framed messages prior to their appointments over the six-month period were significantly more likely to attend the scheduled appointment than those assigned to receive the neutral letter (odds ratio=1.52; 95% confidence interval=1.11–2.08; p=.01).”
  • “[T]here were no significant differences in attendance rates across patients receiving loss-framed messages and patients receiving gain-framed or neutral messages.”

Results from this analysis of the association between message framing and specialty mental health care appointment attendance further support the idea that adding a brief, positive, gain-framed message to a routine appointment reminder letter is associated with increased attendance rates over time.

A few thoughts:

  1. This is a good paper.
  1. A quick observation: the messaging wasn’t so important, so much as the message – both loss-framed and gain-framed messages increased attendance rates.
  1. This low-tech solution (a couple of lines added to a letter) offered a measureable impact. The authors didn’t do an economic analysis – but the intervention would surely be cost effective.
  1. Is there broad applicability here? The authors seem to think so, closing:

[T]he study findings have numerous potential applications in current practice and in future work. Modifying standard appointment reminder notices, which many health systems use, to clearly highlight the potentially positive, as opposed to negative, consequences of attending a specialty mental health care appointment may improve engagement rates in a timely, efficient, and cost-effective manner. Although this study utilized paper reminder letters sent by mail, future studies may examine the effect of modifying message frames by using different modes of message delivery at the individual level (for example, telephone reminders and text-based or Web-based prompts) and within different contexts (such as broader, system-level visual, print, or digital public health communications and social marketing campaigns).

  1. The original paper considered appointment letters for initial specialty care appointments. The results were robust.


For the record, p=0.04. You can find this paper here:

  1. Psychiatric Services may be one of the most underappreciated journals in psychiatry. I note that they have run other practical papers like this in the past, including one on the impact of texting appointment reminders to patients on no-show rates. You can find the paper here:


CBT and Intensity

“With Short, Intense Sessions, Some Patients Finish Therapy in Just Weeks”

Andrea Petersen

The New York Times, 13 August 2018

Six middle- and high-school students sat around a table on a Monday afternoon, watching a psychologist write three letters on a whiteboard:


‘What does O.C.D. stand for?’ the psychologist, Avital Falk, asked the group.

‘Obsessive-compulsive disorder,’ answered a timid 12-year-old boy wearing a blue blazer and red tie.

‘What makes it a disorder?’ Dr. Falk asked.

‘Because it’s messing up our lives,’ said Sydney, a chatty 14-year-old with long red hair.

These young people have O.C.D., an illness characterized by recurrent, intrusive thoughts and repetitive behaviors, or other problems with anxiety. They also are participants in a novel treatment program at Weill Cornell Medicine in New York.

Typically patients with O.C.D. see a therapist once a week for an hour over several months, but this program consists of two-hour group meetings three times a week, plus up to four additional hours of individual therapy per week. Some patients complete the treatment in just two weeks.

The program, which began in 2016, is part of a new wave of concentrated, intensive therapy programs for psychiatric disorders. The Child Mind Institute in New York launched a two-day ‘boot camp’ for teens with social anxiety last year. The Houston O.C.D. Program in Texas operated its first weeklong treatment program for adolescents during spring break for local schools.

1520615920388Andrea Petersen

So begins an article by Petersen.

The author interviews several people about short, intensive sessions, including Dr. Thomas H. Ollendick, a Virginia Tech psychologist, who has developed a one-day treatment for phobias. She quotes him: “you don’t have a week in between to unlearn what you learned in the session or have additional experiences that can lead you to think, ‘Oh, I better be afraid.’”

She also notes a couple of recent papers:

  • “A meta-analysis of randomized, controlled trials published last year in the journal Behaviour Research and Therapy found remission rates of 54 percent for children in intensive, concentrated cognitive behavioral therapy (C.B.T.) for anxiety disorders and 57 percent for those in standard C.B.T., a difference that was not statistically significant. Just 2.3 percent of patients who did the concentrated therapy dropped out during treatment, compared with 6.5 percent for standard C.B.T.”
  • “Another meta-analysis (this one of both randomized, controlled trials and studies without a control group), published in 2015 in the Journal of Obsessive-Compulsive and Related Disorders, found that O.C.D. patients who were treated with intensive, concentrated therapy were more improved after treatment ended than those who received traditional weekly or twice weekly C.B.T. At a follow-up point of about three months, both groups were equally improved.”

A few thoughts:

  1. This is a highly readable article – and it draws nicely from the literature.
  1. Of course, many clinics and organizations experiment with ways of delivering therapy.
  1. For some of our patients, focused sessions would make sense; others, though, would want longer treatments. The point is not that there is one solution for the needs of all patients, but that a broader range of options would likely address the high dropout rates found in many mental health outpatient clinics.
  1. I’ll return to the point that opens this Reading: innovation can involve more than wearables, VR, and genetics.


Reading of the Week. Every week I pick articles and papers from the world of Psychiatry.