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The efficacy and effectiveness of psychotherapeutic interventions have been proven time and again. We therefore know that, in general, evidence-based treatments work for the average patient. However, it has also repeatedly been shown that some patients do not profit from or even deteriorate during treatment. Patient-focused psychotherapy research takes these differences between patients into account by focusing on the individual patient. The aim of this research approach is to analyze individual treatment courses in order to evaluate when and under which circumstances a generally effective treatment works for an individual patient. The goal is to identify evidence based clinical decision rules for the adaptation of treatment to prevent treatment failure. Patient-focused research has illustrated how different intake indicators and early change patterns predict the individual course of treatment, but they leave a lot of variance unexplained. The thesis at hand analyzed whether Ecological Momentary Assessment (EMA) strategies could be integrated into patient-focused psychotherapy research in order to improve treatment response prediction models. EMA is an electronically supported diary approach, in which multiple real-time assessments are conducted in participants" everyday lives. We applied EMA over a two-week period before treatment onset in a mixed sample of patients seeking outpatient treatment. The four daily measurements in the patients" everyday environment focused on assessing momentary affect and levels of rumination, perceived self-efficacy, social support and positive or negative life events since the previous assessment. The aim of this thesis project was threefold: First, to test the feasibility of EMA in a routine care outpatient setting. Second, to analyze the interrelation of different psychological processes within patients" everyday lives. Third and last, to test whether individual indicators of psychological processes during everyday life, which were assessed before treatment onset, could be used to improve prediction models of early treatment response. Results from Study I indicate good feasibility of EMA application during the waiting period for outpatient treatment. High average compliance rates over the entire assessment period and low average burdens perceived by the patients support good applicability. Technical challenges and the results of in-depth missing analyses are reported to guide future EMA applications in outpatient settings. Results from Study II shed further light on the rumination-affect link. We replicated results from earlier studies, which identified a negative association between state rumination and affect on a within-person level and additionally showed a) that this finding holds for the majority but not every individual in a diverse patient sample with mixed Axis-I disorders, b) that rumination is linked to negative but also to positive affect and c) that dispositional rumination significantly affects the state rumination-affect association. The results provide exploratory evidence that rumination might be considered a transdiagnostic mechanism of psychological functioning and well-being. Results from Study III finally suggest that the integration of indicators derived from EMA applications before treatment onset can improve prediction models of early treatment response. Positive-negative affect ratios as well as fluctuations in negative affect measured during patients" daily lives allow the prediction of early treatment response. Our results indicate that the combination of commonly applied intake predictors and EMA indicators of individual patients" daily experiences can improve treatment response predictions models. We therefore conclude that EMA can successfully be integrated into patient-focused research approaches in routine care settings to ameliorate or optimize individual care.
Numerous RCTs demonstrate that cognitive behavioral therapy (CBT) for depression is effective. However, these findings are not necessarily representative of CBT under routine care conditions. Routine care studies are not usually subjected to comparable standardizations, e.g. often therapists may not follow treatment manuals and patients are less homogeneous with regard to their diagnoses and sociodemographic variables. Results on the transferability of findings from clinical trials to routine care are sparse and point in different directions. As RCT samples are selective due to a stringent application of inclusion/exclusion criteria, comparisons between routine care and clinical trials must be based on a consistent analytic strategy. The present work demonstrates the merits of propensity score matching (PSM), which offers solutions to reduce bias by balancing two samples based on a range of pretreatment differences. The objective of this dissertation is the investigation of the transferability of findings from RCTs to routine care settings.