Quality of cognitive-behavioural therapy in routine psychiatric care: therapist adherence and competence, and patient outcomes for depression and anxiety disorders

Background: Quality of care is essential for the dissemination of evidence-based practices, yet therapist adherence and competence are seldom assessed. We examined the quality of delivery of cognitive-behavioural therapy (CBT) in routine psychiatric care for depression and anxiety disorders, considering therapist adherence and competence, and therapy effectiveness, as well as their associations. Methods: Twenty-nine therapists recruited 85 patients with a principal diagnosis of depression or anxiety disorder from two routine psychiatric outpatient clinics in Stockholm, Sweden. Therapist adherence was assessed mid-CBT by observers and post-CBT by patients and therapists, respectively, using an instrument developed as part of the present study. Therapist competence was assessed using role-plays with a standardised patient. Patients rated symptoms, functional impairment, and global health pre- and post-CBT. Linear mixed models were used to analyse associations. Results: Therapist adherence was high according to patients, moderate to high according to therapists, and moderate according to observers. Most therapists demonstrated competence in CBT, as assessed using the Cognitive Therapy Scale-Revised (M = 40.5, SD = 6.5; 76% passed the ≥ 36 points competence threshold). Patients improved significantly from pre- to post-CBT across outcome measures (Cohen’s ds = 0.80 – 1.36). Neither therapist adherence nor competence was associated with patient outcomes. Conclusions: In routine psychiatric care, therapists delivered CBT with adherence, competence, and improvements for patients with depression and anxiety disorders, on par with previous research results in controlled settings. The implications for quality assessment and improvement are discussed. Trial registration: ClinicalTrials.gov NCT03625024 10/08/2018.