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The Thrill of Victory, the Agony of the Unknown

Our PHQ-9 data collection and analysis project revealed that over time, our clients’ depression symptoms improved. The question is, why?

As we revealed in our second blog entry, our independent research confirms that when it comes to treating depression, we’re doing something right. We can’t pinpoint precisely what that something is, but we do know that what we offer is very different from how psychiatry is often practiced today. In the past 20 years, insurance reimbursement policies have slowly and steadily tried to make psychiatric treatment echo primary care. In many practices, the famed "50-minute hour" is a relic, as relevant to 21st-century living as the dial telephone.

In 2017, a number of psychiatry practices limit visit time to 15 minutes or less, with a focus on medication efficacy and return appointments in 4-6 weeks. While that’s an effective approach for sinus infections, it’s not always adequate for conditions such as depression. For most depressed clients, symptoms are not just related to an imbalance of neurotransmitters, but a complex interplay of biology, personal history, and life circumstances. All these factors are complicated on their own. Trying to explore all of them in 15 minutes or less—particularly when the client is building trust with a new provider—is impossible.

From the very beginning of treatment, Pondworks builds in the ability to alter the length, frequency, and type of visit depending upon where the client is in terms of symptoms and progress. If a client thrives on a 15-minute appointment, no problem. But if he or she needs more time per visit and more frequent visits, we adjust accordingly. Regardless of how often a client is seen, all visits are conducted using a supportive psychotherapeutic approach. We couldn’t measure these intangibles—at least not in this report—but we believe that these factors contribute to better client outcomes.

However, when it comes to those outcomes, what we believe and what we can prove with actual data are two very different entities. To be sure, scales and surveys are extremely helpful in measuring specifics such as depression levels or confidence in a provider. It’s harder to interpret how all those measurable factors come together, and if this synergistic effect is the key to client symptom improvement.

Furthermore, the quality of the methods used to analyze that data determines how meaningful it is. Why do some studies get published in the Journal of the American Medical Association and others in the National Enquirer? The Journal people have real inquiring minds. They scour their research for study flaws and publish them along with the data. We're following suit with our findings, featured below.


Our study sample was small, and we did not separate clients by diagnoses. We could have been studying a group for whom depression was not an issue; the majority of the sample could have ADHD or anxiety alone. We also did not separate by gender. Statistically speaking, women are more likely to suffer from and seek treatment for depression than men, so the sample could have been more than 50% male.

It’s also important to note that we analyzed the change in numbers from one category of PHQ-9 to the next—not the change in scores of individual clients. For example, the number of clients reporting mild depression (a 0-4 score) increased over time from 9 to 19. We don’t know if the initial 9 stayed in that category and were joined by 10 others, or if 19 new people occupied the category and the original 9 reported higher scores and wound up in another category.

And since we are a therapy-focused practice, it’s important to note that we did not split clients who engaged in therapy from those who didn’t. There is ample evidence to support that clients with depression who engage in psychotherapy in addition to taking medication have better treatment outcomes than those who take medications alone. A 2014 meta-analysis of 52 studies published in the journal World Psychiatry concluded that there is “a moderately large effect and clinically meaningful difference in favor of combined treatment.”

There is ample evidence to support that clients with depression who engage in psychotherapy in addition to taking medication have better treatment outcomes than those who take medications alone.

Another factor that we could not account for is treatment alliance. Put simply, do the client and provider work well together? Does the client feel understood, heard, and important? Are their goals aligned? If so, that client is primed for treatment success—regardless of the type of therapy he or she is receiving. A 2013 study published in the Journal of Consulting and Clinical Psychology followed 395 chronically depressed adults through a 12-week psychotherapy program. The clients received brief supportive psychotherapy or cognitive behavioral analysis psychotherapy. Two-hundred and twenty-four subjects rated their mood symptoms with the Hamilton Rating Scale for Depression every 2 weeks and their treatment alliance with their provider with the Working Alliance Inventory Short Form at weeks 2 and 4. The results? A positive working alliance with a therapist was associated with lower symptom ratings over the course of the therapy—regardless of the kind of therapy.

So, what did we at Pondworks learn from this endeavor? At face value, it may seem that this project resulted in more questions than answers—but as anyone who has even glanced at a study abstract will attest, most journal articles end with this sentence: “More research is needed.” This exercise proved that there is value in measuring how our clients are doing, but ultimately, we need to keep asking more questions—and different questions—to continue to improve our service.

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