Highlights In this paper we explore the statistical characteristics of depressive symptom change (PHQ9; Kroenke, Spitzer, & Williams, 2001) associated with a large web-based psychotherapy sample (ICBT; n=1096), and compare between two common ways to measure and interpret symptom change (linear and proportional change). Results demonstrated that within both treatment and waitlist conditions, symptoms changed proportionally to baseline (e.g. 50-55% treatment related change across individuals from different baselines, and ±30% change for individuals the waitlist).Additional features such as (1) a strong relationship between an individual's baseline score and the rate of symptom change, and (2) positive distributional skewness at post treatment, also suggest proportional change. Analyses demonstrate the measurement of proportional symptom change also enabled (1) a more accurate in predicting symptom outcomes (measurement error reduction of over 40%), (2) more interpretable estimate of change (percentage improvement) which is aligned with the aims of treatment (remission of symptoms), (3) a clearer ability to differentiate between treatment related and non-treatment related symptom change, and (4) overcome an artificial increase between the estimation of treatment efficacy and baseline symptom severity. This research suggests that the measurement and interpretation of symptom change as a proportional function (percentage improvement) can be more suitable than common linear alternatives such as Cohen's d. Although some statistical jargon is used, the intention of this paper is to convey the statistical methodology, and the take home messages about symptom measurement in a way that is approachable to any practitioner.
AbstractObjective: The aims of this study were to (1) explore the underlying characteristics of depressive symptom change (PHQ9) following psychotherapy, and (2) compare the suitability of different ways to measure and interpret symptom change. A treatment sample of web-based psychotherapy participants (n=1098), and a waitlist sample (n=96) were used to (1) explore the statistical characteristics of depressive symptom change, and (2) compare the suitability of two common types of change functions; linear and proportional change.Methods: These objectives were explored using hypotheses which tested (1) the relationship between baseline symptoms and the rate of change, (2) the shape of symptom score distribution following treatment, and (3) Conclusions: This study suggests that symptom scales, sharing an implicit feature of score bounding, are associated with a proportional function of change. Selecting statistics that overlook this proportional change (e.g., Cohen's d) is problematic and leads to (1) artificially increased estimates of change with higher baseline symptoms, (2) increased measurement error, and (3) confounded estimates of treatment efficacy and clinical change.