Measurement and psychotherapy. Evidence-based practice and practice-based evidence

How is return on investment from quality improvement programmes conceptualised by mental healthcare leaders and why: a qualitative study

BACKGROUND

Return on Investment (ROI), whereby the ratio of costs to benefits is assessed, is encouraged in-order to justify the value of Quality Improvement (QI) programmes. We previously performed a literature review to develop a ROI conceptual framework for QI programmes. We concluded that, QI-ROI is conceptualised as any monetary and non-monetary benefit. In the current study, we explored if this finding is shared by mental healthcare leaders. We also investigated the stability of this conceptualisation against influencing factors and potential for disinvestment.

METHODS

We performed qualitative interviews with leaders in an NHS mental health organisation. There were 16 participants: nine board members and seven senior leaders. The interviews were held online via Microsoft Teams and lasted an hour on average. We performed deductive-inductive analysis to seek data from our initial ROI framework and any new data.

RESULTS

We found that in mental healthcare, QI-ROI is also conceptualised as any valued monetary and non-monetary benefits. There was a strong emphasis on benefits to external partners and a de-emphasis of benefit monetisation. This conceptualisation was influenced by the 1) perceived mandates to improve quality and manage scarce resources, 2) expectations from QI, 3) health and social care values, 4) ambiguity over expectations, and 5) uncertainty over outcomes. Uncertainty, ambiguity, and potential for disinvestment posed a threat to the stability of this conceptualisation but did not ultimately change it. Health and social care values supported maintaining the QI-ROI as any benefit, with a focus on patients and staff outcomes. Socio-political desires to improve quality were strong drivers for QI investment.

CONCLUSION

Mental healthcare leaders primarily conceptualise QI-ROI as any valued benefit. The inclusion of externalised outcomes which are hard to attribute may be challenging. However, mental healthcare services do collaborate with external partners. The de-emphases of benefit monetisation may also be controversial due to the need for financial accountability. Mental healthcare leaders recognise the importance of efficiency savings. However, they raised concerns over the legitimacy and utility of traditional ROI as a tool for assessing QI value. Further research is needed to bring more clarity on these aspects of the QI-ROI concept.

A scoping review of integrated yoga and psychological approaches for the treatment of eating disorders

BACKGROUND

Eating disorders are serious mental health conditions that significantly impact the social and economic burden of mental ill health in Australia. Best practice treatment for eating disorders includes a multi-axial approach, including medical, psychiatric, and psychological approaches. More recently, complementary and alternative therapy approaches, such as yoga, are used to support eating disorder recovery.

METHODS

This scoping review identified and examined current research exploring the use of yoga alongside psychological approaches for the treatment and management of eating disorders across the lifespan.

RESULTS

Results highlighted the lack of available research, with only four studies identified. Three of these studies piloted programs and identified promising results with a reduction of eating disorder symptomatology. However, these results remain tentative due to methodological limitations and the overall lack of available evidence. In the future, researchers are encouraged to clearly articulate the theoretical concepts that underpin their yoga programs and focus on adequately powered and designed trials, such as RCTs, to accurately compare treatment effects between interventions combining yoga with psychological interventions and standard psychological treatment. Qualitative enquiry is also recommended to provide further insights regarding what makes interventions successful.

CONCLUSIONS

Current evidence suggests further guidance and pragmatic recommendations to guide researchers and clinicians alike are required, ultimately improving outcomes for people experiencing an eating disorder across the lifespan.

Fostering practice-based evidence through routine outcome monitoring in a university psychotherapy service for common mental health problems: a protocol for a naturalistic, observational study

INTRODUCTION

Data-informed psychotherapy and routine outcome monitoring are growing as referents in psychotherapy research and practice. In Ecuador, standardised web-based routine outcome monitoring systems have not been used yet, precluding data-driven clinical decisions and service management. Hence, this project aims at fostering and disseminating practice-based evidence in psychotherapy in Ecuador by implementing a web-based routine outcome monitoring system in a university psychotherapy service.

METHODS AND ANALYSES

This is a protocol for an observational naturalistic longitudinal study. Progress and outcomes of treatment in the Centro de Psicología Aplicada of the Universidad de Las Américas in Quito, Ecuador will be examined. Participants will be adolescents and adults (≥11 years) seeking treatment, as well as therapists and trainees working at the centre between October 2022 and September 2025. Clients' progress will be monitored by a range of key variables: psychological distress, ambivalence to change, family functioning, therapeutic alliance and life satisfaction. Sociodemographic information and satisfaction with treatment data will be collected before and at the end of treatment, respectively. Also, semi-structured interviews to explore therapists' and trainees' perceptions, expectations and experiences will be conducted. We will analyse first contact data, psychometrics of the measures, reliable and clinically significant change, outcome predictors as well as trajectories of changes. Moreover, we will conduct a framework analysis for the interviews.

ETHICS AND DISSEMINATION

The protocol for this study was approved by the Human Research Ethics Committee of the Pontificia Universidad Católica del Ecuador (#PV-10-2022). The results will be disseminated in peer-reviewed scientific articles, at conferences and in workshops.

TRIAL REGISTRATION NUMBER

NCT05343741.

Theory-driven treatment modifications: A discussion on meeting the linguistic, cognitive, and psychosocial needs of individual clients with aphasia

There is a growing body of literature demonstrating that language rehabilitation can improve naming impairments for individuals with aphasia. However, there are challenges applying evidence-based research to clinical practice. Well-controlled clinical studies often consist of homogenous samples and exclude individuals who may confound group-level results. Consequently, the findings may not generalize to the diverse clients serviced by speech-language therapists. Within evidence-based guidelines, clinicians can leverage their experiences and theoretical rationale to adapt interventions to meet the needs of individual clients. However, modifications to evidence-based interventions should not alter aspects of treatment that are necessary to produce change within the treatment target. The current discussion paper uses errorless learning, errorful learning, and retrieval practice for naming in aphasia to model how treatment theories can guide clinicians in making theory-informed modifications to interventions. First, we briefly describe the learning mechanisms hypothesized to underlie errorless learning, errorful learning, and retrieval practice. Next, we identify ways clinicians can provide targeted supports to optimize learning for individual clients. The paper ends with a reflection on how well-defined treatment theories can facilitate the generation of practice-based evidence and clinically relevant decision making.

Peer-led interventions to reduce alcohol consumption in college students: A scoping review

Risky alcohol consumption among college students is a significant public health issue. In the college setting, students can collaborate in the implementation of peer-led interventions. To date, evidence of peer-led programmes in reducing harmful alcohol consumption in this population is inconclusive. The aim of the current scoping review is to provide a broad overview by systematically examining and mapping the literature on peer-led interventions for preventing risky alcohol consumption by college students. The specific aims were to (1) identify the underlying focus of the interventions and assess their (2) effectiveness and (3) feasibility. A comprehensive search was conducted in PubMed, PsycINFO, CINAHL, Cochrane Library, Web of Science, DART-Europe, RCAAP, Trove and ProQuest. The inclusion criteria were peer-led interventions that exclusively addressed alcohol consumption, college students as the target population and interventional studies (randomised controlled trials, quasi-experimental studies, systematic reviews and meta-analyses of interventions). The methodological quality of the articles was evaluated. From 6654 potential studies, 13 were included. Nine interventions were described within these studies: Voice of Reason programme, Brief Advice sessions, Peer Theatre, Alcohol Education programme, Perceptions of Alcohol Norms intervention, Motivational Intervention, Alcohol Skills Training programme, Lifestyle Management Class and the Brief Alcohol Screening and Intervention for College Students. Only the last showed significant reductions in three of the four outcome measures: quantity and frequency of drinking, estimated peak blood alcohol concentration and alcohol-related consequences. It did not significantly decrease the number of heavy-drinking episodes. Peer interventions may be effective in preventing alcohol use among college students, although the evidence is weak and scarce. Further research is needed to strengthen the findings about peer-led interventions.

Practice-Based Evidence to Support Return to Work in Cancer Patients

Background

International research emphasizes the importance of providing early, hospital-based support in return to work (RTW) for cancer patients. Even though oncology health professionals are aware of the scientific evidence, it remains unclear whether they implement this knowledge in current practice. This paper presents the knowledge and viewpoints of health care professionals (HCPs) on their potential role in their patients' RTW process.

Methods

Semi-structured interviews with oncology HCPs were used to describe current practice. Results of these interviews served as input for focus group discussions with managers in oncology hospitals, which led to an agreement on of best practice.

Results

This research had the participation of 75% of Belgian institutions involved in oncology health care services. Five themes were identified that influence care providers and staff to implement scientific evidence on RTW in cancer patients: (1) Opinions on the role that care institutions can take in RTW support; (2) Current content of RTW support during oncology care; (3) Scientific bases; (4) Barriers and success factors; and (5) Legislation and regulations. The key elements of the best practice included a generic approach adapted to the needs of the cancer patient supported by a RTW coordinator.

Conclusions

Health care providers include RTW support in their current care, but in very varied ways. They follow a process that starts with setting the indication (meaning the identification of patients for whom the provision of work-related care would be useful) and ends with a clear objective agreed upon by HCPs and the patient. We recommend that specific points of interest be included in regulation at both the patient and hospital levels.

Youth Top Problems and Early Treatment Response to the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents

The Top Problems assessment is an idiographic measure of client concerns that may allow clinicians to identify early treatment response. Few studies have examined early response to evidence-based therapies using Top Problems. We collected weekly Top Problems ratings from 95 youth with emotional disorders who received treatment using the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/UP-A). We assessed Top Problems rating change from session 1 to session 4, the role of pre-treatment variables in early Top Problems rating change, and the role of early Top Problems rating change in post-treatment symptom outcomes. Top Problems ratings decreased significantly from session 1 to session 4. Younger child age and higher parent cognitive flexibility were associated with early Top Problems improvement. Controlling for pre-treatment, early Top Problems rating change did not explain the variance in post-treatment outcomes. Future research should examine Top Problems trajectories over treatment course.

ENhancing Assessment of Common Therapeutic factors (ENACT) tool: adaptation and psychometric properties in South Africa

Background

The ENhancing Assessment of Common Therapeutic factors (ENACT) tool measures a set of therapeutic competencies required for the effective psychological intervention, including delivery by non-specialists. This paper describes the systematic adaptation of the ENACT for the South African (SA) context and presents the tool's initial psychometric properties.

Methods

We employed a four-step process: (1) Item generation: 204 therapeutic factors were generated by SA psychologists and drawn from the original ENACT as potential items; (2) Item relevance: SA therapists identified 96 items that were thematically coded according to their relationship to one another and were assigned to six domains; (3) Item utility: The ENACT-SA scale was piloted by rating recordings of psychological therapy sessions and stakeholder input; and (4) Psychometric properties: Internal consistency and inter-rater reliability of the final 12-item ENACT-SA were explored using Cronbach's alpha and intraclass correlation co-efficient (ICC) for both clinical psychologists and registered counsellors.

Results

Although the original ENACT provided a framework for developing a tool for use in SA, several modifications were made to improve the applicability of the tool for the SA context, and optimise its adaptability other contexts. The adapted 12-item tool's internal consistency was good, while the inter-rater reliability was acceptable for both clinical psychologists and registered counsellors.

Conclusion

The ENACT-SA is a reliable tool to assess common factors in psychological treatments. It is recommended that the tool be used in conjunction with assessment protocols and treatment-specific competency measures to fully assess implementation fidelity and potential mechanisms of therapeutic change.

Appraising psychotherapy case studies in practice-based evidence: introducing Case Study Evaluation-tool (CaSE)

Systematic case studies are often placed at the low end of evidence-based practice (EBP) due to lack of critical appraisal. This paper seeks to attend to this research gap by introducing a novel Case Study Evaluation-tool (CaSE). First, issues around knowledge generation and validity are assessed in both EBP and practice-based evidence (PBE) paradigms. Although systematic case studies are more aligned with PBE paradigm, the paper argues for a complimentary, third way approach between the two paradigms and their 'exemplary' methodologies: case studies and randomised controlled trials (RCTs). Second, the paper argues that all forms of research can produce 'valid evidence' but the validity itself needs to be assessed against each specific research method and purpose. Existing appraisal tools for qualitative research (JBI, CASP, ETQS) are shown to have limited relevance for the appraisal of systematic case studies through a comparative tool assessment. Third, the paper develops purpose-oriented evaluation criteria for systematic case studies through CaSE Checklist for Essential Components in Systematic Case Studies and CaSE Purpose-based Evaluative Framework for Systematic Case Studies. The checklist approach aids reviewers in assessing the presence or absence of essential case study components (internal validity). The framework approach aims to assess the effectiveness of each case against its set out research objectives and aims (external validity), based on different systematic case study purposes in psychotherapy. Finally, the paper demonstrates the application of the tool with a case example and notes further research trajectories for the development of CaSE tool.

Effectiveness of integrated treatment for eating disorders in Spain: protocol for a multicentre, naturalistic, observational study

INTRODUCTION

Eating disorders (EDs) are complex pathologies which require equally complex treatment strategies. These strategies should be multidisciplinary, personalised interventions, performed in appropriate settings along a healthcare continuum from inpatient to community care. Personalisation, and the complexity of levels of care and interventions make evaluation of treatments difficult. The present study aims to measure the effectiveness of a complex treatment programme for EDs which includes hospitalisation, day hospital and outpatient settings. Our purpose is to assess the complete therapeutic process of each patient through all these levels of care, capturing the multiplicity of trajectories that a programme of these characteristics involves.

METHODS AND ANALYSIS

This protocol describes a multicentre, naturalistic, observational study. All patients starting between November 2017 and October 2020 in a healthcare network for EDs in Spain are being invited to participate. The first phase of intensive change monitoring to November 2020 is followed by lower intensity follow-up until October 2025. In the first phase progress of all participants is assessed every 3 weeks using specific measures for ED and the Clinical Outcomes Routine Evaluation system, a family of instruments specifically designed to measure change in psychotherapy. In the second phase data collection will happen quarterly. Both cross-sectional and longitudinal analyses will be conducted, with a special focus on patterns and predictors of change studied through multilevel linear models.

ETHICS AND DISSEMINATION

The study has been approved by the Research Bioethics Committee of the University of Barcelona (no. IRB00003099) and the ethical committee of ITA Mental Health, the organisation to which all participating centres belong. Dissemination will be in papers for peer-reviewed research journals and to clinicians working with ED.

TRIAL REGISTRATION NUMBER

NCT04127214.

The acceptability, effectiveness, and durability of cognitive analytic therapy: Systematic review and meta-analysis

OBJECTIVES

This paper sought to conduct a meta-analysis of the effectiveness and durability of cognitive analytic therapy (CAT) and assess the acceptability of CAT in terms of dropout rates.

DESIGN

Systematic review and meta-analysis.

METHODS

PROSPERO registration: CRD42018086009. Searches identified CAT treatment outcome studies eligible to be narratively synthesized. Pre-post/post-follow-up effect sizes (ESs) were extracted and synthesized in a random-effects meta-analysis. Variations in effect sizes were explored using moderator analyses. Dropout rates were extracted. Secondary analyses synthesized between-group ES from trials of CAT.

RESULTS

Twenty-five studies providing pre-post CAT treatment outcomes were aggregated across three outcome comparisons of functioning, depression, and interpersonal problems. CAT produced large pre-post improvements in global functioning (ES = 0.86; 95% CI 0.71-1.01, N = 628), moderate-to-large improvements in interpersonal problems (ES = 0.74, 95% CI 0.51-0.97, N = 460), and large reductions in depression symptoms (ES = 1.05, 95% CI 0.80-1.29, N = 586). All these effects were maintained or improved upon at follow-up. Limited moderators of CAT treatment effect were identified. CAT demonstrated small-moderate, significant post-treatment benefits compared to comparators in nine clinical trials (ES = 0.36-0.53; N = 352). The average dropout rate for CAT was 16% (range 0-33%).

CONCLUSIONS

Patients with a range of presenting problems appear to experience durable improvements in their difficulties after undergoing CAT. Recommendations are provided to guide the further progression of the CAT outcome evidence base.

PRACTITIONER POINTS

Large pre-post reductions in global functioning and depression outcomes and moderate-large reductions in interpersonal problems are evident after CAT. The effects of CAT appear durable, and interpersonal functioning significantly improves over follow-up time. CAT produces small-moderate benefits compared to trial comparators. CAT appears to be an engaging psychotherapy that maintains patients in treatment.

Partnering with School Providers to Co-Design Mental Health Interventions: An Open Trial of Act & Adapt in Urban Public Middle Schools

Schools are well positioned to provide access to youth mental health services, but implementing effective programs that promote emotional and behavioral functioning in school settings is complicated by the poor fit of interventions developed in research settings to complex school contexts. The current study formed a research-practice partnership with two urban public schools and mental health providers employed by those schools (N = 6, 100% female, 50% Black/African American, 50% White/Caucasian) in the adaptation of a depression prevention intervention, Act & Adapt. The intervention was modified by decreasing meeting time and streamlining session content, increasing flexibility, making intervention materials more similar to academic curriculum, and increasing the focus on managing disruptive behavior within group sessions. In an open trial, 6^th grade students (N = 22; 59% boys, 31% Hispanic, 22% Black/African American, 4% Asian, 30% White/Caucasian) at both schools who were identified as clinically "at risk" reported improvements from baseline to post-intervention and at one-year follow-up on measures of emotional and behavioral difficulties and coping strategies, with parallel results by caregiver report. The providers reported satisfaction with the intervention, and qualitative analyses of provider focus groups suggested both barriers and facilitators to research-practice collaborations to implement mental health interventions in schools.

Influences of Sex, Education, and Country of Birth on Clinical Presentations and Overall Outcomes of Interdisciplinary Pain Rehabilitation in Chronic Pain Patients: A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

This study investigates the effects of sex, education, and country of birth on clinical presentations and outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRPs). A multivariate improvement score (MIS) and two retrospective estimations of changes in pain and ability to handle life situations were used as the three overall outcomes of IMMRPs. The study population consisted of chronic pain patients within specialist care in the Swedish Quality Registry for Pain Rehabilitation (SQRP) between 2008 and 2016 at baseline (n = 39,916), and for the subset participating in IMMRPs (n = 14,666). A cluster analysis based on sex, education, and country of origin revealed significant differences in the following aspects: best baseline clinical situation was for European women with university educations and the worst baseline clinical situation was for all patients born outside Europe of both sexes and different educations (i.e., moderate-large effect sizes). In addition, European women with university educations also had the most favorable overall outcomes in response to IMMRPs (small effect sizes). These results raise important questions concerning fairness and equality and need to be considered when optimizing assessments and content and delivery of IMMRPs for patients with chronic pain.

The Role of Entrapment in Crisis-Focused Psychotherapy Delivered in Psychiatric Emergency Settings: A Comparative Study

Although many mental health centers offer crisis intervention services as part of their psychiatric emergency facilities, studies assessing outcome, and process of crisis intervention psychotherapy are scarce. One potential psychological construct that might be unique to crisis intervention psychotherapy is entrapment, a psychological construct which reflects an individual's subjective perception of being in uncontrollable, unremitting, and inescapable circumstances. In this study we aimed to investigate whether changes in entrapment affect the process and outcome of crisis intervention psychotherapy, as compared to its effect in short-term psychotherapy delivered in outpatient units. Sixty-nine patients were recruited for the study. Patients were assessed for level of entrapment, symptoms, well-being, and the working alliance at three time points. The moderating effect of the type of therapy on the associations between changes in entrapment and changes in symptoms, well-being, and the working alliance were assessed using the Hayes process script. The dynamics of change following crisis intervention psychotherapy, as well as the effect of changes in entrapment on symptomatic relief, were illustrated using a clinical vignette of a patient treated in the crisis unit. Results of the moderation analyses indicated that entrapment had a more substantial effect on symptom distress in crisis intervention psychotherapy as compared to its effect in the short-term psychotherapy. Further, the difference in the effect of entrapment across the study groups was manifested primarily in internal entrapment, whereas no moderating effect was found for external entrapment. Clinical vignettes demonstrated the dynamics through which crisis intervention psychotherapy produces changes in entrapment by offering potential outlets from internal thoughts and interpretations of life circumstances. These results suggest that entrapment is a potential underlying process unique to crisis intervention psychotherapy. Limitations, directions for future research, and clinical implications are discussed.

Measurement-Based Care in the Veteran's Health Administration: A Critique and Recommendations for Future Use in Mental Health Practice

Measurement-based care (MBC), a mechanism through which feedback is given to providers and patients, is increasingly being used in mental health care and has a number of benefits. These include providing information about treatment progress, encouraging a discussion around these topics, providing a method for shared decision-making and personalized treatment, and improving treatment outcomes. Although there are many benefits to using MBC, it is still not being used regularly. Barriers include time to administer measures and uncertainty regarding which measures to administer. This paper will briefly describe MBC and its use in mental health care and then will focus on the use and implementation of MBC within the Veteran's Health Administration (VHA). The VHA is a large healthcare system in which there have been ongoing efforts to implement MBC. Suggestions for successful implementation will be discussed.

Consensus-based good practice guidelines for clinical psychologists to support care staff in enabling sexual expression in people with intellectual disabilities-A Delphi study

BACKGROUND

Care staff supporting people with intellectual disabilities (PWID) report accepting views on PWID's sexual expression, but people with intellectual disabilities report their sexual expression is restricted by care staff.

METHODS

We recruited a panel of 17 UK clinical psychologists experienced in helping care staff support PWID's sexual expression. We used the Delphi Method to develop consensus-based practice guidelines for UK clinical psychologists supporting care staff in this way.

RESULTS

Having proposed three guidelines each in Round One, panel members reached consensus (≥90% agreement) that 12 were important, falling under four themes: "Addressing staff attitudes," "Addressing uncertainty about rights and responsibilities of people with intellectual disabilities," "Locating the problem, being part of the solution," and "Supporting care staff to understand and reflect upon their role."

CONCLUSIONS

Clinical psychologists help care staff support PWID's sexual expression by normalizing care staff concerns, encouraging reflection, clarifying PWID's rights, and prompting those at managerial and service level to support care staff.

Access, accountability, and the proliferation of psychological therapy: On the introduction of the IAPT initiative and the transformation of mental healthcare

Psychological therapy today plays a key role in UK public mental health. In large part, this has been through the development of the (specifically English) Improving Access to Psychological Therapies (IAPT) programme. Through IAPT, millions of citizens have encountered interventions such as cognitive behaviour therapy, largely for the treatment of depression and anxiety. This article interrogates how this national response to problems of mental ill-health - and the problematization itself - was developed, accounted for, and sustained. By imbricating economic expertise with accounts of mental ill-health and mechanisms of treatment, IAPT has revivified psychological framings of pathology and therapy. However, it has done so in ways that are more familiar within biomedical contexts (e.g. through recourse to randomized controlled trial studies). Today, the initiative is a principal player in relation to which other services are increasingly developed. Indeed, in many respects IAPT has transformed from content to context within UK public mental health (in a process of what I term 'contextification'). By documenting these developments, this paper contributes to re-centring questions about the place and role of psychology in contemporary healthcare. Doing so helps to complicate assumptions about the dominance of linear forms of (de)biomedicalization in health-systems.

Moderate and Stable Pain Reductions as a Result of Interdisciplinary Pain Rehabilitation-A Cohort Study from the Swedish Quality Registry for Pain Rehabilitation (SQRP)

Few studies have investigated the real-life outcomes of interdisciplinary multimodal pain rehabilitation programs (IMMRP) for chronic pain. This study has four aims: investigate effect sizes (ES); analyse correlation patterns of outcome changes; define a multivariate outcome measure; and investigate whether the clinical self-reported presentation pre-IMMRP predicts the multivariate outcome. To this end, this study analysed chronic pain patients in specialist care included in the Swedish Quality Registry for Pain Rehabilitation for 22 outcomes (pain, psychological distress, participation, and health) on three occasions: pre-IMMRP, post-IMMRP, and 12-month follow-up. Moderate stable ES were demonstrated for pain intensity, interference in daily life, vitality, and health; most other outcomes showed small ES. Using a Multivariate Improvement Score (MIS), we identified three clusters. Cluster 1 had marked positive MIS and was associated with the overall worst situation pre-IMMRP. However, the pre-IMMRP situation could only predict 8% of the variation in MIS. Specialist care IMPRPs showed moderate ES for pain, interference, vitality, and health. Outcomes were best for patients with the worst clinical presentation pre-IMMRP. It was not possible to predict who would clinically benefit most from IMMRP.

Knowledge management

Knowledge management sounds superficially like yet another of those topical expressions describing something that has been developed outside medicine and is possibly ill-suited for application within the field, but offering an excuse for yet more change. However, one of the distinguishing features of every profession is that it applies a body of specialist knowledge and skills to a defined purpose. Knowledge in medicine is growing exponentially. In a recent survey of just 22 general practices, the practice guidelines identified weighed 28 kg (Hibble et al, 1998)! In psychiatry, about 5500 papers which potentially have clinical relevance are published annually. Keeping pace with knowledge as it grows is a major challenge for all clinicians. This is reflected in the National Health Service (NHS) information strategy, which identifies three specific needs of clinicians (NHS Executive, 1998). These are: •

A bottom-up approach to assess verbal therapeutic techniques. Development of the Psychodynamic Interventions List (PIL)

OBJECTIVE

Knowing which specific verbal techniques "good" therapists use in their daily work is important for training and evaluation purposes. In order to systematize what is being practiced in the field, our aim was to empirically identify verbal techniques applied in psychodynamic sessions and to differentiate them according to their basic semantic features using a bottom-up, qualitative approach.

METHOD

Mixed-Method-Design: In a comprehensive qualitative study, types of techniques were identified at the level of utterances based on transcribed psychodynamic therapy sessions using Qualitative Content Analysis (4211 utterances). The definitions of the identified categories were successively refined and modified until saturation was achieved. In a subsequent quantitative study, inter-rater reliability was assessed both at the level of utterances (n = 8717) and at the session level (n = 38). The convergent validity of the categories was investigated by analyzing associations with the Interpretive and Supportive Technique Scale (ISTS).

RESULTS

The inductive approach resulted in a classification system with 37 categories (Psychodynamic Interventions List, PIL). According to their semantic content, the categories can be allocated to three dimensions: form (24 categories), thematic content (9) and temporal focus (4). Most categories showed good or excellent inter-rater reliability and expected associations with the ISTS were predominantly confirmed. The rare use of the residual category "Other" suggests that the identified categories might comprehensively describe the breadth of applied techniques.

CONCLUSIONS

The atheoretical orientation and the clear focus on overt linguistic features should enable the PIL to be used without intensive training or prior theoretical knowledge. The PIL can be used to investigate the links between verbal techniques derived from practice and micro-outcomes (at the session level) as well as the overall therapeutic outcomes. This approach might enable us to determine to what extent the outcome of therapy is due to unintended or non-theoretically relevant techniques.

A case study of lessons learnt from implementing a routine outcome monitoring system for psychotherapy in a South African community clinic

Monitoring outcomes in psychotherapy is important for advancing research into empirically supported treatments, collecting data to inform practice-based evidence and for monitoring patient treatment responses during routine care. We implemented two routine outcome monitoring measures in a community psychology clinic in South Africa, namely, the Outcome Rating Scale and Kessler Psychological Distress Scale. In this article, we adopt a case study methodology to describe and critically reflect on the implementation process and evaluate the utility of the outcome data collected during the first year of implementation. Our findings suggest that the measures have some utility but that there were significant problems with implementation. We found that Outcome Rating Scale and Kessler Psychological Distress Scale scores correlated in the expected direction; however, Outcome Rating Scale intake scores for the present population were at odds with the measure’s norms. The findings highlight the care that needs to be taken to change routine clinical practice when outcome measures are implemented in local settings and the need for research to validate the use of these ROM measures in South African clinical settings.

Establishing Language Benchmarks for Children With Typically Developing Language and Children With Language Impairment

PURPOSE

Practitioners, researchers, and policymakers (i.e., stakeholders) have vested interests in children's language growth yet currently do not have empirically driven methods for measuring such outcomes. The present study established language benchmarks for children with typically developing language (TDL) and children with language impairment (LI) from 3 to 9 years of age.

METHOD

Effect sizes for grammar, vocabulary, and overall language were calculated for children with TDL (n = 20,018) using raw score means and standard deviations from 8 norm-referenced measures of language. Effect sizes for children with LI were calculated using fall and spring norm-referenced language measures for 497 children with LI receiving business-as-usual therapy in the public schools.

RESULTS

Considerable variability was found in expected change across both samples of children over time, with preschoolers exhibiting larger effect sizes (d = 0.82 and 0.70, respectively) compared with school-age children (d = 0.49 and 0.55, respectively).

CONCLUSIONS

This study provides a first step toward establishing empirically based language benchmarks for children. These data offer stakeholders an initial tool for setting goals based on expected growth (practitioners), making informed decisions on language-based curricula (policymakers), and measuring effectiveness of intervention research (researchers).

Practice-Based Evidence in Community Guide Systematic Reviews

OBJECTIVES

To assess the relative contributions and quality of practice-based evidence (PBE) and research-based evidence (RBE) in The Guide to Community Preventive Services (The Community Guide).

METHODS

We developed operational definitions for PBE and RBE in which the main distinguishing feature was whether allocation of participants to intervention and comparison conditions was under the control of researchers (RBE) or not (PBE). We conceptualized a continuum between RBE and PBE. We then categorized 3656 studies in 202 reviews completed since The Community Guide began in 1996.

RESULTS

Fifty-four percent of studies were PBE and 46% RBE. Community-based and policy reviews had more PBE. Health care system and programmatic reviews had more RBE. The majority of both PBE and RBE studies were of high quality according to Community Guide scoring methods.

CONCLUSIONS

The inclusion of substantial PBE in Community Guide reviews suggests that evidence of adequate rigor to inform practice is being produced. This should increase stakeholders' confidence that The Community Guide provides recommendations with real-world relevance. Limitations in some PBE studies suggest a need for strengthening practice-relevant designs and external validity reporting standards.

Weak outcome predictors of multimodal rehabilitation at one-year follow-up in patients with chronic pain-a practice based evidence study from two SQRP centres

BACKGROUND

For patients with chronic pain, the heterogeneity of clinical presentations makes it difficult to identify patients who would benefit from multimodal rehabilitation programs (MMRP). Yet, there is limited knowledge regarding the predictors of MMRP's outcomes. This study identifies predictors of outcome of MMRPs at a 12-month follow-up (FU-12) based on data from the Swedish Quality Registry for Pain Rehabilitation (SQRP).

METHODS

Patients with chronic pain from two clinical departments in Sweden completed the SQRP questionnaires-background, pain characteristics, psychological symptoms, function, activity/participation, health and quality of life-on three occasions: 1) during their first visit; 2) immediately after the completion of their MMRP; and 3) 12 months after completing the MMRP (n = 227). During the FU-12, the patients also retrospectively reported their global impressions of any changes in their perception of pain and their ability to handle their life situation in general.

RESULTS

Significant improvements were found for pain, psychological symptoms, activity/participation, health, and quality of life aspects with low/medium strong effects. A general pattern was observed from the analyses of the changes from baseline to FU-12; the largest improvements in outcomes were significantly associated with poor situations according to their respective baseline scores. Although significant regressors of the investigated outcomes were found, the significant predictors were weak and explained a minor part of the variation in outcomes (15-25%). At the FU-12, 53.6% of the patients reported that their pain had decreased and 80.1% reported that their life situation in general had improved. These improvements were associated with high education, low pain intensity, high health level, and work importance (only pain perception). The explained variations were low (9-11%).

CONCLUSIONS

Representing patients in real-world clinical settings, this study confirmed systematic reviews that outcomes of MMRP are associated with broad positive effects. A mix of background and baseline variables influenced the outcomes investigated, but the explained variations in outcomes were low. There is still a need to develop standardized and relatively simple outcomes that can be used to evaluate MMRP in trials, in clinical evaluations at group level, and for individual patients.

Relearning and Retaining Personally-Relevant Words using Computer-Based Flashcard Software in Primary Progressive Aphasia

Although anomia treatments have often focused on training small sets of words in the hopes of promoting generalization to untrained items, an alternative is to directly train a larger set of words more efficiently. The current case study reports on a novel treatment for a patient with semantic variant Primary Progressive Aphasia (svPPA), in which the patient was taught to make and practice flashcards for personally-relevant words using an open-source computer program (Anki). Results show that the patient was able to relearn and retain a large subset of her studied words for up to 20 months, the full duration of the study period. At the end of treatment, she showed good retention for 139 words. While only a subset of the 591 studied overall, this is still far more words than is typically targeted in svPPA interventions. Furthermore, she showed evidence of generalization to perceptually distinct stimuli during confrontation naming and temporary gains in semantic fluency, suggesting limited gains in semantic knowledge as a result of training. This case represents a successful example of patient-centered treatment, where the patient used a computer-based intervention independently at home. It also illustrates how data captured from computer-based treatments during routine clinical care can provide valuable “practice-based evidence” for motivating further treatment research.

Involvement of parents in intervention for childhood speech sound disorders: a review of the evidence

BACKGROUND

Internationally, speech and language therapists (SLTs) are involving parents and providing home tasks in intervention for phonology-based speech sound disorder (SSD). To ensure that SLTs' involvement of parents is guided by empirical research, a review of peer-reviewed published evidence is needed.

AIMS

To provide SLTs and researchers with a comprehensive appraisal and analysis of peer-reviewed published intervention research reporting parent involvement and the provision of home tasks in intervention studies for children with phonology-based SSD.

METHODS & PROCEDURES

A systematic search and review was conducted. Academic databases were searched for peer-reviewed research papers published between 1979 and 2013 reporting on phonological intervention for SSD. Of the 176 papers that met the criteria, 61 were identified that reported on the involvement of parents and/or home tasks within the intervention. These papers were analysed using a quality appraisal tool. Details regarding the involvement of parents and home tasks were extracted and analysed to provide a summary of these practices within the evidence base.

MAIN CONTRIBUTION

Parents have been involved in intervention research for phonology-based SSD. However, most of the peer-reviewed published papers reporting this research have provided limited details regarding what this involved. This paucity of information presents challenges for SLTs wishing to integrate external evidence into their clinical services and clinical decision-making. It also raises issues regarding treatment fidelity for researchers wishing to replicate published intervention research.

CONCLUSIONS & IMPLICATIONS

The range of tasks in which parents were involved, and the limited details reported in the literature, present challenges for SLTs wanting to involve parents in intervention. Further high-quality research reporting more detail regarding the involvement of parents and home tasks in intervention for SSD is needed.

Effectiveness of community-based treatment on clinical outcome in children with autism spectrum disorders: An Italian prospective study

OBJECTIVE

Little is known about outcomes of Autism Spectrum Disorders (ASDs) interventions in real-life settings. The main aim of this naturalistic study was to collect real-life data on the actual ASDs treatment practices in Italy.

METHODS

A cohort of 48 children undergoing community-based interventions was observed in terms of personal and environmental characteristics, treatment typology and outcomes.

RESULTS

An earlier start of treatment was associated with an improvement of autistic symptoms, independently from symptoms severity (p < 0.05), but not with improvements in terms of intelligence quotient (p = 0.8). Children belonging to lower socioeconomic status families began treatment later (48.0 months) than those belonging to middle (39.8 months) or upper (39.2 months) classes (p < 0.05), and received less hours of treatment.

CONCLUSION

The study showed that ASDs interventions should be observed not only in experimental settings, but also in naturalistic environments, so to appraise the actual effectiveness of integrating different treatment methods in community settings.

Neurobiological Correlates of Psychological Treatments for Insomnia

Abstract. Sleep disorders and sleep disturbances are considered nowadays a major public health problem. Within sleep problems, insomnia is the most common health complaint. The maintenance of insomnia symptoms may lead to a clinical disorder – Insomnia Disorder (ID). A significant amount of literature has shown the efficacy and effectiveness of psychological treatments for ID. Often, the evaluation of therapeutic processes and outcomes focuses on subjective measures such as sleep diaries. In this work, we review the few published studies that evaluate modifications in neurobiological domain related to evidence-based psychological interventions, namely cognitive-behavioral therapy for insomnia (CBT-I). The search was carried out consulting Scopus, PubMed, and ISI Web of Knowledge databases. Only 12 studies were found. From the reviewed papers it was observed that the results are diverse, perhaps due to significant differences pertaining to the methodologies used. However, one interesting finding emerged: daytime experiments on insomnia comprising mainly cognitive tasks denoted hypofunction in ID patients, whereas nighttime experiments mainly associated with affective/emotional tasks denoted hyperarousal. We suggest that the study of the neural changes prompted by CBT-I is a major topic in the domain of psychotherapy and sleep medicine. Despite the scarce studies on neurobiological mechanisms of CBT-I, the results achieved until now are promising and should be taken into account in the future. Nonetheless, more research on this topic is needed.

Practice-Based Evidence for a Brief Time-Intensive Multi-Modal Therapy Guided by Group-Analytic Principles and Method

Group analysts are increasingly being called upon to provide effectiveness evidence, which may be critical to the development of group analysis as a therapeutic intervention in National Health Service provision of psychotherapies. This article describes a practice-based outcomes research initiative conducted in a time-limited group-analytic programme. The research was manageable and informative for profiling patients before therapy, recording benefits during therapy, and measuring outcomes at the end of the programme. Results suggest that the therapeutic programme is effective in terms of yielding decreased symptoms and improved mental health, but longer follow-up is needed to measure benefits in interpersonal functioning. The research was conducted by clinicians in collaboration with academic researchers and demonstrates the benefits of a positive clinician-researcher relationship. Carrying out the research has helped the clinicians to address the national agenda of evidence-based practice and accountability.

Computer-Based Cognitive Rehabilitation for Individuals With Traumatic Brain Injury: A Systematic Review

Purpose

The purpose of this review is to evaluate the efficacy of computer-based cognitive rehabilitation (CCR) for improving cognitive and cognitive-communication skills in individuals with traumatic brain injury (TBI).

Method

A systematic search using key words related to CCR and TBI was conducted in 11 databases. Studies investigating CCR in children, adolescents, and adults with TBI were identified using a set of predetermined clinical questions, inclusion/exclusion criteria, and search parameters. Studies were evaluated for methodological quality according to American Academy of Neurology guidelines (AAN, 2011).

Results

Thirteen studies were included in this review. One study was classified as AAN Class II and 12 were rated as AAN Class III. Results across studies were inconsistent. In addition, studies contained a range of limitations that reduced the confidence of the reported findings.

Conclusion

At this time, there is insufficient evidence to support or refute the efficacy of CCR in improving the cognitive or cognitive-communication skills of individuals with TBI. Additional, high-quality research is needed to determine if individuals with TBI will benefit from CCR. Until this occurs, clinicians are encouraged to review existing expert recommendations and engage in practice-based evidence to determine if CCR is appropriate for their individual clients with TBI.

Annual Research Review: Building a science of personalized intervention for youth mental health

BACKGROUND

Within the past decade, health care service and research priorities have shifted from evidence-based medicine to personalized medicine. In mental health care, a similar shift to personalized intervention may boost the effectiveness and clinical utility of empirically supported therapies (ESTs). The emerging science of personalized intervention will need to encompass evidence-based methods for determining which problems to target and in which order, selecting treatments and deciding whether and how to combine them, and informing ongoing clinical decision-making through monitoring of treatment response throughout episodes of care. We review efforts to develop these methods, drawing primarily from psychotherapy research with youths. Then we propose strategies for building a science of personalized intervention in youth mental health.

FINDINGS

The growing evidence base for personalizing interventions includes research on therapies adapted for specific subgroups; treatments targeting youths' environments; modular therapies; sequential, multiple assignment, randomized trials; measurement feedback systems; meta-analyses comparing treatments for specific patient characteristics; data-mining decision trees; and individualized metrics.

CONCLUSION

The science of personalized intervention presents questions that can be addressed in several ways. First, to evaluate and organize personalized interventions, we propose modifying the system used to evaluate and organize ESTs. Second, to help personalizing research keep pace with practice needs, we propose exploiting existing randomized trial data to inform personalizing approaches, prioritizing the personalizing approaches likely to have the greatest impact, conducting more idiographic research, and studying tailoring strategies in usual care. Third, to encourage clinicians' use of personalized intervention research to inform their practice, we propose expanding outlets for research summaries and case studies, developing heuristic frameworks that incorporate personalizing approaches into practice, and integrating personalizing approaches into service delivery systems. Finally, to build a richer understanding of how and why treatments work for particular individuals, we propose accelerating research to identify mediators within and across RCTs, to isolate mechanisms of change, and to inform the shift from diagnoses to psychopathological processes. This ambitious agenda for personalized intervention science, although challenging, could markedly alter the nature of mental health care and the benefit provided to youths and families.

Toward rapid learning in cancer treatment selection: An analytical engine for practice-based clinical data

OBJECTIVE

Wide-scale adoption of electronic medical records (EMRs) has created an unprecedented opportunity for the implementation of Rapid Learning Systems (RLSs) that leverage primary clinical data for real-time decision support. In cancer, where large variations among patient features leave gaps in traditional forms of medical evidence, the potential impact of a RLS is particularly promising. We developed the Melanoma Rapid Learning Utility (MRLU), a component of the RLS, providing an analytical engine and user interface that enables physicians to gain clinical insights by rapidly identifying and analyzing cohorts of patients similar to their own.

MATERIALS AND METHODS

A new approach for clinical decision support in Melanoma was developed and implemented, in which patient-centered cohorts are generated from practice-based evidence and used to power on-the-fly stratified survival analyses. A database to underlie the system was generated from clinical, pharmaceutical, and molecular data from 237 patients with metastatic melanoma from two academic medical centers. The system was assessed in two ways: (1) ability to rediscover known knowledge and (2) potential clinical utility and usability through a user study of 13 practicing oncologists.

RESULTS

The MRLU enables physician-driven cohort selection and stratified survival analysis. The system successfully identified several known clinical trends in melanoma, including frequency of BRAF mutations, survival rate of patients with BRAF mutant tumors in response to BRAF inhibitor therapy, and sex-based trends in prevalence and survival. Surveyed physician users expressed great interest in using such on-the-fly evidence systems in practice (mean response from relevant survey questions 4.54/5.0), and generally found the MRLU in particular to be both useful (mean score 4.2/5.0) and useable (4.42/5.0).

DISCUSSION

The MRLU is an RLS analytical engine and user interface for Melanoma treatment planning that presents design principles useful in building RLSs. Further research is necessary to evaluate when and how to best use this functionality within the EMR clinical workflow for guiding clinical decision making.

CONCLUSION

The MRLU is an important component in building a RLS for data driven precision medicine in Melanoma treatment that could be generalized to other clinical disorders.

Psychometric properties of the Spanish version of the Clinical Outcomes in Routine Evaluation - Outcome Measure

OBJECTIVE

The objective of this paper is to assess the reliability and validity of the Spanish translation of the Clinical Outcomes in Routine Evaluation - Outcome Measure, a 34-item self-report questionnaire that measures the client's status in the domains of Subjective well-being, Problems/Symptoms, Life functioning, and Risk.

METHOD

Six hundred and forty-four adult participants were included in two samples: the clinical sample (n=192) from different mental health and primary care centers; and the nonclinical sample (n=452), which included a student and a community sample.

RESULTS

The questionnaire showed good acceptability and internal consistency, appropriate test-retest reliability, and acceptable convergent validity. Strong differentiation between clinical and nonclinical samples was found. As expected, the Risk domain had different characteristics than other domains, but all findings were comparable with the UK referential data. Cutoff scores were calculated for clinical significant change assessment.

CONCLUSION

The Spanish version of the Clinical Outcomes in Routine Evaluation - Outcome Measure showed acceptable psychometric properties, providing support for using the questionnaire for monitoring the progress of Spanish-speaking psychotherapy clients.

Development of a scoring system for non-specialist ratings of clinical competence in global mental health: a qualitative process evaluation of the Enhancing Assessment of Common Therapeutic Factors (ENACT) scale

Task-sharing is the involvement of non-specialist providers to deliver mental health services. A challenge for task-sharing programs is to achieve and maintain clinical competence of non-specialists, including primary care workers, paraprofessionals, and lay providers. We developed a tool for non-specialist peer ratings of common factors clinical competency to evaluate and optimize competence during training and supervision in global mental health task-sharing initiatives. The 18-item ENhancing Assessment of Common Therapeutic factors (ENACT) tool was pilot-tested with non-specialists participating in mental health Gap Action Programme trainings in Nepal. Qualitative process evaluation was used to document development of the peer rating scoring system. Qualitative data included interviews with trainers and raters as well as transcripts of pre- and post-training observed structured clinical evaluations. Five challenges for non-specialist peer ratings were identified through the process evaluation: (1) balance of training and supervision objectives with research objectives; (2) burden for peer raters due to number of scale items, number of response options, and use of behavioral counts; (3) capturing hierarchy of clinical skills; (4) objective v. subjective aspects of rating; and (5) social desirability when rating peers. The process culminated in five recommendations based on the key findings for the development of scales to be used by non-specialists for peer ratings in low-resource settings. Further research is needed to determine the ability of ENACT to capture the relationship of clinical competence with client outcomes and to explore the relevance of these recommendations for non-specialist peer ratings in high-resource settings.

Measuring Verbal Psychotherapeutic Techniques-A Systematic Review of Intervention Characteristics and Measures

Language is one of the most important “tools” of psychotherapists. The working mechanisms of verbal therapeutic techniques, however, are still marginally understood. In part, this is due to the lack of a generally acknowledged typology as well as a gold standard for the assessment of verbal techniques, which limits the possibility of conducting studies focusing this topic. The present study reviews measures used in clinical research which assess directly observable dimensions of verbal interventions in a reliable manner. All measures were evaluated with respect to their theoretical foundation, research goals, assessment modes, and various psychometric properties. A systematic search in databases (PubMed, PsycInfo, PsycArticles, PSYNDEX, Web of Science, Embase) followed by an additional “snowballing” search covering the years 1940–2013 yielded n = 179 publications eligible for review. Within these publications, 34 measures were identified showing great heterogeneity regarding the aspects under study. Only two measures reached the highest psychometric standards and can be recommended for clinical use without any reservation. Central problems include deficiencies in the systematization of techniques as well as their partly ambiguous and inconsistent definitions. To promote this field of research, it will be important to achieve a consensus concerning the terminology, conceptions and measures of verbal interventions.

Practice-Based Research: Ex Post Facto Evaluation of Evidence-Based Police Practices Implemented in Residential Burglary Micro-Time Hot Spots

BACKGROUND

Police agencies around the country are implementing various strategies to reduce crime in their communities that need to be evaluated. These strategies are often based on systematic crime analysis and are focused on crime occurring in hot spots, which are areas of disproportionate amounts of crime.

OBJECTIVE

This article takes a practice-based research approach to evaluate whether evidence-based police strategies implemented by one police agency as its normal everyday crime reduction practice are effective in reducing residential burglary incidents in micro-time hot spots.

RESEARCH DESIGN

A quasi-experimental ex post facto design is employed using 5 years of data from one police agency that has institutionalized the identification and response to micro-time hot spots into its day-to-day practices. Propensity score matching is used to match 54 pairs of micro-time hot spots using logistic regression to compute the propensity scores and greedy 1 to 1 matching with a caliper width of 0.5 of the standard deviation of the logit to match the cases.

RESULTS

Independent t-tests show that tactical police response to micro-time hot spots can lead to significant reductions in residential burglary incidents without the spatial displacement of crime.

CONCLUSION

Tactical police responses that seek to achieve short-term reductions in crime appear to be well suited for micro-time hot spots since they are, by nature, short term. Importantly, the conclusions are based on the evaluation of an agency's systematic implementation of the evidence-based practices as its normal practices and not for the sake of research.

Case series: the application of "third wave" cognitive behavioural therapies in difficult to treat asthma

OBJECTIVE

This paper provides for the first time cases of individual psychological therapy undertaken in tertiary, difficult to treat asthma services using "third wave" cognitive behavioural therapy (CBT) approaches.

METHODS

These cases were selected to represent common psychological presentations in difficult to treat asthma clinics, namely denial of severity and over-identification with asthma. Assessment, formulation, intervention and results are outlined.

RESULTS

Case 1 demonstrated change from severe to mild depression and anxiety, reduction in shame and improved well-being. Case 2 demonstrated improvements in well-being and psychological symptoms. Both interventions were experienced by the patients as highly satisfactory.

CONCLUSIONS

It is concluded that a psychological understanding of patients' presentations can open up new avenues for intervention. Further research into the potential utility of third wave cognitive therapies in difficult to treat asthma is warranted.

Observing the determinants of the psychotherapeutic process in depressive disorders. A clinical case study within a psychodynamic approach

This paper focuses on the relationship between depressive disorders, personality configurations, and mental functioning. A one-year treatment of a young man with the diagnosis of Depression is presented: the clinical and empirical points of view are described in depth through an assessment at the beginning and at one year after of an oriented psychodynamic psychotherapy. SCID I and II and HAMRS were administered to the patient in assessment phase. In the same phase he filled in BDI-II, and DEQ; the psychotherapist completed SWAP-200. These clinician instruments were used again after 1 year of the treatment. The PDM point of view is also presented. All sessions are audiotaped: 12 verbatim transcripts were coded with the Defense Mechanisms Rating Scale and CCRT. The results show a decrease in depressive symptoms, a change in some personality configurations, but a substantial invariance of the introjective profile, and a modification in mental functioning.

Supportive therapy for schizophrenia

BACKGROUND

Supportive therapy is often used in everyday clinical care and in evaluative studies of other treatments.

OBJECTIVES

To review the effects of supportive therapy compared with standard care, or other treatments in addition to standard care for people with schizophrenia.

SEARCH METHODS

For this update, we searched the Cochrane Schizophrenia Group's register of trials (November 2012).

SELECTION CRITERIA

All randomised trials involving people with schizophrenia and comparing supportive therapy with any other treatment or standard care.

DATA COLLECTION AND ANALYSIS

We reliably selected studies, quality rated these and extracted data. For dichotomous data, we estimated the risk ratio (RR) using a fixed-effect model with 95% confidence intervals (CIs). Where possible, we undertook intention-to-treat analyses. For continuous data, we estimated the mean difference (MD) fixed-effect with 95% CIs. We estimated heterogeneity (I(2) technique) and publication bias. We used GRADE to rate quality of evidence.

MAIN RESULTS

Four new trials were added after the 2012 search. The review now includes 24 relevant studies, with 2126 participants. Overall, the evidence was very low quality.We found no significant differences in the primary outcomes of relapse, hospitalisation and general functioning between supportive therapy and standard care.There were, however, significant differences favouring other psychological or psychosocial treatments over supportive therapy. These included hospitalisation rates (4 RCTs, n = 306, RR 1.82 CI 1.11 to 2.99, very low quality of evidence), clinical improvement in mental state (3 RCTs, n = 194, RR 1.27 CI 1.04 to 1.54, very low quality of evidence) and satisfaction of treatment for the recipient of care (1 RCT, n = 45, RR 3.19 CI 1.01 to 10.7, very low quality of evidence). For this comparison, we found no evidence of significant differences for rate of relapse, leaving the study early and quality of life.When we compared supportive therapy to cognitive behavioural therapy CBT), we again found no significant differences in primary outcomes. There were very limited data to compare supportive therapy with family therapy and psychoeducation, and no studies provided data regarding clinically important change in general functioning, one of our primary outcomes of interest.

AUTHORS' CONCLUSIONS

There are insufficient data to identify a difference in outcome between supportive therapy and standard care. There are several outcomes, including hospitalisation and general mental state, indicating advantages for other psychological therapies over supportive therapy but these findings are based on a few small studies where we graded the evidence as very low quality. Future research would benefit from larger trials that use supportive therapy as the main treatment arm rather than the comparator.