Routine Monitoring of Outcome over 11 Years in a Residential Behavioural Psychotherapy Unit

Background: Results from randomized controlled trials (RCTs) are considered to give the most reliable information on treatment outcome (efficacy). Yet, the generalizability of efficacy results to daily practice (effectiveness) might be diminished by the design of RCTs. The STAR*D trial approached daily practice as much as possible, but still has some properties of an RCT. In this study, we compare results from treatment of major depressive disorder (MDD) in routine clinical practice to those of RCTs and STAR*D. Methods: Effectiveness in routine clinical practice was compared with efficacy results from 15 meta-analyses on antidepressant, psychotherapeutic and combination treatment and results from STAR*D. Data on daily practice patients and treatments were derived from a routine outcome monitoring (ROM) system. Treatment outcome was defined as proportion of remitters (MADRS ≤10) and within-group effect size. Results: From ROM, 598 patients suffering from a MDD episode according to the MINI-plus were included. Remission percentages were lower in routine practice than in meta-analyses for all treatment modalities (32 vs.40–74%). Differences were less explicit for antidepressants (21 vs. 34–47%) than for individual psychotherapy (27 vs. 34–58%; effect size 0.85 vs. 1.71) and combination therapy (21 vs. 45–63%), since only 60% of the meta-analyses for antidepressants showed significant differences with ROM, while for psychotherapy and combination treatment almost all meta-analyses showed significant differences. No differences in effectiveness were found between routine practice and STAR*D (antidepressants 27 vs. 28%; individual psychotherapy 27 vs. 25%; combination treatment 21 vs. 23%, respectively). Conclusions: Effectiveness of treatment for mild-to-moderate MDD in daily practice is similar to STAR*D and significantly lower than efficacy results from RCTs.

Section: Discussionmentioning

confidence: 99%

Efficacy versus Effectiveness: A Direct Comparison of the Outcome of Treatment for Mild to Moderate Depression in Randomized Controlled Trials and Daily Practice

Lem

Wee

Veen

et al. 2012

“…It should of course be emphasised that these all arise from the naturalistic focus of the South Verona Outcome Project – a complete battery of assessments cannot be measured repeatedly in routine services, and the main focus of clinical services is on patients still in contact [16]. …”

Section: Discussionmentioning

confidence: 99%

Does Meeting Needs Improve Quality of Life?

Slade¹,

Leese

Ruggeri³

et al. 2004

149

Background: This study investigated the relationship between patient-rated unmet needs and subjective quality of life using routine outcome data. Methods: 265 mental health service patients from South Verona were assessed using the Camberwell Assessment of Need, the Lancashire Quality of Life Profile, and other standardised assessments of symptoms, disability, function and service satisfaction. At 1-year follow-up, 166 patients were still in contact, of whom 121 patients (73%) were re-assessed. Results: Higher baseline quality of life was associated with being male, a diagnosis of psychosis, higher disability, higher satisfaction with care, fewer staff-rated or patient-rated unmet needs, and fewer patient-rated met needs (accounting for 40% of the variance). Specifically, fewer baseline patient-rated unmet needs were cross-sectionally associated with a higher quality of life (B = –0.08, 95% CI –0.12 to –0.04). Apart from its baseline value, the only baseline predictor of follow-up QoL was patient-rated unmet need (B = –0.08, 95% CI –0.21 to –0.09), accounting for 58% of the variance in follow-up quality of life. Graphical chain modelling confirmed this association. Conclusions: The association between high numbers of unmet needs and low subjective quality of life appears increasingly robust across several studies. Future research will need to investigate whether changes in needs precede changes in quality of life. This study provides further evidence that a policy of actively assessing and addressing patient-rated unmet needs may lead to improved quality of life.

“…All patients were treated with CBT including exposure and response management, either as outpatients [18 patients (35%)] or as inpatients [34 patients (65%)]. Exposure was started with therapist-assisted sessions, based on the concept of exposure and response management by Hand [29] , followed by self-exposure and self-imposed response management without the therapist [36,37] . The mean treatment duration of the two settings was comparable (10.0 weeks and 9.2 weeks, respectively).…”

Section: Samplementioning

confidence: 99%

Dissociation as a Predictor of Cognitive Behavior Therapy Outcome in Patients with Obsessive-Compulsive Disorder

Rufer

Held

Cremer

et al. 2005

118

Background: Previous studies have found a strong association between dissociation and obsessive-compulsive disorder (OCD). The purpose of the present study was to evaluate whether dissociation is a predictor of cognitive behavior therapy (CBT) outcome in patients with OCD. Methods: Fifty-two patients with OCD were assessed using the Dissociative Experience Scale (DES), the Yale-Brown Obsessive-Compulsive Scale and the Beck Depression Inventory. CBT lasted on average 9.5 weeks and included exposure therapy. Results: Patients who dropped out due to noncompliance had higher baseline DES scores and depression scores compared to the 43 patients (83%) who completed the study. Significant OCD symptom reduction at posttreatment was observed in study completers with a large effect size (d = 1.7). More severe OCD symptoms at posttreatment were associated with higher DES scores at baseline, and treatment nonresponders had significantly higher baseline DES scores compared to responders. These associations with outcome were mainly due to the DES subfactor absorption-imaginative involvement. In regression analyses, higher absorption-imaginative involvement scores at baseline predicted poorer CBT outcome, even after controlling for depressive symptoms, comorbid axis I disorders and concomitant psychotropic drugs. Conclusions: Results from this preliminary study suggest that higher levels of dissociation (particularly absorption-imaginative involvement) in patients with OCD might predict poorer CBT outcome. If our results can be replicated, treatment outcome might be improved by additional interventions for those patients with OCD who indicate high levels of dissociation, for example by using interventions aimed at improving coping with emotionally stressful situations.