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

BACKGROUND

Measurement is the foundation of evidence-based practice. Advances in measurement procedures should extend to psychotherapy practice.

AIMS

To review the developments in measurement relevant to psychotherapy.

METHOD

Domains reviewed are: (a) interventions; (b) case formulation; (c) treatment integrity; (d) performance (including adherence, competence and skillfulness); (e) treatment definitions; (f) therapeutic alliance; and (g) routine outcome measurement.

RESULTS

Modern methods of measurement can support 'evidence-based practice' for psychological treatments. They also support 'practice-based evidence', a complementary paradigm to improve clinical effectiveness in routine practice via the infrastructure of Practice Research Networks (PRNs).

CONCLUSIONS

Advances in measurement derived from psychotherapy research support a model of professional self-management (practice-based evidence) which is widely applicable in psychiatry and medicine.

Does a visual perceptual disturbance characterize trauma-related anxiety syndromes?

The i-test was developed to assess the visual-perceptual disturbances (VPDs) frequently reported by anxious patients. Persons with the disturbance report a specific abnormal illusion of movement when they maintain a fixed gaze at the i-test stimulus. Base rates for positive responses to the i-test and for reports of a "recurrent specific memory" (RSM) of a fear experience were obtained in psychiatric outpatient (n = 301) and community (n = 128) samples. In each case, approximately one fifth of participants had a positive response to the i-test and one fifth of participants reported an RSM of fear. A positive response to the i-test is observed in women more frequently than in men. Among psychiatric patients, approximately 90% of patients who report one symptom also report the other symptom; among community members, the concordance rate is approximately 33%. When psychiatric patients with both an abnormal illusion of movement response and an RSM of trauma are treated with eye movement desensitization, both symptoms are removed in 70% of cases; when these patients undergo some other form of treatment, both symptoms are removed in 30% of cases. These results indicate that the i-test is an effective way of identifying VPDs associated with psychopathologic conditions; the association between the abnormal illusion of movement and reports of recurrent specific memories of fear experiences suggests that the VPD may be a marker of traumatic stress syndromes.

Cost-effectiveness of brief psychodynamic-interpersonal therapy in high utilizers of psychiatric services

BACKGROUND

It is known that a small number of patients with mental health problems have chronic disorders and account for a disproportionate amount of mental health costs. This randomized controlled trial evaluated the cost-effectiveness of psychodynamic-interpersonal therapy vs treatment as usual in patients with mental health problems who were unresponsive to usual treatment.

METHOD

Subjects (N = 110) with nonpsychotic disorders unresponsive to 6 months of routine specialist mental health treatment were enrolled in a randomized controlled trial. Sixty-three percent were women, the mean age was 41.4 years, the median duration of illness was 5 years, 68% were unemployed or receiving state benefits because of illness, and 75.5% had a depressive illness. Intervention patients received 8 weekly sessions of psychodynamic-interpersonal psychotherapy. Control patients received usual care from their psychiatrist. Outcome measures included ratings of psychological distress and health status and a detailed economic evaluation. Analysis was conducted on an intent-to-treat basis.

RESULTS

Subjects randomized to psychotherapy had a significantly greater improvement than controls in psychological distress and social functioning 6 months after the trial. Baseline treatment costs were similar for both groups. Subjects who received psychotherapy showed significant reductions in the cost of health care utilization in the 6 months after treatment compared with controls. The extra cost of psychotherapy was recouped within 6 months through reductions in health care use.

CONCLUSION

These preliminary findings suggest that brief psychodynamic-interpersonal therapy may be cost-effective relative to usual care for patients with enduring nonpsychotic symptoms who are not helped by conventional psychiatric treatment.

Detection and treatment of psychiatric illness in a general medical ward: a modified cost-benefit analysis

This article describes a prospective, randomized, controlled trial of screening and treatment for psychiatric disorder in medical in-patients. The study has assessed whether increased recognition of psychiatric disorder among medical in-patients improves clinical outcome and reduces the costs of care, and whether routine involvement of a psychiatrist in the assessment and care of medical in-patients with probable psychiatric disorder is superior to the efforts of the physicians alone. A total of 218 medical in-patients who scored over the screening threshold for psychiatric disorder on the General Health Questionnaire were randomly allocated to one of two intervention groups or a control group. Six months later their mental health, subjective health status, quality of life, and costs of care was reassessed. Mental health and quality of life at 6 months were similar in the two intervention groups and the control group. Patients whose physicians were told the results of the screening test had lower costs for subsequent admissions, but this was probably due to differences between the groups in terms of employment status. Treatments recommended by psychiatrists broke down when patients were discharged home, leading to inadequate treatment of psychiatric disorders. We have not been able to show that routine screening for psychiatric disorder produces any benefit, either in better outcome for patients or reduced costs for the NHS. Further research should: consider examining a more homogeneous group in terms of costs of care; screen only for disorders likely to respond to a specific treatment; and ensure that treatment recommendations are carried out.

Large-volume sample stacking of selected drugs of forensic significance by capillary electrophoresis

Large-volume sample stacking capillary electrophoresis (LVSS-CE) and conventional capillary electrophoresis (CE) are compared for the separation of drugs of significance to forensic and clinical analyses. LVSS-CE for cations requires the use of an electroosmotic flow (EOF) modifier in conjunction with polarity switching to effect on-column concentration of an analyte and its subsequent migration in the capillary. The run buffer consists of 0.05 mol dm(-3) disodium tetraborate adjusted to pH 2.2 with orthophosphoric acid, and the EOF modifier is 0.002 mol dm(-3) cetyltrimethylammonium bromide. CE investigations used an identical run buffer minus the EOF modifier. LVSS-CE and CE investigations used injection times of 30 s and 3 s, respectively. Both modes of capillary electrophoresis are compared in terms of their limits of detection, efficiency, resolution and reproducibility. LVSS-CE is also applied to the analysis of a spiked urine sample.

Improving the skills of established general practitioners: the long-term benefits of group teaching

This study set out to determine the long-term benefits of teaching psychiatric interview skills. Nine established general practitioners, eight of whom were also trainers, took part some 18 months after attending a problem-based interviewing course. Interview skills were assessed by rating behaviour during 10-minute videorecorded simulated consultations with role-players, recorded before and after training and at follow-up. The finding of an earlier study that, in terms of the course model, training successfully modified the doctor's behaviour, was largely replicated. In addition, not only were acquired skills maintained but further change took place during the follow-up period, change that can be seen as improvement in terms of the course model.

Psychotherapy and general practice

The authors review the development of liaison psychotherapy in general practice, and argue that a 'skill-sharing' approach, where the general practitioner retains the treatment role, is a more efficient model than a 'consultation' approach. Skill-sharing models are reviewed, and the need for psychiatrists and psychotherapists to be more directly involved in teaching basic psychotherapeutic skills to general practitioners is emphasised.

Psychiatric day hospitals--another route to institutionalization?

Nineteen long-stay day patients were referred to a rehabilitation team and their outcome after a year is compared with 19 day patients who were not referred, but were matched for age, sex and diagnosis. Seven rehabilitation team patients had been discharged at 12 months as against 3 of the non-rehabilitation patients, but this was not a significant difference. Discharged patients were less disturbed at the beginning of the study and had fewer negative symptoms throughout. Discharge did not reduce the frequency of social contact. There was a suggestion that morale was sustained better in the rehabilitation patient and in their nurses. We conclude that rehabilitation planning may have beneficially accelerated the discharge of less ill day-patients, but that more resources are needed to prevent 'institutionalization' within the day-hospital.

Psychiatric morbidity in spouses of women admitted to a mother and baby unit

The spouses of 40 women admitted to a psychiatric Mother and Baby Unit were interviewed to detect psychiatric morbidity, and aspects of their social and marital functioning. This group was compared with 25 men whose wives had not shown obvious psychiatric disorder in the puerperium. Psychiatric morbidity, using DSM-III (American Psychiatric Association, 1980) criteria, was present in 42% of the index group, and 4% of the comparison group. The main diagnoses were major depressive episode and generalised anxiety disorder. This was associated with poorer marital and social function in the index group. Male psychopathology after delivery has been studied little but may be significant in the management of postpartum syndromes.

Long-stay patients in a psychiatric day hospital. A case note review

The case notes of all non-psychogeriatric patients attending the Psychiatric Day Hospital at the University Hospital of South Manchester during one week in October 1982 were reviewed. Clinical, demographic, social and occupational data were gathered for all patients, and their attendance at the day hospital monitored for the year following the census period. No significant differences between patients could be found on any of the factors that it was predicted would distinguish short from long-stay patients. The best predictor of length of day hospital attendance in the current admission was the total quantity of previous hospital treatment whether as an in-patient or a day-patient. It is concluded that in the day hospital studied all patients had similar characteristics, and the majority could be seen as 'new long-stay' patients. The implications of this finding are discussed.

Assessing the benefits of psychotherapy: the economic approach

Recent debate about the place of psychotherapy in the National Health Service, while emphasising the importance of economic evaluation, has concentrated almost exclusively on issues of clinical outcome. This paper argues that the debate has focussed on too narrow a definition of psychotherapy and too limited a view of the possible effects of psychotherapy, both good and bad. It reviews evidence concerning the demand and need for psychotherapy services in a number of clinical settings, and discusses the economic implications of the provision of such services. Economic studies of psychotherapy are reviewed and a conclusion drawn that it might be possible to justify the provision of psychotherapy services on economic grounds, but that considerably more research needs to be done in this area. The directions such future research might take are outlined.

Cardiac dysfunction during status epilepticus in the neonatal pig

Cardiovascular complications frequently occur during status epilepticus. To determine the changes in systemic and pulmonary arterial pressure, cardi output, and left ventricular contractility during seizures, 1-week-old pigs were intubated, paralyzed, mechanicall entilated, and catheterized with a Swan-Ganz catheter. Seizures were induced with intravenous bicuculline. Early changes consisted of significant systemic and pulmonary arterial hypertension. After 2 hours of seizures, the animals developed progressive systemic hypotension and decreased cardiac output. M-mode echocardiography disclosed a decrease in left ventricular contractility. Cardiac tissue frozen in situ showed a significant increase in lactate and reductions in glucose, triglyceride, and adenosine triphosphate levels. Prolonged seizures in the neonatal pig result in cardiac dysfunction, which may play a role in the development of epileptic brain damage.

Humour in group psychotherapy

The role of humour in group psychotherapy has received scant attention from both clinician and researcher. We have identified, and attempted to classify, several uses to which humour can be put in a group. We also point out the destructive potential of humour, and categorize its misapplications. We hope our scheme will serve as a framework within which systematic research can be conducted.