Service profiling and outcomes benchmarking using the CORE-OM: toward practice-based evidence in the psychological therapies. Clinical Outcomes in Routine Evaluation-Outcome Measures

"It's hard to tell": the challenges of scoring patients on standardised outcome measures by multidisciplinary teams: a case study of neurorehabilitation

Background

Interest is increasing in the application of standardised outcome measures in clinical practice. Measures designed for use in research may not be sufficiently precise to be used in monitoring individual patients. However, little is known about how clinicians and in particular, multidisciplinary teams, score patients using these measures. This paper explores the challenges faced by multidisciplinary teams in allocating scores on standardised outcome measures in clinical practice.

Methods

Qualitative case study of an inpatient neurorehabilitation team who routinely collected standardised outcome measures on their patients. Data were collected using non participant observation, fieldnotes and tape recordings of 16 multidisciplinary team meetings during which the measures were recited and scored. Eleven clinicians from a range of different professions were also interviewed. Data were analysed used grounded theory techniques.

Results

We identified a number of instances where scoring the patient was 'problematic'. In 'problematic' scoring, the scores were uncertain and subject to revision and adjustment. They sometimes required negotiation to agree on a shared understanding of concepts to be measured and the guidelines for scoring. Several factors gave rise to this problematic scoring. Team members' knowledge about patients' problems changed over time so that initial scores had to be revised or dismissed, creating an impression of deterioration when none had occurred. Patients had complex problems which could not easily be distinguished from each other and patients themselves varied in their ability to perform tasks over time and across different settings. Team members from different professions worked with patients in different ways and had different perspectives on patients' problems. This was particularly an issue in the scoring of concepts such as anxiety, depression, orientation, social integration and cognitive problems.

Conclusion

From a psychometric perspective these problems would raise questions about the validity, reliability and responsiveness of the scores. However, from a clinical perspective, such characteristics are an inherent part of clinical judgement and reasoning. It is important to highlight the challenges faced by multidisciplinary teams in scoring patients on standardised outcome measures but it would be unwarranted to conclude that such challenges imply that these measures should not be used in clinical practice for decision making about individual patients. However, our findings do raise some concerns about the use of such measures for performance management.

Measuring and valuing mental health for use in economic evaluation

This article presents research undertaken as part of a wider programme of work concerned with measuring and health and wellbeing for economic evaluation. The focus is on developing quality adjusted life years (QALYs) in mental health, but the issues are common across all areas of health care. The article begins by reviewing the issues of what should be valued (health or broader notions of wellbeing), how mental health and wellbeing should be described, how mental health states should be valued and who should do the valuing. The article presents four pieces of work. The first is a re-analysis of the ONS Psychiatric Morbidity 2000 Survey to provide evidence on the relevance of generic measures across different mental health disorders. It found that common mental health problems, such as anxiety and depression, had a significant impact on the generic preference-based measure of health in the SF-6D, but psychosis and personality disorders did not. The article then presents two studies using the ratings of people experiencing the states of health. Both studies found that people experiencing different health states gave mental health greater weight than physical health compared to members of the general public trying to imagine the health states. Finally, the article presents a study developing a condition-specific preference-based measure for calculating QALYs from an existing measure of mental health, the CORE-OM, using modern psychometric methods to construct health states amenable to valuation. It also considers a proposal to develop an entirely new QALY measure in mental health.

The effectiveness of psychodynamic-interpersonal therapy (PIT) in routine clinical practice: a benchmarking comparison

AIMS

To investigate the effectiveness of psychodynamic-interpersonal therapy (PIT) in a routine clinical practice setting.

METHODS

Full pre-post data were available on 62 out of a total of 67 patients aged between 19 and 60 years. Patients were seen over a 52-month period (2001-2005) receiving a course of PIT therapy (mean number of sessions = 16.9, median number of sessions = 16). The outcomes were assessed using a range of outcome measures: the 32-item version of the Inventory of Interpersonal Problems (IIP-32), the Clinical Outcomes in Routine Evaluation Outcome Measure (CORE-OM), and the Beck Depression Inventory - Second Edition (BDI-II). Study data were benchmarked against comparative national and local data.

RESULTS

There were significant pre-post reductions on all measures: IIP-32 effect size (ES) = 0.56; CORE-OM ES = 0.76; BDI-II ES = 0.76. Reliable and clinically significant change was achieved by 34% of clients on the BDI-II and by 40% of clients on the CORE-OM. Clients with high pre-therapy levels of interpersonal problems had poorer outcomes.

CONCLUSION

Benchmarking our results against both national and local comparative data showed that our results were less favourable than those obtained where PIT had been used in efficacy trials, but were comparable with reports of other therapies (including cognitive behavioural therapy (CBT)) in routine practice settings. The results show that PIT can yield acceptable clinical outcomes, comparable to CBT in a routine care setting, within the context of current limitations of the practice-based evidence paradigm.

Facilitating access to voluntary and community services for patients with psychosocial problems: a before-after evaluation

Background

Patients with psychosocial problems may benefit from a variety of community, educational, recreational and voluntary sector resources, but GPs often under-refer to these through lack of knowledge and time. This study evaluated the acceptability and effectiveness of graduate primary care mental health workers (GPCMHWs) facilitating access to voluntary and community sector services for patients with psychosocial problems.

Methods

Patients with psychosocial problems from 13 general practices in London were referred to a GPCMHW Community Link scheme providing information and support to access voluntary and community resources. Patient satisfaction, mental health and social outcomes, and use of primary care resources, were evaluated.

Results

108 patients consented to take part in the study. At three-month follow-up, 63 (58%) had made contact with a community service identified as suitable for their needs. Most were satisfied with the help provided by the GPCMHW in identifying and supporting access to a suitable service. There was a reduction in the number of patients with a probable mental health problem on the GHQ-12 from 83% to 52% (difference 31% (95% CI, 17% – 44%). Social adjustment improved and frequencies of primary care consultations and of prescription of psychotropic medications were reduced.

Conclusion

Graduates with limited training in mental health and no prior knowledge of local community resources can help patients with psychosocial problems access voluntary and community services, and patients value such a scheme. There was some evidence of effectiveness in reducing psychosocial and mental health problems.

Effectiveness of cognitive-behavioural, person-centred, and psychodynamic therapies in UK primary-care routine practice: replication in a larger sample

BACKGROUND

Psychotherapy's equivalence paradox is that treatments tend to have equivalently positive outcomes despite non-equivalent theories and techniques. We replicated an earlier comparison of treatment approaches in a sample four times larger and restricted to primary-care mental health.

METHOD

Patients (n=5613) who received cognitive-behavioural therapy (CBT), person-centred therapy (PCT) or psychodynamic therapy (PDT) at one of 32 NHS primary-care services during a 3-year period (2002-2005) completed the Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) at the beginning and end of treatment. Therapists indicated which approaches were used on an End of Therapy form. We compared outcomes of groups treated with CBT (n=1045), PCT (n=1709), or PDT (n=261) only or with one of these plus one additional approach (e.g. integrative, supportive, art), designated CBT+1 (n=1035), PCT+1 (n=1033), or PDT+1 (n=530), respectively.

RESULTS

All six groups began treatment with equivalent CORE-OM scores, and all averaged marked improvement (overall pre/post effect size=1.39). Neither treatment approach nor degree of purity ('only' v. '+1') had a statistically significant effect. Distributions of change scores were all similar.

CONCLUSIONS

Replicating the earlier results, the theoretically different approaches tended to have equivalent outcomes. Caution is warranted because of limited treatment specification, non-random assignment, incomplete data, and other issues. Insofar as these routine treatments appear effective for patients who complete them, those who fail to complete (or to begin) treatment deserve attention by researchers and policymakers.

Preventive interventions addressing underage drinking: state of the evidence and steps toward public health impact

The epidemiological features of underage drinking and evidence of its social, health, and economic consequences suggest compelling reasons for the development and dissemination of effective preventive interventions. To clarify the nature and extent of the current evidence base on preventive interventions addressing underage drinking, a review of the literature was conducted through extensive searches of the research literature on outcome evaluations, existing reviews of this body of outcome research (N = 25), and summary reports of evidence on specific interventions. More than 400 interventions were identified and screened, and the evidence for 127 was reviewed. Criteria for the evaluation of evidence were established for intervention studies with alcohol-specific outcome measures for 3 developmental periods (< 10, 10-15, and 16 to > or = 20 years of age). Ultimately, 12 interventions met criteria for "most promising" evidence and 29 met criteria for "mixed or emerging" evidence. Conducting this review revealed clear advances in the number of evidence-based interventions available and the quality of outcome research; however, much work remains to achieve greater public health impact through evidence-based interventions. This work should consider (1) the great need for intervention research related to understudied developmental phases, intervention domains (eg, family, school, community, and media), and populations (eg, early tweens, late teens, young adults not attending college, and nonmajority populations); (2) the critical importance of addressing key issues in research design and methods (eg, limited longitudinal studies, replication studies, and dissemination research); and (3) the need for improved consistency in application of evidence and reporting standards. Finally, we recommend the application of emerging consumer-oriented and community-participatory models for intervention development and research, designed to increase the likelihood of "real-world" public health impact through improved translation of intervention science into practice.

Collaborative care for depression in UK primary care: a randomized controlled trial

BACKGROUND

Collaborative care is an effective intervention for depression which includes both organizational and patient-level intervention components. The effect in the UK is unknown, as is whether cluster- or patient-randomization would be the most appropriate design for a Phase III clinical trial.

METHOD

We undertook a Phase II patient-level randomized controlled trial in primary care, nested within a cluster-randomized trial. Depressed participants were randomized to 'collaborative care' - case manager-coordinated medication support and brief psychological treatment, enhanced specialist and GP communication - or a usual care control. The primary outcome was symptoms of depression (PHQ-9).

RESULTS

We recruited 114 participants, 41 to the intervention group, 38 to the patient randomized control group and 35 to the cluster-randomized control group. For the intervention compared to the cluster control the PHQ-9 effect size was 0.63 (95% CI 0.18-1.07). There was evidence of substantial contamination between intervention and patient-randomized control participants with less difference between the intervention group and patient-randomized control group (-2.99, 95% CI -7.56 to 1.58, p=0.186) than between the intervention and cluster-randomized control group (-4.64, 95% CI -7.93 to -1.35, p=0.008). The intra-class correlation coefficient for our primary outcome was 0.06 (95% CI 0.00-0.32).

CONCLUSIONS

Collaborative care is a potentially powerful organizational intervention for improving depression treatment in UK primary care, the effect of which is probably partly mediated through the organizational aspects of the intervention. A large Phase III cluster-randomized trial is required to provide the most methodologically accurate test of these initial encouraging findings.

Differences in clinical characteristics between patients assessed for NHS specialist psychotherapy and primary care counselling

OBJECTIVES

Although several studies have described patient populations in primary care counselling settings and NHS (National Health Service) specialist psychotherapy settings, there is a paucity of studies specifically comparing differences in clinical characteristics between the two groups of patients. The aim of this study is to ascertain if specialist psychotherapy referrals represent a more challenging client group than primary care counselling patients.

DESIGN

We compare the socio-demographic features and severity of presentation in the symptomatic, interpersonal problems and global adjustment dimensions of a sample of patients (N=384) assessed by a primary care counselling service located in North London and a sample of patients (N=853) assessed in eight NHS psychotherapy centres located within urban settings in England.

METHODS

Both the groups completed the Brief Symptom Inventory, the Inventory of Interpersonal Problems and Clinical Outcomes in Routine Evaluation Outcome Measure.

RESULTS

Patients referred for specialist psychotherapy services were more dysfunctional than those referred for primary care counselling. The linear function constructed to discriminate the groups showed that a combination of more psychotic symptoms, social inhibitions and higher risk of self-harm effectively identified those referred to psychotherapy services, while patients exhibiting greater levels of somatic and anxiety symptoms and non-assertiveness were more likely to be seen in primary care settings. However, similarities between the two samples were also marked, as shown by the overlap in the distribution of clinical outcomes in routine evaluation clinical scores in the two samples.

CONCLUSIONS

The findings are discussed in terms of their implications for policy and service delivery of these two types of psychological therapy services.

Plötzliche Gewinne und Verluste im Behandlungsverlauf von Angststörungen, depressiven und komorbiden Störungen

Zusammenfassung. Theoretischer Hintergrund: In der aktuellen Psychotherapieforschung wird die Identifikation und Vorhersage von individuellen sowie kontinuierlichen und diskontinuierlichen Therapieverläufen in Form plötzlicher Gewinne und Verluste immer bedeutsamer. Fragestellungen: Ziel der vorliegenden Studie ist die Identifikation von plötzlichen Gewinnen und Verlusten im Therapieverlauf sowie deren Vorhersagbarkeit und deren Zusammenhang zum Therapieerfolg. Zudem wird eine Erweiterung des Konzeptes der Gewinne in negative Richtung vorgenommen, um Verluste im Behandlungsverlauf zu identifizieren. Methode: In einer ambulanten Patientenstichprobe (N = 434) mit depressiven Patienten (n = 55), Angststörungspatienten (n = 115) und komorbid Angst- und depressiven Störungen (n = 225), wurden die Therapieverläufe hinsichtlich des Auftretens von Veränderungssprüngen sowie deren Zusammenhang zu dem Therapieergebnis untersucht. Resultate: In 26.27% der Patientenstichprobe traten Veränderungssprünge auf. Interessanterweise haben insbesondere Patienten, welche einen Gewinn und einen Verlust in ihrem Verlauf erleben, eine signifikant längere Therapiedauer sowie niedrigere Effektstärken auf der Symptomebene am Therapieende (BSI und BDI). Schlussfolgerung: In dieser Studie werden spezifische Vorgehensweisen zur Analyse von Therapieverläufen, der Identifikation fluktuierender oder negativer Behandlungsverläufe sowie deren Bedeutung für die patientenorientierte Forschung und der Evaluation von Behandlungsfortschritt aufgezeigt und diskutiert.

Evidence-based assessment

Evidence-based assessment (EBA) emphasizes the use of research and theory to inform the selection of assessment targets, the methods and measures used in the assessment, and the assessment process itself. Our review focuses on efforts to develop and promote EBA within clinical psychology. We begin by highlighting some weaknesses in current assessment practices and then present recent efforts to develop EBA guidelines for commonly encountered clinical conditions. Next, we address the need to attend to several critical factors in developing such guidelines, including defining psychometric adequacy, ensuring appropriate attention is paid to the influence of comorbidity and diversity, and disseminating accurate and up-to-date information on EBAs. Examples are provided of how data on incremental validity and clinical utility can inform EBA. Given the central role that assessment should play in evidence-based practice, there is a pressing need for clinically relevant research that can inform EBAs.

Stability of the CORE-OM and the BDI-I prior to therapy: evidence from routine practice

BACKGROUND

It is important to know the stability of standard outcome measures prior to therapy over differing periods of time that map onto the realities of waiting times in routine service settings.

METHOD

We studied 1,684 clients who completed one or both the targeted measures Clinical Outcomes in Routine Evaluation-Outcome Measures (CORE-OM) and Beck Depression Inventory-I (BDI-I) two times, at intervals of up to 12 months, prior to beginning psychotherapy. We also selected an additional 1,623 clients who completed the CORE-OM (N=1,623), BDI-I (N=980) or both at referral, but had no records of further contact with the service.

RESULTS

There was little change in the mean CORE-OM or BDI-I scores between referral and clinical assessment. The test-retest correlations showed substantial stability on both measures, declining only moderately at the longer intervals studied.

CONCLUSION

The high test-retest correlations for periods of up to 6 months suggest that psychological disturbance was both reliably measured by the CORE-OM and the BDI-I, and reasonably stable among clients waiting to be assessed. Implications for routine practice are discussed.

Maytree: A Respite Center for the Suicidal

Abstract. This paper evaluates the contribution to suicide prevention made by an innovative project, Maytree, a respite center for the suicidal. Maytree offers a distinctive brief period of sanctuary for four nights for suicidal people; within this limited time it aims to provide opportunities through talking, reflecting, and relaxing for reducing the intense feelings that lead to suicidal behavior. The focus of this paper is on evaluating the first 3 years of Maytree's operation, exploring how Maytree works, and its effects on the people who stay there as “guests.” This shows that Maytree reaches people who are at significant risk of suicide. Guests report both short term relief and longer term benefits. These changes are understood, through applying crisis intervention theory, as being generated by the opportunities for change in the Maytree approach. Thus, there is the potential for a benign cycle to be established. Maytree's model is different from that of mainstream, statutory services; we conclude that Maytree complements these services and also challenges the values and frameworks of statutory provision in the field of suicide prevention.

Die Identifikation früher Veränderungsmuster in der ambulanten Psychotherapie

Zusammenfassung. Theoretischer Hintergrund: Im Rahmen einer patientenorientierten Psychotherapieforschung werden Patientenausgangsmerkmale und Veränderungsmuster in einer frühen Therapiephase genutzt, um Behandlungsergebnisse und Behandlungsdauer vorherzusagen. Fragestellung: Lassen sich in frühen Therapiephasen verschiedene Muster der Veränderung (Verlaufscluster) identifizieren und durch Patientencharakteristika vorhersagen? Erlauben diese Verlaufscluster eine Vorhersage bezüglich Therapieergebnis und -dauer? Methode: Anhand des Growth Mixture Modeling Ansatzes wurden in einer Stichprobe von N = 2206 ambulanten Patienten einer US-amerikanischen Psychotherapieambulanz verschiedene latente Klassen des frühen Therapieverlaufs ermittelt und unter Berücksichtigung unterschiedlicher Patientenausgangscharakteristika als Prädiktoren der frühen Veränderungen mit dem Therapieergebnis und der Therapiedauer in Beziehung gesetzt. Ergebnisse: Für leicht, mittelschwer und schwer beeinträchtigte Patienten konnten je vier unterschiedliche Verlaufscluster mit jeweils spezifischen Prädiktoren identifiziert werden. Die Identifikation der frühen Verlaufsmuster ermöglichte weiterhin eine spezifische Vorhersage für die unterschiedlichen Verlaufscluster bezüglich des Therapieergebnisses und der Therapiedauer. Schlussfolgerungen: Frühe Psychotherapieverlaufsmuster können einen Beitrag zu einer frühzeitigen Identifikation günstiger sowie ungünstiger Therapieverläufe leisten.

The effectiveness of computerized cognitive behavioural therapy in routine care

OBJECTIVES AND DESIGN

The efficacy of a Computerized Cognitive Behavioural Therapy (CCBT) package, Beating the Blues, has been demonstrated in a large randomized controlled trial. The current study tests the generalizability of this finding in a naturalistic non-randomized trial.

METHOD

219 patients with anxiety and/or depression were recruited to receive CCBT in routine care. The Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and Work and Social Adjustment scale (WSA) were administered pre-treatment, immediately on completing treatment and at 6 months post-treatment. Single-item self-report measures of anxiety and depression were also collected during each treatment session.

RESULTS

Completer and intention-to-treat analysis demonstrated statistically and clinically significant improvements on the CORE-OM, WSA and in self-reported anxiety and depression. Intention-to-treat analysis indicated an average 0.29-point drop on the CORE-OM, equating to an uncontrolled pre-post effect size of 0.50. Research completers achieved an average 0.61-point drop equating to an uncontrolled pre-post size of 1.00 on the same measure. Where data was available (18%), these benefits were maintained at week 32 (6 months follow-up).

CONCLUSION

CCBT can be an effective first line tool within a stepped care framework for the management of common mental health problems.

Evaluating the clinical significance of responses by psychiatric inpatients to the mental health subscales of the SF-36

BACKGROUND

The Mental Health subscales of the Medical Outcomes Short Form Questionnaire (SF-36; [Ware, J.E., Snow, K.K., Kosinski, M., Gandek, B., 1993. SF-36 Health Survey: Manual and Interpretation Guide. Boston: The Health Institute, New England Medical Center]) are increasingly being used to evaluate treatment outcomes, but data to assess the clinical significance of changes are absent. The present study applied Jacobson and Truax's [Jacobson, N.S., Truax, P. 1991.

CLINICAL SIGNIFICANCE

a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology 59, 12-19] criteria for clinical significance to the mental health items of the SF-36.

METHOD

Admission and discharge data were collated from 1830 consecutive inpatients at a psychiatric hospital, using the SF-36, the Depression Anxiety Stress Scale, the Quality of Life Enjoyment and Satisfaction Questionnaire and the clinician-rated Health of the Nation Outcome Scale.

RESULTS

Appropriate improvement cut-off scores for the mental health subscales of the SF-36 are reported, and significant differences were found between outcome groups according to clinically significant improvement.

LIMITATIONS

CLINICAL SIGNIFICANCE as a means of assessing outcome should be used with caution in inpatient settings, as further improvement is often expected upon discharge from the hospital.

CONCLUSIONS

Assessing clinically significant improvement is an effective means of measuring treatment outcome in terms of quality of life and symptom improvement in psychiatric care.

Why some clinicians use outcome measures and others do not

Due to their potential as helpful clinical tools, it is necessary to understand the reasons why certain practitioners are currently using outcome measures and certain others are not. This study investigated the reasons why clinicians use outcome measures based upon factors such as work setting, theoretical orientation and source of payment. Similar analyses were conducted for reasons that clinicians do not use outcome measures. Findings suggest that several practical barriers are the primary reasons for not using outcome measures, although a subset of clinicians have additional concerns. Results also emphasized the need for clinicians to be trained on how to maximize the clinical benefits of formalized outcome assessment.

Distribution of CORE-OM scores in a general population, clinical cut-off points and comparison with the CIS-R

BACKGROUND

Although measures of psychopathology are designed for use in clinical populations, their meaning derives from comparison with normal populations.

AIMS

To compare the distribution of scores on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) from a general population sample with the distribution in an aggregated clinical sample to derive recommended cut-off points for determining clinical significance.

METHOD

The CORE-OM general population sample was based on a weighted subsample of participants in the psychiatric morbidity follow-up survey who completed valid CORE-OM forms following their interview (effective n=535).

RESULTS

Comparison of the CORE-OM general population sample with a clinical sample aggregated from previous studies (n=10761) yielded a cut-off score of 9.9 on the 0-40 scale of the CORE-OM. The CORE-OM was highly correlated (r=0.77) with the Clinical Interview Schedule-Revised, supporting convergent validity.

CONCLUSIONS

We recommend rounding the CORE-OM cut-off score to 10. However, cut-off scores must be used thoughtfully and adjusted to fit context and purpose.

Transforming between Beck Depression Inventory and CORE-OM scores in routine clinical practice

OBJECTIVES

The Clinical Outcomes in Routine Evaluation - Outcome Measure (CORE-OM) and the Beck Depression Inventory (BDI) are routinely used to assess emotional problems. It would be helpful to be able to compare scores when only one of the measures is available. We investigated the relationship between the measures and produced translation tables.

METHODS

Level of agreement between CORE-OM and BDI-I was assessed for 2,234 clients who had completed both measures at referral for routine secondary care. Tables for predicting between the measures were constructed using several methods, including non-linear regression and non-parametric smoothing. Results were cross-validated on a separate sample of 326 clients.

RESULTS

High correlations between the measures were obtained (r=.862 for female clients; r=.855 for male clients). Accuracy in predicting caseness is higher than predicting depression levels.

CONCLUSIONS

CORE-OM and BDI can be compared in routine clinical settings with acceptable accuracy.

Dose-effect relations and responsive regulation of treatment duration: the good enough level

This study examined rates of improvement in psychotherapy as a function of the number of sessions attended. The clients (N=1,868; 73.1% female; 92.4% White; average age=40), who were seen for a variety of problems in routine primary care mental health practices, attended 1 to 12 sessions, had planned endings, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at the beginning and end of their treatment. The percentage of clients achieving reliable and clinically significant improvement (RCSI) on the CORE-OM did not increase with number of sessions attended. Among clients who began treatment above the CORE-OM clinical cutoff (n=1,472), the RCSI rate ranged from 88% for clients who attended 1 session down to 62% for clients who attended 12 sessions (r=-.91). Previously reported negatively accelerating aggregate curves may reflect progressive ending of treatment by clients who had achieved a good enough level of improvement.

Therapists' recall of early sudden gains in routine clinical practice

This study followed up one by Stiles et al. (2003), which identified sudden gains -- large reductions from one session to the next on a short form of clinical outcomes in routine evaluation outcome measure (CORE-SF) -- by some clients in routine clinical practice. We interviewed the therapists who had treated sudden gain and non-sudden gain clients. Results showed that therapists could retrospectively identify which clients had or had not experienced sudden CORE-SF gains at substantially better than chance rates, although they identified only about half of the clients who had experienced such gains.

Wie effektiv sind systematische Rückmeldungen des Therapieverlaufs an den Therapeuten?

Zusammenfassung. Theoretischer Hintergrund: Die systematische Rückmeldung des Therapieverlaufs an den Therapeuten erwies sich in mehreren Studien an ambulant behandelten, überwiegend gering beeinträchtigten Patienten als effektives Mittel, um die Wirksamkeit psychotherapeutischer Behandlungen für potenziell problematische Patienten zu steigern. Fragestellung: Lassen sich diese Befunde auch in einem stationär-verhaltenstherapeutischen Setting replizieren und inwieweit sind sie wirklich auf misserfolgsgefährdete Patienten beschränkt? Methode: In einem randomisierten Gruppenvergleich (N = 118) erhielt die Hälfte der Therapeuten ein systematisches Feedback über den Therapieverlauf. Ergebnisse: Die Patienten in der Feedback-Bedingung verbesserten sich bei allen untersuchten Therapieerfolgsmaßen stärker als die Patienten der Kontrollgruppe. Schlussfolgerung: Ein systematisches Feedback des Therapieverlaufs an den Therapeuten führt zu einer Verbesserung der Effektivität stationär-verhaltenstherapeutischer Behandlungen. Zukünftige Forschung sollte nach Wegen suchen, die monetären und psychologischen Kosten von Feedbacksystemen zu reduzieren, um deren Einsatz in Settings der Routineversorgung zu erleichtern.

Empirically and clinically useful decision making in psychotherapy: Differential predictions with treatment response models

In the delivery of clinical services, outcomes monitoring (i.e., repeated assessments of a patient's response to treatment) can be used to support clinical decision making (i.e., recurrent revisions of outcome expectations on the basis of that response). Outcomes monitoring can be particularly useful in the context of established practice research networks. This article presents a strategy to disaggregate patients into homogeneous subgroups to generate optimal expected treatment response profiles, which can be used to predict and track the progress of patients in different treatment modalities. The study was based on data from 618 diagnostically diverse patients treated with either a cognitive-behavioral treatment protocol (n = 262) or an integrative cognitive-behavioral and interpersonal treatment protocol (n = 356). The validity of expected treatment response models to predict treatment in those 2 protocols for individual patients was evaluated. The ways such a procedure might be used in outpatient centers to learn more about patients, predict treatment response, and improve clinical practice are discussed.

Reliabilität von Kurzformen gängiger psychometrischer Instrumente zur Evaluation des therapeutischen Fortschritts in Psychotherapie und Psychiatrie

Zusammenfassung. Im Rahmen der sich in den letzten Jahren immer stärker etablierenden Wissenschaftler-Praktiker-Netzwerke und Qualitätssicherungsstudien in der Psychotherapie und Psychiatrie wird der Einsatz von ökonomischen, aber multidimensionalen und veränderungssensitiven klinischen Messinstrumenten zur Verlaufs- und Ergebnismessung therapeutischer Behandlungen immer wichtiger. In der vorliegenden Arbeit wird die Entwicklung von Kurzfragebögen vier gängiger Messinstrumente (der Symptom-Checkliste, SCL-90-R; dem Emotionalitätsinventar, EMI; dem Inventar Interpersonaler Probleme, IIP und dem Inkongruenzfragebogen, INK) sowie die Validität, Reliabilität und Veränderungssensitivität dieser Kurzfragebögen anhand einer Stichprobe der Allgemeinbevölkerung (N = 436), einer Stichprobe ambulanter Psychotherapiepatienten (N = 169) sowie einer Stichprobe von Patienten in stationärer Psychotherapie (N = 134) dargestellt. Die psychometrischen Eigenschaften dieser Kurzformen sowie ein daraus generierter auf 43 Items beruhender Gesamtwert für die allgemeine psychische Beeinträchtigung erlauben den kombinierten Einsatz dieser Instrumente für eine kontinuierliche und ökonomische Erhebung des therapeutischen Fortschritts.

Early maladaptive schemas and adult attachment in a UK clinical population

OBJECTIVES

Both insecure attachment style and early maladaptive schemas have been associated with mental health difficulties. This study aimed to investigate how schemas relate to attachment style classification in mental health service users. A further aim was to investigate the nature of the relationship between psychological distress, common psychological difficulties, and attachment style.

METHOD

Participants were 72 people in contact with mental health services who completed the short form of Young's schema questionnaire, a measure identifying their attachment style (experience of close relationships), and the clinical outcomes in routine evaluation (CORE; Evans et al., 1998) outcome measure.

RESULTS

Overall, 81% of the participants had an insecure attachment style. The fearful group were the most distressed across several domains of the CORE, followed by the preoccupied group. Schemas differed significantly according to attachment style grouping, with the fearful group possessing the greatest degree of maladaptive schemas, followed by the preoccupied group. Discriminant function analysis identified differing patterns of schemas associated with attachment style.

CONCLUSIONS

The results supported the relevance of both attachment style and maladaptive schemas to individuals with mental health difficulties. Importantly, several aspects of the individuals' symptoms and difficulties and their schemas were meaningfully related to their adult attachment style. Limitations included the small number of dismissing individuals identified, the problems of self-report in this area, and the absence of information about the quality of participants' current relationships.

Predicting outcomes of inpatient psychotherapy using quality management data: comparing classification and regression trees with logistic regression and linear discriminant analysis

Abstract Three classification models are compared with regard to their ability to identify unsuccessful treatment outcomes. Data from the Stuttgart-Heidelberg model on quality management of 1,401 inpatients were used. According to the evaluation algorithm used, 82% benefited from therapy. Outcomes were classified using logistic regression, linear discriminant analysis, and classification and regression trees. For the regression techniques, variables were selected stepwise backward; for the CART model, the method-inherent selection scheme was adopted. Because there were few signal cases in the data, these cases were double weighted. Model performance was obtained using classic cross-validation. Overall misclassification rates did not differ between methods for the construction sample but differed when applied to the validation sample. Overall classification rates for the given problem are modest.