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

Standards of Evidence: Criteria for Efficacy, Effectiveness and Dissemination

Ever increasing demands for accountability, together with the proliferation of lists of evidence-based prevention programs and policies, led the Society for Prevention Research to charge a committee with establishing standards for identifying effective prevention programs and policies. Recognizing that interventions that are effective and ready for dissemination are a subset of effective programs and policies, and that effective programs and policies are a subset of efficacious interventions, SPR's Standards Committee developed overlapping sets of standards. We designed these Standards to assist practitioners, policy makers, and administrators to determine which interventions are efficacious, which are effective, and which are ready for dissemination. Under these Standards, an efficacious intervention will have been tested in at least two rigorous trials that (1) involved defined samples from defined populations, (2) used psychometrically sound measures and data collection procedures; (3) analyzed their data with rigorous statistical approaches; (4) showed consistent positive effects (without serious iatrogenic effects); and (5) reported at least one significant long-term follow-up. An effective intervention under these Standards will not only meet all standards for efficacious interventions, but also will have (1) manuals, appropriate training, and technical support available to allow third parties to adopt and implement the intervention; (2) been evaluated under real-world conditions in studies that included sound measurement of the level of implementation and engagement of the target audience (in both the intervention and control conditions); (3) indicated the practical importance of intervention outcome effects; and (4) clearly demonstrated to whom intervention findings can be generalized. An intervention recognized as ready for broad dissemination under these Standards will not only meet all standards for efficacious and effective interventions, but will also provide (1) evidence of the ability to "go to scale"; (2) clear cost information; and (3) monitoring and evaluation tools so that adopting agencies can monitor or evaluate how well the intervention works in their settings. Finally, the Standards Committee identified possible standards desirable for current and future areas of prevention science as the field develops. If successful, these Standards will inform efforts in the field to find prevention programs and policies that are of proven efficacy, effectiveness, or readiness for adoption and will guide prevention scientists as they seek to discover, research, and bring to the field new prevention programs and policies.

The CORE-OM in an older adult population: psychometric status, acceptability, and feasibility

There is a need to extend and test the feasibility and acceptability of mental health outcome measures in the older population (i.e., aged 65-100). We present data on the CORE-OM (Clinical Outcomes in Routine Evaluation-Outcome Measure) on a sample of 118 people aged 65-97 presenting for mental health treatment and 214 people aged 65-94 drawn from a non-clinical population. Results show the CORE-OM to be a reliable measure in both samples when the overall mean item is used but the reliability is not as high for the specific domains as psychometrically stable structures. The CORE-OM showed large overall differences between the non-clinical and clinical samples indicating that it is equally as sensitive to these differing populations across this older age band as with working-age adults. However, the norms for the clinical sample were consistently lower than the equivalent clinical norms for a working-age sample. These findings suggest that the collection and compilation of age-specific norms is crucial in ensuring that appropriately referenced norms are used rather than assuming that norms are generalizable across the whole adult life-span.

Suitability and utility of the CORE-OM and CORE-A for assessing severity of presenting problems in psychological therapy services based in primary and secondary care settings

BACKGROUND

There is a need for reliable assessment tools that are suitable for the counselling and the psychological therapy services in primary and secondary care settings.

AIMS

To test the suitability and utility of the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) and CORE-Assessment (CORE-A) assessment tools.

METHOD

Service intake data were analysed from counselling and psychological therapy services in 32 primary care settings and 17 secondary care settings.

RESULTS

Completion rates exceeded 98% in both of the settings sampled. Intake severity levels were similar but secondary care patients were more likely to score above the risk cut-off and the severe threshold and to have experienced their problems for a greater duration.

CONCLUSIONS

The CORE-OM and CORE-A are suitable assessment tools that show small but logical differences between psychological therapy services in primary- and secondary-based care.

Sudden Gains in Cognitive Therapy for Depression: A Replication and Extension

Of 76 clients receiving 8-20 sessions of cognitive therapy (CT) in a joint university and a national health service clinic, 31 experienced sudden gains that appeared very similar to those first reported in clinical trials of CT by T. Z. Tang and R. J. DeRubeis (1999) and subsequently replicated in other studies. The sudden gains appeared less stable in the present study's more routine clinical practice settings than they were in the clinical trials. Life events did not appear to account for sudden gains.

Predicting change for individual psychotherapy clients on the basis of their nearest neighbors

This study extended client-focused research by using the nearest neighbor (NN) approach, a client-specific sampling and prediction strategy derived from research on alpine avalanches. Psychotherapy clients (N=203) seen in routine practice settings in the United Kingdom completed a battery of intake measures and then completed symptom intensity ratings before each session. Forecasts of each client's rate of change and session-by-session variability were computed on the basis of that client's NNs (n=10-50 in different comparisons). Alternative forecasts used linear or log-linear slopes and were compared with an alternative prediction strategy. Results showed that the NN approach was superior to the alternative model in predicting rate of change, though the advantage was less clear for predicting variability.

A conceptual framework for drug treatment process and outcomes

Evidence from specialized treatment evaluations and large-scale natural studies of treatment effectiveness is organized conceptually into a "treatment model" for summarizing how drug treatment works. Sequential relationships between patient and treatment program attributes, early patient engagement, recovery stages, retention, and favorable outcomes are discussed--along with behavioral, cognitive, and skills training interventions that have been shown to be effective for enhancing specific stages of the patient recovery process. Applications of the treatment model for incorporating science-based innovations into clinical practice for improving early engagement and retention, performance measurements of patient progress, program monitoring and management using aggregated patient records, and organizational functioning and systems change also are addressed.

Computer-supported monitoring of patient treatment response

The use of information technology (IT) for the purpose of improving psychotherapy outcomes in the context of routine clinical practice is described. IT efforts from two research programs, one in Germany and the other in the United States, are based on evidence that not all patients who enter treatment have a positive outcome and that continuous monitoring of patient treatment response with immediate feedback to therapists can be used to increase the likelihood of success for the poorly responding client. Such monitoring and feedback can best be accomplished by IT methodologies. Suitable IT systems are described, and their strengths and limitations are highlighted. Evidence is presented that supports the positive value of such efforts for improving patient treatment response.

Practice-informed research and research-informed psychotherapy

The information processing demands of planning and conducting psychotherapy and the types of information that clinicians value potentially can inform research that is likely to be useful to clinicians. Four approaches to conducting research on psychotherapy issues-technology transfer studies, quasi-experimental single-case designs, mental health services research, and case-focused patient profiling-have the potential to inform the practicing therapist. These approaches generally are either treatment focused or patient focused, and can vary in their relevance to the individual case.

Towards a standardised brief outcome measure: psychometric properties and utility of the CORE-OM

BACKGROUND

An acceptable, standardised outcome measure to assess efficacy and effectiveness is needed across multiple disciplines offering psychological therapies.

AIMS

To present psychometric data on reliability, validity and sensitivity to change for the CORE-OM (Clinical Outcomes in Routine Evaluation--Outcome Measure).

METHOD

A 34-item self-report instrument was-developed, with domains of subjective well-being, symptoms, function and risk. Analysis includes internal reliability, test-retest reliability, socio-demographic differences, exploratory principal-component analysis, correlations with other instruments, differences between clinical and non-clinical samples and assessment of change within a clinical group.

RESULTS

Internal and test-retest reliability were good (0.75-0.95), as was convergent validity with seven other instruments, with large differences between clinical and non-clinical samples and good sensitivity to change.

CONCLUSIONS

The CORE-OM is a reliable and valid instrument with good sensitivity to change. It is acceptable in a wide range of practice settings.

Counselling and interpersonal therapies for depression: towards securing an evidence-base

Both generic counselling (delivered by BACP level counsellors in primary care settings) and the interpersonal therapies place a central value on the role and function of relationships--both within and outside the practice setting - as a vehicle for understanding and treating people presenting with depression. Recent studies have compared generic counselling with antidepressant medication, usual GP care, cognitive-behaviour therapy (CBT), and as an adjunct to GP care (i.e. in combination with GP care). Findings suggest either that there is no difference between generic counselling and other treatment conditions, or that there are small advantages to counselling over usual GP care but only in the short-term with such differences disappearing at 1-year. Studies investigating the interpersonal therapies (IPT) have established that the content of such therapies differ in their content from behavioural and cognitive therapies despite the outcomes being broadly similar. Considerable research effort has focused on the process of change in IP therapies. Important factors include the level of prior commitment by the patient to psychological therapy and their confidence in the therapist. Patients with well assimilated problems tend to do better in CBT than psychodynamic-interpersonal therapy. Therapists need to be flexible and responsive to patient needs particularly concerning interpersonal and attachment issues. Future research in counselling needs to identify the effective components of generic counselling and relate these to a theoretical base. In the IP therapies, there needs to be a greater focus on the change outside the therapy session and on the effectiveness of such therapies in non-research settings.