David Saxon

Patterns of Therapist Variability: Therapist Effects and the Contribution of Patient Severity and Risk.

OBJECTIVE To investigate the size of therapist effects using multilevel modeling (MLM), to compare the outcomes of therapists identified as above and below average, and to consider how key variables--in particular patient severity and risk and therapist caseload--contribute to therapist variability and outcomes. METHOD We used a large practice-based data set comprising patients referred to the U.K.s National Health Service primary care counseling and psychological therapy services between 2000 and 2008. Patients were included if they had received ≥2 sessions of 1-to-1 therapy (including an assessment), had a planned ending to treatment, and completed the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM; Barkham et al., 2001; Barkham, Mellor-Clark, Connell, & Cahill, 2006; Evans et al., 2002) at pre- and post-treatment. The study sample comprised 119 therapists and 10,786 patients, whose mean age was 42.1 years (71.5% were female). MLM, including Markov chain Monte Carlo procedures, was used to derive estimates to produce therapist effects and to analyze therapist variability. RESULTS The model yielded a therapist effect of 6.6% for average patient severity, but it ranged from 1% to 10% as patient non-risk scores increased. Recovery rates for individual therapists ranged from 23.5% to 95.6%, and greater patient severity and greater levels of aggregated patient risk in a therapists caseload were associated with poorer outcomes. CONCLUSIONS The size of therapist effect was similar to those found elsewhere, but the effect was greater for more severe patients. Differences in patient outcomes between those therapists identified as above or below average were large, and greater therapist risk caseload, rather than non-risk caseload, was associated with poorer patient outcomes.

Cognitive Behavioural Treatment for Anger in Adults with Intellectual Disabilities: A Systematic Review and Meta-analysis

BACKGROUND The cognitive behavioural treatment for anger in adults with intellectual disabilities has received increasing interest. The current study aims to review the current literature and provide a meta-analysis. METHOD A literature search found 12 studies eligible for the quality appraisal. The studies examined cognitive behavioural treatment for anger in adults with intellectual disabilities published since 1999. Nine studies were eligible to be included in the meta-analysis. RESULTS The meta-analysis revealed large uncontrolled effect sizes for the treatment for anger in adults with intellectual disabilities, but is viewed with caution due to low sample sizes. The narrative review showed improved methodological quality of the literature. CONCLUSIONS The emerging literature is encouraging. However, it is limited through concatenated data, a lack of comparative control groups and small study samples.

Reliability of Therapist Effects in Practice-Based Psychotherapy Research: A Guide for the Planning of Future Studies

This paper aims to provide researchers with practical information on sample sizes for accurate estimations of therapist effects (TEs). The investigations are based on an integrated sample of 48,648 patients treated by 1800 therapists. Multilevel modeling and resampling were used to realize varying sample size conditions to generate empirical estimates of TEs. Sample size tables, including varying sample size conditions, were constructed and study examples given. This study gives an insight into the potential size of the TE and provides researchers with a practical guide to aid the planning of future studies in this field.

Predictors of patient non-attendance at Improving Access to Psychological Therapy services demonstration sites

Background Improving Access to Psychological Therapy (IAPT) services have increased the number of people with common mental health disorders receiving psychological therapy in England, but concerns remain about how equitably these services are accessed. Method Using cohort patient data (N=363) collected as part of the independent evaluation of the two demonstration sites, logistic regression was utilised to identify socio-demographic, clinical and service factors predictive of IAPT non-attendance. Results Significant predictors of IAPT first session non-attendance by patients were: lower non-risk score on the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM); more frequent thoughts of “being better off dead” (derived from the CORE-OM); either a very recent onset of common mental health disorder (1 month or less) or a long term condition (more than 2 years); and site. Limitations The small sample and low response rate are limitations, as the sample may not be representative of all those referred to IAPT services. The predictive power of the logistic regression model is limited and suggests other variables not available in the dataset may also be important predictors. Conclusions The clinical characteristics of risk to self, severity of emotional distress, and illness duration, along with site, were more predictive of IAPT non-attendance than socio-demographic characteristics. Further testing of the relationship between these variables and IAPT non-attendance is recommended. Clinicians should monitor IAPT uptake in those they refer and implement strategies to increase their engagement with services, particularly when referring people presenting with suicidal ideation or more chronic illness.

Psychotherapy provision, socioeconomic deprivation, and the inverse care law

Abstract In this study of routine service data and census data, the authors explore the influence of socioeconomic status on patients entering an integrated psychotherapy service. Between January 1, 2000, and September 30, 725 patients were assessed and had their Townsend Index of Material Deprivation (TIMD) scores derived from postcodes. Results showed no correlation between TIMD score and those attending their assessment and no significant difference in TIMD score between those allocated to psychoanalytic psychotherapy (PAP) or cognitive–behavioral psychotherapy (CBP) and between those accepted and not accepted for each treatment. No correlation was found between Townsend score and numbers presenting to the service, suggesting that the inverse care law applies. Deprivation is not a predictor of patient allocation to or acceptance for PAP or CBP.

Who drops-out? Do measures of risk to self and to others predict unplanned endings in primary care counselling?

Abstract Aims: Unplanned endings, where clients unilaterally end therapy, are of concern for psychological therapy services generally as they raise questions about the appropriateness of the treatment and its delivery for some clients. Limited available data indicates that those who drop-out often have more severe symptoms at entry, and have poorer clinical outcomes. This raises further questions about risk to self and others for those clients who leave therapy prematurely and how these clients might be identified and kept engaged. Method: This paper uses a large dataset of CORE data collected routinely in a primary care counselling service between 2000 and 2003. Logistic regression was utilised to consider different measures of risk and other client characteristics recorded at assessment to predict drop-out from the service. Results: These indicate that younger age, greater psychological distress at assessment, an addiction problem and greater risk to others, are associated with an unplanned ending. How...

A mixed-method investigation of patient monitoring and enhanced feedback in routine practice: Barriers and facilitators

Abstract Objective: To investigate the barriers and facilitators of an effective implementation of an outcome monitoring and feedback system in a UK National Health Service psychological therapy service. Method: An outcome monitoring system was introduced in two services. Enhanced feedback was given to therapists after session 4. Qualitative and quantitative methods were used, including questionnaires for therapists and patients. Thematic analysis was carried out on written and verbal feedback from therapists. Analysis of patient outcomes for 202 episodes of therapy was compared with benchmark data of 136 episodes of therapy for which feedback was not given to therapists. Results: Themes influencing the feasibility and acceptability of the feedback system were the extent to which therapists integrated the measures and feedback into the therapy, availability of administrative support, information technology, and complexity of the service. There were low levels of therapist actions resulting from the feedback, including discussing the feedback in supervision and with patients. Conclusions: The findings support the feasibility and acceptability of setting up a routine system in a complex service, but a number of challenges and barriers have to be overcome and therapist differences are apparent. More research on implementation and effectiveness is needed in diverse clinical settings.

Innovation in health economic modelling of service improvements for longer-term depression: demonstration in a local health community

BackgroundThe purpose of the analysis was to develop a health economic model to estimate the costs and health benefits of alternative National Health Service (NHS) service configurations for people with longer-term depression.MethodModelling methods were used to develop a conceptual and health economic model of the current configuration of services in Sheffield, England for people with longer-term depression. Data and assumptions were synthesised to estimate cost per Quality Adjusted Life Years (QALYs).ResultsThree service changes were developed and resulted in increased QALYs at increased cost. Versus current care, the incremental cost-effectiveness ratio (ICER) for a self-referral service was £11,378 per QALY. The ICER was £2,227 per QALY for the dropout reduction service and £223 per QALY for an increase in non-therapy services. These results were robust when compared to current cost-effectiveness thresholds and accounting for uncertainty.ConclusionsCost-effective service improvements for longer-term depression have been identified. Also identified were limitations of the current evidence for the long term impact of services.

The Contribution of Therapist Effects to Patient Dropout and Deterioration in the Psychological Therapies.

BACKGROUND In the psychological therapies, patient outcomes are not always positive. Some patients leave therapy prematurely (dropout), while others experience deterioration in their psychological well-being. METHODS The sample for dropout comprised patients (n = 10 521) seen by 85 therapists, who attended at least the initial session of one-to-one therapy and completed a Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM) at pre-treatment. The subsample for patient deterioration comprised patients (n = 6405) seen by the same 85 therapists but who attended two or more sessions, completed therapy and returned a CORE-OM at pre-treatment and post-treatment. Multilevel modelling was used to estimate the extent of therapist effects for both outcomes after controlling for patient characteristics. RESULTS Therapist effects accounted for 12.6% of dropout variance and 10.1% of deterioration variance. Dropout rates for therapists ranged from 1.2% to 73.2%, while rates of deterioration ranged from 0% to 15.4%. There was no significant correlation between therapist dropout rate and deterioration rate (Spearmans rho = 0.07, p = 0.52). CONCLUSIONS The methods provide a reliable means for identifying therapists who return consistently poorer rates of patient dropout and deterioration compared with their peers. The variability between therapists and the identification of patient risk factors as significant predictors has implications for the delivery of safe psychological therapy services. Copyright

Group psychoeducative cognitive-behaviour therapy for mixed anxiety and depression with older adults

Objectives: There is a dearth of older adult evidence regarding the group treatment for co-morbid anxiety and depression. This research evaluated the effectiveness of a low-intensity group psychoeducational approach. Method: Patients attended six sessions of a manualised cognitive-behavioural group. Validated measures of anxiety, depression and psychological well-being were taken at assessment, termination and six-week follow-up from patients, who also rated the alliance and their anxiety/depression at each group session. Staff rated patients regarding their functioning at assessment, termination and six-week follow-up. Outcomes were categorised according to whether patients had recovered, improved, deteriorated or been harmed. Effect sizes were compared to extant group interventions for anxiety and depression. Results: Eight groups were completed with 34 patients, with a drop-out rate of 17%. Staff and patient rated outcome measures showed significant improvements (with small effect sizes) in assessment to termination and assessment to follow-up comparisons. Over one quarter (26.47%) of patients met the recovery criteria at follow-up and no patients were harmed. Outcomes for anxiety were better than for depression with the alliance in groups stable over time. Conclusion: The intervention evaluated shows clinical and organisational promise. The group approach needs to be further developed and tested in research with greater methodological control.