everyday evidence – therapy outcomes in swedish public health service settings spr 42nd annual...
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Everyday evidence – therapy outcomes in Swedish public health service settings
SPR 42nd annual meeting Bern, June 31, 2011
Andrzej Werbart & Lars Levin
Background
Dodo bird & Equivalence paradox Empirically supported treatment (EST) Randomized controlled trials (RCT)
Pro’s & con’s
Evidence based practice in psychotherapy (EBPP)
QAPS
Research questions To investigate which patients get which
treatment – comparing pre-treatment characteristics Total sample and by therapy type
To compare outcomes from different forms of psychotherapy (CBT, PDT, INT) Replication of prior studies (CORE)
To investigate whether different measures capture different aspects of change
Method Data collection 2007-2010 Participants
13 outpatient services 1,500 pre-therapy questionnaires Attrition
Procedure Self-ratings: SCL-90, QOLI (SRH, HAQ, CSQ) Therapist assessments Treatment methods: CBT, PDT, INT
Statistical analysis Cohen’s d, RCSI
AttritionAll patients where data
at t1 is availableN=1,498
DO from data collection n=535 (35.71%)
Non-startersn=204 (13.62%)
DO from treatmentn=260 (17.36%)
Completed therapiesn=188 (12.55%)
Ongoing therapiesn=311 (20.76%)
Core groupn=180
Complete data t1SCL-90: n=177QOLI: n=178
Complete data t2SCL-90: n=175QOLI: n=176
Other or unspecified therapy type
n=8
Treatment startersn=1,294 (86.38%)
Remainingn=499 (33.31%)
Analysis of attrition Differences
DO from treatment slightly younger
DO from data collection more men slightly fewer
previous psychiatric contacts
Self-ratings – no significant differences
Large groups
All patients where data at t1 is available
N=1,498
DO from data collection n=535 (35.71%)
Non-startersn=204 (13.62%)
DO from treatmentn=260 (17.36%)
Completed therapiesn=188 (12.55%)
Ongoing therapiesn=311 (20.76%)
Core groupn=180
Complete data t1SCL-90: n=177QOLI: n=178
Complete data t2SCL-90: n=175QOLI: n=176
Other or unspecified therapy type
n=8
Treatment startersn=1,294 (86.38%)
Remainingn=499 (33.31%)
Three groups (n=350) CBT 63, PDT 206, INT 59 (22 other)
No significant differences regarding: Gender (ca 70% female) Self-rating
Significant differences: Age (INT younger, M=24.7 yrs vs 32.2 & 32.3) Level of education (INT less educated) Occupation Previous psychiatric contacts (CBT more)
Characteristics - by therapy type
Self-rating - by therapy type
CBT PDT INT F p
GSI, SCL-90 (n=3211) 61 202 58 2.266 0.105Mean 1,17 1,23 1,39SD 0,64 0,58 0,67
QOLI (n=3241) 62 203 59 0.218 0.804Mean 0,52 0,40 0,49SD 1,69 1,44 1,38
SRH (n=3221) 62 201 59 0.448 0.640Mean 3,71 3,61 3,39SD 1,41 1,27 1,25
HAQ (n=3061) 59 191 56 1.702 0.184Mean 4,13 4,10 4,20SD 0,35 0,38 0,32
1) n varies due to the varying number of respondents to each specific item.
*p<0.05, **p<0.01
Therapy type
Results - core group, effectiveness
All patients where data at t1 is available
N=1,498
DO from data collection n=535 (35.71%)
Non-startersn=204 (13.62%)
DO from treatmentn=260 (17.36%)
Completed therapiesn=188 (12.55%)
Ongoing therapiesn=311 (20.76%)
Core groupn=180
Complete data t1SCL-90: n=177QOLI: n=178
Complete data t2SCL-90: n=175QOLI: n=176
Other or unspecified therapy type
n=8
Treatment startersn=1,294 (86.38%)
Remainingn=499 (33.31%)
Results, core group- Effect size by therapy type
ES
Mean SD Mean SD Cohen’s d
GSI
CBT (n= 29) 1.30 0.60 0.77 0.58 0.88
PDT (n= 115) 1.19 0.57 0.77 0.59 0.74
INT (n= 31) 1.46 0.73 0.72 0.53 1.02
Total (n= 175) 1.25 0.61 0.76 0.58 0.81
QOLI
CBT (n= 29) 0.64 1.63 1.38 1.53 0.45
PDT (n= 116) 0.41 1.45 1.56 1.52 0.80
INT (n= 31) 0.58 1.11 1.91 1.29 1.20
Total (n= 176) 0.48 1.42 1.59 1.49 0.78
Post-therapyPre-therapy
Results, core group- RCSI & RC by therapy type (GSI)
GSI RCSI (%)
Reliable improvem.
(%)
No reliable change
(%)
Deterior-ation (%)
RCSI
CBT (n= 22) 59.1 18.2 22.7 0.0
PDT (n= 79) 49.4 21.5 20.3 8.9
INT (n= 26) 65.4 23.1 7.7 3.8
Total (n= 127) 54.3 21.3 18.1 6.3
RC
CBT (n= 29) 69.0 27.6 3.4
PDT (n= 115) 60.9 30.4 8.7
INT (n= 31) 77.4 19.4 3.2
Total (n= 175) 65.1 28.0 6.9
Results, core group- RCSI & RC by therapy type (QOLI)
QOLI RCSI (%)
Reliable improvem.
(%)
No reliable change
(%)
Deterior-ation (%)
RCSI
CBT (n= 22) 13.6 9.1 77.3 0.0
PDT (n= 100) 19.0 10.0 70.0 1.0
INT (n= 28) 35.7 7.1 53.6 3.6
Total (n= 150) 21.3 9.3 68.0 1.3
RC
CBT (n= 29) 17.2 82.8 0.0
PDT (n= 116) 26.7 72.4 0.9
INT (n= 31) 38.7 58.1 3.2
Total (n= 176) 27.3 71.6 1.1
Discussion Psychotherapy in public health services
is effective for patients who complete treatment Cohen’s d 0.81 (GSI), 0.78 (QOLI) Clinical improvement larger when
measured by GSI (54.8%) compared to QOLI (21.3%)
Differences toward UK studies (CORE) Cohen’s d 1.39, RCSI=58.3% Different patients (primary care vs outpatient
psychiatric services)
Discussion
The different therapy methods did not differ significantly in effectiveness But effective for different aspects?
Symptom (SCL-90) vs Quality of Life (QOLI) Systematic distribution of patients to
treatments or therapists? Dose-effect: longer treatment necessary
for changes in quality of life? Effects after termination?
Further research
Dropouts Non-starters Non-responders
Welcome to the poster session tonight!
