Evidence-based interventions

Question 1

What is evidence-based therapy?

Answer 1

Any psychotherapy, intervention, or mental health treatment which has been shown to be effective.

Question 2

What are the origins of the evidence-based therapy movement?

Answer 2

• As a medical movement it started in the early 1980s by Canadian epidemiologist David Sackett.
• He defined it as the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients.
• Encouraged clinical decision-making that was grounded in evidence.
• Idea spread throughout medicine including psychiatry.

Question 3

What has research found about most psychotherapies?

Answer 3

• Most psychotherapies work for more people

Question 4

Why did psychology adopt the concept of EBT?

Answer 4

• Psychiatry guidelines underplayed the value of psychological treatments for the EBT movement adopted the FDA evidence model to give psychological treatments greater perceived validity.

Question 5

What has happened since psychology adopted the EBT model?

Answer 5

• The focus has shifted towards brief, focal treatments for specific disorders.
• Research shows impressive advancements
• RCT have remained the gold standard of evidence

Question 6

What was the APA’s stance of EB practice in psychology in 2006?

Answer 6

This policy emphasizes integrating the best-available research with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences.
- This policy was intended to maximise patients’ choices about treatment.

Question 7

What does best research evidence mean according to the APA? And what types of research methodologies are included?

Answer 7

• Data from a range of research methodology including:
• meta-analyses
  -randomised controlled trials
• effectiveness studies
• process studies
• single-case reports
• systematic case studies
• qualitative and ethnographic research
• clinical observation

Question 8

What is the Global Mental Health movement?

Answer 8

It was started in 2007 to address global inequalities in mental health care and lack of access to services.

Question 9

What are the two fundamental principles of the GMHM?

Answer 9

Scientific evidence and human rights.

Question 10

What are the two primary goals of the Global Mental Health movement?

Answer 10

• To address human rights issues in mental health
• Only support interventions/programmes/treatments that are based on scientific evidence.

Question 11

What is the criteria of an EB psychotherapy?

Answer 11

According to Kazdin (2014) it is a treatment that has been tested and:
1. Clearly specifies patient characteristics
2. With participants randomised to intervention and control groups
3. Using a manualized intervention
4. Multiple outcome measures
5. Statistically significant effect size
6. Outcomes can be replicated

Question 12

How many EB interventions are there?

Answer 12

Over 320

Question 13

So what does evidence-based therapy really mean?

Answer 13

It refers to psychological interventions that have been shown by means of empirical research to reduce symptomatology and increase functioning among clients, at a rate that is beyond what would have occurred by chance.

Question 14

What is the difference between efficacy and effectiveness?

Answer 14

• Efficacy refers to evidence derived from trials where threat to internal validity is minimised.
• Effectiveness refers to performance under real-world conditions.

Question 15

What is wrong with the first criteria for EBT? (Clearly and carefully specifying patient population)

Answer 15

Pros:
- RCTs require careful specification of participants
- Inclusion and exclusion criteria are clear
- NB to reduce in-group variability
- More than 1 diagnosis/problem often leads to exclusion
Cons:
- This is unrealistic
- Intervention only shown to be effective for people with only that problem
- People rarely have just one diagnosis.

Question 16

Pros and Cons of Randomisation to intervention and control groups

Answer 16

Pros:
- Randomising participants reduces bias
- Using a control group allows for suitable comparison
- Different types: no treatment, TAU, attention as placebo
Cons:
- No treatment: the bar is too low (most therapies are effective)
- Comparison studies often use under-trained therapists

Question 17

How is attention used as a placebo?

Answer 17

• participants are given a form of intervention that mimics the amount of attention and interaction they would receive in the experimental treatment but without the active components of the intervention. This type of control is used to isolate the effects of the specific therapeutic elements from the general effects of receiving attention and care.

Question 18

Pros and Cons of Manualized interventions

Answer 18

Pros:
- Consistency in application
- Prevents drift (everyone doing the same thing at the same time)
- NB for replication
- NB for task sharing
Cons:
- Manuals can be obstacles to relating
- Highlight the assumption that technique is curative, despite evidence for non-specific factors
- Manuals focus on addressing one problem
- Assumes one-approach fits all
- Based on assumptions about what healthy is and what is the healthy point we want to reach.

Question 19

Pros and Cons of using multiple outcome measures

Answer 19

Pros:
- Most studies use many outcome measures
- Outcomes measure variety of variables, which can generate a lot of data
Cons:
- Interventions may show improvements on some outcomes but not others. Often there is a mixed set of effects across the various measures, but researchers may only report on outcomes that show improvement to support the intervention they are studying.
- The appropriateness of the selected measures may vary influenced by psychometric validity
- Importance and sensitivity to change: is the change that is being measured important to participants’ lives. Does it affect their functioning or daily living? Or does it measure some arbitrary construct that has no real bearing on patients’ lives?
- Slanted: people can report the data for one thing which wasn’t what their initial goals were. They end up not reporting on their actual goals and just report the “accidental” finding.
- Validity is often not reported. Validity also has cultural implications
- Measures pick up on the slightest change but is the change significant to the individual?

Question 20

What are the pros and cons of the significant effect size criterion

Answer 20

Pros:
- Evidence relies on significant outcomes (this means establishing statistical significance, and establishing the effect size)
Cons:
- Statistical significance seen as evidence of efficacy
- Has little bearing on functioning (i.e. clinical significance)
-Also, improvement does not mean recovery

Question 21

What are the different types of significance?

Answer 21

• Statistical significance (change did not occur by chance)
• Clinical significance (effect on functioning)
  -Effect size (size of pre- and post-intervention difference)

Question 22

How do you measure clinical significance?

Answer 22

• Self report (asking the patient how they feel after going through an intervention)

Question 23

What are the pros and cons of the “outcomes can be replicated” criterion?

Answer 23

Pros:
- Repeating methods other studies will produce the same result
-Presumably following manuals faithfully will produce same outcomes
Cons:
- Assumes a cookbook approach to therapy
-One-size-fits-all
-Assumptions about what it means to be mentally “healthy”

Question 24

In summary, what are the main critiques of EBT?

Answer 24

• Evidence has come to only mean results from RCTs, making the criteria for EBT essentially that for RCT methodology
• Specifying patient characteristics is unrealistic and means treatments aren’t suitable for most people as most people rarely have only one condition.
• Manuals reduce therapy to technique and strategy, whereas evidence shows that most therapies work for most people, meaning that its not necessarily the techniques which are helpful.
• The issue with have multiple outcome measures is that evidence that doesn’t support the therapy can be excluded
  -Statistical significance does not equal real-world benefits or recovery.
• Replication of outcomes implies one-size-fits-all, highlights assumption of what it means to be healthy
• So, claims about efficacy are misleading.

Question 25

How did task-shifting come about?

Answer 25

Task shifting came out of the HIV/AIDS pandemic when there were shortages of resources and unnecessary reliance on specialists.

Question 26

What is task-shifting?

Answer 26

Task shifting is the rational distribution of tasks among health workforce teams. Specific tasks are moved, where appropriate, from highly qualified health workers to health workers with shorter training and fewer qualifications in order to make more efficient use of the available human resources for health.

Question 27

What is meant by “optimal mix of services?”

Answer 27

To maximise access to treatment and ensure that the needs are addressed at the appropriate level, the WHO envisioned an “optimal mix of services” that would reduce pressure on specialist services, by developing non-specialist services in community and primary health care setting further.

Question 28

What is the triangle of optimal mix of services

Answer 28

-Self-care
-Informal community care
-Mental health services through PHC
- Community mental health services| Psychiatric services in general hospitals
- Long-stay facilities and specialist services

Question 29

How has task-shifting been adapted for the mental health setting?

Answer 29

• New tasks have been invented to make mental health services more accessible.
• Evidence-based therapies were adapted for delivery by non-specialists to treat CMDs
• Generally, evidence has been positive

Question 30

What are 4 pros of evidence-based interventions?

Answer 30

1. Supporting evidence suggests they are effective
2. Addresses GMHM’s mandate of ensuring cost-effective interventions that are accessible and grounded in science
3. Provide frameworks from which to build on our knowledge of what works
4. Allows for development of interventions that can be task-shared.

Question 31

What are the cons of evidence-based interventions?

Answer 31

1. EB treatments often ignore cultures within which treatment occurs
2. Assumptions about what it means to be mentally healthy are not interrogated.
3. treatments can assume a one-size-fits-all approach
4. Little to no acknowledgement of the relational or intersubjective context.
5. Assumptions about what constitutes “evidence” are grounded in the scientific model
6. Compared to other therapies, the evidence for EBT is not all that good.