Psychological Interventions: Opportunities and Challenges
AheadAPA State Leadership ConferenceMarch 2014
David H. Barlow, PhD, ABPPProfessor of Psychology and PsychiatryFounder and Director Emeritus, Center for Anxiety & Related Disorders Boston University
How Far Have We Come?
Eysenck, H. J. (1952). The effects of psychotherapy: An evaluation. Journal of Consulting Psychology, 16, 319-324.
Conclusion: Psychotherapy no more effective than passage of time.
Current Status
Nature: Editorial (September 2012)
Therapy deficit:Studies to enhance psychological
treatments are scandalously under-supported
“Psychological therapies have the potential to make a substantive difference to patients”
Evidence Based Practice: Definition
Integration ofBest research evidence withClinical expertise (advanced clinical skills to diagnose, assess, and treat disorders) andPatient values and preferences(including the patient fully in a risk/benefit analysis of the EBP, using quantitative presentations where possible)
Sackett, D.L., Straus, S.E., Richardson, W.S., Rosenberg, W., & Haynes, R.B., 2000; Institute of Medicine., 2001
Specific Psychological Treatments (PT) vs. Medication or Alternative Treatments published in JAMA or NEJM
1. Stress Incontinence in the Elderly/Women: PT > Meds + Control at acute and follow-up(Burgio et al., 1998; Goode et al., 2003;
2. Insomnia: PT > Meds or Placebo at acute + follow-up(Morin et al., 1999;Sivertsen et al., 2006 )
3. Depression & Physical Health in Alzheimer’s PT > Routine medical care(Teri, et al., 2003)
5. Depression: PT = Meds with PT + Meds > than either aloneat follow up.(Keller et al., 2000)
6. Panic Disorder: PT = Meds at acute – both > placeboPT > Meds (or PT + Meds) at follow-up(Barlow et al., 2000)
7. PTSD: PT > present centered psychotherapy.(Schnurr, et., al., 2007)
8. Tourette Disorder:. PT > supportive therapy & educationEffect size = .68(Piacentini et al., 2010)
9. Adult ADHD PT > relaxation and educational support (Safren et al., 2010)
New World Health Organization mhGAPRecommendations
Patient Preferences for Treatment: Meta Analysis of 33 Studies
Studies across diverse settings indicate that, on average, patients prefer psychological treatment to pharmacologic treatment for depression and anxiety at a rate of 3 to 1. Consideration of patient preference, along with treatment efficacy and clinical expertise, may be important to optimizing outcomes in clinical settings.
McHugh et al., 2013 Journal of Clinical Psychiatry
Reasons for Successful Treatment Development
Greater understanding of pathology, resulting in new, more precisely targeted treatmentsSubstantial improvement in clinical research methodologiesHealth care systems and governments promoting evidence based practice
Population-based Survey of Use of Anti-Depressants
1996 2005
Rate of use 5.84%(13 million)
10.12%(27 million)
Also receiving psychotherapy(1 visit or more)
31.5% 19.9%
Adapted from Olfson & Marcus, 2009
Antipsychotics being prescribed for anxiety disorders
Comer, Mojtabai, & Olfson, Am J Psychiatry 2011
Antipsychotics being prescribed for anxiety disorders
• From 1996-2007, antipsychotic prescriptions by psychiatrists for outpatient anxiety disorders increased from 10.6% to 21.3% of anxiety disorder visits
• Largest increase is among new outpatients; Psychiatrists appear increasingly comfortable prescribing antipsychotics for anxious patients before adjusting current meds or initiating trials of other med classes
• Among anxiety disorders, largest increase was observed for visits for panic disorder – no controlled trials have evaluated antipsychotics for the tx of panic disorder
Comer, Mojtabai, & Olfson, Am J Psychiatry 2011
WHY THE DISCREPANCY
Medications readily available—heavily promotedPsychological interventions—not so much.
The problem of dissemination and implementation
American Academy of Sleep Medicine (AASM)
AASM: CBT 1st line treatment for all types of insomniaIn 2008, 136 doctoral level sleep specialists certified by AASM—in 2014, 210But, 1600 AASM accredited sleep centers required to have behavioral services available
Staph infections in hospitals
Every year… 2 million acquire an infection 90,000 die in U.S. hospitals
Gawande, 2007; CDC
But, rates of handwashing 33-50%
Improving Handwashing Practices –The problem of implementation
Reasons for not washing handsInconvenientNot enough timeHigh alcohol content noxious building airIrritation to skin (aloe)Aloe stinks (remove aloe)Gel reduces fertilityImproved from 40-70% no drop in infections
Gawande, 2007
Two models for dissemination and implementation
Intensive community training model: (ICT) doctoral level specialists intensively trained to criteria Examples: IAPT, SAMHSA, DBT
Public health model: telehealth --remotely supervised health workers Examples: Roy-Byrne et al., 2010; Proudfoot
et al., 2004; Rollman et al., 2005
THE NATIONAL HEALTH SERVICE IN THE UK
By 2015, the NHS will have spent more than €700m on psychological therapies, this investment in improving Access to Psychological Therapies (IAPT) will mean:
Over 600 more newly trained psychological therapists providing evidence –based treatment
(60% high intensity—40% PWP)
All GP practices having access to psychological therapies as the program rolls out
DEPARTMENT OF VETERANS AFFAIRS AS A
LOCUS OF CHANGE
– Largest health care system in the United States
– Serves over 6 million veterans annually
– Serves over 1 million veterans with mental health concerns annually
MHSP IMPLEMENTATION
$316 million spent in FY 2007 Over $380 million spent in FY 2008Over $510 million spent in FY 2009Over 2,000 new programs nation-wide to date Over 6,000 new mental health professionals and support staff hired since FY 2005, for a total mental health staff in the system of over 20,000
(Ruzek, Karlin, & Zeiss, 2012)
VAH D+I Efforts
$20 million through 2010 on these efforts alone & 3,800 VAH staff trained:
Prolonged exposure + cognitive processing for PTSD
CBT+ ACT for Depression
Social skills training for SMI
(Ruzek et al., 2012)
Transferring Prolonged Exposure PTSD Treatment to Mental Health
Professionals: Making it Work
Afsoon Eftekhari, Ph.D., Josef I. Ruzek, Ph.D., Jill Crowley, Ph.D., Craig Rosen, Ph.D., Andrea Chambers, Ph.D., Gina Gregory,
National Center for PTSD, Dissemination and Training Division&
Bradley E. Karlin, Ph.D.Office of Mental Health Services, VACO
Please Note: These slides are not to be duplicated/reproduced without the author’s written
Numbers Trained
Total # Clinicians Trained through VA rollout 1125
Total # Clinicians Completed Consultation 680
Total # Currently in Consultation 281
Total # Dropped/Removed 164
Consultants 70
Trainers 16
Total # Clinicians Trained outside of but in coordination with the VA rollout 241
Change in PCL and BDI Scores From Session 1 to Final Session*
*Graphic displays outcomes for completed cases.*PCL Average drop of 20.5 points. BDI Average drop of 10.9 points.
62.00
28.12
41.50
17.19
0
10
20
30
40
50
60
70
PCL Scores BDI Scores
Session 1
t(599)=32.33, p<.001 t(585)=25.04, p<.001
National Child Traumatic Stress Network Sites
LOS ANGELES
Category I - National Center for Child Traumatic Stress
MA
CT
NY
PA
NM
UT CO MO
OH
VA
Category II – Intervention Development and Evaluation Centers
Category III – Community Treatment and Service Centers
ME
FL
AL
CA
OR
WA
IL DC
Terrorism and Disaster Branch
NCDURHAMOK
MT
ID WIMI
SC
NJMD
TX
TN
GA
LA
MS
NYC
Procedures for Comprehensive Assessment and Training in Leading
Dissemination Programs
Needs and barrier assessmentTraining structureDidactic trainingCompetence trainingOutcomes collectedSustainability
Adapted from McHugh & Barlow, 2010
Training for 140 Community Practitioners Learning Treatments for Panic Disorder in
AdolescentsTraining Conditions
Text Only (Text) Interactive Online Training (OL)OL+Learning Community– weekly conference calls + Twitter (OL+LC)
Satisfaction: OL, OL+LC > TextProficiency: OL+LC > OL, Text
Ehrenreich-May, J. et al., submitted
Two models for dissemination and implementation
Intensive community training model: doctoral level specialists intensively trained to criteria(iapt,samhsa,dbt)
Public health model: telehealth -- remotely supervised health workers
e.g., CRASKE, ROY-BYRNE ET. AL., 2010
Results from the CALM trialRCT of Coordinated Anxiety Learning and Management (CALM) compared with usual care17 primary care settings in 4 U.S. cities1004 patients4 most common anxiety disorders (PD, GAD, SAD, PTSD)Web-based CBT (with or w/out meds – 9% chose meds alone) supervised by “Anxiety Clinical Specialists” mostly nurses and social workers
Roy-Byrne et al., 2010
Results from the CALM trial
Roy-Byrne et al., 2010
CALM Usual CareResponders 63.7% 44.7%Remitters 51.5% 33.3%
Cognitive-behavior therapy-based intervention by community health workers for mothers with depression and
their infants in rural Pakistan
Rahman et al., The Lancet 2008; 372:902-909 (DOI:10.1016/S0140-6736(08)61400-2)
Present Status
Effective treatment, but plentyof room for improvement
Too many distinct protocols–manuals
Protocols still relatively complex-restricting dissemination
SOME CURRENT TRENDS
Transdiagnostic treatments with core psychological principles of change in primary care settings .Advances in telehealth based interventions.Emerging role for specialty psychological clinics.Direct to consumer advertising
Unified Protocol for Transdiagnostic Treatment of
Emotional Disorders
Directly targeting temperament; specifically : neuroticism---positive affect
Unified Protocol: A Modular ApproachModule 1: Motivation Enhancement for Treatment Engagement
(1 session)
Module 2: Psychoeducation and Treatment Rationale (1-2 sessions)
Module 3: Emotional Awareness Training (1-2 sessions)
Module 4: Cognitive Appraisal and Reappraisal (1-2 sessions)
Module 5: Emotion Driven Behaviors (EDBs) and Emotional Avoidance (1-2 sessions)
Module 6: Interoceptive Awareness and Tolerance (1-2 sessions)
Module 7: Situational Exposures (3-6 sessions)
Module 8: Relapse Prevention (1 session)Barlow et al., 2011
NIMH Research Domain Criteria (RDoC)
Brain circuits: 5 broad mental domainsNegative emotionality– Stress and anxiety (CRF & HPA systems)– Fear (amygdala & connected regions)– Aggression (hypothalamus, amygdala,
neurohormones)
Multi-dimensional emotional disorders inventory (MEDI)
Effects on Neuroticism
Significant effect of time on N (F1,13=10.55, p<.001)Clinical significance of change in N:– Pre-treatment – 27% patients achieved
scores within normal range– Post-treatment – increased to 67% (as
compared to 56% in study 1)– 6-month follow-up – increased further to 82%
Ellard et al., 2012
Web Intervention for OEF/OIF Veterans with Problem Drinking
and PTSD Symptoms:A Randomized Clinical Trial
By: Deborah Brief, Amy Rubin, Terence M. Keane, Justin L. Enggasser, Monica Roy, Eric Helmuth, John
Hermos, Mark Lachowicz, Denis Rybin, & David Rosenbloom
In Press: JCCP
Advantages of WWWIncreased confidentiality.Easy to use within schedule.Low costs per capita involvement.Addresses public health nature of trauma.Military would utilize evidence based treatments for adaptation, coping, & recovery.
DesignRCT with a wait-list control group
2:1 ratio to IIG or a DIG
Based on EBPs, so likely to be of benefit.
Anonymous web-based treatment.
Amazon.com gift codes for assessments.
RECRUITMENT
The Facebook CampaignConcerns about security led to Facebook
Facebook allowed us to track if people came from correct link and, combined with IP address, they were likely to be legitimate participants.
Cost = $30 per randomized participant.
Sample Facebook Ads• Seen by at
least 317,000 users likely to be returning veterans, over 43 recruiting days.
• $30 per subject ($1.27 per click, $17,964 total)
Drinking and Alcohol-Related Outcomes
* p < .001
* *
*
PTSD Symptom Changes
33
35
37
39
41
43
45
Time 1 Time 2
PCL5 Total Scores *
IIG
DIG
* p < .001
Occasional case against broad dissemination and implementation to
generalist providers
We must be cautious against putting all of our eggs in the broad dissemination and implementation basket– What about complex EBPs?– What about EBPs for low base rate disorders?
Need for a Specialty Behavioral Telehealthworkforce, transacting with the generalist practitioner workforce
See Comer & Barlow, in press, American Psychologist
Telehealth
The use of electronic media to facilitate real-time interactions for the provision of care usually delivered in person
Internet-delivered treatmentMay expand the reach of expert mental health careExtend availability of expert servicesOvercome geographic barriers to care; Address regional workforce shortages in care
• Families dwelling in rural or impoverished regions can participate in real-time treatment conducted by experts, regardless of geographic proximity to a clinic
• May enhance ecological validity
• May overcome issues of stigma
Internet-delivered PCITInstead of:
We do:
Empirically examining direct-to-consumer advertising
• DTC marketing has been utilized for many years in the U.S.• Similar mechanisms are not in place to inform the public about
effective psychological treatments.• A recent randomized controlled study examined the preliminary
utility of direct-to-consumer (DTC) advertising of psychological treatments Participants who were randomized to a marketing campaign for psychological treatments demonstrated increases from baseline in newly considering and intending psychological treatments (as compared to participants randomized to a marketing campaign for drug interventions or to a control condition).
• (Gallo, Barlow, Clarke, Antony, and Comer, in preparation).
Thank you for your attention