Evidence-Based Practice: What is it? Why Should We … Practice: What is it? ... False beliefs about...

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Evidence-Based Practice: What is it?

Why Should We Care?

Jason J. Washburn, Ph.D., Jason J. Washburn, Ph.D., ABPPABPPCenter for EvidenceCenter for Evidence--Based PracticeBased Practice

What isEvidence-Based Practice?

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Some definitions

“The conscientious, explicit, and judicious use of the current best evidence in making decisions

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about the care of individual patients”

-Sackett et al., (2000)

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Some definitions

“Integration of best research evidence with clinical expertise and patient values”

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-Institute of Medicine (2001)

Some definitions

“Integration of the best available research with clinical expertise in the context of patient

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characteristics, culture, and preferences”

-APA (2005)

National Association of Social Workers, SSW Standards (2012)

Standard 4. Intervention

School social workers shall understand and use evidence-informed practices in their interventions

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evidence informed practices in their interventions

School social workers shall remain current with school-based intervention research and use evidence-informed practices in service delivery.

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Best available research evidence

Clinical DecisionClinical Decision--MakingMaking

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Patient’s values, characteristics, and

circumstances

Clinical Expertise

Haynes, Devereaux, and Guyatt, 2002; Spring, 2011


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What are the relevant research findings?

What is the quality of the research? Use systematic reviews

Learn how to evaluate research quality

Is the research relevant to your patient?


What are your existing skills and resources?

Do you have the skills to use best-evidence model?

Is training and/or supervision available?

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Clinical Expertise


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Is the best-evidence model(s) : Applicable to the characteristics of this patient?

Acceptable to this patient?

Likely to succeed with this patient?

What are your patient’s values and preferences?

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circumstances


Clinical DecisionClinical Decision--MakingMaking

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circumstances

Clinical Expertise

gg


But it works? So who cares?

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Consumer Reports Study

2,900 subscribers 37% psychologists

22% psychiatrists

14% social workers

9% marriage counselors

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9% marriage counselors

18% other MH professionals

Results: Most reported getting better

• 87-92% reported improvement

Long-term better than short-term therapy

CR results

Results continued… Psychologists, psychiatrists, and social workers did

better than marriage counselors

Family doctors fine in the short-term, not long-term

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AA better than anyone

“No specific modality of psychotherapy did any better than any other for any problem”

• Dodo bird hypothesis

Those with insurance limitations did worse

“Everyone has won, so all must have

prizes!”

Problems with the CR study

Non-random Likely biased sample

Cognitive dissonance = positive bias

Regression to the mean

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Regression to the mean No control group

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The Role of Evidence…

Evidence-Based Medicine Movement

Evolution: Does psychotherapy work?

Empirically-Validated Treatment

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Empirically Validated Treatment

Empirically-Support Treatments

Evidence-Based Practice

The First Evidence-Based Medicine

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1910 - Flexner report

1972 - Archie Cochrane: Effectiveness and Efficiency: Random Reflections on Health Services

1973 John Wennberg: widespread unwarranted practice variation

History of EBMBecause resources are limited, Because resources are limited, they should be used to provide they should be used to provide equitably those forms of health equitably those forms of health care which had been shown in care which had been shown in

properly designed evaluations to be properly designed evaluations to be effective. effective.

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1973 – John Wennberg: widespread, unwarranted practice variation

1985 – IOM: 15% medical practices evidence-based

1992 – Cochrane Collaboration

1997 – How to Read a Paper: The Basics of Evidence-Based Medicine

2000- Sackett - How to Practice and Teach EBM

Spring, 2011

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EBP in Mental Health

1995: First EBP Psychiatry article in Canadian Journal of Psychiatry

1998: Evidence-Based Mental Health Journal

2001: Volume in Psychiatric Services devoted to EBP

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2005: Adoption of EBP policy by American Psychological Association

2012: NASW, Standards for School Social Work Services

The Research Practice Gap

10-15 year gap between research & practice“Despite substantial evidence documenting

the efficacy of numerous treatments for mental and substance-use problems and illnesses, mental and/ or substance-use

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,health care (like all health care) often fails to provide care consistent with this evidence” IOM (2006)

False beliefs about EBP

• Manualized or “cookbook” approach to treatment

• All about cutting costs

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• All about cutting costs

• Must rigidly follow treatment guidelines and pathways

• Dictates my practice from the “top-down”

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Connie Sensus

Connie sought treatment for anxiety.Her counselor, recently trained in anEBP for anxiety, began to apply thetreatment to Connie’s anxiety.Connie participated in the sessions,but did not find them helpful; indeed,the enthusiastic counselor was so

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the enthusiastic counselor was soexcited about implementing the newtherapy, she never got thebackground to Connie’s anxiety (ie.,sexual assault). Rather thandisappoint her counselor, shereported that she was better and lefttreatment.

Koocher et al., 2008

Non-EBP Approaches

• Eminence-based medicine

• Eloquence-based medicine

• Vehemence-based medicine

• Nervousness based medicine

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• Nervousness-based medicine

Typical Non-EBP Approaches

• Training from graduate school

• Clinical experience

• Uncritical acceptance of the results of one study

• Over-reliance on expert opinion

• Approaches that are nicely packaged

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• Approaches that are nicely packaged

• Approaches that are easiest to do

• Cure-alls

• Propaganda from Pharmaceutical companies

• Unfounded beliefs

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Sammy Soggy

Sammy Soggy has had nighttimebedwetting accidents for 4 yearssince he was trained at age 2.Accidents have increased since thebirth of a sibling. Dr. Seymour

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g yToodoo, an analyst, advisesSammy’s parents that his enuresisrepresents displaced aggressiontied to sibling rivalry, andrecommends psychodynamictherapy 3Xs per week.

Koocher et al., 2008

5 steps of EBP

a question

Outcome

Treatment

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evidence for answers

evidence for quality and relevance

the evidence

Spring, 2008

Ask a Question

Ask client-oriented, relevant, answerable questions

Distinguish between background (general) and foreground (specific) questions

Formulate foreground questions using a structured framework: PICO

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Patient/Population characteristics

Intervention

Comparison condition

Outcome

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Ask a Question: PICO

What is the patient and/or problem you want an answer to? “In patients with depression…

What is the intervention you are interested in does adding psychotherapy to pharmacotherapy,

C t l lt ti t t t

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Control or alternative treatment when compared to pharmacotherapy alone,

Outcome of interest prevent relapse?”

Ask a Question

Prioritize questions by the importance/significance of the problem

Distinguish between different types of questions Assessment

Intervention

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Prevention, Response, Remission, Recovery, Relapse Prevention

Prognosis

Harm

Cost-effectiveness

Know the best type(s) of evidence to answer each kind of question

Acquire the Evidence

Find the best available evidence to answer your question

Primary research

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Secondary (synthesized) research evidence

• Critical registry and listings

• Critical synthesis of secondary research

Guidelines & practice parameters

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Acquire the Evidence: Primary

PubMed (free) http://www.ncbi.nlm.nih.gov/pubmed/

PsychInfo ($) http://www.apa.org/pubs/databases/psycinfo/index.aspx

Individual Journal Subscriptions:

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Individual Journal Subscriptions: Archives of General Psychiatry

American Journal of Psychiatry

Journal of Consulting and Clinical Psychology

Clinical Psychology Review

Psychological Medicine

Journal of Clinical Psychiatry

Clinical Psychology Review

Evidence-Based Mental Health

Acquire the Evidence: Secondary

SAMHSA’s National Registry of Evidence-based Programs and Practice http://nrepp.samhsa.gov/

AHRQ’s National Guideline Clearninghouse

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AHRQ s National Guideline Clearninghouse http://www.guideline.gov/

Hawaii’s Department of Health: http://hawaii.gov/health/mental-

health/camhd/library/webs/ebs/ebs-index.html

Society of Clinical Child & Adolescent Psychology http://effectivechildtherapy.com/

Acquire the Evidence: Secondary

Cochrane Summaries http://summaries.cochrane.org/

DARE http://agatha.york.ac.uk/darehp.htm

BMJ E id C t

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BMJ Evidence Centre http://group.bmj.com/products/evidence-centre

TRIP database http://www.tripdatabase.com/

SUMSearch http://sumsearch.org/

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Acquire the Evidence: Guidelines & Practice Parameters

American Psychiatric Association http://www.psych.org/psych_pract/treatg/pg/prac_guide.cfm

American Academy of Child & Adolescent Psychiatry

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http://www.aacap.org/cs/root/member_information/practice_information/practice_parameters/practice_parameters

American Psychological Association http://www.apapracticecentral.org/ce/guidelines/index.aspx

Example:Postnatal Depression at BMJ’s Clinical

Evidence

SSRIs may improve symptoms of postnatal depression, but we found few studies evaluating their effect specifically in postpartum women.

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We don't know whether other types of antidepressant are effective compared with placebo or psychological treatments.

We don't know whether oestrogen treatment or St John's Wortimprove symptoms compared with placebo.

ExamplePostnatal Depression at BMJ’s Clinical

Evidence

Psychological treatments such as individual CBT, non-directive counselling, interpersonal psychotherapy, and psychodynamic therapy are likely to improve symptoms

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compared with routine care, but long-term benefits are unclear

We don't know whether light therapy, group CBT,psychoeducation with the partner, mother–infant interaction coaching, telephone-based peer support, infant massage,or physical exercise improve symptoms of postnatal depression as we found few studies

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Appraise the Evidence

Is the study valid? Was it a randomized controlled trial?

Was the randomization list concealed?

Were subjects and clinicians blinded?

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Were all subjects accounted for?

Was intention-to-treat analysis used?

Despite randomization, were the groups dissimilar?

Aside from the experimental treatment, were the groups treated equally?

Appraise the Evidence: Pyramid

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AHRQ: Levels of Evidence1++: High quality meta-analyses, systematic reviews of randomized clinical

trials, or high-quality clinical trials with a very low risk of bias.

1+: Well conducted meta-analyses, systematic reviews, or randomized clinical trials with a low risk of bias.

1-: Meta-analyses, systematic reviews of clinical trials, or clinical trials with a high risk of bias.

2++: High quality systematic reviews of cohort studies or case control studies or

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2++: High quality systematic reviews of cohort studies or case-control studies or high-quality diagnostic test studies, high-quality cohort studies or case-control studies of diagnostic tests with a very low risk of bias and a high probability that the relationship is causal.

2+: Well conducted cohort studies or case-control studies or diagnostic test studies with a low risk of bias and a moderate probability that the relationship is causal.

2-: Cohort studies or case-control studies with a high risk of bias.

3: Non-analytical studies, such as case reports and case series.

4: Expert opinion.

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AHRQ: Strength of Recommendation

A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), rated as 1++, and directly applicable to the target population, or sufficient evidence derived from level 1+ studies that are directly applicable to the target population and that demonstrate overall consistency of results.

B: A body of evidence derived from level 2++ studies that are directly

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applicable to the target population and that demonstrate overall consistency of results. Extrapolated evidence from level 1++ or 1+ studies.

C: A body of evidence derived from level 2+ studies that are directly applicable to the target population and that demonstrate overall consistency of results. Extrapolated evidence from level 2++ studies.

D: Evidence level 3 or 4. Extrapolated evidence from level 2+ studies.

Good Clinical Practice: Recommended best practice based on the clinical experience and the consensus of the guideline development group.


Are the results important? How large is the treatment effect?

How precise are the results?

Types of effects

# of people needed to receive a treatment

before one person would

General term for the amount of change

produced by a treatment

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Types of effects Effect Size

Number Needed to Treat

Odds Ratio

Hazard Ratio

experience a beneficial or harmful outcome

The ratio of the odds of an event in one group to the odds of an event in

another groupThe increased risk that one group is likely to

experience an outcome


Can I apply the results to my patient? Is my patient too different from those in the

study?

Is the treatment consistent with my patient’s

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Is the treatment consistent with my patient s values and preferences?

Is the treatment feasible in my setting?

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Apply the Evidence

Integrate appraisal of the evidence with: Available expertise and resources

Patient’s characteristics, values, preferences, and context

Engage in collaborative decision making

Decide on an approach

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Decide on an approach

Self-assess skills

If needed: Locate training and supervisory resources

Learn new interventions

Update skills

Analyze and Adjust

Practice-based continuous quality improvement

Assess process & outcomes Compare change to published findings

Evaluate process & outcomes measurements

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Evaluate process & outcomes measurements Compare change to benchmarks, published findings

Adjust treatment if needed Adjust for specific patients

Adjust overall approach

Adjust programming

Analyze and Adjust

What do you measure?

Outcomes• Symptoms, Functioning, Quality of life

Process

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• Common Factors

– e.g., Therapeutic relationship/alliance, Motivation, positive expectancies (hope), social support

• Specific Factors

– E.g., Cognitive distortions, behavioral activation, interpersonal relationships, insight,

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Alliance Interventions

Concerns with Therapeutic

Alliance?Yes

No

Motivation Interventions

Problems with Motivation? Yes

No


•Discuss alliance with patient

•Give and ask for feedback on relationship

•Spend more time exploring patient’s experience

•Discuss shared experiences

•Reassess/agree on therapeutic


•Discuss readiness to change with patient

•Give and ask for feedback about readiness for change

•Adjust goals and tasks to be challenging but not too

•difficult

Social Support Interventions

•Refer to group therapy

•Refer to biofeedback treatment

•Refer to assertiveness training

•Role play social situations

•Assign related homework

•Assess patient’s self beliefs

•Bring others to sessions

Modify Treatment Plan

•Have I missed something?

•Is my target sequence off?

•Is there a more effective treatment option?

•Am I doing the treatment correctly?

•Is medication or a medication change necessary?

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No

Social Support

Interventions

Inadequate Social

Support?Yes

No

Modify Treatment

Plan

Inaccurate Formulation? Yes

tasks and goals

•Clarify possible misunderstandings

•Give more positive feedback

•Use more empathic engagements

•Discuss therapist and therapeutic style match

•Process transference

Whipple & Lambert, 2011

•Discuss consequences of changing or not changing

•Discuss the processes involved with change and specific

•skills that help

•Bring others to sessions

•Encourage activities with others (e.g., family, friends,

•significant others

•Work on concerns related to trusting others

•Encourage greater involvement in organizations characterized by social interaction (e.g., clubs)

Outcome Systems

Outcome Questionnaire-45/30 ($) Symptoms

Interpersonal problems

Social role functioning

Assessment for Signal Caseshttp://www oqmeasures com

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Therapeutic relationship

Social support network

Patient motivation

Youth-Outcome Questionnaire-64 Interpersonal Distress, Somatic, Intrapersonal Relations, Critical

Items, Social Problems, Behavioral Dysfunction

http://www.oqmeasures.com

Outcome Systems

Clinical Outcomes in Routine Evaluation-34 (free) Subjective well-being

Problems/symptoms

Life functioning

http://www.coreims.co.uk/

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Risk/harm

Treatment Outcome Package (free -> $$) Multidimensional

• Depression, anxiety, bipolar, SUD, ADHD, psychosis, eating disorders, elimination, insomnia, suicide, violence,

• Quality of Life, work/social/sexual functioning

• Assertiveness, strengths

www.bhealthlabs.com

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Outcome Systems

Partners for Change Outcome Management System ($) Outcome Rating Scale

Session Rating Scalehttps://www.myoutcomes.com/

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Outcome Systems - Child

Peabody Treatment Progress Battery (free) Treatment Progress:

• Symptoms & Functioning

• Life Satisfaction

• Hope

Treatment Process:

peabody.vanderbilt.edu/ptpb

http://cfsystemsonline.com/

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Treatment Process: • Therapeutic Alliance

• Treatment Motivation

• Treatment Expectancies

• Service Satisfaction

• Perceived Session Impact

• Caregiver Strain

• Life Satisfaction

p y

General Outcome Measures

Behavior and Symptom Identification Scale ($) http://www.basissurvey.org/

Symptom Checklist-90-Revised ($) http://www pearsonassessments com/tests/scl90r htm

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http://www.pearsonassessments.com/tests/scl90r.htm

Brief Symptom Inventory ($) www.pearsonassessments.com/tests/bsi.htm

Short Form Health Survey ($) http://www.sf-36.org/

Sheehan Disability Scale (Free) http://www.cqaimh.org/pdf/tool_lof_sds.pdf

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Outcome Measures - Child

Pediatric Symptom Checklist (free) http://www2.massgeneral.org/allpsych/psc/psc_home.ht

m

Strengths & Difficulties Questionnaire (free)

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http://www.sdqinfo.com/

Child Behavior Checklist ($) http://www.aseba.org/

Behavior Assessment System for Children ($) http://ags.pearsonassessments.com/

Specific Symptom Measures

Depression & Anxiety Patient Health Questionnaire – 9 (free)

• http://www.phqscreeners.com

Inventory of Depressive Symptomatology (free)• http://www.ids-qids.org/

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Hamilton Rating Scale for Depression (free)• http://healthnet.umassmed.edu/mhealth/HAMD.pdf

Generalized Anxiety Disorder Assessment – 7 (free)• http://www.phqscreeners.com

Beck Depression & Anxiety Inventories ($)• http://www.pearsonassessments.com


OCD Yale—Brown Obsessive Compulsive Scale (free)

• http://healthnet.umassmed.edu/mhealth/YBOCSymptomChecklist.pdf

Dimensional Obsessive-Compulsive Scale (free)htt // d / j b /DOCS ht l

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• http://www.unc.edu/~jonabram/DOCS.html

Substance Abuse Alcohol Use Disorders Identification Test (free)

• http://www.cqaimh.org/pdf/tool_auditc.pdf

CAGE-AID (free)• http://www.cqaimh.org/pdf/tool_cageaid.pdf

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Eating disorders Eating Disorder Examination (free)

• http://www.psychiatry.ox.ac.uk/research/researchunits/credo

Eating Attitudes Test – 26 (free?)• http://eat-26.com/

ADHD: Adult AD HD Self Report Scale (free)

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ADHD: Adult AD HD Self-Report Scale (free) http://www.hcp.med.harvard.edu/ncs/ftpdir/adhd/18%20Question

%20ADHD-ASRS-v1-1.pdf


Psychosis: Brief Psychiatric Rating Scale (free) http://medicaidmentalhealth.org/files/RelatedLiterature/BPRS_Q

uest2010100709182563.pdf

http://www.public-

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health.uiowa.edu/icmha/outreach/documents/BPRS_expanded.PDF


Bipolar Disorder Altman Self-Rating Mania Scale (free)

• http://www.cqaimh.org/pdf/tool_asrm.pdf

Mood Disorder Questionnaire (free)

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• http://www.cqaimh.org/pdf/tool_mdq.pdf

Young Mania Rating Scale (free)• http://dcf.psychiatry.ufl.edu/files/2011/05/Young-Mania-

Rating-Scale-Measure-with-background.pdf

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Suicide Suicide Behaviors Questionnaire-Revised

• http://www.cqaimh.org/pdf/tool_sbq-r.pdf

Suicidal Ideation and Risk Level Assessment:

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• http://www.cqaimh.org/pdf/tool_suicide_risklevl.pdf

5 steps of EBP

a question

Outcome

Treatment

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evidence for answers

evidence for quality and relevance

the evidence

Treatment

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EXAMPLES

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Simple Example: Depression

34 year-old woman with Major Depressive Disorder IDS-SR = 33 (Moderate)

HAM-D = 19 (Moderate, close to Severe)

First onset

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No co-occurring disorders Some marital problems

Some interpersonal problems at work and with extended family


Ask the Question: For an adult woman with Major Depressive Disorder,

what psychotherapy is the most effective in reducing symptoms?

P Ad lt W MDD

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• P = Adult Woman, MDD

• I = Psychotherapy

• C = Vs. other psychotherapies

• O = Reducing symptoms


Acquire the Evidence: Primary: PubMed:

• Search Terms: depression therapy meta-analysis

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Cognitive therapy might be an effective treatment for Cognitive therapy might be an effective treatment for depression measured on Hamilton Rating Scale for depression measured on Hamilton Rating Scale for

Depression and Beck Depression Inventory, but these Depression and Beck Depression Inventory, but these outcomes may be overestimated due to risks of systematic outcomes may be overestimated due to risks of systematic

errors (bias) and random errors (play of chance). errors (bias) and random errors (play of chance). Furthermore, the effects of cognitive therapy on no Furthermore, the effects of cognitive therapy on no

remission, remission, suicidalitysuicidality, adverse events, and quality of life , adverse events, and quality of life are unclear. There is a need for randomized trials with low are unclear. There is a need for randomized trials with low

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risk of bias, low risk of random errors, and longer followrisk of bias, low risk of random errors, and longer follow--up up assessing both benefits and harms with clinically relevant assessing both benefits and harms with clinically relevant

outcome measures.outcome measures.


Acquire the Evidence: Secondary: AHRQ Website:

• Search Term: “depression”

• Working Group on the Management of Major Depression in Ad lt Cli i l ti id li th t f

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Adults. Clinical practice guideline on the management of major depression in adults. Madrid: Ministry of Health and Consumer Affairs, Galician Health Technology Assessment Agency (HTA) (avalia-t); 2008. 120 p.

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AHRQ: Major Recommendations

In mild and moderate depression, specific and brief psychological treatment (such as problem-solving therapy, cognitive behavioural therapy, or counselling) in 6 to 8 sessions during 10 to 12

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weeks should be considered (Strength of Recommendation B).

The preferred psychological treatment for moderate, severe, or resistant depression is cognitive behavioural therapy. Interpersonal therapy can be considered as a reasonable alternative (Strength of Recommendation B).


For moderate and severe depression, suitable psychological treatment should include 16 to 20 sessions during at least 5 months (Strength of Recommendation B).

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For moderate depression, either antidepressant drug treatment or suitable psychological intervention can be recommended (Strength of Recommendation B).


Cognitive behavioural therapy should be offered to patients with moderate or severe depression who reject drug treatment or for whom avoiding the secondary effects of antidepressants is a clinical

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priority or who express that personal preference (Strength of Recommendation B).

Couples therapy should be considered, if applicable, in the event that a suitable response is not obtained with previous individual intervention (Strength of Recommendation B).

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Cognitive behavioural therapy should be considered for patients who have: not had a suitable response to other interventions or who may

have a prior history of relapses or residual symptoms, despite

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treatment (Strength of Recommendation B).

recurrent depression and who have relapsed despite antidepressant treatment or who express a preference for psychological treatment (Strength of Recommendation B).


For patients whose depression is resistant to pharmacological treatment and/or who have multiple episodes of recurrence, a combination of antidepressants and cognitive behavioural therapy should be offered

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g py(Strength of Recommendation A).

A combination of cognitive behavioural therapy and antidepressant medication should be offered to patients with chronic depression (Strength of Recommendation A).


Whenever cognitive behavioural therapy is applied to more severe patients, the techniques based on behavioural activation should be given priority (Strength of Recommendation C).

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)

Psychological interventions other than the aforementioned could be useful for dealing with comorbidity or the complexity of the family relationships frequently associated with the depressive disorder (Strength of Recommendation C).

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A: At least one meta-analysis, systematic review of randomized controlled trials (RCTs), rated as 1++, and directly applicable to the target population, or sufficient evidence derived from level 1+ studies that are directly applicable to the target population and that demonstrate overall consistency of results.

B: A body of evidence derived from level 2++ studies that are directly applicable to the target population and that demonstrate overall consistency of results Extrapolated evidence from level 1++ or 1+

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consistency of results. Extrapolated evidence from level 1++ or 1+ studies.

C: A body of evidence derived from level 2+ studies that are directly applicable to the target population and that demonstrate overall consistency of results. Extrapolated evidence from level 2++ studies.

D: Evidence level 3 or 4. Extrapolated evidence from level 2+ studies.

Good Clinical Practice: Recommended best practice based on the clinical experience and the consensus of the guideline development group.

Apply: Match Evidence to Patient

Moderate-to-Severe: CBT or IPT, 16 to 20 sessions for at least 5 months

Consider starting with behavioral activation

First episode Hold off on antidepressant medication

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Hold off on antidepressant medication

Marital problems: Consider couples therapy if individual is not effective

Interpersonal Problems: interpersonal effectiveness skills training (DBT), Consider

intepersonal approaches (IPT), brief psychodynamic transference-based therapies

Apply: Resources

Prior Training

Books & Manuals

Training ABBHH Certificate program with Art Freeman:

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ABBHH Certificate program with Art Freeman: Cognitive-Behavioral Therapy (CBT) Treatment for Different Disorders, Populations, Modalities, & Settings

Supervision & Consultation

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Analyze & Adjust

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Analyze & Adjust

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Concerns with Therapeutic

Alliance?Yes

No


Problems with Motivation? Yes

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No

Social Support

Interventions

Inadequate Social

Support?Yes

No

Modify Treatment

Plan

Inaccurate Formulation? Yes

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More Complex Example

28 year-old male with PTSD and Substance Abuse PTSD Checklist - Civilian = 74 (cutoff = 50)

• http://www.ncdhhs.gov/mhddsas/providers/DWI/dualdiagnosis/PCL%20(PTSD).pdf

AUDIT S 22 ( t ff 20)

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AUDIT Screener = 22 (cutoff = 20)

Recurrent; onset at age 19

Numerous functional impairments Unemployed

Divorced

Minimal sober social support

Ask the Question

For an adult man with recurrent Alcohol Dependence and PTSD, what psychotherapy is the most effective in improving functioning and preventing relapse?

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P = Adult Male, Alcohol Dependence with co-occurring PTSD

I = Psychotherapy

C = Vs. other psychotherapies

O = Improving functioning and preventing relapse


Primary: PubMed: Search Terms: alcohol PTSD psychotherapy meta-analysis

• NOTHING

Search Terms: alcohol dependence PTSD treatment

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ParoxetineParoxetine did not show statistical superiority to did not show statistical superiority to desipraminedesipramine for the treatment of for the treatment of PTSDPTSD symptoms. symptoms.

However, However, desipraminedesipramine was superior to was superior to paroxetineparoxetine with with respect to study retention and alcohol use outcomes. respect to study retention and alcohol use outcomes.

NaltrexoneNaltrexone reduced alcohol craving relative to placebo, but reduced alcohol craving relative to placebo, but it conferred no advantage on drinking use outcomes. it conferred no advantage on drinking use outcomes.

Although the serotonin uptake inhibitors are the only FDAAlthough the serotonin uptake inhibitors are the only FDA--approved medications for the treatment ofapproved medications for the treatment of PTSDPTSD, the, the

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approved medications for the treatment of approved medications for the treatment of PTSDPTSD, the , the current study suggests that current study suggests that norepinephrinenorepinephrine uptake uptake

inhibitors may present clinical advantages when treating inhibitors may present clinical advantages when treating male veterans with male veterans with PTSDPTSD and and AD.AD. However, However, naltrexonenaltrexone did did

not show evidence of efficacy in this population. not show evidence of efficacy in this population.


Primary: PubMed: Search Terms: alcohol dependence PTSD psychotherapy

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PTSDPTSD severity reductions were more likely to be severity reductions were more likely to be associated with substance use improvement, with associated with substance use improvement, with

minimal evidence of substance use symptom reduction minimal evidence of substance use symptom reduction improving improving PTSDPTSD symptoms. Results support the selfsymptoms. Results support the self--

di ti d l f i ithdi ti d l f i ith PTSDPTSD t dt d

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medication model of coping with medication model of coping with PTSDPTSD symptoms and symptoms and an empirical basis for integrated interventions for an empirical basis for integrated interventions for

improved substance use outcomes in patients with improved substance use outcomes in patients with severe symptomssevere symptoms


Secondary: SAMHSA’s NREPP Website: Search Term: “PTSD substance abuse”

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Seeking Safety

Seeking Safety is a present-focused treatment for clients with a history of trauma and substance abuse. The treatment was designed for flexible use: group or individual format, male and female clients, and a variety of settings (e.g., outpatient, inpatient, residential). Seeking Safety focuses on coping skills and psychoeducation and has five key principles: (1) safety as the overarching goal (helping clients attain safety in their

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the overarching goal (helping clients attain safety in their relationships, thinking, behavior, and emotions); (2) integrated treatment (working on both posttraumatic stress disorder (PTSD) and substance abuse at the same time); (3) a focus on ideals to counteract the loss of ideals in both PTSD and substance abuse; (4) four content areas: cognitive, behavioral, interpersonal, and case management; and (5) attention to clinician processes (helping clinicians work on countertransference, self-care, and other issues).


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Reviewers use a scale of 0.0 to 4.0, with 4.0 being the highest rating given.


Secondary: AHRQ’s Clearinghouse Search Term: “PTSD substance abuse”

VA/DoD clinical practice guideline for management of post-traumatic stress (2008)

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AHRQ’s Recommendation

• Co-occurring mild to moderate disorders, such as substance use, pain disorders, and sleep problems, can frequently be effectively treated in the context of PTSDtreatment and do not require a referral to specialty care.

• Co-occurring severe psychiatric disorders, while not precluding concurrent PTSD treatment, typically justify

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referral to specialty care for evaluation and treatment. These disorders may include: severe major depression or major depression with suicidality, unstable bipolar disorder, severe personality disorders, psychotic disorders, significant TBI, and severe substance use disorder (SUD) or substance abuse of such intensity that PTSD treatment components are likely to be difficult to implement.

AHRQ’s Recommendation

• Patients with SUD and PTSD should be educated about the relationships between PTSD and substance abuse. The patient's prior treatment experience and preference should be considered since no single intervention approach for the co-

bidit h t d th t t t f

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morbidity has yet emerged as the treatment of choice.

• There is insufficient evidence to recommend for or against any specific psychosocial approach to addressing PTSD that is co-morbid with SUD.

• Treat other concurrent substance use disorders, including concurrent pharmacotherapy.


Cochrane Review Search Terms “PTSD and Substance Abuse”

Psychosocial interventions for people with both severe mental illness and substance misuse (2010)

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They used different psychosocial interventions, with They used different psychosocial interventions, with four trials using integrated models of care, four using four trials using integrated models of care, four using

nonnon--integrated, three combining Motivational integrated, three combining Motivational Interviewing (MI) and CBT, four using CBT, five using MI Interviewing (MI) and CBT, four using CBT, five using MI

and two using skills training... No trial showed any and two using skills training... No trial showed any definitive difference between the psychosocial definitive difference between the psychosocial

intervention and the usual treatment… There are also intervention and the usual treatment… There are also bl d b hi h d t t diff ibl d b hi h d t t diff i

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problems caused by high dropout rates, differences in problems caused by high dropout rates, differences in the outcome measures and dependability in the way the outcome measures and dependability in the way

psychological interventions were used. To allow more psychological interventions were used. To allow more thorough assessment of whether psychosocial thorough assessment of whether psychosocial

interventions work for people with substance abuse interventions work for people with substance abuse problems and severe mental illnesses, more quality problems and severe mental illnesses, more quality

trials are needed which address these problemstrials are needed which address these problems

Other Treatments*

Transcend 12 week PHP: skill development & trauma processing

Substance Abuse Rehabilitation within 6 months of starting

Evidence: 1 uncontrolled cohort study (Level 2; D)

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Concurrent Treatment of Posttraumatic Stress Disorder and Cocaine Dependence 16-session individual CBT for SA & exposure for PTSD


*National Center for PTSD Research Quarterly, Vol. 22(2), 2010

Other Treatments

Substance Dependence Posttraumatic Stress Disorder Therapy (Assisted Recovery from Trauma and Substances ) 40-session individual therapy; CBT for SA and stress-

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inoculation for PTSD

Evidence: 1 pilot RCT, but no difference from 12-step control

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Appraise the Evidence: Summary

No strong evidence-based treatment for co-occurring Substance Abuse = CBT, MI, 12-step

PTSD = exposure-based therapies

SA & PTSD??

Sequential vs. Concurrent vs. Integrative treatment?

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q g Some evidence supporting integrative

• E.g., Seeking Safety

• PubMed study

Some evidence supports self-medication hypothesis• PTSD drives SUD

Apply: Match Evidence to Patient

Recurrent PTSD & SA Integrative treatment

Use MI pre-treatment

Attempt Seeking Safety

If not enough, consider integrating:

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• Additional motivational enhancement

• CBT and Relapse Prevention for SA

• ERP for PTSD

Not a brief treatment Between 16-40 sessions

Consider specialty PHP level of care if non-responsive

Consider relapse prevention medication

Apply: Resources

Prior Training

Book & articles

Training http://www seekingsafety org/

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http://www.seekingsafety.org/

Supervision & Consultation

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Analyze & Adjust

60

70

80

90

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0

10

20

30

40

50

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

PTSD

SA

SeekySeeky SafetySafetyERPERP

Relapse Relapse PreventionPrevention

Why Should I adopt EBP?

EBP should result in: Improve quality and accountability

More effective and efficient

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More effective and efficient treatment

Less costly care

Less use of restrictive settings

Why Should I adopt EBP?

The EBP process helps to differentiate: Evidence from propaganda

(advertisement)

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Probability from certainty

Data from assertions

Rational belief from superstitions

Science from folklore

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Why should I adopt EBP?

EBP provides a RoadMap for: Staying current

Using the best available treatments

Maintaining effective in a clinical reality

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EBP is orientation agnostic! Sidesteps the religious fervor of theoretical orientations

Requires a pluralistic, evidence-based but reality-grounded approach to treatment

What gets in the way

Belief that it is “all about the relationship” Specific treatments/strategies are unimportant

Belief that evidence-based practices will conflict with a specific theoretical orientation

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Graduate training that did not emphasize psychotherapy research

Having many years of therapy experience!

Downsides of EBP

Takes extra time

Requires information resources

Available evidence is often limited But can only improve!

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But can only improve!

May need to pay for training & supervision

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What do you think? Ready to use it?

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Questions? Comments?

Jason J. Washburn, Ph.D., ABPP

[email protected]

Evidence-Based Practice: What is it? Why Should We … Practice: What is it? ... False beliefs about...

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