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Evidence-Based Psychiatric Practice? Long Live the (Individual) Difference

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Evidence-Based Psychiatric Practice? Long Live the (Individual) Difference Isr J Psychiatry Relat Sci Vol 44 No. 4 (2007) 301–308 Evidence-Based Psychiatric Practice? Long Live the (Individual) Difference Nirit Soffer, BA,1 and Golan Shahar, PhD1, 2 1 Department of Behavioral Sciences, Ben-Gurion University of the Negev, Beersheba, Israel 2 Department of Psychiatry, Yale University School of Medicine, New Haven, Connecticut, U.S.A.. Abstract: Mental health services in Israel are about to undergo a major, and quite controversial, reform. Yet both those advocating these reforms and those opposing them refrain from resorting to empirical science in arguing their respec- tive cases. In the present article, we present findings concerning the central role of patients’ individual differences in the outcome of mental health services. Data is presented from three research projects: 1. The National Institute of Mental Health (NIMH) Treatment of Depression Collaborative Research Program (TDCRP), in particular recent publications by Blatt, Zuroff, Shahar and their collaborators, 2. The Partnership Project in severe mental illness, and 3. The Menninger Psychotherapy Research Project (MPRP). Findings from these three projects, largely predicted by Blatt’s theory of interpersonal relatedness and self-definition, suggest that an effective, evidence-based mental health practice is contingent upon practitioners’ sensitivity to pretreatment patient characteristics. Clinical and policy impli- cations of this conclusion are discussed. Mental health services in Israel are about to undergo cent decades in empirically-validated forms of psy- a major reform. With this reform, responsibility for chotherapy and psychopharmacology for various mental health services will shift from the govern- psychiatric disorders. The knowledge attained mental Department of Health to private health man- through research could have been conducive to re- agement organizations (HMOs). The above- solving at least some of the controversies surround- mentioned reform is meant to decrease hospitaliza- ing the Israeli reform. For example, given the tion rates and reduce stigma. Nevertheless, the re- demonstrated efficacy of Cognitive-Behavioral form is highly controversial. For instance, the Israeli Treatment (CBT) for various anxiety disorders such Psychological Association as well as the clinical psy- as Panic Disorder, Obsessive-Compulsive Disorder, chology division of the Israeli Council of Psycholo- Post-Traumatic Stress Disorder, and others, one gists strongly object to this reform, arguing that it would expect reform designers to ensure adequate will seriously compromise the delivery of psycholog- coverage for CBT in these disorders. Unfortunately, ical interventions (e.g., psychotherapy) which will in the number of psychotherapy sessions to be covered turn impede the quality of mental health treatment. by HMOs under the new reform is even considerably Several social work organizations expressed similar lower than the number suggested by Randomized concerns (1). Conversely, consumer organizations Clinical Trials (RCTs) demonstrating the efficacy of appear to be highly in favor of the upcoming reform, CBT in anxiety disorders. particularly because they believe that the reform is Further complicating this issue is recent scientific likely to reduce stigmatization (2). criticism regarding RCTs in mental health practice Conspicuously absent, however, in the debate (e.g., 3, 4), including (1) these trials’ exclusion of over the upcoming reform is the voice of empirical comorbid cases, thereby severely limiting the ecolog- science. Specifically, both those advocating the re- ical validity of the tested treatments, (2) the trials’ form and those objecting to it do not base their argu- disregard for patients’ treatment preferences, which ments on currently available data on the outcome of has been recently demonstrated to play a key role in various mental health treatments. This is highly un- treatment, and (3) the distinct brevity of manualized fortunate given the important advances made in re- treatment which, at least in the case of unipolar de- Address for Correspondence: Nirit Soffer, Department of Behavioral Sciences, Ben-Gurion University of the Negev, Beersheba 84105, Israel. E-mail: [email protected] 302 EVIDENCE-BASED PSYCHIATRIC PRACTICE? LONG LIVE THE (INDIVIDUAL) DIFFERENCE pression, impedes outcome (4). In the present arti- uations of patients were conducted throughout the cle, we would like to address another important study (at pretreatment and every 4-week interval), as limitation: RCTs’ disregard for the role of patients’ wellasthreefollow-upmeasurementsat6,12,and pretreatment characteristics in treatment outcome 18 months. This large-scale project, consisting of (4). Such disregard goes counter to an established over 200 seriously depressed patients, and 28 experi- tradition in psychotherapy research, dating back to enced, well-trained clinicians, was carefully imple- the great methodologist, Lee Cronbach (5), who mented. Patient assessments included an extensive urged investigators to be attuned to Treatment-Apti- battery of self-report and interview-based measures tude Effects, i.e., to the effects of patients’ pretreat- of symptoms, personality, attitudes and social con- ment characteristics. Other theoreticians and text variables. investigators have highlighted the important role of Initial results focusing on differences between the patients’ individual differences in the treatment pro- three active treatments were largely disappointing, cess (6, 7), but until recently, these qualifications in that such differences were not detected (8). How- were largely ignored in the zeal to conduct “horse ever, further analyses (for a review, see 4) revealed race” studies comparing the efficacy of several treat- the significance of patient pretreatment personality ments. characteristics in predicting therapeutic outcome. In what follows, we will illustrate the crucial role Using the Dysfunctional Attitudes Scale (DAS)(9), of patients’ pretreatment characteristics in three Blatt and his colleagues were able to isolate patients’ major clinical studies: the Treatment of Depression pretreatment perfectionism and to demonstrate that Collaborative Research Project (TDCRP) sponsored this personality trait predicted treatment outcome by the National Institution of Mental Health, which according to several measures. focused on the treatment for major depression, the Thus, Blatt et al. (10) found that high levels of Partnership Project (TPP), which focused on a part- pretreatment perfectionism significantly impeded nership-based community intervention for people consequent symptom reduction among two-thirds with severe, and largely psychotic, mental illness, of patients in the study. Specifically, it was shown and the now classic Menninger Psychotherapy Re- that during the first half of treatment (initial 8 search Project (MPRP) in which classical psycho- weeks), all patients generally had a decrease in symp- analysis and supportive-expressive psychotherapy tomatic maladjustment, whereas in the second half were compared. After presenting the findings attest- of treatment (9 to 16 weeks), those patients with high ing to the importance of patients’ individual differ- or medium perfectionism ceased to improve signifi- ences in the treatment process, we will discuss cantly in symptom reduction, while low-perfection- implications of these findings to clinical practice and ism patients continued to improve. As argued by mental health policy. Blatt and Zuroff (4), introjective, self-critical, con- trol-focused, perfectionist patients are likely to react negatively to a pre-defined, externally determined The Treatment of Depression treatment termination date and review their degree Collaborative Research Project (TDCRP) of improvement pessimistically in prospect of this The TDCRP is perhaps the most well known Ran- uncontrollable cessation of therapy. domized Clinical Trial (RCT) for the treatment of In addition to symptom reduction, another im- unipolar depression. It was sponsored by the Ameri- portant outcome variable is the quality of the thera- can National Institute of Mental Health (NIMH). peutic alliance. Zuroff et al. (11) found that Data from this project consists of four conditions for pretreatment perfectionism significantly interfered treatment of severe depression. Two conditions are with patients’ participation in the therapeutic alli- active, brief (16-week) outpatient psychotherapies ance during the latter half of treatment, in turn lead- for depression: Cognitive-Behavioral (CBT) and In- ing to failure to respond to this treatment. terpersonal therapy (IPT). The third condition is an- Nevertheless, the path leading from pretreatment tidepressant medication (Imipramine) and the perfectionism to poor response to treatment via the fourth, a double-blind placebo. Comprehensive eval- therapeutic alliance did not account for the entire NIRIT SOFFER AND GOLAN SHAHAR 303 deleterious effect of pretreatment perfectionism on ventory (BDI)(15), the total score on the Hopkins treatment outcome. In an attempt to account for the Symptoms Checklist-90 (SCL-90)(16), the 17-item entire effect, Shahar et al. (12) found another equally Hamilton Rating Depression Scale (HRDS)(17), the important mechanism of the adverse effect of perfec- Global Assessment Scale (GAS)(18), and the sum of tionism: patients’ social network. Specifically, these the global ratings from the Social Adjustment Scale investigators found that patients’ pretreatment per- (SAS)(19).
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