Clinical Psych 2
Term 3 Content
Evidence-based interventions
Background
Evidence based treatment/psychotherapy/practice/interventions…
A working definition
• Simply: any psychotherapy, intervention or mental health treatment which has been shown to be effective
• Shown = proof (evidence based on scientific research)
• Effective/efficacious = it works (it causes change that did not occur by chance or randomly)
Origins of the EB movement
• Concept of EB Practice has been around for a while
• But, as a medical movement was started in early 1980s by Canadian epidemiologist, David Sackett: 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
Origins of EB practice in psychology
• Research: most psychotherapies work for most people*
• Psychiatry guidelines tended to underplay the value of psychological treatments
• So EBT movement in psychology adopted the FDA evidence model
• Developed to give psychological treatments greater perceived validity
• Focus on brief, focal treatments for specific disorders
• Research showed impressive advancements
• But, gold standard of RCT (randomised control trials) retained as best evidence
Policy on EB practice in psychology
• 2006: APA released policy on EB practice in psychology: “This policy emphasizes integrating the best-available research
with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences”*
(emphases all mine)
• Policy intended to maximise patients’ choices about treatment
• Clinical choices for treatment can be framed in best evidence
• Best research evidence = data from a range of research methodology:
• meta-analyses
• randomised controlled trials
• effectiveness studies
• process studies
• single-case reports
• systematic case studies
• qualitative and ethnographic research
• clinical observation
Rabbit hole
• At the same time:
Increased recognition of the impact of mental disorders
• Studies showed common mental disorders (CMD) are highly prevalent
• Depression: leading cause of disability worldwide by 2030
, • Greater impairment from mental disorders
• And they are EXPENSIVE
- lost productivity
- lost income
- costs of treatment
• Access to care is NOT equal: Treatment gap of up to 90% in Low-and-Middle Income Countries (LMIC)
• Globally, lifetime rates of psychiatric disorders range from 12-47%
• SASH (Williams et al., 2008) showed 12 month prevalence rate of 16.5% for CMDs and a lifetime prevalence of 30.3%
(Herman et al., 2009)
• Depression projected to become leading cause of disability worldwide by 2030, ahead of cardiovascular disease, car
accidents, and HIV/AIDS.
• Mental disorders also lead to greater impairment than chronic medical disorders do.
• Direct and indirect costs to individuals, communities and economies are enormous.
• In SA, 23.6 days spent ‘out of role’; days when people are unable to work or carry out usual daily activities due to mental
illness (Mall et al., 2014)
• Loss of income for South Africans with CMDs has been calculated at US$4,798 annually: total annual cost of US$3.6
billion in lost income (Lund, Myer, Stein, Williams, & Flisher, 2012).
• South African health care expenditure reflects the country’s profound socio-economic inequalities, where public health
expenditure of US$150 per capita serves 84% of the population, while private expenditure is ten times as much serving
only 16% of South Africans (Benatar, 2013).
• In 2012, 8.8% of GDP allocated to total health expenditure, below the global average of 9.2% (Mcintyre, Doherty, &
Ataguba, 2014).
• Only R501m of South Africa’s (R4,5 trillion) state budget dedicated to mental health services
• means a ratio of 0.32 psychologists and 0.28 psychiatrists for every 100 000 people in public service (Lund, Kleintjes,
Kakuma, & Flisher, 2010b)
• AND in SA, treatment gap is 75% (SASH)
Global Mental Health movement:
• 2007: Global Mental Health (GMH) movement started to address global inequalities in mental health care and lack of
access to services
“The Movement for Global Mental Health is a virtual network of individuals and organisations that aim to improve services for
people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income
countries (LMIC) where effective services are often scarce. Two principles are fundamental to the Movement: scientific
evidence and human rights.”*
• Global network of agencies, NGOs, universities, government departments, Multinational research collaborations
• Produce international publications
• Host international conferences and congresses
• Advocacy in governments
• Involved in policy-making at national and global levels
• Two primary goals:
1. address human rights issues in mental health
2. only support interventions / programmes / treatments that are based on scientific evidence
, Remember – Best research evidence = data from a range of research
methodology: meta-analyses, randomised controlled trials, effectiveness
studies, process studies, single-case reports, systematic case studies,
qualitative and ethnographic research, clinical observation…
Criteria of EB psychotherapy according to Kazdin:
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 manualised intervention
4. Multiple outcome measures
5. Statistically significant effect size
6. Outcomes can be replicated
This is exactly the criteria of a randomised control trial. It reduces evidence based psychotherapy to RCT and not any of the other
forms. But this is flawed thinking.
Tau = treatment as usual
So then what does ‘evidence-based’ “really” mean?
Evidence = empirical data; data gathered using the ‘scientific method’
‘Evidence-based’ means interventions are supported by scientific research to consistently show improved outcomes: “Those
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” (Kagee & Lund, 2012, p.103)
Efficacy vs Effectiveness
Efficacy: evidence derived from trials where threat to internal validity is minimized
RCT considered ‘gold standard’
Enables researchers to establish cause and effect
EB treatment has become synonymous with efficacy
Effectiveness: performance under real-world conditions (doesn’t tell us how it will work for real life people with the genuine
issues. Should be tested on samples that are not so ‘clean’ as how can that claim to be truly effective)
Testing pharmacological treatments is a little different to testing psychotherapy
1) Clearly and carefully specifying patient population
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
But…
This is unrealistic! Intervention only shown to be effective for people with only that problem (and no others)
Term 3 Content
Evidence-based interventions
Background
Evidence based treatment/psychotherapy/practice/interventions…
A working definition
• Simply: any psychotherapy, intervention or mental health treatment which has been shown to be effective
• Shown = proof (evidence based on scientific research)
• Effective/efficacious = it works (it causes change that did not occur by chance or randomly)
Origins of the EB movement
• Concept of EB Practice has been around for a while
• But, as a medical movement was started in early 1980s by Canadian epidemiologist, David Sackett: 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
Origins of EB practice in psychology
• Research: most psychotherapies work for most people*
• Psychiatry guidelines tended to underplay the value of psychological treatments
• So EBT movement in psychology adopted the FDA evidence model
• Developed to give psychological treatments greater perceived validity
• Focus on brief, focal treatments for specific disorders
• Research showed impressive advancements
• But, gold standard of RCT (randomised control trials) retained as best evidence
Policy on EB practice in psychology
• 2006: APA released policy on EB practice in psychology: “This policy emphasizes integrating the best-available research
with clinical expertise in the context of the patient’s culture, individual characteristics, and personal preferences”*
(emphases all mine)
• Policy intended to maximise patients’ choices about treatment
• Clinical choices for treatment can be framed in best evidence
• Best research evidence = data from a range of research methodology:
• meta-analyses
• randomised controlled trials
• effectiveness studies
• process studies
• single-case reports
• systematic case studies
• qualitative and ethnographic research
• clinical observation
Rabbit hole
• At the same time:
Increased recognition of the impact of mental disorders
• Studies showed common mental disorders (CMD) are highly prevalent
• Depression: leading cause of disability worldwide by 2030
, • Greater impairment from mental disorders
• And they are EXPENSIVE
- lost productivity
- lost income
- costs of treatment
• Access to care is NOT equal: Treatment gap of up to 90% in Low-and-Middle Income Countries (LMIC)
• Globally, lifetime rates of psychiatric disorders range from 12-47%
• SASH (Williams et al., 2008) showed 12 month prevalence rate of 16.5% for CMDs and a lifetime prevalence of 30.3%
(Herman et al., 2009)
• Depression projected to become leading cause of disability worldwide by 2030, ahead of cardiovascular disease, car
accidents, and HIV/AIDS.
• Mental disorders also lead to greater impairment than chronic medical disorders do.
• Direct and indirect costs to individuals, communities and economies are enormous.
• In SA, 23.6 days spent ‘out of role’; days when people are unable to work or carry out usual daily activities due to mental
illness (Mall et al., 2014)
• Loss of income for South Africans with CMDs has been calculated at US$4,798 annually: total annual cost of US$3.6
billion in lost income (Lund, Myer, Stein, Williams, & Flisher, 2012).
• South African health care expenditure reflects the country’s profound socio-economic inequalities, where public health
expenditure of US$150 per capita serves 84% of the population, while private expenditure is ten times as much serving
only 16% of South Africans (Benatar, 2013).
• In 2012, 8.8% of GDP allocated to total health expenditure, below the global average of 9.2% (Mcintyre, Doherty, &
Ataguba, 2014).
• Only R501m of South Africa’s (R4,5 trillion) state budget dedicated to mental health services
• means a ratio of 0.32 psychologists and 0.28 psychiatrists for every 100 000 people in public service (Lund, Kleintjes,
Kakuma, & Flisher, 2010b)
• AND in SA, treatment gap is 75% (SASH)
Global Mental Health movement:
• 2007: Global Mental Health (GMH) movement started to address global inequalities in mental health care and lack of
access to services
“The Movement for Global Mental Health is a virtual network of individuals and organisations that aim to improve services for
people living with mental health problems and psychosocial disabilities worldwide, especially in low- and middle-income
countries (LMIC) where effective services are often scarce. Two principles are fundamental to the Movement: scientific
evidence and human rights.”*
• Global network of agencies, NGOs, universities, government departments, Multinational research collaborations
• Produce international publications
• Host international conferences and congresses
• Advocacy in governments
• Involved in policy-making at national and global levels
• Two primary goals:
1. address human rights issues in mental health
2. only support interventions / programmes / treatments that are based on scientific evidence
, Remember – Best research evidence = data from a range of research
methodology: meta-analyses, randomised controlled trials, effectiveness
studies, process studies, single-case reports, systematic case studies,
qualitative and ethnographic research, clinical observation…
Criteria of EB psychotherapy according to Kazdin:
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 manualised intervention
4. Multiple outcome measures
5. Statistically significant effect size
6. Outcomes can be replicated
This is exactly the criteria of a randomised control trial. It reduces evidence based psychotherapy to RCT and not any of the other
forms. But this is flawed thinking.
Tau = treatment as usual
So then what does ‘evidence-based’ “really” mean?
Evidence = empirical data; data gathered using the ‘scientific method’
‘Evidence-based’ means interventions are supported by scientific research to consistently show improved outcomes: “Those
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” (Kagee & Lund, 2012, p.103)
Efficacy vs Effectiveness
Efficacy: evidence derived from trials where threat to internal validity is minimized
RCT considered ‘gold standard’
Enables researchers to establish cause and effect
EB treatment has become synonymous with efficacy
Effectiveness: performance under real-world conditions (doesn’t tell us how it will work for real life people with the genuine
issues. Should be tested on samples that are not so ‘clean’ as how can that claim to be truly effective)
Testing pharmacological treatments is a little different to testing psychotherapy
1) Clearly and carefully specifying patient population
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
But…
This is unrealistic! Intervention only shown to be effective for people with only that problem (and no others)
