OUTCOMES AND EVIDENCE
| MEASURING AND USING OUTCOMES IN YOUR CLINICAL PRACTICE —Patricia A. Areán, PhD, Associate
Professor of Psychiatry, University of California, San Francisco, School of Medicine
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| Why use outcomes? considered part of quality of care for depression (several states require outcome monitoring as
part of quality control); provides objective means of tracking treatment efficacy; can be important in decision making;
helps patients see their progress
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| What to track? ideally, symptoms and function; additionally, anything patient thinks worth tracking; in speaker’s
problem-solving therapy model, patient and therapist list all goals at beginning of therapy and track progress toward
achieving them
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| Common measures: semistructured interviews—used in research to confirm diagnosis, but easily modified for use in
clinical practice; help in ruling out alternative diagnoses and in identifying comorbid diagnoses; include Structured
Clinical Interview for Diagnostic and Statistical Manual of Mental Disorders (SCID) and Mini-International Neuropsychiatric
Interview (MINI); Hamilton Depression Rating Scale (HAM-D)—does not provide or confirm diagnosis,
but helps determine severity of symptoms once diagnosis of depression established; self-report
instruments—do not provide or confirm diagnosis, but measure symptom severity (people with conditions other
than depression can have high scores on self-report instruments); include Beck Depression Inventory (BDI), Center for
Epidemiological Studies Depression scale (CESD), and Patient Health Questionnaire, 9-item (PHQ-9); functional
measures—include World Health Organization Disability Assessment Scale (WHO-DAS), Medical Outcomes
Study scale, short form (SF-12), and Quality of Life Inventory (QOLI); qualitative measures—Likert-type mood
and function scales; books (for works cited, see Lewinsohn and Muñoz in “Suggested Readings,” p. 3); patient’s
perception of whether he or she has met goals; speaker uses term “deliverables” for variant of goal achievement in
which patient finds method of dealing with problem that is not depression but may contribute to depression (eg, alcohol
consumption)
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| Using semistructured interviews in clinical setting: semistructured interviews designed to assure reliability in research,
but easily adapted to clinical practice; in clinical practice, not necessary to ask questions word for word, but rather, used
as guide to assure symptoms detected consistently in all patients; may elicit information patient did not think important
or allow clarification of information patient volunteers
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| Self-reports: allow clinician to detect severity of symptoms, but also used for tracking progress in resolution of symptoms;
administer before each therapy session (people think about past moods based on feelings they are experiencing
now; interaction with clinician can influence those “now” feelings); do not ignore self-report instrument, but
discuss it with patient for efficacy of therapy (eg, “do you feel therapy was particularly helpful with your sleep this
week?”); reviewing self-reports with patient helps clarify increases or decreases in symptoms, reinforces idea that
patient not “just filling out these questionnaires for some bureaucratic reason, that you actually are using it clinically
and that it’s important to you,” and gives sense of which symptoms might need to be monitored by patient
once therapy ends
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| When to track outcomes: speaker recommends using American Health Care Policy and Research (AHCPR) guidelines;
establish firm preliminary diagnosis; during first phase of treatment, monitor symptoms at least every other
week until patient responds; after response seen, monitor once monthly for 1 yr; if patient desires to discontinue
medication after 1 yr, return to monitoring symptoms every other week until patient stable off medication
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| Using outcomes clinically: initially set reasonable symptom or functional goal; ideally, decrease of 50% in symptoms
and increase of 50% in functioning at end of 4 wk; if that goal met, continue as usual; if goal not met, discuss evidence
with patient; is he or she close to meeting goal? or has there been no real change? involve patient in decision
about how to proceed so goals can be met (eg, increasing, changing, or augmenting therapy); speaker’s study used
stepped-care approach, augmenting treatment after 4 wk if improvement inadequate; if treatment still inadequate at
2 to 3 mo, step 3 was to obtain psychiatric consultation to examine whether diagnosis correct and to discuss strategies
for further intervention; rationale behind this approach is to use all information from tracking to see objectively
how patient’s symptoms are doing and what his or her level of functioning is to make informed treatment
decisions that would result in better outcome
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| Remission: patient considered in remission if he or she has ≤2 depressive symptoms; help patient make relapse-prevention
plan; educate him or her about likelihood of recurrence of depression; discuss how patient recognizes when depressive
episode starting and at what point to seek help from clinician; one group of clinicians has relapse-prevention
model in which patients at increased risk for relapse visit 3 times in year after treatment response for clinician to check
up on patient’s progress and to reinforce education about relapse prevention; in speaker’s study, patients could elect
whether to participate in monthly maintenance groups, and those who did not care to participate in groups met with
care managers individually; data undergoing analysis, but it appears that attendance at groups “didn’t necessarily
help”
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| EVIDENCE-BASED TREATMENTS FOR CHILDREN AND ADOLESCENTS —Heather Hoover, PhD, Child
and Adolescent Psychologist, Geisinger Health System, Danville, PA
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| Why evidence-based practice? to determine what treatments being provided, to whom provided, whether those treatments
work better than nothing at all, and whether they work better than some other treatment
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| What works? key variables include relationship factors and treatment methods and content (usually summarized in
form of manuals; important to know what other therapists use); other variables include patient factors (eg, level of
motivation, social support, financial resources, expectations for improvement
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 | Relationship factors: study of adults with bulimia found patient’s expectation of improvement highly correlated
with therapeutic alliance, which in turn affected treatment outcome; same kind of study needed in child and adolescent
psychotherapy
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| Evidence-based criteria: evidence for bulk of treatments in child and adolescent psychology/psychiatry unclear or
not empirically supported due to lack of research; for example, although many child and adolescent therapists incorporate
family therapy, it has not been well investigated and its efficacy is unknown; more research being done in
child and adolescent psychology/psychiatry, and it should increase evidence base; speaker optimistic that more
negative studies will be published, rather than being relegated to file drawer and forgotten; negative results important
for telling clinicians what not to do
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| Attention-deficit/hyperactivity disorder (ADHD): Multimodal Treatment Study of Children with ADHD (MTA) enrolled
579 children 7 to 9 yr of age and randomized them to monthly medication management, intensive behavioral
treatment, combination of first 2, or community care (in which clinicians invited to “do whatever you want
to do”) as control condition; results showed 1) combined therapy equivalent to medication alone in some domains,
better in other domains, 2) reduced amount of medications required, 3) treatment effects continued after
medication withdrawn, and 4) greater consumer satisfaction; also, combined treatment better than medication
alone in children with comorbid disorders
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| Summary of findings of MTA study: medication most effective treatment for ADHD; children in medication-only
arm got higher doses of medication than children in community-care arm and, therefore, had better symptom reduction;
in some psychosocial domains, combined treatment helpful above and beyond symptom remission; behavioral
therapy alone not very beneficial in ADHD
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| Other studies: found medication effects at 14 mo only half of what they were at beginning of trials (perhaps because
clinicians slowly reduced doses of medications over time); children who received medication and behavioral
therapy could be on lower dose of medication, thus reducing side effects; parents of children with ADHD
want behavioral therapy in addition to medication
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| Medications: methylphenidate (Ritalin) most studied, other psychostimulants next; only 1 trial studied bupropion
(Wellbutrin), but results must be replicated before being considered “evidence”; several randomized controlled trials
done to get atomoxetine (Strattera) to market, but to date, no head-to-head trials with stimulants; 70% of children
with ADHD respond to methylphenidate or dextroamphetamine (Dexedrine), 90% respond to combination
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| Promising or mixed evidence: amphetamine mixtures (Adderall); social-skills training
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| Oppositional defiant disorder (ODD) and conduct problems: sometimes comorbid with ADHD; most efficacious
treatment and with most research is parent management training (PMT); problem-solving skills training has
some research behind it; social-skills training found not to have strong generalizable effects; multisystemic therapy
(MST) takes broader approach and has some evidence of being helpful
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| Parent management training: teaches parents principles of contingency management, identifying antecedents to
problem behavior in child; parents also learn about importance of consequences and how to use positive as well
as negative consequences
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| Problem-solving skills training: child-focused treatment that helps child develop interpersonal cognitive problem-
solving skills; teaches child to identify problems in his or her behavior and to find solutions, anticipating outcomes
of these solutions for himself or herself and for others
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| Behavioral approaches: first-line treatment; family participation key; medications may treat symptoms (eg, aggression)
but none treat disorder; no medications proven consistently effective in treating ODD or conduct disorder
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| Anxiety disorders: evidence-based treatments include cognitive behavioral therapy (CBT) and exposure therapy;
psychotherapy first-line treatment approach, with medication considered as possible augmentation; currently not
enough data to make strong argument for any medication or combination; whether to use medication and which
medication depends on symptoms and whether anxiety episodic or generalized and pervasive
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| Medications: good evidence—one study showed sertraline (Zoloft) efficacious in treating generalized anxiety disorder
(GAD); several other studies show sertraline and fluoxetine (Prozac) efficacious in treating pediatric obsessive-compulsive
disorder (OCD); some evidence supports efficacy of fluvoxamine (Luvox) in treating
pediatric GAD and OCD, but side effects worrisome; unclear evidence—tricyclic antidepressants, except clomipramine
(Anafranil), which has been shown effective in pediatric OCD, but again, beware of side effects; little or
no evidence—benzodiazepines
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| OCD: has most medication research (see above); research supports use of CBT with exposure and response prevention
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| Phobias: research supports psychotherapy over medication; consider systemic desensitization, modeling, CBT, and
contingency management
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| Depression: good evidence base for treatment of adolescent depression, less for childhood; CBT and interpersonal
therapy well supported; speaker recommends that “treatment of pediatric mood disorders should always incorporate
psychological intervention components and medication be viewed as a possible augmentation”; tricyclic
antidepressants—“very well studied with absolutely no evidence they are efficacious for the treatment of pediatric
depression”; selective serotonin reuptake inhibitors (SSRIs)—fluoxetine only SSRI approved by Food and
Drug Administration (FDA) for treatment of pediatric depression; trials produced mixed evidence on efficacy of
sertraline; manufacturer of venlafaxine (Effexor) admitted that its efficacy not established for pediatric major depressive
disorder or GAD
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| Relationship factors: adult literature shows importance of therapeutic alliance and of consensus and collaboration between
patient and therapist on setting and reaching goals; pediatric literature sparse, but beginning to indicate that
same true in treating children and adolescents; difficult to interpret results of pediatric studies because almost all
used different measures, but apparently, age of child and type of treatment irrelevant in determining whether therapeutic
alliance affects outcomes; type of problem matters (powerful positive relationship with therapist affected
outcome of externalizing behavior problems but not of internalizing behavior problems); studies of therapist factors
under way
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Educational Objectives
| The goal of this program is to educate the listener about using outcomes and evidence in his or her clinical practice. After
hearing and assimilating this program, the clinician will be better able to:
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| 1. Describe how measuring and using outcomes can enhance the quality of care in his or her practice.
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| 2. Discuss several types of outcome-measurement instruments that can be adapted to clinical practice.
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| 3. Compare and contrast the evidence available for treatment of adult and pediatric mental disorders.
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| 4. Summarize the evidence available for treating several pediatric mental disorders and behavior disorders.
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| 5. Explain which areas of pediatric mental disorders require more research.
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Discussed on This Program
Alprazolam [Xanax, Xanax XR, Niravam]
Amphetamine and dextroamphetamine [Adderall, Adderall XR]
Atomoxetine hydrochloride [Strattera]
Bupropion hydrochloride [Wellbutrin, Wellbutrin SR, Wellbutrin XL, Zyban]
Clomipramine hydrochloride [Anafranil]
Clonazepam [Klonopin]
Dextroamphetamine sulfate [Dexedrine, Dexedrine Spansules, Dextrostat]
Fluoxetine hydrochloride [Prozac, Sarafem]
Fluvoxamine maleate [Luvox]
Lorazepam [Ativan, Lorazepam Intensol]
Methylphenidate hydrochloride [Ritalin, others]
Sertraline hydrochloride [Zoloft]
Venlafaxine hydrochloride [Effexor, Effexor XR]
Suggested Reading
Alexopoulos GS, Raue P, Areán P: Problem-solving therapy versus supportive therapy in geriatric major depression with
executive dysfunction. Am J Geriatr Psychiatry 11:46, 2003; Areán PA et al: Treatment of depression in low-income
older adults. Psychol Aging 20:601, 2005; Bartels SJ, Drake RE: Evidence-based geriatric psychiatry: an overview. Psychiatr
Clin North Am 28:763, 2005; Bartels SJ: Evidence-based geriatric psychiatry. Psychiatr Clin North Am 28:xiii,
2005; Burns BJ, Hoagwood K, Mrazek PJ: Effective treatment for mental disorders in children and adolescents. Clin
Child Fam Psychol Rev 2:199, 1999; Cole MG: Evidence-based review of risk factors for geriatric depression and brief
preventive interventions. Psychiatr Clin North Am 28:785, 2005; Compton SN et al: Cognitive-behavioral psychotherapy
for anxiety and depressive disorders in children and adolescents: an evidence-based medicine review. J Am Acad Child Adolesc
Psychiatry 43:930, 2004; Drake RE et al: What is evidence? Child Adolesc Psychiatr Clin N Am 13:717, 2004;
Dulcan MK: Practitioner perspectives on evidence-based practice. Child Adolesc Psychiatr Clin N Am 14:225, 2005;
Gauthier N et al: Beyond knowledge transfer: a model of knowledge integration in a clinical setting. Healthc Manage Forum
18:33, 2005; Graham P: Treatment interventions and findings from research: bridging the chasm in child psychiatry.
Br J Psychiatry 176:414, 2000; Gum AM, Areán PA et al: Depression treatment preferences in older primary care patients.
Gerontologist 46:14, 2006; Haverkamp R, Areán P et al: Problem-solving treatment for complicated depression in
late life: a case study in primary care. Perspect Psychiatr Care 40:45, 2004; Hunkeler EM, Areán P et al: Long term outcomes
from the IMPACT randomised trial for depressed elderly patients in primary care. BMJ 332:259, 2006; Kaslow NJ,
Thompson MP: Applying the criteria for empirically supported treatments to studies of psychosocial interventions for child
and adolescent depression. J Clin Child Psychol 27:146, 1998; Lewinsohn P: Control Your Depression, Revised Edition.
New York: Fireside, 1992; Lonigan CJ, Elbert JC, Johnson SB: Empirically supported psychosocial interventions
for children: an overview. J Clin Child Psychol 27:138, 1998; Mackin RS, Areán PA: Evidence-based psychotherapeutic
interventions for geriatric depression. Psychiatr Clin North Am 28:805, 2005; March JS et al: Duke Pediatric Psychiatry
EBM Seminar Team. Using and teaching evidence-based medicine: the Duke University child and adolescent psychiatry
model. Child Adolesc Psychiatr Clin N Am 14:273, 2005; McClellan JM, Werry JS: Evidence-based treatments in child
and adolescent psychiatry: an inventory. J Am Acad Child Adolesc Psychiatry 42:1388, 2003; Muñoz RF, Miranda J:
Group Therapy Manual for Cognitive-Behavioral Treatment of Depression. Santa Monica, CA: Rand, 2000; Muñoz
RF, Miranda J: Individual Therapy Manual for Cognitive-Behavioral Treatment of Depression. Santa Monica, CA:
Rand, 2000; Shirk SR, Karver M: Prediction of treatment outcome from relationship variables in child and adolescent therapy:
a meta-analytic review. J Consult Clin Psychol 71:452, 2003; Torrey WC, Lynde DW, Gorman P: Promoting the
implementation of practices that are supported by research: the National Implementing Evidence-Based Practice Project.
Child Adolesc Psychiatr Clin N Am 14:297, 2005; Unutzer J, Areán PA et al: IMPACT Investigators. Improving Mood:
Promoting Access to Collaborative Treatment. Collaborative care management of late-life depression in the primary care setting:
a randomized controlled trial. JAMA 288:2836, 2002; Weisz JR, Hawley KM: Finding, evaluating, refining, and applying
empirically supported treatments for children and adolescents. J Clin Child Psychol 27:206, 1998; Winters NC,
Collett BR, Myers KM: Ten-year review of rating scales, VII: scales assessing functional impairment. J Am Acad Child
Adolesc Psychiatry 44:309, 2005.
Faculty Disclosure
In adherence to ACCME guidelines, the Audio-Digest Foundation requests all lecturers to disclose any significant financial relationship
with the manufacturer or provider of any commercial product or service discussed. For this issue, the faculty reported
nothing to disclose.
Dr. Areán was recorded at New Frontiers in Depression Research and Treatment, held March 24-26, 2006, in San Francisco,
CA, and sponsored by the University of California, San Francisco, School of Medicine. Dr. Hoover was recorded at
Psychiatry and Behavioral Medicine CME Update: 2005, held April 20, 2005, in Danville, PA, and sponsored by Geisinger
Health System. The Audio-Digest Foundation thanks the speakers and the sponsors for their cooperation in the production
of this program.
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