Exploring psychological treatment mechanisms using data ... · Exploring psychological treatment...
Transcript of Exploring psychological treatment mechanisms using data ... · Exploring psychological treatment...
Exploring psychological treatment
mechanisms using data from TAU
Dr Andy Fugard UCL Research Department of Clinical, Educational & Health Psychology
8 Jan 2014, University of Kent, EBM+ Workshop:
Evidence of mechanisms in evidence-based medicine
Mental health conditions
Picture from Blakemore and Mills (2014) using data from Kessler et al (2005)
Story of best practice:
1. Theory derived from
“basic science”, e.g.,
experimental psychology
2. Develop and manualise
treatments
3. Demonstrate efficacy
using RCTs
4. Systematic reviews
5. Implement whatever
works (EBP)
(How true is this tale…?)
Efficacy effectiveness via
Routine Outcomes Monitoring (ROM)
• RCTs are often run in very special contexts
• ROM evaluates effectiveness:
whether treatments work in “the real world”
• “Practice-based” evidence
• Usually multi-use data:
– Formal assessment checklists used as a clinical tool
– Progress monitoring (e.g., weekly)
– Various data for audit, driven by national datasets,
“key performance indicators”
The plan for this talk
Let’s take seriously the idea
that all data need to be
interpreted (not obvious from KPIs!)
What (if anything?) can we learn about mechanisms
using data from TAU*
* Spoiler: not completely answered in this talk!
Routine outcomes monitoring in the UK (Macdonald & Fugard, submitted)
YP-CORE (Twigg et al., 2009)
… two sides A4 …
Strengths and Difficulties Questionnaire
(SDQ; Goodman & Scott, 1999)
A challenge
WHAT DO PSYCHOLOGICAL
MECHANISMS LOOK LIKE?
Narrowing scope… the/a cognitive tradition
• Informational analysis following Neisser (1967): “…all processes by which the sensory input is transformed,
reduced, elaborated, stored, recovered, and used. It is concerned
with these processes even when they operate in the absence of
relevant stimulation … cognitive psychology is concerned with all
human activity rather than some fraction of it, the concern is from a
particular point of view”
• Cognition here doesn’t mean “conscious thought”
• There are ripples of debate, e.g.,
– Rowland (2010), Adams & Garrison (2012)
– “Cognitive processes ain’t (all) in the head!”
(Clark & Chalmers, 1998)
Marr’s (1982) multiple levels
Specification of input-output relations
Algorithms
Neural implementation
- What’s the system doing?
- What information is represented?
- How is it transformed? (Step-by-step.)
- How does it look in biology?
Lessons from the psychology of reasoning
• Mental models
• Mental rules/logic
• “Non-logical” Bayesian models
• Probability logics
• …
Often/usually difficult to distinguish representations
and processes empirically but something algorithmic
can be extracted (occasionally!)
What does biology look like?
Levels all the way down…
Multiple levels common in engineering, e.g.,
Open Systems Interconnection model (OSI)
Sun, Coward and Zenzen’s (2005) extension
Mental rules in cognitive therapy (Beck, 1976)
Procedures and mechanisms (Power 2010)
Variations of exposure (Telch et al, 2014)
Illustrative example study of mechanisms
(Goldin et al, 2014)
• CBT for social anxiety vs. waiting list
• CBT included
– “psychoeducation” (teaching the mechanism!)
– graduated exposure to feared social situations, within
session and as homework
– reappraising/reinterpreting situations
– uncovering and challenging negative core beliefs
Tasks: key tools for uncovering mechanisms
Self-report results
fMRI results
• (Long tables of differences between people and
conditions in BOLD signal)
• Example interpretation:
“The reappraisal-related right SFG region found in
this study overlaps with the medial PFC and has
been implicated in multiple executive cognitive
functions, including monitoring, mentalizing,
introspection, self-referential meta-cognitive
evaluations, and reappraisal of emotional
reactivity”
Loops: the mechanisms of reasoning about
mechanisms with patients
• Clinicians explain the theory to patients
• Jointly reason to a “formulation” including
– What’s up?
– Why me?
– Why now?
– Why still?
– What helps?
Template
(Dummett, 2010)
Example
(Dummett, 2010)
Causal maps – example drawn by a clinician
(De Kwaadsteniet et al 2010)
BACK TO ROUTINE OUTCOME
MONITORING
What works for whom?
• Defined in terms of self-, carer-, or clinician-
completed questionnaires
• Problem of regression to the mean and other
forms of non-treatment-mediated change partly
solved by using simulated control data
• No randomisation and matching imperfect
still problem of unknown variables
Time 1 Time 2
Avera
ge d
istr
ess
(Cooper, Fugard, Pybis, McArthur, & Pearce, in press)
Counselling
Estimated non-intervention
outcome (ENO)
Estimated
Effect
Outcome
Diagnosis
Treatment
?
Child Outcomes Research Consortium
• Founded 2002 by
clinicians and service
managers
• Members (service
providers) pay an
annual fee
• Over half UK CAMHS
are members + parts of
Scandinavia
Analysis of CORC data (Fugard, Stapley, Ford, Law, Wolpert & York, 2014)
School counselling data (work with Mick Cooper)
School counselling data (work with Mick Cooper)
What seems to cause outliers…?
Mechanisms lurking here?
• Data quality
• Return rates
• What’s covered in the
questionnaire
• Chosen outcome
variable
• Presenting problems
• Organisational factors
• Stage in episode of
care
• Therapeutic modality
• Therapist skill
• Goals set with young
person/family
Sketch of ongoing work
• Using data from a large NHS Foundation Trust
• Cases selected with a diagnosis of anxiety
• “Outcome” (end of treatment) based on clinician-
rated pre-post change
• Cases selected showing little vs. lots of change
• Case notes now being investigated using a
“thematic analysis”
WHAT’S THE TREATMENT?
Clinical coding in physical health
Example 1
– ICD-10 O300 (twin pregnancy)
Z37.2 (twin both live born)
– OPCS-4 R17.2 (elective lower uterine
segment caesarean delivery)
Example 2
– ICD-10 S7200 (fractured neck of femur)
W19.0 (unspecified fall at home)
– OPCS-4 W37.1 (primary total prosthetic
replacement of hip joint using
cement)
Z94.3 (left sided operation)
Children and young people’s mental health
(CYP IAPT) – long list but little detail
Procedure taxonomies, e.g., Common Language
for Psychotherapy (CLP) procedures
http://www.commonlanguagepsychotherapy.org
Example content of case notes
• Who’s involved, in sessions, in patient’s life
• Contact outside session, e.g., with school
• What the patient wants, e.g., parent there or not
• What the clinician did
• Session content, e.g., psychoeducation, breathing
exercises, giving/discussing homework…
• Clinician’s speculations about what the young
person understood the treatment
• Supervision discussions
• Also what hasn’t been mentioned in the notes
Gluing this all together:
any representations and algorithms…?
• TAU data can tell us about the elements of an
intervention, e.g., people involved, procedures
• The sequence of events
• Duration of phases of treatment
• The recorded wishes of patients and something
about to what extent wishes were granted
Instead of dichotomous can we vs. can’t we, think,
what kinds of mechanism can we reason about?