Issues of Disseminating CBTIssues of Disseminating CBT

C. Barr Taylor, Vickie ChangDepartment of PsychiatryStanford Medical School.

Note: Other references will be in Taylor CB, Chang V: Issues in the Dissemination of CBT, Nordic J Psychiatry, submitted.

Anxiety and Mood Disorders Are Common Debiliatating Problems

World-wide life-time prevalence: anxiety disorders 5-31% and mood disorders 3-21% (Kessler et al World Psychiatry, 6, 168.)

WHO found that depression has a worse impact on a person’s functioning than does angina, asthma, diabetes or arthritis and may contribute to 40% of disability worldwide

Depression (and anxiety) are under treated, e.g. in UK only 1/3 of people with diagnosed depression and 1/4 with anxiety receive treatment of any sort; only 40% of patients with mood or anxiety disorders receive any treatment.

What Is the Reach of CBT?

Should all depressed and anxious people have an opportunity to receive CBT? Recent evidence based reviews, guidelines would say yes!

Reach: Number of individuals within a defined population who would benefit from an intervention and who receive it.

The % of patients with depression and or anxiety who receive any CBT is not known. A survey of 2,281 practicing psychologists in the US found that 69% reported using some CBT but less than 4% used CBT exclusively.

The % of patients with depression and or anxiety who receive an adequatecourse of CBT is not known. Community, VA, HMO surveys report low use of evidence based procedures.

What Is An Adequate Dose of CBT?

Access to CBT provided by a “competent” therapist (e.g one with a score of >40 on the cognitive therapy rating scale”)?

Completion of a recommended number of sessions (e.g. 10-16 for mild-moderate depression, 6-8 for panic disorder?)

Attainment of specific outcomes (e.g. 50% reduction in depression symptoms)

Client demonstrated use of cognitive or behavioral techniques?

Completion of CBT program materials (manual/on-line course)

To our knowledge, no data is available on these issues for defined-population/disseminated programs

Models of DisseminationImproved reach is the product of successful dissemination

Dissemination of evidence-based techniques is a major focus across all aspects of medicine, psychology and public health

Theories of dissemination exist and can be informative:

For instance, Roger’s highly influential model would imply that an organization interested in disseminating CBT would examine the perceived advantage to the therapist of using CBT over her other current practices:

*Will the use of CBT generate more business or make the work more enjoyable?

*Does the therapist believe that the use of CBT will achieve better, and faster outcomes? If so does this constitute an advantage?

Models of Dissemination--contOther models:

Social Marketing, the application of marketing techniques for dissemination of socially valuable activities (used in the large US CVD community-based prevention trials)

RE-AIM (consider the reach, efficacy/effectiveness, adoption, implementation and maintenance of intervention

Community organization/within community focused combinations of these and others.

However, “There is an imperfect evidence base to support decisions about which guideline dissemination and implementation strategies are likely to be efficient under different circumstances”

Grimshaw et al Health Technol Assess 2004;8, 1.

A list of some factors involved in implementationFoundation

Evidence base for interventionClinical guidelines, Quality Assurance and InsuranceProgram Administration and managementProgram ParametersTarget population and reach

Champions, advisory Committees, stakeholders, community resources, financing and budgeting

Program DevelopmentIdentifying providersIdentifying patientsTraining providersProgram evaluationData and measurementProgram promotion

Ramp-up and DeliveryPolicy, procedures, protocols and systemsQuality assurance (monitoring outcomes, improving

program etc)

Smith and Taylor. Implementing an Inpatient smoking cessation program.Lea, New York, 2006.

What Are the Barriers to Dissemination?Patients: Lack of patient interest, e.g. in STAR*D only 30% of patients were willing to use CBT alone or in combination with medication (high biased sample)

Solution: Advertise like drug companies

Researchers: the assumption that empirical evidence is sufficient for dissemination to occur; the assumption that a little better is better than good enough; getting it right is better than getting it out, focus on ideal condition, single problems, limited populations

Solution: NIH requires a dissemination/relevance plan (but how often does it occur?)

What Are the Barriers to Dissemination--2?

Clinicians: Little interest in evidence based practice, lack of incentives for practice, negative attitudes towards CBT (boring, inflexible, impersonal,demeaning)

Solution: Train, incentivize, inform, educate, use dedicated, compliant, providers

Cost/availability

Solution: Manuals, computers

Self-Help and Manualized Programs

Self-help (SH) and manualized CBT programs can be helpful:

S-H for depression has been associated with significant but low effect sizes (e.g. Standardized mean difference = 1.36, 95CI -1.8 to -.96). (Anderson et al Br J Gen Pract 2005, 55; 387)

S-H for anxiety disorders found controlled effect sizes of .62 at post treatment and .51 at follow-up. (Hirai & Clum. Behav Ther 2006, 37:99.)

S-H for eating disorders found S-H did as well as guided S-H (Perkins et al Cochrane Database, 2006, July 19:CD004191)

Computer/Internet Delivered CBT Programs Are Also Effective

Review of 103 randomized trials across a number of problems found that patients often improved more with CCBT than with contrasting approaches (typically WLC), with an average reduction of 50% in therapist time. (Marks et al. Computer-aided psychotherapy. New York: Psychology Press, 2007)

Meta-analyses have found low to moderate effect sizes, however.(Spek et al Psychol Med 2008:38:635.)

Manualized Therapist Delivered CBT Vs Patient Focused, Individualized CBT

Manualized Therapist Delivered CBT might require less training, facilitate dissemination. Therapists could use the manual to provide the core elements and focus on other issues using their expertise.

Many training programs assume that therapists need to be trainedto do CBT without the use of structured programs (e.g. the Beck Institute model)

Top: % panic free at posttreatment and 6-month follow-up.

Bottom: %panic free at posttreatmentusing intent-to-treatanalysis.

W/List = waitlist

CBT12 = 12 sessions of therapist-delivered CBT

CBT6CA = 6 sessions of therapist-delivered CBT+ computer

CBT6 = 6 sessions of therapist-delivered CBT.

CBT Training: What Works Best?Research protocols have standardized training and methods to ensure

fidelity.

However, little work has been conducted on how to train therapists in real world settings.

In one study, manual + training seminar + supervised case work was superior to manual + web-based training which was superior to manual only. (Sholomskas, et al JCCP, 2005, 73:106).

Conventional wisdom is that workshops alone are not sufficient

However, access to CBT training is not a rate limiting step for dissemination

Stepped-Care ApproachesMany have argued that stepped-care approaches provide a cost-effective

method for dissemination CBT interventions

Stepped-care approaches have become a core feature of many evidence based interventions

However, little data exists on their effectiveness in real world settings.

The next figure illustrates a model of stepped-care we have been using

Population Screening

No or low risk of being treated for ED. No further contact, universal program and/or occasional monitoring

Subclinical/Clinical

BN/BED/EDNOS

High RiskHigh-riskintervention(self-help)

6-monthoutcome

+ nc -50% 40% 10%

Step 1. Self-help

Figure 1. A Model for Population BasedUniversal, Targeted, and Clinical Intervention

continued on next slideED = eating disorder, nc = no change

better nc/worse25% 75%

Step 1. Self-help

Figure 1. A Model for Population BasedUniversal, Targeted, and Clinical Intervention--cont

Step 2. CBT

better nc/worse50% 50%

Step 3. IPT/Medication

better nc/worse40% 60%

ImprovedTreatments?

An example of a CBT psychoeducation program

Psychoeducation

Body Image Journal

Personal Journal: Reflection

Personal Journal: Reflection

Discussion Group

At risk of overweight

High weight and shape concerns

(Killen et al IJED, 1994, 16, 227; The McKnight Investigators, AJP 2003, 160, 248)

At risk of overweight groupHigh weight and shape concerns groupReferral for eating disorderHealthy weight regulation program only

At risk of overweight groupHigh weight and shape concerns groupReferral for eating disorderHealthy weight regulation program onlyOther?

Models of Dissemination 1:A strategy to reach a defined population: inpatientswho used tobacco before admission

PRACTICE SETTINGS ARECOMMUNITY-BASED INTERVENTIONS

Community

Hospital

POINT OF ACCESS: THE USE OF HOSPITALS FOR SMOKING CESSATION

• 30-40 million people hospitalized annually• 20-40% of hospitalized patients smoke• Most smokers have had to quit• Greater motivation to quit• Available for counseling

ADVANTAGES OF A HOSPITAL AS A PUBLIC HEALTH SITE

• Reaches most people• Relatively easy access to patients• Pool of trained providers• Patients are motivated to change• Consistent with hospital image• Prevention/Risk Reduction

MULTIFITCase managementSocial Learning TheoryHome-basedNurse directed

--Clinic visits (2 hours)--Telephone (7 hours)

Targets of intervention:Smoking cessationLipid lowering

--nutrition counseling--nicotinic acid, lovastatin or gemfibrozil (review 120, 150, 180 days)

Exercise training--symptom limited

Stress managementMaterials

--workbook--videos--relaxation tape

DeBusk et al, A case-management system for coronary risk factor modification after acute myocardial infarction.Ann Intern Med. 1994;120(9):721-9.Miller & Taylor. Lifestyle modification in patients with coronary heart disease.Kinetics, New York, 1995

MULTIFIT-- EvaluationSample: 583 post MI patients randomized to intervention or control

Assessment:One year follow-upSmoking: cotinine confirmedNutrition: food frequency questionnaireLipids: LDL, HDL, Total, Exercise: Functional capacity on TM

triglycerides

MULTIFIT DISSEMINATION OUTCOMES -- cont.

Trial Practice*OUTCOME UC TARGET N=293 N=2182Adherence to

Exercise Rx 55% 80% 71% 81%

LDL Chol (mg/dL) 132 95 107 106

Quit Smoking 53% 60% 70% 74%

LDL <100mg/dL 15% 40% 42% 47%

STAYING FREE INTERVENTIONWHAT PATIENTS RECEIVE

– A STRONG MD MESSAGE ABOUT THE HAZARDS OF SMOKING

– A 17 PAGE, CBT BASEd, WORKBOOK ON QUITTING SMOKING

– A 16 MINUTE VIDEOTAPE SHOWN AT THE BEDSIDE ABOUT HOW TO REMAIN AN EX-SMOKER

– RELAXATION AUDIO TAPE

STAYING FREE INTERVENTION (CONT.)

– A COUNSELING SESSION AT THE BEDSIDE BY A HEALTH CARE PROFESSIONAL

– PHARMACOLOGICAL THERAPY AS NEEDED

– FOLLOW-UP PHONE CALLS FROM HOSPITAL STAFF AND/OR PUBLIC HEALTH (1 TO 4)

– OUTPATIENT REFERRALS TO PUBLIC HEALTH PROGRAMS AND OTHER LOCAL RESOURCES

General Hospital Patients

3735

2021

51

40

49

2731

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10

20

30

40

50

60

70

80

90

100

Taylor 1996 Miller 1997 Smith 2000 Smith 2001 Smith 2001

% N

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COST PER ADDITIONAL YEAR OF LIFE

$0

$5,000

$10,000

$15,000

$20,000

$25,000

Smoking Medical Rx Thrombo. Rx

Dissemination

Will it work as well under “real world”conditions, during efficacy and effectiveness trials?

TOOLS FOR DISSEMINATION

ISSUE METHODStandardized • Algorithms

Intervention • Computerized management• Intervention manuals• Audiovisual materials• Manuals

Standardized • 3-day training programTraining • Training materials

• Competency measure

Quality Assurance • Outcome measures built intotreatment system

• Outcome goalsConsultants,

Adopters, Models

SUPPORTING ELEMENTS

• Policy• Coordination• Implementation plan• Orientation and training• Resources• Audit• Maintenance

Dissemination of Staying FreeHOSPITALHOSPITAL Implementation InstitutionalizationImplementation InstitutionalizationVAVA 21%21% 13%13%CountyCounty 21%21% 19%19%Community (large)Community (large) 28%28% 49%49%Community (small)Community (small) 26%26% 25%25%UniversityUniversity 18%18% 22%22%HMOHMO 55%55% ----

Target: 25% quit rateTarget: 25% quit rate**PATIENT SELFPATIENT SELF--REPORT 6 MONTHS POSTREPORT 6 MONTHS POST--DISCHARGE. All PATIENTS DISCHARGE. All PATIENTS

WHO COULD NOT BE REACHED FOR FOLLOWWHO COULD NOT BE REACHED FOR FOLLOW--UP WERE COUNTED AS UP WERE COUNTED AS SMOKERS.SMOKERS.

GETTING GRANDIOSE

What if you wanted every patient in the U.S. who used tobacco before hospitalization to have a chance to quit during that hospitalization?

……..and you only had $50K

Push-Pull and Policy1. Establish national policy related to outcome:

Joint Commission oN Accreditation of HospitalOrganizations

2. Establish public assessment system

Table 2. Staying Free Hospital Dissemination ModelStep 1. Identify all hospitals in a geographic region.

Step 2. Collect the most recent results from the JCAHO performance measures for these hospitals on smoking cessation.Step 3. Prepare a letter reporting the hospital's performance on smoking cessation advice/ counseling measures and notify hospitals that we will be publishing the data in their local paper within a year. Send the letter to the hospital CEO, Medical Director and/or Chairman of the Board, and one or two other relevant individuals (e.g. Director of Health Promotion or Quality Improvement).

Step 4. Provide regional face-to-face training if desired (at cost).

Step 5. Send a six-month reminder letter.

Step 6. Organize (and publish hospital performance data for smoking cessation advice/ counseling in the local media about one year after the initial letter is sent.

Name of CEOHospitalAddress

Dear Dr. (Name of CEO),

SUBJECT: Performance Measures for Inpatient Smoking Cessation Services

I am writing from the Center for Excellence for Inpatient Tobacco Cessation at Stanford University School of Medicine. Our mission is to ensure that all hospitalized patients who smoked prior to admission are given an opportunity to stop smoking. As a step towards this, we plan to inform the public about how well their local hospitals are performing on several measures on inpatient smoking counseling put forward by the Joint Commission on Accreditation of Health Care Organizations (JCAHO).

Below are you scores for the "Adult smoking cessation advice/counseling" performance measures according to the 2004/2005 JCAHO Quality Reports:

JCAHO Quality Report Scores

46%

100% 97%93%

79%

66%61%

69%

44%

21%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Heart Attack Care Heart Failure Care Pneumonia Care Your Rate for All

Rates of Top 10%Nationwide

Average Rate Nationwide

Your Rate

Overall Percent

About six months from now, the Center will be publishing resultsfrom theupdated JACHO data for hospitals in your region for adult smoking cessation advice counseling in the (NAME OF PAPER). We hope to make the public aware of how well their health care provides aremeeting smoking cessation performance measures. We have not yet finalized howe will display the data in the (NAME Of PAPER) but a working modeling is shown below:

(example)

We then offer consultation and training at cost

Change in RatesControl Intervention

N Mean (sd) N Mean(sd)

p

50 14% (2%) 67 15% (2%) 0.07

17 12% (18%) 28 16% (2%) 0.09

15 11% (18%) 24 14% (16%) 0.09

10 8% (25%) 18 16% (27%) 0.13

12 12% (12% 6 3% (3%) 0.2

2 -11 (26% 3 25% (36%) 0.6

Conclusion: Policy with teeth has impact; the inteventioneffects appear minor but large reach (33M?, at low cost)

Models of Dissemination -- 2

Main Goals1) PCT Coverage

At least 20 primary care trusts to implement IAPT by 2008/9. About 40 properly trained therapists/250,000 people. Working in a team consisting of director, supervisors, low- and high- intensity therapists.

2) Building a skilled workforceTraining programs to deliver 3,600 therapists by 2010/11 with an appropriate skill mix (low and high intensity) and supervision arrangements

3) Extending access to evidence-based care900,000 more people accessing treatment, with the expectation that half of those who complete the program will recover completely, with 25,000 fewer sick days by 2010/11

4) EffectivenessAt least 90% of patients will have pre-post treatment outcome dataAssess reductions in symptoms, functional impairment, acceptability and quality, equity of access, population coverage

United Kingdom Program to Improve Access To Psychological Therapies

Treatment

1) Every person receives a "patient-centered assessment,” using a stepped-care approach.

2) Mild-moderate depression: Watchful waiting, guided self-help (which can be delivered over the telephone, or brief face-to-face psychological interventions (up to seven sessions) or include guided use of computerized CBT.

3) Moderate-severe: up to 20 sessions; including medication.

4) Routine outcome monitoring

Cost

L33 million in 2008/09

L70 million in 2009/10

L70 million in 2020/11

United Kingdom Program to Improve Access To Psychological Therapies--2

Positive Parenting Program

Evidence based

Training

World-wide dissemination

see: http://www.triplep.net

United States VA-CBT Dissemination Program forEvidence Based Treatments

Train 500 therapists in CBT/ACT fortreating depression

--workshop (3 days)--therapist manual--Web-based assessments, patient materials--6 month case supervision towards competency--process monitoring

MoodGYM, e-couch (Australian National University)

Other Important Models

Combined Delivery Modes Are Becoming More Common

For instance, we are evaluated a integrated treatment programs for bipolar disorder in a large HMO that combines:

(1) Self-directed internet delivered, interactive psychoeducationbased on an effective CBT, self-help program

(2) On-line, therapists moderated support group(3) Nurse care-management(4) Algorithm driven psychopharmacology(5) Use of a electronic record with monitoring of adherence (via

automatic refill of meds.)

Up to 400 patients will be randomized to the intervention or usual care and evaluated at 1 and 2 years

Using Social Networks and theInternet in New Ways

Social networking has the potential to develop new ways to sustain interventions.

Large “Ns” can permit component analysis in new ways.--what components to users like? Benefit from?Recommend.

With all the unknowns, outcomes are an excellent approach

Patients should be expected to achieve a standard outcomeby a standard time

Consistent failure to reach that outcome, should indicate thatretraining/refocusing required adoption of an evidencebased intervention

Blame the therapy not the therapist

If all goes well, this may help:C. Barr Taylor. How To Practice Evidence BasedPsychiatry. APPI, Washington, in preparation

Outcomes, Outcomes, Outcomes

Leadership

Friendship

Thank you,

Gunnar,

For All You Have Done