for treatment selection in personality disorders: preliminary data

1
Development of a Clinical Decision Support System

• for treatment selection in personality disorders
  preliminary data
• Janine van Manen1), Roel Verheul1) 2)
• 1)Viersprong Institute for Studies on Personality
  Disorders (VISPD),
• Halsteren, the Netherlands
• 2)University of Amsterdam, Amsterdam, the
  Netherlands
• janine.van.manen_at_deviersprong.nl tel
  31-164-632200 www.vispd.nl

2
Why a Clinical Decision Support System?

• Different dosages psychotherapeutic treatment
• setting outpatient, day hospital, inpatient
• duration shorter than half a year, longer than
  half year
• intensity confronting, supportive
• theoretical orientation cognitive behavioural,
  psychodynamic
• Rational assignment optimizes the
  (cost)effectiveness of treatment.......

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Why a Clinical Decision Support System?

• Different dosages psychotherapeutic treatment
• Rational assignment? (cost)effectiveness
• ...... but treatment selection is partly based
  on
• patient preferences
• intake clinician preferences
• local treatment program supply
• There is little empirical knowledge
• and they are in contradiction
• Clinical Decision Support System

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Objective of this study

• Development of evidence based Clinical Decision
  Support System
• evidence based means based on a optimal
  integration of
• clinical knowledge and expertise
• interviews with intake clinicians
• steering committee
• clinical literature
• empirical data
• non-Randomized Clinical Trial (nRCT) among 800
  patients
• empirical literature
• patient preferences
• advisory board

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Objective of this study

• Development of a Clinical Decision Support System
• Evidence based
• User-friendly instrument
• administration within 10-30 minutes
• transparent ? decision tree

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Hypothesistentative relations between patient
characteristic and dosage

• Setting (outpatient, inpatient, day hospital)
  severity
• severity and rigidity of the pathology, treatment
  history
• Duration (short, long) psychological capacities
• psychological mindedness, focality, motivation
• Intensity (supportive, confronting)
  vulnerability
• ego strength, risk for regression and acting-out

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Hypothesistentative relations between patient
characteristic and dosage

• Setting (outpatient, inpatient, day hospital)
  severity
• Duration (short, long) psychological capacity
• Intensity (supportive, confronting)
  vulnerability
• Theoretical orientation (psychodynamic, cognitive
  behavioural) personality
• extraversion and openness

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Method

• Step 1 Development prototype decision tree
• interviews with intake clinicians
• clinical and empirical literature search
• development of a prototype decision tree
• Step 2 Optimizing and validating the prototype
• Optimizing adjusting the prototype
• investigating concordance model and reality
  (retrospective)
• examining arguments for discrepancies model and
  reality (prospective)
• Validating empirical testing of the prototype
• test of matching hypothesis
• better results if indicated treatment is in
  concordance with decision tree?

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Method

• Step 1 Development prototype decision tree
• interviews with intake clinicians
• clinical and empirical literature search
• development of a prototype decision tree
• Step 2 Optimizing and validating the prototype
• Optimizing adjusting the prototype
• investigating concordance model and reality
  (retrospective)
• examining arguments for discrepancies model and
  reality (prospective)
• Validating empirical testing of the prototype
• test of matching hypothesis
• better results if indicated treatment is in
  concordance with decision tree?

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Interviews with intake cliniciansobjectives

• Objectives of the interview
• matching patient characteristics to treatment
  dosages setting, duration, intensity,
  theoretical orientation ? junctions
• importance of patient characteristics ? hierarchy

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Interviews with intake cliniciansdevelopment and
examples

• Identification of patient characteristics for
  treatment allocation
• prior research at de Viersprong, empirical and
  clinical literature, input from intake staff ? 18
  patient characteristics
• questionnaire was sent to 29 senior intake
  clinicians to select the most important patient
  characteristics ? 12 patient characteristics

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Interviews with intake cliniciansdevelopment and
examples

• Identification of patient characteristics
• Semi-structured interview to identify relations
  between patient characteristics (12) and dosages
  treatment (4) e.g.

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Interviews with intake cliniciansdevelopment and
examples

• Identification of patient characteristics
• Semi-structured interview to identify relations
  between patient characteristics (12) and dosages
  treatment (4) e.g.

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Interviews with intake cliniciansdevelopment and
examples

• Identification of patient characteristics for
  treatment allocation
• Semi-structured interview
• 3 possible response patterns

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Interviews with intake cliniciansinterviewees

• 26 interviewees characteristics
• Profession
• 5 psychiatrists, 19 psychotherapists, 2
  psychotherapists in training
• Location
• 5 different psychotherapeutic centres in the
  Netherlands
• Setting
• 4 outpatient setting,12 day hospital, 8 inpatient
  setting
• Duration
• treatment program 4 shorter than half a year, 20
  longer, 2 longer and shorter

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Interviews with intake cliniciansinterviewees

• 26 interviewees characteristics
• Profession
• Location
• Setting
• Duration
• Theoretical orientation
• 16 psychodynamic, 5 cognitive behavioural and
  psychodynamic, 3 client-centered, 2 cognitive
  behavioural
• Work experience

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Interviews with intake cliniciansvalidity and
reliability

• Validity
• We asked intake clinicians how much of their
  knowledge and expertise they could express in
  this interview.
• Reliability
• And we asked how many of the answers would be the
  same, if the intake clinician was being
  interviewed a month later.
• Answers ranges from above average level to a high
  level
• There are indications that the validity and
  reliability is moderate to high

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Interviews with intake clinicianshow did we
analysed the data?

• Objectives of the interview
• matching patients characteristics to treatment
  dosages setting, duration, intensity,
  theoretical orientation ? junctions
• importance of patient characteristics ? hierarchy
• We are looking for patient characteristics that
  discriminate between different treatments. Or
  more specific different levels of the indicated
  patient characteristics match different levels of
  dosage.

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Interviews with intake clinicianshow did we
analysed the data?

• Example What is the relation between motivation
  for change and the indicated treatment?

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Interviews with intake clinicianshow did we
analysed the data?

• Full matching both levels of the patient
  characteristic indicate different treatment
  dosages (2 possibilities)
• Partial matching one level patient
  characteristic indicates a certain treatment
  dosage (4 possibilities)
• Definition three levels of consensus at least
  30, 40, or 50 of intake clinicians endorsed a
  full or partial matching pattern

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Interviews with intake clinicianshow did we
analysed the data?

• Definition three levels of consensus at least
  30, 40, or 50 of intake clinicians endorsed a
  full or partial matching pattern
• There are 9 different response patterns
• nominal change of endorsing a certain response
  pattern is
• 1/9 11
• lowest consensus level 30 is almost 3 times
  the nominal change level

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Results 1
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Results 1level of consensus

• Level of consensus
• 21/48 matching relationships 11 x 30, 2 x 40,
  8 x 50
• 8 x partial, 13 x full matching patterns
• Evidence for matching is
• Modest for setting
• Moderate for duration and theoretical orientation
• Strong for intensity

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Results 1specific relationships

• Setting
• Severity/rigidity type PD, treatment history
• Practicalities work, care responsibility
• Duration
• Vulnerability ego strength, quality of defence
  mechanisms
• Severity/rigidity symptomatology, type of PD
• Psychological capacities psychological
  mindedness, focality
• Intensity
• Vulnerability ego strength, quality of defence
  mechanisms
• Severity/rigidity symptomatology, type PD
• Psychological capacities capacity to relate,
  capacity for a therapeutic relation,
  psychological mindedness

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Results 1specific relationships

• Setting
• Duration
• Intensity
• Theoretical orientation
• Psychological capacities psychological
  mindedness, capacity to relate

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Results 1support for hypotheses?
hypothesis X finding
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Interviews with intake clinicianshow did we
analyse the data?

• Objectives of the interview
• matching patients characteristics to treatment
  dosages setting, duration, intensity, frame of
  reference ? junctions
• importance of patient characteristics ? hierarchy
• Question in the interview
• Which are the 4 most important patient
  characteristics for treatment selection? And
  which are 4 least important characteristics?

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Results 2

• Importance of the patient characteristics in the
  intake

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Summary of the findings

• The hypotheses were supported, but some
  additional findings
• Thus, in general, patient characteristics are not
  specific for certain dosage parameters, except
  for
• Setting treatment history, work, care
• Duration focality
• Intensity capacity for a therapeutic relation
• We found a moderate level of consensus (30-50)
• Patient characteristics differ widely in terms of
  observed importance

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Conclusions

• This interview strategy does seem to detect
• important patient characteristics that match with
  dosage psychotherapeutic treatment
• hierarchy of importance among the patient
  characteristics
• Since consensus moderate, additional strategies
  necessary to develop prototype decision model
• empirical literature review
• consensus formation among the experts in steering
  committee
• Finally, prototype will be empirically tested