Predicting Change in an Integrated Dual Diagnosis Substance Abuse Intensive Outpatient Program.

Research on routine outcome monitoring in psychotherapy settings is plentiful but not without implementation obstacles. In fact, there is a relative dearth of real-time outcome monitoring in substance use treatment settings. Numerous barriers to the development and implementation of clinical decision support tools and outcome monitoring of substance use patients, including the need to establish expected trajectories of change and use of reliable change indices have been identified (Goodman, McKay, & DePhilippis, 2013 ). The current study was undertaken to develop expected trajectories of change and to demonstrate the treatment effectiveness of a dual diagnosis intensive outpatient program. The expected trajectories of change for days of substance use and depression scores were developed using predictive equation models from derivation samples and then applied to cross-validation samples. Predictive equations to monitor substance use were developed and validated for all patients and for only patients who were actively using substance at the time of admission, as well as to monitor severity of their depression symptom on a weekly basis. Validation of the equations was assessed through the use of Cohen's kappa (κ), receiver operating characteristic curves, reliable change index, and percentage improvement. Large effect sizes for reductions in substance use (Cohen's d = .76) and depressive symptoms (d = 1.10) are reported. The best predictive models we developed had absolute accuracy rates ranging from 95 to 100%. The findings from this study indicate that predictive equations for depressive symptoms and days of substance use can be derived and validated on dual diagnosis samples.

Predicting individual change during the course of treatment.

OBJECTIVE: An empirically derived prediction model was developed in a private practice setting to monitor on-track and off-track weekly treatment progress in an intensive outpatient program (IOP). METHOD: The predictive equation was derived as a function of the baseline measure and time. The formulae for the predictive equations were derived from two groups of psychiatric patients (N = 400 each) in an IOP diagnosed with major depression. Each equation was cross-validated between these two psychiatric IOP samples and a dual diagnosis sample (N = 198) using κ, the reliable change index (RCI), receiver operating characteristic curves, and Youden's J. RESULTS: Using varying RCI classifications, approximately 66-75% of both samples reliably improved, 23-24% were indeterminant, and only 1-3% deteriorated. Of patients identified as off-track, which included patients classified as indeterminant and deteriorated, 83% were correctly identified. Of those identified as on-track, 85% were correctly classified. Those identified as on-track (85%) are highly likely to respond to treatment as expected. CONCLUSIONS: The overall efficiency index (hit rate) for the correct classification of all patients was 85%. Implications for using this predictive model as a clinical support decision tool with relatively homogeneous populations in other practice settings are discussed.

A comparison of the millon behavioral medical diagnostic and millon behavioral health inventory with medical populations.

There is a lack of normative data on broadband omnibus types of personality tests with medical populations. In fact, the only two tests normed on medical populations are the Millon Behavioral Medicine Diagnostic (MBMD) and the Millon Behavioral Health Inventory (MBHI). The internal consistency, test-retest reliabilities, and validity studies of these instruments are reviewed and compared in an effort to aid clinicians in discerning their relative psychometric strengths and weaknesses. Due to the lack of validity studies with the MBMD and the fact that reliability limits the ceiling of validity coefficients, the MBMD has yet to meet the challenges it was designed to meet. Implications for practice are addressed.

Pilot trial investigating a brief behavioral economic intervention as an adjunctive treatment for alcohol use disorder.

OBJECTIVE: Behavioral economic research suggests that increasing the salience of a delayed reward may improve capacity for delaying gratification and increase behavior allocated toward obtaining larger, delayed substance-free reward rather than smaller, more immediate reward such as alcohol use. This study aimed to improve the efficacy of outpatient alcohol use disorder (AUD) treatment by adding elements that target behavioral economic mechanisms of change. METHOD: Forty-one (N = 41) adults in outpatient AUD treatment were recruited and 37 participants were retained at follow-up. Following baseline assessment, participants received either the Substance Free Activity Session (SFAS), a single-session behavioral economic-informed intervention focused on increasing future orientation and engagement in values-based substance-free activities or a health education control intervention. Participants in both conditions received weekly prompts (via text or email) relevant to their respective intervention for four weeks. Participants (68.3% male; 70.7% Caucasian, M age = 38.24, SD = 12.69) reported an average of 3.95 (SD = 4.72) binge drinking episodes (4/5 drinks per occasion for a woman/man) and 5.05 (SD = 5.32) drinks per drinking day 30-days prior to treatment entry. RESULTS: The study provided initial support for the feasibility and acceptability of implementing the SFAS within a treatment setting. Participants reported high levels of satisfaction with the SFAS (M = 9.08 (SD = 0.94), on a scale of 1-10). At 3-month follow-up, the SFAS was associated with reductions in the proportion of activity participation and enjoyment (reinforcement) related to substance-use relative to substance-free activities and in alcohol demand compared to control. CONCLUSION: These preliminary results provide initial support for targeting behavioral economic mechanisms of change in an outpatient AUD treatment with a single-session intervention plus remote delivery of booster prompts.

Limitations of the Millon Behavioral Medicine Diagnostic (MBMD) with bariatric surgical candidates.

BACKGROUND: In this paper, we critique the Millon Behavioral Medicine Diagnostic's (MBMD) psychometric characteristics for use with bariatric surgery patients. METHODS: The reliability data presented by the test authors in their manual were examined. RESULTS: The results found 16 of 32 scales of have internal consistency reliability coefficients that do not meet minimal standards for use with bariatric populations. Of the remaining 16 scales, 13 do not have any compelling evidence that they are reliable. We suggest that if a test is not psychometrically reliable then its validity is called into question. Based on these data, 16 of the MBMD's 32 scales have inadequate reliability and 13 are lacking evidence of reliability. We urge clinicians to carefully consider these findings and the implications for their work with bariatric surgery patients.

Effectiveness of intensive outpatient programming in private practice: integrating practice, outcomes, and business.

The development of a model for treating acutely depressed patients on a frequent basis in an independent practice setting is described. Strategies to collaborate with managed care organizations, employee assistance programs, and local provider networks to recruit these patients are outlined. The patients treated in the intensive outpatient program described in this article were primarily depressed, were more acutely distressed than national and local inpatient samples, were often in suicidal crises, and had multiple comorbidities. Nonetheless, they demonstrated significant pre- and posttest improvements on a variety of client- and clinician-rated measures. A dose-response curve further illustrated that significant improvement in depressive symptoms was predictable. Private practitioners can expand their services through the development, implementation, delivery, management, and evaluation of mental health services that respond to market dynamics.

Work-related trauma, PTSD, and workers compensation legislation: Implications for practice and policy.

The current review examines work-related traumatic events, with particular focus on posttraumatic stress disorder (PTSD) as a potential mental health outcome. Despite considerable empirical knowledge about trauma and PTSD, a gap exists with respect to laws undergirding Workers Compensation (WC) insurance coverage for work-related mental health injuries. In this article, state and federal WC statutes are examined with an eye toward coverage of PTSD following work-related trauma. Examples of differences between states, as well as state-specific idiosyncratic facets of WC laws, are discussed. Federal WC programs are also examined. Two policy issues are highlighted: (a) lack of parity between WC coverage for work-related physical versus mental health injuries and (b) lack of reliance on psychological science in scripting legislation and determining WC benefits. The cost of untreated PTSD following work-related trauma is examined, focusing on costs to the individual, the employer, and society at large. The authors provide 3 recommendations designed to address discrepancies related to compensable psychological injuries following work-related trauma exposure.

Empirical validation of a mental health intensive outpatient program in a private practice setting.

This article demonstrates the treatment effectiveness of a mental health Intensive Outpatient Program (IOP) in a private practice setting. Pretreatment and posttreatment symptom and clinician-rated Global Assessment of Functioning (GAP; American Psychiatric Association, 2000) scores were used to determine treatment effectiveness. Reliable change indices and clinically significant change scores were used to control for measurement error and to validate functional change. The IOP patients demonstrated statistically and clinically significant symptom reductions on all 9 clinical scales and 4 global measures of distress, demonstrated movement to less severe levels of functioning, and reported a very high degree of consumer satisfaction. Follow-up data indicated continued improvement and satisfaction. Client satisfaction data and follow-up survey data are also reported.

Relationships of personality disorders with MMPI-2 malingering, defensiveness, and inconsistent response scales among forensic examinees.

MMPI-2 validity scales were correlated with MCMI-II personality disorder scales to examine relationships between response styles and personality disorders in a sample of 84 criminal defendants. 14 MMPI-2 validity scales were significantly correlated with 13 personality disorders. All of the personality disorder scales were significantly correlated with at least one validity measure and 11 of 13 personality disorder scales were significantly correlated with two or more MMPI-2 validity scales. While a personality disorder diagnosis may have a general effect on validity scales, relationships theoretically consistent with a given personality disorder were also found. This means that response set appears to be a manifestation of personality, and as such, examiners should expect symptom amplification or minimization or inconsistent responses, based on an individual's personality. Subsequently, forensic examiners are encouraged to evaluate the relationships between MCMI-II personality disorders and MMPI-2 validity scales to avoid misjudging MMPI-2 profiles as invalid when they accurately reflect manifestations of personality.

Statistical significance testing and clinical effectiveness studies.

Effectiveness studies, by definition, must reflect patient and treatment variables that exist in the real world of practice. This includes identifying the covariates that contribute to both positive and negative outcomes. The use of clinically significant change and reliable change indices is reviewed to demonstrate that patient changes can be made on the basis of normative comparisons, using outcome relevant variables that reflect the diversity of problems that are of concern to our clients. Therefore, neither agreement on a single outcome index nor plotting the entire outcome frequency distributions of the comparison group, as called for by Krause (see record 2011-19228-002), is required. Various methods currently exist and are used to address the limitations Krause cites with respect to randomized trials, outcome relevant covariates, file-drawer effects, and so forth. The identification and prediction of an individual's treatment response can be done in treatment as usual studies, where outcome relevant covariates have not been controlled, by studying change at the individual level. By studying such individuals and their combined continuums of treatment response, we can then identify clinically relevant outcome variables and alter the course of treatment accordingly.

Methods for analyzing psychotherapy outcomes: a review of clinical significance, reliable change, and recommendations for future directions.

The purpose of this article is to provide a brief review of the history, development, and current status of the concepts of clinical significance (CS) and the reliable change index (RCI). I address issues regarding the development, criticisms, and applications of CS and RCI. I review the use of normative data, cutoff points, formula adjustments, and the comparative validity of various RCI methods. An examination of the convergence of multiple domains and multiple measures demonstrates ways to further develop the concepts of reliable change and CS. Finally, I make some recommendations and implications for future research and the development of assessment tools.