The Development of a Therapist Feedback System for MDD in Community Mental Health

描述（由申请人提供）：拟议研究的目标是开发和评估一种成本效益高且易于传播的干预措施的可行性，以改善在社区精神卫生系统中治疗的重度抑郁症患者的心理治疗效果。许多研究表明，反馈系统可以识别潜在的治疗失败，并提供结果信息，使心理治疗师能够改变治疗过程以最大化结果。然而，没有调查评估反馈干预在社区精神卫生中心的效果，这些中心迫切需要具有成本效益和有效的干预措施来改善结果。我们的目标是开发一个反馈系统，为治疗师提供基于BASIS-24的患者早期治疗进展信息，以及基于人格评估量表（PAI）的重要临床信息来指导治疗。我们提出了一个两阶段的干预发展计划，其中我们将1)评估BASIS-24和PAI的计算机化评估的可行性，2)进行治疗师焦点小组开发社区友好反馈报告，3)在社区精神卫生中心进行反馈系统的随机对照试验，评估研究方案的可行性和反馈干预对社区精神卫生系统的可接受性。我们将随机分配在两个社区精神卫生中心提供服务的治疗师，接收或不接收关于新患者进入重度抑郁症治疗的早期进展的反馈。所有在精神卫生机构被诊断为重度抑郁症的患者将在基线和每次治疗期间完成BASIS-24，作为常规临床程序的一部分。在早期治疗之前，反馈组患者的治疗师将收到一份基于BASIS-24的简短报告，表明患者迄今为止的进展。该报告还将包括一个颜色代码系统，该系统根据估计的恢复曲线向治疗师指示患者是否在改善治疗的轨道上。对于预期表现不佳的患者，报告将向治疗师提示患者应在治疗后完成PAI。患者将在治疗结束后在电脑上完成PAI，并在下次治疗前向治疗师提供一份临床报告，其中包括有用的临床建议。该试点试验将提供必要的可行性和可接受性数据，以支持未来的全动力试验，并证明该反馈系统在临床上的潜在成功。

DESCRIPTION (provided by applicant): The goal of the proposed research is to develop and evaluate the feasibility of a cost-efficient and easily disseminated intervention for improving psychotherapy outcomes for patients with major depressive disorder treated in the community mental health system. A number of studies have demonstrated promising results for feedback systems that identify potential treatment failures and provide outcome information that enables psychotherapists to alter the treatment process to maximize outcomes. Yet no investigations have evaluated the effects of feedback interventions in community mental health centers that are in dire need of cost-efficient and effective interventions to improve outcomes. Our goal is to develop a feedback system that provides information to therapists on the patient's early progress in treatment based on the BASIS-24 as well as important clinical information to guide treatment based on the Personality Assessment Inventory (PAI). We propose a two phase intervention development program in which we will 1) evaluate the feasibility of computerized assessment of the BASIS-24 and PAI, 2) conduct therapist focus groups to develop community friendly feedback reports, and 3) conduct a pilot randomized controlled trial of the feedback system in the community mental health center for the purpose of evaluating the feasibility of the research protocol and the acceptability of the feedback intervention to the community mental health system.. We will randomize therapists delivering services at two community mental health centers to either receive feedback or not receive feedback on the early progress of new patients entering treatment for major depressive disorder. All patients diagnosed with major depressive disorder at the mental health agency will complete the BASIS-24 at baseline and at each treatment session as part of regular clinic procedures. Therapists of patients in the feedback group will receive a brief report based on the BASIS-24 prior to the early sessions of treatment that indicates the patient's progress to date. The report will also include a color code system that indicates to the therapist whether the patient is on track to improve in treatment based on the estimated recovery curves. For patients who are predicted to do poorly, the report will indicate to the therapist that the patient should complete the PAI following the session. The patient will complete the PAI on a computer following his/her therapy session and a clinical report that includes useful clinical recommendations will be given to the therapist prior to the next session. This pilot trial will provide the necessary feasibility and acceptability data to support a future fully-powered trial and to justify the potential success of this feedback system clinically. PUBLIC HEALTH RELEVANCE: Major depressive disorder is a severe and disabling disorder afflicting 7% of individuals in the United States annually and approximately 17% of individuals across their lifetime (Kessler et al., 2005). Depression has been ranked as the fourth greatest public health problem by the World Health Organization (Murray & Lopez, 1996) and is considered the most likely illness to result in disability (Murray & Lopez, 1996). Despite multiple investigations demonstrating that both medications as well as psychotherapeutic interventions are effective in the treatment of major depressive disorder (APA, 2000), response rates in well-done efficacy trials still reach only 40 to 60% (DeRubeis et al., 2005; Bielski, Ventura, & Chang, 2004; Keller et al., 2000), and response rates for public sector clients are less than 30% (Rush, Trivedi, Carmody, et al., 2004). While many have suggested that outcomes in community-based settings could be improved through the dissemination of empirically-supported psychotherapies (Stirman, Crits-Christoph, & DeRubeis, 2004; Barlow et al., 1999; Chorpita et al., 2002; Henggler et al., 1995), such efforts have a variety of hurdles, including the cost of training therapists in new methods, and resistances of therapists to adopting new approaches that are discrepant from their own preferred style of therapy. The current research paradigm represents an alternative way to improve outpatient mental health outcomes, through performance feedback to the therapist that has the potential to improve mental health outcomes in community clinics in a feasible and sustainable way.