Department of Psychology, University of Sheffield, Sheffield, UK.
BMC Psychiatry. 2018 Oct 3;18(1):321. doi: 10.1186/s12888-018-1899-0.
A previously published article in this journal reported the service effects from 103 services within the UK Improving Access to Psychological Therapies (IAPT) initiative and the comparative effectiveness of CBT and Counselling provision. All patients received High-intensity CBT or High-intensity Counselling, but some also received Low-intensity CBT before being stepped-up to High intensity treatments. The report did not distinguish between patients who received low-intensity CBT before being stepped-up. This article clarifies the basis for collapsing low- and high-intensity interventions by analysing the four treatment conditions separately.
Data from 33,243 patients included in the second round of the National Audit of Psychological Therapies (NAPT) were re-analysed as four separate conditions: High-intensity CBT only (n = 5975); High-intensity Counselling only (n = 3003); Low-intensity CBT plus High-intensity CBT (n = 17,620); and Low-intensity CBT plus High-intensity Counselling (n = 6645). Analyses considered levels of pre-post therapy effect sizes (ESs), reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session.
Significant differences obtained on various outcome indices but were so small they carried no clinical significance. Including the four treatment groups in a multilevel model comprising patient intake severity, patient ethnicity and number of sessions attended showed no significant differences between the four treatment groups. Comparisons between the two high-intensity interventions only (N = 8978) indicated Counselling showed more improvement than CBT by 0.3 of a point on PHQ-9 for the mean number of sessions attended. However, this result was moderated by the number of sessions and for 12 or more sessions, the advantage went to CBT.
This re-analysis showed no evidence of clinically meaningful differences between the four treatment conditions using standard indices of patient outcomes. However, a differential advantage to high-intensity Counselling for fewer than average sessions attended and high-intensity CBT for more than average sessions attended has important service implications. The finding of equivalent outcomes between high-intensity CBT and Counselling for more severe patients also has important policy implications. Empirically-informed procedures (e.g., predictive modelling) for assigning patients to interventions need to be considered to improve patient outcomes.
本刊之前发表的一篇文章报告了英国改善心理治疗服务（IAPT）计划内的 103 项服务的服务效果以及认知行为疗法（CBT）和咨询提供的比较效果。所有患者均接受高强度 CBT 或高强度咨询，但有些患者在接受高强度治疗前也接受过低强度 CBT。该报告没有区分接受低强度 CBT 后被提升的患者。本文通过分别分析四种治疗情况，阐明了合并低强度和高强度干预措施的依据。
对纳入第二轮全国心理治疗审计（NAPT）的 33243 名患者的数据进行了重新分析，分为四种单独的情况：高强度 CBT 组（n=5975）；高强度咨询组（n=3003）；低强度 CBT 加高强度 CBT 组（n=17620）；低强度 CBT 加高强度咨询组（n=6645）。分析考虑了治疗前后的效应大小（ES）、可靠改善（RI）和可靠且具有临床意义的改善（RCSI）的水平。使用多层次模型来预测结果，即患者在最后一次治疗时 PHQ-9 评分的治疗前后变化。
在各种结果指标上都有显著差异，但差异太小，没有临床意义。将四个治疗组纳入包括患者摄入严重程度、患者种族和参加的疗程数在内的多层次模型中，四个治疗组之间没有显著差异。仅对两种高强度干预措施（n=8978）进行比较，表明在平均疗程数上，咨询比 CBT 在 PHQ-9 上的改善程度高 0.3 个点。然而，这一结果受到疗程数的调节，对于 12 个或更多疗程，优势转向 CBT。
本重新分析显示，使用患者结果的标准指标，四种治疗条件之间没有证据表明存在具有临床意义的差异。然而，对于接受疗程少于平均疗程的患者，高强度咨询具有明显优势，对于接受疗程多于平均疗程的患者，高强度 CBT 具有明显优势，这对服务具有重要意义。对于更严重的患者，高强度 CBT 和咨询的结果相等也具有重要的政策意义。需要考虑基于经验的程序（例如，预测建模）来为患者分配干预措施，以改善患者的结果。
