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Monday, June 3, 2019

Rationale and importance of case formulation


By: PETER STURMEY

Clinicians must determine which treatment is best for which client. There are now a very large number of treatments available for all the common mental health disorders. Clinicians may well be perplexed as to which treatment to select for each particular client.

One approach to solve this problem is to use psychiatric diagnosis to predict treatment. The terms used to describe both pharmacological and psychological treatments often refer to diagnosis. Psychotropic medications are called ‘anti-depressants’, ‘anti-psychotics’ and ‘anxiolytics’. Psychological treatments also often refer to diagnosis, for example when we refer to treatment groups as ‘anxiety management groups’ or ‘support groups for eating disorders’ and so on. Treatment algorithms, randomized controlled trials (RCTs), reviews of the outcome literature and reviews of evidence-based treatment, such as Cochrane reviews, National Institute for Clinical Excellence guidelines and the APA guidelines (APA, 2005), all are organized around diagnostic categories. Many mental health advocacy groups are also organized around specific diagnostic groups. Thus, the notion that diagnosis predicts effective and ineffective treatment is pervasive. This model suggests that diagnosis 1 predicts that treatment A will be relatively effective for this diagnosis and treatment B will be relatively ineffective for this diagnosis, and diagnosis 2 predicts that treatment A will be relatively ineffective and treatment B will be relatively effective for this diagnosis. Thus, we might recommend anti-depressants for people with Major Depression, but not for a Psychotic Disorder. Likewise, we would place people with anxiety disorders in an anxiety management group, not in a support group for people with eating disorders. This model is based on an interaction between diagnosis and treatment.

This model of predicting treatment efficacy has many limitations. First, most outcome research using RCTs does not address the question of diagnosis by treatment interaction. Rather, most RCTs merely compare one treatment with some other procedure, such as a waiting list control, or, more rarely, some placebo or perhaps a second treatment. Researchers select participants to ensure that they all meet the same diagnosis. Thus, these kinds of RCTs permit us to conclude that treatment A may be effective for diagnosis.

They tell us nothing about the effectiveness of this treatment for diagnosis and nothing about whether this treatment is the most effective treatment for this diagnosis. Wilson (1996) proposed a contrary argument. He has noted that some standardized, manualized treatments for eating disorders are highly effective. He suggested that treatment determined by diagnosis might be highly desirable because the clinician can learn one highly effective treatment procedure to a high degree of proficiency. Further, there may be little room left for individualization of treatment – which in any case might be unreliable and capricious – to improve over this standard treatment. (Ghaderi [2006] presented some evidence to the contrary.)


A second limitation to this model of predicting which treatments might be effective is that response to treatment is highly varied. RCTs emphasize statistical significance – changes that are unlikely to be due to chance – and changes in the score of the average, but non-existent, subject. Statistically significant results may emerge from many patterns of response to treatment. For example, a statistically significant result might occur if 50% of the treatment group have a large, positive response to treatment, 25% have no response and 25% have a modest negative response to treatment, if the experiment has a large enough number of participants and if the dependent measures are sufficiently sensitive. A statistically significant result may also emerge if most of the participants make a modest improvement but one that has no practical significance for any particular person. The average client does not exist: the clinician will never treat this mythical person. The clinician treats specific clients. Even when there is a strong evidence base for a particular treatment, it may be unclear at the outset of treatment if the clinician is working with someone who will respond positively, not respond or respond negatively to this particular treatment.

A third limitation is that clinicians frequently work with clients who have apparently already had standard, diagnosis-based treatment and who did not respond to any meaningful degree. For example, it is common for clinicians to work with people who have taken anti-depressants or anxiolytic medication for many years and still have significant problems; indeed their failure to respond to standard treatments is often the reason for referral. Further, after standardized psychological treatments, such as anger management, cognitive behaviour therapy for depression and so on, a significant proportion of clients have residual problems, did not respond or responded badly to standard treatment.

A fourth limitation in diagnosis predicting the most effective treatment for each client is that many clients meet diagnostic criteria for more than one diagnosis. When a clinician works with a client who meets diagnostic criteria for Major Depression, Substance Abuse and Generalized Anxiety Disorder, which of these three diagnoses predict the most effective treatment for this client? If all three predict effective treatments, in which order should the clinician implement these treatments? Will effective treatment of the Major Depression result in a generalized improvement in the client’s functioning, or will treatment of the Generalized Anxiety Disorder result in the broadest spread of treatment effects?

The ability of psychiatric diagnosis to predict the most effective treatment depends on the reliability and validity of that diagnosis. The developers of the third edition (revised) of the Diagnostic and Statistical Manual (DSM) trumpeted its arrival as a triumph of science (Kutchins and Kirk, 1997). The number of psychiatric diagnoses has expanded considerably with each edition of DSM (Houts, 2002) and the developers of DSM did not conduct reliability trials for almost all the hundreds of diagnoses in DSM-III-R (Kutchins and Kirk, 1997). Where researchers did conduct diagnostic trials, they were conducted after the diagnostic criteria had already been set; thus, the results of reliability trials did not inform the development of the diagnostic criteria. Indeed, careful examination of the reliability of DSM-III-R revealed that the reliability of the new diagnostic criteria may not have been very much different from the reliability of the old criteria (Kutchins and Kirk, 1997). In any case, this may be of limited relevance, since the reliability of diagnosis by routine practitioners may have little to do with the diagnostic practices of eager, well-trained government-funded researchers. Some structured clinical interview procedures may result in quite high reliability. However, most clinicians do not use these assessment methods routinely. In any case, the validity of these measures to differentially predict an effective treatment is still little researched.

Clinicians may often work with clients with rare, idiosyncratic, subclinical problems or other problems that do not meet diagnostic criteria. In these situations too, psychiatric diagnosis may be of limited use to predict treatment. Finally, some clinicians often feel that they have something more to offer than skilled, but technocratic, application of diagnostic algorithms and manualized treatment. Whether true or not, many clinicians believe that their input into understanding the case and designing treatment for each individual client has something to contribute to treatment.

These limitations to predict treatment based on diagnosis, if true, are serious. Consequently, clinicians and professional training standards have argued that case formulation is a better way to guide selection of the most effective treatment.

References

Peter Sturmey, Clinical Case Formulation; Varieties of Approaches, 2009, John Wiley Ltd.

Read Also

Clinical Expertise
Evidence-Based Practice in Psychology
Best Available Research Evidence
Definitions of case formulation

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