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Find the right combination of evidence-based and individualized treatment

January 5, 2015
by Michael Levin-Epstein
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Behavioral health clinicians increasingly are using treatments that combine evidence-based medicine—which incorporates clinical pathways, scientific studies and electronic medical records—with more traditional patient-centered, shared decision-making approaches. But the question that remains is how to balance the two so that protocol is neither a rigid “cookbook” nor dubious “gut instinct.”

Compared to a decade ago, there is more opportunity for incorporating evidence-based medicine because the body of evidence has increased in recent years.

“As the scientific knowledge base in behavioral science establishes firmer ground, there is a wider acceptance among clinicians to use evidence-based practices,” says Raymond Garcia, MD, medical director for Rosecrance’s Harrison campus, in Rockford, Ill. “Using new tools to enhance diagnostic accuracy and determine more specific etiologies for behavioral health conditions, we will be better able to individualize care.”

For example, there are genetic assays that show promise in guiding treatment options based on the individual’s ability to metabolize certain medications. And, he says, clinicians are starting to use the tests to choose specific medications, especially in individuals who have had poor outcomes previously. New technologies can help at the initial diagnosis stage as well.

“Enhanced/functional brain imaging studies can be used in aiding diagnosis, especially as costs come down,” says Garcia.

Policy influence

Provisions of the Affordable Care Act (ACA) that foster quality-based reimbursement models and pressure from insurance companies are also driving the use of evidence-based approaches. More insurers are expecting providers to use step therapy and obtain patients’ coverage approvals after a medical review process.

“If you want to get reimbursed, you’d better be able to demonstrate scientific research and treatment efficacy,” says Constance Scharff, senior addiction research fellow and director of addiction research, Cliffside Malibu in California. “If there is any influence that is causing clinicians to lean toward following pathways and guidelines, it comes from government regulation and insurance companies. It is not uncommon for an insurance company to require the use of certain treatments first before they will approve other treatment options.”

Rosecrance ensures an evidence-based approach by having committees routinely review and approve any new clinical practice. In addition, Garcia says, no clinical practice is implemented before a Standard Operating Procedure (SOP) is written, and staff are trained to ensure compliance with the practice.  However, he notes, at Rosecrance, clinicians have the latitude to individualize care and are expected to provide a client-centered approach that includes shared decision making.

“We don’t believe that evidence-based practices and shared decision-making are mutually exclusive,” he says.

Recent research, such as STAR-D, for example, has supported this combined approach, according to Garcia, and relying on one approach to the detriment of the other doesn’t benefit the patient.

Evidence-based approaches have their limitations, many practitioners argue. Evidence is based on statistical analyses and outcomes, but human beings are undeniably complex. What’s more, the factors that contribute to behavioral health issues are myriad, according to Garcia. Statistics do not account for these individual nuances, no matter how well a study is controlled.

“Look at what has recently occurred in the release of the DSM-5,” he says. “There was serious consideration to eliminating personality disorders as a category completely, and there have been significant changes in the diagnosis of certain disorders, such as autism. Under these conditions, I find it difficult to reliably say that a certain practice is ‘gospel.’” 

When it comes to a client centered approach and shared decision making, what is most important is that the approach improves adherence to treatment recommendations and improved outcomes, Garcia says. Indeed, the evidence-based movement will never fully supplant the more patient-centered approach.

“Training programs are now incorporating the client centered approach and teaching trainees how to practice shared decision making,” says Garcia.

 Addiction treatment is also becoming more evidence-based because the 12-Step program on its own and rehabilitation treatment is often limited to 30 days, which is not particularly effective in the real world, according to Scharff.

“What is happening today,” she says, “is that Cliffside Malibu and other addiction treatment centers are using a host of holistic, complementary and alternative medicine (CAM) approaches, which are increasingly evidence-based, such as cognitive behavioral therapy, equine therapy, mindfulness meditation, acupuncture, and nutritional regimens—all of which have neuroscience and evidence-based research behind them.”

Along with using CAM treatment, addiction specialists are also using new generation medications, such as the buprenorphine and naloxone combination as a long-term treatment for opioid addiction. As harm reduction, the medication attempts to treat the symptoms of addiction using an evidence-based approach.

“This doesn’t get to the underlying cause of the problem,” she says. “We now know scientifically that, through techniques such as mindfulness meditation, we can rewire our brain in positive ways and avoid using pharmacological therapies.”

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We spent two decades refining this.

Phase I is to establish "best practices" and provide decision support for selection. i.e. record symptoms/signs, select a disorder from a list of prioritized candidates.

Then gain access to a set of modalities your selected disorder, (for forensic cases, record observations at criteria sets and get back a "meets diagnostic threshold/does not meet" as opposed to simply picking a disorder).

Next, do a differential diagnosis in case another disorder should perhaps have received the focus, then select from a short list for this disorder\modality various goals/objectives.

At each modality panel in your healthcare management system you need a boilerplate section where users can view evidence of efficacy (i.e. Treatments that Work).

It pays to also list modalities that do not work and why because patients and relatives often ask "why don't you try this?".

Once you have a disorder/modality/ plus goal(s) and objective(s) it is important to monitor these. Things change, one tx will work for a while then reach a stage of diminishing returns or you start to see untoward effects.

When you have more than one presenting problem, it is important to understand that Tx plans are written up by disorder. If more than one is present, a 1st line protocol for one might be contraindicated because of the tx plan for the other. You might need a blend of two or more Tx plans.

Finally, a rigid approach will not work - healthcare professionals need to be able to deviate away from "best practices" but this has to be constrained by "guardrails" to prevent extreme deviations that could harm the patient or the agency.

ACM and BPM in conjunction with non-subjective 'bubble' diagnostic algorithms and Figure of Merit (to avoid non-subjective assessment of progress toward discharge) are needed.

No one said it would be easy.

We love the idea of talking about treatment modalities that don't work to proactively inform families and patients. It's especially good in this era of endless Youtube videos that too many folks rely on for information, whether true or not.

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