Putting measurement-based care into action: A mixed methods study of the benefits of integrating routine client feedback in coordinated specialty care programs for early psychosis.

Background: Measurement-based care (MBC) is an effective tool in the delivery of evidence-based practices (EBPs). MBC utilizes feedback loops to share information and drive changes throughout a learning healthcare system. Few studies have demonstrated this practice in team-based care for people with early psychosis. This paper describes the development of a personalized feedback report derived from routine assessments that is shared with clients and clinicians as part of a MBC process. Methods: We used a quasi pre-post comparison design with mixed methods to evaluate the implementation of a personalized feedback report at 5 early psychosis coordinated specialty care programs (CSC). We compared clients enrolled in CSC who did and did not receive a feedback report over the first 6 months of treatment. The sample included 204 clients: 146 who did not receive the feedback report and were enrolled over 2 years, and 58 who received the feedback report. A subset of 67 clients completed measures at both intake and 6-month follow-up, including 42 who received the report and 25 who did not. We compared the two groups with regard to self-reported symptoms, likelihood of completing treatment, and perception of shared decision making. We conducted qualitative interviews with 5 clients and 5 clinicians to identify the benefits and challenges associated with the personalized feedback report. Results: People who received a personalized feedback report reported significant improvements in shared decision-making and had greater improvements over time in their intent to attend future treatment sessions. They engaged in more sessions for Supported Employment and Education (SEE), case management, and peer support, and fewer medication visits over the first 6 months of treatment. Both groups showed significant improvement in symptoms and functioning. Results from the qualitative analysis indicated that the experience of receiving the reports was valuable and validating for both patients and clinicians. Conclusions: A personalized feedback report was integrated into standard of care for early psychosis programs. This process may improve shared decision-making, strengthen the likelihood to stay in treatment, and increase engagement in psychosocial interventions. We posit that this process facilitates strengths-focused discussions, enhances intrinsic motivation, and strengthens the therapeutic alliance.

Dropout rate of training cases: who and when.

Training cases define clinical immersion for candidates and are essential to their education, progression, and graduation. While dropouts from treatment are expected, repeated dropouts can be detrimental to a candidate's education and progression. In a study of the rate and timing of dropout in 145 cases at the Columbia University Center for Psychoanalytic Training and Research, 40 percent of patients were found to have dropped out within the first twelve months of treatment, though converted cases were less likely to drop out than were new patients evaluated at intake. This high dropout rate raises many questions about the reasons for it and suggests that there are critical educational issues regarding supervision and/or regarding candidates' technique during the induction phase.

A prospective study of career development and analytic practice: the first five years.

To better understand the professional development of early career analysts, the Columbia University Center for Psychoanalytic Training and Research initiated a prospective longitudinal study of its graduates beginning in June 2003. Twenty-six of 29 graduates (90%) have completed confidential baseline questionnaires focusing on four domains: experience in analytic training, current private practice, postgraduate activities, and career goals. Participants are followed longitudinally with annual follow-up questionnaires and interviews. Of the cohort of graduates from 2003-2007, 58% were female, compared to 20% female in the cohort of graduates from 1973-1977. A bimodal distribution emerges wherein half of all graduates continue to sustain immersion of at least three ongoing cases in analysis at a four-times-weekly frequency. The other half do not maintain this immersion in four-times-a-week treatment; they primarily apply their training to psychotherapy practice. The more immersed group indicate significantly stronger interest in pursuing training analyst appointment as a primary career goal. The nonimmersed group conduct psychotherapy, feel positive about their training experience, teach at the institute, and have high morale, yet do not consider being a psychoanalyst their primary career identity. Thus, by five years, two viable and satisfying career paths emerge among our graduates. These data are important for training programs, both in preparing their graduates for future practice and in supporting their postgraduate experience.

Why we recommend analytic treatment for some patients and not for others.

One hundred consecutive patients applying for analysis completed a comprehensive battery of structured interviews and self-report questionnaires assessing dimensions of psychopathology and psychological functions that analysts consider important when evaluating patients for analysis. Patients were evaluated for analysis by a candidate supervised by a training analyst. Fifty patients were accepted for analysis and fifty rejected. In both groups, psychiatric morbidity and psychosocial impairment were high, with a 50% current and 74% lifetime diagnosis of mood disorder, 56% current and 61% lifetime history of anxiety disorder. The mean Beck Depression Inventory score fell in the moderate range, 19.1 (SD = 11.0), mean Hamilton Depression score in the mild range, 14.1 (SD = 7.8), and the mean Hamilton Anxiety score in the moderate range, 14.6 ( SD = 8.1), with 57% meeting criteria for an Axis II diagnosis, and mean social adjustment in the moderate to high pathology range. Patients accepted and rejected for analysis did not differ with regard to any of these dimensions. Accepted patients scored lower on measures of impulsivity, aggression, and sociopathy, and on scores of personality rigidity, primitive defenses, and outward aggression. The major finding was the striking similarity between patients accepted and rejected for psychoanalytic treatment.