Algorithms in Psychological Health Care

On the one hand, I see the value of having general guidelines for health care providers to follow.  But on the other hand, I see that there are more fundamental principles, such as establishing trusting relationships, practicing listening and interviewing skills, etc., that are far more important as standards of care, than following some kind of mechanical algorithm.   Most of the so-called "algorithmic" elements in managing psychological distress are things that most any clinician or therapist would have studied extensively in their long years of schooling, hence it is potentially quite redundant (and wasteful of time) to dwell at length on the preparation of such standards.    But I do think there are many ways in which care standards could be improved in a caring and collaborative community.  For example, I think that regular multidisciplinary "rounds"-style meetings to jointly discuss ways to manage particular problems, could be a fruitful, meaningful,  immediately useful, intellectually stimulating and robust process.  
 

Preamble

Algorithms of care can improve the efficiency of treating disease in a population, particularly when resources are limited, and when individual practices may have idiosyncratic variation.   Good examples of care algorithms which can lead to vast reductions of illness and death, and vast reductions in cost (both in terms of money and of effort), include those for treating cholera or for treating insulin-dependent diabetes.    For cholera, a simple standardized pathway of giving fluid and electrolyte replacement can be readily learned by all caregivers, and can very simply prevent death by dehydration.  For diabetes, standardized glucose monitoring regimes with basic guidance for insulin type and dosing can similarly be learned by all members of a care team (including the patients), leading to great improvements in safety, reductions in diabetes-related medical emergencies, and improvements in long-term morbidity. 

In managing mental illnesses, it can be valuable to consider a similar style of care algorithms. 

Patient Preference

In many cases, a given person may wish to have a certain type of care for a psychiatric problem.  Many patients simply want to talk to someone regularly, and do not necessarily wish to do CBT exercises.   Some patients strongly desire a medication therapy.  Other patients are strongly opposed to having a medication therapy. 

We cannot push patients into a care algorithm which is too rigid to account for patient preferences.  It is, however,  fair to introduce all patients to the various options available. In most cases, different varieties of care (such as different styles of psychotherapy, different specific medications, etc.) have far fewer differences in effectiveness than one might expect.  There are certain generalities for almost all psychiatric syndromes, however:  while all types of psychotherapy are helpful, there is good evidence that ideas from CBT should be encouraged irrespective of the style.  “Formal” CBT is not necessarily superior to “informal CBT,” particularly if a particular patient does not actually wish to have “formal CBT” but rather simply wants a supportive therapist to talk to, or perhaps a trial of psychodynamic therapy.  In practice today, most therapists use eclectic styles, such as a psychodynamically-informed variation of CBT, etc.  

Therapist Preference

Different individual therapists have different backgrounds, personality styles, areas of interest, and strengths.  Some particular therapists may excel in CBT-style therapies.  Other therapists may be experts in meditation.  Others may have a unique eclectic approach.  All of these individual therapist strengths and variations should be nurtured.  While it is good to have some unifying features of care, in the form of care algorithms,  it would be bad for the morale of the staff, and bad for patient care, for all therapists and physicians to have to conform to an identical pathway.  

Once again, patient preference may also guide which therapist would be most suitable; this fact should be respected deeply, especially for such an intimate matter as dealing with a mental health issue. 

Most of us, if were to start seeing a therapist, would want to choose the person we see, based on a variety of personal and professional factors.  

Especially in a university such as UBC which values the notion of diversity and personal autonomy, we should emphasize the ability for students seeing a mental health worker to choose the style of care that they would prefer, within the constraints of the system, as opposed to be sent on a rigidly observed care algorithm. 

 Comorbidities

Some of the most common clinical presentations in mental health care are of people who have so-called comorbidities.  These are people who meet criteria for more than one formal diagnostic category at the same time.  

Prevalence of comorbidity:  According to Brown et al (2001) a patient with an anxiety disorder diagnosis has a 57% chance of having additional DSM-IV Axis 1 comorbidities; a patient with a mood disorder diagnosis has an 81% chance of having additional DSM-IV Axis 1 comorbidities.  This figure does not even account for Axis II (personality), Axis III (physical health), or Axis IV (psychosocial) comorbidity. 

Barlow’s “Unified Protocol for the Transdiagnostic Treatment of Emotional Disorders” in an example of a therapeutic system which addresses comorbidities, by recognizing what Barlow considered an emotional syndrome which underlies many of the specific diagnostic manifestations.  In their words,

heterogeneity in the expression of emotional disorder symptoms (e.g.,individual differences in the prominence of social anxiety, panic attacks, anhedonia) is regarded as a trivial variation in the manifestation of a broader syndrome. (Farchione et al, 2012)

The example of Barlow’s system carries highly relevant practical wisdom, in terms of running an efficient mental health service:  it is possible to offer a quite similar treatment strategy  to individuals with a broad range of diagnoses and comorbidities. 

In many other cases, a given person may not wish to receive a diagnostic label at all, and a suggested treatment regime for a given diagnosis may be problematic.  Some people may find such labels and ensuing label-specific streams of care to be objectionable or even discriminatory. 

Therefore, given the issue of comorbidities and of clients’ reservations about labeling, it is important to view  “algorithms” with extreme flexibility and sensitivity, and perhaps consider not using them except as a very rough guideline. 

Readiness for Change

A therapeutic philosophy called  “motivational interviewing” is intended to address the fact that many people with the same diagnosis (such as an addiction, a mood disorder, or a relationship problem) may differ in their willingness to participate in a change process, whether this be psychotherapy, medication treatments, or even environmental change (e.g. dropping a course, seeking financial aid, etc.). 

All treatment algorithms must consider the differences between people in their degree of insight about their health concerns, and their willingness or readiness for change. 

It is highly counterproductive to prescribe a change strategy to someone who does not desire it.  And it is also highly counterproductive to simply send such a person away, if they do not choose to participate in a given program of action. 

Therapeutic Alliance

The goodness of the relationship between a patient or client and a caregiver (a therapist, physician, or other support) is strongly related to clinical improvements in all psychiatric conditions.  It is intuitively obvious that this so-called “therapeutic alliance” must be tended to as the highest priority in any care regime.  An algorithm of care must begin by developing a positive, trusting relationship between the patient or client and the caregiver, and the algorithm must not be applied in a mechanical manner which could harm the “therapeutic alliance.”  The research literature about this stretches back for decades.   Martin et al (2000) in a meta-analysis, show that therapeutic alliance is strongly related to outcome.   A more recent research example is Arnow et al (2013), who show that therapeutic alliance is strongly related to improvement in a group of chronically depressed adults; of note, this effect was particularly strong in a subgroup receiving a type of therapy called CBASP, which is similar to the varieties of therapy most commonly recommended in standard care algorithms in the past decade.  

However, it should be noted that problems with the therapeutic alliance are more likely if the severity of symptoms is higher.  In many cases, a factor which impacts care of any serious psychological problem is a difficulty establishing trusting relationships with a caregiver, regardless of the quality of care offered.  Therefore, we may see that therapeutic alliance is excellent in many cases, for particular cohorts, but this may simply be due to the clinical problems in this cohort being mild, rather than the care being somehow exemplary.  Conversely, a clinician dealing with severely symptomatic clients may have lower therapeutic alliance measures, but this could be due to the severity of the clients’ problems, not to problems in the quality or propriety of care.  

But another good recent research paper by DelRe et al (2012) shows that therapeutic alliance is more strongly determined by the therapist than by the client; here is a quote from their conclusion:

In summary, therapist variability in the alliance appears to be more important than patient variability for improved patient outcomes (as assessed with the PTR moderator). This relationship remained significant even when simultaneously controlling for several potential covariates of this relationship. These results suggest that some therapists develop stronger alliances with their patients (irrespective of diagnosis) and that these therapist's patients do better at the conclusion of therapy. (DelRe et al, 2012)

Other recent research shows that a poor therapeutic alliance can not only cause a regime of therapy to be ineffective, it can cause it to be actively harmful.   Goldsmith et al (2015) show that early psychosis patients can benefit from psychotherapy, but are harmed by attending therapeutic sessions with poor therapeutic alliance. 

Therefore, it is important in this “algorithmic” process to remember the massively important issue, which transcends all other issues of technical details, decision trees, etc.–of attending to the therapeutic alliance, by fostering compassionate, wise interpersonal skills in all counseling professionals, as the cornerstone of any algorithm. 

But how to do this?   There are many ideas, but in a collaborative model, it would be a good idea to focus on collaborative teaching and feedback between different clinicians who have varying degrees of experience and skill, as an important element of any care pathway.  

Does Conformity to a “manualized” standard improve clinical outcome? 

There are many so-called “manualized” therapy techniques.  These are designed as an attempt to standardize care, and are particularly useful in research, to determine and measure whether particular styles or techniques are actually better or worse than alternatives.

Yet, existing evidence does not support the notion that variations in therapeutic style strongly impact clinical outcome.  While it is wise for therapists to follow and learn new therapy ideas, such as CBT, the most important thing, once again, is for therapists to develop ways to optimize the therapeutic alliance, rather than focus on particular details from a manualized approach. 

This is also an evolving area of research, one example being Tschuschke et al (2015), who demonstrate that therapists’ adherence to a prescribed treatment regimen should be flexible, particularly for people who have more severe symptoms or problems.  According to the authors, such flexibility is more consistently present in more experienced therapists, and may reflect, in general, the degree of competence in the therapist. 

We can speculate that therapists might have to make sure that the therapeutic process can continue and that the relationship is improving or at least stabilizing on an acceptable level, so as to assure that the treatment can continue. This probably includes therapists easing their treatment protocol temporarily. Thus, treatment adherence in psychotherapy is not always a stable factor but instead depends on therapists’ level of professional experience, clients’ abilities to establish a good enough working alliance, and the climate of the therapeutic cooperation in the dyad, although it might, on average, remain on a relatively low level in most sessions. Nevertheless, the flexibility of therapists treatment adherence reactions seems to impact treatment outcomes substantially if clients’ severity of psychological problems hampers the working alliance. (Tschuschke et al, 2015)

Therefore, with respect to algorithms of care, it should be emphasized that flexibility must be called for in their interpretation, particularly for the many clinical situations in which there are complications or difficulties due to higher levels of severity, complexity, therapeutic alliance problems, or limitations due to low readiness for change. 

References

Brown, T. A., Campbell, L. A., Lehman, C. L., Grisham, J. R., & Mancill, R. B. (2001). Current and lifetime comorbidity of the DSM-IV anxiety and mood disorders in a large clinical sample. Journal of abnormal psychology, 110(4), 585.

Del Re, A. C., Flückiger, C., Horvath, A. O., Symonds, D., & Wampold, B. E. (2012). Therapist effects in the therapeutic alliance–outcome relationship: A restricted-maximum likelihood meta-analysis. Clinical Psychology Review, 32(7), 642-649.

Farchione, T. J., Fairholme, C. P., Ellard, K. K., Boisseau, C. L., Thompson-Hollands, J., Carl, J. R., ... & Barlow, D. H. (2012). Unified protocol for transdiagnostic treatment of emotional disorders: a randomized controlled trial. Behavior therapy, 43(3), 666-678

Goldsmith, L. P., Lewis, S. W., Dunn, G., & Bentall, R. P. (2015). Psychological treatments for early psychosis can be beneficial or harmful, depending on the therapeutic alliance: an instrumental variable analysis. Psychological medicine, 45(11), 2365-2373.

Martin, D. J., Garske, J. P., & Davis, M. K. (2000). Relation of the therapeutic alliance with outcome and other variables: a meta-analytic review. Journal of consulting and clinical psychology, 68(3), 438.

Tschuschke, V., Crameri, A., Koehler, M., Berglar, J., Muth, K., Staczan, P., ... & Koemeda-Lutz, M. (2015). The role of therapists' treatment adherence, professional experience, therapeutic alliance, and clients' severity of psychological problems: Prediction of treatment outcome in eight different psychotherapy approaches. Preliminary results of a naturalistic study. Psychotherapy Research, 25(4), 420-434.

Addendum (March 9, 2017):

Here's an interesting Pew Research article, looking at the pros and cons of algorithms in health care and other areas:  http://www.pewinternet.org/2017/02/08/code-dependent-pros-and-cons-of-the-algorithm-age/
The authors argue that algorithmic approaches, while improving efficiency in some ways, also carry the risk of deepening divides and creating filter bubbles.  They can rely on biased data, may particularly have negative effects on people who are poor, less educated, and disadvantaged, and can limit freedom of choice.

Feeling Trapped in a Life You Don't Want: Hopelessness & Chronic Depression

I originally published this post in March, 2009.  I was just looking at it again today, while browsing through my blog...I thought I would re-publish this, and maybe work on adding to it.   I have been reviewing treatment guidelines for mental illness, and have been asked to help prepare some official guidelines for my workplace...while I find this task, of preparing "guidelines,"  meaningful or useful in some ways, with some worthwhile observations and tips to be discovered in the existing research, I finally find the task a great source of weariness and frustration.  This particular post really represents something that is much, much closer to the "core" of who I am, or who I want to be, as a psychiatrist.  And it reflects more deeply--than any "guideline" could-- my beliefs about caring for people who are suffering.   


This post is in response to a comment on my previous post "What to expect from an antidepressant".

What is the purpose of a life?

What needs to be present in a life to make it worthwhile?

If a life is like a work of art, a giant canvas that you have been working on for decades--what if you feel that the canvas has already been wrecked? The damage may have been caused by "bad genes" (e.g. an inherited tendency to be depressed, etc.), which in the canvas metaphor might mean the canvas itself is fragile, thin, easily damaged, doesn't hold pigment very well, etc.

Or the damage may have been caused by "bad environment" (e.g. a traumatic childhood, lack of support, lack of opportunity, natural disasters, war, poverty, etc.), which in the canvas metaphor might mean the canvas itself has been damaged by others, or by environmental adversity, causing it to be very difficult or painful to work with in the present.

Or the damage may have been caused by your own past efforts (e.g. a history of spending years trying to develop oneself-- in school, in relationships, in work, etc.--but where these efforts have ended in failure, pain, breakups, sorrow, regret, guilt, or a sense of having burned your bridges--and where the past failures obstruct future opportunities, e.g. via a poor academic transcript, work record, etc.). In the canvas metaphor this might mean there is a lot of paint on the canvas, but none of it is what you want, none of it is where you wanted it to be, none of it you actually like, it all looks like a collection of mistakes. If it was a literal canvas, you might feel like the best action would be to just throw the painting away, and either start fresh, or give up painting altogether. You might feel like you never wanted to paint in the first place, that the task was forced upon you by the fact of your birth, and by the social expectation that you are supposed to live out your life.

For many people who struggle with chronic depression, I think there is some combination of all these three possibilities: genes, external environment, and personal efforts which haven't worked out, all contributing to a state of hopelessness, tiredness, exhaustion. It can feel like a daily struggle just to make it through the day, a yearning for time to pass just for things to be over. Life can feel like a trap, a life sentence to a prison term, a forced existence that you never really wanted, or have long since stopped wanting.

The idea of a medication somehow "treating" this problem can seem absurd. Or the idea of so-called "cognitive therapy" changing this problem can seem insulting. It is like observing a painting you don't like in an art gallery, and then being told that you have to do some exercises to change your thinking, so that you will start to like it, then have it up on your living room wall for the next 60 years. In some ways this dynamic reminds me of salesmanship, in which case it can feel like the therapist, or even the whole external world, is trying to "sell you" the idea that your life is supposed to be worthwhile, when all you see is something you hate and want to get rid of.

I don't have easy answers to this problem.

But here are some of my beliefs about approaching it:


There are people who will care about you, and who will sit with you through your suffering. A role of a therapist in this type of situation, I think, is to sit quietly, to be gently and consistently present.

The world is full of possibility. No matter how bad conditions have been--internally or externally, past or present--growth and change are possible. The brain is a dynamic structure. It is as powerful and consistently active when alive as is the heart. But the brain reinforces its own pathways. If these pathways give rise to feelings of despair, hopelessness, and futility, then every moment of life can become experiences of despair, hopelessness, and futility. If these pathways of thought, emotion, and felt experience, have been trodden for decades, it can be hard to forge new pathways within the mind.

Immense, profound life change is possible, regardless of how severe problems have been, how long they have been present, or how much damage the problems have caused.

Such changes may require an enormous amount of energy and time, and may require a lot of external support.

There are many individual life stories of profound life change, stories of journeys through chronic hopelessness towards meaning, energy, and joy. Historically, some of these stories are of mythical proportion, and are present in literature and the other creative arts. Many religious stories contain themes of this sort.

Contemporary examples include stories of individuals overcoming lifelong addictions which had devastated their previous life histories (here I am not saying chronic depression is an addiction, but that addictions and depression can both be characterized by feeling very stuck in something bleak and hopeless). The lore in addiction treatment has wisdom to share about making radical life change--in "12 step" models, for example, individuals are called upon to admit "powerlessness" over their problem, and to make a set of statements of faith about a "Power greater than ourselves", etc. While I am wary of the potential for dogmatic religiosity in such statements, I also see that if dogma can be set aside, the "12 steps" can be seen as a sort of "leap of faith", a new contract with life, to live--and work-- with the help of a supportive community. It admits, powerfully, that one must reach out to connect with the possibility of change, it is almost impossible to do alone (the "higher power" idea can simply be an admission that one needs external help).

Psychiatric medications in chronic depression usually do not lead to "profound life change" (sometimes they do, but really this is in a small minority of cases). However, often they help a small to moderate amount. Either to relieve some suffering or pain, or to potentiate energy that might then help to effect a new course in living. I do not feel that any effective treatment leads a person to become resigned to an unpleasant status quo, and then to learn how to "accept a bad life". I feel that effective treatments allow unpleasant circumstances to feel more bearable, then to facilitate the hope and actions that are necessary to improve the unpleasant circumstances.

Cognitive therapy can help. The goal, however, in cognitive therapy, cannot be simple "salesmanship". I think the goal has to be building a satisfying life, where there are healthy, stable relationships: meaningful work, meaningful love relationships, and meaningful activities that bring joy or happiness.

With any type of process that causes deep changes in the brain, the pathway may require you to go right back to the simplest foundations.

I'm reading Norman Doidge's book about "neuroplasticity" right now (The Brain that Changes Itself), which incidentally I recommend highly. The evidence he presents is quite convincing, to some degree surprising, but on another level intuitively very obvious--the brain can change itself, sometimes very radically.

But if new paths are to be formed in one's "mental forest" one may need to start with tasks that seem extremely simple, even infantile, perhaps even "insulting" in their simplicity. Cognitive therapy can seem extremely trite, or even a ridiculous exercise in mental manipulation--an exercise to comform oneself to how society as a whole expects you to think or feel, trying to convince you to think good thoughts about a bad situation.

The thing is, though, these seemingly ridiculous tasks (such as cognitive therapy, etc.) can start new paths forming. In conjunction with this, new connections can begin with the external world, in the form of new friendships, new involvements in creative work, new involvements in education, etc.

There may well be burned bridges, but there is a vast energy available to build new bridges, if you so wish. And your past experiences may eventually become more useful to you than they are right now.

Depression can be extremely tenacious. It is so extremely tenacious that in some cases it is almost like a character that wants to perpetuate itself. The depression itself, so to speak, sets up arguments in one's mind about why this or that action (e.g. medication, therapy, life change of other sorts) cannot or should not happen. In the forest path metaphor, it is like the depression not only has become an extremely well-trodden pathway in a dense forest, but it has also put high fences around the pathway, and a deep moat full of crocodiles on the other side of the fence too.

Once again, I emphasize that I have no easy answers. As I look at the above post, I see that it is rambling. Parts of it probably sound preachy or trite. Probably annoying to look at if you are feeling trapped in a depressive state. I think I come off sounding like a salesman myself, trying to convince you to buy that painting you don't really like.

My intention, though, is to convey my belief that change is possible. There is proof that change is possible. I see this proof in my own clinical experience, as well as in the stories of others. Deep change in a chronically unhappy life is possible, but may require a great deal of external help, and may require a type of commitment to change that is extremely difficult or exhausting to initiate. And your depression won't want you to make any such commitment.