EFFECTIVENESS BANK ABSTRACT BULLETIN 30 June 2011
EFFECTIVENESS BANK ABSTRACT BULLETIN 30 June 2011The entries below summarise documents collected by Drug and Alcohol Findings. Citation here does not imply that these documents are particularly relevant to Britain and of particular merit, though they may well be both. The original documents were not published by Findings; click on the Titles to obtain copies. Free reprints may also be available from the authors; if displayed, click Request reprint to send or adapt the pre-prepared e-mail message. The Summary is intended to convey the findings and views expressed in the study. Below may be comments from Drug and Alcohol Findings. Links to source documents are in blue. Hover mouse over orange text for explanatory notes.
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This set of studies all relate to the treatment of substance use problems – how much money it saves society, how effective it is per pound spent, and how to recognise a high quality service. From the Netherlands too, a unique spotlight on the degree to which a clinician influences their patients simply by the kind of person they are, and how this influence can be supplemented by joint decision-making.
UK youth substance misuse treatment saves society money ...
First-month attendance better outcome predictor than retention ...
Putting patients in the co-pilot seat boosts confidence...
Family therapies effective but not always most cost-effective ...
Specialist drug and alcohol services for young people – a cost benefit analysis.Frontier Economics.
[UK] Department for Education, 2011.
Study published by UK government estimates that every £1 spent on specialist substance misuse treatment for under-18s in Britain averts social costs totalling £4.66–£8.38.
Summary This report looks at the costs and benefits associated with young people's drug and alcohol treatment. About 24,000 young people received specialist drug and alcohol treatment in the UK in 2008–09. This is defined as "a care planned medical, psychosocial or specialist harm reduction intervention". As set out in the Drug Strategy 2010, such treatment is aimed at preventing escalation of use or harm and should "respond incrementally to the risks in terms of drug use, vulnerability and, particularly, age". Most of these young people were treated primarily for alcohol (37%) or cannabis (53%) misuse, with the remaining 10% misusing drugs in class A of the Misuse of Drugs Act, including heroin and crack. They had also experienced a range of other problems, including involvement in crime (shoplifting, theft, assault); being NEET (not in education, employment or training); or housing problems.
The National Treatment Agency (NTA) has oversight of young people's specialist substance misuse services and systematically collects information on young people accessing them. This information includes data on young people's characteristics and, for most 16- and 17-year-olds, a range of outcomes comparing treatment start and exit (such as crime, health, housing and education). We have drawn on this data and the evidence from a range of academic studies and policy reports to assess the cost-effectiveness of young people's specialist drug and alcohol treatment in the UK.
Throughout the report the term 'young people' is taken to refer to those aged under 18 unless stated otherwise. However, much of the evidence base applies to those aged 16 or 17.
There are two main elements of our study:
• Costs Understanding the amount spent in total and per person on specialist drug and alcohol services for young people in 2008–09.
• Benefits Estimating and valuing the benefits of young people's drug and alcohol treatment – measured as a reduction in the economic and social costs of drug and alcohol misuse.
While measuring the costs of treatment is relatively straightforward, assessing the associated benefits is more complicated. First, we need to establish a counterfactual, ie, what would have happened without treatment. There is significant evidence that many of these young people would then have imposed significant economic and social costs on society. These can be split into:
• Immediate
costs
There may be other type of immediate costs (eg, teenage pregnancies) which we do not quantify in this study.
The cost of crime committed by young people misusing drugs, NHS costs associated with treatment of drug and alcohol-related conditions affecting young people, and the cost of drug and alcohol-related deaths for young people; and
• Long-term costs Costs incurred if young substance misusers become problematic drug users (PDUs) or problematic alcohol users as adults. If this happens, the costs imposed on society are likely to increase further as adult PDUs and problematic alcohol users tend to commit more frequent and serious crimes, impose higher costs on the NHS, are more likely to die prematurely and have high unemployment rates. Finally, those young people who do not become PDUs or problematic alcohol users as adults might still incur long-term costs. Indeed, young substance misusers are more likely to be NEET (not in education, employment or training) and leave school without qualifications. This too has a cost, in terms of lower wages and poorer employment prospects.
We rely on (NTA) data from the National Drug Treatment Monitoring System (NDTMS) and the associated Treatment Outcomes Profile data (TOP) and a range of academic studies and policy reports to estimate these counterfactual costs.
We estimate that the immediate counterfactual cost of crime committed by young people misusing drugs and alcohol is just under £100m per year. This equates to an annual cost of crime per young drug and alcohol user of around £4000 per person per year in the absence of treatment. These costs appear to be driven by a relatively few young people misusing drugs or alcohol, with most reporting no offending. The annual counterfactual health care cost is around £4.3m per year, or £179 per person per year. Within this, the counterfactual cost of drug and alcohol-related death accounts for £4.2m per year; the remainder is the cost of drug and alcohol-related illness.
To estimate the long-term counterfactual costs of adult substance misuse for young people in treatment, we look at three types of adult substance misuse:
• adult alcohol misuse;
• adult
problematic drug use
Throughout this report, the term problematic drug user (PDU) refers to clients citing opiates, crack cocaine, or both as any of their presenting substances. Non-problematic drug users (non-PDUs) are clients using illegal drugs other than opiates or crack when presenting for treatment. It should be noted here that even non-problematic drug use can impose considerable economic and social costs to society. Alcohol misuse in this report includes not just dependent drinking, but also harmful alcohol use (defined as drinking over the recommended weekly amount and experiencing health problems directly related to alcohol) and is consistent with our estimates of the costs of adult alcohol misuse.
(PDU); and
• adult non-problematic drug use (non-PDU).
It is likely that young people's substance misuse contributes to further costs, including those associated with children's services, and particularly the costs of being taken into care. However, it was not possible to isolate the proportion of these costs attributable to substance misuse, so these were not factored into the overall cost figures. Throughout the report we have taken a cautious approach to constructing cost and benefit figures to ensure that the final calculations provide a robust lower estimate of any projected savings.
In Table 1 we summarise the costs associated with adult substance misuse; these are the costs of crime, poor health, premature death and lost output due to absenteeism and low employment levels. These costs are high and vary between £21,300–£45,100 per year for non-problematic adult drug users, £173,090–£238,397 per year for adult alcohol abusers, and £550,388–£958,848 per year The cost estimates reported for adult problematic drug users are broadly consistent with previous estimates made by NICE, and subsequently adopted by the NTA in their recent analysis of the value for money of adult drug treatment. In particular, these studies estimate a lifetime crime cost of £445,000 for an injecting drug user, and a lifetime health cost of £35,000. Although at the lower end of our estimates of the lifetime cost of an adult PDU, these studies do not include costs such as lower productivity or other lost output and are therefore broadly in line with the estimates shown here. for problematic adult drug users.
However, not all young substance misusers will become problematic adult substance users, or experience other wider problems, even if not treated. Studies suggest that between 30% and 40% of moderate/heavy teenage alcohol and cannabis users would develop drug/alcohol misuse problems as adults while the remaining 60%–70% would experience natural remission (even if not treated). The proportion is however higher for teenage class A Of the Misuse of Drugs Act including heroin and cocaine. drug users (up to 95% of teenage class A drug users continue to use drugs in adulthood).
We combine the lifetime costs of adult substance misuse with the probabilities that young people currently in treatment would have become adult problematic and non-problematic drug users in the absence of treatment. The results of the counterfactual cost calculations are presented in Table 2.
It is worth noting that these average costs are lower than the unit costs of being a PDU or a problematic alcohol user. This is because some young people (between 56% and 64% of the sample) are expected to experience natural remission (ie, reduce or halt their drug or alcohol use as they move out of adolescence) and, therefore, not incur these costs in the future. In addition, 17.5% of the sample are expected to become non-PDUs (if not treated), with the costs of non-PDU being somewhat lower – between £21,300 and £45,100 over a 20-year period.
The final element of long-term counterfactual costs that we have considered is the cost associated with being NEET. This leads to poorer educational attainment and labour market outcomes in later life. Recent academic literature has valued the lifetime cost of educational underachievement and poor employment prospects at between £92,000 and £356,000 per person, expressed as a net present value. The net present value (NPV) is the total value now of a stream of future costs and benefits. The value of each future cost or benefit is discounted, as the value of a payment made in a future period is lower than if the same nominal amount had been paid in the current period.
After the counterfactual costs are established, we can estimate the benefits of treatment. As a result of treatment, most young people reduce their drug and alcohol consumption, commit fewer crimes and report improved wellbeing. The likelihood of their becoming PDUs or problematic alcohol users as adults also decreases. Therefore, some of the costs that these young people would have imposed on society if not treated are now averted. We estimate these reductions in the counterfactual costs (ie, the benefits of treatment) and compare them against the cost of treatment. Throughout this report, all of the immediate and long-term counterfactual costs and future benefits have been appropriately discounted, and are reported in terms of their net present value. Our findings are discussed in detail below.
The total amount spent on local services for young substance misusers in 2008–09 was £62.2m. Around 40% of this funding came from the Young Person's Pooled Treatment Budget. The remainder was provided through Area Based Grants, Home Office funding for youth offending teams or youth justice board spending via the secure estate. It is not possible to entirely distinguish between funding that is allocated for drug and alcohol treatment and funding that is allocated to provide drug information and preventative advice. However, despite these limitations, we believe that the figure of £62.2m is a good estimate of the total cost of providing treatment services for young people in 2008–09.
Both the immediate and long-term benefits of treatment describe the economic and social costs that are avoided as a result of getting people into specialist drug and alcohol treatment. The immediate benefits of treatment are lower levels of drug and alcohol related crime, and fewer drug and alcohol related inpatient admissions and deaths. The long-term benefits of treatment are a lower likelihood (and therefore lower expected cost) of young people developing substance misuse problems as adults, and improved educational attainment and labour market outcomes.
Data provided by the NTA indicates that the potential immediate benefit of drug and alcohol treatment could be up to a 55–65% reduction in offending by young people receiving treatment. This equates to a £59.3m net annual saving as a result of treatment.
Our analysis also shows around a 40% drop in the estimated number of drug and alcohol-related deaths and hospital admissions post-treatment. This equates to a benefit of around £1.8m per year in terms of the NHS and wider social costs that can be avoided.
The immediate benefit from reduced crime alone appears to be sufficiently large to suggest a positive net benefit of drug and alcohol treatment for young people. Even assuming no long-term benefits or immediate health benefits, we calculate that in order for young people's treatment to be cost-effective, the required reduction in the immediate amount of crime committed by young people is just 32%.
It should be noted that the proportion of young people in treatment who are offending appears to be low. However, these rates probably underreport levels of offending as young people may be reluctant to admit to offending behaviour. In addition, those who do offend appear to be fairly prolific, contributing to the costs identified within this report. By treatment exit, the amount of self-reported offending committed by young people has fallen on average by 55–65%.
Unlike the immediate benefits of treatment, the long-term benefits are very difficult to assess. The NDTMS/TOP data includes information on a range of outcomes immediately after treatment, such as substance use, education, employment, crime and health. These immediate impacts, however, cannot easily be 'translated' into long-term effects.
To assess the long-term benefits of fewer adult substance misuse problems, we look at the re-presentation rates for young people four years after treatment. These are:
• 40% for
class A
Of the Misuse of Drugs Act including heroin and cocaine.
drug users (comparable to adult PDUs);
• 16% for alcohol users;
• 17% for cannabis users.
Compared to long-term substance misuse rates expected without treatment (37%–44%), treatment is effective for many young people. That is to say that many young people who would otherwise be expected to escalate their drug or alcohol use and develop further problems appear to have effectively reduced or halted their misuse for up to four years after treatment (judged by NTA re-presentation data).
However, we need to exercise caution when using these re-presentation rates as a proxy for the treatment's effectiveness. This is because some young people may relapse after the period covered by the re-presentation data. Others may have developed problematic drug or alcohol use again, but without re-accessing treatment. Therefore, in our hypothetical scenarios below, we adopt a conservative approach and use slightly lower effectiveness rates – 7% and 10% – than the four-year re-presentation rates of 20% reported by the NTA.
In the absence of concrete evidence on long-term effectiveness of young people's treatment, we adopt a scenario-based approach. We find that if the number of those who are likely to develop substance misuse problems as adults is reduced by 2.8%–5.6%, the long-term benefits of treatment would offset the cost of treatment (assuming that the immediate benefits are excluded from this analysis). Moreover, with a slightly higher 7%–10% reduction in the number who would have long-term drug-related problems, the long-term benefits of treatment would exceed the cost of treatment. More specifically:
• a 7% reduction in the number of young people who are likely to become adult substance misusers in their lifetime would generate £15.5 million–£92.6 million net benefits; and
• a 10% reduction in the number of young people who are likely to become adult substance misusers in their lifetime would generate £48.8 million–£159.0 million net benefits.
If these reductions (7%–10%) are achieved, the long-term net benefits of treatment would be high – up to £159 million.
To estimate the long-term benefits of improved educational outcomes, we have modelled the effect of treatment on the proportion of young people who are not in education, employment in training. When entering treatment, 45% of young people in our sample are NEET, compared to 9% of the wider population. Data from the NTA however indicates that treatment could potentially reduce the proportion of young people that are NEET by 6.5%.
Using estimates of the lifetime cost of being NEET, a 6.5% reduction in the proportion who are NEET leads to a total lifetime benefit for young people in our sample of £159m, equivalent to £6590 per person. If the reduction in the NEET percentage was just 5%, this would still lead to significant benefits totalling £121m. On the other hand, a 10% reduction in the NEET percentage would generate £242m of benefits, more than £10,080 per person. This only takes into account changes in NEET status by the time of treatment exit. It does not include any impact of treatment in supporting young people to be ready for employment or education and may therefore underestimate the benefits of treatment in this area.
We sought to assess the costs faced by wider children's services, including costs of children being taken into care. However, it is difficult to identify the proportion of such costs that could be directly attributed to young people's substance misuse. As such, and in the interests of robust estimates, we have not included such costs within this analysis.
Table 3 summarises our results and brings together both estimates of immediate and long-term benefits. All of the immediate and long-term benefits in this report have been appropriately discounted and are expressed in NPV terms.
Throughout this report, we highlight several key limitations of our analysis, particularly relating to the practical or conceptual difficulties in identifying and quantifying the benefits associated with young people's drug treatment. However, despite these limitations, our results provide a robust yet conservative estimate of the benefit of young people's drug treatment.
In particular, the results shown in Table 3 are robust to changes in the assumptions surrounding both the immediate and long-term benefits of treatment. When compiling figures we have tended to use the upper estimate of costs associated with treatment and the lower estimate of any benefits. Finally, to the extent we have been unable to capture certain benefits in our analysis, our results again represent a conservative estimate of total benefits.
Overall, the study has shown that the immediate and long-term benefits of specialist substance misuse treatment for young people are likely to significantly outweigh the cost of providing this treatment. In particular, we have estimated a benefit of £4.66–£8.38 for every £1 spent on young people's drug and alcohol treatment. Furthermore, our central case estimates are based on a conservative set of assumptions. Therefore, the benefit of specialist drug and alcohol treatment for young people may be larger than we report here.
Last revised 23 June 2011
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Motivational arm twisting: contradiction in terms? FINDINGS REVIEW 2006
Drug Strategy 2010. Reducing Demand, Restricting Supply, Building Recovery: Supporting People to Live a Drug Free Life DOCUMENT 2010
Testing children pointless but arrest referral offers early intervention opportunities STUDY 2008
Alcohol-use disorders: Preventing the development of hazardous and harmful drinking REVIEW 2010
The Drug Treatment Outcomes Research Study (DTORS): final outcomes report STUDY 2009
Independent review of the effects of alcohol pricing and promotion STUDY 2008
Project SUCCESS' effects on the substance use of alternative high school students STUDY 2010
Developing and validating process measures of health care quality.Harris A.H.S., Kivlahan D.R., Bowe T. et al.
Medical Care: 2009, 47(12), p. 1244–1250.
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Finding that a retention benchmark like that used for years in Britain was only loosely related to patient improvement led a US health service to start a comprehensive search for better indicators. Intensity of contact in the first month best predicted which services most benefited their patients.
Summary Collecting information on the intended outcomes of treatment such as remission of dependence and reduction in substance use is difficult and costly and data is often incomplete and subject to manipulation. An alternative is to use routinely collected information on the process (such as retention, attendance, and staffing) rather than the outcomes of treatment, and to use these to construct quality indicators which predict good outcomes. The problem is that though these may be inexpensive and easy to generate, often they are poorly related to the intended outcomes or the relationship has not been investigated. To address this issue, the US's health service for former military personnel generated a range of candidate indicators and assessed their relationships to the outcomes of alcohol/drug problem treatment.
The researchers reasoned that process quality indicators should meet three criteria:
• at the agency level, across all their patients treatment agencies which score higher should on average have better outcomes;
• at the individual level, individual patients whose treatment embodied these indicators should do relatively well;
• the kind of care implied by the indicators should be supported by research and acceptable to patients and clinical staff.
Many widely implemented indicators do not meet these criteria, largely because they were derived from expert opinion or consensus without being validated against real outcomes. For example, an indicator focused on retention for at least three months in low-intensity treatment has not been found to predict which treatment agencies for former US military personnel have on average the best outcomes, and only modestly to predict which individual patients do well, and then only for some types of patients.
An alternative development model tested in this study begins on the one hand by collecting treatment outcome data from enough agencies to detect clinically significant differences, and on the other, by developing a set of candidate quality indicators (based on expert opinion or some other method) which can be constructed from existing data sources. The relationships between these two are then assessed to discover which potential indicators really do predict good outcomes, both at the level of the agency and the individual patient.
That is as far as the example given by the current report extended ( below), but the process should go further to test the same relationships using a new set of agencies and/or patients. Indicators which survive this double check should be assessed by experts and stakeholders for (among other issues) their compatibility with clinical guidelines or recognised evidence, clinical acceptability, the risk of manipulation, and possible unintended consequences. After this, the indicators can be piloted and re-evaluated in the light of new clinical evidence and/or unintended consequences.
The first part of this procedure was piloted using data from 2701 patients starting treatment for substance use problems at 71 outpatient programmes based at 54 agencies run by the US health service for former military personnel. Indications that quality indicators might differ for different types of substance use problems led the researchers to focus on alcohol-related outcomes. The patients in the study completed assessments of the severity of their problems at treatment entry, and about two thirds For the remainder the scores they would have registered were estimated on the basis of their baseline scores, diagnostic data, age and sex. returned repeat assessments by mail about seven months later. At issue was whether the degree to which they had improved on drink-related measures could have been predicted by what happened during their treatment as reflected in indicators derived from routinely collected administrative and clinical data.
All the candidate indicators considered feasible given the available data, and supported by theory or research, were concerned with intensity and duration of care. Their constituents were composed of retention periods, number of times the patient attended during those periods at different stages (the first month as opposed to the first two or three months), and whether the visits related to their addiction or mental health problems. Over 100 possible indicators were constructed from permutations of these constituents. Each was assessed for the degree to which it was associated with drink-related improvements at the seven-month follow-up both at agency and individual levels.
Combining mental health with addiction attendances did not improve any of the possible indicators' abilities to predict outcomes, so only addiction attendances were considered. Just nine of the candidate indicators were significantly linked to improvements in the main measure The Addiction Severity Index's Alcohol Composite score. of patients' drink-related problems at both agency and individual levels. Five of the indicators – the ones most closely related to outcomes – reflected the number of times patients attended in the first month of their treatment. The remainder concerned numbers of attendances per month over the first two or three months of treatment.
At the agency level, the strongest indicator of which agencies had the best average outcomes was the proportion of their patients who attended at least three times in the first month – though how many attended at least twice, four, five or six times were not far behind. These indicators accounted for about a quarter of the variation between agencies in how well their patients did. Also significantly related to patient improvement (but less strongly than first-month indicators) were the average number of months over the first two or three months during which patients attended five, six or seven times.
By design, these same indicators also significantly predicted how well each individual patient did, but these relationships were much weaker, accounting at best for 1% to 2% of the variance in outcomes. Again, attendance in the first month provided stronger indicators than over the first two or three months, and stronger still the more often the patient had attended between the range from two to six times.
This picture was broadly confirmed by other analysis methods and in relation to other drink-related outcomes including the number of days on which a patient was drunk, experienced alcohol-related problem, or did not drink.
The study found nine possible indicators of the quality of outpatient treatment which predicted the degree to which on average an agency's patients improved, and also which individual patients improved most. The strongest were attending from three to six times during the first month of care. Though strongly related to an agency's average performance, these indicators did much less well at predicting which individuals would improve most.
Identifying candidate indicators by their relations to outcomes is (as explained above) just the first part of the process. It is also important to bear in mind that this process for developing indicators cannot determine whether relationships found with outcomes mean these processes actually cause patients to improve. The processes and the outcomes might, for example, both be related to another influence such as the motivation of the patients. In this scenario, raising attendance levels 'artificially' might not improve outcomes unless it also somehow affected the real outcome-generator – the patient's motivation.
Accepting the cautions of the authors, the fact that at an agency level, first-month attendance was so strongly related to an agency's performance suggests that treatment services which offer and are able to encourage their patients to accept several visits are the kind of organisations which foster the greatest positive change. It is reasonable to expect these agencies to be welcoming and to rapidly forge relationships with patients which encourage them to return. It also seems to make sense to (within the not very frequent limits found by the study – around weekly) front-load scheduled sessions at the start of treatment when patients' expectations, appetite for treatment, motivation, and need for support may be at their height. It is also of interest that the impetus for the study was the poor performance of an indicator – three-month retention – very similar to the 12-week retention indicator used recently as a benchmark for British drug dependence treatment services, though in relation mainly to the treatment of opiate-addicted patients.
Last revised 30 June 2011
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Shared decision-making: increases autonomy in substance-dependent patients.Joosten E.A.G., De Jong C.A.J., de Weert-van Oene G.H. et al.
Substance Use and Misuse: 2011, 46(8), p. 1037–1038
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An innovative Dutch study tested a way of involving substance users as equals in decisions over issues addressed in their treatment. The effect was to give these typically submissive personalities a greater sense of control over their lives. Just as influential was the lead offered by the clinician's personality.
Summary Drawing on motivational interviewing, 'shared decision-making' aims to facilitate collaboration between clinician and patient via a structured system for reaching joint decisions on goals and expectations for treatment. It is considered particularly appropriate for chronic illnesses whose management involves a wide range of decisions about changing one's lifestyle. The underlying aim is to even out the asymmetry in knowledge and power between doctors and patients by informing patients and promoting their sense of autonomy and/or control.
The study tested an intervention for addiction developed on shared decision-making principles. Specifically, patients and clinicians complete the Goals of Treatment Questionnaire. Derived from the Camberwell Assessment of Need, it lists 24 domains in which the patient may have problems. These include drinking and drug use, but also others such as physical and mental health, psychological distress, housing, eating, relationships, social life, and daytime activities. Patients tick indicating whether they definitely, possibly, or definitely do not want to work on each of these issues during treatment. Clinicians do the same, except that they indicate whether the patient should be encouraged to work on these issues. In the shared decision-making intervention, this is extended by ranking how important each issue is in relation to the others; 24 cards corresponding to the questionnaire's items are grouped into two piles duplicating the 'definite' and 'possible' choices, then within each pile sorted in order of importance and priority. During counselling patients and clinicians compare their choices, typically generating dialogue over the feasibility and benefits of the various treatment goals and expectations.
For the study this shared decision-making intervention was spread over five sessions. In the first the patient completed their version of the goal selection and ranking exercise. A week later clinician and patient met again to compare this with the clinician's version, resulting in the negotiation of agreed goals formalised in a treatment contract. Halfway through treatment patients and clinicians repeated the selection and ranking exercise so that goals and expectations were reviewed and adapted to progress and needs at that stage. At the end of treatment (or if treatment had been prematurely terminated, at an exit interview) the goals and expectations in the treatment contract were reviewed, and new ones explored through a further goal selection and ranking exercise. Finally, three months after treatment had ended patient and clinician met again to review the goals and expectations agreed at the end of treatment and to evaluate the treatment and how well how the patient was doing.
These five sessions took place in the context of a three-month cognitive-behavioural inpatient programme for drug and/or alcohol dependent patients in need of further help after outpatient treatment. Clinicians at the three centres in the study may have used motivational interviewing and other ways of assessing patient needs and goals, but none used the kind of structured method tested by the study. The centres' 31 available clinicians (mainly social and nursing workers) joined the study, and were randomly allocated to carry on as usual or to be trained in and implement the shared decision-making intervention during counselling. They were allocated patients in the normal way, without respect to whether they were implementing the intervention, meaning that patients too were allocated to the intervention in a quasi-random Had patients truly been allocated at random to the intervention, there would have been a greater risk that trained clinicians would inadvertently implement parts of the intervention with patients intended to be treated using normal methods. manner. Nearly all those asked to join the study did so, resulting in 107 patients being treated by clinicians assigned to shared decision-making and 105 to treatment as usual. However, just 76 patients adequately completed all three sets of personality questionnaires (at the start of the study, end of treatment, and three months later) intended to assess the impact of the intervention. The study's findings are based on these patients, who as far as the researchers could tell were similar to the other patients. Typically they were men in their 30s and 40s with long-standing alcohol dependence and quite severe psychological or emotional problems.
As intended, the structured shared decision-making process resulted in patients feeling more able to make their own decisions and more in control and (the opposite end of this dimension) less submissive. These assessments were made on the basis of a self-report personality survey and not specifically in relation to treatment, but life in general. Compared to where they had started, at the end of treatment and three months later these patients had moved further towards the autonomy/control end of this dimension than patients treated as usual, a statistically significant difference. Importantly though, they remained towards the 'friendly and cooperative' end of the other major personality dimension rather than asserting their control in an aggressive or competitive manner. However, the pattern of this friendly attitude changed differently for the two groups; patients engaged in shared decision-making had moved further towards being extravert, open and sociable, while treatment-as-usual patients assessed as relatively more silent and reserved.
On both of the major personality dimensions, it also seemed that patients were drawn towards their clinician's way of relating. Regardless of the intervention, the greater the starting gap between the patient's submissiveness and the clinician's sense of being autonomous and in control, the further during treatment the patient moved towards also being assessed as autonomous and in control. Similarly, the greater the gap between the friendliness of the clinician and the relative lack of friendliness of the patient, the further along this dimension the patient moved towards also being assessed as friendly. Conversely, clinicians rated initially as relatively aggressive had patients who during treatment also moved towards being assessed as aggressive.
For the authors the findings supported their theory that the shared decision-making intervention would lead patients to become more independent and more able to stand up for themselves, reflected in their greater movement towards feelings of autonomy, control and extraversion. These effects were additional to the tendency for patients whose personalities and interpersonal styles were at variance with those of their clinicians to move towards their clinicians' profiles over the course of treatment. The implication is that one task of addiction treatment – whose patients are typically relatively submissive – might be to teach patients to stand up for themselves better. Clinicians who embody this attribute foster such a change, as does engaging the patient systematically and comprehensively in treatment-related decisions over their lives. It must however be remembered that these results were derived only from a minority of patients. It may also be that simply expecting the intervention to facilitate patient autonomy was an active ingredient, a kind of placebo effect.
An earlier report from the same study assessed whether the intervention affected the patients' drinking and drugtaking and other problems and their quality of life. Unlike the featured report, it was based on
all 212 patients,
Although only 166 patients completed the three-month follow-up assessment, the assumption was made that all the other patients had remained as they were at the start of the study.
not the minority who completed all three personality assessments.
Among the many dimensions measured at the start of the study and repeated at the three month follow-up, only on two had shared decision-making patients improved significantly more – the severity of their psychological/emotional and their drug use problems. There was no significant differential impact on use of alcohol – the main substance used by most patients – nor on their primary substance use problem, or how many remained dependent. Neither was there on quality of life or problems related to health, family and employment, among the other issues assessed. On several of these dimensions – especially drink problems – shared decision-making patients had improved more, but too slightly and inconsistently to create a statistically significant difference.
Thanks for their comments on this entry Evelien Joosten of the Radboud University in The Netherlands. Commentators bear no responsibility for the text including the interpretations and any remaining errors.
Last revised 29 June 2011
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Style not content key to matching patients to therapeutic approaches STUDY 2008
Evidence-based psychotherapy relationships: Empathy REVIEW 2011
Cost-effectiveness of family-based substance abuse treatment.Morgan T.B., Crane D.R.
Journal of Marital and Family Therapy: 2010, 36(4), p. 486–498.
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For suitable patients, family-based therapies are among the most effective – but are they the most cost-effective? Not always finds this US-focused review, which argues that to compete in today's financially sensitive health care system, treatments must deliver the most clinical outcomes per unit of cost.
Summary Because it has been shown more effective than alternative approaches (individual treatment, family psychoeducation, and peer group therapy), family therapy is of interest not only to the focal patients, but also to their families and to the insurance companies which fund US health care. Including families in treatment is crucial because when a client's 'system' (family, siblings, spouse, partner, etc) is treated, it becomes healthier, affording the client a stronger support network to aid their recovery. There is no question that some family-based treatments are effective – but are they cost-effective? And how do costs influence the take-up of these treatments in a health care system? To compete in an increasingly financially sensitive health care system, successful treatments must deliver the most clinical outcome per unit of cost.
A search uncovered just eight studies which have documented the cost-effectiveness of explicitly family-based substance abuse treatment. They demonstrate that certain treatments not only work, but are also sometimes more cost-effective than the treatments against which they were compared.
The family-based treatments tested in these studies included brief relationship therapy, standard behavioural couple's therapy, Multisystemic Therapy, Multidimensional Family Therapy, Family Support Network, Adolescent Community Reinforcement Approach, interactional couples group therapy, and behavioural couple/marital therapy. Among these and the alternatives against which they were compared, in terms of the cost to achieve a given outcome, the most cost-effective were (family-based treatments are italicised):
• brief relationship therapy;
• a five-session version of motivational enhancement combined with cognitive behavioural therapy;
• behavioural couples therapy;
• a form of behavioural marital therapy; and
• a form of individual therapy.
These studies show that although family therapy is effective, work is needed to make it more cost-effective. Among the five relevant studies, in three family-based treatments were more cost-effective than individual treatments.
For a treatment that is already more effective than the alternatives, the prime way to improve cost-effectiveness is to cut costs without unduly affecting outcomes. The interests of health insurance companies, as well as competition for insurance claim money, mean treatments will compete with each other to produce the most desirable results at the lowest cost, leading developers to fine-tune available treatments. This phenomenon was illustrated by a study in which standard behavioural couples therapy was shortened to lower cost brief relationship therapy without compromising its efficacy in curbing drinking. This kind of fine-tuning promises to assuage the economic burden on society, health care insurers, families, and individuals.
A case has been made that the question research should address has moved from 'Does this treatment work?' to 'How much does this treatment cost to deliver, and is it really worth it?' This requires the collection of cost as well as outcome data. To compare the cost effectiveness of different approaches, outcomes and follow-up periods need to be comparable across studies. Costs would also ideally be calculated in a standard way. Outcomes should include impacts on the social and institutional systems in which the patients are involved. There is also a case for the client's needs and concern to determine which outcomes are measured. For example, what an adolescent substance user in trouble with the courts wants out of treatment is likely to be very different from the objectives of a married adult problem drinker with poor communication skills.
Conducting cost-effectiveness studies on family-based substance abuse treatment will not only demonstrate effectiveness but also that these approaches are competitive in terms of costs. Given the financial impact of substance abuse on society, individuals, and the health care system, and with health care companies dictating which treatments are on their preferred provider lists, it is imperative to produce cost-effective treatments. By doing so, substance abusers and their families will receive the most effective treatments, and health care insurers will receive an effective treatment at a competitive cost.
Last revised 24 June 2011
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