Effect of Matching Therapists to Patients vs Assignment as Usual on Adult Psychotherapy Outcomes: A Randomized Clinical Trial

Abstract

Importance: Psychotherapists possess strengths and weaknesses in treating different mental health problems, yet performance information is rarely harnessed in mental health care (MHC). To our knowledge, no prior studies have tested the causal efficacy of prospectively matching patients to therapists with empirically derived strengths in treating patients' specific concerns.

Objective: To test the effect of measurement-based matching vs case assignment as usual (CAU) on psychotherapy outcomes.

Design, setting, and participants: In this randomized clinical trial, adult outpatients were recruited between November 2017 and April 2019. Assessments occurred at baseline and repeatedly during treatment at 6 community MHC clinics in Cleveland, Ohio. To be eligible, patients had to make their own MHC decisions. Of 1329 individuals screened, 288 were randomized. Excluding those who withdrew or provided no assessments beyond baseline, 218 patients treated by 48 therapists were included in the primary modified intent-to-treat analyses.

Interventions: Therapist performance was assessed pretrial across 15 or more historical cases based on patients' pre-post reporting across 12 problem domains of the routinely administered Treatment Outcome Package (TOP). Therapists were classified in each domain as effective (on average, patients' symptoms reliably improved), neutral (on average, patients' symptoms neither reliably improved nor deteriorated), or ineffective (on average, patients' symptoms reliably deteriorated). Trial patients were randomly assigned to good-fitting therapists (matched group) or were assigned to therapists pragmatically (CAU group). There were multiple match levels, ranging from therapists being effective on the 3 most elevated domains reported by patients and not ineffective on any others (highest) to not effective on the most elevated domains reported by patients but also not ineffective on any domain (lowest). Therapists treated patients in the matched and CAU groups, and treatment was unmanipulated.

Main outcomes and measures: General symptomatic and functional impairment across all TOP domains (average z scores relative to the general population mean; higher scores indicate greater impairment), global distress (Symptom Checklist-10; higher scores indicate greater distress), and domain-specific impairment on each individual's most elevated TOP-assessed problem.

Results: Of 218 patients, 147 (67.4%) were female, and 193 (88.5%) were White. The mean (SD) age was 33.9 (11.2) years. Multilevel modeling indicated a match effect on reductions in weekly general symptomatic and functional impairment (γ110 = -0.03; 95% CI, -0.05 to -0.01; d = 0.75), global distress (γ110 = -0.16; 95% CI, -0.30 to -0.02; d = 0.50), and domain-specific impairment (γ110 = -0.01; 95% CI -0.01 to -0.006; d = 0.60), with no adverse events.

Conclusions and relevance: Matching patients with therapists based on therapists' performance strengths can improve MHC outcomes.

Trial registration: ClinicalTrials.gov Identifier: NCT02990000.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Constantino reports a grant from Patient-Centered Outcomes Research Institute and nonfinancial support from a data and safety monitoring board during the conduct of the study. Dr Boswell reports grant support from PCORI paid to the University of Massachusetts. Ms Coyne reports consulting fees from Center for Research on Families during the conduct of the study. Dr Swales reports grant support from PCORI paid to the University of Massachusetts. Dr Kraus reports grant support from PCORI paid to the University of Massachusetts; being the founder, president, and chief scientific officer of Outcome Referrals, Inc, which owns and processes the Treatment Outcome Package; and is the inventor of US Patent No. 7,873,525 entitled, “Method and system for outcome based medical referrals.” No other conflicts were reported.

Figures

Figure 1.. CONSORT Diagram Depicting the Patient Flow Through the Trial

To follow reporting conventions, we present information separately on participants who did not start treatment and those who were lost to follow-up. However, both groups of patients were excluded from the modified intent-to-treat analyses because the patients in these groups did not provide at least 1 assessment beyond baseline.

Figure 2.. Model-Estimated Match Effects on Change in Severity of General Impairment During Treatment Among 218 Mental Health Care Patients

Patients in the matched group experienced significantly greater reductions in general impairment compared with patients in the case assignment as usual (CAU) condition across 17 weeks (16 weeks of treatment and 1 baseline week). In terms of overall impairment severity, a score of 0 represents the mean level of impairment shown by non–treatment-seeking individuals in the community. Therefore, a score of 1 represents an impairment level that is 1 SD higher than the community mean and a score of −1 represents impairment that is 1 SD lower than the community mean.