Feedback informed treatment – FIT. Continous follow up of patient/client views upon relation and treatment

Feedback means that client/patient views are given to the caregiver. These views concern both the treatment and their relationship. When this information is collected routinely in order to improve or tailor continued treatment it could be mentioned as FIT, feedback informed treatment. FIT is used in Sweden within social services and health care, but the extent is unknown.

Question

What systematic reviews are there on Feedback informed treatment – FIT within social services and psychiatry?

Identified literature

Table 1. Systematic reviews with low or moderate risk of bias

Included studies Population/Intervention Outcome
Pejtersen et al 2020 [3]
14 RCT-studies from US (n=6), Norway (n=3), Denmark (n=2), Ireland (n=1), Netherlands (n=1), China (n=1).  One study was from an inpatient setting, whereas the 13 other studies were performed in an outpatient setting. Children and young persons (3–17 years), and adults e.g. soldiers, students. Number of participants varied between 70–453.

Various primary treatments: Five studies concerned treatment within a psychiatric setting, of which one study concerned eating disorders. Two studies were on treatment for drug or cannabis abuse, two studies were on couples or family therapy, and five studies concerned treatment at university counselling services.

Intervention should be based on PCOMS, the control group should not receive any feedback.
Effect:
Number of sessions
Rather small effect size favoring the PCOMS intervention (Hedges’s g=0.13 (95% CI, 0.001 to 0.26). The effect size corresponded to a difference of less than 1 session (n=1697).
Wellbeing
The effect size from 6 studies was insignificant (Hedges’s g =0.03 (95% Cl, 0.18 to 0.23)
(n=686)
Adverse effect:
Not reported
Authors' conclusion:
“In the present review we found no evidence that the PCOMS has an effect on the number of sessions attended by clients or that the PCOMS improves the well-being of clients.”
Østergård et al 2020 [4]
18 studies, 14 RCTs and four non-RCTs conducted in  US (n=7), Australia (n=1), Denmark (n=1), Ireland (n=1), Netherlands (n=3), Norway (n=3), Singapore (n=1), and China (n=1). Ten studies were from psychiatric settings whereas eight studies were from counselling settings including student counselling services, university graduate training clinics, family counselling clinic, and military substance abuse counselling center. 2910 participants in total (range 39 to 741). Participants had a variety of diagnoses and presenting problems with depression and anxiety being most frequent.
Eclectic, cognitive-behavioral or interpersonal treatment approach during 1.8 to 15.0 with a total mean of 7.8 sessions. The experimental condition had to include the PCOMS as an “add on intervention” to an intervention without the PCOMS in the control condition.
Effect:
The overall combined effect comparing the PCOMS and the control condition was small g=0.27, (95% CI, 0.14, 0.41), p<0.001.
A positive effect of the PCOMS was indicated for all the analyses by Hedges g>0, or OR<1. (Primary outcome was a generic outcome measure of general symptoms or distress).
The 10 studies from psychiatric settings did not reveal a significant effect of the PCOMS g=0.10, (95% CI, −0.03 to 0.23), p=0.144), whereas the eight studies from counselling settings had a significant effect, g=0.45, 95% CI, (0.31 to 0.59), p<0.001). The difference was significant and large, Q=13.08, df=1, p<0.001; R2=0.76).
No effect of the PCOMS was found on the number of deteriorated clients, OR=0.91, (95% CI, 0.67 to 1.23), p=0.537, k=13); or number of psychotherapy sessions attended, g=0.06, (95% CI, −0.09 to 0.21), p=0.418, k=14).
Adverse effect:
Not reported
Authors' conclusion:
“Based on this meta-analysis of 18 studies including 2910 participants, the overall effect of using the PCOMS is small, g=0.27, (95% CI, 0.14 to 0.41). The heterogeneity of studies was substantial. Even though the effect was significant, the prediction interval was in the range from −0.22 to 0.76 indicating that a wide dispersion in effect across populations should be expected when using the PCOMS. The 10 studies from psychiatric settings did not reveal an effect of the PCOMS, whereas the eight studies from counselling settings had a moderate effect. However, the positive effect in counselling settings may be biased due to positive researcher allegiance and use of the ORS as the only outcome measure. The ORS score is likely to be influenced by social desirability when completed in therapy. There is a need for more studies, especially in counselling settings, using other outcome measures than the ORS. Future studies should also measure therapist adherence and report information about how the PCOMS is used to understand better the conditions under which the PCOMS might work and for whom. Further studies might also investigate the potential mechanisms of change in the PCOMS. It may be essential to adapt feedback systems to the requirements of clinical settings and specific client characteristics and needs.”
Bergman et al 2018 [1]
Six RCTs, conducted in the US (n=5) and Israel (n=1). 1097 children and adolescents, 11 to 18 years old, with mental health problems.
Client feedback was given in psychological therapy. Participants received mixed types of psychological therapy, and in three of the studies the therapy was part of a wider package of care, also including support measures, such as crisis stabilization, skills building, and educational instruction. The comparison was psychological therapy (CBT, psychotherapy, humanistic or integrative) without systematic client feedback.
Effect:
Improvement as reported by youth at post-intervention assessed with Ohio Scale severity and Youth Outcome Questionnaire. Results were not pooled due to substantial heterogeneity; very low confidence.

Therapeutic alliance as reported by youth at post intervention assessed with the Session Rating Scale or the Working Alliance Inventory. Results were not pooled due to substantial heterogeneity; very low confidence.
Treatment acceptability drop out: RR 1.08 (0.73 to 1.61); very low confidence.
Treatment duration
The mean in the intervention group was 0.28 weeks shorter (1.57 shorter to 1.01 longer); moderate confidence
Adverse effect:
Not reported
Authors' conclusion:
“Due to the paucity of high-quality data and considerable inconsistency in results from different studies, there is currently insufficient evidence to reach any firm conclusions regarding the role of client feedback in psychological therapies for children and adolescents with mental health problems, and further research on this important topic is needed. Future studies should avoid risks of performance, detection and attrition biases, as seen in the studies included in this review. Studies from countries other than the USA are needed, as well as studies including children younger than 10 years.”
Kendrick et al 2016 [2]
17 RCT-studies from multi-disciplinary mental health care (n=9), psychological therapy settings (n=6), primary care (n=2). Studies were conducted in the US (n=9) and Europe out of which one from Sweden and Norway respectively. 8797 adult participants, aged 18 to 75 years, mean age 35,1 years.
Feedback was usually given in the form of scores on the PROMs (patient reported outcome measures), together with information on whether this meant the participant had improved or not. The comparator was usual care for CMHDs without feeding back the results of PROMs.
Effect:
Primary outcomes:
Health- related quality of Life
Medical Outcomes Study
Short Form (SF-36). Follow-up: 1–5 months Medical Outcomes Study (SF-12) physical and mental subscales). Study results could not be combined in a meta-analysis; moderate confidence
Mean improvement in symptom scores
Standard mean difference in symptom scores at end of study in feedback groups was 0.07 standard deviations lower (0.16 lower to 0.01 higher); low confidence
Social functioning
No difference found; low confidence
Secondary outcomes:
Changes in the management of CMHDs
Changes in drug therapy and referrals for specialist care
Follow-up: 1–6 months. Study results could not be combined in a meta-analysis; moderate confidence
Number of treatment sessions received. Follow-up: 1–6 months. Mean difference in number of treatment sessions in feedback groups was 0.02 lower (0.42 lower to 0.39 higher); low confidence.
Costs not estimable
Adverse effect:
Information on adverse events (thoughts of self-harm or suicide) was collected in one study (n=642), but differences between arms were not reported; moderate confidence.
Authors' conclusion:
“We found insufficient evidence to support the use of routine outcome monitoring using PROMs in the treatment of common mental health disorders, CMDH, in terms of improving patient outcomes or in improving management. The findings are subject to considerable uncertainty however, due to the high risk of bias in the large majority of trials meeting the inclusion criteria, which means further research is very likely to have an important impact on the estimate of effect and is likely to change the estimate. More research of better quality is therefore required, particularly in primary care where most CMHDs are treated.
Future research should address issues of blinding of assessors and attrition, and measure a range of relevant symptom outcomes, as well as possible harmful effects of monitoring, health-related quality of life, social functioning, and costs. Studies should include people treated with drugs as well as psychological therapies and should follow them up for longer than six months.”
Solstad et al 2019 [5]
16 qualitative studies from the UK (n=6), Australia (n=5), US (n=2), 1 each from Norway, New Zealand, and Portugal. Qualitative methods focusing on patient perspectives were found, but also larger quantitative and mixed-methods studies, examining the views of different stakeholders. Children, young people and adults in various psychiatric care settings.
Routine outcome monitoring (ROM) and clinical feedback (CF) systems along with psychological therapies.
Effect:
Four meta-themes: (1) Suspicion towards service providers, (2) Flexibility and support to capture complexity, (3) Empowering patients, and (4) Developing collaborative practice.
Adverse effect:
Disadvantages are addressed under limitations
Authors' conclusion:
“… provide insights into how the use of ROM/CF can be helpful or hindering in psychological therapies, many of them reflecting the convergence of major themes. Among them is the fact that ROM/CF can be experienced by clients as suspicious and limited in its ability to capture the complexity of their lives and their needs from mental health services. When patients have to answer questionnaires mandatorily, without a proper rationale, or without seeing the results, ROM/CF can be a hindering process, or merely a “bureaucratic exercise”.
Some limitations are: ROM/CF has been implemented in many countries that are not studied in projects included in our meta synthesis. Popular ROM/CF systems such as TOP, OQ-45 and POLARIS-MH were not featured in any of the studies. Different measures will presumably create differing patient experiences and therapeutic processes. To better understand the process and experience of ROM/CF, we suggest qualitative studies from the patient perspective on a wider variety of measures.

References

  1. Pejtersen JH, Viinholt BCA, Hansen H. Feedback-informed treatment: A systematic review and meta-analysis of the partners for change outcome management system. J Couns Psychol 2020.
  2. Østergård OK, Randa H, Hougaard E. The effect of using the partners for change outcome management system as feedback tool in psychotherapy—a systematic review and meta-analysis. Psychotherapy Research 2018.
  3. Bergman H, Kornør H, Nikolakopoulou A, Hanssen-Bauer K, Soares-Weiser K, Tollefsen TK, et al. Client feedback in psychological therapy for children and adolescents with mental health problems. Cochrane Database Syst Rev 2018;8:Cd011729.
  4. Kendrick T, El-Gohary M, Stuart B, Gilbody S, Churchill R, Aiken L, et al. Routine use of patient reported outcome measures (PROMs) for improving treatment of common mental health disorders in adults. Cochrane Database of Systematic Reviews 2016;2016.
  5. Solstad SM, Castonguay LG, Moltu C. Patients' experiences with routine outcome monitoring and clinical feedback systems: A systematic review and synthesis of qualitative empirical literature. Psychotherapy research : journal of the Society for Psychotherapy Research 2019;29:157-170.

 

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 12/2/2020
Report no: ut202033
Registration no: SBU 2020/141