Patient-therapist matching via therapist's performance strengths may improve outcomes

Matching patients and therapists based on therapists’ performance strengths may improve mental health care outcomes, according to results of a randomized clinical trial published in JAMA Psychiatry.

“Because current assignments are typically nonpersonalized and based on convenience or self-defined therapist expertise (which is often overestimated or inaccurate), it is largely left to chance whether patients will be assigned to therapists who are historically exceptional or average at treating the patients’ primary problems vs. being below average in these areas,” Michael J. Constantino, PhD, of the department of psychological and brain sciences at the University of Massachusetts Amherst, and colleagues wrote. “Conversely, there may be an advantage to intentionally matching patients to therapists based on therapist-level outcome data, and [mental health care] patients have endorsed such matching as a valued priority. Accordingly, we developed a personalized match system based on therapist performance report cards determined with a multidimensional outcomes tool: the Treatment Outcome Package (TOP).”

The researchers sought to assess the effect of matching based on measurement compared with case assignment as usual on psychotherapy outcomes. In primary modified intent-to-treat analyses, they included 218 adult outpatients, of whom 67.4% were women and 88.5% were white, treated by 48 therapists. Eligible patients made their own mental health decisions. The researchers conducted assessments at baseline and repeatedly during treatment at six community mental health care clinics, and they assessed therapist performance pretrial across at least 15 historical cases based on patients’ pre-post reporting across 12 problem domains of the routinely administered TOP. Further, they classified therapists in each domain as effective, meaning patients’ symptoms reliably improved, on average; neutral, meaning patients’ symptoms did not reliably improve nor deteriorate, on average; or ineffective, meaning patients’ symptoms reliably deteriorated, on average.

Constantino randomly assigned trial patients to good-fitting therapists, which they considered the matched group, or to therapists pragmatically, which they considered the case assignment as usual group. Therapist match levels ranged from therapists being effective on the three most elevated domains that patients reported and not ineffective on any others, which was the highest, to therapists being not effective on the most elevated domains that patients reported but also not ineffective on any domain, which was the lowest. General symptomatic and functional impairment across all TOP domains, global distress according to the Symptom Checklist-10 and domain-specific impairment on each individual’s most elevated TOP-assessed problem served as the main outcomes and measures.

Results of multilevel modeling showed a match effect on reductions in weekly general symptomatic and functional impairment, global distress and domain-specific impairment. The researchers reported no adverse events.

“[Mental health care] can be substantially improved by using therapist performance data to determine who they treat,” Constantino and colleagues wrote. “This method provides stakeholders (ie, patients, therapists and administrators) a choice (as a shortlist) for optimizing care beyond chance levels, while also minimizing ineffectiveness.”