Clinical Guide to the Evidence-Based Assessment Approach to Diagnosis and Treatment

doi:10.1016/j.cbpra.2013.12.005

Cognitive and Behavioral Practice

Volume 22, Issue 1, February 2015, Pages 20-35

https://doi.org/10.1016/j.cbpra.2013.12.005 Get rights and content

Highlights

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Evidence-based assessment can work in most clinical settings for common problems
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EBA combines base rates, risk factors, and checklists quickly and accurately
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Clinicians work with clients to decide when to test more and how to treat
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EBA helps define benchmarks for treatment progress and outcome
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A case example illustrates EBA methods in practice

Abstract

Assessment plays an essential role in diagnosis, treatment planning, and progress monitoring, but assessment data are often used in ways that are impressionistic and prone to biases. Evidence-based medicine (EBM) principles, underutilized in psychology, can be used to streamline the assessment process and increase the accuracy of conclusions. Using a case example to illustrate the application of each step, this paper outlines a 12-step approach for applying EBM assessment strategies in clinical practice. The initial steps utilize information about clinical base rates, psychopathology risk factors, rating scale scores, and selected in-depth assessment to conduct an iterative, efficient approach to estimating the probability of a given diagnosis until that probability falls into a range suggesting the diagnosis is unlikely to be present, or likely enough to warrant treatment. Once the practitioner and client agree on the treatment plan, subsequent steps monitor progress and outcomes and use that information to make decisions about termination, and then continued monitoring guards against relapse.

Section snippets

Base Rates and Probabilities: Foundations of the EBM Diagnostic Approach

The EBM approach to diagnosis focuses on determining the probability of a client’s having each diagnosis. In the absence of other information, Meehl (1954) advised “betting the base rate.” In other words, if 20% of all of our clients have anxiety, prior to learning anything about a new client, there is a 20% chance that the next client has anxiety. EBM provides strategies for integrating information from risk factors and test results to revise the probability of each diagnosis. Bayes’ Theorem

Steps A and B: Setting the Stage for EBA

Table 1 lays out a dozen steps to reorganize assessment practices to integrate EBM ideas. The first two steps lay a foundation to support a system of evaluation for all subsequent clients. They will take a few hours to fully implement, requiring a start-up investment of time and effort, but then adding no additional time or cost to individual assessments.

Steps C to H: Assessment of the Client Before Treatment

The next several steps involve gathering and interpreting data regarding symptoms and risk factors in order to determine whether a client falls in the Red, Yellow, or Green zones. Clinicians typically do this intuitively and impressionistically, changing formulations while listening to the client describe the presenting problem and looking at the scores on checklists they completed before starting the session. The EBM approach makes the interpretation more formal and systematic, but not much

Assessment During and After Treatment

We were doing a comprehensive psychological evaluation with Lea, and not providing treatment, so this case example ends here. However, there are ways to lay a good foundation for assessment during active treatment and maintenance in the recommendations section of assessment reports. At our clinic, we provide a “care package” of EBA methods that the client can take with them, or that we can send directly to their other care providers.

I. Measure Progress and Process

After the initial treatment plan is clear, then the role of assessment shifts from diagnostic clarification to measuring progress. Borrowing the metaphor of therapy as a journey, the prior stages of assessment are akin to getting oriented, picking a mutually agreeable destination, and then charting a route that should reach the goal reasonably directly. Once under way, assessment becomes the dashboard for monitoring changes and alerting to critical events.

Progress measures need to be brief

Discussion

The evidence-based assessment model we describe integrates many different sources of information, including the types of problems seen at different clinical settings, and information about risk factors and test results, to provide updated probability estimates of different clinical hypotheses. The same assessment approaches also can provide information about treatment targets and define intermediate and outcome goals. Changes in technology also make it possible to use innovative tools, such as

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View full text

Clinical Guide to the Evidence-Based Assessment Approach to Diagnosis and Treatment

Highlights

Abstract

Section snippets

Base Rates and Probabilities: Foundations of the EBM Diagnostic Approach

Steps A and B: Setting the Stage for EBA

Steps C to H: Assessment of the Client Before Treatment

Assessment During and After Treatment

I. Measure Progress and Process

Discussion

Cognitive and Behavioral Practice

Journal of the American Academy of Child & Adolescent Psychiatry

Child & Adolescent Psychiatric Clinics of North America

Journal of the American Academy of Child & Adolescent Psychiatry

Behavior Therapy

Journal of the American Academy of Child & Adolescent Psychiatry

Research in Developmental Disabilities

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Journal of the American Academy of Child & Adolescent Psychiatry

Manual for the ASEBA School-Age Forms & Profiles

An inexpensive family index of risk for mood issues improves identification of pediatric bipolar disorder

Psychological Assessment

Diagnostic and statistical manual of mental disorders

Personality and bipolar disorder: Dissecting state and trait associations between mood and personality

Psychological Medicine

Beck depression inventory manual

A probabilistic and individualized approach for predicting treatment gains: An extension and application to anxiety disordered youth

Behavior Therapy

Bipolar II disorder: a review

Bipolar Disorders

The Tools of Quality, Part VI: Pareto Charts

Quality Progress

Conners

A standard of care for the assessment of suicide risk and associated treatment: The Florida State University psychology clinic as an example

Journal of Contemporary Psychotherapy

SCL-90: Administration, scoring, and procedures manual for the R(evised) version

A transportable assessment protocol for prescribing youth psychosocial treatments in real-world settings: Reducing assessment burden via self-report scales

Psychological Assessment

Medical decision making: A selective review for child psychiatrists and psychologists

Journal of Child Psychology and Psychiatry

The Checklist Manifesto

Reasoning the fast and frugal way: Models of bounded rationality

Psychological Review

The EBM journal selection process: How to find the 1 in 400 valid and highly relevant new research articles

Evidence-Based Medicine

Evaluation of psychotherapy: Efficacy, effectiveness, and patient progress

American Psychologist

Clinical significance: A statistical approach to defining meaningful change in psychotherapy research

Journal of Consulting and Clinical Psychology

Methods for defining and determining the clinical significance of treatment effects: Description, application, and alternatives

Journal of Consulting and Clinical Psychology