Title: Dynamic Treatment Regimes: Interventions for Chronic Conditions (such as Poverty or Criminality?)
1Dynamic Treatment Regimes Interventions for
Chronic Conditions (such as Poverty or
Criminality?)
- S.A. Murphy
- Univ. of Michigan
- In Honor of Clifford C. Clogg
2Outline
- Dynamic Treatment Regimes
- Dynamic Treatment Regimes in Social Science
- Considerations in Constructing Dynamic Treatment
Regimes - Discussion
3Dynamic Treatment Regimes
4- Challenges in managing the chronic forms of
addiction and mental disorders and HIV
(poverty?, unemployment?, criminality?) - High variability across patients in response to
any one intervention - May need a sequence of interventions prior to
improvement - No Cure
- Relapse is likely without either continuous or
intermittent treatment for a large proportion of
people.
5- Challenges in managing the chronic forms of
addiction and mental disorders and HIV
(poverty?, unemployment?, criminality?) - Treatment is burdensome.
- Adherence is a problem.
- Reduce intensity of intervention whenever
possible. - Co-occurring disorders are common.
6- Dynamic Treatment Regimes are individually
tailored interventions, with treatment type and
dosage changing with subject outcomes. - Brooner et al. (2002) Treatment of Opioid
Addiction - Breslin et al. (1999) Treatment of Alcohol
Addiction - Prokaska et al. (2001) Treatment of Tobacco
Addiction - Rush et al. (2003) Treatment of Depression
7Example of a Dynamic Treatment Regime Treatment
of alcohol dependence. Goal is to reduce
drinking. Following graduation from the
intensive outpatient program the patient is
prescribed naltrexone. The patient is monitored
weekly over the next two months. If the patient
experiences 2 or more heavy drinking days during
this period then the patients medication is
augmented by CBI. If the patient is able to make
the entire 2 months with 1 or no heavy drinking
days then the patient is continued on naltrexone
and is provided telephone disease management.
8- Components of a dynamic treatment regime
- Tailoring Variables (which ones and how to
measure?) - Decisions/Interventions (what are the options at
this time?) - Decision Rules (input the tailoring variables and
output a decision) one per key decision - A dynamic treatment regime is a sequence of
decision rules that input tailoring variables and
output recommended decisions
9- The Message
- Dynamic Treatment Regimes operationalize the
adaptive, sequential, decision making that occurs
in clinical practice. (by welfare case
managers? by social workers? by the judicial
system?) - The operationalization of the decisions allows
them to be studied and thus improved upon. - In practice, decision rules become best practice
guidelines.
10- The Big Questions
- What is the best sequencing of interventions?
- What is the best timings of alterations in
interventions? - What information do we use to make these
decisions?
11Dynamic Treatment Regimes in Social Science
12- Dynamic Treatment Regimes in Social Science
Practice - Dynamic treatment regimes are being implemented!
- Sometimes little or no evidence is available
concerning what information should be used in
decision making. (tailoring variables) - Sometimes little or no evidence is available
concerning how to use available information in
decision making. (best practice guidelines)
13Example of a Dynamic Treatment Regime
- Jobs First Program in Connecticut
- Tailoring Variables characteristics of the
individual (offensesnon-cooperation with
Employment Services..), characteristics of the
environment (domestic violence, incapacitated
family member, ) - Interventions amount of cash benefit
- Goal maximizing social/monetary gain.
14(No Transcript)
15- Dynamic Treatment Regimes in Social Science
Research - Education Papers by S. Raudenbush, D. Cohen
- Economics J. Abbring G. van den Berg M.
Lechner and colleagues J. Rust J. Heckman and
colleagues - (cites are provided on notes pages)
16- Dynamic Treatment Regimes
- As an inferential goal How do I best construct
a dynamic treatment regime so as to create a high
quality welfare program? - Data-generating mechanism What causal structure
led to the selection of the time varying
treatments I have recorded in my data?
17How does Social Science research inform the
construction of dynamic treatment regimes?
- Understanding the interaction between the social
context and intervention on individual responses. - Designing intervention components that improve
the social context of the individual. - Suggest environmental, social triggers for a need
to change/intensify/taper-off the present
intervention
18Considerations in Constructing Dynamic Treatment
Regimes
19Important considerations in constructing dynamic
treatment regimes
- In deciding which intervention to provide at a
given time, we should pay attention to the range
of feasible future decisions/interventions. - Sometimes the best decision leads to a worsening
of the situation (but lays the foundation for an
improved long term benefit).
20Examples
- Sometimes the best decision does not lead to an
improved situation (but lays the foundation for
an improved long term benefit). Consider women
receiving welfare. - -- An intervention designed to improve competency
in dealing with change may not lead to improved
employment in the short run but - -- The same intervention followed by training and
job search skill development may lead to greater
employment.
21Examples
- Sometimes the best decision does not lead to an
improved situation (but lays the foundation for
an improved long term benefit). Consider children
in the criminal justice system. - Detention may lead to increased societal
alienation as compared to detention diversion.
However when these are followed by an
intervention designed to alter peer group
affiliation, detention may be more effective in
reducing recidivism than detention diversion.
22Examples
- In deciding which intervention to provide at a
given time, pay attention to the range of
feasible future decisions/interventions. - Detention with standard follow-up may be worse in
reducing recidivism/cost than a detention
diversion program followed by a standard
follow-up. - yet
- Detention followed by an intervention designed to
alter peer group affiliation may be more
effective in reducing recidivism/cost than
detention diversion followed by an intervention
designed to alter peer group affiliation.
23Can you think of more realistic examples?
- In deciding which intervention to provide at a
given time, we should pay attention to the range
of feasible future decisions or interventions. - Sometimes the best decision does not immediately
lead to an improvement (but lays the foundation
for an improved long term benefit).
24Discussion
- Conceptually it is important to pay attention to
subsequent interventions when evaluating the
present intervention. The analog holds for the
methodology. - The methodology must allow for the best decision
leading to a worsening of the situation but
laying the foundation for an improved long term
benefit.
25 - This seminar can be found at
- http//www.stat.lsa.umich.edu/samurphy/seminars/P
SUSociology10-05.ppt - My email address
- samurphy_at_umich.edu
26Conceptual Structure in the Behavioral/Social/Medi
cal Sciences