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Dynamic Treatment Regimes: Interventions for

Chronic Conditions (such as Poverty or Criminality?)

S.A. Murphy

Univ. of Michigan

In Honor of Clifford C. Clogg

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Outline

– Dynamic Treatment Regimes– Dynamic Treatment Regimes in Social Science– Considerations in Constructing Dynamic

Treatment Regimes– Discussion

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Dynamic Treatment Regimes

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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.

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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.

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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

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Example 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 patient’s 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.

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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

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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.”

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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?

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Dynamic Treatment Regimes in Social Science

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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”)

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Example of a Dynamic Treatment Regime

• “Jobs First” Program in Connecticut– Tailoring Variables: characteristics of the

individual (offenses—non-cooperation with Employment Services…..), characteristics of the environment (domestic violence, incapacitated family member, …)

– Interventions: amount of cash benefit– Goal: maximizing social/monetary gain.

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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)

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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?

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How 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

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Considerations in Constructing Dynamic Treatment Regimes

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Important 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).

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ExamplesSometimes 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.

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Examples• 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.

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ExamplesIn 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.

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Can 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).

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Discussion

• 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.

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This seminar can be found at:http://www.stat.lsa.umich.edu/~samurphy/seminars/PSUSociology10-05.ppt

My email address:

samurphy@umich.edu

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Unknown UnknownCauses Causes

Observations Action or Observations Action or RewardTreatment 1 Treatment 2

Time 2 Time 3

Conceptual Structure in the Behavioral/Social/Medical Sciences