Elsevier

Psychiatry Research

Volume 237, 30 March 2016, Pages 331-338
Psychiatry Research

Treating Hoarding Disorder in a real-world setting: Results from the Mental Health Association of San Francisco

https://doi.org/10.1016/j.psychres.2016.01.019Get rights and content

Highlights

  • We compare group treatment for hoarding disorder led by psychologists to that led by peers.

  • Participants in both groups improved at a rate consistent with previous work.

  • We found no significant differences between treatment types at post treatment.

  • Peer-led treatment was slightly more cost effective than psychologist-led treatment.

Abstract

Hoarding Disorder (HD) is associated with substantial distress, impairment, and individual and societal costs. Cognitive-behavioral therapy (CBT) tailored to HD is the best-studied form of treatment and can be led by mental health professionals or by non-professionals (peers) with specific training. No previous study has directly compared outcomes for therapist-led and peer-led groups, and none have examined the effectiveness of these groups in a real-world setting. We used retrospective data to compare psychologist-led CBT groups (G-CBT) to groups led by peer facilitators using the Buried in Treasures workbooks (G-BiT) in individuals who sought treatment for HD from the Mental Health Association of San Francisco. The primary outcome was change in Hoarding Severity Scale scores. Approximate costs per participant were also examined. Both G-CBT and G-BiT showed improvement consistent with previous reports (22% improvement overall). After controlling for baseline group characteristics, there were no significant differences in outcomes between G-CBT and G-BiT. For G-CBT, where additional outcome data were available, functional impairment and severity of hoarding symptoms improved to a similar degree as compared to previous G-CBT studies, while hoarding-related cognition improved to a lesser degree (also consistent with previous studies). G-BiT cost approximately $100 less per participant than did G-CBT.

Introduction

Hoarding Disorder (HD) is a chronic neuropsychiatric disorder that affects up to 6% of the population (Best-Lavigniac, 2006; Frost and Gross, 1993; Grisham et al., 2006; Kim et al., 2001; Samuels et al., 2002; Seedat and Stein, 2002), and is associated with high levels of distress, social disruption, functional impairment, and personal and societal costs (Ayers et al., 2009; Frost et al., 2000a, 2000b; Kim et al., 2001; Tolin et al., 2007a). In one large study, individuals with self-reported hoarding behaviors had an average of 7 work impairment days per month related to psychiatric problems (Tolin et al., 2008b). Cluttered homes due to hoarding behaviors are associated with safety hazards, leading to increased physical morbidity and mortality, and social, financial, and familial consequences. Hoarding also increases the risk of falls, health code violations, fire, eviction, and problems with self-care (Ayers et al., 2009; Frost et al., 2000a, 2000b; Frost et al., 1999; Harris, 2010; Kim et al., 2001; Tolin et al., 2008a; Tolin et al., 2008b; Welfare, 2007). Each year, public service agencies expend tremendous time and financial resources on HD; in San Francisco, more than 6 million dollars per year is spent by service agencies and landlords on hoarding-related issues (not including costs associated with treatment) (San Francisco Task Force on Compulsive Hoarding, 2009).

Because of its chronic nature, HD is similar to other persistent neuropsychiatric disorders in that the goal of treatment is improvement of symptoms rather than remission. Although pharmacological treatments are of use for HD, behavioral approaches are the most commonly used, and a variety of behavioral interventions designed specifically for individuals with HD have been developed and tested over the last 8–10 years (Ayers et al., 2012; Ayers et al., 2011; Frost, 2010; Gilliam et al., 2011; Meyer et al., 2010; Muroff et al., 2012; Steketee et al., 2010; Steketee and Tolin, 2011; Tolin, 2011). These interventions typically include several components, including psychoeducation about HD and its treatment, motivational interviewing or similar approaches designed to increase motivation to change, cognitive restructuring, and exercises (both in session and as homework) aimed at improving sorting and discarding, and reducing cluttering and acquisition behaviors (Steketee and Frost, 2006; Tolin et al., 2015). Both group and individual treatment approaches have been examined for efficacy in HD, usually compared to a waitlist control (Ayers et al., 2012; Ayers et al., 2011; Gilliam et al., 2011; Muroff et al., 2012; Steketee et al., 2010; Steketee and Tolin, 2011; Tolin et al., 2012; Tolin et al., 2007). For most, but not all studies, a change in total score on the Saving-Inventory, Revised (SI-R) was the outcome measure (Frost et al., 2004). The SI-R is a self-report measure of hoarding symptoms and their impact on functioning that is widely used in hoarding research. An improvement (change score) of 14 points or more indicates clinically significant improvement, and a change score of 10 points or more indicates a clinically meaningful improvement (Frost et al., 2012). Although there is wide variability in outcomes between the currently published studies, these studies consistently show evidence of overall improvement after treatment. A recent meta analysis by Tolin et al. showed large effect sizes for CBT for HD interventions, regardless of treatment type (group vs. individual) but also noted that SI-R scores typically remained within the HD range (SI-R≥42) post-treatment (Tolin et al., 2015).

In part because of the intensive and specialized nature of CBT for HD, and the limited number of trained treatment providers outside of specialty clinics, a number of self-help books have been developed. For example, Tolin, Frost, and Steketee published a book called Buried in Treasures: Help for Compulsive Acquiring, Saving, and Hoarding, aimed at providing information, psychoeducation, and practical approaches to reducing clutter and acquisition (Tolin et al., 2007b). This group subsequently developed a facilitator’s guide for leading BiT groups, called Buried in Treasures (BiT) (Shuer and Frost, 2011). BiT is a workbook-based approach that was designed for use either by individuals working on their own or by individuals in a group context with facilitators who were trained to lead the groups but were not clinicians. Only a few studies examining the efficacy of BiT have been published, where individuals were given the BiT workbook to read, but had no other intervention, as a control arm for a CBT study, two open trials of group BiT, and one examining group BiT compared to a waitlist control (Frost et al., 2011, 2012; Muroff et al., 2012). The meta-analysis by Tolin et al. suggested that CBT groups facilitated by mental health professionals and BiT groups facilitated by non-professionals were similar in outcome, although only two studies using non-professionals were used in the comparison (Tolin et al., 2015). Table 1, which expands upon and updates information provided in the Tolin et al. meta-analysis (Tolin et al., 2015), shows the published studies of both individual and group CBT and BiT for HD, as well as weighted group means and percent change in hoarding symptom severity for each subgroup. Weighted group means were calculated as follows: 1) The mean change score for each study was multiplied by the sample size in that study. 2) These scores were then summed, and divided by the sum of the sample sizes for all of the studies. The data in Table 1 suggest that in a research setting with trained facilitators, group BiT is as effective or more effective than both individual CBT and group CBT conducted by mental health professionals, with mean improvement scores of 14.1 for G-BiT compared to 13.9 for G-CBT and 17.1 for I-CBT including the study incorporating cognitive rehabilitation (Ayers et al., 2014), and 13.6 excluding this study. As expected, individual self-help approaches, whether they were internet-based moderated interactions that were CBT-style in nature (Muroff et al., 2010), or providing individuals with the BiT workbook but no other assistance (Muroff et al., 2012), appeared to be less effective, resulting in a 6.5 point improvement on average.

While providing an important context for investigating the effectiveness of group treatment for HD, the generalizability of these studies into a real world setting is unclear, perhaps with the exception of the internet studies, which are naturalistic in nature (Muroff et al., 2010). Most treatment groups were facilitated by experts in the treatment of HD, and/or by individuals trained and closely supervised by such experts. In addition, individuals who volunteer for research studies may not be representative of the larger population of individuals with HD, particularly as HD is not yet widely recognized in the lay community as a treatable neuropsychiatric disorder. Thus, there is a need to examine and compare the effectiveness and cost-effectiveness of the currently available treatments for HD in a community setting. Outside of academic institutions, treatment for HD is likely to be provided by therapists or non-professional facilitators who do not have extensive training in HD-specific treatments, and who may or may not have a foundation in the principles of CBT or group facilitation.

This study presents preliminary outcomes of G-CBT and G-BiT in a community setting using data collected primarily for treatment purposes over the course of three years (2011 to 2013) from CBT and BiT groups run by the Mental Health Association of San Francisco (MHA-SF) for individuals with hoarding problems in the San Francisco Bay Area. Examining the outcomes of CBT and BiT groups provided in a real-world setting to individuals presenting for treatment of HD rather than for treatment studies will 1) help to assess the generalizability of these approaches outside of an academic setting and 2) set the stage for larger community-based studies aimed at more directly comparing G-BiT to G-CBT and identifying specific predictors of treatment outcome. The aims of this study were to examine the effectiveness and costs of group CBT (G-CBT) and group BiT (G-BiT) using therapists and peer facilitators drawn from the community in a real-world setting, to compare treatment outcomes between G-CBT and G-BiT in this context, as well as to the outcomes reported in the literature, and to compare the approximate costs of these treatment. We hypothesized that 1) both G-CBT and G-BiT would have treatment outcomes that are similar to those reported previously, 2) there would be no statistically significant differences between the two types of groups, and 3) G-BiT would be more cost effective in the long term than would G-CBT.

Section snippets

Method

This is a retrospective study that analyzes pre- and post-treatment data collected opportunistically by the Mental Health Association of San Francisco (MHA-SF) during treatment groups run for clinical rather than research purposes. Below, we describe the characteristics of these treatment groups, including the setting, the clinical design of the groups, the measures used to assess severity, and the clinical inclusion and exclusion criteria used to enroll participants in the treatment groups. We

Results

Four G-CBT groups were held during the time period from 2011 to 2013 (one or two per year), and two G-BiT groups were held, one each in 2012 and 2013. CBT groups were 10–12 members each, and BiT groups were 10 members each. All individuals who were eligible based on residence and insurance status were included in treatment; no one was excluded for mental health or medical reasons. Two of the participants in the CBT groups had received prior CBT treatment, and 6 participants in the BiT groups

Discussion

The aim of this study was to examine and compare outcomes for two types of group treatment for Hoarding Disorder conducted in a naturalistic community setting. Although other studies have been conducted in a community setting, to our knowledge, this is the only study to examine data collected not for research purposes, but primarily for treatment purposes by an advocacy group whose goal is to provide mental health services. Similarly, this is the first study to directly compare groups

Acknowledgments

This work was partially supported through a Patient-Centered Outcomes Research Institute (PCORI) Assessment of Prevention, Diagnosis, and Treatment Options Program Award (#CE-1304-6000). All statements in this report, including its finding and conclusions, are solely those of the authors and do not necessarily represent the views of the Patient-Centered Outcomes Research Institute (PCORI), its Board of Governors or Methodology Committee.

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