Patient-Treatment Matching: Rationale and Results.

For many years, the desire to improve the outcome of alcoholism treatment has prompted researchers and clinicians to compare different treatments in the hope of discovering the "best treatment." This race to find a single solution has produced a large volume of literature on the efficacy of a wide range of treatments involving social; behavioral; psychiatric; and, most recently, pharmacologic components. Although a few treatments have emerged that seem to outperform others (e.g., social skills training, motivational enhancement therapy, and the community reinforcement approach; for a more complete description of these treatments, see the article by Kadden, pp. 279-286), researchers now generally recognize that no single form of treatment is likely to be effective for all people with alcohol problems(1) (Hester and Miller 1989; Holder et al. 1991; Allen and Kadden in press). The treatment field now seeks to obtain optimal outcomes by considering both the main effects of a treatment and the additional improvement that may result if a client is matched to the most appropriate treatment. In alcoholism treatment research, analyses comparing the main effects of different treatments often have revealed that they have similar benefits. However, by performing analyses that examine the interactions between certain patient and treatment types, differential benefits may then become evident. That is, particular treatments work better for some patients than for others, and in some cases, treatment can be improved by "matching" subgroups of patients with the therapies most suited to their needs, based on a specific treatment's record of success for clients of the same description. The matching approach recognizes that alcoholism is a multifaceted disorder; thus, all treatments will not have the same effect on all people diagnosed with this condition. This perspective reframes the central question of alcoholism treatment research as follows: "What treatment, by whom, is most effective for this individual with these specific problems, and under which set of circumstances?" (Institute of Medicine [IOM] 1990, p. 143). Although in recent years practitioners have given considerable attention to individualizing treatment, client-treatment matching is not a new concept in the alcoholism treatment field (Bowman and Jellinek 1941; Wallerstein 1956, 1957), nor is it new in psychiatry, medicine, or educational research (Snow 1991). Indeed, matching treatment to individuals is not "a unique and idiosyncratic development" but "a particular application of a general strategy in human therapeutics" (IOM 1990, p. 280). Thus, it is the way in which matching is now being evaluated, rather than the concept of matching, that is relatively new. Considerable preliminary evidence from numerous clinical trials suggests that matching may be a promising approach to improving treatment outcomes (Mattson et al. 1994). According to the IOM: Reason for optimism in the treatment of alcohol problems lies in the range of promising alternatives that are available, each of which may be optimal for different types of individuals (IOM 1990, p. 147). This article reviews the role of matching in alcoholism treatment and research and describes the major features of Project MATCH, an ongoing multisite trial of patient-treatment matching (see sidebar). WHAT IS PATIENT-TREATMENT MATCHING? In its simplest terms, patient-treatment matching means prescribing treatment based on individual patient needs, as opposed to providing the same therapy to all patients with a common diagnosis. The ultimate goal of matching research is to develop valid, practical rules for clinicians to use in assigning patients to treatment regimens. The Current Practice of Assigning Treatment Ideally, clinicians today assign patients to treatment based on criteria such as the severity of their alcoholism or the presence of co-occurring pathology or other problems (e. …