EVIDENCE-BASED MENTAL HEALTH PRACTICES

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EVIDENCE-BASED MENTAL HEALTH PRACTICES

• Anthony F. Lehman, M.D., M.S.P.H.
• Professor and Chair
• Department of Psychiatry
• University of Maryland

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10 Leading Causes of Disability in the World
(WHO, 1997)

• Unipolar Depression
• Iron-deficiency Anemia
• Falls
• Alcohol Use
• COPD
• Bipolar disorder
• Congenital anomalies
• Osteoarthritis
• Schizophrenia
• Obsessive-compulsive disorder

• 10.7
• 4.7
• 4.6
• 3.3
• 3.1
• 3.0
• 2.9
• 2.8
• 2.6
• 2.2

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CHANGES IN PRIVATE HEALTH CARE EXPENDITURES1988-1
997(HAY GROUP STUDY, 1998)

• Overall health care expenditures decreased by 7
  between 1988-1997
• Mental health care expenditures decreased by 54

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PORT Process

• Review literature regarding evidence for practice
  (efficacy)
• Analyze data on variations in practice
• Develop outcomes information to examine
  relationship of treatment and patient outcomes
  (effectiveness)
• Develop treatment recommendations based on
  literature and outcome studies
• Disseminate findings to change current practices

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Schizophrenia PORT Treatment Recommendations

• Recommendation 1 Antipsychotic medications,
  other than clozapine, should be used as the
  first-line treatment to reduce psychotic symptoms
  for persons experiencing an acute symptom episode
  of schizophrenia.

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Conventional Antipsychotics Efficacy-Effectivenes
s Gap

• Annual Relapse Rates
• - Placebo 70
• - Efficacy in clinical trails 23
• - Effectiveness in practice 50
• Factors Affecting Efficacy-Effectiveness Gap
• - Patient heterogeneity
• - Prescribing practices
• - Noncompliance
• (from Kissling, 1992) _________________
• Schizophrenia PORT

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Schizophrenia PORT Treatment Recommendations

• Recommendation 2 The dosage of antipsychotic
  medication for an acute symptom episode should be
  in the range of 300-1000 chlorpromazine (CPZ)
  equivalents per day for a minimum of 6 weeks.
  Reasons for dosages outside of this range should
  be justified. The minimum effective dose should
  be used.

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Effective Dosage Range Acute Treatment
Improvement (2-4 h)
1
2
3
5
10
20
30
50
Dose, mg (Fluphenazine)
Baldessarini et al. (1988), Arch Gen Psych
4579-91
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Schizophrenia PORT Treatment Recommendations

• Recommendation 9 The maintenance dosage should
  be in the range of 300-600 CPZ equivalents (oral
  or depot) per day.

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Effective Dosage RangeMaintenance Treatment
not relapsed (1 yr)
Fluphenazine Decanoate, mg/2 wk
Schizophrenia PORT
Baldessarini et al. (1988), Arch Gen Psych
4579-91
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Schizophrenia PORT Treatment Recommendations

• Recommendation 23 Individual and group therapies
  employing well-specified combinations of support,
  education, and behavioral and cognitive skills
  training approaches designed to address the
  specific deficits of persons with schizophrenia
  should be offered over time to improve
  functioning and enhance other targeted problems,
  such as medication non-compliance.

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Cumulative Effect Sizes Adjustment Outcomes
N148
N151
N128
(Begin N151)
(End N125)
Year in Treatment
From Hogarty et. al. (1996)
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Schizophrenia PORT Treatment Recommendations

• Recommendation 24 Patients who have on-going
  contact with their families should be offered a
  family psychosocial intervention which spans at
  least nine months and which provides a
  combination of education about the illness,
  family support, crisis intervention, and problem
  solving skills training. Such interventions
  should also be offered to non-family caregivers.

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Combined Therapies for SchizophreniaAnnual
Relapse Rates (Hogarty et al., 1986)
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Schizophrenia PORT Treatment Recommendations

• Recommendation 27 Persons with schizophrenia who
  have any of the following characteristics should
  be offered vocational services. The person a)
  identifies competitive employment as a personal
  goal b) has a history of prior competitive
  employment c) has a minimal history of
  psychiatric hospitalization d) is judged on the
  basis of a formal vocational assessment to have
  good work skills.

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VOCATIONAL STUDIES
Working
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Employment Intervention Demonstration Project

• Sponsored by Center for Mental Health Services
• A multi-center, longitudinal evaluation of
  employment interventions for persons with severe
  mental illness
• Randomly assigned and followed for two years.

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EIDP TREND 1

• JOB TENURE SHOWED A TREND TOWARD INCREASED
  LENGTH OF JOB OVER TIME.

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Average Length of Jobs (EIDP, 2001)
Average Length in Days
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EIDP TREND 2

• TIME BETWEEN JOBS DECREASED OVER TIME
•  

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Number of Days Between Jobs Among EIDP
Participants with More than One Job
Average Number of Days
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EIDP TREND 3

• RECEIPT OF JOB SUPPORT WAS ASSOCIATED WITH LONGER
  JOB TENURE ON FIRST JOB

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DEFINITION OF JOB SUPPORT

• On-site counseling, support, and problem solving.
  Providing on-the job help with vocational skills
  in different work situations and production
  levels, social skill in the work environment, and
  job-related skills may include on-the-job
  training/assistance.

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Mean Length (in days) of First Competitive Job by
Receipt of Job Support
Mean Length in Days
Received Job Support
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Schizophrenia PORT Treatment Recommendations

• Recommendation 29 Systems of care serving
  persons with schizophrenia who are high service
  utilizers should include assertive case
  management and assertive community treatment
  programs.

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CONTROLLED ACT RESEARCH
25 Studies
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Inpatient Days ACT vs. ComparisonLehman et al,
1998
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Days Homeless on Streets ACT vs.
ComparisonLehman et al., 1997
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Outpatient Visits ACT vs. ComparisonLehman et
al, 1997
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SCHIZOPHRENIA PORT Current Practices

• Maintenance dose of antipsychotic within
  recommended range 29
• Adjunctive antidepressant 46
• Psychological Interventions 45
• Family psychoeducation 10
• Vocational rehabilitation 22

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Rates of Conformance with PORT Psychosocial
Treatment Recommendations APA Office of Quality
Improvement and Psychiatric Services
32
Medicare Claims 1991 Proportion of Study
Population with At Least One Visit for Outpatient
Service (N16,480)
of Patients
Schizophrenia PORT
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Major Depression Treatment

• Acute Phase (Symptom Response_
• Placebo... 20-50
• Antidepressant. 65-70
• Psychotherapies.. 47-55
• Maintenance Phase (Relapse Prevention)
• Placebo 15-45
• Antidepressant.. 65-79

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Child and adolescent treatments that have been
found to be effective

• Empirically supported treatments
• Cognitive-behavior therapy for childhood anxiety
  disorders
• Cognitive-behavioral coping skills therapy for
  depression (including school-based treatments)
• Parent management training for disruptive
  behaviors (including videos for parents)
• Problem-solving skills therapy for disruptive
  behaviors
• Social skills training for young children who are
  aggressive (including school-based treatments)
• Psychotropic medication for Attention Disorders
  and Obsessive-Compulsive disorders
• Empirically promising treatments
• Intensive home-based behavior modification for
  autism
• Family therapy for parent-adolescent conflict
• Teacher consultation models for disruptive
  behaviors (reduction in Special Ed. referrals
  found effects on behavior problems unclear)
• Psychotropic medication for a number of other
  symptoms (e.g., depression, anxiety, autistic
  behaviors)

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Empirically Supported Treatments

• Conduct Problems
• Multi-System Treatment
• 84 youth categorized as serious juvenile
  offenders randomly assigned to MST and standard
  care through juvenile justice
• After two years, 40 of youth treated with MST
  avoided re-arrest versus 20 of youth receiving
  standard care (Henggler, et al 1996)
• Behavioral family/parent training
• A large average effect size of .86 was found
  across studies of family behavioral skills
  interventions with disruptive behavior disorders
  (Serketich, Dumas 1996)

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Empirically Supported Treatments

• Depression in Adolescents
• Cognitive Behavioral Therapy
• Results of large controlled study showed
  reduction in symptoms in 70 of those treated
  with CBT
• Coping with Depression (CWD) course
• 96 youth with major depression randomized to CWD
  course or wait-list control
• 97.5 of CWD group no longer met criteria for
  depression disorder at 2 year follow-up

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Pediatric Psychopharmacology1
1 Jensen, Bhatara, Vitiello, et al 1999
2 A 2 RCTs B 1 RCT C clinical
consensus
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Different Perspectives on Outcomes Example
Utility for Mild Symptoms plus Side Effects
Versus Moderate Symptoms and No Side Effects
(Lenert et al., 2000)
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EVOLUTION OF MEDICAL TECHNOLOGY AND COSTS OF
TREATING DISEASE (Pardes et al., 1999)

• Costs
• palliative treatment cure
• Stages of Technology