The Once and FutureNow

1
The Once and FutureNow

• The Intersection of Neuroscience and Nonprofit
  Behavioral Health Care

2
Five Key Advancements for Nonprofit Behavioral
Health Care

• More accurate diagnoses using genotyping and
  brain imaging
• Electrical stimulation as treatments for PTSD,
  depression, and other psychological disorders
• Improved drugs developed from a better
  neuroscientific understanding of psychological
  disorders
• Use of brain imaging to establish treatment
  responses and monitor progress towards those
  responses
• Integration of cognitive-enhancing drugs with
  traditional talk-based therapies

3
Genotyping As A Diagnostic Tool

• Using genotyping in combination with
  psychological assessments, researchers have found
  that high levels of antisocial behavior were
  strongly correlated with a combination of low
  levels of the MAOA gene and severe maltreatment.
• Diagnostic tests emerging from recent research on
  expression of genes in RNA. Given the changes in
  brain activity documented in psychological
  disorders, scientists anticipate a corresponding
  change in gene expression that could be monitored
  through blood work.

4
Brain Imaging to Diagnose Behavioral Health Issues

• Scientists using brain imaging to look for a
  network of regions that consistently display
  correlated differences in depression.
• Brain imaging used to identify damaged areas of
  brain known to impact behavior violence,
  attention deficit disorder, etc.

5
Electrical Stimulation

• Electrodes surgically implanted in the brain
  produce high-frequency electric impulses to alter
  signals produced by a region connected to
  depression. Result symptoms of depression
  reduced or put into remission.
• Other methods being studied or applied as a
  treatment for depression include
  Electroconvulsive therapy (currently considered
  safe and effective) and Transcranial Magnetic
  Stimulation.

6
Improved Drugs

• In the past, trial-and-error experimentation has
  dominated the search for new antidepressants and
  other drugs for psychological disorders.
  Increasingly, scientists are trying to understand
  the underlying neurobiology of these disorders in
  order to target treatments more effectively.
• Example PTSD has been associated with damage to
  the hippocampus. Researchers have tested drugs to
  foster neuron growth in the hippocampus, or to
  alter its ability to take up neurotransmitters.
  In both cases these medications have helped
  restore memories

7
Improved Drugs, continued

• Pharmacogenomicsthe study of how different
  genotypes can influence the effectiveness and
  side-effects of psychiatric medications.
  Genotyping may become an important element in
  individualizing treatment. For now however, it is
  difficult to establish positive findings because
  many genes are most likely involved in medication
  responses, and because genes are influenced by an
  interplay with environment. Nevertheless, field
  is moving forward rapidly and may someday lead to
  personalized medicine.

8
Brain Imaging to Establish and Monitor Treatment

• Scientists have studied depressed people who
  benefit from medication or psychotherapy,
  comparing their brain activity before and after
  treatment. Brain scans show early changes in
  subcortical regions, but people report only
  feeling better when changes occur to cortical
  regions.
• Researchers have looked for differences between
  the brains of depressed patients who respond to
  different kinds of treatment, as well as to
  patients who do not respond to any of them.

9
Integration of Cognitive-Enhancing Drugs With
Therapy

• While medication has become much more common for
  the treatment of psychological disorders, its
  increase does not spell the doom of
  psychotherapy.
• Neuroscience research is helping to document how
  psychotherapy produces significant biological
  changes in the brain.

10
Research shows medication and psychotherapy more
effective in combination than either is on its
own.

• Psychotherapy may act as emotional learning
  tool. Decades of research on learning shows it
  involves the formation of new connections between
  neurons and the severing of old connections.
  Experiments on animals have shown that certain
  drugs enhance this process, allowing animals to
  learn new tasks faster.

11
Research on the genetics of psychological
disorders provides support for traditional social
work.

• Genes only predispose people to antisocial
  behavior, depression, and other psychological
  disorders. The environment plays a powerful role
  in shaping behavior. Long term studies have shown
  that children who were abused did not have more
  conduct problems than non-abused children if they
  were in a home visitation program

12
How Soon?

• Immediately available Brain imaging technologies
  for use as diagnostic tools, treatment
  establishment and management protocols
• On the horizon Improved drugs to treat
  psychological disorders and enhance cognitive
  therapies. Behind those lie opportunities for
  neurosurgical intervention as treatments for
  behavioral health issues.
• Just over the horizon (but considered by many to
  be likely) research on genes will lead to further
  advances in treatment and diagnosis strategies

13
Implications For Nonprofits From Neuroscience
Advances?

• Clinical
• Systemic/Institutional
• Societal

14
Clinical Implications

• Once new treatments penetrate the evidence base
  and start becoming treatment as usual, they are
  likely to affect every aspect of current clinical
  practices
• how clients are referred into treatment, to
  assessments, diagnosis, and treatment planning,
  core treatment mechanisms, supportive services,
  and aftercare.

15
Clinical Implications, continued

• Treatment inputs, including staffing, client
  characteristics, and service structure, will also
  evolve.
• Depending on what treatments emerge (and when)
  and what services are reimbursed (and at what
  level), there may also be fundamental changes in
  the populations served by behavioral health
  agencies.

16
Clinical Implications, continued

• Individual clinicians and agencies will need to
  implement new practices and treatment paradigms.
  Process will involve activities including
• Assessing program, clinician and support staff
  readiness
• Developing knowledge about the new treatments
  evaluating the degree of substantive change
  required to move from current practice to the new
  state of service delivery
• Examining various barriers to implementation
• Identifying supports needed for the change
  process.

17
New Clinical Paradigm Emerges

• Agencies create a research-friendly environment
  
• Clinicians trained in identifying those
  conditions for which innovative effective
  treatments are available
• Agencies adopt evidence-based practices

18
Evidence-Based Practice

• Continuum between the worlds of practice and
  science. Both can and should inform one another
  practice needs to be informed by science, but
  science also need to be informed by the realities
  encountered in actual clinical settings
  something that has come to be called
  practice-based evidence.

19
Practice-Based Evidence

• Adopting a strategy of practice-based evidence
  requires that agencies engage in systematic
  efforts to collect, document, understand and
  monitor clinical outcomes of specific treatments
  as they are applied to specific populations of
  interest.

20
Institutional /Systemic Implications

• Neuroscience is accelerating the medicalization
  of behavioral health as a field. This will create
  a need for new professional skills, new
  technological equipment, new service delivery
  structures, and new cost reimbursement
  strategies.

21
Institutional /Systemic Implications, continued

• New model likely to be realized through
• new partnerships and institutional relationships,
  including linkages between traditional behavioral
  health agencies and other types of providers such
  as psychiatric and medical-surgical hospitals,
  and private diagnostic and screening centers with
  sophisticated imaging and other medical
  equipment.

22
Societal Implications

• New technologies will give rise to new types of
  ethical questions
• What applications of brainotyping will be
  acceptable?
• Who can and should have access to such
  information and for what uses or purposes?
• How will neuro-based information be protected
  from misuse and who will enforce these
  protections?

23
New Ethical Questions Arise

• Are enhancements of normal brain-states a
  legitimate use of neurocognitive medications and
  other technologies?
• Will diagnostic creep occur - will behavior
  that was once thought to be within the range of
  normal instead be seen as impaired and in need
  of a neurocognitive intervention?

24
Old Ethical Questions Still Remain

• Informed Consent
• Privacy
• Safety Concerns

25
Other Societal Implications

• May be less stigma attached to criminal behaviors
  that are brain-based this in turn may lead to
  more treatment and rehabilitation and less
  chronic incarceration of people with serious
  mental illnesses.
• Likely that courts and other justice and social
  service agencies will increasingly mandate
  neuropsychiatric interventions.

26
Other Societal Implications, continued

• May also lead to changes in how we define such
  things as moral and legal responsibility, and
  impaired consent.
• Fundamental notions such as free will and
  personal identity may be reconsidered and
  redefined.

27
Other Societal Implications, continued

• The potential both to create and remedy serious
  social inequities among groups is produced -
  among groups that are already disenfranchised
  and/or experiencing discrimination minority
  racial/ethnic groups, people with learning
  disabilities or mental illnesses, chronically
  homeless people, people who are repeatedly
  incarcerated, etc.
• Access to neuroscientific interventions that can
  be used for treatment and/or enhancements may not
  be equally distributed technologies may add to
  the existing divide separating those with and
  without.

28
The New Face of a Nonprofit Behavioral Health
Provider

• Informed and knowledgeable on both the promises
  and limitations of the new advancements.
• Evidence-based practice models adopted as the
  protocol for agency service delivery.
• Research friendly environment created inside the
  agency by collecting high quality treatment and
  outcome data, linking the two, and acting on the
  findings
• Collaboration opportunities with researchers in
  the neurosciences sought out. Diversity of
  researchers and research participants in studies
  fostered.

29
The New Face of a Nonprofit Behavioral Health
Provider, continued

• Strategic partnerships built with a diversity of
  other service providers.
• Agencies prepared to respond to and educate
  consumers and their families about
  pharmaceuticals, genetic testing, and imaging
  centers.
• Agencies facilitate the full participation of
  consumers and advocates in any decision-making
  related to the integration of neuroscience
  advances with behavioral health care.
• Flexible, unrestricted funding to underwrite the
  pursuit of new and innovative behavioral health
  treatments is secured.

30
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• 90 of survey participants report they do not use
  neuroscience technology
• Nearly half report they integrate cognitive
  enhancing drugs into talk-based therapies

31
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• No survey participants provide neuroscience
  technology through partnership with a research
  university.
• Most provide the technology through collaboration
  with another behavioral health care provider
• A few provide the technology in house
• One provides through a hospital-based service

32
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• Less than 8 of those survey participants who are
  non-users of neuroscience technology are
  considering adopting any of the seven
  neuroscience advancements

33
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• Majority of survey participants say they lack the
  agency capacity to adopt neuroscience technology

34
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• say they lack the agency capacity to adopt
  neuroscience technology because
• Lack knowledge
• Lack qualifications/certifications
• Lack technical training

35
Where are Alliance Member Agencies in Adopting
Neuroscience Advancements?

• 70.9 report their agency is engaged in
  evidence-based practice within their behavioral
  health care program. BUT based on examples of
  evidence-based efforts provided by participants,
  it appears there is no consistent understanding
  of what constitutes evidence-based practice.

36
Public Policy Implications?

• Who has access to advancements?
• Who has access to/use of neuro-based information?
• Advancements used to resolve impairments or
  enhance normal?
• Who mandates neuropsychiatric interventions?
• Who sets informed consent, privacy, safety
  policies?
• Who enforces standards/policies?
• Are reimbursement decisions cost-driven?