Future of EvidenceBased Practices in Mental Health

1
Future of Evidence-Based Practices in Mental
Health

• Robert E. Drake
• Dartmouth Medical School

2
Disclosure

• This presentation will not include discussion of
  off-label, experimental, and/or investigational
  uses of drugs or devices

3
Overview

• Evidence-based Practices
• Effective structural approaches
• Evidence-based Medicine
• Effective decision-making
• Current Science, Patient Values, Practitioner
  Skills

4
History of Mental Health

• Cottage industry
• Little attention to outcomes
• Ineffective and harmful interventions persist for
  years
• Effective interventions rarely used

5
Evidence-Based Practices

• Standardized interventions
• Controlled research
• More than 1 research group
• Objective outcome measures
• Meaningful outcomes

6
THE ABSENCE OF EBPS IN MENTAL HEALTH SETTINGS

• Surgeon Generals Report
• Institute of Medicine Report
• Schizophrenia PORT
• Presidents New Freedom Commission on MH
• NIMH Bridges from Science to Services
• Kay Jamison The difference between what we know
  and what we do is often the tragedy of suicide.

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SCHIZOPHRENIA PORT DATA

• Appropriate maintenance dose of antipsychotic
  29
• Family psychoeducation 10
• Vocational rehabilitation 22

8
Evidence-Based Rehabilitation Practices

• Assertive Community Treatment
• Supported Employment
• Family Psychoeducation
• Illness Management and Recovery
• Integrated Treatment for Co-occurring Disorders

9
Assertive Community Treatment (ACT)

• Community-based team
• Low caseload
• Multidisciplinary
• Outreach
• Direct service provision
• 24 hours/7days

10
Research on ACT (cont.)
25 Randomized Controlled Trials
ACT better than standard treatment
ACT not better than standard treatment
Number of Studies
Time inHospital
HousingStability
Qualityof Life
ClientSatisfaction
Symptoms
SocialFunctioning
Vocational
Jail/Arrests
Mueser KT, et al. Schizophr Bull.
199824(1)37-74.
11
Days Homeless on Streets ACT vs Usual Community
Services
250
ACT
Usual community services
N152
200
150
Days Homeless
100
50
0
FirstQuarter
SecondQuarter
ThirdQuarter
FourthQuarter
Lehman AF. Unpublished data.
12
Supported Employment

• Focus on competitive work
• Rapid job search
• De-emphasis on prevocational training and
  assessment
• Attention to client preferences
• Follow-along supports provided

13
Supported Employment RCTs
14
Individual Placement and Support (IPS) vs
Enhanced Vocational Rehabilitation (EVR) in
Maintaining Competitive Jobs
40
IPS (n74)
EVR (n76)
35
30
25
Working in Competitive Jobs
20
15
10
5
0
18
17
16
15
14
13
12
11
10
9
8
7
6
5
4
3
2
1
Study Months
Drake RE, et al. Arch Gen Psychiatry.
199956(7)627-633.
15
Family Psychoeducation

• Provided by professionals
• Long-term (over 6 months)
• Single and multiple familygroup formats
• Focus on education, stress reduction, coping, and
  other support
• Oriented toward future, not past

16
Effects of Family Intervention on2-Year Relapse
Rates (12 Studies)
Cumulative Relapse Rate
Standard Care(n203)
Single FamilyTreatment(n231)
Multiple FamilyGroup Treatment(n266)
Single and MultipleFamily GroupTreatment(n243)
Mueser KT, Glynn SM. Behavioral Family Therapy
for Psychiatric Disorders 1999.Montero I, et
al. Schizophr Bull. 200127(4)661-670.
17
Illness Management Training

• Helping people learn to manage their own
  illnesses
• Relapse prevention
• Minimize the effects ofresidual symptoms

18
Research on Illness Management Training

• Psychoeducation increases knowledge and awareness
• Behavioral tailoring increases effective use of
  medications
• Warning sign recognitionreduces relapses
• Cognitive-behavioral treatment reduces residual
  symptoms

19
Social Adjustment Outcomes Cumulative Effect
Sizes
0.9
Personal therapy (n74)
0.8
No personal therapy (n77)
0.7
p.004
0.6
0.5
Effect Size onSocial Adjustment
0.4
0.3
0.2
0.1
0
Intake
Year 1
Year 2
Year 3
Years in Treatment
Social adjustmentwork performance, relations in
the home and with external family, social
leisure, general adjustment, interpersonal
anguish, social relations, role performance,
normal functioning,Brief Psychiatric Rating
Scale (BPRS) score, and Global Assessment Scale
(GAS) score.Hogarty GE, et al. Am J Psychiatry.
1997154(11)1514-1524.
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Integrated Dual Disorders Treatment

• Mental health and substance abuse treatments
  combined by 1 team
• Assertive
• Stage-wise
• Individualized
• Comprehensive
• Long-term

21
ACT and Integrated DualDisorders Treatment
60
High-fidelity ACT programs (n61)
50
Low-fidelity ACT programs (n26)
40
30
of Patients in Stable Remission
20
10
0
Baseline
6
12
18
24
30
36
Assessment Point
McHugo GJ, et al. Psychiatr Serv.
199950(6)818-824.
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Common Features of Evidence-Based Rehabilitation
Practices

• Client/consumer choice
• Individualization
• Skills and supports in the community
• Autonomous adult roles
• Quality of life

23
Additional Rehabilitation Practices

• Social skills training
• Supported housing
• Supported education
• Integrated medical care
• Trauma interventions

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Dissemination and Implementation

• Science to service gap
• No simple solution for complex systems
• Multiple strategies
• Phases of implementation
• All stakeholders
• Fidelity

25
National EBP Project

• Phase I conduct reviews, prepare implementation
  packages (toolkits), and establish state
  technical assistance centers
• Phase II field tests to refine procedures and
  resource materials
• Phase III national demonstration

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Johnson Johnson-Dartmouth Community Mental
Health Project

• Mental health-vocational rehabilitation
  collaboration
• implement evidence-based SE
• Local programs selected by states
• Dartmouth provides training, consultation, and
  evaluation
• First states CT, DC, KS, MD, OR, SC, VT
• New states DE, IL, MN, OH
• 
  (Drake, 2006)

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System Changes 1

• Align with evidence-based medicine
• Address 3 components science, consumer
  involvement, practitioner competence
• Align financing with goals
• Integrate services and supports mental health,
  substance abuse, vocational rehabilitation,
  general health, housing, self-help, family
  supports

30
System Changes 2

• Improve data systems and focus on outcomes
• Electronic records education, assessment,
  client portals, standardized outcomes, decision
  supports for practitioners
• Engineer micro-systems of care

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Status of EBPs in 2002
32
Current Concerns

• Fidelity
• Quality
• Access
• Durability
• Flexibility
• Financing
• Organization

33
Information books, videos, research articles

• Karen Dunn
• Karen.Dunn_at_Dartmouth.edu
• 603-448-0263
• www.mentalhealth.samhsa.gov

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EBP Future Directions

• More effective interventions
• Outcomes, neuroscience, genomics
• Specific diagnosis and treatment

35
EBP Future Directions

• Clinical Skills
• Basic skills
• Keeping up
• Shared decision-making

36
EBP Future Directions

• Consumer activation
• Peer support
• Self-help

37
EBP Future Directions

• Computerization
• Electronic medical records
• Decision Support systems

38
EBP Future Directions

• Integrated healthcare
• Insurance
• Disability
• Legal standards

39
Limitations of SE

• One-fourth do not work
• Most people do not work full-time
• Nearly all people stay on benefits

40
Amplifying the Effects of Supported Employment

• External barriers
• Implement evidence-based practices (Social
  Security Study, 2006)
• Early intervention (Neuchterlein, 2005)
• Policy changes (Suter, 2006)

41
Social Security Administration Mental Health
Treatment Study

• RCT in 22 cities
• 3,000 SSDI beneficiaries
• Interventions
• IPS supported employment
• EB medication management
• EB mental health practices
• Insurance package
• Waiver from SSA review

42
UCLA Study (Neuchterlein, 2005)
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Policy Changes

• People with disabilities need cash, health
  insurance, and a job
• They do not need to be assigned to a lifetime of
  unemployment and poverty in order to get health
  insurance
• Legislative change is needed
• Carl Suter (2006)

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Amplifying the Effects of Supported Employment

• Internal barriers
• Skills training (Marder)
• Errorless learning (Kern)
• Benefits counseling (Tremblay)
• Motivational interviewing (Drebing)
• Contingency management (Drebing)
• Cognitive training (McGurk)
• Compensatory mechanisms (Velligan)
• Medications (MATRICS)

45
Skills Training

• Pre-employment skills training is ineffective
• Skills training while working (Mueser, 2006
  Marder, 2006)
• Errorless learning (Kern, 2006)

46
Critical Influence of Benefits

• Most consumers report fear of losing benefits
  (SSI, SSDI, and Medicaid) as barrier
• Rules are often difficult to understand and apply
• Source 2003 NAMI survey

47
Benefits Counseling (Tremblay, 2006)
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Motivational Interviewing

• Counseling to help people clarify their own
  goals,
• Resolve their ambivalence,
• And develop motivation
• (Drebing, 2006)

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Contingency Management

• Behavioral principles
• Reinforce desired behaviors
• Attendance, reduced substance abuse, job finding
  tasks
• (Drebing, 2006)

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Cognitive Training

• Practicing cognitive tasks to create new neuronal
  connections
• Tasks can be directly relevant to work tasks
• New capacity may translate to work
• 
  (McGurk, 2005)

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Medications

• MATRICS study
• Cognitive medications
• If they impact the cognitive deficits of
  schizophrenia, will they impact functioning?

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Overview

• Evidence-based Practices
• Effective structural approaches
• Evidence-based Medicine
• Effective decision-making
• Current Science, Patient Values, Practitioner
  Skills

55
Evidence-based Medicine

• The combination of science, client
  values/preference, and clinical expertise
• In mental health care, this means combining
  science and recovery ideology

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Alternatives to EBM

• Clinical experience
• Continuing education
• Eminence-based medicine
• Ideology-based medicine
• Free market of ideas

57
Evidence-based Medicine Techniques

• 1. Assessment
• 2. Asking a question
• 3. Finding the evidence
• 4. Determining validity
• 5. Determining applicability
• 6. Shared decision-making

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Future of Shared Decision Making

• Unbiased processes of synthesizing and updating
  the evidence
• Electronic risk adjustment
• Electronic decision supports
• Multiple access points
• Resource centers
• Decision aids
• Activated clients and practitioners

59
Conclusions

• Evidence-based rehabilitation interventions are
  available and will improve rapidly
• Implementation will require changes in
  organization and financing
• Flexible, individualized application will require
  evidence-based medicine techniques