evidence-based practices in psychiatric rehabilitation bob drake october, 2010
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Evidence-Based Practices in Evidence-Based Practices in Psychiatric RehabilitationPsychiatric Rehabilitation
Bob Drake
October, 2010
Financial Support to PRCFinancial Support to PRC
Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA
Contracts from Guilford Press, Hazelden Press, MacArthur Foundation, Oxford Press, New York Office of Mental Health, Research Foundation for Mental Health
Gifts from Johnson & Johnson Corporate Contributions, Segal Foundation, Thomson Foundation, Vail Foundation, West Foundation
OVERVIEWOVERVIEW
Definition Update on evidence-based practices Common themes Dissemination and implementation
History of Mental Health in U.S.History of Mental Health in U.S.
Cottage industry Little attention to outcomes Ineffective and harmful
interventions persist for years Effective interventions rarely used
Evidence-based MedicineEvidence-based Medicine
The combination of science, client values/preference, and clinical expertise
In mental health care, this means combining science and recovery ideology
Evidence-Based Evidence-Based PracticesPractices
Standardized interventions
Controlled research
More than 1 research group
Objective outcome measures
Meaningful outcomes
Evidence-Based Rehabilitation PracticesEvidence-Based Rehabilitation PracticesRobert Wood Johnson Foundation 1998Robert Wood Johnson Foundation 1998 Assertive Community Treatment Supported Employment Family Psychoeducation Illness Management and Recovery Integrated Treatment for Co-
occurring Disorders
Assertive Community Treatment (ACT)Assertive Community Treatment (ACT)
Community-based team
Low caseload
Multidisciplinary
Outreach
Direct service provision
24 hours/7days
Research on ACT Research on ACT (cont.)(cont.)
0
2
4
6
8
10
12
14
16
18
Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74.
ACT better than standard treatmentACT not better than standard treatment
Time inHospital
HousingStability
Qualityof Life
ClientSatisfaction
Symptoms SocialFunctioning
Vocational Jail/Arrests
Num
ber o
f Stu
dies
25 Randomized Controlled Trials
Days Homeless on Streets: Days Homeless on Streets: ACT vs Usual Community ServicesACT vs Usual Community Services
0
50
100
150
200
250
FirstQuarter
SecondQuarter
ThirdQuarter
FourthQuarter
ACTUsual community servicesN=152
Lehman AF. Unpublished data.
Day
s H
omel
ess
Current ACT IssuesCurrent ACT Issues
1. Hospital system changes
2. Quality of usual services
3. Forensic ACT
4. Other expansions and components
5. Transitions
Supported EmploymentSupported Employment
Focus on competitive work
Rapid job search
De-emphasis on prevocational training and assessment
Attention to client preferences
Follow-along supports as needed
Supported Employment RCTsSupported Employment RCTs
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
96 NH (IPS)
94 NY(SE)
04 CA
(IPS)
04 IL
(IPS)
04 CT (IPS)
06 SC
(IPS)
05 HK
(IPS)
99 DC (IPS)
95 IN (SE)
06 EUR(IPS)
00 NY(SE)
05QUE(IPS)
97 CA (SE)
02 MD
(IPS)
Supported Employment Control
Individual Placement and Support (IPS) vs Individual Placement and Support (IPS) vs Enhanced Vocational Rehabilitation (EVR) in Enhanced Vocational Rehabilitation (EVR) in
Maintaining Competitive JobsMaintaining Competitive JobsIPS (n=74)EVR (n=76)
40
35
30
25
20
15
10
5
0181716151413121110987654321
Study Months
% W
orki
ng in
Com
petit
ive
Jobs
Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.
Current SE IssuesCurrent SE Issues
1. Financing
2. Cognitive strategies
3. Effective specialists
4. Disability reform
Family PsychoeducationFamily 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
0
25
50
75
100
Effects of Family Intervention onEffects of Family Intervention on2-Year Relapse Rates (12 Studies)2-Year Relapse Rates (12 Studies)
% C
umul
ativ
e R
elap
se R
ate
Standard Care(n=203)
Single FamilyTreatment
(n=231)
Multiple FamilyGroup Treatment
(n=266)
Single and MultipleFamily Group
Treatment(n=243)
Mueser KT, Glynn SM. Behavioral Family Therapy for Psychiatric Disorders; 1999.Montero I, et al. Schizophr Bull. 2001;27(4):661-670.
Current FPE IssuesCurrent FPE Issues
1. Effectiveness failure
2. Family-to-family and alternatives
Illness Management TrainingIllness Management Training
Helping people learn to manage their own illnesses
Relapse prevention
Minimize the effects ofresidual symptoms
Research on Illness Research on Illness Management ComponentsManagement Components
Psychoeducation increases knowledge and awareness
Behavioral tailoring increases effective use of medications
Warning sign recognitionreduces relapses
Cognitive-behavioral treatment reduces residual symptoms
Social AdjustmentSocial Adjustment** Outcomes: Outcomes: Cumulative Effect Sizes Cumulative Effect Sizes
*Social adjustment=work 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. 1997;154(11):1514-1524.
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
Intake Year 1 Year 2 Year 3Years in Treatment
Personal therapy (n=74)No personal therapy (n=77)
p=.004
Effe
ct S
ize
onSo
cial
Adj
ustm
ent
Current IMR IssuesCurrent IMR Issues
1. More research
2. Training
3. Hard outcomes
4. Simplification
Integrated Dual Disorders TreatmentIntegrated Dual Disorders Treatment
Mental health and substance abuse treatments combined by 1 team•Assertive
•Stage-wise
• Individualized
•Comprehensive
•Long-term
ACT and Integrated DualACT and Integrated DualDisorders Treatment Disorders Treatment
Assessment Point
0
10
20
30
40
50
60
Baseline 6 12 18 24 30 36
McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824.
% o
f Pat
ient
s in
Sta
ble
Rem
issi
on High-fidelity ACT programs (n=61)
Low-fidelity ACT programs (n=26)
Current IDDT IssuesCurrent IDDT Issues
1. Standardization
2. Group and residential interventions
3. Supported employment
4. Staging
5. Simplification
Common Features of Evidence-Based Common Features of Evidence-Based Rehabilitation PracticesRehabilitation Practices Shared decision
making and choice Individualization Skills and supports in
the community Adult roles Quality of life
Additional Rehabilitation PracticesAdditional Rehabilitation Practices
Social skills training
Supported housing
Supported education
Integrated medical care
Trauma interventions
Dissemination and ImplementationDissemination and Implementation
Science to service gap
No simple solution for complex systems
Multiple strategies
Phases of implementation
All stakeholders
Fidelity
National EBP ProjectNational 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
ClientOutcomes
Evidence-Based
Practice
ProgramLeader
Practitioners
Administration
Strategiesand
Barriers
Consumers
Mental Health
Authority
Families
ImplementationPackage
Intervention Stakeholders ImplementationProcess
OtherFactors
ImplementationOutcome
Community MentalHealth Center
Conceptual Framework for Implementing an Evidence-Based Practice
System Changes 1System Changes 1
Evidence-based medicine Address 3 components: science, consumer
involvement, practitioner skills Align financing and structures with goals Integrate treatment and rehabilitation: mental
health, substance abuse, vocational rehabilitation, general health, housing, self-help, family supports
System Changes 2System Changes 2
Improve data systems to focus on outcomes and fidelity
Enhance self-management Electronic records and decision supports:
education, assessment, outcomes, decision making
Engineer micro-systems of care Learning collaboratives Distance learning
Current ConcernsCurrent Concerns Fidelity and outcomes Access and acceptability Durability Multi-cultural services Flexibility Financing Organization
ConclusionsConclusions
Evidence-based rehabilitation interventions are available and will improve rapidly
Implementation requires changes in organization and financing
Flexible, individualized application requires flexible clinicians and organizations
Further InformationFurther Information
Patti O’Brien Patti.O’Brien@Dartmouth.edu 603-448-0263 www.mentalhealth.samhsa.gov
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