Evidence-Based Practices in Evidence-Based Practices in Psychiatric RehabilitationPsychiatric Rehabilitation

Bob DrakeOctober, 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.)

02468

1012141618

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 Unpublished data.

Days

Hom

eles

s

Current ACT IssuesCurrent ACT Issues

1. Hospital system changes2. Quality of usual services3. Forensic ACT4. Other expansions and components5. 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. Financing2. Cognitive strategies3. Effective specialists4. Disability reform

Family PsychoeducationFamily Psychoeducation

Provided by professionals Long-term (over 6 months) Single and multiple family

group 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 Re

laps

e Ra

te

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 failure2. 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 recognition

reduces 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.

00.10.20.30.40.50.60.70.80.9

Intake Year 1 Year 2 Year 3Years in Treatment

Personal therapy (n=74)No personal therapy (n=77)

p=.004

Effe

ct S

ize o

nSo

cial

Adj

ustm

ent

Current IMR IssuesCurrent IMR Issues

1. More research2. Training3. Hard outcomes4. 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 Dual

Disorders 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. Standardization2. Group and residential interventions3. Supported employment4. Staging5. 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