Evidence-Based Practices in Psychiatric Rehabilitation
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Transcript Evidence-Based Practices in Psychiatric Rehabilitation
Evidence-Based Practices in
Psychiatric Rehabilitation
Bob Drake
October, 2010
Financial 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
OVERVIEW
Definition
Update on evidence-based practices
Common themes
Dissemination and implementation
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 Medicine
The combination of science, client
values/preference, and clinical
expertise
In mental health care, this means
combining science and recovery
ideology
Evidence-Based
Practices
Standardized interventions
Controlled research
More than 1 research group
Objective outcome measures
Meaningful outcomes
Evidence-Based Rehabilitation Practices
Robert 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)
Community-based team
Low caseload
Multidisciplinary
Outreach
Direct service provision
24 hours/7days
Number of Studies
Research on ACT (cont.)
18
16
14
12
10
8
6
4
2
0
25 Randomized Controlled Trials
ACT better than standard treatment
ACT not better than standard treatment
Time in
Hospital
Housing
Stability
Quality
Client Symptoms Social Vocational
Jail/
of Life Satisfaction
Functioning
Arrests
Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74.
Days Homeless on Streets:
ACT vs Usual Community Services
250
ACT
Usual community services
N=152
Days Homeless
200
150
100
50
0
First
Quarter
Lehman AF. Unpublished data.
Second
Quarter
Third
Quarter
Fourth
Quarter
Current ACT Issues
1. Hospital system changes
2. Quality of usual services
3. Forensic ACT
4. Other expansions and components
5. Transitions
Supported 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 RCTs
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96
94
04
04
04
06
05
99
95
06
00
05 97
02
NH NY CA IL
CT
SC
HK DC IN
EUR NY QUE CA
MD
(IP S) (SE) (IP S) (IP S) (IP S) (IP S) (IP S) (IP S) (SE) (IP S) (SE) (IP S) (SE) (IP S)
Individual Placement and Support (IPS) vs
Enhanced Vocational Rehabilitation (EVR) in
Maintaining Competitive Jobs
% Working in Competitive Jobs
40
IPS (n=74)
EVR (n=76)
35
30
25
20
15
10
5
0
1
2 3
4 5
6 7 8 9 10 11 12 13 14 15 16 17 18
Study Months
Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.
Current SE Issues
1. Financing
2. Cognitive strategies
3. Effective specialists
4. Disability reform
Family 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
Effects of Family Intervention on
2-Year Relapse Rates (12 Studies)
% Cumulative Relapse Rate
100
75
50
25
0
Standard Care
(n=203)
Single Family
Treatment
(n=231)
Multiple Family Single and Multiple
Group Treatment
Family Group
(n=266)
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 Issues
1. Effectiveness failure
2. Family-to-family and alternatives
Illness Management Training
Helping people learn to
manage their own illnesses
Relapse prevention
Minimize the effects of
residual symptoms
Research on Illness
Management Components
Psychoeducation increases
knowledge and awareness
Behavioral tailoring increases
effective use of medications
Warning sign recognition
reduces relapses
Cognitive-behavioral treatment
reduces residual symptoms
Effect Size on
Social Adjustment
Social Adjustment* Outcomes:
Cumulative Effect Sizes
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Personal therapy (n=74)
No personal therapy (n=77)
p=.004
Intake
Year 1
Year 2
Years in Treatment
Year 3
*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.
Current IMR Issues
1. More research
2. Training
3. Hard outcomes
4. Simplification
Integrated Dual Disorders Treatment
Mental health and substance abuse
treatments combined by 1 team
• Assertive
• Stage-wise
• Individualized
• Comprehensive
• Long-term
% of Patients in Stable Remission
ACT and Integrated Dual
Disorders Treatment
60
50
High-fidelity ACT programs (n=61)
Low-fidelity ACT programs (n=26)
40
30
20
10
0
Baseline
6
12
18
24
Assessment Point
McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824.
30
36
Current IDDT Issues
1. Standardization
2. Group and residential interventions
3. Supported employment
4. Staging
5. Simplification
Common Features of Evidence-Based
Rehabilitation Practices
Shared decision
making and choice
Individualization
Skills and supports in
the community
Adult roles
Quality of life
Additional Rehabilitation Practices
Social skills training
Supported housing
Supported education
Integrated medical care
Trauma interventions
Dissemination and Implementation
Science to service gap
No simple solution for
complex systems
Multiple strategies
Phases of implementation
All stakeholders
Fidelity
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
Conceptual Framework for Implementing an Evidence-Based Practice
Families
Consumers
Implementation
Package
Mental
Health
Authority
Strategies
and
Barriers
EvidenceBased
Practice
Client
Outcomes
Administration
Program
Leader
Other
Factors
Practitioners
Com m unity Me ntal
He alth Ce nte r
Intervention
Stakeholders
Implementation
Process
Implementation
Outcome
System 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, selfhelp, family supports
System 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 Concerns
Fidelity and outcomes
Access and acceptability
Durability
Multi-cultural services
Flexibility
Financing
Organization
Conclusions
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 Information
Patti O’Brien
Patti.O’[email protected]
603-448-0263
www.mentalhealth.samhsa.gov