Transcript Slide 1

Adolescent Treatment Effectiveness
What we have learned (so far)
Michael Dennis, Ph.D.
Chestnut Health Systems, Normal, IL
Presentation at the Substance Abuse and
Mental Health Services Administration
Center for Substance Abuse Treatment
May 25, 2011, Rockville, MD
Goals
 To take stock of how far we have come as a
field, particularly in the last few years
 To identify reoccurring themes that represent
what we have learn (so far)
 To focus on the road ahead
Early Adolescent Treatment Work
1910
Worth Street Narcotic Clinic in NY – 743 youth
1920
Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 440/yr
1930
Riverside Hospital in NYC – 250 youth
1940
Teen Addiction Hospital Wards in several cities
1950
Drug Abuse Reporting Program (DARP)- 5,405 youth (587 followed)
1960
Treatment Outcome Prospective Study (TOPS)-1042 youth (256 followed)
1970
Services Research Outcome Study (SROS) - 156 youth
1980
National Treatment Improvement Evaluation Study (NTIES) - 236 youth
1990
Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) - 3,382
youth (1,785 followed)
1996
Source: Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003)
What these early studies taught us
• Treatment of adolescents with adult models and/or
mixed with adults does not work and is actually
associated with drop out and increased use
• Need to modify models to be more developmentally
appropriate for youth
• Need for assess and treat a wider range of problems
including victimization, co-occurring mental health
and education needs
• Need to modify materials to be more concrete and
use examples relevant to youth
Major limits through 1997
• Lack of standardized and evidenced based
assessment and treatment limited the reliability of
what was done
• Participation, treatment completion, and followup
rates were often low limiting the validity of what
could be learned
• The lack of any manualized evidenced based
adolescent approaches limited the ability to
disseminate and replicate what did work
• Difficult for clinicians, evaluators and/or researchers
to work together or even enter the field
CSAT’s 10+ Year Investment in Improving
Adolescent Treatment Effectiveness
•
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•
•
•
•
•
•
•
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1997-2001, Cannabis Youth Treatment (CYT) – 600 youth
1998-2001, Adolescent Treatment Models (ATM) -1334 youth
1998-2004, CSAT/NIAAA experiments – several hundred youth
2000-2002, Persistent Effects of Treatment Study of Adolescents
(PETS-A) - 1200 youth
2001-2003, CSAT/RWJF Reclaiming Futures, 445 youth
2002-2007, Strengthening Communities for Youth (SCY) – 2,249 youth
2002-2012, Targeted Capacity Expansion (TCE) – 1,417 youth
2003-2006, Adolescent Residential Treatment (ART) – 1,458 youth
2003-2007, Effective Adolescent Treatment (EAT) – 5,854 youth
2004-2009, Co-occurring State Infrastructure Grants (COSIG) -system
2004-2009, Young Offender Re-entry Program (YORP) – 1,597 youth
2005-2008, State Adolescent Coordinator (SAC) -system
2005-2010, Juvenile Treatment Drug Court (JTDC) – 1,678 youth
2006-2010, Adolescent Assertive Family Tx (AAFT)-2,769 youth
2007-2011, Brief Interventions and Referrals to Treatment (BIRT)
and other Office of Juvenile Justice and Delinquency
Prevention and Robert Woods Johnson Foundation
(OJJDP/RWJF)- 315 youth
2010Currently working to extend work in collaboration with
CSAP, ED, DOL, HRSA, and OJJDP
6
Big Changes
• Over 80% participation, use of evidenced based
assessment, use of evidenced based intervention, and
follow-up
• Have pooled data from 21,531 adolescents (12-17),
3,153 young adults (18-25) and 1,695 adults (26+)
assessed with the Global Appraisal of Individual
Needs (GAIN), including 88% with one more follow-up
• Data made available for program evaluation and
secondary analysis, and helped to generate over 200
publications
• Have supported the creation and evaluation of over
20 adolescent treatment manuals
• Several System level grants
Big Changes - Continued
• Funded large scale replications of three major
evidenced based practices
– Motivational Enhancement Therapy/ Cognitive Behavior
Therapy (MET/CBT) in the 36 site EAT program and
multiple independent grants
– Adolescent Community Reinforcement Approach (A-CRA)
and Assertive Continuing Care (ACC) in the 78 Site AAFT
program and multiple independent grants
• Also funded multiple state and independent grants
to replicate other evidenced based practices
including
–
–
–
–
–
Family Support Network (FSN)
Motivational Interviewing
Multidimensional Family Therapy (MDFT)
Multi-Systemic Therapy (MST)
Seven Challenges (7C)
CSAT Sites with adolescent clients 12-17 and included
in the 2009 Summary Analytic GAIN Data Set
NH
WA
MT
OR
ND
ID
WY
MN
CA
SD
AZ
AK
HI
PA
CT
NJ
DC
IN
IL
DE AAFT
VA
MO
MD ART
KY
ATM
NC
CYT
TN
EAT
SC
AR
JTDC
MS AL GA
OJJDP
OJJDP-BIRT
LA
SCY
TCE
YORP
FL
OH
OK
TX
RI
IA
KS
NM
MA
NY
MI
UT
CO
ME
WI
NE
NV
VT
PR
VI
9
Female
African American
100%
90%
80%
70%
60%
CSAT data is
diverse with
large numbers
of females
minorities, and
younger
adolescents
16%
39%
18%
Hispanic*
12 to 14 Years Old
50%
26%
Caucasian
Mixed/Other
40%
30%
20%
10%
0%
Demographic Characteristics
33%
18%
15 to 17 Years Old
Single Parent
82%
51%
*Any Hispanic ethnicity separate from race group
Sources: CSAT 2009 SA data set Adolescent Subset (n=19,145).
10
Employed
Controlled environment
Prior Substance Abuse Treatment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Youth are involved in multiple systems placing
competing demands on them and potentially in
conflict with each other
9%
22%
33%
Prior Mental Health Treatment
Current justice system involvement
In School
Source: CSAT 2009 SA Data Set Adolescent Subset (n=19,108)
40%
68%
73%
11
Alcohol
100%
90%
80%
70%
33%
Other drug disorder
27%
34%
Depression
14%
24%
Trauma
ADHD
41%
CD
Suicide
60%
20%
Cannabis
Anxiety
50%
40%
30%
20%
10%
0%
Multiple Clinical Problems are the NORM!
48%
11%
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
63%
80%
12
The Number of Clinical Problems is related to
Level of Care
100%
None
90%
80%
One
70%
Two
60%
Three
50%
80%
40%
65%
30%
20%
41%
45%
53%
Five Plus
10%
0%
Outpatient
Intensive
Outpatient
OP Cont.
Care
Four
Long Term Short Term
Resid.
Resid.
Source: CSAT 2009 Summary Analytic Data Set (n=21,332)
Significantly
more likely to
have 5+
problems
(OR=5.8)
13
The Number of Major Clinical Problems
is highly related to Victimization
100%
None
90%
80%
One
70%
Two
60%
Three
50%
40%
71%
30%
10%
Five to Twelve
46%
20%
15%
0%
Low (0)
Moderate (1-3)
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
Four
High (4-15)
Significantly
more likely to
have 5+ problems
(OR=13.9)
14
Sexually Active
100%
90%
80%
70%
63%
30%
Multiple Sex Partners
Any Unprotected Sex
26%
19%
High Risk Sex*
20%
Victimized
Any Needle Use
60%
50%
40%
30%
20%
10%
0%
Past 90 day HIV Risk Behaviors are more Related
to Sexual Activity than Needle Use
Also important to
recognize the role of
interpersonal violence
as a HIV risk factor –
particularly for girls
2%
*Based on 1+ times had sex while intoxicated, with an injection drug user, with a man who had sex
with men, with someone who was HIV positive, or traded sex for goods (n=415)
Source: CSAT 2009 SA Data Set Adolescent Subset (n=18,674)
15
Doing well at close friends
89%
Listening, caring or comm. w/ others
75%
Sports, exercise, physical activity
73%
Doing well at with your family
73%
Problem solving and figuring things out
67%
Doing well at school or training
59%
Working or playing with computers
59%
Music, dancing, acting, other perf. art
49%
44%
Drawing, painting, design or other art
Doing well at work
33%
Avearge No. of Strenths (0-10)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Individual Strengths
6.20
0
2
4
6
8
10
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sources of Social Support
Doing well at close friends
Listening, caring or comm. w/ others
90%
85%
79%
77%
77%
71%
71%
57%
53%
Sports, exercise, physical activity
Doing well at with your family
Problem solving and figuring things out
Doing well at school or training
Working or playing with computers
Music, dancing, acting, other perf. art
Drawing, painting, design or other art
Average No. of Sources (0-9)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
6.57
0
2
4
6
8
Social
Peers
School or
Work
Home
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
Average Attributes (0-12)
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Potential Mentors in the
Recovery Environment
52%
75%
25%
18%
58%
41%
30%
16%
63%
46%
29%
16%
4.6
0
2
4
6
8
10
12
Major Predictors of Bigger Effects Found in
Multiple Meta Analyses (Lipsey, 1997, 2005)
1. A strong intervention protocol based on prior
evidence
2. Quality assurance to ensure protocol
adherence and project implementation
3. Proactive case supervision of individual
4. Triage to focus on the highest severity
subgroup
Impact of the numbers of these Favorable
features on Recidivism in 509 Juvenile Justice
Studies in Lipsey Meta Analysis
Average
Practice
Source: Adapted from Lipsey, 1997, 2005
The more
features,
the lower
the
recidivism
Evidenced Based Treatment (EBT) that
Typically do Better than Usual Practice in
Reducing Juvenile Use & Recidivism
• Adolescent Community Reinforcement Approach (ACRA)
• Aggression Replacement Training (ART)
• Assertive Continuing Care (ACC)
• Cognitive Behavior Therapy (CBT)
• Functional Family Therapy (FFT)
• Moral Reconation Therapy (MRT)
• Thinking for a Change (TFC)
• Interpersonal Social Problem Solving (ISPS)
• Motivational Interviewing (MI)
Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004
Evidenced Based Treatment (EBT) that
Typically do Better than Usual Practice in
Reducing Juvenile Use & Recidivism
• Motivational Enhancement Therapy/Cognitive
Behavior Therapy (MET/CBT)
• Multi Systemic Therapy (MST)
• Multidimensional Family Therapy (MDFT)
• Reasoning & Rehabilitation (RR)
• Seven Challenges (7C)
No evidence of an iatrogenic effect of group treatment
Small or no differences in mean effect size between
these brand names
Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004
Other Common Findings
 Low structure and ad hoc “treatment as usual” does
not do as well as evidenced based practice
 Wilderness programs have mixed effects
 Treating adolescents like adults and in boot camp
causes harm on average
 Relapse is still common and there is a need for ongoing support, monitoring and when necessary reintervention
Similarity of Clinical Outcomes :
Cannabis Youth Treatment (CYT)
Trial 2
Trial 1
300
50%
280
40%
260
30%
240
20%
But better than the
average for OP in220
ATM (200 days of
200
abstinence)
10%
MET/ CBT5
(n=102)
MET/
CBT12
FSN
(n=102)
MET/ CBT5
(n=99)
ACRA
(n=100)
MDFT
(n=99)
Total Days Abstinent*
269
256
260
251
265
257
Percent in Recovery**
0.28
0.17
0.22
0.23
0.34
0.19
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.12
Source: Dennis et al., 2004
* n.s.d., effect size f=0.06
** n.s.d., effect size f=0.16
0%
Percent in Recovery .
at Month 12
Total days abstinent
over 12 months
.
Not significantly different
by condition.
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
MET/
CBT5
MET/
CBT12
CPDA*
$4.91
CPPR**
$3,958
$0
FSN
MET/
CBT5
ACRA
MDFT
$6.15
$15.13
$9.00
$6.62
$10.38
$7,377
$15,116
$6,611
$4,460
$11,775
* p<.05 effect size f=0.48
** p<.05, effect size f=0.72
Source: Dennis et al., 2004
* p<.05 effect size f=0.22
** p<.05, effect size f=0.78
Suggest the need to consider cost-effectiveness of
treatment approaches
Cost per person in recovery
at month 12
Cost per day of abstinence
over 12 months
$20
ACRA did better than
MET/CBT5,
and both did
Trial 2
better than MDFT
MET/CBT5 and
Trial 1
12 did better
than FSN
Implementation is Essential
(Reduction in Recidivism from .50 Control Group Rate)
The best is to
have a strong
program
implemented
well
Thus one should optimally pick the
strongest intervention that one can
implement well
Source: Adapted from Lipsey, 1997, 2005
The effect of a well
implemented weak program is
as big as a strong program
implemented poorly
% Point Change in Abstinence
Change in Abstinence by level of Quality
Assurance: Adolescent Community
Reinforcement Approach (A-CRA)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Effects associated with
Coaching, Certification
and Monitoring (OR=7.6)
24%
4%
Training Only
Training, Coaching,
Certification, Monitoring
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
27
Which general approaches address cooccurring mental health/trauma issues?
•
Nine Treatment Outpatient Approaches
•
•
Seven Challenges (Schwebel, 2004) (n=114)
Chestnut Health Systems (CHS; Godley et al. 2002)
Treatment (n=192)
Adolescent Community Reinforcement Approach (A-CRA;
Godley et al., 2001) -CYT/AAFT (n=2144) and -Other (n=276)
Multi-Systemic Therapy (MST; Henggeler et al., 1998)
(n=85)
Multi-Dimensional Family Therapy (MDFT; Liddle, 2002)
(n=258)
Motivational Enhancement Therapy-Cognitive Behavior
Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT
(n=5262) and -Other (n=878)
Family Support Network (FSN; Hamilton et al., 2001)
(n=369)
•
•
•
•
•
28
Two sets of outcomes
•
•
•
•
•
•
•
•
•
•
Mental Health
Emotional Problems Scale
Days of Victimization
Days of Traumatic Memories
Other Outcomes
Substance Problems Scale
Substance Frequency Scale
Illegal Activities Scale
HIV Risk Change Index
Average Across
29
Change (post-pre) Effect Size for Emotional
Problems
by Type
offorTreatment
Figure
8. Change (post-pre)
Effect Size
Emotional Problems
by Type of Evidenced Based Treatment
Seven
Challenges
(n=114)
CHS
Treatment
(n=192)
A-CRACYT/AAFT
(n=2144)
MST
(n=85)
METCBTCYT/EAT
(n=5262)
MDFT
(n=258)
METCBTOther
(n=878)
FSN
(n=369)
A-CRAOther
(n=276)
-0.60
-0.29
-0.08
-0.16
-0.13
-0.08
-0.29
-0.34
-0.37
-0.21
-0.15
-0.13
-0.12
-0.04
-0.19
-0.37
-0.39
-0.32
-0.45
-0.43
-0.40
-0.22
-0.19
-0.14
-0.28
-0.18
-0.20
-0.09
-0.08
0.00
-0.54
Change Effect Size d
((mean follow-up - mean intake)/ std dev. intake)
0.20
Four best on mental health
outcomes include 7 challenges,
CHS, A-CRA, & MST
-0.80
Emotional Problem Scale
Days of traumatic memories
Days of victimization
Change (post-pre) Effect Size for Core
Figure 9. ChangeOutcomes
(post-pre) Effect Size
Core Treatment
Outcomes
Treatment
byfor Type
of Treatment
CHS
A-CRATreatment CYT/AAFT
(n=192)
(n=2144)
MST
(n=85)
MDFT
(n=258)
-0.37
-0.38
-0.38
-0.36
Seven
Challenges
(n=114)
-0.39
-0.45
-0.43
-0.39
-0.38
-0.41
by Type of Evidenced Based Treatment
METCBTCYT/EAT
(n=5262)
METCBTOther
(n=878)
A-CRAOther
(n=276)
FSN
(n=369)
-0.29
-0.36
-0.48
-0.23
-0.18
-0.31
-0.29
-0.30
-0.37
-0.29
-0.47
-0.51
-0.34
-0.33
-0.26
-0.19
-0.17
-0.26
-0.27
-0.37
-0.38
-0.33
-0.18
-0.28
-0.23
-0.36
-0.45
-0.43
-0.42
-0.17
-0.11
0.04
-0.43
-0.37
-0.30
-0.11
0.00
-0.80
-0.50
-0.60
-0.65
-0.40
-0.30
-0.20
-0.32
-0.15
0.00
-0.54
-0.62
Change Effect Size d
((mean follow-up - mean intake)/ std dev. intake)
0.20
Four best on treatment outcomes include
A-CRA, MST, MDFT, & FSN
Emotional Problem Scale
Substance Problem Scale
Substance Frequency Scale
HIV Risk Scale
Illegal Activity Scale
Average
Findings
• All programs reduced mental health / trauma problems with 4
doing particularly well: 7 challenges, CHS, A-CRA, & MST
• All programs reduced general outcomes on average, with 4
doing particularly well: A-CRA, MST, MDFT, FSN
– All more assertive/family/systemic programs
– All have formal training, quality assurance, monitoring &
technical assistance
• Where we could break in two (A-CRA & MET/CBT), programs
with more training, quality assurance, monitoring and technical
assistance did better than those with less
• A-CRA with a mix of BA/MA did as well as MST which targets
MA level therapists and family therapists that are often in short
supply
• While it is not as effective, the shortest & least expensive
(MET/CBT5) still has positive effects
• CSAT Funding large scale dissemination of A-CRA
• and MET/CBT
32
Adolescents Have Complex
Pathways to Recovery
What predicts who
enters and maintains
recovery?
Change occurs in ever
possible direction
Incarcerated
(41% stable)
4%
16%
17%
In the
Community
Using
(60% stable)
17%
Avg of 48% change
status each quarter
18%
4%
27%
In Recovery
(61% stable)
21%
9%
22%
24%
In Treatment
(45% stable)
Source: 2009 CSAT AT data set; unique n = 11,710
14%
Treatment is the
most likely path
to recovery
Risk and Protective Factors Associated with
Transitioning to/Remaining in Recovery
• Risk Factors
–
–
–
–
–
–
–
–
–
Older
Male
Caucasian
Substance Problems
Substance Frequency
Repeated Treatment
Mental Health Problems
Illegal Activity
Employment
Source: 2009 CSAT Adolescent Treatment Dataset
• Protective Factors
–
–
–
–
–
–
–
–
Younger
Female
Racial Minority
Recent Treatment
Number of Drug Screens
Attend 12 Step Meetings
Positive Social Peers
Positive Recovery
Environment
– School Attendance/ Conduct
Percent in Past Month Recovery*
Recovery* by Level of Care
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
CC
better
OP &
Resid
Similar
Pre-Intake
Mon 1-3
Mon 4-6
Mon 7-9
Mon 10-12
•Recovery defined as no past month use, abuse, or dependence symptoms while living in the
community. Percentages in parentheses are the treatment outcome (intake
to 12 month change) and the stability of the outcomes (3months to 12 month
change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)
Time to Enter Continuing Care and Relapse
after Residential Treatment (Age 12-17)
100%
Percent of Clients
90%
80%
70%
Relapse
60%
50%
Cont.
Care
Admis.
40%
30%
20%
10%
0%
0
10
20
30
40
50
60
70
80
90
Days after Residential (capped at 90)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
Weekly Tx
Weekly 12 step meetings
Relapse prevention*
Communication skills training*
Problem solving component*
Regular urine tests
Meet with parents 1-2x month*
Weekly telephone contact*
Contact w/probation/school
Referrals to other services*
Follow up on referrals*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
Source: Godley et al 2002, 2007
UCC
ACC
* p<.05
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Assertive Continuing Care (ACC) can
Improved General Aftercare Adherence
High GCCA Improves
Early (0-3 mon.) Abstinence
100%
90%
80%
70%
60%
55%
50%
43%
36%
40%
30%
55%
38%
24%
20%
10%
0%
Any AOD (OR=2.16*)
Low (0-6/12) GCCA
Source: Godley et al 2002, 2007
Alcohol (OR=1.94*)
High (7-12/12) GCCA
Marijuana (OR=1.98*)
* p<.05
Percent of Days Abstinent from AOD
in Offender Re-entry Programs by Age
6m
3m
Release
(initial)
<18 years
18-25 years
26+ years
Precontrolled
environment
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Limit of current GPRA, starts measurement at release
and does not control for or even measure time in a
controlled environment
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
Comparison of Treatment Outcomes:
Adolescent Outpatient (AOP) vs.
Juvenile
Treatment Drug Court (JTDC)
JTDC
Reduced Use
More than AOP
(d between= -0.24)
Days out of 90 Days
35
Others Outcomes
Not Significantly Different
30
25
20
AOP Weighted
(n=1120)
JTDC
(n=1120)
15
10
5
Substance
Use*
( d=-0.45, -0.57)
Emotional
Problems
(d=-0.32, -0.22)
Source: Ives et al., in press
Trouble w/
Family
(d= -0.23, -0.18)
In Controlled
Environment
(d=-0.02, -0.08)
6 months*
Intake
6 months*
Intake
6 months*
Intake
6 months*
Intake
6 months*
PostPre d
(AOP,
JTDC)
Intake
0
Illegal
Activity
(d=-0.11, -0.02)
*p<.05 change greater for JTDC vs AOP (d=-0.24)
Outcome Data has also been used to
make comparison groups for
• GPRA, NOMS and other outcomes by gender, race,
age, level of care, type of evidenced based practice,
and program
• CYT interventions vs. regular outpatient treatment
• Post residential treatment recovery support services
vs. aftercare as usual
• Opioid Users vs. Alcohol/Marijuana Users
• Transitional Age Youth vs. adolescents & adults
• Impact of experience and certification on GAIN quality
• Deaf and hard of hearing vs. hearing
• Gender, Race and Ethnicity differences
•
in the response to A-CRA
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$0
Many SBIRT, School,
Workplace and other early
intervention programs
focus on brief intervention
$10,000
Cost of Substance Abuse Treatment Episode
• $750 per night in Detox
Screening & Brief Inter.(1-2 days) $407
• $1,115 per night in hospital
In-prison Therap. Com. (28 weeks) $1,249
• $13,000 per week in intensive
Outpatient (18 weeks) $1,132
care for premature baby
Intensive Outpatient (12 weeks) $1,384
• $27,000 per robbery
Treatment Drug Court (46 weeks) $2,486
• $67,000 per assault
Residential (13 weeks) $2,907
$4,277
Methadone Maint. (87 weeks)
Adol. Residential (13 weeks)
$10,228
$14,818
Therapeutic Com. (33 weeks)
$22,000 / year
to incarcerate
an adult
$30,000/
child-year in
foster care
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004
$70,000/year to
keep a child in
detention
Quarterly Costs to Society* associated with
higher intensity of justice system involvement
Past year illegal act
$1,832
Past JJ status
$2,544
Average
Quarterly
Costs to
Society
(Prior to
Intake)
$2,410
Other JJ status
$2,633
Other prob/ parole/
detention
$4,065
$6,746
Prob/parole 14+ days
w/ 1+ drug screens
$10,149
$14,000
$12,000
$10,000
$8,000
$6,000
$4,000
$2,000
$0
Detention 14-29 days
Detention 30+ days
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars
Investing in Treatment has a Positive Annual
Return on Investment (ROI)
• Substance abuse treatment has been shown to have
a ROI of between $1.28 to $7.26 per dollar invested
• Treatment drug courts have an average ROI of $2.14
to $2.71 per dollar invested
This also means that for every dollar treatment
is cut, we lose more money than we saved.
Source: Bhati et al., (2008); Ettner et al., (2006)
SAMHSA/CSAT’s Adolescent Clients
• Data were pooled on clients from 148 local
evaluations, recruited between 1997 to 2009 and
followed quarterly for 6 to 12 months (over 80%
completion).
• In 2009 dollars, the 16,915 adolescents averaged
$3,908 in costs to taxpayers in the 90 days before
intake ($15,633 in the year before intake).
• This would be $3.9 Million per 1,000 adolescents
served.
• Within 12 months, the cost of treatment provided by
CSAT grantees was offset by reductions in other
costs producing a net benefit to taxpayers of $4,592
per adolescent.
Economic Benefit to Society of SAMHSA/CSAT
Funded Treatment by Level of Care
Adolescent Level of Care
Year
before
intake
Year
after
Intakea
One
Year
Savingsb
Outpatient
$10,993
$10,433
$560
Intensive Outpatient
$20,745
$15,064
$5,682
Outpatient Continuing Care
$34,323
$17,000
$17,323
Long Term Residential
$27,489
$26,656
$833
Short Term Residential
$25,255
$21,900
$3,355
Total
$15,633
$13,642
$1,992
\a Includes the cost of treatment
\b Year after intake (including treatment) - year before treatment
In practice we need a Continuum of Measurement
(Common Measures)
Quick
Comprehensive Special
More Extensive / Longer/ Expensive
Screener
•
•
•
•
Screening to Identify Who Needs to be “Assessed” (5-10 min)
– Focus on brevity, simplicity for administration & scoring
– Needs to be adequate for triage and referral
– GAIN Short Screener for SUD, MH & Crime
– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD
– SCL, HSCL, BSI, CANS for Mental Health
– LSI, MAYSI, YLS for Crime
Quick Assessment for Targeted Referral (20-30 min)
– Assessment of who needs a feedback, brief intervention or referral for more
specialized assessment or treatment
– Needs to be adequate for brief intervention
– GAIN Quick
– ADI, ASI, SASSI, T-ASI, MINI
Comprehensive Biopsychosocial (1-2 hours)
– Used to identify common problems and how they are interrelated
– Needs to be adequate for diagnosis, treatment planning and placement of
common problems
– GAIN Initial (Clinical Core and Full)
– CASI, A-CASI, MATE
Specialized Assessment (additional time per area)
– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed)
may be needed to rule out a diagnosis or develop a treatment plan or
individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
Longer assessments identify more
areas to address in treatment planning
100%
90%
7%
9%
3%
8%
8%
22%
13%
80%
70%
1%
0%
98%
0 Reported
1 Prob.
69%
60%
50%
1%
1%
3%
94%
22%
2 Probs.
40%
30%
40%
3 Probs.
20%
10%
4 Probs.
0%
GAIN SS GAIN Q GAIN Q GAIN I
(v2)
(v3 -Beta)
5 min.
20 min
30 min
1-2 hr
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Most substance
users have
multiple
problems
Importance of Targeting on
Performance Measures
Mental Health Need
at Intake
No/Low
Mod/High
Treatment Received
in the first 3 months
Any Treatment
6
218
Total
224
218/224=97% to targeted
No Treatment
205
553
758
Total
211
771
982
553/771=72%
unmet need
771/982=79% in need
Size of the Problem
Extent to which services are not reaching those in most need
Extent to which services are currently being targeted
Source: 2008 CSAT AAFT Summary Analytic Dataset
Mental Health Problem (at intake) vs.
Any MH Treatment by 3 months
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
97%
79%
% of Clients With
Mod/High Need
(n=771/982)*
72%
% w Need but No Service % of Services Going to
After 3 months
Those in Need
(n=553/771)
(n=218/224)
Source: 2008 CSAT AAFT Summary Analytic Dataset
Why Do We Care About Unmet Need?
• If we subset to those in need, getting mental health
services predicts reduced mental health problems
• Both psychosocial and medication interventions are
associated with reduced problems
• If we subset to those NOT in need, getting mental
health services does NOT predict change in mental
health problems
Conversely, we also care about services being
poorly targeted to those in need.
Residential Treatment need (at intake) vs.
7+ Residential days at 3 months
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
90%
Opportunity to
redirect
existing funds
through better
targeting
52%
36%
% of Clients With
Mod/High Need
(n=349/980)*
% w Need but No
% of Services Going to
Service After 3 months Those in Need (n=34/66)
(n=315/349)
Source: 2008 CSAT AAFT Summary Analytic Dataset
2010 SAMHSA/CSAT Grantee Data Set
(185 sites)
NH
WA
MT
VT
ND
OR
MN
ID
WY
CA
NV
WI
SD
NE
UT
IL
CO
KS
AZ
TX
AK
HI
CSAT
DC
WV VA
NC
SC
TN
AR
LA
PA
OH
KY
MO
OK
NM
IN
MA
NY
MI
IA
ME
MS AL GA
FL
NJ
RI
CT
DE
MD
23 Programs
185 Sites
26,390 clients
VI
PR
Expanded Data Set
(2010 CSAT + 120 Other Sites)
NH
WA
MT
OR
ID
ND
VT
MN
WI
SD
WY
CA
NV
NE
UT
MI
IA
MA
NY
RI
CT
PA
NJ
OH
DC
IL
WV
DE
KY VA
MO
MD
NC
AR TN
SC
MS AL GA
50 Programs
LA
305 Sites
FL
58,934 clients
IN
CO
KS
AZ
OK
NM
TX
AK
VI
HI
CSAT
ME
PR
Other 2011
2011 Expanded Data Set
Age
11-17
18-25
26+
Total
(N=34,627)
(N=8,746)
(N=14,805)
(N=58,934)
Female
28%
38%
45%
34%
Minority
Prior Treatment
58%
29%
44%
49%
45%
66%
52%
42%
First use under 15
Ever Homeless
Any Victimization
82%
10%
52%
59%
28%
63%
46%
44%
68%
69%
21%
6%
Veteran
0%
1%
6%
2%
All GAIN Collaborators in the U.S
(1700 agencies in 48 states, 6 Canadian provinces and 6 other contries)
NH
WA
MT
VT
ME
ND
MA
MN
OR
ID
WY
NV
CA
UT
WI
SD
MI
NE
CO
KS
AZ
OK
NM
TX
AK
NY
PA
IA
NJ
OH
DE
WV VA
MO
MD
KY
DC
NC
TN
State or
No. of
AR
SC
GAIN Sites Regional System
GA
GAIN Short
None (Yet)
MS AL
Screener
1 to 14
GAIN Quick
LA
15 to 30
FL
IL IN
31 to 165
HI
RI
CT
More in BZ, CA,
CN, JP, MX
GAIN Full
VI
PR
3/10 56
Recent Initiatives
• 2 page GAIN short screener already implemented in a dozen
states, translated into 19 languages and spreading fast
• Using web-based GAIN & ACRA training modules to reduced the
duration of off-site training, to provide support for local trainers
to train new staff, and to be used in college course to prepare the
work force coming out
• Computer based support for clinical decision making related to
diagnosis, treatment planning, and placement using narrative
and graphical reports
• Up grading site profiles to more closely reflect the individual
reports so that clinicians and evaluators are speaking the same
language
• GAIN evaluation manual and training to help local evaluators and
others interested in secondary analysis use the data at the
program or group level
• Linkage to multiple HIT systems
Recent Initiatives (Continued)
• Monitoring assessment and treatment sessions to measure
and improve fidelity
• Randomized trial of therapist performance incentives to
improve implementation/fidelity and client outcomes
• Expansion of A-CRA/ACC modules targeting trauma and HIV
risk behaviors
• Addition of A-CRA/ACC supervisor training
• Analysis of health disparities by gender, race, age, pregnancy,
and disabilities
• Multi-cultural training on how to adapt training and
assessment to better serve clientele
• Revisions to GAIN Quick (25-30 min) to better support
screening, brief intervention, and referral to treatment in
behavioral health settings (e.g., SAP, EAP,DCF, Justice) where
there are health, stress, mental health, substance use and
crime/violence issues
New Initiatives
• Testing the GAIN Q in school and justice settings
• Testing ability to recruit, train and certify staff on GAIN & ACRA with incentives but without SAMHSA/CSAT grants to
demonstrate the feasibility of transferring the technology to
state and local governments
• Doing reviews of school based behavioral health intervention
research in the literature and in SAMHSA/CSAT
demonstrations to understand how they are similar/different
from community based adolescent treatment
• Created a CSAT + non-CSAT analytic file that can be used to
better understand the needs of smaller groups (e.g. Emerging
adults, Mixed Race, Vets, GLBTQ)
• Demonstrate the feasibility of using the web-based training
modules as part of College Courses to better prepare the
work force
Substance
Abuse Tx
No use in past year
Less than weekly use
Weekly Use
Abuse or dependence
29%
34%
45%
43%
90%
96%
93%
95%
Hosptial
0%
1%
3%
12%
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
4%
5%
8%
9%
% Any Contact
Potential AOD Screening & Intervention Sites for
Adolescents Age 12 to 17
Emergency
Dept.
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
School
Key potential of School
Based Health Clinics
being expand under
health care reform
Why Schools Care
60%
13%
2%
6%
7%
5%
9%
19%
5%
10%
5%
4%
8%
9%
13%
17%
30%
13%
18%
22%
27%
31%
40%
41%
30%
32%
28%
40%
20%
41%
50%
10%
12%
9%
16%
21%
Substance use severity is
related to family, school and
emotional problems
0%
10 or More
Disliked School
Arguments with
Parents
GPA = D or
lower
No PY AOD Use (64.3%)
Any Drug or Heavy Alc Use (8.8%)
Abuse (4.2%)
Major
Depression
Any MH
Treatment
Light Alc Use (12.4%)
Weekly AOD Use (6.4%)
Dependence (3.9%)
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
Why Society Cares if we fail to help in School
48%
60%
34%
Serious
Fight At
School
Fighting Sold Drugs Attacked
with Group
with intent
to harm
No PY AOD Use (64.3%)
Any Drug or Heavy Alc Use (8.8%)
Abuse (4.2%)
Stole
(>$50)
1%
3%
5%
13%
8%
9%
2%
3%
3%
Carried Any Arrests
Handgun
Light Alc Use (12.4%)
Weekly AOD Use (6.4%)
Dependence (3.9%)
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
11%
15%
23%
27%
18%
12%
2%
4%
7%
5%
6%
11%
12%
14%
0%
1%
3%
10%
0%
17%
20%
22%
27%
29%
36%
12%
15%
20%
18%
21%
30%
28%
40%
Substance use severity is
related to crime and violence
39%
40%
42%
50%
Evidenced Based Practices You Can Use Now
• General approaches to adolescent substance abuse treatment at
www.chestnut.org/li/apss or http://www.nrepp.samhsa.gov/
• Guidance for ambulatory/outpatient detoxification at
http://www.aafp.org/afp/2005/0201/p495.html
• Trauma informed therapy and sucide prevention at
http://www.nctsn.org/nccts and http://www.sprc.org/
• Externalizing disorders medication & practices
http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html
• Tobacco cessation protocols for youth
http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco
_cessation/index.htm
• HIV prevention with more focus on sexual risk and interpersonal
victimization at http://www.who.int/gender/violence/en/ or
http://www.effectiveinterventions.org/en/home.aspx
• For individual level strengths see
http://www.chestnut.org/li/apss/CSAT/protocols/index.html
• For improving customer services http://www.niatx.net
Acknowledgement and
Contact Information
•
•
•
•
•
•
Borrowed slides from earlier presentations by myself, Randy Muck & Doreen Cavanaugh
This presentation was supported by analytic runs provided by Chestnut Health Systems for the
Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance
Abuse Treatment (CSAT) under Contracts 207-98-7047, 277-00-6500, 270-2003-00006 and 2702007-00004C using data provided by the following 152 grantees: TI11317 TI11321 TI11323
TI11324 TI11422 TI11423 TI11424 TI11432 TI11433 TI11871 TI11874 TI11888 TI11892 TI11894
TI13190TI13305 TI13308 TI13313 TI13322 TI13323 TI13344 TI13345 TI13354 TI13356 TI13601
TI14090 TI14188 TI14189 TI14196 TI14252 TI14261 TI14267 TI14271 TI14272 TI14283 TI14311
TI14315 TI14376 TI15413 TI15415 TI15421 TI15433 TI15438 TI15446 TI15447 TI15458 TI15461
TI15466 TI15467 TI15469 TI15475 TI15478 TI15479 TI15481 TI15483 TI15485 TI15486 TI15489
TI15511 TI15514 TI15524 TI15524 TI15527 TI15545 TI15562 TI15577 TI15584 TI15586 TI15670
TI15671 TI15672 TI15674 TI15677 TI15678 TI15682 TI15686 TI16386 TI16400 TI16414 TI16904
TI16928 TI16939 TI16961 TI16984 TI16992 TI17046 TI17070 TI17071 TI17334 TI17433 TI17434
TI17446 TI17475 TI17476 TI17484 TI17486 TI17490 TI17517 TI17523 TI17535 TI17547 TI17589
TI17604 TI17605 TI17638 TI17646 TI17648 TI17673 TI17702 TI17719 TI17724 TI17728 TI17742
TI17744 TI17751 TI17755 TI17761 TI17763 TI17765 TI17769 TI17775 TI17779 TI17786 TI17788
TI17812 TI17817 TI17825 TI17830 TI17831 TI17864 TI18406 TI18587 TI18671 TI18723 TI19313
TI19323 TI655374.
Any opinions about this data are those of the authors and do not reflect official positions of the
government or individual grantees.
Comments or questions can be addressed to Michael Dennis, Chestnut Health Systems, 448 Wylie
Drive, Normal, IL 61761. Phone 1-309-451-7801; E-mail:
[email protected] . More information on the GAIN is available
at www.chestnut.org/li/gain or by e-mailing [email protected] .