Transcript EAT MetaAnalysis

Effective Brief Treatments for
Adolescents & Transition Age Youth
Michael L. Dennis, Ph.D.,
Chestnut Health Systems, Normal, IL
Randolph Muck, M.Ed.
Substance Abuse and Mental Health Services Administration
(SAMHSA), Center for Substance Abuse Treatment (CSAT), Rockville,
MD
Presentation at the YouthBuild Learning Exchange, Chicago, IL, May 27, 2010. This
presentation was supported by the Center for Substance Abuse Treatment (CSAT),
Substance Abuse and Mental Health Services Administration (SAMHSA) under contracts
270-07-0191, as well as several individual CSAT, NIAAA, NIDA and private foundation
grants. The opinions are those of the authors and do not reflect official positions of the
consortium or government. Available on line at www.chestnut.org/LI/Posters or by
contacting Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761,
phone 309-451-7801, fax 309-451-7765, e-Mail: [email protected] Questions about
the GAIN can also be sent to [email protected] . Questions about SAMHSA and
funding should be directed to Mr. Randolph D. Muck, 1 Choke Cherry Drive, Room 51097, Rockville, MD 20857, [email protected] .
Background
• In 1997 the third wave of cannabis use was the largest and
youngest cohort to date, double the number of adolescents
presenting to publicly funded treatment
• There were no publicly available manual guided evidenced
based practices targeting this population
• The Cannabis Youth Treatment (CYT; Dennis et al 2004)
experiments (n=600) were designed to manualize and field test
five promising intervention for short term outpatient treatment
of adolescent with cannabis (and other) substance use disorders
• While all five approaches did better than treatment as usual and
were similar in their clinical effectiveness, were easier and less
expensive to delivery and hence found to be more cost effective:
– Motivational Enhancement Therapy/ Cognitive Behavior Therapy for 5
sessions (MET/CBT5; Sample & Kadden 2001)
– Adolescent Community Reinforcement approach (ACRA; Godley,
Meyers, Smith, Karvinen, Titus, Godley, Dent, Passetti, & Kelberg,
2001)
Moderate to large differences
in Cost-Effectiveness by Condition
$16
$20,000
$16,000
$12
$12,000
$8
$8,000
$4
$4,000
$0
$0
MET/ CBT5
MET/
CBT12
FSN
MET/ CBT5
ACRA
MDFT
CPDA*
$4.91
$6.15
$15.13
$9.00
$6.62
$10.38
CPPR**
$3,958
$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
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
Recovery (CPPR)
Cost Per Person in
Cost Per Person in Recovery at 12 and 30
Months After Intake by CYT Condition
Stability of
Trial 1 (n=299)
MET/CBT-5
findings
$30,000 MET/CBT-5, -12
mixed atand
30 months
ACRA more
Trial 2 (n=297)
ACRA Effect
Largely Sustained
$25,000 cost effective at
$20,000
12 months
$15,000
$10,000
$5,000
$0
MET/ CBT5 MET/ CBT12
FSNM
MET/ CBT5
ACRA
MDFT
CPPR at 30 months**
$6,437
$10,405
$24,725
$27,109
$8,257
$14,222
CPPR at 12 months*
$3,958
$7,377
$15,116
$6,611
$4,460
$11,775
* P<.0001, Cohen’s f= 1.42 and 1.77 at 12 months
** P<.0001, Cohen’s f= 0.76 and 0.94 at 30 months
Source: Dennis et al., 2003; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
Effective Adolescent Treatment (EAT)
• From 2003 to 2008 SAMHSA’s Center for Substance Abuse
Treatment (CSAT) conducted a phase IV (i.e., post
randomization) replication of MET/CBT5 in 36 sites.
• All sites received standardized training, quality assurance and
monitoring on their implementation of MET/CBT5, as well as
the collection of data with the Global Appraisal of Individual
Needs (GAIN) to facilitate comparison with the original CYT
study in terms of implementation and outcome.
• The objectives of this program were to :
1. Demonstrate that EAT used MET/CBT5 with a more
diverse population
2. Replicate the implementation and outcomes of MET/CBT5
3. Identify participant characteristics moderators and
intervention mediators that are associated with outcomes
EAT More Geographically Diverse
WA
NH
MT
VT
ND
OR
MN
ID
WY
WI
SD
UT
CA
AZ
CO
IL
KS
OK
NM
MO
KY
OH
WV VA
NC
AR
MA
RI
CT
NJ
DE
MD
DC
SC
MS AL
LA
HI
IN
TN
TX
AK
PA
IA
NE
NV
NY
MI
ME
GA
CYT: 4 Sites
FL
Included
EAT: 24 Sites
Excluded
EAT: 12 Sites
Demographics
Male*
CYT MET/CBT5
(n=199)
EAT MET/CBT5
(n=2756)
Race groups*
AA
White
Hispanic
EAT Clients were more likely
to be female, non-white, and
have a wider age range
11-14
15-17
*p<.01
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
18-22
0%
Age groups*
Mixed /Other
Clinical Characteristics
Primary
Substance
Alcohol
Marijuana
Amphetamines
EAT Clients less likely to
have cannabis as primary
substance, similar in their
comorbidity, and to have
more justice system
involvement.
Cocaine, Opioids, Other
Comobidity
None
Internalizing Only
Both
None
CYT MET/CBT5
(n=199)
Unofficial
Arrest/police contact
EAT MET/CBT5
(n=2756)
Court/Probation/Parole
90%
80%
70%
60%
50%
40%
30%
20%
100%
*p<.01
10%
Correctional Institution
0%
Delinquency Level*
Externalizing Only
EAT did as well or Better as CYT on
Service Engagement
39%
Initiation within
14 days
90%
63%
Engagement for
42 days
74%
19%
100%
90%
80%
60%
50%
40%
30%
20%
10%
40%
0%
*p<.01
CYT MET/CBT5
(n=201)
EAT MET/CBT5
(n=3355)
70%
Continuing Care
after 90 days
Days of Treatment in the First 3 Months
Days of Treatment
84%
4.2
Outpatient
4.7 94%
1.4
Other
Treatment
*p<.01
CYT MET/CBT5
(n=201)
EAT MET/CBT5
(n=3355)
1.1
0
1
2
3
4
5
Change in Days Abstinent by
Study (f=.02)
90
80
70
60
50
40
30
20
10
0
EAT (d=0.38)
CYT (d=0.36
Slopes are
NOT
significantly
different
EAT more
severe
Intake
Last Follow-up
Replication and Site Effects – 12 months
• Treatment can vary by
implementation within
site/clinic
• We want to compare the
range of implementation in
practice with the clinical
trials
• In order to compare sites,
we will at both the central
tendency (median) and
distribution using a Tukey
Box Plot like the one shown
here.
3.00
Median
2.50
2.00
Middle 50%
1.50
1.00
0.50
“Range”
0.00
-0.50
-1.00
-1.50
-2.00
Criteria
Range of Effect Sizes (d) for Change in Days of Abstinence
(intake to 12 months) by Site
1.40
Cohen’s d
1.20
6 programs
completely
above CYT
EAT Programs did
Better than CYT on
average
1.40
1.20
1.00
1.00
0.80
0.80
0.60
0.60
0.40
0.40
0.20
0.20
75% above CYT
median
0.00
4 CYT Sites (f=0.39)
(median within site d=0.29)
Source: Dennis, Ives, & Muck, 2008
36 EAT Sites (f=0.21)
(median within site d=0.49)
0.00
Change in Days Abstinent by
Cocaine/Crack Problem Severity at Intake (f=.27)*
90
80
70
No cocaine use
(d=0.33)
60
50
40
30
Some cocaine
use/problems
(d=0.58)
Weekly Cocaine
Use or
Dependence
(d=1.1)
20
10
0
Intake
Last Follow-up
* P<.0001
Change in Days Abstinent by
Any Opioid Use in community at Intake (f=.16)*
90
80
70
60
50
40
30
None (d=0.35)
Any (d=0.79)
20
10
0
Intake
Last Follow-up
* P<.0001
Change in Days Abstinent by
Age group at intake (f=.05)
90
80
70
60
50
40
30
11-14 (d=0.29)
15-17 (d=0.41)
18-21 (d=0.33)
20
10
0
Intake
Last Follow-up
Other Client Characteristics that did NOT
Predict the Amount of Change
•
•
•
•
•
Race
Single Parent
Metropolitan size
Primary drug
Days of use or problem group for alcohol,
cannabis, amphetamine
• Victimization
• Psychopathology
• Delinquency levels
Assertive Adolescent Family Therapy (AAFT)
• From 2006 to 2013 SAMHSA’s Center for Substance
Abuse Treatment (CSAT) is funding a phase IV
replication of ACRA plus Assertive Continuing Care
(ACC) in 47 sites so far and plans to fund 33 or more
later this year.
• All sites received standardized training, quality
assurance and monitoring on their implementation of
ACRA and ACC, as well as the collection of data with
the GAIN to facilitate comparison with the original
CYT study and EAT in terms of implementation and
outcome.
• Goals to replicate the implementation of ACRA/ACC
in a broader range of populations/settings and to
identify if its effectiveness varies by them in any way.
Assertive Adolescent Family Treatment
(AAFT) Grant Sites by Funding Cohort*
NH
Seattle
WA
VT
MT
ND
OR
Syracuse
MN
ID
CA
Oakland
RenoNV
San Francisco
UT
Fresno
Tarzana
Los Angeles AZ
Phoenix
Downey
NM
AK
HI
MI
NE
IA
NY
New
York
Manchester
MA
Cambridge
Boston
Fitchburg
RI
CT
NJ
PA
OH
IL IN Columbus
DC
Mission
WV VA
DE
KY Huntington
KS
Columbia
MO
Knoxville
MD
NC
TN
Nashville
AR
OK
2006 (15)
TX
SC
Little Rock
2007 (16)
GA
Ft Worth
AL
2009 (14)
MS
Huntsville LA
Jacksonville
San Antonio
FL
Lk Charles
Orlando
Pinellas Park
Laredo
Houston
Miami
PR
VI
Thornton
Denver Aurora
CO
Tucson
Cleveland
WI
SD
WY
ME
*33 or more to be funded in 2010
Change in Abstinence (6 mo-Intake) after ACRA by degree of Implementation Monitoring
% Point Change in Abstinence
100%
90%
Effects associated with
intensity of quality
assurance and
monitoring
80%
70%
60%
50%
40%
36%
24%
30%
20%
4%
10%
0%
CYT
AAFT
Other
(high monitoring)
(mod. monitoring)
(training only)
Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)
20
% Change in GPRA Abstinence Measure
((6 month – intake)/ intake)
100%
80%
Relative Change
69%
61%
60%
40%
21%
20%
13%
0%
ACRA/
ACC
* GAIN Mandated, ** GAIN Optional
Source: SAIS System (GPRA)
MET/
CBT5
Include
Any Youth
Target
Youth
Conclusions
• EAT & AAFT grantees were more diverse
geographically, demographically and clinically
• EAT & AAFT grantees implementation was better
than CYT in terms of engagement, similar in dosage,
and only slightly less in content
• Baseline severity was the primary factor explaining
differences in the amount of change observed in EAT
• Engagement, dosage and content were not the major
mediator of change – environmental variables were in
EAT and overall outcomes were similar or better
• Both EAT and AAFT are doing better than general
CSAT grantees involving and even targeting youth.