Cannabis Youth Treatment (CYT) Trials: 12 and 30 Month Main Findings Michael Dennis, Ph.D. (On Behalf of the CYT Steering Committee) Chestnut Health Systems Bloomington, IL Presentation.
Download ReportTranscript Cannabis Youth Treatment (CYT) Trials: 12 and 30 Month Main Findings Michael Dennis, Ph.D. (On Behalf of the CYT Steering Committee) Chestnut Health Systems Bloomington, IL Presentation.
Slide 1
Cannabis Youth Treatment (CYT) Trials:
12 and 30 Month Main Findings
Michael Dennis, Ph.D.
(On Behalf of the
CYT Steering Committee)
Chestnut Health Systems
Bloomington, IL
Presentation for the Kentucky
Adolescent Substance Abuse Consortium,
Lexington, KY, September 19, 2003. The
opinions are those of the author do not
reflect official positions of the consortium
or government . Available on-line at
www.chestnut.org/li/posters.
Slide 2
Acknowledgement
This presentation is based on the work, input and contributions from several
other people including: Nancy Angelovich, Tom Babor, Laura (Bunch)
Brantley, Joseph A. Burleson, George Dent, Guy Diamond, James Fraser,
Michael French, Rod Funk, Mark Godley, Susan H. Godley, Nancy
Hamilton, James Herrell, David Hodgkins, Ronald Kadden, Yifrah Kaminer,
Tracy L. Karvinen, Pamela Kelberg, Jodi (Johnson) Leckrone, Howard
Liddle, Barbara McDougal, Kerry Anne McGeary, Robert Meyers, Suzie
Panichelli-Mindel, Lora Passetti, Nancy Petry, M. Christopher Roebuck,
Susan Sampl, Meleny Scudder, Christy Scott, Melissa Siekmann, Jane Smith,
Zeena Tawfik, Frank Tims, Janet Titus, Jane Ungemack, Joan Unsicker,
Chuck Webb, James West, Bill White, Michelle White, Caroline Hunter
Williams, the other CYT staff, and the families who participated in this study.
This presentation was supported by funds and data from the Center for
Substance Abuse Treatment (CSAT’s) Persistent Effects of Treatment Study
(PETS, Contract No. 270-97-7011) and the Cannabis Youth Treatment (CYT)
Cooperative Agreement (Grant Nos. TI11317, TI11320, TI11321, TI11323,
and TI11324). The opinions are those of the author and steering committee
and do not reflect official positions of the government .
Slide 3
CYT
Cannabis Youth Treatment
Randomized Field Trial
Coordinating Center:
Chestnut Health Systems, Bloomington, IL,
and Chicago, IL
University of Miami, Miami, FL
University of Conn. Health Center, Farmington, CT
Sites:
Univ. of Conn. Health Center, Farmington, CT
Operation PAR, St. Petersburg, FL
Chestnut Health Systems, Madison County, IL
Children’s Hosp. of Philadelphia, Phil. ,PA
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
Slide 4
Marijuana
Use is starting at younger ages
Is at an historically high level among adolescents
Potency increased 3-fold from 1980 to 1997
Is three times more likely to lead to dependence
among adolescents than adults
Is associated with many health, mental and
behavioral problems
Is the leading substance mentioned in adolescent
emergency room admissions and autopsies
Slide 5
Treatment
Marijuana related admissions to adolescent substance
abuse treatment increased by 115% from 1992 to
1998
Over 80% of adolescents entering treatment in 1998
had a marijuana problem
Over 80% are entering outpatient treatment
Over 75% receive less than 90 days of treatment
(median of 6 weeks)
Evaluations of existing adolescent outpatient
treatment suggest that last than 90 days of outpatient
treatment is rarely effective for reducing marijuana
use.
Slide 6
Purpose of CYT
To learn more about the characteristics and needs of
adolescent marijuana users presenting for outpatient
treatment.
To adapt evidence-based, manual-guided therapies for use
in 1.5 to 3 month adolescent outpatient treatment programs
in medical centers or community based settings.
To field test the relative effectiveness, cost, costeffectiveness, and benefit cost of five interventions
targeted at marijuana use and associated problems in
adolescents.
To provide validated models of these interventions to the
treatment field in order to address the pressing demands for
expanded and more effective services.
Slide 7
Design
Target Population: Adolescents with marijuana
disorders who are appropriate for 1 to 3 months of
outpatient treatment.
Inclusion Criteria: 12 to 18 year olds with symptoms of
cannabis abuse or dependence, past 90 day use, and
meeting ASAM criteria for outpatient treatment
Data Sources: self report, collateral reports, on-site and
laboratory urine testing, therapist alliance and discharge
reports, staff service logs, and cost analysis.
Random Assignment: to one of three treatments within
site in two research arms and quarterly follow-up
interview for 12 months
Long Term Follow-up: under a supplement from
PETSA follow-up was extended to 30 months (42 for a
subsample)
Slide 8
Two Trials or Study Arms
Trial 1
Incremental Arm
Trial 2
Alternative Arm
Randomly Assigns to:
Randomly Assigns to:
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Source: Dennis et al, 2002
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
ACRA
Adolescent Community
Reinforcement Approach(12 weeks)
MDFT
Multidimensional Family Therapy
(12 weeks)
Slide 9
Contrast of the Treatment Structures
MET/
CBT5
MET/
CBT12
FSN
ACRA
MDFT
Individual Adolescent Sessions
2
2
2
10
6
CBT Group Sessions
3
10
10
2
3
2
6
22
14
15
As
needed
As
needed
As
needed
Type of Service
Individual Parent Sessions
Family Sessions/Home Visits
4
Parent Education Sessions
6
Total Formal Sessions
5
12
Case management/
Other Contacts
Total Expected Contacts
5
12
22+
14+
15+
Total Expected Hours
5
12
22+
14+
15+
Total Expected Weeks
6-7
12-13
12-13
12-13
12-13
Source: Diamond et al, 2002
Slide 10
Actual Treatment Received by Condition
23
FSN adds multi
family group,
family
home visits
20
and more case
MET/CBT12
adds 7 management
more
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
family therapy
With ACRA
using more
11
individual
therapy
Hours
15 of
sessions
group
10
10
5
Case
M anagement
Family
Counseling
14
Collateral only
Days
25
5
M ulti-Family
group
M ulti-P articipant
Group
5
P articipant only
0
M E T/
M E T/
M E T/
M E T/
CBT5
CBT12
CBT12 +
CBT5
ACRA
M DFT
FSN
In crem en tal Arm
Source: Dennis et al, under review
Altern ative Arm
Slide 11
Average Episode Cost ($US) of Treatment
Average Cost Per Client-Episode of Care
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
$4,000
Less thanLess than
average average
for 6 weeks
for 12 weeks
$3,322
$3,500
$3,000
$3,495
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,197
$1,000
$500
$-
Source: French et al., 2002
$1,413
Slide 12
Implementation of Evaluation
Over 85% of eligible families agreed to participate
Quarterly follow-up of 94 to 98% of the adolescents from 3- to
12-months (88% all five interviews)
Long term follow-up completed on 90% at 30-months and 91%
(of 116 subsample) at 42-months
Collateral interviews were obtained at intake, 3- and 6-months
on over 92-100% of the adolescents interviewed
Urine test data were obtained at intake, 3, 6, 30 and 42 months
90-100% of the adolescents who were not incarcerated or
interviewed by phone (85% or more of all adolescents).
Self report marijuana use largely in agreement with urine test at
30 months (13.8% false negative, kappa=.63)
5 Treatment manuals drafted, field tested, revised, send out for
field review, and finalized (10-30,000 copies of each already
printed and distributed)
Descriptive, outcome and economic analyses completed
Source: Dennis et al, 2002, under review
Slide 13
Adolescent Cannabis Users in CYT were
as or More Severe Than Those in TEDS*
100%
% of Admissions
.
85%
78%
80%
71%
60%
47%
46%
40%
26%
26%
26%
20%
0%
F irst used
D ependence
W eekly or
P rior
under age
m ore use at
T reatm ent
15
intake
CY T O utpatient(n=600)
TE D S O utpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
Source: Tims et al, 2002
Slide 14
Demographic Characteristics
100%
83%
80%
62%
55%
60%
50%
40%
30%
17%
15%
20%
0%
Female
Male
African
American
Caucasian Under 15
15 to 16
Single
parent
family
Source: Tims et al, 2002
Slide 15
Institutional Involvement
100%
87%
80%
62%
60%
47%
40%
25%
20%
0%
In sch o o l
E m p lo yed
C u rren t C J
C o m in g fro m
In vo lvem en t
C o n tro lled
E n viro n m en t
Source: Tims et al, 2002
Slide 16
Patterns of Substance Use
100%
80%
73%
71%
60%
40%
17%
20%
9%
0%
Weekly
Tobacco Use
Source: Tims et al, 2002
Weekly Alcohol Significant Time
Weekly
Cannabis Use
Use
in Controlled
Environment
Slide 17
Multiple Problems are the NORM
Self-Reported in Past Year
0%
20%
40%
60%
80% 100%
86%
Any Marijuana Use Disorder
37%
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
12%
25%
Any External Disorder
61%
Lifetime History of Victimization
60%
Acts of Physical Violence
66%
Any (other) Illegal Activity
83%
Three to Twelve Problems
83%
Source: Dennis et al, under review
Slide 18
Co-occurring Problems are Higher for those
Self-Reporting Past Year Dependence
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
H e a lth P roble m
A c ute M e nta l
A c ute
A tte ntion
C onduc t
D istre ss*
D istre ss*
T ra um a tic
D e fic it
D isorde r*
D istre ss*
H ype ra c tivity
D isorde r*
P ast Y ear D ep en d en ce (n = 2 7 8 )
Source: Tims et al., 2002
O th er (n = 3 2 2 )
* p<.05
Slide 19
Evaluating the Effects of Treatment
Treatment Outcome
Long Term Stability
Difference between intake and
Difference between average of short term
average of all short term
follow-ups (3-12) and long term follow-up (30)
follow-ups (3-12)
Month
0.00
Z-Score
-0.10
-0.20
-0.30
-0.40
-0.50
-0.60
Short Term Outcome Stability
Difference between average of
early (3-6) and latter (9-12)
follow-up interviews
Source: Dennis et al, under review, forthcoming
F req . o f U se
S u b . P ro b .
Slide 20
Change in Substance Frequency Scale in
S ubstance F requency Index
CYT Trial 1: Incremental
Arm
Increm ental A rm
0.25
Treatment Outcome:
-Use reduced (-34%)
- No Sig. Dif. by condition
0.20
M E T /C B T 5
M E T /C B T 12
FSN
0.15
0.10
0.05
0.00
0
3
6
Short Term Stability:
- Outcomes stable (-1%)
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
9
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Use increases (+64%)
- No Sig. Dif. by condition
Slide 21
Change in Number of Substance Problems in
P ast M onth S ubstance P roblem s
CYT Trial 1: Incremental
Arm
Increm ental A rm
Treatment Outcome:
-Problems reduced (-46%)
- Sig. Dif. by condition
(-50% vs. –33% vs. –51%)
5
4
M E T /C B T 5
M E T /C B T 12
FSN
3
2
1
0
0
3
6
9
12
15
18
Short Term Stability:
-Further reductions (-25%) Months from Intake
- No difference by condition
Source: Dennis et al, forthcoming
21
24
27
30
Long Term Stability:
-Problems increase (+17%)
-Sig. Dif. by condition
(+37% vs +10% vs +7%)
Slide 22
Change in Substance Frequency Scale in
S ubstance F requency Index
CYT Trial 2: Alternative
Arm
A lternative A rm
Treatment Outcome:
- Use reduced (-35%)
- No Sig. Dif. by condition
0.25
0.20
M E T /C B T 5
ACRA
M D FT
0.15
0.10
0.05
0.00
0
3
6
Short Term Stability:
-Further reductions (-6%)
- Sig. Dif. by condition
(+4% vs. –10% vs. –11%)
Source: Dennis et al, forthcoming
9
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Outcomes stable (+20%)
-No Sig. Dif. by condition
Slide 23
Change in Number of Substance Problems in
P ast M onth SArm
ubstance P roblem s
CYT Trial 2: Alternative
A lternative A rm
5
Treatment Outcome:
- Problems reduced (-43%)
- No difference by condition
4
M E T /C B T 5
ACRA
M D FT
3
2
1
0
0
3
6
9
12
15
18
Short Term Stability:
- Outcomes stable (-8%) Months from Intake
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
21
24
27
30
Long Term Stability:
- Outcomes stable (+7%)
-No Sig. Dif. by condition
Slide 24
Percent in Past Month Recovery
(no use or problems while living in the community)
50%
40%
30%
18%
20%
17%
14%
14%
11%
10%
6%
0%
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
M ET/ CBT5
M E T / C B T 12
FSN
M ET/ CBT5
ACRA
M DFT
Source: Dennis et al, forthcoming
Slide 25
Cumulative Recovery Pattern at 30 months:
(The Majority Vacillate in and out of Recovery)
5 % S u stain ed
R eco v ery
3 7 % S u stain ed
P ro b lem s
1 9 % In term itten t,
cu rren tly in
reco v ery
3 9 % In term itten t,
cu rren tly n o t in
reco v ery
Source: Dennis et al, forthcoming
Slide 26
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-5MET/CBT-5,
findings
-12
$30,000
mixed at 30and
months
ACRA more
$25,000
$20,000
Trial 2 (n=297)
cost effective at
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., under review; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
Slide 27
Reduction in Average Cost to Society in
CYT Trial 1: Incremental Arm
Includes the
cost of CYT
Treatment
Reductions
(-23%) in Average
Cost to Society
offset Treatment
Costs within 12
months
Source: French et al, in press; forthcoming
Further
Reductions
(-47%)
occurred out to
30 months
Slide 28
Reduction in Average Cost to Society in
CYT Trial 2: Alternative Arm
Includes the
cost of CYT
Treatment
Average Cost to
Society goes up
then down and
does not offset Tx
Costs within 12
months (+7%)
Source: French et al, in press; forthcoming
Further
Reductions
occurred out to
30 months
(-40%)
Slide 29
Average Cost to Society Varied
More by Site than Condition
UCHC, Farmington, CT (-24%, -44%)
$6,000
PAR, St. Petersburg, FL (-22%, -49%)
CHS, Madison Co., IL (-8%, -51%)
$5,000
CHOP, Philadelphia, PA (+18%, -34%)
$4,000
$3,000
$2,000
$1,000
$0
0
3
6
9
Source: French et al, in press; forthcoming
12
15
18
Months from Intake
21
24
27
30
Slide 30
Reprise of Clinical Outcomes
Co-occurring problems were the norm and varied with substance
use severity.
In Trial 1, FSN and MET/CBT5 were relatively more effective
than MET/CBT12 in reducing substance abuse/dependence
problems (treatment effect); With FSN doing better at holding its
gains out to 30 months
In Trial 2, ACRA and MDFT were more effective than
MET/CBT5 in reducing substance abuse/dependence problems
(treatment effect) and short term stability on substance use; With
ACRA and MDFT doing better at holding their gains out to 30
months.
These were not easily explained simply by dosage or level of
family therapy and there was no evidence of iatrogenic effects of
group therapy.
While more effective than many earlier outpatient treatments,
2/3rds of the CYT adolescents were still having problems 12
months latter, 4/5ths were still having problems 30 months latter.
Slide 31
Reprise of Economic Outcomes
There were considerable differences in the cost of providing
each of the interventions.
MET/CBT-5, -12 and ACRA were the most cost effective at
12 months, though the stability of the MET/CBT findings
were mixed at 30 months.
Reductions in Average Quarterly Cost to Society offset the
cost of treatment within 12 months in trial 1 and with 30
months in trial 2.
At 12 months the MET/CBT5 intervention clearly had the
highest rate of return.
By 30 months MET/CBT12, ACRA and MDFT were doing
better and FSN was doing as well as MET/CBT in terms of
costs to society.
Results of clinical outcomes, cost-effectiveness, and benefit
cost were different – suggesting the importance of multiple
perspectives
Slide 32
Impact and Next Steps
Papers published on design, validation, characteristics,
matching, clinical contrast, treatment manuals,
therapist reactions, 6 month outcomes, cost, benefit
cost
Papers with main clinical and cost-effectiveness
findings at 12 months under review and 30 month
findings being submitted this year.
Interventions being replicated as part of over two
dozen studies currently or about to go into the field
20 to 30,000 copies of each of the 5 manuals
distributed to policy makers, providers, individual
clinicians and training programs
Source: Dennis et al, 2002, under review
Slide 33
Implications
The CYT interventions provide replicable models of
brief (1.5 to 3 month) treatments that can be used to
help the field maintain quality while expanding
capacity.
While a good start, the CYT interventions were still not
an adequate dose of treatment for the majority of
adolescents.
The majority of adolescents continued to vacillate in
and out of recovery after discharge from CYT.
More work needs to be done on providing a continuum
of care, longer term engagement and on going recovery
management.
Slide 34
Contact Information
Michael L. Dennis, Ph.D., CYT Coordinating Center PI
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Manuals and Additional Information are Available at:
CYT:
www.chestnut.org/li/cyt/findings or
www.chestnut.org/li/bookstore
NCADI: www.health.org/govpubs
PETSA: www.samhsa.gov/centers/csat/csat.html
(then select PETS from program resources)
Cannabis Youth Treatment (CYT) Trials:
12 and 30 Month Main Findings
Michael Dennis, Ph.D.
(On Behalf of the
CYT Steering Committee)
Chestnut Health Systems
Bloomington, IL
Presentation for the Kentucky
Adolescent Substance Abuse Consortium,
Lexington, KY, September 19, 2003. The
opinions are those of the author do not
reflect official positions of the consortium
or government . Available on-line at
www.chestnut.org/li/posters.
Slide 2
Acknowledgement
This presentation is based on the work, input and contributions from several
other people including: Nancy Angelovich, Tom Babor, Laura (Bunch)
Brantley, Joseph A. Burleson, George Dent, Guy Diamond, James Fraser,
Michael French, Rod Funk, Mark Godley, Susan H. Godley, Nancy
Hamilton, James Herrell, David Hodgkins, Ronald Kadden, Yifrah Kaminer,
Tracy L. Karvinen, Pamela Kelberg, Jodi (Johnson) Leckrone, Howard
Liddle, Barbara McDougal, Kerry Anne McGeary, Robert Meyers, Suzie
Panichelli-Mindel, Lora Passetti, Nancy Petry, M. Christopher Roebuck,
Susan Sampl, Meleny Scudder, Christy Scott, Melissa Siekmann, Jane Smith,
Zeena Tawfik, Frank Tims, Janet Titus, Jane Ungemack, Joan Unsicker,
Chuck Webb, James West, Bill White, Michelle White, Caroline Hunter
Williams, the other CYT staff, and the families who participated in this study.
This presentation was supported by funds and data from the Center for
Substance Abuse Treatment (CSAT’s) Persistent Effects of Treatment Study
(PETS, Contract No. 270-97-7011) and the Cannabis Youth Treatment (CYT)
Cooperative Agreement (Grant Nos. TI11317, TI11320, TI11321, TI11323,
and TI11324). The opinions are those of the author and steering committee
and do not reflect official positions of the government .
Slide 3
CYT
Cannabis Youth Treatment
Randomized Field Trial
Coordinating Center:
Chestnut Health Systems, Bloomington, IL,
and Chicago, IL
University of Miami, Miami, FL
University of Conn. Health Center, Farmington, CT
Sites:
Univ. of Conn. Health Center, Farmington, CT
Operation PAR, St. Petersburg, FL
Chestnut Health Systems, Madison County, IL
Children’s Hosp. of Philadelphia, Phil. ,PA
Sponsored by: Center for Substance Abuse Treatment (CSAT), Substance Abuse and Mental Health Services
Administration (SAMHSA), U.S. Department of Health and Human Services
Slide 4
Marijuana
Use is starting at younger ages
Is at an historically high level among adolescents
Potency increased 3-fold from 1980 to 1997
Is three times more likely to lead to dependence
among adolescents than adults
Is associated with many health, mental and
behavioral problems
Is the leading substance mentioned in adolescent
emergency room admissions and autopsies
Slide 5
Treatment
Marijuana related admissions to adolescent substance
abuse treatment increased by 115% from 1992 to
1998
Over 80% of adolescents entering treatment in 1998
had a marijuana problem
Over 80% are entering outpatient treatment
Over 75% receive less than 90 days of treatment
(median of 6 weeks)
Evaluations of existing adolescent outpatient
treatment suggest that last than 90 days of outpatient
treatment is rarely effective for reducing marijuana
use.
Slide 6
Purpose of CYT
To learn more about the characteristics and needs of
adolescent marijuana users presenting for outpatient
treatment.
To adapt evidence-based, manual-guided therapies for use
in 1.5 to 3 month adolescent outpatient treatment programs
in medical centers or community based settings.
To field test the relative effectiveness, cost, costeffectiveness, and benefit cost of five interventions
targeted at marijuana use and associated problems in
adolescents.
To provide validated models of these interventions to the
treatment field in order to address the pressing demands for
expanded and more effective services.
Slide 7
Design
Target Population: Adolescents with marijuana
disorders who are appropriate for 1 to 3 months of
outpatient treatment.
Inclusion Criteria: 12 to 18 year olds with symptoms of
cannabis abuse or dependence, past 90 day use, and
meeting ASAM criteria for outpatient treatment
Data Sources: self report, collateral reports, on-site and
laboratory urine testing, therapist alliance and discharge
reports, staff service logs, and cost analysis.
Random Assignment: to one of three treatments within
site in two research arms and quarterly follow-up
interview for 12 months
Long Term Follow-up: under a supplement from
PETSA follow-up was extended to 30 months (42 for a
subsample)
Slide 8
Two Trials or Study Arms
Trial 1
Incremental Arm
Trial 2
Alternative Arm
Randomly Assigns to:
Randomly Assigns to:
MET/CBT5
MET/CBT5
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
MET/CBT12
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (12 weeks)
FSN
Family Support Network
Plus MET/CBT12 (12 weeks)
Source: Dennis et al, 2002
Motivational Enhancement Therapy/
Cognitive Behavioral Therapy (5 weeks)
ACRA
Adolescent Community
Reinforcement Approach(12 weeks)
MDFT
Multidimensional Family Therapy
(12 weeks)
Slide 9
Contrast of the Treatment Structures
MET/
CBT5
MET/
CBT12
FSN
ACRA
MDFT
Individual Adolescent Sessions
2
2
2
10
6
CBT Group Sessions
3
10
10
2
3
2
6
22
14
15
As
needed
As
needed
As
needed
Type of Service
Individual Parent Sessions
Family Sessions/Home Visits
4
Parent Education Sessions
6
Total Formal Sessions
5
12
Case management/
Other Contacts
Total Expected Contacts
5
12
22+
14+
15+
Total Expected Hours
5
12
22+
14+
15+
Total Expected Weeks
6-7
12-13
12-13
12-13
12-13
Source: Diamond et al, 2002
Slide 10
Actual Treatment Received by Condition
23
FSN adds multi
family group,
family
home visits
20
and more case
MET/CBT12
adds 7 management
more
ACRA and MDFT
both rely on
individual, family and
case
management
And
MDFT
instead
using
moreof group
family therapy
With ACRA
using more
11
individual
therapy
Hours
15 of
sessions
group
10
10
5
Case
M anagement
Family
Counseling
14
Collateral only
Days
25
5
M ulti-Family
group
M ulti-P articipant
Group
5
P articipant only
0
M E T/
M E T/
M E T/
M E T/
CBT5
CBT12
CBT12 +
CBT5
ACRA
M DFT
FSN
In crem en tal Arm
Source: Dennis et al, under review
Altern ative Arm
Slide 11
Average Episode Cost ($US) of Treatment
Average Cost Per Client-Episode of Care
|--------------------------------------------Economic Cost-------------------------------------------|-------- Director Estimate-----|
$4,000
Less thanLess than
average average
for 6 weeks
for 12 weeks
$3,322
$3,500
$3,000
$3,495
$2,500
$1,984
$1,776
$2,000
$1,559
$1,500
$1,126
$1,197
$1,000
$500
$-
Source: French et al., 2002
$1,413
Slide 12
Implementation of Evaluation
Over 85% of eligible families agreed to participate
Quarterly follow-up of 94 to 98% of the adolescents from 3- to
12-months (88% all five interviews)
Long term follow-up completed on 90% at 30-months and 91%
(of 116 subsample) at 42-months
Collateral interviews were obtained at intake, 3- and 6-months
on over 92-100% of the adolescents interviewed
Urine test data were obtained at intake, 3, 6, 30 and 42 months
90-100% of the adolescents who were not incarcerated or
interviewed by phone (85% or more of all adolescents).
Self report marijuana use largely in agreement with urine test at
30 months (13.8% false negative, kappa=.63)
5 Treatment manuals drafted, field tested, revised, send out for
field review, and finalized (10-30,000 copies of each already
printed and distributed)
Descriptive, outcome and economic analyses completed
Source: Dennis et al, 2002, under review
Slide 13
Adolescent Cannabis Users in CYT were
as or More Severe Than Those in TEDS*
100%
% of Admissions
.
85%
78%
80%
71%
60%
47%
46%
40%
26%
26%
26%
20%
0%
F irst used
D ependence
W eekly or
P rior
under age
m ore use at
T reatm ent
15
intake
CY T O utpatient(n=600)
TE D S O utpatient (n=16,480)
* Adolescents w ith m arijuana problem s adm itted to outpatient treatm ent
Source: Tims et al, 2002
Slide 14
Demographic Characteristics
100%
83%
80%
62%
55%
60%
50%
40%
30%
17%
15%
20%
0%
Female
Male
African
American
Caucasian Under 15
15 to 16
Single
parent
family
Source: Tims et al, 2002
Slide 15
Institutional Involvement
100%
87%
80%
62%
60%
47%
40%
25%
20%
0%
In sch o o l
E m p lo yed
C u rren t C J
C o m in g fro m
In vo lvem en t
C o n tro lled
E n viro n m en t
Source: Tims et al, 2002
Slide 16
Patterns of Substance Use
100%
80%
73%
71%
60%
40%
17%
20%
9%
0%
Weekly
Tobacco Use
Source: Tims et al, 2002
Weekly Alcohol Significant Time
Weekly
Cannabis Use
Use
in Controlled
Environment
Slide 17
Multiple Problems are the NORM
Self-Reported in Past Year
0%
20%
40%
60%
80% 100%
86%
Any Marijuana Use Disorder
37%
Any Alcohol Use Disorder
Other Substance Use Disorders
Any Internal Disorder
12%
25%
Any External Disorder
61%
Lifetime History of Victimization
60%
Acts of Physical Violence
66%
Any (other) Illegal Activity
83%
Three to Twelve Problems
83%
Source: Dennis et al, under review
Slide 18
Co-occurring Problems are Higher for those
Self-Reporting Past Year Dependence
100%
80%
71%
57%
60%
42%
40%
37%
30%
25%
22%
22%
20%
13%
5%
0%
H e a lth P roble m
A c ute M e nta l
A c ute
A tte ntion
C onduc t
D istre ss*
D istre ss*
T ra um a tic
D e fic it
D isorde r*
D istre ss*
H ype ra c tivity
D isorde r*
P ast Y ear D ep en d en ce (n = 2 7 8 )
Source: Tims et al., 2002
O th er (n = 3 2 2 )
* p<.05
Slide 19
Evaluating the Effects of Treatment
Treatment Outcome
Long Term Stability
Difference between intake and
Difference between average of short term
average of all short term
follow-ups (3-12) and long term follow-up (30)
follow-ups (3-12)
Month
0.00
Z-Score
-0.10
-0.20
-0.30
-0.40
-0.50
-0.60
Short Term Outcome Stability
Difference between average of
early (3-6) and latter (9-12)
follow-up interviews
Source: Dennis et al, under review, forthcoming
F req . o f U se
S u b . P ro b .
Slide 20
Change in Substance Frequency Scale in
S ubstance F requency Index
CYT Trial 1: Incremental
Arm
Increm ental A rm
0.25
Treatment Outcome:
-Use reduced (-34%)
- No Sig. Dif. by condition
0.20
M E T /C B T 5
M E T /C B T 12
FSN
0.15
0.10
0.05
0.00
0
3
6
Short Term Stability:
- Outcomes stable (-1%)
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
9
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Use increases (+64%)
- No Sig. Dif. by condition
Slide 21
Change in Number of Substance Problems in
P ast M onth S ubstance P roblem s
CYT Trial 1: Incremental
Arm
Increm ental A rm
Treatment Outcome:
-Problems reduced (-46%)
- Sig. Dif. by condition
(-50% vs. –33% vs. –51%)
5
4
M E T /C B T 5
M E T /C B T 12
FSN
3
2
1
0
0
3
6
9
12
15
18
Short Term Stability:
-Further reductions (-25%) Months from Intake
- No difference by condition
Source: Dennis et al, forthcoming
21
24
27
30
Long Term Stability:
-Problems increase (+17%)
-Sig. Dif. by condition
(+37% vs +10% vs +7%)
Slide 22
Change in Substance Frequency Scale in
S ubstance F requency Index
CYT Trial 2: Alternative
Arm
A lternative A rm
Treatment Outcome:
- Use reduced (-35%)
- No Sig. Dif. by condition
0.25
0.20
M E T /C B T 5
ACRA
M D FT
0.15
0.10
0.05
0.00
0
3
6
Short Term Stability:
-Further reductions (-6%)
- Sig. Dif. by condition
(+4% vs. –10% vs. –11%)
Source: Dennis et al, forthcoming
9
12
15
18
Months from Intake
21
24
27
30
Long Term Stability:
- Outcomes stable (+20%)
-No Sig. Dif. by condition
Slide 23
Change in Number of Substance Problems in
P ast M onth SArm
ubstance P roblem s
CYT Trial 2: Alternative
A lternative A rm
5
Treatment Outcome:
- Problems reduced (-43%)
- No difference by condition
4
M E T /C B T 5
ACRA
M D FT
3
2
1
0
0
3
6
9
12
15
18
Short Term Stability:
- Outcomes stable (-8%) Months from Intake
- No Sig. Dif. by condition
Source: Dennis et al, forthcoming
21
24
27
30
Long Term Stability:
- Outcomes stable (+7%)
-No Sig. Dif. by condition
Slide 24
Percent in Past Month Recovery
(no use or problems while living in the community)
50%
40%
30%
18%
20%
17%
14%
14%
11%
10%
6%
0%
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
0 3 6 9 12 30
M ET/ CBT5
M E T / C B T 12
FSN
M ET/ CBT5
ACRA
M DFT
Source: Dennis et al, forthcoming
Slide 25
Cumulative Recovery Pattern at 30 months:
(The Majority Vacillate in and out of Recovery)
5 % S u stain ed
R eco v ery
3 7 % S u stain ed
P ro b lem s
1 9 % In term itten t,
cu rren tly in
reco v ery
3 9 % In term itten t,
cu rren tly n o t in
reco v ery
Source: Dennis et al, forthcoming
Slide 26
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-5MET/CBT-5,
findings
-12
$30,000
mixed at 30and
months
ACRA more
$25,000
$20,000
Trial 2 (n=297)
cost effective at
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., under review; forthcoming
Integrated family therapy (MDFT)
was more cost effective than adding
it on top of treatment (FSN) at 30
months
Slide 27
Reduction in Average Cost to Society in
CYT Trial 1: Incremental Arm
Includes the
cost of CYT
Treatment
Reductions
(-23%) in Average
Cost to Society
offset Treatment
Costs within 12
months
Source: French et al, in press; forthcoming
Further
Reductions
(-47%)
occurred out to
30 months
Slide 28
Reduction in Average Cost to Society in
CYT Trial 2: Alternative Arm
Includes the
cost of CYT
Treatment
Average Cost to
Society goes up
then down and
does not offset Tx
Costs within 12
months (+7%)
Source: French et al, in press; forthcoming
Further
Reductions
occurred out to
30 months
(-40%)
Slide 29
Average Cost to Society Varied
More by Site than Condition
UCHC, Farmington, CT (-24%, -44%)
$6,000
PAR, St. Petersburg, FL (-22%, -49%)
CHS, Madison Co., IL (-8%, -51%)
$5,000
CHOP, Philadelphia, PA (+18%, -34%)
$4,000
$3,000
$2,000
$1,000
$0
0
3
6
9
Source: French et al, in press; forthcoming
12
15
18
Months from Intake
21
24
27
30
Slide 30
Reprise of Clinical Outcomes
Co-occurring problems were the norm and varied with substance
use severity.
In Trial 1, FSN and MET/CBT5 were relatively more effective
than MET/CBT12 in reducing substance abuse/dependence
problems (treatment effect); With FSN doing better at holding its
gains out to 30 months
In Trial 2, ACRA and MDFT were more effective than
MET/CBT5 in reducing substance abuse/dependence problems
(treatment effect) and short term stability on substance use; With
ACRA and MDFT doing better at holding their gains out to 30
months.
These were not easily explained simply by dosage or level of
family therapy and there was no evidence of iatrogenic effects of
group therapy.
While more effective than many earlier outpatient treatments,
2/3rds of the CYT adolescents were still having problems 12
months latter, 4/5ths were still having problems 30 months latter.
Slide 31
Reprise of Economic Outcomes
There were considerable differences in the cost of providing
each of the interventions.
MET/CBT-5, -12 and ACRA were the most cost effective at
12 months, though the stability of the MET/CBT findings
were mixed at 30 months.
Reductions in Average Quarterly Cost to Society offset the
cost of treatment within 12 months in trial 1 and with 30
months in trial 2.
At 12 months the MET/CBT5 intervention clearly had the
highest rate of return.
By 30 months MET/CBT12, ACRA and MDFT were doing
better and FSN was doing as well as MET/CBT in terms of
costs to society.
Results of clinical outcomes, cost-effectiveness, and benefit
cost were different – suggesting the importance of multiple
perspectives
Slide 32
Impact and Next Steps
Papers published on design, validation, characteristics,
matching, clinical contrast, treatment manuals,
therapist reactions, 6 month outcomes, cost, benefit
cost
Papers with main clinical and cost-effectiveness
findings at 12 months under review and 30 month
findings being submitted this year.
Interventions being replicated as part of over two
dozen studies currently or about to go into the field
20 to 30,000 copies of each of the 5 manuals
distributed to policy makers, providers, individual
clinicians and training programs
Source: Dennis et al, 2002, under review
Slide 33
Implications
The CYT interventions provide replicable models of
brief (1.5 to 3 month) treatments that can be used to
help the field maintain quality while expanding
capacity.
While a good start, the CYT interventions were still not
an adequate dose of treatment for the majority of
adolescents.
The majority of adolescents continued to vacillate in
and out of recovery after discharge from CYT.
More work needs to be done on providing a continuum
of care, longer term engagement and on going recovery
management.
Slide 34
Contact Information
Michael L. Dennis, Ph.D., CYT Coordinating Center PI
Lighthouse Institute, Chestnut Health Systems
720 West Chestnut, Bloomington, IL 61701
Phone: (309) 827-6026, Fax: (309) 829-4661
E-Mail: [email protected]
Manuals and Additional Information are Available at:
CYT:
www.chestnut.org/li/cyt/findings or
www.chestnut.org/li/bookstore
NCADI: www.health.org/govpubs
PETSA: www.samhsa.gov/centers/csat/csat.html
(then select PETS from program resources)