EVIDENCE-BASED MENTAL HEALTH PRACTICES

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EVIDENCE-BASED MENTAL HEALTH PRACTICES Powered By Docstoc
					EVIDENCE-BASED MENTAL
   HEALTH PRACTICES


 Anthony F. Lehman, M.D., M.S.P.H.
        Professor and Chair
      Department of Psychiatry
       University of Maryland
    10 Leading Causes of Disability in
        the World (WHO, 1997)

   Unipolar Depression         10.7%
   Iron-deficiency Anemia      4.7
   Falls                       4.6
   Alcohol Use                 3.3
   COPD                        3.1
   Bipolar disorder            3.0
   Congenital anomalies        2.9
   Osteoarthritis              2.8
   Schizophrenia               2.6
   Obsessive-compulsive        2.2
    disorder
     CHANGES IN PRIVATE HEALTH
        CARE EXPENDITURES
              1988-1997
             (HAY GROUP STUDY, 1998)



   Overall health care expenditures
    decreased by 7% between 1988-1997

   Mental health care expenditures
    decreased by 54%
              PORT Process

   Review literature regarding evidence for
    practice (efficacy)
   Analyze data on variations in practice
   Develop outcomes information to examine
    relationship of treatment and patient
    outcomes (effectiveness)
   Develop treatment recommendations
    based on literature and outcome studies
   Disseminate findings to change current
    practices
        Schizophrenia PORT
     Treatment Recommendations

   Recommendation 1: Antipsychotic
    medications, other than clozapine,
    should be used as the first-line
    treatment to reduce psychotic
    symptoms for persons experiencing
    an acute symptom episode of
    schizophrenia.
      Conventional Antipsychotics:
       Efficacy-Effectiveness Gap
   Annual Relapse Rates
    - Placebo: 70%
    - Efficacy in clinical trails: 23%
    - Effectiveness in practice: 50%

   Factors Affecting Efficacy-Effectiveness Gap
    - Patient heterogeneity
    - Prescribing practices
    - Noncompliance

(from Kissling, 1992)                    _________________
                                         Schizophrenia PORT
        Schizophrenia PORT
     Treatment Recommendations
   Recommendation 2: The dosage of
    antipsychotic medication for an acute
    symptom episode should be in the range
    of 300-1000 chlorpromazine (CPZ)
    equivalents per day for a minimum of 6
    weeks. Reasons for dosages outside of
    this range should be justified. The
    minimum effective dose should be used.
  Effective Dosage Range: Acute Treatment




    %
Improvement
  (2-4 h)




                1           2   3     5             10        20 30       50
                Dose, mg (Fluphenazine)

                    Baldessarini et al. (1988), Arch Gen Psych 45:79-91
        Schizophrenia PORT
     Treatment Recommendations
   Recommendation 9: The
    maintenance dosage should be in the
    range of 300-600 CPZ equivalents
    (oral or depot) per day.
                     Effective Dosage Range:
                     Maintenance Treatment



  % not
  relapsed
  (1 yr)




                       Fluphenazine Decanoate, mg/2 wk

Baldessarini et al. (1988), Arch Gen Psych 45:79-91      Schizophrenia PORT
        Schizophrenia PORT
     Treatment Recommendations
   Recommendation 23: Individual and
    group therapies employing well-specified
    combinations of support, education, and
    behavioral and cognitive skills training
    approaches designed to address the
    specific deficits of persons with
    schizophrenia should be offered over time
    to improve functioning and enhance other
    targeted problems, such as medication
    non-compliance.
          Cumulative Effect Sizes
          Adjustment Outcomes




            N=148       N=151           N=128

(Begin: N=151)                                  (End: N=125)
                    Year in Treatment
                                                       From Hogarty et. al. (1996)
        Schizophrenia PORT
     Treatment Recommendations
   Recommendation 24:        Patients who
    have on-going contact with their families
    should be offered a family psychosocial
    intervention which spans at least nine
    months and which provides a combination
    of education about the illness, family
    support, crisis intervention, and problem
    solving skills training. Such interventions
    should also be offered to non-family
    caregivers.
Combined Therapies for Schizophrenia
   Annual Relapse Rates (Hogarty et al., 1986)
        Schizophrenia PORT
     Treatment Recommendations
   Recommendation 27: Persons with
    schizophrenia who have any of the
    following characteristics should be
    offered vocational services. The person: a)
    identifies competitive employment as a
    personal goal; b) has a history of prior
    competitive employment; c) has a minimal
    history of psychiatric hospitalization; d) is
    judged on the basis of a formal vocational
    assessment to have good work skills.
VOCATIONAL STUDIES




         % Working
     Employment Intervention
      Demonstration Project

 Sponsored by Center for Mental Health
  Services
 A multi-center, longitudinal evaluation of
  employment interventions for persons
  with severe mental illness
 Randomly assigned and followed for two
  years.
       EIDP TREND # 1


JOB TENURE SHOWED A TREND
 TOWARD INCREASED LENGTH OF
 JOB OVER TIME.
Average Length in Days   Average Length of Jobs (EIDP, 2001)
        EIDP TREND #2



TIME BETWEEN JOBS DECREASED
  OVER TIME
                           Number of Days Between Jobs Among
                         EIDP Participants with More than One Job
Average Number of Days
       EIDP TREND # 3


RECEIPT OF JOB SUPPORT WAS
 ASSOCIATED WITH LONGER JOB
 TENURE ON FIRST JOB
    DEFINITION OF JOB SUPPORT

On-site counseling, support, and problem
 solving. Providing on-the job help with
 vocational skills in different work
 situations and production levels, social
 skill in the work environment, and job-
 related skills; may include on-the-job
 training/assistance.
Mean Length (in days) of First Competitive
     Job by Receipt of Job Support
  Mean Length in Days




                        Received Job Support
        Schizophrenia PORT
     Treatment Recommendations

   Recommendation 29: Systems of
    care serving persons with
    schizophrenia who are high service
    utilizers should include assertive
    case management and assertive
    community treatment programs.
CONTROLLED ACT RESEARCH
             25 Studies
Inpatient Days: ACT vs. Comparison
            Lehman et al, 1998
Days Homeless on Streets:
  ACT vs. Comparison
        Lehman et al., 1997
Outpatient Visits: ACT vs.
      Comparison
        Lehman et al, 1997
    SCHIZOPHRENIA PORT
       Current Practices

 Maintenance dose of antipsychotic
  within recommended range: 29%
 Adjunctive antidepressant: 46%
 Psychological Interventions: 45%
 Family psychoeducation: 10%
 Vocational rehabilitation: 22%
Rates of Conformance with PORT Psychosocial
         Treatment Recommendations
   APA Office of Quality Improvement and Psychiatric Services
                 Medicare Claims: 1991
        Proportion of Study Population with At Least
         One Visit for Outpatient Service (N=16,480)



   %
   of
Patients




                                          Schizophrenia PORT
     Major Depression Treatment

   Acute Phase (Symptom Response_
    – Placebo……………………... 20-50%
    – Antidepressant……………. 65-70%
    – Psychotherapies………….. 47-55%
   Maintenance Phase (Relapse
    Prevention)
    – Placebo……………………… 15-45%
    – Antidepressant…………….. 65-79%
         Child and adolescent treatments that have
                 been found to be effective
   Empirically supported treatments
    – Cognitive-behavior therapy for childhood anxiety disorders
    – Cognitive-behavioral coping skills therapy for depression (including school-
      based treatments)
    – Parent management training for disruptive behaviors (including videos for
      parents)
    – Problem-solving skills therapy for disruptive behaviors
    – Social skills training for young children who are aggressive (including school-
      based treatments)
    – Psychotropic medication for Attention Disorders and Obsessive-Compulsive
      disorders
   Empirically promising treatments
    –   Intensive home-based behavior modification for autism
    –   Family therapy for parent-adolescent conflict
    –   Teacher consultation models for disruptive behaviors (reduction in Special Ed. referrals
        found; effects on behavior problems unclear)
    –   Psychotropic medication for a number of other symptoms (e.g., depression, anxiety,
        autistic behaviors)
    Empirically Supported Treatments
                Conduct Problems
   Multi-System Treatment
    – 84 youth categorized as serious juvenile offenders
      randomly assigned to MST and standard care through
      juvenile justice
    – After two years, 40% of youth treated with MST avoided
      re-arrest versus 20% of youth receiving standard care
      (Henggler, et al 1996)
   Behavioral family/parent training
    – A large average effect size of .86 was found across
      studies of family behavioral skills interventions with
      disruptive behavior disorders (Serketich, Dumas 1996)
    Empirically Supported Treatments
         Depression in Adolescents
   Cognitive Behavioral Therapy
    – Results of large controlled study showed reduction in
      symptoms in 70% of those treated with CBT
   Coping with Depression (CWD) course
    – 96 youth with major depression randomized to CWD
      course or wait-list control
    – 97.5% of CWD group no longer met criteria for
      depression disorder at 2 year follow-up
                       Pediatric Psychopharmacology1
                                                                               Efficacy2
                Class                       Indication
                                                                   Short-term            Long-term
        Stimulants                 ADHD                                   A                    B
                                   Major depression                       B                    C
        SSRIs                      OCD                                    A                    C
                                   Anxiety disorders                      C                    C
        Adrenergic                 Tourette’s disorder                    B                    C
        agonists                   ADHD                                   C                    C
        Valproate &                Bipolar disorder                       C                    C
        Carbamazepine              Aggressive behavior                    C                    C
                                   Major depression                       C                    C
        TCAs
                                   ADHD                                   B                    C
                                   Schizophrenia                          B                    C
        Antipsychotics
                                   Tourette’s disorder                    A                    C
                                   Bipolar disorders                      B                    C
        Lithium                    Aggressive behaviors                   B                    C
1   Jensen, Bhatara, Vitiello, et al 1999         2A=    2 RCTs; B = 1 RCT; C = clinical consensus
      Different Perspectives on Outcomes
 Example: Utility for Mild Symptoms plus Side
Effects Versus Moderate Symptoms and No Side
           Effects (Lenert et al., 2000)
EVOLUTION OF MEDICAL TECHNOLOGY
  AND COSTS OF TREATING DISEASE
                           (Pardes et al., 1999)




   Costs




            – palliative            treatment      cure

                • Stages of Technology
rrent Practices

 Maintenance dose of antipsychotic
  within recommended range: 29%
 Adjunctive antidepressant: 46%
 Psychological Interventions: 45%
 Family psychoeducation: 10%
 Vocational rehabilitation: 22%
Rates of Conformance with PORT Psychosocial
         Treatment Recommendations
   APA Office of Quality Improvement and Psychiatric Services

100%
 90%
 80%
 70%
 60%
 50%
 40%
 30%
 20%
 10%
  0%




                                                 Voc Rehab
                                       Therapy
        Management


                       Psychotherapy




                                                             Psychosocial
                                        Family
           Case




                                                                 Any
                  Medicare Claims: 1991
        Proportion of Study Population with At Least
         One Visit for Outpatient Service (N=16,480)

            100
             90
             80
   %
             70
   of
             60
Patients     50
             40
             30
             20
             10
              0
                   Total   Individual   Group Therapy Family Therapy
                            Therapy

                                                    Schizophrenia PORT
     Major Depression Treatment

   Acute Phase (Symptom Response_
    – Placebo……………………... 20-50%
    – Antidepressant……………. 65-70%
    – Psychotherapies………….. 47-55%
   Maintenance Phase (Relapse
    Prevention)
    – Placebo……………………… 15-45%
    – Antidepressant…………….. 65-79%
         Child and adolescent treatments that have
                 been found to be effective
   Empirically supported treatments
    – Cognitive-behavior therapy for childhood anxiety disorders
    – Cognitive-behavioral coping skills therapy for depression (including school-
      based treatments)
    – Parent management training for disruptive behaviors (including videos for
      parents)
    – Problem-solving skills therapy for disruptive behaviors
    – Social skills training for young children who are aggressive (including school-
      based treatments)
    – Psychotropic medication for Attention Disorders and Obsessive-Compulsive
      disorders
   Empirically promising treatments
    –   Intensive home-based behavior modification for autism
    –   Family therapy for parent-adolescent conflict
    –   Teacher consultation models for disruptive behaviors (reduction in Special Ed. referrals
        found; effects on behavior problems unclear)
    –   Psychotropic medication for a number of other symptoms (e.g., depression, anxiety,
        autistic behaviors)
    Empirically Supported Treatments
                Conduct Problems
   Multi-System Treatment
    – 84 youth categorized as serious juvenile offenders
      randomly assigned to MST and standard care through
      juvenile justice
    – After two years, 40% of youth treated with MST avoided
      re-arrest versus 20% of youth receiving standard care
      (Henggler, et al 1996)
   Behavioral family/parent training
    – A large average effect size of .86 was found across
      studies of family behavioral skills interventions with
      disruptive behavior disorders (Serketich, Dumas 1996)
    Empirically Supported Treatments
         Depression in Adolescents
   Cognitive Behavioral Therapy
    – Results of large controlled study showed reduction in
      symptoms in 70% of those treated with CBT
   Coping with Depression (CWD) course
    – 96 youth with major depression randomized to CWD
      course or wait-list control
    – 97.5% of CWD group no longer met criteria for
      depression disorder at 2 year follow-up
                       Pediatric Psychopharmacology1
                                                                               Efficacy2
                Class                       Indication
                                                                   Short-term            Long-term
        Stimulants                 ADHD                                   A                    B
                                   Major depression                       B                    C
        SSRIs                      OCD                                    A                    C
                                   Anxiety disorders                      C                    C
        Adrenergic                 Tourette’s disorder                    B                    C
        agonists                   ADHD                                   C                    C
        Valproate &                Bipolar disorder                       C                    C
        Carbamazepine              Aggressive behavior                    C                    C
                                   Major depression                       C                    C
        TCAs
                                   ADHD                                   B                    C
                                   Schizophrenia                          B                    C
        Antipsychotics
                                   Tourette’s disorder                    A                    C
                                   Bipolar disorders                      B                    C
        Lithium                    Aggressive behaviors                   B                    C
1   Jensen, Bhatara, Vitiello, et al 1999         2A=    2 RCTs; B = 1 RCT; C = clinical consensus
      Different Perspectives on Outcomes
 Example: Utility for Mild Symptoms plus Side
Effects Versus Moderate Symptoms and No Side
           Effects (Lenert et al., 2000)
 0.1
0.08
0.06
                                       Patients
0.04
                                       Familes
0.02                                   Providers
   0
-0.02
-0.04
EVOLUTION OF MEDICAL TECHNOLOGY
  AND COSTS OF TREATING DISEASE
                           (Pardes et al., 1999)




   Costs




            – palliative            treatment      cure

                • Stages of Technology

				
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