Evidence-Based Practices in Psychiatric Rehabilitation
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Transcript of Evidence-Based Practices in Psychiatric Rehabilitation
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Evidence-Based Practices in Evidence-Based Practices in Psychiatric RehabilitationPsychiatric Rehabilitation
Bob DrakeOctober, 2010
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Financial Support to PRCFinancial Support to PRC
Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA
Contracts from Guilford Press, Hazelden Press, MacArthur Foundation, Oxford Press, New York Office of Mental Health, Research Foundation for Mental Health
Gifts from Johnson & Johnson Corporate Contributions, Segal Foundation, Thomson Foundation, Vail Foundation, West Foundation
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OVERVIEWOVERVIEW
Definition Update on evidence-based practices Common themes Dissemination and implementation
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History of Mental Health in U.S.History of Mental Health in U.S.
Cottage industry Little attention to outcomes Ineffective and harmful interventions
persist for years Effective interventions rarely used
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Evidence-based MedicineEvidence-based Medicine
The combination of science, client values/preference, and clinical expertise
In mental health care, this means combining science and recovery ideology
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Evidence-Based Evidence-Based
PracticesPractices Standardized interventions
Controlled research
More than 1 research group
Objective outcome measures
Meaningful outcomes
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Evidence-Based Rehabilitation PracticesEvidence-Based Rehabilitation PracticesRobert Wood Johnson Foundation 1998Robert Wood Johnson Foundation 1998 Assertive Community Treatment Supported Employment Family Psychoeducation Illness Management and Recovery Integrated Treatment for Co-
occurring Disorders
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Assertive Community Treatment (ACT)Assertive Community Treatment (ACT)
Community-based team Low caseload Multidisciplinary Outreach Direct service provision 24 hours/7days
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Research on ACT Research on ACT (cont.)(cont.)
02468
1012141618
Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74.
ACT better than standard treatmentACT not better than standard treatment
Time inHospital
HousingStability
Qualityof Life
ClientSatisfaction
Symptoms SocialFunctioning
Vocational Jail/Arrests
Num
ber o
f Stu
dies
25 Randomized Controlled Trials
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Days Homeless on Streets: Days Homeless on Streets:
ACT vs Usual Community ServicesACT vs Usual Community Services
0
50
100
150
200
250
FirstQuarter
SecondQuarter
ThirdQuarter
FourthQuarter
ACTUsual community servicesN=152
Lehman AF. Unpublished data.
Days
Hom
eles
s
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Current ACT IssuesCurrent ACT Issues
1. Hospital system changes2. Quality of usual services3. Forensic ACT4. Other expansions and components5. Transitions
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Supported EmploymentSupported Employment Focus on competitive work
Rapid job search
De-emphasis on prevocational training and assessment
Attention to client preferences
Follow-along supports as needed
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Supported Employment RCTsSupported Employment RCTs
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
96 NH (IPS)
94 NY(SE)
04 CA
(IPS)
04 IL
(IPS)
04 CT (IPS)
06 SC
(IPS)
05 HK
(IPS)
99 DC (IPS)
95 IN (SE)
06 EUR(IPS)
00 NY(SE)
05QUE(IPS)
97 CA (SE)
02 MD
(IPS)
Supported Employment Control
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Individual Placement and Support (IPS) vs Individual Placement and Support (IPS) vs Enhanced Vocational Rehabilitation (EVR) in Enhanced Vocational Rehabilitation (EVR) in
Maintaining Competitive JobsMaintaining Competitive JobsIPS (n=74)EVR (n=76)
40
35
30
25
20
15
10
5
0181716151413121110987654321
Study Months
% W
orki
ng in
Com
petit
ive
Jobs
Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.
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Current SE IssuesCurrent SE Issues
1. Financing2. Cognitive strategies3. Effective specialists4. Disability reform
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Family PsychoeducationFamily Psychoeducation
Provided by professionals Long-term (over 6 months) Single and multiple family
group formats Focus on education, stress reduction, coping,
and other support Oriented toward future, not past
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0
25
50
75
100
Effects of Family Intervention onEffects of Family Intervention on2-Year Relapse Rates (12 Studies)2-Year Relapse Rates (12 Studies)
% C
umul
ativ
e Re
laps
e Ra
te
Standard Care(n=203)
Single FamilyTreatment
(n=231)
Multiple FamilyGroup Treatment
(n=266)
Single and MultipleFamily Group
Treatment(n=243)
Mueser KT, Glynn SM. Behavioral Family Therapy for Psychiatric Disorders; 1999.Montero I, et al. Schizophr Bull. 2001;27(4):661-670.
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Current FPE IssuesCurrent FPE Issues
1. Effectiveness failure2. Family-to-family and alternatives
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Illness Management TrainingIllness Management Training
Helping people learn to manage their own illnesses
Relapse prevention
Minimize the effects ofresidual symptoms
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Research on Illness Research on Illness
Management ComponentsManagement Components Psychoeducation increases knowledge
and awareness Behavioral tailoring increases effective
use of medications Warning sign recognition
reduces relapses Cognitive-behavioral treatment reduces
residual symptoms
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Social AdjustmentSocial Adjustment** Outcomes: Outcomes:
Cumulative Effect Sizes Cumulative Effect Sizes
*Social adjustment=work performance, relations in the home and with external family, social leisure, general adjustment, interpersonal anguish, social relations, role performance, normal functioning,Brief Psychiatric Rating Scale (BPRS) score, and Global Assessment Scale (GAS) score.Hogarty GE, et al. Am J Psychiatry. 1997;154(11):1514-1524.
00.10.20.30.40.50.60.70.80.9
Intake Year 1 Year 2 Year 3Years in Treatment
Personal therapy (n=74)No personal therapy (n=77)
p=.004
Effe
ct S
ize o
nSo
cial
Adj
ustm
ent
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Current IMR IssuesCurrent IMR Issues
1. More research2. Training3. Hard outcomes4. Simplification
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Integrated Dual Disorders TreatmentIntegrated Dual Disorders Treatment
Mental health and substance abuse treatments combined by 1 team•Assertive •Stage-wise• Individualized •Comprehensive•Long-term
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ACT and Integrated DualACT and Integrated Dual
Disorders Treatment Disorders Treatment
Assessment Point
0
10
20
30
40
50
60
Baseline 6 12 18 24 30 36
McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824.
% o
f Pat
ient
s in
Sta
ble
Rem
issi
on High-fidelity ACT programs (n=61)Low-fidelity ACT programs (n=26)
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Current IDDT IssuesCurrent IDDT Issues
1. Standardization2. Group and residential interventions3. Supported employment4. Staging5. Simplification
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Common Features of Evidence-Based Common Features of Evidence-Based
Rehabilitation PracticesRehabilitation Practices Shared decision
making and choice Individualization Skills and supports in
the community Adult roles Quality of life
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Additional Rehabilitation PracticesAdditional Rehabilitation Practices
Social skills training
Supported housing
Supported education
Integrated medical care
Trauma interventions
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Dissemination and ImplementationDissemination and Implementation Science to service gap No simple solution for complex
systems Multiple strategies Phases of implementation All stakeholders Fidelity
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National EBP ProjectNational EBP Project
Phase I: conduct reviews, prepare implementation packages (toolkits), and establish state technical assistance centers
Phase II: field tests to refine procedures and resource materials
Phase III: national demonstration
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ClientOutcomes
Evidence-Based
Practice
ProgramLeader
Practitioners
Administration
Strategiesand
Barriers
Consumers
Mental Health
Authority
Families
ImplementationPackage
Intervention Stakeholders ImplementationProcess
OtherFactors
ImplementationOutcome
Community MentalHealth Center
Conceptual Framework for Implementing an Evidence-Based Practice
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System Changes 1System Changes 1 Evidence-based medicine Address 3 components: science, consumer
involvement, practitioner skills Align financing and structures with goals Integrate treatment and rehabilitation: mental
health, substance abuse, vocational rehabilitation, general health, housing, self-help, family supports
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System Changes 2System Changes 2 Improve data systems to focus on outcomes
and fidelity Enhance self-management Electronic records and decision supports:
education, assessment, outcomes, decision making
Engineer micro-systems of care Learning collaboratives Distance learning
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Current ConcernsCurrent Concerns Fidelity and outcomes Access and acceptability Durability Multi-cultural services Flexibility Financing Organization
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ConclusionsConclusions Evidence-based rehabilitation
interventions are available and will improve rapidly
Implementation requires changes in organization and financing
Flexible, individualized application requires flexible clinicians and organizations
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Further InformationFurther Information
Patti O’Brien Patti.O’[email protected] 603-448-0263 www.mentalhealth.samhsa.gov