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 Iron-deficiency Anemia Falls Alcohol Use COPD Bipolar disorder Congenital anomalies Osteoarthritis Schizophrenia Obsessive-compulsive disorder 10.7%

CHANGES IN PRIVATE HEALTH CARE EXPENDITURES (HAY GROUP STUDY, 1998) Overall health care expenditures decreased by 7% between 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 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.

% Improvement (2-4 h) Dose, mg (Fluphenazine) Baldessarini et al. (1988), Arch Gen Psych 45:79-91 Effective Dosage Range: Acute Treatment

Schizophrenia PORT Treatment Recommendations Recommendation 9:The maintenance dosage should be in the range of CPZ equivalents (oral or depot) per day.

% not relapsed (1 yr) Fluphenazine Decanoate, mg/2 wk Baldessarini et al. (1988), Arch Gen Psych 45:79-91 Effective Dosage Range: Maintenance Treatment 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 (Begin: N=151) (End: N=125) N=148 N=151N=128 From Hogarty et. al. (1996) Year in Treatment

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 of Jobs (EIDP, 2001) Average Length in Days

EIDP TREND #2 TIME BETWEEN JOBS DECREASED OVER TIME

Number of Days Between Jobs Among EIDP Participants with More than One Job 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

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

Major Depression Treatment Acute Phase (Symptom Response_ –Placebo…………………… % –Antidepressant…………… % –Psychotherapies………… % Maintenance Phase (Relapse Prevention) –Placebo……………………… 15-45% –Antidepressant…………… %

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 Psychopharmacology 1 Long-termShort-term CCCC BBBB Bipolar disorders Aggressive behaviors Lithium CCCC BABA Schizophrenia Tourette’s disorder Antipsychotics CCCC CBCB Major depression ADHD TCAs CCCC CCCC Bipolar disorder Aggressive behavior Valproate & Carbamazepine CCCC BCBC Tourette’s disorder ADHD Adrenergic agonists CCCCCC BACBAC Major depression OCD Anxiety disorders SSRIs BAADHD Stimulants Efficacy 2 IndicationClass 1 Jensen, Bhatara, Vitiello, et al A = 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 –palliativetreatmentcure Stages of Technology