Getting Evidence Based Psychosocial Treatments into Practice – Schizophrenia David L. Shern, Ph.D De la Parte Florida Mental Health Institute University of South Florida Presented to AcademyHealth Annual Research Conference June 6, 2004 San Diego, California

Special Thanks to Tony Lehman, M.D. for his Slides and Thoughts on the Implementation of Evidence Based Practices for Schizophrenia NIMH Outreach Partners Behavioral Health Services Research Association

Overview of Presentation Substantial Gap between Knowledge Base and Practice in Ordinary Settings Examples from Schizophrenia Strategies for Improving –The Generation of Knowledge –Dissemination and Implementation of EBPs

The Absence Of EBP’s In Mental Health Settings President’s New Freedom Commission Surgeon General’s Report Institute of Medicine Report Schizophrenia PORT

Schizophrenia PORT Treatment Recommendations Recommendation 1:Antipsychotic medications, other than clozapine, should be used as the first-line treatment to reduce positive psychotic symptoms for persons with multi-episode schizophrenia who are experiencing an acute exacerbation of their illness.

Conventional Antipsychotics: Efficacy-Effectiveness Gap Annual Relapse Rates - Placebo: 70% - Efficacy in clinical trials: 23% - Effectiveness in practice: 50% Factors Affecting Efficacy-Effectiveness Gap - Patient heterogeneity - Prescribing practices - Noncompliance (from Kissling, 1992) _________________ Schizophrenia PORT

Issues Regarding Pharmacotherapy Recommendation Reluctance of Prescribers to Change Behavior Costs of Second Generation Antipsychotic Medications Utilization Management Techniques –Prior Approval –Fail First Policies

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

Effect Sizes of CBT on Schizophrenia Symptoms (Rector and Beck, 2001)

Schizophrenia PORT Treatment Recommendations Recommendation 24: Persons with schizophrenia who have on-going contact with their families should be offered a family psychosocial intervention, the key elements of which include a duration of at least three months, illness education, crisis intervention, emotional support, and training in how to cope with illness symptoms.

Combined Therapies for Schizophrenia Annual Relapse Rates (Hogarty et al., 1986)

Schizophrenia PORT Treatment Recommendations Recommendation 25: Persons with schizophrenia should be offered supported employment, the key elements of which include individualized job development, rapid placement emphasizing competitive employment, ongoing job supports, and integration of vocational and mental health services.

VOCATIONAL STUDIES % Working

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

Barriers to Implementing Psychosocial Interventions Workforce Preparation Work Environment Supports and Incentives Policy Maker Knowledge Knowledge Development and Dissemination Strategies Demand Side Pressures for Improvement Differential Utilities for Treatments and Outcomes

Managing the Workforce Pre-Service Training –Annapolis Coalition In Service Training –Spray and Pray Training Ongoing Support for Effective Practices –Information Support Systems Activity Templates/Fidelity Measures Outcome Benchmarks Reimbursement Systems Consumer Demand for Specific Treatments

System Barriers Reimbursement Practices Don’t Track Evidence Base Complex Categorical Funding Streams Frustrate Integrated Care Narrow Focus on Agency Specific Budgets in Cost Containment Policy Makers Unaware of Evidence Based and Informed Practices Systematic Outcome and Process Data are not Available Differing Values for Differing Outcomes –Reduction in Hospital Use Versus Normal Life in the Community

Preference Ratings for Differing Outcomes From Shumway et al, 2003

Different Perspectives on Outcomes Example: Utility for Mild Symptoms plus Side Effects Versus Moderate Symptoms and No Side Effects (Lenert et al., 2000)

Consumer and Family Barriers Stigmatized Disorders Inhibit Information Flow among Consumers Research Results Complex and Difficult to Interpret Differential Power Relationships with Providers – Particularly for People with Mental Illnesses Personal Desires may not Comport with Reimbursed Treatments –Rehabilitation Often Not Available Difficult to Determine if Receiving EBP

Research Barriers Research Culture –Questions Derived Within Researcher Defined Framework –Control of Heterogeneity which doesn’t Map Real World Applications –Dissemination through Limited Channels Peer Reviewed Publication Limited Systematic Attention to Implementation of Findings Limited Opportunities to Meaningfully Interact with Multiple Stakeholders who impact Implementation of Work

Behavioral Health Services Research Association/Academy Health Interest Group Goals –To Improve the Knowledge Development and Dissemination Strategy –To Advocate for the Importance of Behavioral Health Services Research in Improving our Human Services Systems To Join –

BHSRA Strategy Conduct Issue Forums in Conjunction with Other Scheduled Meetings –NASMHPD, NAMI, APA, ACMHA, AcademyHealth, etc. Issue Forums Composed of Multiple Stakeholders and Focused on a Particular Issue Form Working Groups to Develop Research Questions and Settings within which to Conduct Work Advocate with National and State Leadership about the Importance of Rigorous Approach to Studying and Managing Behavioral Health Care Settings