1. Evidence-Based Practices in Psychiatric Rehabilitation Bob Drake October, 2010

2. Financial 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

3. OVERVIEW  Definition  Update on evidence-based practices  Common themes  Dissemination and implementation

4. History of Mental Health in U.S.  Cottage industry  Little attention to outcomes  Ineffective and harmful interventions persist for years  Effective interventions rarely used

5. Evidence-based Medicine  The combination of science, client values/preference, and clinical expertise  In mental health care, this means combining science and recovery ideology

6. Evidence-Based Practices  Standardized interventions  Controlled research  More than 1 research group  Objective outcome measures  Meaningful outcomes

7. Evidence-Based Rehabilitation Practices Robert Wood Johnson Foundation 1998  Assertive Community Treatment  Supported Employment  Family Psychoeducation  Illness Management and Recovery  Integrated Treatment for Co- occurring Disorders

8. Assertive Community Treatment (ACT)  Community-based team  Low caseload  Multidisciplinary  Outreach  Direct service provision  24 hours/7days

9. Research on ACT (cont.) Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74. ACT better than standard treatment ACT not better than standard treatment Time in Hospital Housing Stability Quality of Life Client Satisfaction SymptomsSocial Functioning VocationalJail/ Arrests Number of Studies 25 Randomized Controlled Trials

10. Days Homeless on Streets: ACT vs Usual Community Services 0 50 100 150 200 250 First Quarter Second Quarter Third Quarter Fourth Quarter ACT Usual community services N=152 Lehman AF. Unpublished data. Days Homeless

11. Current ACT Issues 1. Hospital system changes 2. Quality of usual services 3. Forensic ACT 4. Other expansions and components 5. Transitions

12. Supported Employment  Focus on competitive work  Rapid job search  De-emphasis on prevocational training and assessment  Attention to client preferences  Follow-along supports as needed

13. Supported Employment RCTs

14. Individual Placement and Support (IPS) vs Enhanced Vocational Rehabilitation (EVR) in Maintaining Competitive Jobs IPS (n=74) EVR (n=76) 40 35 30 25 20 15 10 5 0 181716151413121110987654321 Study Months % Working in Competitive Jobs Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.

15. Current SE Issues 1. Financing 2. Cognitive strategies 3. Effective specialists 4. Disability reform

16. Family 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

17. Effects of Family Intervention on 2-Year Relapse Rates (12 Studies) % Cumulative Relapse Rate Standard Care (n=203) Single Family Treatment (n=231) Multiple Family Group Treatment (n=266) Single and Multiple Family 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.

18. Current FPE Issues 1. Effectiveness failure 2. Family-to-family and alternatives

19. Illness Management Training  Helping people learn to manage their own illnesses  Relapse prevention  Minimize the effects of residual symptoms

20. Research on Illness Management Components  Psychoeducation increases knowledge and awareness  Behavioral tailoring increases effective use of medications  Warning sign recognition reduces relapses  Cognitive-behavioral treatment reduces residual symptoms

21. Social Adjustment* Outcomes: 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. 0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 0.9 IntakeYear 1Year 2Year 3 Years in Treatment Personal therapy (n=74) No personal therapy (n=77) p=.004 Effect Size on Social Adjustment

22. Current IMR Issues 1. More research 2. Training 3. Hard outcomes 4. Simplification

23. Integrated Dual Disorders Treatment  Mental health and substance abuse treatments combined by 1 team Assertive Stage-wise Individualized Comprehensive Long-term

24. ACT and Integrated Dual Disorders Treatment Assessment Point 0 10 20 30 40 50 60 Baseline61218243036 McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824. % of Patients in Stable Remission High-fidelity ACT programs (n=61) Low-fidelity ACT programs (n=26)

25. Current IDDT Issues 1. Standardization 2. Group and residential interventions 3. Supported employment 4. Staging 5. Simplification

26. Common Features of Evidence-Based Rehabilitation Practices  Shared decision making and choice  Individualization  Skills and supports in the community  Adult roles  Quality of life

27. Additional Rehabilitation Practices  Social skills training  Supported housing  Supported education  Integrated medical care  Trauma interventions

28. Dissemination and Implementation  Science to service gap  No simple solution for complex systems  Multiple strategies  Phases of implementation  All stakeholders  Fidelity

29. National 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

31. System 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

32. System 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

33. Current Concerns  Fidelity and outcomes  Access and acceptability  Durability  Multi-cultural services  Flexibility  Financing  Organization

34. Conclusions  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

35. Further Information  Patti O’Brien  Patti.O’Brien@Dartmouth.edu Patti.O’Brien@Dartmouth.edu  603-448-0263  www.mentalhealth.samhsa.gov