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Evidence-Based Practices in Psychiatric Rehabilitation

Evidence-Based Practices in Psychiatric Rehabilitation. Bob Drake October, 2010. Financial Support to PRC. Grants from NIDA, NIDRR, NIMH, RWJF, SAMHSA

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Evidence-Based Practices in Psychiatric Rehabilitation

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  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 PracticesRobert 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.) 25 Randomized Controlled Trials ACT better than standard treatment ACT not better than standard treatment Number of Studies Time inHospital HousingStability Qualityof Life ClientSatisfaction Symptoms SocialFunctioning Vocational Jail/Arrests Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74.

  10. Days Homeless on Streets: ACT vs Usual Community Services 250 ACT Usual community services N=152 200 150 Days Homeless 100 50 0 FirstQuarter SecondQuarter ThirdQuarter FourthQuarter Lehman AF. Unpublished data.

  11. Current ACT Issues Hospital system changes Quality of usual services Forensic ACT Other expansions and components 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 40 IPS (n=74) EVR (n=76) 35 30 25 % Working in Competitive Jobs 20 15 10 5 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 Study Months Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.

  15. Current SE Issues Financing Cognitive strategies Effective specialists Disability reform

  16. Family Psychoeducation • Provided by professionals • Long-term (over 6 months) • Single and multiple familygroup formats • Focus on education, stress reduction, coping, and other support • Oriented toward future, not past

  17. Effects of Family Intervention on2-Year Relapse Rates (12 Studies) % Cumulative Relapse Rate Standard Care(n=203) Single FamilyTreatment(n=231) Multiple FamilyGroup Treatment(n=266) Single and MultipleFamily GroupTreatment(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 Effectiveness failure Family-to-family and alternatives

  19. Illness Management Training • Helping people learn to manage their own illnesses • Relapse prevention • Minimize the effects ofresidual symptoms

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

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

  22. Current IMR Issues More research Training Hard outcomes 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 DualDisorders Treatment 60 High-fidelity ACT programs (n=61) 50 Low-fidelity ACT programs (n=26) 40 30 % of Patients in Stable Remission 20 10 0 Baseline 6 12 18 24 30 36 Assessment Point McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824.

  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

  30. 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

  31. 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

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

  33. 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

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

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