1 the quality chasm in the behavioral health treatment for america's youth michael l. dennis,...

1

The Quality Chasm in the Behavioral Health Treatment For America's Youth

Michael L. Dennis, Ph.D. Chestnut Health Systems

Normal, IL

Presentation for the 26th Annual Children’s Mental Health Research & Policy Conference, Tampa, FL, Mark 3-6, 2013. Hosted by the University of South Florida’s The Department of

Child & Family Studies and The Institute for Translational Research in Adolescent Behavioral Health (National Institute of Drug Abuse Grant no. R25DA031103). This presentation uses

data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174,, CSAT contract no. 270-12-0397, Library of Congress contract no. LCFRD11C0007 and several public data sets.

The author would like to thank Christy Scott, Barb Estrada, Rodney Funk, Lilia Hristova, , Brook Hunter, Rachel Kohlbecker, Lisa Nicholson, and Belinda Willis for their assistance in

preparing this presentation. The opinions expressed are those of the author and do not reflect positions of the government. The presentation is available electronically at

www.chestnut.org/li/posters . Please address comments or questions to the author at [email protected] or 309-451-7801.

.p

http://www.chestnut.org/li/posters

mailto:[email protected]

2

The Goals of this Presentation are to Examine:

1. The quality chasm in behavioral health care, including the low rates of treatment access and engagement, including evidence of health disparities by gender, race, age and involvement in the juvenile justice system.

2. The prevalence and co-morbidity of internalizing and externalizing mental health disorders, substance use disorders, and crime/violence including how they vary with age

3. The general factors associated with better outcomes in terms of reduced mental health, substance use and illegal activities

Size & Overlaps of Mental Health and Substance Use Disorder Populations (in millions)

3

Any Comor-bid

Severe Treat-ment

Any Comor-bid

Severe Treat-ment

Mental Health

58 15 14 25

Substance

21 15 7 2

% MH

1 0.2586206896551

72

0.2413793103448

28

0.4310344827586

21

% SUD

1 0.7142857142857

14

0.3333333333333

33

0.0952380952380

952

1030507090

10%30%50%70%90%

Source: Institute of Medicine (2005) Improving the quality of health care for mental health and substance-use conditions. Crossing the Quality Chasm Series. Washington, DC: Author

Comorbidity 15% of those with MH but 71% of those with SUD

Very Low Rates of Treatment Participation

More MH than SUD

Quality Chasm in Treatment (in millions)

4

AnyTreatment

TreatmentCompliant

ActualComorbid

Identifiedin Practice

Getting ContinuingCare

AnyTreatment

TreatmentCompliant

ActualComorbid

Identifiedin Practice

Getting ContinuingCare

Mental Health

25 7.5 9.125 4.25 3.5

Substance

2 1 1.4 0.38 0.36

% MH

1 0.3 0.365 0.17 0.14

% SUD

1 0.5 0.7 0.19 0.18

5

15

25

35

45

10%

30%

50%

70%

90%

Source: Institute of Medicine (2005) Improving the quality of health care for mental health and substance-use conditions. Crossing the Quality Chasm Series. Washington, DC: Author

Low rates of Treatment Compliance

Low rates of Identifying Comorbidity

Low rates of Cont. Care

12 to 17 18 to 25 26 or older0%

5%

10%

15%

20%

25%

7.4%

20.1%

7.0%

0.4% 1.1% 0.6%

Abuse or Dependence in past yearTreatment in past year

Problems and Treatment Participation Rates Vary by Age

Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded

Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults

Potential to Improve Identification by Screening for SUD in more sites

Source: SAMHSA 2010. National Survey On Drug Use And Health, 2010 [Computer file]

SUD Tx

Det./Ja

il

Prob/

Parol

e

Hospt

ial

MH T

x

Emer

. Dep

t.

Wor

k

Schoo

l 0%

20%

40%

60%

80%

100%10

%

8%

15%

11% 23

%

49%

46%

95%

10%

8% 11%

11% 23

%

38%

80%

Adolescents Adults

% A

ny

Con

tact

ACA’s expansion of School Based Health Centers present a major opportunity to close the gap

Rise of Workplace Wellness programs with health risk assessments

Less than 80% of the Clients Engage in Treatment for 45 days or more (ONC measure of quality)

Total Outpatient Intensive Outpatient

Residential0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

68%74%

68%

48%

59%

72%

58%

28%

58%

73%

59%

29%

Adolescents Young Adults Adults

Source: Office of Applied Studies 2009 Discharge – Treatment Episode Data Set (TEDS)

Less than Half of the Clients Stay in Treatment the 90 days Recommended by Research

Source: Office of Applied Studies 2009 Discharge – Treatment Episode Data Set (TEDS)

Total Outpatient Intensive Outpatient

Residential0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

44%50%

40%

24%

38%

50%

32%

14%

39%

53%

34%

16%

Adolescents Young Adults Adults

Data on 29,782 clients from 230 local evaluations in2011 SAMHSA/CSAT GAIN Data Set

(89% with 1+ follow-up)

AK

AL

ARAZ

CA CO

CTDC

DE

FL

GA

HI

IA

ID

IL IN

KS KY

LA

MA

MD

ME

MI

MN

MO

MS

MT

NC

ND

NE

NH

NJ

NM

NV

NY

OH

OK

OR

PARI

SC

SD

TN

TX

UTVA

VT

WA

WI

WV

WY

PR

VI

GU

AAFTARTATDCATMBIRTCYTDCEATFDC

JTDCOJJDPORPRF-JDCSCYTCEYORP

Primary Substance by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

24% 25% 30% 33%

65% 63%40%

9%

Other Drug

Opioids

Amphetamines

Cocaine

Marijuana

Alcohol

SAMHSA 2011 GAIN Summary Analytic Data Set (n=27,716)

Past Year Substance Severity by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

41%49% 51% 48%

PY De-pendence

PY Abuse

PY Use

No PY Use


Tobacco Diagnosis by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

26%37%

49% 51%

Dependence/Daily Use

Current PY Use

Past Use

Never Used


Mental Health Disorders by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

33% 34% 31% 26% Both

Internalizing Disorders Only

Externalizing Disorders Only

Neither


Type of Crime by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45% 43%

27%

9%

Violent Crime*

Other Crime**

Drug Use only


* Violent crime includes assault, rape, murder, and arson.** Other crime includes vandalism, possession of stolen goods, forgery, and theft.

Severity of Victimization by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

39% 44%53% 59%

High Severity (4-15)

Moderate Severity (1-3)

Low Severity (0)


Homicidal/Suicidal Thoughts by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 3% 3%2% 3%

#REF!

#REF!

#REF!


Count of Major Clinical Problems at Intake

Other drug disorder

Cannabis disorder

Alcohol disorder

CD

ADHD

Depression

Trauma

Anxiety

Violence/ illegal activity

Victimization

Suicidial Thoughts

Major Clinical Problems*

0% 20% 40% 60% 80% 100%

34%

33%

21%

50%

43%

35%

25%

14%

79%62%

12%48% 13% 13% 11% 9% 6%

East

Five to Twelve

Four

Three

Two

One

Source: CSAT 2010 AT Summary Analytic Data Set (n=17,978)

Multiple Problems are the Norm Across All age Groups

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

45% 48% 46% 42%

Five to Twelve

Four

Three

Two

One

None


LowSeverity(OR=1.0)

ModerateSeverity(OR=5.1)

HighSeverity

(OR=15.2)

0%10%20%30%40%50%60%70%80%90%

100%

16%

49%

74%

None

One

Two

Three

Four

Five to Twelve

The Elephant in the Room is the Severity of Victimization

Source: CSAT 2010 AT Summary Analytic Data Set (n=18,120)

Environmental Strengths Index by Age

<15 15-17 18-25 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100% 5% 6% 11% 16%Low Strength(0-2)

Moderate Strength (3-5)

High Strength(12-16)


Unmet Need for Mental Health Treatment by 3 Months

<15 15-17 18-26 26+0%

10%20%30%40%50%60%70%80%90%

100%

72% 71%74%

53%

* p<.05

Age*

SAMHSA 2011 GAIN SA Data Set subset to has 3m Follow up (n=14,358)

Higher for Adolescents and

Young Adults

Unmet Need for Medical Treatment by 3 Months

<15 15-17 18-26 26+0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

54% 55%58% 45%

* p<.05 Age*SAMHSA 2011 GAIN SA Data Set subset to has 3m Follow up (n=8,517)

Significantly higher for Young Adults and Adolescents

Relative Percent Change in Abstinence (6 months minus intake/intake) by Age

<15 15-17 18-25 26+0%

10%20%30%40%50%60%70%80%90%

100%

62%51%

32%24%

SAMHSA 2011 GAIN SA Data Set subset to 6 Month Follow up (n=20,181)

Inta

ke

Las

t W

ave

Inta

ke

Las

t W

ave

Inta

ke

Las

t W

ave

Abstinence No Social Conseq.

No Justice Involv.

0%10%20%30%40%50%60%70%80%90%

100%

26+

18-25

15-17

<15

Change in GPRA Outcomes by Age (Intake to Last Wave*)

*Last wave is the last follow-up

SAMHSA 2011 GAIN SA Data Set subset to 1+ Follow ups

Inta

ke

Las

t W

ave

Inta

ke

Las

t W

ave

Inta

ke

Las

t W

ave

Housing Vocationally Engaged

Socially Connected

0%10%20%30%40%50%60%70%80%90%

100%

26+

18-25

15-17

<15

Change in GPRA Outcomes by Age (Intake to Last Wave*)

*Last wave is the last follow-up

SAMHSA 2011 GAIN SA Data Set subset to 1+ Follow ups

26

General Predictors of Bigger Effects

1. A strong intervention protocol based on prior evidence

2. Quality assurance to ensure protocol adherence and project implementation

3. Proactive case supervision of individual4. Triage to focus on the highest severity

subgroup

27

Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice

Studies in Lipsey Meta Analysis

Source: Adapted from Lipsey, 1997, 2005

Average Practice

The more features, the lower the recidivism

28

Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing

Juvenile Recidivism (29% vs. 40%)

• Aggression Replacement Training• Reasoning & Rehabilitation• Moral Reconation Therapy• Thinking for a Change• Interpersonal Social Problem Solving• MET/CBT combinations and Other manualized CBT• Multisystemic Therapy (MST)• Functional Family Therapy (FFT)• Multidimensional Family Therapy (MDFT)• Adolescent Community Reinforcement Approach (ACRA)• Assertive Continuing Care

Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004

NOTE: There is generally little or no differences in mean effect size between these brand names

29

Implementation is Essential (Reduction in Recidivism from .50 Control Group Rate)

The effect of a well implemented weak program is as big as a strong program implemented poorly

The best is to have a strong program implemented well

Thus one should optimally pick the strongest intervention that one can implement well

Source: Adapted from Lipsey, 1997, 2005

30

Change in Abstinence by level of Support: Adolescent Community Reinforcement

Approach (A-CRA)

4%

24%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Training Only Training, Coaching,Certification, Monitoring

% P

oin

t C

han

ge in

Ab

stin

ence

Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961)

Effects associated with Coaching, Certification

and Monitoring (OR=7.6)

Key Points to Take Away

• There is a major quality chasm in current practice that are even worse for adolescents and young adults

• Multiple co-occurring problems are the norm, vary in mix by age and heavily related to victimization and trauma

• The best predictors of outcome are the use of evidenced based assessment and practice that have worked for others, have strong quality assurance, strong case supervision, and good triage of services to well defined problems.

1 the quality chasm in the behavioral health treatment for america's youth michael l. dennis,...

Documents