Adolescent Treatment EffectivenessWhat we have learned (so far)
Michael Dennis, Ph.D. Chestnut Health Systems, Normal, IL
Presentation at the Substance Abuse and Mental Health Services Administration Center for Substance Abuse Treatment
May 25, 2011, Rockville, MD
Goals
To take stock of how far we have come as a field, particularly in the last few years
To identify reoccurring themes that represent what we have learn (so far)
To focus on the road ahead
EarlyEarly Adolescent Treatment Work
Source: Dennis, M.L., Dawud-Noursi, S., Muck, R., & McDermeit, M. (2003)
Worth Street Narcotic Clinic in NY – 743 youth
Federal Narcotic Farms in Lexington, KY & Fort Worth, TX 440/yr
Riverside Hospital in NYC – 250 youth
Teen Addiction Hospital Wards in several cities
Drug Abuse Reporting Program (DARP)- 5,405 youth (587 followed)
Treatment Outcome Prospective Study (TOPS)-1042 youth (256 followed)
Services Research Outcome Study (SROS) - 156 youth
1910
1920
1930
1940
1950
1960
1970
1980
1990
1996
National Treatment Improvement Evaluation Study (NTIES) - 236 youth
Drug Abuse Treatment Outcome Study of Adolescents (DATOS-A) - 3,382 youth (1,785 followed)
What these early studies taught us
• Treatment of adolescents with adult models and/or mixed with adults does not work and is actually associated with drop out and increased use
• Need to modify models to be more developmentally appropriate for youth
• Need for assess and treat a wider range of problems including victimization, co-occurring mental health and education needs
• Need to modify materials to be more concrete and use examples relevant to youth
Major limits through 1997
• Lack of standardized and evidenced based assessment and treatment limited the reliability of what was done
• Participation, treatment completion, and followup rates were often low limiting the validity of what could be learned
• The lack of any manualized evidenced based adolescent approaches limited the ability to disseminate and replicate what did work
• Difficult for clinicians, evaluators and/or researchers to work together or even enter the field
6
CSAT’s 10+ Year Investment in ImprovingAdolescent Treatment Effectiveness
• 1997-2001, Cannabis Youth Treatment (CYT) – 600 youth• 1998-2001, Adolescent Treatment Models (ATM) -1334 youth• 1998-2004, CSAT/NIAAA experiments – several hundred youth • 2000-2002, Persistent Effects of Treatment Study of Adolescents (PETS-A) - 1200 youth• 2001-2003, CSAT/RWJF Reclaiming Futures, 445 youth• 2002-2007, Strengthening Communities for Youth (SCY) – 2,249 youth• 2002-2012, Targeted Capacity Expansion (TCE) – 1,417 youth• 2003-2006, Adolescent Residential Treatment (ART) – 1,458 youth• 2003-2007, Effective Adolescent Treatment (EAT) – 5,854 youth• 2004-2009, Co-occurring State Infrastructure Grants (COSIG) -system• 2004-2009, Young Offender Re-entry Program (YORP) – 1,597 youth• 2005-2008, State Adolescent Coordinator (SAC) -system• 2005-2010, Juvenile Treatment Drug Court (JTDC) – 1,678 youth• 2006-2010, Adolescent Assertive Family Tx (AAFT)-2,769 youth• 2007-2011, Brief Interventions and Referrals to Treatment (BIRT) and other Office of Juvenile Justice and Delinquency Prevention and Robert Woods Johnson Foundation (OJJDP/RWJF)- 315 youth• 2010- Currently working to extend work in collaboration with CSAP, ED, DOL, HRSA, and OJJDP
Big Changes
• Over 80% participation, use of evidenced based assessment, use of evidenced based intervention, and follow-up
• Have pooled data from 21,531 adolescents (12-17), 3,153 young adults (18-25) and 1,695 adults (26+) assessed with the Global Appraisal of Individual Needs (GAIN), including 88% with one more follow-up
• Data made available for program evaluation and secondary analysis, and helped to generate over 200 publications
• Have supported the creation and evaluation of over 20 adolescent treatment manuals
• Several System level grants
Big Changes - Continued
• Funded large scale replications of three major evidenced based practices– Motivational Enhancement Therapy/ Cognitive Behavior
Therapy (MET/CBT) in the 36 site EAT program and multiple independent grants
– Adolescent Community Reinforcement Approach (A-CRA) and Assertive Continuing Care (ACC) in the 78 Site AAFT program and multiple independent grants
• Also funded multiple state and independent grants to replicate other evidenced based practices including– Family Support Network (FSN)– Motivational Interviewing– Multidimensional Family Therapy (MDFT)– Multi-Systemic Therapy (MST)– Seven Challenges (7C)
9
CSAT Sites with adolescent clients 12-17 and included in the 2009 Summary Analytic GAIN Data Set
AK
ALAR
AZ
CACO
CTDC
DE
FL
GA
HI
IA
ID
ILIN
KSKY
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
VTWA
WI
WV
WY
PRVI
JTDCOJJDP
ATM
TCE
AAFT
CYT
ART
EAT
OJJDP-BIRTSCY
YORP
10
Demographic Characteristics
*Any Hispanic ethnicity separate from race group
51%
82%
33%
39%
26%
18%
18%
16%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Single Parent
15 to 17 Years Old
12 to 14 Years Old
Hispanic*
Mixed/Other
Caucasian
African American
Female
CSAT data is diverse with
large numbers of females
minorities, and younger
adolescents
Sources: CSAT 2009 SA data set Adolescent Subset (n=19,145).
11
Youth are involved in multiple systems placing competing demands on them and potentially in
conflict with each other
9%
22%
33%
40%
68%
73%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Employed
Controlled environment
Prior Substance Abuse Treatment
Prior Mental Health Treatment
Current justice system involvement
In School
Source: CSAT 2009 SA Data Set Adolescent Subset (n=19,108)
12
Multiple Clinical Problems are the NORM!
20%
41%
80%
48%
33%
63%
11%
24%
14%
34%
27%0% 10
%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Alcohol
Cannabis
Other drug disorder
Depression
Anxiety
Trauma
ADHD
CD
Suicide
Victimization
Violence/ illegal activity
Source: CSAT 2009 Summary Analytic Data Set (n=20,826)
13
The Number of Clinical Problems is related to Level of Care
41% 45%53%
65%
80%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Outpatient IntensiveOutpatient
OP Cont.Care
Long TermResid.
Short TermResid.
None
One
Two
Three
Four
Five Plus
Source: CSAT 2009 Summary Analytic Data Set (n=21,332)
Significantly more likely to
have 5+ problems (OR=5.8)
14
46%
71%
15%0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Low (0) Moderate (1-3) High (4-15)
None
One
Two
Three
Four
Five to Twelve
The Number of Major Clinical Problemsis highly related to Victimization
Source: CSAT 2009 Summary Analytic Data Set (n=21,784)
Significantly more likely to
have 5+ problems (OR=13.9)
15
Past 90 day HIV Risk Behaviors are more Related to Sexual Activity than Needle Use
63%
2%
20%
19%
26%
30%
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Sexually Active
Multiple Sex Partners
Any Unprotected Sex
High Risk Sex*
Victimized
Any Needle Use
*Based on 1+ times had sex while intoxicated, with an injection drug user, with a man who had sex with men, with someone who was HIV positive, or traded sex for goods (n=415)
Source: CSAT 2009 SA Data Set Adolescent Subset (n=18,674)
Also important to recognize the role of
interpersonal violence as a HIV risk factor – particularly for girls
Individual Strengths
89%
44%
33%
73%
73%
67%
59%
59%
49%
75%
6.20
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Avearge No. of Strenths (0-10)
0 2 4 6 8 10
Doing well at close friends
Listening, caring or comm. w/ others
Sports, exercise, physical activity
Doing well at with your family
Problem solving and figuring things out
Drawing, painting, design or other art
Doing well at school or training
Working or playing with computers
Music, dancing, acting, other perf. art
Doing well at work
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
Sources of Social Support
90%85%
79%77%77%71%
71%57%
53%6.57
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Average No. of Sources (0-9)
0 2 4 6 8
Doing well at close friends
Listening, caring or comm. w/ others
Sports, exercise, physical activity
Doing well at with your family Problem solving and figuring things out
Drawing, painting, design or other art
Doing well at school or training
Working or playing with computers Music, dancing, acting, other perf. art
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
18
Potential Mentors in the Recovery Environment
52%
75%
25%
18%
58%
41%
30%
16%
63%
46%
29%
16%
4.6
0% 10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
None involved in fighting
None involved in illegal activity
Been in treatment
Currently in recovery
Average Attributes (0-12)
0 2 4 6 8 10 12
Hom
eS
choo
l or
Wor
kS
ocia
l P
eers
Source: SAMHSA/CSAT 2009 adolescent data set (n=6,681)
Major Predictors of Bigger Effects Found in Multiple Meta Analyses (Lipsey, 1997, 2005)
1. A strong intervention protocol based on prior evidence
2. Quality assurance to ensure protocol adherence and project implementation
3. Proactive case supervision of individual
4. Triage to focus on the highest severity subgroup
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
Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in
Reducing Juvenile Use & Recidivism
• Adolescent Community Reinforcement Approach (A-CRA)• Aggression Replacement Training (ART)• Assertive Continuing Care (ACC)• Cognitive Behavior Therapy (CBT)• Functional Family Therapy (FFT)• Moral Reconation Therapy (MRT)• Thinking for a Change (TFC)• Interpersonal Social Problem Solving (ISPS)• Motivational Interviewing (MI)
Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004
Evidenced Based Treatment (EBT) that Typically do Better than Usual Practice in
Reducing Juvenile Use & Recidivism
• Motivational Enhancement Therapy/Cognitive Behavior Therapy (MET/CBT)
• Multi Systemic Therapy (MST)• Multidimensional Family Therapy (MDFT)• Reasoning & Rehabilitation (RR)• Seven Challenges (7C)
Source: Adapted from Lipsey et al 2001, 2010; Waldron et al, 2001, Dennis et al, 2004
No evidence of an iatrogenic effect of group treatment
Small or no differences in mean effect size between these brand names
Other Common Findings
Low structure and ad hoc “treatment as usual” does not do as well as evidenced based practice
Wilderness programs have mixed effects
Treating adolescents like adults and in boot camp causes harm on average
Relapse is still common and there is a need for on-going support, monitoring and when necessary re-intervention
Similarity of Clinical Outcomes : Cannabis Youth Treatment (CYT)
Source: Dennis et al., 2004
200
220
240
260
280
300
Tot
al d
ays
abst
inen
t.
over
12
mon
ths
0%
10%
20%
30%
40%
50%
Per
cent
in R
ecov
ery
. at
Mon
th 1
2
Total Days Abstinent* 269 256 260 251 265 257
Percent in Recovery** 0.28 0.17 0.22 0.23 0.34 0.19
MET/ CBT5 (n=102)
MET/ CBT12
FSN (n=102)
MET/ CBT5 (n=99)
ACRA (n=100)
MDFT (n=99)
Trial 1 Trial 2
* n.s.d., effect size f=0.06** n.s.d., effect size f=0.12
* n.s.d., effect size f=0.06 ** n.s.d., effect size f=0.16
Not significantly different by condition.
But better than the average for OP in ATM (200 days of
abstinence)
Moderate to large differences in Cost-Effectiveness by Condition
Source: Dennis et al., 2004
$0
$4
$8
$12
$16
$20
Cos
t per
day
of
abst
inen
ce o
ver
12 m
onth
s
$0
$4,000
$8,000
$12,000
$16,000
$20,000
Cos
t per
per
son
in r
ecov
ery
at m
onth
12
CPDA* $4.91 $6.15 $15.13 $9.00 $6.62 $10.38
CPPR** $3,958 $7,377 $15,116 $6,611 $4,460 $11,775
MET/ CBT5
MET/ CBT12
FSN MET/ CBT5
ACRA MDFT
* p<.05 effect size f=0.48** p<.05, effect size f=0.72
Trial 1 Trial 2
* p<.05 effect size f=0.22 ** p<.05, effect size f=0.78
MET/CBT5 and 12 did better
than FSN
ACRA did better than MET/CBT5, and both did better than MDFT
Suggest the need to consider cost-effectiveness of treatment approaches
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 wellSource: Adapted from Lipsey, 1997, 2005
27
Change in Abstinence by level of Quality Assurance: 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)
Which general approaches address co-occurring mental health/trauma issues?
• Nine Treatment Outpatient Approaches • Seven Challenges (Schwebel, 2004) (n=114)• Chestnut Health Systems (CHS; Godley et al. 2002)
Treatment (n=192)• Adolescent Community Reinforcement Approach (A-CRA;
Godley et al., 2001) -CYT/AAFT (n=2144) and -Other (n=276)• Multi-Systemic Therapy (MST; Henggeler et al., 1998)
(n=85)• Multi-Dimensional Family Therapy (MDFT; Liddle, 2002)
(n=258)• Motivational Enhancement Therapy-Cognitive Behavior
Therapy (METCBT; Sampl & Kadden, 2001)-CYT/EAT (n=5262) and -Other (n=878)
• Family Support Network (FSN; Hamilton et al., 2001) (n=369)
28
Two sets of outcomes
• Mental Health• Emotional Problems Scale • Days of Victimization • Days of Traumatic Memories• Other Outcomes• Substance Problems Scale • Substance Frequency Scale • Illegal Activities Scale • HIV Risk Change Index • Average Across
29
Change (post-pre) Effect Size for Emotional Problems by Type of Treatment
-0.5
4
-0.4
3
-0.4
5 -0.3
9
-0.3
7
-0.3
7
-0.3
4 -0.2
9
-0.2
9
-0.1
8
-0.2
8
-0.1
9
-0.3
2
-0.1
9
-0.1
5
-0.2
1 -0.1
3 -0.0
8
-0.0
8
-0.0
9
-0.1
4
-0.2
2
-0.0
4
-0.1
3
-0.1
2 -0.0
8
-0.1
6
-0.80
-0.60
-0.40
-0.20
0.00
0.20
SevenChallenges
(n=114)
CHSTreatment(n=192)
A-CRA-CYT/AAFT
(n=2144) MST(n=85)
MDFT(n=258)
METCBT-CYT/EAT(n=5262)
METCBT-Other
(n=878) FSN
(n=369)
A-CRA-Other
(n=276)
Cha
nge
Eff
ect S
ize
d ((
mea
n fo
llow
-up
- m
ean
inta
ke)/
std
dev
. int
ake)
Emotional Problem Scale Days of traumatic memories Days of victimization
Four best on mental health outcomes include 7 challenges,
CHS, A-CRA, & MST
Change (post-pre) Effect Size for Core Treatment Outcomes by Type of Treatment
-0.5
4
-0.4
3
-0.4
5 -0.3
9
-0.3
7
-0.3
7
-0.3
4 -0.2
9
-0.2
9
-0.6
2
-0.6
5
-0.4
3
-0.4
5
-0.5
0
-0.3
8 -0.3
3
-0.4
7
-0.3
6-0.3
0
-0.3
7
-0.4
2
-0.4
3 -0.3
8 -0.3
3 -0.2
6
-0.5
1
-0.4
8
-0.1
5 -0.1
1
-0.2
8
-0.3
9
-0.3
8
-0.1
7
-0.1
9
-0.2
9 -0.2
3
0.00 0.
04
-0.2
3
-0.3
8
-0.1
8 -0.1
1
-0.1
7
-0.3
0
-0.1
8
-0.3
2
-0.3
0
-0.3
6
-0.4
1 -0.3
6
-0.2
7
-0.2
6
-0.3
7 -0.3
1
-0.80
-0.60
-0.40
-0.20
0.00
0.20
SevenChallenges
(n=114)
CHSTreatment(n=192)
A-CRA-CYT/AAFT
(n=2144) MST(n=85)
MDFT(n=258)
METCBT-CYT/EAT(n=5262)
METCBT-Other
(n=878) FSN
(n=369)
A-CRA-Other
(n=276)
Cha
nge
Eff
ect S
ize
d ((
mea
n fo
llow
-up
- m
ean
inta
ke)/
std
dev
. int
ake)
Emotional Problem Scale Substance Problem Scale Substance Frequency Scale
HIV Risk Scale Illegal Activity Scale Average
Four best on treatment outcomes include A-CRA, MST, MDFT, & FSN
Findings
• All programs reduced mental health / trauma problems with 4 doing particularly well: 7 challenges, CHS, A-CRA, & MST
• All programs reduced general outcomes on average, with 4 doing particularly well: A-CRA, MST, MDFT, FSN
– All more assertive/family/systemic programs – All have formal training, quality assurance, monitoring &
technical assistance• Where we could break in two (A-CRA & MET/CBT), programs
with more training, quality assurance, monitoring and technical assistance did better than those with less
• A-CRA with a mix of BA/MA did as well as MST which targets MA level therapists and family therapists that are often in short supply
• While it is not as effective, the shortest & least expensive (MET/CBT5) still has positive effects
• CSAT Funding large scale dissemination of A-CRA • and MET/CBT 32
Adolescents Have Complex Pathways to Recovery
In the Community
Using (60% stable)
In Treatment (45% stable)
In Recovery (61% stable)
Incarcerated(41% stable)
Source: 2009 CSAT AT data set; unique n = 11,710
Avg of 48% change status each quarter
18%
16%
22%17%
27%
14%
17%
24%
21%9 %
4%4%
Treatment is the most likely path
to recovery
What predicts who enters and maintains
recovery?
Change occurs in ever possible direction
Risk and Protective Factors Associated with Transitioning to/Remaining in Recovery
• Risk Factors– Older – Male– Caucasian– Substance Problems – Substance Frequency– Repeated Treatment– Mental Health Problems– Illegal Activity– Employment
• Protective Factors– Younger– Female– Racial Minority – Recent Treatment – Number of Drug Screens– Attend 12 Step Meetings– Positive Social Peers– Positive Recovery
Environment– School Attendance/ Conduct
Source: 2009 CSAT Adolescent Treatment Dataset
Recovery* by Level of Care
•Recovery defined as no past month use, abuse, or dependence symptoms while living in the community. Percentages in parentheses are the treatment outcome (intake to 12 month change) and the stability of the outcomes (3months to 12 month change) Source: CSAT Adolescent Treatment Outcome Data Set (n-9,276)
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Pre-Intake Mon 1-3 Mon 4-6 Mon 7-9 Mon 10-12
Per
cent
in P
ast
Mon
th R
ecov
ery* Outpatient (+79%, -1%)
Residential(+143%, +17%)
Post Corr/Res (+220%, +18%)
OP & Resid
Similar
CC better
Time to Enter Continuing Care and Relapse after Residential Treatment (Age 12-17)
Source: Godley et al., 2004 for relapse and 2000 Statewide Illinois DARTS data for CC admissions
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0 10 20 30 40 50 60 70 80 90
Days after Residential (capped at 90)
Per
cen
t of
Clie
nts
Cont.CareAdmis.
Relapse
Assertive Continuing Care (ACC) can Improved General Aftercare Adherence
Source: Godley et al 2002, 2007
0% 10%
20%
30%
40%
50%
60%
70%
80%
Weekly Tx Weekly 12 step meetings
Regular urine tests
Contact w/probation/school
Follow up on referrals*
ACC * p<.05
90%
100%
Relapse prevention*
Communication skills training*
Problem solving component*
Meet with parents 1-2x month*
Weekly telephone contact*
Referrals to other services*
Discuss probation/school compliance*
Adherence: Meets 7/12 criteria*
UCC
High GCCA Improves Early (0-3 mon.) Abstinence
Source: Godley et al 2002, 2007
24%
36% 38%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Any AOD (OR=2.16*) Alcohol (OR=1.94*) Marijuana (OR=1.98*)
Low (0-6/12) GCCA
43%
55% 55%
High (7-12/12) GCCA * p<.05
0%10%20%30%40%50%60%70%80%90%
100%Pr
e-co
ntro
lled
envi
ronm
ent
Rele
ase
(initi
al)
3m 6m
<18 years18-25 years26+ years
Percent of Days Abstinent from AOD in Offender Re-entry Programs by Age
Source: CSAT 2010 SA Horizontal, YORP and ORP studies only (N = 2,966)
Limit of current GPRA, starts measurement at release and does not control for or even measure time in a
controlled environment
Comparison of Treatment Outcomes: Adolescent Outpatient (AOP) vs.
Juvenile Treatment Drug Court (JTDC)
Source: Ives et al., in press *p<.05 change greater for JTDC vs AOP (d=-0.24)
0
5
10
15
20
25
30
35
Inta
ke
6 m
onth
s*
Inta
ke
6 m
onth
s*
Inta
ke
6 m
onth
s*
Inta
ke
6 m
onth
s*
Inta
ke
6 m
onth
s*
Day
s ou
t of
90
Day
s AOP Weighted(n=1120) JTDC(n=1120)
Substance Use*
( d=-0.45, -0.57)
Emotional Problems
(d=-0.32, -0.22)
Trouble w/ Family
(d= -0.23, -0.18)
In Controlled Environment
(d=-0.02, -0.08)
Illegal Activity
(d=-0.11, -0.02)
Post-Pre d (AOP, JTDC)
JTDC Reduced Use More than AOP
(d between= -0.24)
Others Outcomes Not Significantly Different
Outcome Data has also been used to make comparison groups for
• GPRA, NOMS and other outcomes by gender, race, age, level of care, type of evidenced based practice, and program
• CYT interventions vs. regular outpatient treatment• Post residential treatment recovery support services vs.
aftercare as usual• Opioid Users vs. Alcohol/Marijuana Users• Transitional Age Youth vs. adolescents & adults• Impact of experience and certification on GAIN quality• Deaf and hard of hearing vs. hearing• Gender, Race and Ethnicity differences• in the response to A-CRA
$407$1,249$1,132$1,384$2,486$2,907$4,277
$10,228$14,818
$0 $10,
000
$20,
000
$30,
000
$40,
000
$50,
000
$60,
000
$70,
000
Screening & Brief Inter.(1-2 days)In-prison Therap. Com. (28 weeks)
Outpatient (18 weeks)Intensive Outpatient (12 weeks)
Treatment Drug Court (46 weeks)Residential (13 weeks)
Methadone Maint. (87 weeks)Adol. Residential (13 weeks)Therapeutic Com. (33 weeks)
Source: French et al., 2008; Chandler et al., 2009; Capriccioso, 2004
Cost of Substance Abuse Treatment Episode
$22,000 / year to incarcerate
an adult
$30,000/ child-year in foster care
$70,000/year to keep a child in
detention
• $750 per night in Detox• $1,115 per night in hospital • $13,000 per week in intensive care for premature baby• $27,000 per robbery• $67,000 per assault
Many SBIRT, School, Workplace and other early
intervention programs focus on brief intervention
Quarterly Costs to Society* associated with higher intensity of justice system involvement
$10,149
$6,746
$4,065
$2,633
$2,410
$2,544
$1,832$0
$2,0
00
$4,0
00
$6,0
00
$8,0
00
$10,
000
$12,
000
$14,
000
AverageQuarterlyCosts toSociety(Prior toIntake)
Past year illegal act
Past JJ status
Other JJ status
Other prob/ parole/detention
Prob/parole 14+ daysw/ 1+ drug screens
Detention 14-29 days
Detention 30+ days
Source: SAMHSA/CSAT 2009 adolescent data set (n=17,335) in 2009 dollars
Investing in Treatment has a Positive Annual Return on Investment (ROI)
• Substance abuse treatment has been shown to have a ROI of between $1.28 to $7.26 per dollar invested
• Treatment drug courts have an average ROI of $2.14 to $2.71 per dollar invested
Source: Bhati et al., (2008); Ettner et al., (2006)
This also means that for every dollar treatment is cut, we lose more money than we saved.
SAMHSA/CSAT’s Adolescent Clients• Data were pooled on clients from 148 local evaluations,
recruited between 1997 to 2009 and followed quarterly for 6 to 12 months (over 80% completion).
• In 2009 dollars, the 16,915 adolescents averaged $3,908 in costs to taxpayers in the 90 days before intake ($15,633 in the year before intake).
• This would be $3.9 Million per 1,000 adolescents served.• Within 12 months, the cost of treatment provided by CSAT
grantees was offset by reductions in other costs producing a net benefit to taxpayers of $4,592 per adolescent.
Economic Benefit to Society of SAMHSA/CSAT Funded Treatment by Level of Care
Adolescent Level of Care
Year before intake
Year after
Intakea
One Year
Savingsb
Outpatient $10,993 $10,433 $560
Intensive Outpatient $20,745 $15,064 $5,682
Outpatient Continuing Care $34,323 $17,000 $17,323
Long Term Residential $27,489 $26,656 $833
Short Term Residential $25,255 $21,900 $3,355
Total $15,633 $13,642 $1,992
\a Includes the cost of treatment\b Year after intake (including treatment) - year before treatment
In practice we need a Continuum of Measurement (Common Measures)
• Screening to Identify Who Needs to be “Assessed” (5-10 min)– Focus on brevity, simplicity for administration & scoring– Needs to be adequate for triage and referral– GAIN Short Screener for SUD, MH & Crime– ASSIST, AUDIT, CAGE, CRAFT, DAST, MAST for SUD– SCL, HSCL, BSI, CANS for Mental Health– LSI, MAYSI, YLS for Crime
• Quick Assessment for Targeted Referral (20-30 min)– Assessment of who needs a feedback, brief intervention or referral for more
specialized assessment or treatment– Needs to be adequate for brief intervention– GAIN Quick – ADI, ASI, SASSI, T-ASI, MINI
• Comprehensive Biopsychosocial (1-2 hours) – Used to identify common problems and how they are interrelated– Needs to be adequate for diagnosis, treatment planning and placement of
common problems– GAIN Initial (Clinical Core and Full)– CASI, A-CASI, MATE
• Specialized Assessment (additional time per area)– Additional assessment by a specialist (e.g., psychiatrist, MD, nurse, spec ed)
may be needed to rule out a diagnosis or develop a treatment plan or individual education plan
– CIDI, DISC, KSADS, PDI, SCAN
Screener Quick C
omprehensive S
pecial
More E
xtensive / Longer/ E
xpensive
Longer assessments identify more areas to address in treatment planning
40%
69%
94%98%
22%
13%
3% 0%
22%
8%
1% 0%
9%8%
1% 1%3% 1% 1%7%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
GAIN SS GAIN Q(v2)
GAIN Q(v3 -Beta)
GAIN I
0 Reported
1 Prob.
2 Probs.
3 Probs.
4 Probs.
Source: Reclaiming Futures Portland, OR and Santa Cruz, CA sites (n=192)
Most substance users have multiple problems
5 min. 20 min 30 min 1-2 hr
Source: 2008 CSAT AAFT Summary Analytic Dataset
553/771=72%unmet need
218/224=97% to targeted
771/982=79% in need
Importance of Targeting on Performance Measures
Size of the Problem
Extent to which services are currently being targeted
Extent to which services are not reaching those in most need
Treatment Received in the first 3 months
Mental Health Need at Intake
No/Low Mod/High Total
Any Treatment 6 218 224
No Treatment 205 553 758
Total 211 771 982
Mental Health Problem (at intake) vs. Any MH Treatment by 3 months
79%
97%
72%
0%10%20%30%40%50%60%70%80%90%
100%
% of Clients WithMod/High Need
(n=771/982)*
% w Need but No ServiceAfter 3 months
(n=553/771)
% of Services Going toThose in Need(n=218/224)
Source: 2008 CSAT AAFT Summary Analytic Dataset
Why Do We Care About Unmet Need?
• If we subset to those in need, getting mental health services predicts reduced mental health problems
• Both psychosocial and medication interventions are associated with reduced problems
• If we subset to those NOT in need, getting mental health services does NOT predict change in mental health problems
Conversely, we also care about services being poorly targeted to those in need.
Residential Treatment need (at intake) vs. 7+ Residential days at 3 months
36%
52%
90%
0%10%20%30%40%50%60%70%80%90%
100%
% of Clients WithMod/High Need
(n=349/980)*
% w Need but NoService After 3 months
(n=315/349)
% of Services Going toThose in Need (n=34/66)
Opportunity to redirect
existing funds through better
targeting
Source: 2008 CSAT AAFT Summary Analytic Dataset
AK
ALAR
AZ
CACO
CTDC
DE
FL
GA
HI
IA
ID
IL IN
KS KY
LA
MA
MD
ME
MIMN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PARI
SC
SD
TN
TX
UTVA
VTWA
WI
WV
WY
CSAT
2010 SAMHSA/CSAT Grantee Data Set(185 sites)
23 Programs185 Sites
26,390 clients
PR
VI
AK
AL
ARAZ
CACO
DC
FL
GA
HI
IA
ID
IL IN
KS KY
LA
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NM
NV
NY
OH
OK
OR
PA
SC
SD
TN
TX
UT
VA
VTWA
WI
WV
WY
CSAT Other 2011
Expanded Data Set (2010 CSAT + 120 Other Sites)
50 Programs305 Sites
58,934 clients
PR
VI
CT
DE
MA
MD
NJ
RI
2011 Expanded Data Set
Age 11-17 (N=34,627)
18-25 (N=8,746)
26+ (N=14,805)
Total (N=58,934)
Female 28% 38% 45% 34%
Minority 58% 44% 45% 52%Prior Treatment 29% 49% 66% 42%
First use under 15 82% 59% 46% 69%Ever Homeless 10% 28% 44% 21%Any Victimization 52% 63% 68% 6%Veteran 0% 1% 6% 2%
More in BZ, CA, CN, JP, MX
ID
ILMO
ND
VI
ME
OK
PR
SD
AR
KS
MS
MT
NM
WVIN
AL
AK
IA
MN
NJNV
RI
SC
UT
HI
LA
DENE
TN
PA
VT
VADC
MI
COKY
GA
OH
OR
MD
AZ
TX
NY
NH
WI
CA
NC
CT
FL
MA
WA
WY
No. of GAIN Sites
None (Yet)
1 to 14
15 to 30
31 to 165
All GAIN Collaborators in the U.S (1700 agencies in 48 states, 6 Canadian provinces and 6 other contries)
State or Regional System
GAIN Short Screener
GAIN Quick
GAIN Full
3/10 56
Recent Initiatives
• 2 page GAIN short screener already implemented in a dozen states, translated into 19 languages and spreading fast
• Using web-based GAIN & ACRA training modules to reduced the duration of off-site training, to provide support for local trainers to train new staff, and to be used in college course to prepare the work force coming out
• Computer based support for clinical decision making related to diagnosis, treatment planning, and placement using narrative and graphical reports
• Up grading site profiles to more closely reflect the individual reports so that clinicians and evaluators are speaking the same language
• GAIN evaluation manual and training to help local evaluators and others interested in secondary analysis use the data at the program or group level
• Linkage to multiple HIT systems
Recent Initiatives (Continued)
• Monitoring assessment and treatment sessions to measure and improve fidelity
• Randomized trial of therapist performance incentives to improve implementation/fidelity and client outcomes
• Expansion of A-CRA/ACC modules targeting trauma and HIV risk behaviors• Addition of A-CRA/ACC supervisor training• Analysis of health disparities by gender, race, age, pregnancy, and
disabilities• Multi-cultural training on how to adapt training and assessment to better
serve clientele• Revisions to GAIN Quick (25-30 min) to better support screening, brief
intervention, and referral to treatment in behavioral health settings (e.g., SAP, EAP,DCF, Justice) where there are health, stress, mental health, substance use and crime/violence issues
New Initiatives
• Testing the GAIN Q in school and justice settings• Testing ability to recruit, train and certify staff on GAIN & A-CRA
with incentives but without SAMHSA/CSAT grants to demonstrate the feasibility of transferring the technology to state and local governments
• Doing reviews of school based behavioral health intervention research in the literature and in SAMHSA/CSAT demonstrations to understand how they are similar/different from community based adolescent treatment
• Created a CSAT + non-CSAT analytic file that can be used to better understand the needs of smaller groups (e.g. Emerging adults, Mixed Race, Vets, GLBTQ)
• Demonstrate the feasibility of using the web-based training modules as part of College Courses to better prepare the work force
Potential AOD Screening & Intervention Sites for Adolescents Age 12 to 17
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
4% 0%
29%
5% 1%
34%
96%
8% 3%
45%
93%
9% 12%
43%
95%
90%
0%10%20%30%40%50%60%70%80%90%
100%
Hosptial SubstanceAbuse Tx
EmergencyDept.
School
% A
ny
Con
tact
No use in past yearLess than weekly useWeekly UseAbuse or dependence
Key potential of School Based Health Clinics being expand under health care reform
Why Schools Care
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
17%
13%
5% 5%
2%
30%
18%
4%
10%
6%
32%
22%
8%
12%
7%
28%
27%
9% 9%
5%
40%
31%
13% 16
%
9%
41%
41%
19% 21
%
13%
0%
10%
20%
30%
40%
50%
60%
10 or MoreArguments with
Parents
Disliked School GPA = D orlower
MajorDepression
Any MHTreatment
No PY AOD Use (64.3%) Light Alc Use (12.4%)
Any Drug or Heavy Alc Use (8.8%) Weekly AOD Use (6.4%)
Abuse (4.2%) Dependence (3.9%)
Substance use severity is related to family, school and
emotional problems
Why Society Cares if we fail to help in School
Source: SAMHSA 2006. National Survey On Drug Use And Health, 2006 [Computer file]
18%
12%
0%
5%
2% 2% 1%
21%
15%
1%
6%
4% 3% 3%
28%
22%
3%
11%
7%
3%
5%
36%
29%
12%
17%
12%
8%
11%
42%
39%
14%
20%
18%
9%
15%
48%
40%
34%
27%
27%
13%
23%
0%
10%
20%
30%
40%
50%
60%
SeriousFight AtSchool
Fightingwith Group
Sold Drugs Attackedwith intent
to harm
Stole(>$50)
CarriedHandgun
Any Arrests
No PY AOD Use (64.3%) Light Alc Use (12.4%)
Any Drug or Heavy Alc Use (8.8%) Weekly AOD Use (6.4%)
Abuse (4.2%) Dependence (3.9%)
Substance use severity is related to crime and violence
Evidenced Based Practices You Can Use Now
• General approaches to adolescent substance abuse treatment at www.chestnut.org/li/apss or http://www.nrepp.samhsa.gov/
• Guidance for ambulatory/outpatient detoxification at http://www.aafp.org/afp/2005/0201/p495.html
• Trauma informed therapy and sucide prevention at http://www.nctsn.org/nccts and http://www.sprc.org/
• Externalizing disorders medication & practices http://systemsofcare.samhsa.gov/ResourceGuide/ebp.html
• Tobacco cessation protocols for youth http://www.cdc.gov/tobacco/quit_smoking/cessation/youth_tobacco_cessation/index.htm
• HIV prevention with more focus on sexual risk and interpersonal victimization at http://www.who.int/gender/violence/en/ or http://www.effectiveinterventions.org/en/home.aspx
• For individual level strengths see http://www.chestnut.org/li/apss/CSAT/protocols/index.html
• For improving customer services http://www.niatx.net
Acknowledgement and Contact Information
• Borrowed slides from earlier presentations by myself, Randy Muck & Doreen Cavanaugh• This presentation was supported by analytic runs provided by Chestnut Health Systems for the
Substance Abuse and Mental Health Services Administration's (SAMHSA's) Center for Substance Abuse Treatment (CSAT) under Contracts 207-98-7047, 277-00-6500, 270-2003-00006 and 270-2007-00004C using data provided by the following 152 grantees: TI11317 TI11321 TI11323 TI11324 TI11422 TI11423 TI11424 TI11432 TI11433 TI11871 TI11874 TI11888 TI11892 TI11894 TI13190TI13305 TI13308 TI13313 TI13322 TI13323 TI13344 TI13345 TI13354 TI13356 TI13601 TI14090 TI14188 TI14189 TI14196 TI14252 TI14261 TI14267 TI14271 TI14272 TI14283 TI14311 TI14315 TI14376 TI15413 TI15415 TI15421 TI15433 TI15438 TI15446 TI15447 TI15458 TI15461 TI15466 TI15467 TI15469 TI15475 TI15478 TI15479 TI15481 TI15483 TI15485 TI15486 TI15489 TI15511 TI15514 TI15524 TI15524 TI15527 TI15545 TI15562 TI15577 TI15584 TI15586 TI15670 TI15671 TI15672 TI15674 TI15677 TI15678 TI15682 TI15686 TI16386 TI16400 TI16414 TI16904 TI16928 TI16939 TI16961 TI16984 TI16992 TI17046 TI17070 TI17071 TI17334 TI17433 TI17434 TI17446 TI17475 TI17476 TI17484 TI17486 TI17490 TI17517 TI17523 TI17535 TI17547 TI17589 TI17604 TI17605 TI17638 TI17646 TI17648 TI17673 TI17702 TI17719 TI17724 TI17728 TI17742 TI17744 TI17751 TI17755 TI17761 TI17763 TI17765 TI17769 TI17775 TI17779 TI17786 TI17788 TI17812 TI17817 TI17825 TI17830 TI17831 TI17864 TI18406 TI18587 TI18671 TI18723 TI19313 TI19323 TI655374.
• Any opinions about this data are those of the authors and do not reflect official positions of the government or individual grantees.
• Comments or questions can be addressed to Michael Dennis, Chestnut Health Systems, 448 Wylie Drive, Normal, IL 61761. Phone 1-309-451-7801; E-mail:
• [email protected] . More information on the GAIN is available • at www.chestnut.org/li/gain or by e-mailing [email protected] .