EVIDENCE-BASED MENTAL EVIDENCE-BASED MENTAL HEALTH PRACTICESHEALTH PRACTICES

Anthony F. Lehman, M.D., M.S.P.H.Professor and Chair

Department of PsychiatryUniversity of Maryland

10 Leading Causes of Disability in 10 Leading Causes of Disability in the World (WHO, 1997)the World (WHO, 1997)

Unipolar Depression Iron-deficiency Anemia Falls Alcohol Use COPD Bipolar disorder Congenital anomalies Osteoarthritis Schizophrenia Obsessive-compulsive

disorder

10.7% 4.7 4.6 3.3 3.1 3.0 2.9 2.8 2.6 2.2

CHANGES IN PRIVATE HEALTH CHANGES IN PRIVATE HEALTH CARE EXPENDITURESCARE EXPENDITURES

1988-19971988-1997(HAY GROUP STUDY, 1998)(HAY GROUP STUDY, 1998)

Overall health care expenditures decreased by 7% between 1988-1997

Mental health care expenditures decreased by 54%

PORT ProcessPORT Process

Review literature regarding evidence for practice (efficacy)

Analyze data on variations in practice Develop outcomes information to examine

relationship of treatment and patient outcomes (effectiveness)

Develop treatment recommendations based on literature and outcome studies

Disseminate findings to change current practices

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 1: Antipsychotic medications, other than clozapine, should be used as the first-line treatment to reduce psychotic symptoms for persons experiencing an acute symptom episode of schizophrenia.

Conventional Antipsychotics: Conventional Antipsychotics: Efficacy-Effectiveness GapEfficacy-Effectiveness Gap

Annual Relapse Rates- Placebo: 70%- Efficacy in clinical trails: 23%- Effectiveness in practice: 50%

Factors Affecting Efficacy-Effectiveness Gap- Patient heterogeneity- Prescribing practices- Noncompliance

(from Kissling, 1992) _________________Schizophrenia PORT

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 2: The dosage of antipsychotic medication for an acute symptom episode should be in the range of 300-1000 chlorpromazine (CPZ) equivalents per day for a minimum of 6 weeks. Reasons for dosages outside of this range should be justified. The minimum effective dose should be used.

0

10

20

30

40

50

60

%

Improvement

(2-4 h)

Dose, mg (Fluphenazine)

Baldessarini et al. (1988), Arch Gen Psych 45:79-91

Effective Dosage Range: Acute Treatment

1 2 3 5 10 20 30 50

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 9: The maintenance dosage should be in the range of 300-600 CPZ equivalents (oral or depot) per day.

% not relapsed

(1 yr)

Fluphenazine Decanoate, mg/2 wk

Baldessarini et al. (1988), Arch Gen Psych 45:79-91

Effective Dosage Range:Maintenance Treatment

Schizophrenia PORT

0102030405060708090

100

0 10 20 30 40

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment 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

00.10.20.30.40.50.60.70.80.9

Intake Year 1 Year 2 Year 3

Personal TherapyVersus No PT

(Begin: N=151) (End: N=125)

N=148 N=151 N=128

From Hogarty et. al. (1996)Year in Treatment

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 24: Patients who have on-going contact with their families should be offered a family psychosocial intervention which spans at least nine months and which provides a combination of education about the illness, family support, crisis intervention, and problem solving skills training. Such interventions should also be offered to non-family caregivers.

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

0%

10%

20%

30%

40%

50%

60%

70%

One Year Two Years

Medications Only

Medications PlusFamilyPsychoeducationMedications PlusSocial Skills

All 3 Treatments

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 27: Persons with schizophrenia who have any of the following characteristics should be offered vocational services. The person: a) identifies competitive employment as a personal goal; b) has a history of prior competitive employment; c) has a minimal history of psychiatric hospitalization; d) is judged on the basis of a formal vocational assessment to have good work skills.

VOCATIONAL STUDIESVOCATIONAL STUDIES

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

Gervey 94

Bond 95

Drake 96

Chandler 97

Drake 99

McFarlane 00ControlSupported Employment

% Working

Employment Intervention Employment Intervention Demonstration ProjectDemonstration Project

Sponsored by Center for Mental Health Services

A multi-center, longitudinal evaluation of employment interventions for persons with severe mental illness

Randomly assigned and followed for two years.

EIDP TREND # 1EIDP TREND # 1

JOB TENURE SHOWED A TREND TOWARD INCREASED LENGTH OF JOB OVER TIME.

Average Length of Jobs (EIDP, 2001)Average Length of Jobs (EIDP, 2001)

0

50

100

150

200

250

1 Job(N=309)

2 Jobs(N=225)

3 Jobs(N=112)

4 Jobs(N=61)

5 Jobs(N=36)

6 Jobs(N=14)

1st Job

2nd Job

3rd Job

4th Job

5th Job

6th JobAve

rage

Len

gth

in D

ays

EIDP TREND #2EIDP TREND #2

TIME BETWEEN JOBS DECREASED OVER TIME

 

Number of Days Between Jobs Among Number of Days Between Jobs Among EIDP Participants with More than One JobEIDP Participants with More than One Job

57597170

8082

107

0

20

40

60

80

100

120

Between1 & 2

N=416

Between2 & 3

N=221

Between3 & 4

N=119

Between4 & 5N=61

Between5 & 6N=31

Between6 & 7N=18

Between7 & 8N=12

Ave

rage

Num

ber o

f Day

s

EIDP TREND # 3EIDP TREND # 3

RECEIPT OF JOB SUPPORT WAS ASSOCIATED WITH LONGER JOB TENURE ON FIRST JOB

DEFINITION OF JOB SUPPORTDEFINITION OF JOB SUPPORT

On-site counseling, support, and problem solving. Providing on-the job help with vocational skills in different work situations and production levels, social skill in the work environment, and job-related skills; may include on-the-job training/assistance.

Mean Length (in days) of First Competitive Job by Receipt of Job Support

Mea

n Le

ngth

in D

ays

Received Job Support

0

40

80

120

160

No Yes

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment Recommendations

Recommendation 29: Systems of care serving persons with schizophrenia who are high service utilizers should include assertive case management and assertive community treatment programs.

CONTROLLED ACT RESEARCHCONTROLLED ACT RESEARCH

17

87 7 7

3 32

6

35

1

910

57

02468

1012141618

Tim

e in

hosp

ital

Hou

sing

stab

ility

Qua

lity

oflif

e

Clie

ntsa

tisfa

ctio

n

Sym

ptom

s

Soci

alFu

nctio

ning

Voca

tiona

l

Jail/

arre

sts

Num

ber o

f Stu

dies

ACT better than Standard

ACT not better than Standard

25 Studies

Inpatient Days: ACT vs. ComparisonInpatient Days: ACT vs. ComparisonLehman et al, 1998Lehman et al, 1998

0500

100015002000250030003500400045005000

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

ACTComparison

Days Homeless on Streets: Days Homeless on Streets: ACT vs. ComparisonACT vs. Comparison

Lehman et al., 1997Lehman et al., 1997

0

500

1000

1500

2000

2500

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

ACTComparison

Outpatient Visits: ACT vs. Outpatient Visits: ACT vs. ComparisonComparison

Lehman et al, 1997Lehman et al, 1997

0100020003000400050006000700080009000

1st Qtr 2nd Qtr 3rd Qtr 4th Qtr

ACTComparison

SCHIZOPHRENIA PORT SCHIZOPHRENIA PORT Current PracticesCurrent 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 Rates of Conformance with PORT Psychosocial Treatment RecommendationsTreatment Recommendations

APA Office of Quality Improvement and Psychiatric ServicesAPA Office of Quality Improvement and Psychiatric Services

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

100%C

ase

Man

agem

ent

Psyc

hoth

erap

y

Fam

ilyTh

erap

y

Voc

Reh

ab

Any

Psyc

hoso

cial

%

of

Patients

0102030405060708090

100

Total IndividualTherapy

Group Therapy Family Therapy

Medicare Claims: 1991Proportion of Study Population with At Least One Visit for Outpatient Service (N=16,480)

Schizophrenia PORT

Major Depression TreatmentMajor Depression Treatment

Acute Phase (Symptom Response_– Placebo……………………... 20-50%– Antidepressant……………. 65-70%– Psychotherapies………….. 47-55%

Maintenance Phase (Relapse Prevention)– Placebo……………………… 15-45%– Antidepressant…………….. 65-79%

Child and adolescent treatments that have Child and adolescent treatments that have been found to be effectivebeen found to be effective

Empirically supported treatments– Cognitive-behavior therapy for childhood anxiety disorders– Cognitive-behavioral coping skills therapy for depression (including school-based

treatments)– Parent management training for disruptive behaviors (including videos for parents)– Problem-solving skills therapy for disruptive behaviors– Social skills training for young children who are aggressive (including school-based

treatments)– Psychotropic medication for Attention Disorders and Obsessive-Compulsive disorders

Empirically promising treatments– Intensive home-based behavior modification for autism– Family therapy for parent-adolescent conflict– Teacher consultation models for disruptive behaviors (reduction in Special Ed. referrals found;

effects on behavior problems unclear)– Psychotropic medication for a number of other symptoms (e.g., depression, anxiety, autistic

behaviors)

Empirically Supported TreatmentsEmpirically Supported Treatments

Conduct Problems Multi-System Treatment

– 84 youth categorized as serious juvenile offenders randomly assigned to MST and standard care through juvenile justice

– After two years, 40% of youth treated with MST avoided re-arrest versus 20% of youth receiving standard care (Henggler, et al 1996)

Behavioral family/parent training – A large average effect size of .86 was found across

studies of family behavioral skills interventions with disruptive behavior disorders (Serketich, Dumas 1996)

Empirically Supported TreatmentsEmpirically Supported Treatments

Depression in Adolescents Cognitive Behavioral Therapy

– Results of large controlled study showed reduction in symptoms in 70% of those treated with CBT

Coping with Depression (CWD) course– 96 youth with major depression randomized to CWD

course or wait-list control– 97.5% of CWD group no longer met criteria for

depression disorder at 2 year follow-up

Pediatric PsychopharmacologyPediatric Psychopharmacology11

Long-termShort-term

CC

BB

Bipolar disordersAggressive behaviorsLithium

CC

BA

SchizophreniaTourette’s disorderAntipsychotics

CC

CB

Major depressionADHDTCAs

CC

CC

Bipolar disorderAggressive behavior

Valproate &Carbamazepine

CC

BC

Tourette’s disorderADHD

Adrenergic agonists

CCC

BAC

Major depressionOCDAnxiety disorders

SSRIs

BAADHDStimulants

Efficacy2

IndicationClass

1 Jensen, Bhatara, Vitiello, et al 1999 2 A = 2 RCTs; B = 1 RCT; C = clinical consensus

Different Perspectives on OutcomesDifferent Perspectives on Outcomes Example: Utility for Mild Symptoms plus Side Example: Utility for Mild Symptoms plus Side Effects Versus Moderate Symptoms and No Side Effects Versus Moderate Symptoms and No Side

Effects (Lenert et al., 2000)Effects (Lenert et al., 2000)

-0.04

-0.02

0

0.02

0.04

0.06

0.08

0.1

PatientsFamilesProviders

EVOLUTION OF MEDICAL TECHNOLOGY EVOLUTION OF MEDICAL TECHNOLOGY AND COSTS OF TREATING DISEASEAND COSTS OF TREATING DISEASE

(Pardes et al., 1999)(Pardes et al., 1999)

Costs

– palliative treatment cure

• Stages of Technology