Symposium:Charting a course in mental health by monitoring outcomes Charting a course in mental

health by : Using readmission as an

indicator of the quality of psychiatric hospitalisations

Using inpatient monitoring to improve hospital outcomes

Turning data into clinically-useful information

Shannon Byrne

Andrew Page

Geoff Hooke

Charting a course in mental health using inpatient

monitoring to improve hospital outcomes

Andrew PageGeoff Hooke &

Shannon ByrneUniversity of Western

AustraliaAnd Perth Clinic

Acknowledgments

Perth Clinic Medibank Private HBF Australian Research Council

Prof Lambert, Brigham Young University Dr Newnham, Harvard University Kale Dyer, University of Western Australia

WHY MONITOR?

National Practice Standards for the Mental Health Workforce (2002)

Standard 11: Evaluation and Research “Mental health professionals systematically

monitor and evaluate their clinical practice … to ensure the best possible outcomes …”

Admission Discharge

But Do We Need Monitoring?

Schulte & Eifert (2002)

30% of treatment goals were established during therapy

Average number of method changes per session was 1.4

Schulte & Eifert (2002)

Changes in treatment direction occur when therapists are pessimistic about outcomes or believe they have little control over treatment … BUT … therapist ratings of session success were poorly correlated with final outcome

Schulte & Eifert (2002)

Therapist mood predicted treatment direction and perceived success of treatment, but therapist mood deteriorated if patients did not express acceptance or signaled dislike Method changes in treatment correlated

negatively (-.49) with outcome

How Well do Practitioners Predict Treatment Failure? (Hannan et al., 2005)

Although therapist correctly identified 16 clients who had worsened during treatment, they did not interpret this information as a predictor of final patient outcome.

The Key

Early treatment response is indicative of final outcome.Howard, Moras, Brill, Martinovich & Lutz,

1996

Dose-Response Curve: Howard, Kopta, Krause, & Orlinsky (1986)

Guiding Psychotherapy

Newnham & Page (2010) Clinical Psychology Review

Newnham & Page (2010) Clinical Psychology Review

WHO-5 Wellbeing Index

Over the last day At no time

Some of the time

< half of the time

> half of time

Most of the time

All of the time

I have felt cheerful and in good spirits

0 1 2 3 4 5

I have felt calm and relaxed

0 1 2 3 4 5

I have felt active and vigorous

0 1 2 3 4 5

I woke up feeling fresh and rested

0 1 2 3 4 5

My daily life has been filled with things that interest me

0 1 2 3 4 5

Reliable (α=.89), Cut off of 11 – clinical significance Moderate sensitivity (.55), & high

specificity (.86) for a cut-off of 11 at discharge.

Convergent validity with DASS-21 & SF-36

WHO-5 Wellbeing Index

Newnham, Hooke & Page, 2009

Day 1

Day 5

Day 9

+

36%*

Outcomes:

• DASS Depression 37%*

• DASS Anxiety 14%*

• DASS Stress 28%*

• Mental Health 32%*

• Vitality 38.8%*

N=316

Newnham, Hooke, & Page, 2010

Illustration of a “Not on Track” Patient Responding to a Friday Feedback Session

50

55

60

65

70

75

80

85

90

95

100

Pre-test Feedback Post-test

OQ

Tot

al S

core

OT_Fb

OT-NFb

NOT-NFb

NOT-Fb

NOT-Fb+CST

T/Pat Fb

Lambert, 2007

Research hypothesis

Monitoring patient progress using the WHO Wellbeing Index, and providing individualized feedback to clinicians and patients during therapy will improve

(i) wellbeing (ii) symptom relief

As measured on a series of standardized self report and clinician rated outcome assessment instruments.

Participants

• Consecutive inpatients and day patients attending CBT group. – 408 feedback– 439 no feedback

• Diagnoses:– Depression 67.7%– Anxiety 25.9%– Substance use 3.0%

• Gender– 63.1% female– 36.9% male

Evaluation of effectiveness

Anticipated results

Newnham, Hooke, Page, in press, Journal of Affective Disorders

Anticipated results

Newnham, Hooke, Page, in press, Journal of Affective Disorders

Wellbeing results

(F(1,569)=1.14,p>.05).

(F(1,569)=237.1, p<.05).

Newnham, Hooke, Page, in press, Journal of Affective Disorders

Depression results

(F(1,649)=6.29,p<.05).

Significant effect:Vitality: (F(1,639)=5.53,p<.05),

Role emotion: (F(1,635)=4.11,p<.05)

Newnham, Hooke, Page, 2010, Journal of Affective Disorders

Wellbeing

Is it :

The measure?

The construct?

New Measure

• Daily Symptoms Index 5-item

• Consultation with mental health professionals.

• Brief, easy, and understandable.• Pairs with WHO-5.

• Item-pool pilot tested, 5 items selected.

Participants

• Non-clinical – 309 (75% female, 25% male)– 18 to 62 years (M = 21.46, SD = 4.38).

• Clinical– 356 (66% female, 34% male) – 17 to 82 years (M = 39.51, SD = 13.44)– 62.64% Depression, 29.49% Anxiety, and 7.87%

Other diagnoses.

Reliability

• Clinical:– Cronbach's α = 0.88

• Nonclinical:– Cronbach's α = 0.80– Test-retest r = 0.64

Concurrent Validity

Existing Measures Nonclinical Clinical

SF-36 Vitality -0.48 -0.54

SF-36 Social Functioning -0.54 -0.56

SF-36 Mental Health -0.72 -0.31

WHO-5 -0.50 -0.61

DASS-21 Depression 0.74 0.65

DASS-21 Anxiety 0.52 0.45

DASS-21 Stress 0.59 0.59

Χ² RMSEA(95% CI) SRMR TLI CFI

550.550,p<0.01

0.07(0.065-0.075) 0.034 0.967 0.976

Penultimate Conclusions

• WHO-5 monitoring successful.

• Expanded to include assessment of symptoms.

• DSI-5 found to demonstrate acceptable:– Reliability– Validity– Stability of latent structures.

Trajectories.

Admission Risk

Gender Previous Harm, etc.

Self-Harm

Current Harm, etc.

Suicidal Ideation

DailyOngoing Risk

WellbeingSymptoms

Prediction of Adverse Events

Will staff use the instrument?