Transcript M7 - Children`s Mental Health Ontario

Lessons Learned and Tools for Rolling out Successful Mental Health Programs for High Risk Youth:
Using DBT for Chronically Suicidal, Self-Harming
Adolescents
Deanne Simms, PhD, RPsych, CPsych
Jonathan Brake, MD, FRCPC
November 21, 2016
CMHO Annual Conference
Toronto, Ontario
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Mindfulness
What
How
Observing
Non-judgmentally
Describing
One-mindfully
Participating
Effectively
Outline: Part 1 – Background
 Describe our current treatment setting and population
at the IWK Health Centre in Halifax, Nova Scotia
 Provide an overview of Dialectical Behavior Therapy
(DBT)
 Discuss the efficacy data supporting the use of DBT in
adolescents
Outline: Part 2 – IWK DBT Pilot Project
 Describe the development of the IWK DBT program
 Outline the results of the pilot program
 Discuss successes and challenges of rolling out this
program
Part 1 – Background
Halifax, Nova Scotia
 Capital of Nova Scotia
 Population of 417,000 (Amalgamation of Halifax, Dartmouth, Bedford,
Halifax County)
 50% of Nova Scotia’s population
 Most populous urban area in the Atlantic region
 Strong maritime and military traditions
IWK Health Centre
Tertiary care centre
providing care to
women, children, and
youth from Nova
Scotia, New Brunswick,
and PEI
IWK Health Centre
Mental Health and Addictions Program
 Inpatient Mental Health Unit
 Forensic Unit – 6 bed inpatient unit
 Urgent Care Clinic
 3 Outpatient Mental Health Clinics
 Mental Health Mobile Crisis Team
 Adolescent Intensive Services
10 bed unit
10 bed concurrent disorders beds
 Children’s Intensive Services
8 bed unit for children 5-12
 Choice and Partnership Approach
(CAPA)
 CHOICES concurrent disorder
service for youth 13-19 years
 School Based Mental Health
Services
Specific Care Clinics
Psychosis
Mood
OCD
Eating Disorders
Pervasive Developmental Disorder
DBT
Chronic Suicidality and Non-Suicidal
Self Injurious Behavior
 Self-harm is becoming increasingly common among youth
 Intentional self harm-related hospitalizations are on the rise
 2009-2014
 Girls - 110% increase (45% of all injury hospitalizations in 2013-2014)
 Boys - 35% increase
(CIHI, 2014)
 In N.S., 15% of hospitalizations for injuries in the 15-29-year-old age
group are for self-harm or suicidal gestures, and 28% of the injuryrelated deaths in this age group are from suicide.
 Nearly 25% of the admissions to the IWK Health Centre Mental
Health Inpatient Unit are for self-harm and approximately 30% of the
cases seen by the IWK Emergency Mental health Service are for
these problems.
Borderline Personality Disorder in
Adolescents
 BPD is a pervasive disorder of emotion regulation system
 Emotional, interpersonal, self, behavioral and cognitive
dysregulation
 Adolescents may develop characteristics of a
personality disorder comparable to adults in terms of:
Symptom constellation
Functional impairment
Stability of diagnosis over time
(Cailhol et al., 2013; Crowell et al.,
2009; Becker et al., 2002; Zanarini
et al., 2007)
Borderline Personality Disorder in
Adolescents
 3% of community dwelling adolescents
(Chanen et al, 2004; 2007; 2008)
 22% of adolescents are treated in outpatient clinics
(Chanen et al, 2004; 2007; 2008)
 30% of adolescents hospitalized meet BPD criteria
(Glenn and Klonsky, 2013)
 Most patients date onset symptoms to period or puberty
(Zanarini, Frankenburg, Khera &
Bleichmar, 2001)
Treatment as Usual
 Youth with features of BPD (e.g., extreme mood
dysregulation, suicidal ideation, self-injurious behavior)
were not treated systematically or effectively within the
IWK MH&A Program
 As a result, these youth engaged in high service
utilization (i.e., involvement in multiple individual and
group treatment formats; repeated presentations to the
ER and admissions to the inpatient unit) and were not
optimally treated
At the IWK, a partial sampling of 96 youth with features of BPD was
conducted between April, 2010 and March, 2011:
Most youth involved in two or more treatment areas (range 1 - 6)
Accessed ER/Crisis an average of 3.18 times
(range 1-13)
Treating BPD
 Psychotherapy is the primary treatment
 Medication to treat comorbid disorders (i.e.,: Depression,
Anxiety)
 Short-term hospitalization is not effective
 Long-term hospitalization is contraindicated
 Problems with conventional therapies
 Change-based therapies can be invalidating
 Rigid, manualized approach is not well equipped to
manage frequent crises
Dialectical Beahvior Therapy
 DBT was initially developed for chronically suicidal adults
with BPD (Linehan, 1993)
 Incorporates principles of behavioural science, dialectical
philosophy, and Zen practice
 Aims to develop a balanced view (synthesis) between two
opposing views (thesis and antithesis)
Aims to decrease
 Life-threatening
behaviours
 Therapy-interfering
behaviours
While Increasing skills
 Mindfulness
 Distress tolerance
 Interpersonal effectiveness
 Quality-of-life interfering
behaviours
 Emotional regulation
DBT – Treatment Components
 Individual therapy (1 year)
 Multifamily skill groups (6 months)
 Consultation team
 Telephone Coaching
 Medication review and monitoring (Psychiatry)
ORIENTATION AND COMMITMENT
DBT is Effective in Adult Populations
 Several studies demonstrate that DBT improves
psychological symptoms in adult populations (Borsch et al. 2002;
Carter et al., 2010; Linehan et al., 2006; McMain et al., 2009)
1) Decreased frequency of suicidal behaviour
2) Decreased suicidal ideation
3) Decreased borderline symptomatology
4) Decreased hopelessness
5) Decreased depressive symptoms
 Improved retention rate compared to other treatments
DBT has been adapted forAdolescents
 DBT has been successfully used to treat adolescents with
a variety of psychiatric disorders including,
 Mood disorders, externalizing disorders, eating disorders,
trichotillomania, oppositional defiant disorder
 In addition to standard outpatient DBT treatment, DBT
has shown benefits in various settings
 Incarcerated youth, residential treatment, inpatient mental
health units, partial hospitalization or day treatment programs
DBT Improves Psychological Symptoms
in Adolescents
DBT Reduces Service Use in Adolescents
DBT is Cost Effective
(Linehan & Heard, 1999;
Comtois et al., 2007)
Estimates of yearly psychiatric costs for TAU in U.S. range from
$12,079 to $29,843
Potential cost savings of treating the 96 identified
patients at the IWK with DBT was estimated at
$2,083,488 per year!
Part 2 – IWK DBT Pilot Project
DBT Specific Care Pilot Clinic
 2012: Through a grant from the Royal Bank of Canada, funding
was attained to develop and implement DBT at the IWK
 2013: Over the course of 6 months, 7 clinicians underwent
Intensive Training through Behavioral Tech.
 2013-’14: Clinicians, administrators, and stakeholders designed
a one year DBT Pilot Program
 2013-’14: A parallel research project was funded by the
Dalhousie University Department of Psychiatry to evaluate:
 Psychiatric symptoms and functioning
 Service use
Challenges and Lessons Learned
Importance of
ORIENTATION AND COMMITMENT
Stakeholders
Administrators
Clinicians (within clinic and within larger program)
...AND THEN from patients
Pilot Clinic
 Participants (N = 16)
 Mean age: 16.88 ( range15-18)
 Gender: 12 female, 2 male, 2 transgendered
 Patients underwent:
 Orientation and Commitment Sessions (up to 4)
 Diagnostic Assessment and Medication
Review/Consultation
 One year of Individual DBT treatment
 Six months of Multifamily Skills Training Group
 Baseline, T2 and T3 Measures of Psychiatric Symptoms
Results
Retention - Patients
 16/21 participants interviewed were eligible and agreed to
participate. Of these:
• 3 dropped out <3 months
• 9 dropped out < 6 months
• 4 dropped out 6 – 12 months
• 2 completed 12 months of treatment
 Low retention rates are noted in the DBT literature:
Drop out rate Length of program
Katz (2004)
1.6%
2 weeks
Rathus and Miller (2002)
38.0%
12 weeks
Mehlum et al. (2014)
25.6%
19 weeks
Tormoen et al. (2014)
22.0%
16 weeks
Courtney and Flament (2015)
52.4%
14 weeks
IWK Study
87.5%
52 weeks
Retention –
Clinicians and Administrators
 1 Clinician was removed from the program
 1 Clinician resigned from the program
 2 Clinicians left for Maternity Leaves of Absence
 1 Clinician had partial EFT returned to another
program
 1 Clinician moved out of province
 Management portfolios changed 3 times
 Chief of Psychiatry left organization
Completion of Questionnaires
Measures
MACI
BDI
RFL
HPLS
BASC
QOLS
N = 16
Baseline % (N)
87.50% (14)
93.75% (15)
68.75% (11)
81.25% (13)
68.75% (11)
43.75% (7)
6 Months % (N)
25.00% (4)
12.50% (2)
12.50% (2)
12.50% (2)
12.50% (2)
12 Months % (N)
12.50% (2)
6.25% (1)
12.50% (2)
6.25% (1)
6.25% (1)
6.25% (1)
 Not all patients who completed treatment completed all questionnaires
 Patients who dropped out were not significantly different than those who
remained in the program
Challenges and Lessons Learned
 Know your patient population
• Balance clinical and research goals
AND
 Know how your clinic fits within the larger
program/system
Psychiatric Symptoms:
MACI: Borderline Personality Scale
21%
79%
 Highly elevated(=>60):
Mean score = 82.5
 Moderately elevated(<60):
Mean score = 38.7
 Total
Mean score = 73.1
Participants (%)
Anxious Feelings
Unlikely similar to other adol. with clinical
characteristics (<60)
Some Similarity to other adol. with clinical
characteristics (60-74)
Moderate levels of syndromal feature (75-84)
High probability of clinical syndome (85+)
MACI: Clinical
Syndromes
43
14
14
29
Depression Affect
102.21
Unlikely similar to other adol. with clinical
characteristics (<60)
Some Similarity to other adol. with clinical
characteristics (60-74)
Moderate levels of syndromal feature (75-84)
High probability of clinical syndome (85+)
7
93
Suicidal Tendency
91.79
Unlikely similar to other adol. with clinical
characteristics (<60)
Some Similarity to other adol. with clinical
characteristics (60-74)
Moderate levels of syndromal feature (75-84)
High probability of clinical syndome (85+)
n = 14
Mean
67.14
7
7
21
64
Depression – Beck Depression Inventory
27%
73%
 Severe range
(Mean score = 47)
 Moderate range
(Mean score = 23.5)
 Total
(Mean score = 40.73)
Suicidality – Kazdin Hopelessness Scale
8%
15%
77%
 High Hopelessness (7+):
Mean score = 13.5
 Moderate Hopelessness (5-6): Mean score = 5.0
 Low Hopelessness (0-4):
Mean score = 0
 Total
Mean score = 11.2
Suicidality – Reasons For Living Inventory
Study
Mean
SD
High School^
Mean
SD
Psychiatric (Suicidal)^
Mean
SD
Future Optimism
2.99*
1.75
5.51
0.61
4.18
1.16
Suicide-Related Concerns
1.94**
1.10
4.51
1.45
2.97
1.39
Family Alliance
2.51*
1.55
5.18
0.74
3.54
1.39
Peer Acceptance
2.59**
1.55
5.13
0.9
4.05
1.24
Self Acceptance
2.94*
1.88
5.31
0.54
3.70
1.19
TOTAL
2.60**
1.40
5.14
0.55
3.70
0.90
^ Osman et al (1998). The reasons for living Inventory for adolescents (RFL-A): Development
and psychometric properties. Journal of Clinical Psychology, 54 (8), 1063-78.
* Significantly lower than high school adolescents (p<0.05)
** Significantly lower than high school and psychiatric (suicidal) adolescents (p<0.05)
n = 11
Measure of General Function – Quality
of Life Inventory
Quality of Life Inventory
Mean
17.71
Standard Error Range
6.01
2- 40
 Scores below 40 indicate Very Low Quality of Life
 Mean is significantly lower than 40 (p<0.05)
Challenges and Lessons Learned
 “Tip of the Iceberg” problem
Psychiatric Symptoms at DBT
Completion
 Some evidence of improvements in measures of BPD:
• Including, personality patterns, identity diffusion, self
devaluation, social insensitivity, family discord, and suicidal
tendencies.
 Some improvements in General Functioning
• Including, internalizing problems, anxiety, and depression.
 Marginal or no improvement in other measures of Suicidality
Service Use Findings
Mean
SD
Compare Before DBT
(z-score)
Number of visits to the emergency department
Number of admissions to inpatient unit
Number of admissions to medical unit
Length of stay for admissions
5.67
1.83
0.00
8.00
9.06
1.53
0.00
10.83
-
Number of visits to the emergency department
Number of admissions to inpatient unit
Number of admissions to medical unit
Length of stay for admissions
2.50
0.92
0.08
2.25
4.36
1.17
0.29
3.52
-1.78 (r = -0.36)
-2.15* (r = -0.44)
-1.00 (r = -0.20)
-2.65* (r = -0.54)
Number of visits to the emergency department
Number of admissions to inpatient unit
Number of admissions to medical unit
Length of stay for admissions
0.67
0.42
0.00
11.50
1.23
1.00
0.00
38.90
-2.61* (r = -0.53)
-2.55* (r = -0.52)
0.00
-1.60 (r = -0.33)
Before DBT (1 year)
During DBT
After DBT
n = 16
* p < 0.05
Average Savings per Patient
86.3% Reduction in cost!
Summary of Results
 Missing information and attrition of participants and clinicians
made it difficult to measure the success of the IWK DBT Pilot
Clinic
 At baseline, participants were much more severely impaired
than participants in other DBT studies (Rathus and Miller, 2002;
Osman et al., 1998)
 Service utilization significantly decreased during DBT
treatment
 Cost per patient significantly decreased (i.e., by 86.3% on
average) during DBT treatment
Current Status of DBT at the IWK
Take Home Messages:
Major Lessons Learned
Communicate, communicate, communicate
• Researchers with stakeholders, administrators, clinicians
• Stakeholders with administrators, clinicians
• Administrators with clinicians
Consider the entire system your program is part of
• Social, political, economical
Evaluation is dynamic and program
development is an iterative process
Acknowledgements
 Funded by Royal Bank of Canada
 DBT Training though Behaviour Tech.