Transcript EVIDENCE-BASED TREATMENTS FOR SEVERE MENTAL ILLNESS

EVIDENCE-BASED MENTAL
HEALTH PRACTICES
Anthony F. Lehman, M.D., M.S.P.H.
Professor and Chair
Department of Psychiatry
University of Maryland
10 Leading Causes of Disability in
the World (WHO, 1997)
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Unipolar Depression
Iron-deficiency Anemia
Falls
Alcohol Use
COPD
Bipolar disorder
Congenital anomalies
Osteoarthritis
Schizophrenia
Obsessive-compulsive
disorder
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10.7%
4.7
4.6
3.3
3.1
3.0
2.9
2.8
2.6
2.2
CHANGES IN PRIVATE HEALTH CARE
EXPENDITURES
1988-1997
(HAY GROUP STUDY, 1998)
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Overall health care expenditures
decreased by 7% between 1988-1997
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Mental health care expenditures
decreased by 54%
PORT Process
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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
Treatment Recommendations
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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:
Efficacy-Effectiveness Gap
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Annual Relapse Rates
- Placebo: 70%
- Efficacy in clinical trails: 23%
- Effectiveness in practice: 50%
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Factors Affecting Efficacy-Effectiveness Gap
- Patient heterogeneity
- Prescribing practices
- Noncompliance
(from Kissling, 1992)
_________________
Schizophrenia PORT
Schizophrenia PORT
Treatment Recommendations
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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.
Effective Dosage Range: Acute Treatment
60
50
40
%
Improvement
30
20
(2-4 h)
10
0
1
2
3
5
10
20 30
Dose, mg (Fluphenazine)
Baldessarini et al. (1988), Arch Gen Psych 45:79-91
50
Schizophrenia PORT
Treatment Recommendations
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Recommendation 9: The
maintenance dosage should be in the
range of 300-600 CPZ equivalents
(oral or depot) per day.
Effective Dosage Range:
Maintenance Treatment
% not
relapsed
(1 yr)
100
90
80
70
60
50
40
30
20
10
0
0
10
20
30
40
Fluphenazine Decanoate, mg/2 wk
Baldessarini et al. (1988), Arch Gen Psych 45:79-91
Schizophrenia PORT
Schizophrenia PORT
Treatment Recommendations
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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
0.9
0.8
0.7
0.6
0.5
Personal Therapy
Versus No PT
0.4
0.3
0.2
0.1
0
Intake
N=148
Year 1 N=151 Year 2
(Begin: N=151)
Year in Treatment
N=128 Year 3
(End: N=125)
From Hogarty et. al. (1996)
Schizophrenia PORT
Treatment Recommendations
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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 Schizophrenia
Annual Relapse Rates (Hogarty et al., 1986)
70%
Medications Only
60%
50%
Medications Plus
Family
Psychoeducation
Medications Plus
Social Skills
40%
30%
20%
10%
All 3 Treatments
0%
One Year
Two Years
Schizophrenia PORT
Treatment Recommendations
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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 STUDIES
Control
McFarlane 00
Supported Employment
Drake 99
Chandler 97
Drake 96
Bond 95
Gervey 94
0%
10% 20% 30% 40% 50% 60% 70% 80% 90%
% Working
Employment Intervention
Demonstration Project
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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 # 1
JOB TENURE SHOWED A TREND
TOWARD INCREASED LENGTH OF
JOB OVER TIME.
Average Length of Jobs (EIDP, 2001)
250
Average Length in Days
1st Job
200
2nd Job
150
3rd Job
100
4th Job
5th Job
50
6th Job
0
1 Job
(N=309)
2 Jobs
3 Jobs
(N=225) (N=112)
4 Jobs
(N=61)
5 Jobs
(N=36)
6 Jobs
(N=14)
EIDP TREND #2
TIME BETWEEN JOBS DECREASED
OVER TIME
Average Number of Days
Number of Days Between Jobs Among
EIDP Participants with More than One Job
120
100
107
82
80
80
70
71
59
60
57
40
20
0
Between Between
1&2
2&3
N=416
N=221
Between Between Between
3&4
4&5
5&6
N=119
N=61
N=31
Between Between
6&7
7&8
N=18
N=12
EIDP TREND # 3
RECEIPT OF JOB SUPPORT WAS
ASSOCIATED WITH LONGER JOB
TENURE ON FIRST JOB
DEFINITION 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 jobrelated skills; may include on-the-job
training/assistance.
Mean Length (in days) of First Competitive
Job by Receipt of Job Support
Mean Length in Days
160
120
80
40
0
No
Yes
Received Job Support
Schizophrenia PORT
Treatment Recommendations
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Recommendation 29: Systems of
care serving persons with
schizophrenia who are high service
utilizers should include assertive
case management and assertive
community treatment programs.
7
7
5
3
3
3
1
Jail/arrests
9
Vocational
17
Social
Functioning
7
Symptoms
6
Client
satisfaction
8
Quality of
life
Housing
stability
18
16
14
12
10
8
6
4
2
0
Time in
hospital
Number of Studies
CONTROLLED ACT RESEARCH
25 Studies
ACT better than Standard
ACT not better than Standard
10
7
5
2
Inpatient Days: ACT vs. Comparison
Lehman et al, 1998
5000
4500
4000
3500
3000
2500
2000
1500
1000
500
0
ACT
Comparison
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Days Homeless on Streets:
ACT vs. Comparison
Lehman et al., 1997
2500
2000
1500
ACT
Comparison
1000
500
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
Outpatient Visits: ACT vs.
Comparison
Lehman et al, 1997
9000
8000
7000
6000
5000
4000
3000
ACT
Comparison
2000
1000
0
1st Qtr
2nd Qtr
3rd Qtr
4th Qtr
SCHIZOPHRENIA PORT
Current Practices
Maintenance dose of antipsychotic
within recommended range: 29%
 Adjunctive antidepressant: 46%
 Psychological Interventions: 45%
 Family psychoeducation: 10%
 Vocational rehabilitation: 22%
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Rates of Conformance with PORT Psychosocial
Treatment Recommendations
Any
Psychosocial
Voc Rehab
Family
Therapy
Psychotherapy
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Case
Management
APA Office of Quality Improvement and Psychiatric Services
Medicare Claims: 1991
Proportion of Study Population with At Least
One Visit for Outpatient Service (N=16,480)
100
90
%
of
Patients
80
70
60
50
40
30
20
10
0
Total
Individual
Therapy
Group Therapy Family Therapy
Schizophrenia PORT
Major Depression Treatment
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Acute Phase (Symptom Response_
– Placebo……………………... 20-50%
– Antidepressant……………. 65-70%
– Psychotherapies………….. 47-55%
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Maintenance Phase (Relapse
Prevention)
– Placebo……………………… 15-45%
– Antidepressant…………….. 65-79%
Child and adolescent treatments that have
been found to be effective
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Empirically supported treatments
– Cognitive-behavior therapy for childhood anxiety disorders
– Cognitive-behavioral coping skills therapy for depression (including schoolbased 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 schoolbased treatments)
– Psychotropic medication for Attention Disorders and Obsessive-Compulsive
disorders
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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 Treatments
Conduct Problems
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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)
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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 Treatments
Depression in Adolescents
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Cognitive Behavioral Therapy
– Results of large controlled study showed reduction in
symptoms in 70% of those treated with CBT
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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 Psychopharmacology1
Class
1
Efficacy2
Indication
Short-term
Long-term
Stimulants
ADHD
A
B
SSRIs
Major depression
OCD
Anxiety disorders
B
A
C
C
C
C
Adrenergic
agonists
Tourette’s disorder
ADHD
B
C
C
C
Valproate &
Carbamazepine
Bipolar disorder
Aggressive behavior
C
C
C
C
TCAs
Major depression
ADHD
C
B
C
C
Antipsychotics
Schizophrenia
Tourette’s disorder
B
A
C
C
Lithium
Bipolar disorders
Aggressive behaviors
B
B
C
C
Jensen, Bhatara, Vitiello, et al 1999
2A=
2 RCTs; B = 1 RCT; C = clinical consensus
Different Perspectives on Outcomes
Example: Utility for Mild Symptoms plus Side
Effects Versus Moderate Symptoms and No Side
Effects (Lenert et al., 2000)
0.1
0.08
0.06
0.04
0.02
0
-0.02
-0.04
Patients
Familes
Providers
EVOLUTION OF MEDICAL TECHNOLOGY
AND COSTS OF TREATING DISEASE
(Pardes et al., 1999)
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Costs
– palliative
treatment
• Stages of Technology
cure