Getting Evidence Based
Psychosocial Treatments into
Practice – Schizophrenia
David L. Shern, Ph.D
De la Parte Florida Mental Health
Institute
University of South Florida
Presented to AcademyHealth Annual Research Conference
June 6, 2004
San Diego, California
Special Thanks to

Tony Lehman, M.D.
for his Slides and Thoughts on the
Implementation of Evidence Based
Practices for Schizophrenia

NIMH Outreach Partners

Behavioral Health Services Research
Association
Overview of Presentation

Substantial Gap between Knowledge Base
and Practice in Ordinary Settings
 Examples from Schizophrenia
 Strategies for Improving
– The Generation of Knowledge
– Dissemination and Implementation of EBPs
The Absence Of EBP’s In Mental
Health Settings
President’s New Freedom
Commission
 Surgeon General’s Report
 Institute of Medicine Report
 Schizophrenia PORT

Schizophrenia PORT
Treatment Recommendations

Recommendation 1: Antipsychotic
medications, other than clozapine,
should be used as the first-line
treatment to reduce positive
psychotic symptoms for persons
with multi-episode schizophrenia
who are experiencing an acute
exacerbation of their illness.
Conventional Antipsychotics:
Efficacy-Effectiveness Gap

Annual Relapse Rates
- Placebo: 70%
- Efficacy in clinical trials: 23%
- Effectiveness in practice: 50%

Factors Affecting Efficacy-Effectiveness Gap
- Patient heterogeneity
- Prescribing practices
- Noncompliance
(from Kissling, 1992)
_________________
Schizophrenia PORT
Issues Regarding Pharmacotherapy
Recommendation
Reluctance of Prescribers to Change
Behavior
 Costs of Second Generation
Antipsychotic Medications
 Utilization Management Techniques

– Prior Approval
– Fail First Policies
Schizophrenia PORT
Treatment 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
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)
Effect Sizes of CBT on
Schizophrenia Symptoms
(Rector and Beck, 2001)
1.4
1.2
1
Cognitive Behavior
Therapy
Supportive Therapy
0.8
0.6
0.4
0.2
0
Positive Symptoms
Negative Symptoms
Schizophrenia PORT
Treatment Recommendations

Recommendation 24: Persons with
schizophrenia who have on-going contact
with their families should be offered a
family psychosocial intervention, the key
elements of which include a duration of at
least three months, illness education,
crisis intervention, emotional support, and
training in how to cope with illness
symptoms.
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

Recommendation 25: Persons with
schizophrenia should be offered
supported employment, the key elements
of which include individualized job
development, rapid placement
emphasizing competitive employment,
ongoing job supports, and integration of
vocational and mental health services.
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
SCHIZOPHRENIA PORT
Current 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
Treatment Recommendations
APA Office of Quality Improvement and Psychiatric Services
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Case
Management
Psychotherapy Family Therapy
Voc Rehab
Any
Psychosocial
Barriers to Implementing
Psychosocial Interventions






Workforce Preparation
Work Environment Supports and
Incentives
Policy Maker Knowledge
Knowledge Development and
Dissemination Strategies
Demand Side Pressures for Improvement
Differential Utilities for Treatments and
Outcomes
Managing the Workforce

Pre-Service Training
– Annapolis Coalition

In Service Training
– Spray and Pray Training

Ongoing Support for Effective Practices
– Information Support Systems
• Activity Templates/Fidelity Measures
• Outcome Benchmarks

Reimbursement Systems
 Consumer Demand for Specific
Treatments
System Barriers
Reimbursement Practices Don’t Track Evidence
Base
 Complex Categorical Funding Streams Frustrate
Integrated Care
 Narrow Focus on Agency Specific Budgets in
Cost Containment
 Policy Makers Unaware of Evidence Based and
Informed Practices
 Systematic Outcome and Process Data are not
Available
 Differing Values for Differing Outcomes

– Reduction in Hospital Use Versus Normal Life in the
Community
Preference Ratings for Differing
Outcomes
0.3
Policymakers (administrators, legislators, aides)
Preference / Importance
0.25
Primary Stakeholders (patients, family, providers)
0.2
0.15
0.1
0.05
0
Productive
Activity
Social
Activity**
Psychotic
Symptoms
Daily Activity
Deficit
Symptoms
Medication
Side Effects*
Outcome Domains
From Shumway et al,
2003
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
Consumer and Family Barriers

Stigmatized Disorders Inhibit Information
Flow among Consumers
 Research Results Complex and Difficult to
Interpret
 Differential Power Relationships with
Providers – Particularly for People with
Mental Illnesses
 Personal Desires may not Comport with
Reimbursed Treatments
– Rehabilitation Often Not Available

Difficult to Determine if Receiving EBP
Research Barriers

Research Culture
– Questions Derived Within Researcher Defined
Framework
– Control of Heterogeneity which doesn’t Map Real World
Applications
– Dissemination through Limited Channels
• Peer Reviewed Publication

Limited Systematic Attention to
Implementation of Findings
 Limited Opportunities to Meaningfully
Interact with Multiple Stakeholders who
impact Implementation of Work
Behavioral Health Services Research
Association/Academy Health Interest Group

Goals
– To Improve the Knowledge Development and
Dissemination Strategy
– To Advocate for the Importance of Behavioral
Health Services Research in Improving our
Human Services Systems

To Join
– Email BHSRA-join@fmhi.usf.edu
BHSRA Strategy

Conduct Issue Forums in Conjunction with Other
Scheduled Meetings
– NASMHPD, NAMI, APA, ACMHA,
AcademyHealth, etc.
 Issue Forums Composed of Multiple Stakeholders
and Focused on a Particular Issue
 Form Working Groups to Develop Research
Questions and Settings within which to Conduct
Work
 Advocate with National and State Leadership
about the Importance of Rigorous Approach to
Studying and Managing Behavioral Health Care
Settings