Getting Evidence Based
Psychosocial Treatments into
Practice – Schizophrenia
Special Thanks to
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
z
z
Substantial Gap between Knowledge Base
and Practice in Ordinary Settings
Examples from Schizophrenia
Strategies for Improving
NIMH Outreach Partners
z
Behavioral Health Services Research
Association
New Freedom
Commission
z Surgeon General’s Report
z Institute of Medicine Report
z Schizophrenia PORT
Conventional Antipsychotics:
EfficacyEfficacy-Effectiveness Gap
Schizophrenia PORT
Treatment Recommendations
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.
z
z President’s
– The Generation of Knowledge
– Dissemination and Implementation of EBPs
z Recommendation
Tony Lehman, M.D.
for his Slides and Thoughts on the
Implementation of Evidence Based
Practices for Schizophrenia
The Absence Of EBP’s In Mental
Health Settings
Overview of Presentation
z
z
z
Annual Relapse Rates
- Placebo: 70%
- Efficacy in clinical trials: 23%
- Effectiveness in practice: 50%
z
Factors Affecting Efficacy-Effectiveness Gap
- Patient heterogeneity
- Prescribing practices
- Noncompliance
(from Kissling, 1992)
_________________
Schizophrenia PORT
1
Schizophrenia PORT
Treatment Recommendations
Issues Regarding Pharmacotherapy
Recommendation
z Recommendation
z Reluctance
of Prescribers to Change
Behavior
of Second Generation
Antipsychotic Medications
z Utilization Management Techniques
z Costs
– Prior Approval
– Fail First Policies
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
Effect Sizes of CBT on
Schizophrenia Symptoms
(Rector and Beck, 2001)
0.9
0.8
1.4
0.7
1.2
0.6
0.5
Personal Therapy
Versus No PT
0.4
1
Cognitive Behavior
Therapy
Supportive Therapy
0.8
0.6
0.3
0.2
0.4
0.1
0.2
0
Intake
N=148
0
Year 1 N=151 Year 2
N=128Year 3
(Begin: N=151)
Year in Treatment
Positive Symptoms
From Hogarty et. al. (1996)
Schizophrenia PORT
Treatment Recommendations
z Recommendation
Negative Symptoms
(End: N=125)
24: Persons with
schizophrenia who have on
- o
ging 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%
All 3 Treatments
10%
0%
One Year
Two Years
2
Schizophrenia PORT
Treatment Recommendations
VOCATIONAL STUDIES
z 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.
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
Rates of Conformance with PORT Psychosocial
Treatment Recommendations
APA Office of Quality Improvement and Psychiatric Services
100%
z Maintenance
dose of antipsychotic
within recommended range:
29%
z Adjunctive antidepressant:
46%
z Psychological Interventions:
45%
z Family psychoeducation:
10%
z Vocational rehabilitation:
22%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
Case
Management
Barriers to Implementing
Psychosocial Interventions
z
z
z
z
z
z
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
Psychotherapy Family Therapy
Voc Rehab
Any
Psychosocial
Managing the Workforce
z
Pre-Service Training
z
In Service Training
z
Ongoing Support for Effective Practices
– Annapolis Coalition
– Spray and Pray Training
– Information Support Systems
• Activity Templates/Fidelity Measures
• Outcome Benchmarks
z
z
Reimbursement Systems
Consumer Demand for Specific
Treatments
3
Preference Ratings for Differing
Outcomes
System Barriers
z
z
z
z
z
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
0.3
Policymakers (administrators, legislators, aides)
0.25
Preference / Importance
z
Primary Stakeholders (patients, family, providers)
0.2
0.15
0.1
0.05
0
Productive
Activity
Social
Activity**
Psychotic
Symptoms
Daily Activity
Deficit
Symptoms
– Reduction in Hospital Use Versus Normal Life in the
Community
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)
Consumer and Family Barriers
z
0.1
0.08
z
0.06
Patients
Familes
Providers
0.04
0.02
z
0
z
-0.02
-0.04
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
z
z
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
z
z
Medication
Side Effects*
Outcome Domains
Limited Systematic Attention to
Implementation of Findings
Limited Opportunities to Meaningfully
Interact with Multiple Stakeholders who
impact Implementation of Work
Difficult to Determine if Receiving EBP
Behavioral Health Services Research
Association/Academy Health Interest Group
z 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
z To
Join
– Email BHSRA-join@fmhi.usf.edu
4
BHSRA Strategy
z
z
z
z
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
5