Evidence-Based Practices in
Psychiatric Rehabilitation
Bob Drake
October, 2010
Financial Support to PRC
 Grants from NIDA, NIDRR, NIMH, RWJF,
SAMHSA
 Contracts from Guilford Press, Hazelden
Press, MacArthur Foundation, Oxford Press,
New York Office of Mental Health, Research
Foundation for Mental Health
 Gifts from Johnson & Johnson Corporate
Contributions, Segal Foundation, Thomson
Foundation, Vail Foundation, West
Foundation
OVERVIEW
 Definition
 Update on evidence-based practices
 Common themes
 Dissemination and implementation
History of Mental Health in U.S.
 Cottage industry
 Little attention to outcomes
 Ineffective and harmful
interventions persist for years
 Effective interventions rarely used
Evidence-based Medicine
 The combination of science, client
values/preference, and clinical
expertise
 In mental health care, this means
combining science and recovery
ideology
Evidence-Based
Practices
 Standardized interventions
 Controlled research
 More than 1 research group
 Objective outcome measures
 Meaningful outcomes
Evidence-Based Rehabilitation Practices
Robert Wood Johnson Foundation 1998
 Assertive Community Treatment
 Supported Employment
 Family Psychoeducation
 Illness Management and Recovery
 Integrated Treatment for Co-
occurring Disorders
Assertive Community Treatment (ACT)
 Community-based team
 Low caseload
 Multidisciplinary
 Outreach
 Direct service provision
 24 hours/7days
Number of Studies
Research on ACT (cont.)
18
16
14
12
10
8
6
4
2
0
25 Randomized Controlled Trials
ACT better than standard treatment
ACT not better than standard treatment
Time in
Hospital
Housing
Stability
Quality
Client Symptoms Social Vocational
Jail/
of Life Satisfaction
Functioning
Arrests
Mueser KT, et al. Schizophr Bull. 1998;24(1):37-74.
Days Homeless on Streets:
ACT vs Usual Community Services
250
ACT
Usual community services
N=152
Days Homeless
200
150
100
50
0
First
Quarter
Lehman AF. Unpublished data.
Second
Quarter
Third
Quarter
Fourth
Quarter
Current ACT Issues
1. Hospital system changes
2. Quality of usual services
3. Forensic ACT
4. Other expansions and components
5. Transitions
Supported Employment
 Focus on competitive work
 Rapid job search
 De-emphasis on prevocational
training and assessment
 Attention to client preferences
 Follow-along supports as needed
Supported Employment RCTs
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
96
94
04
04
04
06
05
99
95
06
00
05 97
02
NH NY CA IL
CT
SC
HK DC IN
EUR NY QUE CA
MD
(IP S) (SE) (IP S) (IP S) (IP S) (IP S) (IP S) (IP S) (SE) (IP S) (SE) (IP S) (SE) (IP S)
Individual Placement and Support (IPS) vs
Enhanced Vocational Rehabilitation (EVR) in
Maintaining Competitive Jobs
% Working in Competitive Jobs
40
IPS (n=74)
EVR (n=76)
35
30
25
20
15
10
5
0
1
2 3
4 5
6 7 8 9 10 11 12 13 14 15 16 17 18
Study Months
Drake RE, et al. Arch Gen Psychiatry. 1999;56(7):627-633.
Current SE Issues
1. Financing
2. Cognitive strategies
3. Effective specialists
4. Disability reform
Family Psychoeducation
 Provided by professionals
 Long-term (over 6 months)
 Single and multiple family
group formats
 Focus on education, stress
reduction, coping, and other support
 Oriented toward future, not past
Effects of Family Intervention on
2-Year Relapse Rates (12 Studies)
% Cumulative Relapse Rate
100
75
50
25
0
Standard Care
(n=203)
Single Family
Treatment
(n=231)
Multiple Family Single and Multiple
Group Treatment
Family Group
(n=266)
Treatment
(n=243)
Mueser KT, Glynn SM. Behavioral Family Therapy for Psychiatric Disorders; 1999.
Montero I, et al. Schizophr Bull. 2001;27(4):661-670.
Current FPE Issues
1. Effectiveness failure
2. Family-to-family and alternatives
Illness Management Training
 Helping people learn to
manage their own illnesses
 Relapse prevention
 Minimize the effects of
residual symptoms
Research on Illness
Management Components
 Psychoeducation increases
knowledge and awareness
 Behavioral tailoring increases
effective use of medications
 Warning sign recognition
reduces relapses
 Cognitive-behavioral treatment
reduces residual symptoms
Effect Size on
Social Adjustment
Social Adjustment* Outcomes:
Cumulative Effect Sizes
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
Personal therapy (n=74)
No personal therapy (n=77)
p=.004
Intake
Year 1
Year 2
Years in Treatment
Year 3
*Social adjustment=work performance, relations in the home and with external family, social leisure,
general adjustment, interpersonal anguish, social relations, role performance, normal functioning,
Brief Psychiatric Rating Scale (BPRS) score, and Global Assessment Scale (GAS) score.
Hogarty GE, et al. Am J Psychiatry. 1997;154(11):1514-1524.
Current IMR Issues
1. More research
2. Training
3. Hard outcomes
4. Simplification
Integrated Dual Disorders Treatment
 Mental health and substance abuse
treatments combined by 1 team
• Assertive
• Stage-wise
• Individualized
• Comprehensive
• Long-term
% of Patients in Stable Remission
ACT and Integrated Dual
Disorders Treatment
60
50
High-fidelity ACT programs (n=61)
Low-fidelity ACT programs (n=26)
40
30
20
10
0
Baseline
6
12
18
24
Assessment Point
McHugo GJ, et al. Psychiatr Serv. 1999;50(6):818-824.
30
36
Current IDDT Issues
1. Standardization
2. Group and residential interventions
3. Supported employment
4. Staging
5. Simplification
Common Features of Evidence-Based
Rehabilitation Practices
 Shared decision
making and choice
 Individualization
 Skills and supports in
the community
 Adult roles
 Quality of life
Additional Rehabilitation Practices
 Social skills training
 Supported housing
 Supported education
 Integrated medical care
 Trauma interventions
Dissemination and Implementation
 Science to service gap
 No simple solution for
complex systems
 Multiple strategies
 Phases of implementation
 All stakeholders
 Fidelity
National EBP Project
 Phase I: conduct reviews, prepare
implementation packages (toolkits), and
establish state technical assistance
centers
 Phase II: field tests to refine procedures
and resource materials
 Phase III: national demonstration
Conceptual Framework for Implementing an Evidence-Based Practice
Families
Consumers
Implementation
Package
Mental
Health
Authority
Strategies
and
Barriers
EvidenceBased
Practice
Client
Outcomes
Administration
Program
Leader
Other
Factors
Practitioners
Com m unity Me ntal
He alth Ce nte r
Intervention
Stakeholders
Implementation
Process
Implementation
Outcome
System Changes 1
 Evidence-based medicine
 Address 3 components: science, consumer
involvement, practitioner skills
 Align financing and structures with goals
 Integrate treatment and rehabilitation: mental
health, substance abuse, vocational
rehabilitation, general health, housing, selfhelp, family supports
System Changes 2
 Improve data systems to focus on
outcomes and fidelity
 Enhance self-management
 Electronic records and decision
supports: education, assessment,
outcomes, decision making
 Engineer micro-systems of care
 Learning collaboratives
 Distance learning
Current Concerns
 Fidelity and outcomes
 Access and acceptability
 Durability
 Multi-cultural services
 Flexibility
 Financing
 Organization
Conclusions
 Evidence-based rehabilitation
interventions are available and will
improve rapidly
 Implementation requires changes in
organization and financing
 Flexible, individualized application requires
flexible clinicians and organizations
Further Information
 Patti O’Brien
 Patti.O’Brien@Dartmouth.edu
 603-448-0263
 www.mentalhealth.samhsa.gov