Getting Evidence Based Getting Evidence Based Psychosocial Treatments into Psychosocial Treatments into

Practice – SchizophreniaPractice – Schizophrenia

David L. Shern, Ph.D

De la Parte Florida Mental Health Institute

University of South FloridaPresented to AcademyHealth Annual Research Conference

June 6, 2004

San Diego, California

Special Thanks to 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 PresentationOverview 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 The Absence Of EBP’s In Mental Health SettingsHealth Settings

President’s New Freedom Commission

Surgeon General’s ReportInstitute of Medicine ReportSchizophrenia PORT

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment 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: Conventional Antipsychotics: Efficacy-Effectiveness GapEfficacy-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 Issues Regarding Pharmacotherapy RecommendationRecommendation

Reluctance of Prescribers to Change Behavior

Costs of Second Generation Antipsychotic Medications

Utilization Management Techniques– Prior Approval– Fail First Policies

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment 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 Cumulative Effect Sizes Adjustment OutcomesAdjustment Outcomes

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

Intake Year 1 Year 2 Year 3

Personal TherapyVersus No PT

(Begin: N=151) (End: N=125)

N=148 N=151 N=128

From Hogarty et. al. (1996)Year in Treatment

Effect Sizes of CBT on Effect Sizes of CBT on Schizophrenia Symptoms Schizophrenia Symptoms

(Rector and Beck, 2001)(Rector and Beck, 2001)

0

0.2

0.4

0.6

0.8

1

1.2

1.4

Positive Symptoms Negative Symptoms

Cognitive BehaviorTherapySupportive Therapy

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment 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 SchizophreniaCombined Therapies for SchizophreniaAnnual Relapse Rates (Hogarty et al., Annual Relapse Rates (Hogarty et al.,

1986)1986)

0%

10%

20%

30%

40%

50%

60%

70%

One Year Two Years

Medications Only

Medications PlusFamilyPsychoeducationMedications PlusSocial Skills

All 3 Treatments

Schizophrenia PORT Schizophrenia PORT Treatment RecommendationsTreatment 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 STUDIESVOCATIONAL STUDIES

0% 10% 20% 30% 40% 50% 60% 70% 80% 90%

Gervey 94

Bond 95

Drake 96

Chandler 97

Drake 99

McFarlane 00Control

Supported Employment

% Working

SCHIZOPHRENIA PORT SCHIZOPHRENIA PORT Current PracticesCurrent 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 Rates of Conformance with PORT Psychosocial Treatment RecommendationsTreatment Recommendations

APA Office of Quality Improvement and Psychiatric ServicesAPA Office of Quality Improvement and Psychiatric Services

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

CaseManagement

Psychotherapy Family Therapy Voc Rehab AnyPsychosocial

Barriers to Implementing Barriers to Implementing Psychosocial InterventionsPsychosocial 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 WorkforceManaging 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 BarriersSystem 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 Preference Ratings for Differing Outcomes Outcomes

0

0.05

0.1

0.15

0.2

0.25

0.3

ProductiveActivity

SocialActivity**

PsychoticSymptoms

Daily Activity DeficitSymptoms

MedicationSide Effects*

Outcome Domains

Pre

fere

nc

e /

Imp

ort

anc

e

Policymakers (administrators, legislators, aides)

Primary Stakeholders (patients, family, providers)

From Shumway et al, 2003

Different Perspectives on OutcomesDifferent Perspectives on Outcomes Example: Utility for Mild Symptoms plus Side Example: Utility for Mild Symptoms plus Side Effects Versus Moderate Symptoms and No Side Effects Versus Moderate Symptoms and No Side

Effects (Lenert et al., 2000)Effects (Lenert et al., 2000)

-0.04

-0.02

0

0.02

0.04

0.06

0.08

0.1

PatientsFamilesProviders

Consumer and Family BarriersConsumer 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 BarriersResearch 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 Behavioral Health Services Research Association/Academy Health Interest GroupAssociation/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 StrategyBHSRA 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