1 The Quality Chasm in the Behavioral Health Treatment For America's Youth Michael L. Dennis, Ph.D. Chestnut Health Systems Normal, IL Presentation for the 26th Annual Children’s Mental Health Research & Policy Conference, Tampa, FL, Mark 3-6, Hosted by the University of South Florida’s The Department of Child & Family Studies and The Institute for Translational Research in Adolescent Behavioral Health (National Institute of Drug Abuse Grant no. R25DA031103). This presentation uses data from NIDA grants no. R01 DA15523, R37-DA11323, R01 DA021174,, CSAT contract no , Library of Congress contract no. LCFRD11C0007 and several public data sets. The author would like to thank Christy Scott, Barb Estrada, Rodney Funk, Lilia Hristova,, Brook Hunter, Rachel Kohlbecker, Lisa Nicholson, and Belinda Willis for their assistance in preparing this presentation. The opinions expressed are those of the author and do not reflect positions of the government. The presentation is available electronically at Please address comments or questions to the author at or

2 The Goals of this Presentation are to Examine: 1.The quality chasm in behavioral health care, including the low rates of treatment access and engagement, including evidence of health disparities by gender, race, age and involvement in the juvenile justice system. 2.The prevalence and co-morbidity of internalizing and externalizing mental health disorders, substance use disorders, and crime/violence including how they vary with age 3.The general factors associated with better outcomes in terms of reduced mental health, substance use and illegal activities

Size & Overlaps of Mental Health and Substance Use Disorder Populations (in millions) 3 Source: Institute of Medicine (2005) Improving the quality of health care for mental health and substance-use conditions. Crossing the Quality Chasm Series. Washington, DC: Author Comorbidity 15% of those with MH but 71% of those with SUD Very Low Rates of Treatment Participation More MH than SUD

Quality Chasm in Treatment (in millions) 4 Source: Institute of Medicine (2005) Improving the quality of health care for mental health and substance-use conditions. Crossing the Quality Chasm Series. Washington, DC: Author Low rates of Treatment Compliance Low rates of Identifying Comorbidity Low rates of Cont. Care

Problems and Treatment Participation Rates Vary by Age Source: SAMHSA National Survey On Drug Use And Health, 2010 [Computer file] Over 88% of adolescent and young adult treatment and over 50% of adult treatment is publicly funded Few Get Treatment: 1 in 20 adolescents, 1 in 18 young adults, 1 in 11 adults

Potential to Improve Identification by Screening for SUD in more sites Source: SAMHSA National Survey On Drug Use And Health, 2010 [Computer file] ACA’s expansion of School Based Health Centers present a major opportunity to close the gap Rise of Workplace Wellness programs with health risk assessments

Less than 80% of the Clients Engage in Treatment for 45 days or more (ONC measure of quality) Source: Office of Applied Studies 2009 Discharge – Treatment Episode Data Set (TEDS)

Less than Half of the Clients Stay in Treatment the 90 days Recommended by Research Source: Office of Applied Studies 2009 Discharge – Treatment Episode Data Set (TEDS)

Data on 29,782 clients from 230 local evaluations in 2011 SAMHSA/CSAT GAIN Data Set (89% with 1+ follow-up)

Primary Substance by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=27,716)

Past Year Substance Severity by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,358)

Tobacco Diagnosis by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=27,384)

Mental Health Disorders by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,684)

Type of Crime by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,377) * Violent crime includes assault, rape, murder, and arson. ** Other crime includes vandalism, possession of stolen goods, forgery, and theft.

Severity of Victimization by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,501)

Homicidal/Suicidal Thoughts by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,469)

Count of Major Clinical Problems at Intake Source: CSAT 2010 AT Summary Analytic Data Set (n=17,978)

Multiple Problems are the Norm Across All age Groups SAMHSA 2011 GAIN Summary Analytic Data Set (n=29,782)

The Elephant in the Room is the Severity of Victimization Source: CSAT 2010 AT Summary Analytic Data Set (n=18,120)

Environmental Strengths Index by Age SAMHSA 2011 GAIN Summary Analytic Data Set (n=27,625)

Unmet Need for Mental Health Treatment by 3 Months * p<.05 Age* SAMHSA 2011 GAIN SA Data Set subset to has 3m Follow up (n=14,358) Higher for Adolescents and Young Adults

Unmet Need for Medical Treatment by 3 Months * p<.05 Age* SAMHSA 2011 GAIN SA Data Set subset to has 3m Follow up (n=8,517) Significantly higher for Young Adults and Adolescents

Relative Percent Change in Abstinence (6 months minus intake/intake) by Age SAMHSA 2011 GAIN SA Data Set subset to 6 Month Follow up (n=20,181)

Change in GPRA Outcomes by Age (Intake to Last Wave*) *Last wave is the last follow-up SAMHSA 2011 GAIN SA Data Set subset to 1+ Follow ups

Change in GPRA Outcomes by Age (Intake to Last Wave*) *Last wave is the last follow-up SAMHSA 2011 GAIN SA Data Set subset to 1+ Follow ups

26 General Predictors of Bigger Effects 1.A strong intervention protocol based on prior evidence 2.Quality assurance to ensure protocol adherence and project implementation 3.Proactive case supervision of individual 4.Triage to focus on the highest severity subgroup

27 Impact of the numbers of these Favorable features on Recidivism in 509 Juvenile Justice Studies in Lipsey Meta Analysis Source: Adapted from Lipsey, 1997, 2005 Average Practice The more features, the lower the recidivism

28 Cognitive Behavioral Therapy (CBT) Interventions that Typically do Better than Usual Practice in Reducing Juvenile Recidivism (29% vs. 40%) Aggression Replacement Training Reasoning & Rehabilitation Moral Reconation Therapy Thinking for a Change Interpersonal Social Problem Solving MET/CBT combinations and Other manualized CBT Multisystemic Therapy (MST) Functional Family Therapy (FFT) Multidimensional Family Therapy (MDFT) Adolescent Community Reinforcement Approach (ACRA) Assertive Continuing Care Source: Adapted from Lipsey et al 2001, Waldron et al, 2001, Dennis et al, 2004 NOTE: There is generally little or no differences in mean effect size between these brand names

29 Implementation is Essential ( Reduction in Recidivism from.50 Control Group Rate) The effect of a well implemented weak program is as big as a strong program implemented poorly The best is to have a strong program implemented well Thus one should optimally pick the strongest intervention that one can implement well Source: Adapted from Lipsey, 1997, 2005

30 Change in Abstinence by level of Support: Adolescent Community Reinforcement Approach (A-CRA) Source: CSAT 2008 SA Dataset subset to 6 Month Follow up (n=1,961) Effects associated with Coaching, Certification and Monitoring (OR=7.6)

Key Points to Take Away There is a major quality chasm in current practice that are even worse for adolescents and young adults Multiple co-occurring problems are the norm, vary in mix by age and heavily related to victimization and trauma The best predictors of outcome are the use of evidenced based assessment and practice that have worked for others, have strong quality assurance, strong case supervision, and good triage of services to well defined problems.