IPS: Institute on Psychiatric Services

SAN FRANCISCO – When it comes to practice transformation, starting from scratch can be better than reinventing the wheel.

At least it was in Texas, when six federally qualified health organizations implemented a novel, collaborative program to treat depressed patients.

Compared with the clinics with no preexisting mental health services, those that already had something in place had a harder time meeting follow-up, treatment, and symptom improvement targets in the first few months.

"They had difficulty thinking about treating people differently. People fell through the cracks," said the lead investigator in an evaluation of the project, Dr. Amy M. Bauer of the department of psychiatry and behavioral sciences at the University of Washington, Seattle.

In short, "reengineering the airplane in midflight" can be tricky, she said, an important lesson at a time when collaborative care models are gaining traction in the United States.

University of Washington researchers developed the model and helped implement it in Texas. One aspect of the model that makes it novel is that it is population based; instead of focusing on individuals, participants, once they’re enrolled, are entered into a Web-based registry and followed as a group by care managers.

The registry makes it possible to help track patients’ clinical progress, as well as their visit history and prescribed medications. Care managers asked patients about their use of medications and used this information to inform treatment and intensify treatment when indicated. If patients do not follow up, care managers give them a call and address the reasons. However, there was no mechanism to independently verify whether patients were actually using medications as they reported.

"Organizations that already have a very established mental health system are going to have to think carefully about ... how they are going to work on changing it."

The care managers also coordinate patients’ care with primary care doctors who write prescriptions and adjust medications as needed. The whole operation is overseen at each clinic by a psychiatrist who reviews treatment plans, consults on difficult cases, and supervises the care managers, but generally doesn’t see patients directly. "The registry and proactive outreach are elements of the collaborative care model that aim to improve treatment engagement and enhance treatment retention," she said in an interview.

It’s "very different from the traditional model where you have a small group of people and if they stop coming, they’re off your case load," Dr. Bauer said.

The clinics treated 2,821 adult patients from 2006 to 2009; the mean age of patients was around 45, and more than 80% or so were women.

Overall, the clinics did well. After almost a year and a half, 70% or more of enrolled patients had either dropped their Patient Health Questionnaire depression scores (PHQ-9) by 50%, or had scores of 5 or less, indicating remission.

The quickest improvements tended to be at several rural health centers in the Rio Grande Valley. They started with no mental health services at all; "primary care doctors [there] felt really glad to have anything in place," Dr. Bauer said. Six months into the project, 60% or more of patients at the clinics starting from scratch met the improvement targets.

Clinics with at least some preexisting mental health services, however, lagged behind. One had a well-established system that treated depressed patients the old-fashioned way: 1 hour of therapy, no outreach, no clinical coordination, no population-based care.

Improvement rates ranged from about 30% to 60% at the clinics that tried to make existing services fit the new model. The results were significant, and differences between clinic populations were factored into the analysis.

Care got bogged down and remained fragmented in some cases. Patients got lost in a shuffle between primary care, care mangers, and the older mental health program. There were buy-in problems, too; some primary care providers didn’t think it was their role to manage mental health conditions.

The findings suggest "that organizations that already have a very established mental health system are going to have to think carefully about the existing culture of care and how they are going to work on changing it," Dr. Bauer said.

Even with the early problems in some clinics, however, the evaluation revealed that the program "got people into treatment and on medication. No site is so underresourced that it can’t implement a collaborative care model. In the real world, you can do remarkably well when implementing this model," she said.

Dr. Bauer said she had no relevant financial disclosures. The demonstration project was funded by the Hogg Foundation for Mental Health.

SAN FRANCISCO – When it comes to practice transformation, starting from scratch can be better than reinventing the wheel.

At least it was in Texas, when six federally qualified health organizations implemented a novel, collaborative program to treat depressed patients.

Compared with the clinics with no preexisting mental health services, those that already had something in place had a harder time meeting follow-up, treatment, and symptom improvement targets in the first few months.

"They had difficulty thinking about treating people differently. People fell through the cracks," said the lead investigator in an evaluation of the project, Dr. Amy M. Bauer of the department of psychiatry and behavioral sciences at the University of Washington, Seattle.

In short, "reengineering the airplane in midflight" can be tricky, she said, an important lesson at a time when collaborative care models are gaining traction in the United States.

University of Washington researchers developed the model and helped implement it in Texas. One aspect of the model that makes it novel is that it is population based; instead of focusing on individuals, participants, once they’re enrolled, are entered into a Web-based registry and followed as a group by care managers.

The registry makes it possible to help track patients’ clinical progress, as well as their visit history and prescribed medications. Care managers asked patients about their use of medications and used this information to inform treatment and intensify treatment when indicated. If patients do not follow up, care managers give them a call and address the reasons. However, there was no mechanism to independently verify whether patients were actually using medications as they reported.

"Organizations that already have a very established mental health system are going to have to think carefully about ... how they are going to work on changing it."

The care managers also coordinate patients’ care with primary care doctors who write prescriptions and adjust medications as needed. The whole operation is overseen at each clinic by a psychiatrist who reviews treatment plans, consults on difficult cases, and supervises the care managers, but generally doesn’t see patients directly. "The registry and proactive outreach are elements of the collaborative care model that aim to improve treatment engagement and enhance treatment retention," she said in an interview.

It’s "very different from the traditional model where you have a small group of people and if they stop coming, they’re off your case load," Dr. Bauer said.

The clinics treated 2,821 adult patients from 2006 to 2009; the mean age of patients was around 45, and more than 80% or so were women.

Overall, the clinics did well. After almost a year and a half, 70% or more of enrolled patients had either dropped their Patient Health Questionnaire depression scores (PHQ-9) by 50%, or had scores of 5 or less, indicating remission.

The quickest improvements tended to be at several rural health centers in the Rio Grande Valley. They started with no mental health services at all; "primary care doctors [there] felt really glad to have anything in place," Dr. Bauer said. Six months into the project, 60% or more of patients at the clinics starting from scratch met the improvement targets.

Clinics with at least some preexisting mental health services, however, lagged behind. One had a well-established system that treated depressed patients the old-fashioned way: 1 hour of therapy, no outreach, no clinical coordination, no population-based care.

Improvement rates ranged from about 30% to 60% at the clinics that tried to make existing services fit the new model. The results were significant, and differences between clinic populations were factored into the analysis.

Care got bogged down and remained fragmented in some cases. Patients got lost in a shuffle between primary care, care mangers, and the older mental health program. There were buy-in problems, too; some primary care providers didn’t think it was their role to manage mental health conditions.

The findings suggest "that organizations that already have a very established mental health system are going to have to think carefully about the existing culture of care and how they are going to work on changing it," Dr. Bauer said.

Even with the early problems in some clinics, however, the evaluation revealed that the program "got people into treatment and on medication. No site is so underresourced that it can’t implement a collaborative care model. In the real world, you can do remarkably well when implementing this model," she said.

Dr. Bauer said she had no relevant financial disclosures. The demonstration project was funded by the Hogg Foundation for Mental Health.

SAN FRANCISCO – When it comes to practice transformation, starting from scratch can be better than reinventing the wheel.

At least it was in Texas, when six federally qualified health organizations implemented a novel, collaborative program to treat depressed patients.

Compared with the clinics with no preexisting mental health services, those that already had something in place had a harder time meeting follow-up, treatment, and symptom improvement targets in the first few months.

"They had difficulty thinking about treating people differently. People fell through the cracks," said the lead investigator in an evaluation of the project, Dr. Amy M. Bauer of the department of psychiatry and behavioral sciences at the University of Washington, Seattle.

In short, "reengineering the airplane in midflight" can be tricky, she said, an important lesson at a time when collaborative care models are gaining traction in the United States.

University of Washington researchers developed the model and helped implement it in Texas. One aspect of the model that makes it novel is that it is population based; instead of focusing on individuals, participants, once they’re enrolled, are entered into a Web-based registry and followed as a group by care managers.

The registry makes it possible to help track patients’ clinical progress, as well as their visit history and prescribed medications. Care managers asked patients about their use of medications and used this information to inform treatment and intensify treatment when indicated. If patients do not follow up, care managers give them a call and address the reasons. However, there was no mechanism to independently verify whether patients were actually using medications as they reported.

"Organizations that already have a very established mental health system are going to have to think carefully about ... how they are going to work on changing it."

The care managers also coordinate patients’ care with primary care doctors who write prescriptions and adjust medications as needed. The whole operation is overseen at each clinic by a psychiatrist who reviews treatment plans, consults on difficult cases, and supervises the care managers, but generally doesn’t see patients directly. "The registry and proactive outreach are elements of the collaborative care model that aim to improve treatment engagement and enhance treatment retention," she said in an interview.

It’s "very different from the traditional model where you have a small group of people and if they stop coming, they’re off your case load," Dr. Bauer said.

The clinics treated 2,821 adult patients from 2006 to 2009; the mean age of patients was around 45, and more than 80% or so were women.

Overall, the clinics did well. After almost a year and a half, 70% or more of enrolled patients had either dropped their Patient Health Questionnaire depression scores (PHQ-9) by 50%, or had scores of 5 or less, indicating remission.

The quickest improvements tended to be at several rural health centers in the Rio Grande Valley. They started with no mental health services at all; "primary care doctors [there] felt really glad to have anything in place," Dr. Bauer said. Six months into the project, 60% or more of patients at the clinics starting from scratch met the improvement targets.

Clinics with at least some preexisting mental health services, however, lagged behind. One had a well-established system that treated depressed patients the old-fashioned way: 1 hour of therapy, no outreach, no clinical coordination, no population-based care.

Improvement rates ranged from about 30% to 60% at the clinics that tried to make existing services fit the new model. The results were significant, and differences between clinic populations were factored into the analysis.

Care got bogged down and remained fragmented in some cases. Patients got lost in a shuffle between primary care, care mangers, and the older mental health program. There were buy-in problems, too; some primary care providers didn’t think it was their role to manage mental health conditions.

The findings suggest "that organizations that already have a very established mental health system are going to have to think carefully about the existing culture of care and how they are going to work on changing it," Dr. Bauer said.

Even with the early problems in some clinics, however, the evaluation revealed that the program "got people into treatment and on medication. No site is so underresourced that it can’t implement a collaborative care model. In the real world, you can do remarkably well when implementing this model," she said.

Dr. Bauer said she had no relevant financial disclosures. The demonstration project was funded by the Hogg Foundation for Mental Health.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.

SAN FRANCISCO – Substance expectation therapy, a newer form of cognitive-behavioral therapy, appears to do a better job helping people quit smoking, and it’s less of a burden on therapists.

Among 20 smokers randomized to substance expectation therapy (SET), 75% (15) completed all 12 weekly, hour-long sessions, and SET participants had a mean carbon monoxide breath concentration during the last three of 11 ppm.

The 20 randomized to more traditional cognitive-behavioral therapy (CBT) didn’t do as well. Just 45% (9) completed the 12 weeks, and participants had a mean carbon monoxide breath concentration of 18 ppm during the last few sessions.

The differences were statistically significant, and may have something to do with the looser, more free-form format of SET therapy. "There’s much less indirect finger-wagging; there might be a little homework, but if they don’t complete it, that’s okay. Whereas within the CBT model, when you give a homework assignment, a lot of times people don’t show up the next week," said lead investigator Charles H. Wilber, assistant director of the Braceland Center for Mental Health and Aging, Hartford, Conn., and a senior scientist at the Burlingame Center for Psychiatric Research and Education at Hartford Hospital.

Developed over the last 15 years by Mr. Wilber and his colleagues at the hospital, Adam Jaffe, Ph.D., SET has proven successful in helping people quit hard drugs. This is the first time it’s been shown to help smokers, too.

Like CBT, SET addresses triggers, but the main emphasis is on shifting the positive expectations clients have about lighting up to negative expectations. It’s a less linear approach than traditional CBT.

In the early sessions, patients are made aware of what they expect from smoking, often relaxation and better focus. Then, and maybe for the first time, they are asked to think about what negative results they can expect – besides bad breath and lung cancer – and to question how real their positive expectations are. They might be asked, "Does smoking always relax you? Does it affect your sleep? How relaxing is it to wake up in a nicotine fit?"

"They begin to make that shift to more negative expectancies. You get them to think more about it and talk about it. Because you’re not being hard on them, they begin to say, ‘Yeah. I understand what you’re saying. Maybe it’s more reasonable I begin to think about stopping smoking,’ " Mr. Wilber said.

For the therapist, it’s "a mellower approach. More of a dialogue, more of a discussion," and so less of a burden, he said.

"The idea is to keep the person engaged, as opposed to being the doctor with the white coat saying you shouldn’t be smoking. I want to keep the person coming back and continuing to talk to me," Mr. Wilber said.

Maybe that’s why early retention rates were better for SET participants, too. Just 5% (1) dropped out during the first 3 weeks; 35% (7) dropped out of the CBT group by the third week. Some of the patients in each arm also got nicotine patches – SET seemed particularly effective in those cases.

The University of New Mexico, Albuquerque, plans to test SET in the state’s prison system to see if it helps with drug problems and impulsivity, Mr. Wilber said.

Mr. Wilber said he has no disclosures.