Unforeseen Benefits Study Richard Ries, M.D.

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Unexpected Benefits Study Richard Ries, M.D. Dennis Dyck Robert Short Mike Hendrix Paul Cope Debra Srebnik Stasia Fisher Barbara MacCalla The Urine Team NIDA SPECIAL THANKS TO: This review was upheld by an allow from the National Institute on Drug Abuse.

Dual Disorders Among the Severely Mentally Ill

Monthly "check impact" An assortment of studies going from extensive information bases to individual ER's and injury units have found that liquor and medication ( esp cocaine) related concedes crest in the main week after receipt of checks or advantages… Catalano 99, 2000, Grossman 97 others Shaner et al exhibited a relationship of cocaine utilize, tox screens and following psych concedes for Veterans with Schizophrenia and cocaine mishandle, demonstrating a first week of the month rehashed design

Dual Treatment Outcome

Harm Reduction in Severely Mentally Ill What Harm? Self (direct) Suicide Psychosis Grave incapacity Housing Loss Victimization Infection Others (indirect) Aggression Inappropriate conduct Property harm Family obliteration

TWO DIMENSIONAL AXIS OF PSYCHIATRIC AND CHEMICAL DEPENDENCY Substance Abuse MICA Severe ACT Border-line Moderate Psychopathology Mild Rehab Mild Severe Moderate Wingerson & Ries, 1999

TREATMENT TRACKS AND CLINICAL VARIABLES Wingerson & Ries, 1999

CLINICAL SEVERITY OF PATIENTS BY TREATMENT TEAM Wingerson & Ries, 1999

TREATMENT TRACKS AND CLINICAL VARIABLES Wingerson & Ries, 1999

CLINICAL SEVERITY OF PATIENTS BY TREATMENT TEAM Wingerson & Ries, 1999

CLINICAL SEVERITY OF PATIENTS BY TREATMENT TEAM Wingerson & Ries, 1999

Engaging the Chronically Psychotic Patient Noncoercive engagement methods Assistance acquiring sustenance, haven, and attire Assistance getting privileges and social administrations Drop-in focuses as section to treatment Recreational exercises Low-push, non-fierce methodologies Outreach to patient's group Coercive engagement systems Involuntary duty Mandated prescriptions Representative payee techniques CSAT TIP 1994

Payee versus Non Payee MICA Patients Ries: Am J Addict 1997

Contingency Management of Disability Benefits in SMI Dually Diagnosed Evaluate attainability and clinical viability of payee mediation Contingency in light of work by Higgins, Stitzer et al Monthly cycle of Disability $ >>> Substance utilize >>> Hospitalization… .Shaner et al NIDA financed randomized clinical trial

Contingency Management of Disability Benefits in SMI Dually Diagnosed MHC based Already have MHC as Payee … ie SSI delegate payee SMI in addition to ebb and flow substance reliance Weekly Case administrator appraisals and U-tox Removed from study if clinically destabilize… however dissected Intent to Treat

CHARACTERISTICS OF SAMPLE AT BASELINE Ries et al., 2003

CHARACTERISTICS OF SAMPLE AT BASELINE: SUBSTANCES USED Ries et al., 2003

"Week Used" Defined as either (+)Case Manager rating OR (+) clinically blinded Research U tox Case supervisors met every week with pts for Payee Log finishing Subjects met with research group every week for U tox and "rewards" Results "In Press" Psych Services 2003

Case chief evaluations versus week after week blinded U-tox… Ries et al: Psych Services 2000 Percentage of weeks substance use by pee toxicology (UT) or caseworker (CM) rating

Monthly example of Substance Use and Adverse Events… Ries AM J Addict, In Press Three-Day Interval Month Ends Month Begins

SUBSTANCES USED AT BASELINE Ries et al., 2003

5. Treatment Adherence a. Participation (% of Rx plan) b. Medicines (frequency/sum; % effectively taken) c. Enter most reduced % of participation or medicine adherence Weekly Adherence Summary Code 0 > 80%; 1=60-79%; 3 < 60% 4. Substance utilize a. Add up to # of days/week utilize (if "0", leave b,c,d clear) b. Particular Days Alcohol M T W Th F Sa S c. Particular Days Drugs M T W Th F Sa S d. Obscure substance M T W Th F Sa S Weekly Substance Use Summary Code 0=No utilize; 1=1 day; 3=2+ days 6. Cash Management Budgets and spends payee cash properly Circle best reaction: 0-19% 20-49% 50-79% 80-100% Weekly Money Management Summary Code 0 > 80%; 1=50-69%; 3 < half

4. Substance utilize a. Add up to # of days/week utilize (if "0", leave b,c,d clear) b. Particular Days Alcohol M T W Th F Sa S c. Particular Days Drugs M T W Th F Sa S d. Obscure substance M T W Th F Sa S Weekly Substance Use Summary Code 0=No utilize; 1=1 day; 3=2+ days

7. A week ago's dispensing plan: 1=weekly 2=2x/week 3=3x/week 4=4x/week 5=5x/week a. On which days of week M T W Th F Sa Su b. A week ago's sum: Cash $____ Coupons/supper tickets $_____ c. Evolving "miscellaneous items" this week? Y/N (if Y note in "Plan") Incidentals? Y/N Plan? Y/N 8. Social & Occupational Functional Assessment Scale (see back of frame)

9. Unfriendly Events: Number of... a. Psych Admissions, Voluntary b. Psych Admissions, Involuntary c. Detox Admissions d. Crisis Room Visits (MH or CD, no affirmation) e. Crisis Room Visits (medicinal just, no confirmation) f. Therapeutic concedes: Psych/CD brought about g. Imprisonments h. Loss of Housing i. Noteworthy mischief to self/others (if yes, call site facilitator 10. Customer in doctor's facility/imprison for an "incomplete week?" Y/N If yes, which days in healing center/imprison (circle all that apply) M T W Th F Sa Su

Scoring: WEEKLY DECISION SUMMARY INSTRUCTIONS If Weekly Status Sum=0, hover "0" in Decision Summary Score (beneath), praise, give gold honor. In the event that Weekly Status Sum=1 or 2, hover "1" in Decision Summary Score (beneath), empower better conduct, give silver honor. On the off chance that Weekly Status Sum=3 or more noteworthy, hover "3" in Decision Summary Score (underneath), support better conduct, give red honor. Week after week Decision Summary Score (circle one): 3 1 0 Type of Award Given (circle one): Red Silver Gold

Scoring: MONTHLY DECISION SUMMARY INSTRUCTIONS Review last 4 week after week logs by the twentieth - when you do your planning. On the off chance that Sum of Weekly Decision Summary Scores is: > 7, fix administration level (either/both shape or frequency- - portray on turn around under "Arrangement") 2-6, keep up administration level 0-1, relax administration level (either/both frame or frequency- - depict on invert under "Arrangement")

OUTCOMES : SUBSTANCE USE AND MONEY MANAGEMENT Ries et al., 2003

OUTCOMES: SUBSTANCE USE % Weeks Used Contingent gathering utilized fundamentally less liquor (p<0.01) and medications and liquor joined (p<.05) Ries et al., 2003

OUTCOMES: MONEY MANAGEMENT Appropriate Money Management Baseline Mean Post Randomization Mean Baseline Mean Post Randomization Mean 1=0-19%; 2=20-49%; 3=50-79%; 4=80-100% p<0.001 Ries et al., 2003

OUTCOMES: ADVERSE EVENTS Total Adverse Events Baseline Mean Post Randomization Mean Baseline Mean Post Randomization Mean Ries et al., 2003 Contingent gathering had essentially more benchmark unfavorable occasions (p<.01) ANOVA at result was NS, ALL 5 Safety Net subjects were Non-Contingent

CONTINGENT BENEFITS STUDY-NIDA POWER: THEORETICAL ANALYSIS 100 Contingency impact 75 Multiple, week by week dispersals 50 25 Having Rx focus be payee 0 Ries unpub. 5/99

CONTINGENT BENEFITS STUDY-NIDA SUMMARY OF PRELIMINARY FINDINGS 1. Unexpected administration of advantages brought about diminished substance utilize. 2. Impact seemed more prominent for liquor amid the week than for medications on the end of the week. 3. Power would likely increment if prior periods of intercession were examined. Ries unpub. 5/99

Correlations Between Case Manager and Patient Satisfaction and Outcome Ratings (n=55) Ries:Community MH Journal 99

DUAL DIAGNOSIS IS: TWO DIAGNOSES TWO SYSTEMS DOUBLE TROUBLE IN THE EYE OF THE BEHOLDER