DATA-DRIVEN
TREATMENT Outcomes Research Summary 2015
WHOLE PERSON
CARE
A different kind of mental health solution.
DATA-DRIVEN TREATMENT WHOLE PERSON CARE We treat each individual, individually, tailoring an approach that includes a broad mix of evidencebased one-on-one and group therapies that help our clients grow, recover, and reclaim their lives.
References 1 Results are significant at the p<.05 significance level. The 32-item Behavior and Symptom Identification Scale (BASIS-32): © Copyright McLean University, Affiliate of Harvard Medical School. 2 Results are statistically significant at the p<.05 significance level. Beck Hopelessness Scale: Beck AT, Weissman A, Lester D, Trexler L. (1074). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), 861-865. 3 Results are statistically significant at the P<.05 significance level. Medication Attitude Inventory: Hogan TP, Awad AG, & Eastwood R. (1983). A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychological Medicine, 13, 177-183. 4 Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychological Reports. 1962; 10:799-812. 5 Montgomery, S.A. & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389. 6 Young RC, Biggs JT, Ziegler VE, Meyer DA: A rating scale for mania: reliability, validity and sensitivity. British Journal of Psychiatry, 133:429-435, 1978. 7 Hamilton M: The assessment of anxiety states by rating. British Journal of Medical Psychology, 32:50-55,1959.
Credits OUTCOMES & RESEARCH Ray Kotwicki, MD, MPH Chief Medical Officer Skyland Trail Philip D. Harvey, PhD Research & Outcomes Director, Skyland Trail Miller School of Medicine, University of Miami Alexandra Balzer, MPH Research & Outcomes Coordinator Skyland Trail EDITOR/DESIGNER Shannon Easley, MPA Communications Director Skyland Trail PHOTOGRAPHY Sarah Tabor
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Skyland Trail is a trailblazer in the area of outcomes research, which is an integral part of our evidence-based treatment model. Our robust outcomes and research program employs evaluative instruments considered to be the gold standards in the mental health field to measure the effectiveness of our treatment programs. Outcome data from 2008 through 2015 confirm that our unique integrated, whole person approach helps our clients grow, recover, and reclaim their lives. People who complete the treatment program at Skyland Trail return to their communities with reduced symptoms and improved skills to pursue more independent and productive lives. When clients begin treatment at Skyland Trail, they complete tests measuring their symptom severity, attitude toward medication adherence, hope for the future, level of functioning, senses of self efficacy and relationships with others, and physical health. We measure those indicators again when they complete their treatment. We supplement these measurements with annual satisfaction surveys. Specialized instruments based on diagnoses and symptoms provide a more detailed picture of the effectiveness of specific treatment programs for bipolar illness, major depression, schizophrenia, and anxiety.
ASSESSMENT SCALES IMPROVEMENT IN FUNCTIONING
• • •
Behavior & Symptom Identification Scale-32 (BASIS-32) Medication Attitude Inventory (MAI) Making Decisions Scale (MDS)
REDUCTION IN SYMPTOMS
• •
Behavior & Symptom Identification Scale-32 (BASIS-32) Beck Hopelessness Scale (BHS)
DISEASE-SPECIFIC OUTCOMES
• • • • • • •
Schizophrenia & Schizoaffective Disorder: Brief Psychiatric Rating Scale (BPRS-24) Major Depression: Montgomery-Asberg Depression Rating Scale (MADRS) Anxiety: Hamilton Anxiety Rating Scale (HAM-A) Bipolar: Young Mania Rating Scale (YMRS) Difficulties in Emotion Regulation Scale (DERS) The Dialectical Behavior Therapy Ways of Coping Checklist (DBT-WCCL) Borderline Symptom List (BSL-23)
PHYSICAL HEALTH OUTCOMES
Indicators of physical health including: • BMI • Cholesterol levels • Sugar metabolism • Vital signs • CBC with differential for signs of infection or anemia • Comprehensive Metabolic Panel (CMP)
SATISFACTION WITH SERVICES
•
Client satisfaction survey
• • • • • •
Thyroid function tests RPR for syphilis HIV test & other STDs Drug screening ppD for TB Nutritional indicators such as B12, folic acid, Vitamin D
2015 KEY OUTCOMES
92
%
80
%
of all clients experienced a statistically significant improvement in their attitude toward activities of daily living & overall functioning1
CONTINUUM OF CARE
of clients who are depressed experienced statistically significant improvement5
98%
79% of clients with anxiety experienced statistically significant improvement in control of anxiety7
of all clients experienced a statistically significant improvement in feelings of hopelessness2
Outpatient Programs: Wellness Clinic, Outpatient DBT, Vocational Services
Average Length of Treatment
4-6
of clients would recommend Skyland Trail to someone else
80%
88%
Residential Treatment Day Treatment Intensive Outpatient
months
Serving Clients from Across the Country National 14% Southeast 27% Georgia 59%
of clients leave treatment with a positive attitude about taking psychiatric medication3
2015 CLIENT COMMUNITY Primary Psychiatric Diagnoses Confirmed at Admission
Age at Admission
Expressed Gender
49% Major depression
60% Ages 18-25
48% Female
17% Bipolar illness
20% Ages 26-35
52% Male
13% Psychotic disorders
5% Ages 46-55
8% Anxiety disorders
11% Ages 36-45
13% Other
4% Ages 55+
PATIENT COMPLEXITY
75%
of clients had > 3 co-occurring diagnoses confirmed at admission
53% Four or more diagnoses 22% Three diagnoses 25% Two or fewer diagnoses
Co-occurring Disorders include: anxiety disorders (OCD in particular) substance abuse (46% of all clients) borderline personality disorder others
â&#x20AC;&#x153;We are coming to understand that not many people have a single, isolated diagnosis...patients often also are struggling with anxiety, substance use, cognitive issues, and physical health problems. To truly meet the needs of our patients and improve health long-term, we need an evidence-based, individualized, and integrated approach - one that helps patients heal in all the ways that matter.â&#x20AC;? - RAY KOTWICKI, MD, MPH, CHIEF MEDICAL OFFICER
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INCREASED HOPEFUL THINKING In 2015, clients continued to experience a statistically significant decrease in feelings of hopelessness, t(120)=10.0, p =.000. This finding was also consistent when broken down by diagnosis, indicating that individuals of all diagnoses improved from feeling very hopeless at admission to having hopeful future expectations at discharge.
88
%
of all clients experienced a statistically significant improvement in feelings of hopelessness2
Beck Hopelessness Scale Scores by Diagnosis 2015 ADMISSION These individuals see very little hope in all domains of their lives.
3–8 Individuals display some hopelessness in their thinking. Individuals closer to 8 can be said to be very hopeless while those scoring closer to 3 can be said to be somewhat hopeless.
IMPROVEMENT
>8 Individuals have nihilistic preoccupations.
10 10 88
9.83 7.98
7.99
7.71
66 (N=121)
44 <3 Individuals are said to be hopeful.
DISCHARGE
2.89
(N=24)
2.67
(N=65)
2.94
22 00
(N=18)
2.67
ALL
BIPOLAR
DEPRESSION
THOUGHT DISORDERS
All
Bipolar
Depression
Thought Disorder
Beck AT, Weissman A, Lester D, Trexler L. (1974). The measurement of pessimism: The Hopelessness Scale. Journal of Consulting and Clinical Psychology, 42(6), 861-865 p<.001 for all comparisons
For individuals with bipolar disorder, improvements indicate a shift from moderate hopeless thinking to hopeful thinking.
For individuals with depression or a thought disorder, the improvements indicate a shift from nihilistic, hopeless thinking to hopeful thinking.
IMPROVED COGNITIVE FUNCTIONING
10
%
increase in treatment program completion rates among patients who participate in cognitive training
In 2015 we began examining the effect of computer-based cognitive remediation training, or cognitive training, on psychiatric symptoms and overall recovery. An initial analysis of patients who participated in cognitive training with the general patient population shows a 10 percent higher rate of “graduation” - or treatment program completion - among patients who participated in cognitive training. We have declared 2016 the “Year of Thinking” and plan to expand our analysis of this promising opportunity to help our patients prevent cognitive decline and perhaps boost their ability to sustain recovery long term. Research indicates that cognitive training may be particularly beneficial for young adults experiencing the early stages of mental illness. As we expand our capacity to treat emerging adults ages 18 to 26 on our new Rollins Campus, cognitive training will be an important component of our treatment program for young adults.
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REDUCED SYMPTOMS BY DIAGNOSIS Skyland Trail administers disease-specific outcome measurement tools every two weeks of treatment, based on the confirmed diagnosis at admission. Though the scales differ for each measurement, lower scores always indicate improved symptomatology. SCORE CLOSEST TO ADMISSION
Scores closest to admission and closest to discharge, show that for all four diagnosis-specific measures, clients show a clinically and statistically significant improvement of symptomatology.
SCORE CLOSEST TO DISCHARGE
BIPOLAR ILLNESS
MAJOR DEPRESSION
79%
80%
of clients with mania experienced statistically significant reduction of their manic symptoms6
of clients who are depressed experienced statistically significant improvement5
Young Mania Rating Scale 2015
Montgomery-Asberg Depression Rating Scale 2015
t(10) = 3.47 p = .004
t(104) = 7.85, p =.000
12.6
12 12 99 66
3.4
33
0 0
IMPROVEMENT
IMPROVEMENT
15 15
2525 2020
22.0 13.3
1515 1010 55 00
Young, et. Al. (1978). A rating scale for mania: reliability, validity, and sensitivity. British Journal of Psychiatry, 133, 429-435.
ANXIETY DISORDERS
Montgomery, S.A. & Åsberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382-389.
THOUGHT DISORDERS
79
of clients with anxiety experienced statistically significant improvement in control of anxiety7
of clients with thought disorders experienced statistically significant improvement in symptoms of psychosis4
Hamilton Scale of Anxiety 2015
Brief Psychotic Rating Scale 2015
t(13) = 3.47, p =.004
t(42) = 4.69, p =.000
9.22
10 10 55 00
Hamilton M: The assessment of anxiety states by rating. British Journal of Medical Psychology 32:50-55,1959.
IMPROVEMENT
IMPROVEMENT
15.11
20 20 15 15
- LOREN P., SKYLAND TRAIL GRADUATE
77%
%
25 25
“The focus of my life and the track that I am on have completely shifted. I have the skills now to make the changes that I always wanted to make but didn’t know how. I had really given up hope, but now I see a positive road ahead.”
50 50 40 40
49.1 39.1
30 30 20 20 10 10 00
Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychological Reports. 1962; 10:799-812.
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IMPROVED FUNCTIONING
92
%
In 2015, patients consistently showed statistically significant functional improvement as measured by the BASIS-32. Comprised of 5 subscales, the BASIS-32 contains an overall average score ranging from 0 to 4, with lower scores indicating greater levels of functioning in daily life, interpersonal relationships, impulsivity, psychosis, depression, and anxiety.
of all clients experienced a statistically significant improvement in their attitude toward activities of daily living & overall functioning1
Clients as a group showed significant impairment at admission, and low-moderate impairment (and in many cases, no impairment) at discharge.
BASIS-32 Overall Change Score 2015 life and/or interpersonal relationships, with extreme impulsivity, psychosis, depression, and/or anxiety present.
IMPROVEMENT
>1.5 Significant and systemic impairment in daily
.5–1.5 Moderate impairment in daily life and/or
2.5 2.0 2.0
Significant Impairment
1.72
1.5 1.5
t(119)=16.37, p=.000
interpersonal relationships, with some impulsivity, psychosis, depression, and/or anxiety present.
1.0 1.0
.84
0.5 0.5
<0.5 Indicates full functioning with no significant impairment in daily life and/or interpersonal relationships, with little or no impulsivity, psychosis, depression, and/or anxiety present.
0.0 0.0
(Paired Sample Means)
ADMISSION
DISCHARGE
Full Functioning
The 32-Item Behavior and Symptom Identification Scale (BASIS-32). © Copyright McLean University, Affiliate of Harvard Medical School.
IMPROVED MEDICATION ADHERENCE Medication Attitude Inventory 2015
80
%
More Positive
6
of all clients leave treatment with a positive attitude about taking psychiatric medication, which correlates with improved medication adherence3
5 4 4
33
Hogan TP, Awad AG, & Eastwood R. (1983). A self-report scale predictive of drug compliance in schizophrenics: reliability and discriminative validity. Psychological Medicine, 13, 177–183.
IMPROVEMENT
>6 Indicates generally positive attitudes towards medication use and are correlated with greater levels of medication adherence in a clinical setting.
t(121)=-6.75, p=.000
3.02
2 11 0 0
ADMISSION
More Negative 5
5.90
DISCHARGE
Scores on the Medication Attitude Inventory (MAI) range from 0 to 10, with higher scores indicating more positive attitudes towards medication use and medication adherence. On average, clients experienced statistically significant improvement with an average attitude score of 3.02 at admission to a 5.90 at discharge.
“I highly recommend Skyland Trail for anyone struggling with dual diagnosis or co-occurring disorders. The staff is incredibly kind, warm and knowledgeable and they meet each individual client where they are. Their additional services focusing on various life skills are crucial to providing a
In 2015, on average, our clients experienced significant improvement in: SOCIAL RELATIONSHIPS
positive path to recovery.”
DEPRESSION & ANXIETY
CYRUS N. SKYLAND TRAIL GRADUATE
DAILY LIVING SKILLS PSYCHOSIS IMPULSIVITY
BASIS-32 Subscales Change Scores 2015 IMPROVEMENT
2.5 2.5
2.35
2.25
2.15
2.0 2.0
DISCHARGE (N=119) p = 0.000
1.5 1.5
1.08
1.0 1.0
1.14
1.13 .68
.67
0.5 0.5 0.0 0.0
Significant Impairment
ADMISSION
RELATION TO SELF/OTHERS
DEPRESSION/ ANXIETY
DAILY LIVING SKILLS
.31
.30
PSYCHOSIS
IMPULSIVITY
Full Functioning
The 32-Item Behavior and Symptom Identification Scale (BASIS-32). © Copyright McLean University, Affiliate of Harvard Medical School.
IMPROVED ABILITY TO MAKE DECISIONS Making Decisions Scale 2015 ADMISSION
More Positive
3.5 3.5 3.0 3.0 2.5 2.5
DISCHARGE (N=123) p < 0.006
3.03 2.50
2.97 2.53
2.56
2.69
2.0 2.0 IMPROVEMENT
A four-point scale, where scores centered around 1 indicate negative beliefs about the ability to make decisions with psychological components like:
1.5 1.5
• self-esteem
1.0 1.0 0.5 0.5
A sample of 123 clients who completed the Making Decisions Scale at admission and discharge demonstrated statistically significant improvement in their ability to use self-esteem, optimism, and personal power in making decisions.
• optimism • activism
SELF-ESTEEM
0.0 0.0
More Negative
OPTIMISM
PERSONAL POWER
• personal power (beliefs in the efficacy to make decisions on one’s own)
Rogers et al. (1997). A consumer-constructed scale to measure empowerment among users of mental health services. Psychiatric Services, 48(8), 1042-1047.
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2015
2016
RESEARCH HIGHLIGHTS
AREAS OF FOCUS
POSTERS:
Cognitive Training:
A Model Wellness Intervention Aimed at Reducing Cardiometabolic Syndrome Risk Associated with Psychotropic Medications
Impact of Cognitive Remediation Training on Psychiatric Symptoms and Treatment Outcomes
APA Annual Meeting 2015 IPS: The Mental Health Services Conference 2015
Impact of Physical Health Interventions on Mental Health Outcomes
Development and Initial Validation of an Abbreviated Assessment of Client Engagement in Outpatient Mental Health Services IPS: The Mental Health Services Conference 2015
Smoking Cessation:
Healthy Challenge:
Cognitive Behavioral Therapy Dialectical Behavior Therapy Cognition and First Episode (Young Adults) Social Integration Dual Diagnosis
(offered as a second area of focus for clients in all communities)
INTEGRATED SERVICES Vocational Services
CONTACT US
Primary Care & Wellness
1961 North Druid Hills Road NE Atlanta, Georgia 30329
Art & Music Therapy
866-528-9593 www.skylandtrail.org
Recreation Therapy
Joint Commission National Quality Gold Seal of Approval Since 1995
FOLLOW US
MEMBER OF
SHAUN H., SKYLAND TRAIL GRADUATE
Effective interventions to encourage and support tobacco use cessation in a psychiatric residential treatment setting
SPECIALIZED, EVIDENCEBASED COMMUNITIES
LOCATED IN ATLANTA, Skyland Trail is a nationally recognized nonprofit mental health treatment organization serving adults ages 18 and older with a primary psychiatric diagnosis. Through our residential, day treatment, and outpatient programs, we help our clients grow, recover, and reclaim their lives.
“Today, I’m breaking the chains of co-dependency. I’m working part-time. I have my own place, and I’m even working on a garden. I’m on a path now – one of certainty. I’m living. One day at a time.”
Horticultural Therapy Pastoral Counseling Nutrition Counseling LEAP Social Club Cognitive Training Family Education, Support & Therapy Certified Peer Counselors
NOT ONE-SIZE-FITS-ALL We offer a tailored mix of evidence-based and supportive therapies to help each client find their own unique path to wellness. Clients help develop an individualized treatment plan and are assigned to a specialized treatment team, schedule, and peer support group based on their diagnoses, symptoms and self-defined goals.
HOLISTIC PATH TO WELLNESS Our integrated medical, mental, and social model includes a wide variety of therapies and services. A structured but diverse daily schedule helps clients develop strategies to improve mental health, physical wellness, independence, and relationships with family and friends.