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TIPS and TOPICS from David Mee-Lee, M.D.
Volume 8, No. 1
April 2010

In this issue
SAVVY  Is Your Innovation Glass Half Empty or Full?
SKILLS Tackling 3 C’s for Healthcare Reform
SOUL   VW, Toyota, and China
Until Next Time

This edition of TIPS and TOPICS (TNT) starts the eighth year of this monthly adventure in communicating to you what crosses my mind for that month.  I had no idea where this would go when I started TNT in April 2003.  And I have no idea where this will go in the coming years. I’ll keep doing it while it is fun and meaningful.


SAVVY
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This is not an advertisement for United Airlines. But I was browsing the United Hemispheres magazine waiting for takeoff when I was interested to read about what United is doing to increase fuel efficiency. With fuel, by far, being the commercial aviation industry’s largest expense, their interest in innovation isn’t all about going green for the environment. What they are doing got me thinking about our behavioral health industry and what we are doing about innovation, efficiency and effectiveness – or not doing.

TIP:
Look at the glass of innovation in the behavioral health field and see if it is half empty or half full.

Here are a few things United Airlines and the aviation industry is doing to improve efficiency and effectiveness in achieving outcomes to reduce delays, improve fuel efficiency and ultimately lower emissions by about 12%.  Airlines today are more than twice as efficient as in the late 1970’s; they are able to carry passengers and cargo twice as far on a gallon of jet fuel.

 • In 2008, they participated with the Federal Aviation Administration in the Asia and South Pacific Initiative to Reduce Emissions.  They used up-to-the-minute fuel data, priority takeoff clearance, new arrival procedures and other techniques. On a single test flight from Sydney, Australia to San Francisco, California, they found they saved 1,564 gallons of fuel and 32,656 pounds of carbon emissions.

 Because a jet uses lots of fuel during descent, United uses Tailored Arrivals- this generates fuel savings through an idled, continuous descent during landings.  They turn landing into a continuous glide toward descent instead of a series of graduated steps.  This results in a more efficient and quieter arrival.

 They cut emissions by using plane winglets, devices which extend the wings’ surface to cut down on induced drag. Pilots taxi on the runway with one engine instead of two, and use less fuel on the ground by taking advantage of electricity at the gate to power the air-conditioning and lights.

It was in the late 1970’s that I completed my psychiatric specialty training and entered the real world of mental health and addiction treatment. I wonder if now we are twice as efficient in helping people get well and whether we could treat twice as many people for the same number of staff and programs. Analogies can be faulty and misleading.  But in thirty years we should have some innovations that have improved our efficiency and effectiveness, if not double. Then I thought about some of the work I had heard this month and pessimistically looked at the glass of innovation in behavioral health and specifically addiction treatment.

Half Empty
 I was browsing the exhibit hall at a national conference this month.  I asked one of the residential programs how much it costs per day.  The friendly service representative quoted me a multi-thousand dollar price for the 28-day program and said they don’t have a daily price.  This was just like the fixed length of stay program I started nearly 30 years ago.

 A week ago, I listened to the anguish of a mother whose son had recently completed 28 days, and the 90 day extended care program, at a famous residential rehab. facility.  She had high hopes for the next program: the 60 day wilderness program he had entered after his relapse. After 30 days there, the insurance company authorized continuing care, only at a less intensive level of care.  She was understandably concerned because, in her eyes, her son had received only half the program promised. No one had explained to her that addiction is a potentially chronic illness, and using a disease management approach addiction treatment involves a continuum of care, just like other behavioral and physical health disorders. It could have been a rigid managed care company she was dealing with, but she told me the counselor had written very little clinical information to explain and justify the need for continued stay in their very intensive program.

 More and more is known about the neurochemistry of addiction as a “brain disease”.  While it certainly is not all in the neurotransmitters, there is an expanding array of anti-addiction medications that can assist treatment and recovery. Yet Cable News Network (CNN) quoted spokespeople of two prominent, nationally known residential programs as saying at one program that “a small proportion of patients receive anti-addiction drugs” and at the other “No patients receive anti-addiction drugs as part of treatment.”

 Tom McLellan, Ph.D., Deputy Director, Office of National Drug Control Strategy (recently resigned), presented some sobering statistics at the American Society of Addiction Medicine Annual Medical-Scientific Conference in San Francisco, California. There are about 68 million people in the USA whose drinking can be classified as “harmful use”. About 2,300,000 people are in addiction treatment in specialty programs of which there are 12,000 programs. BUT:

    1. 31% of those specialty programs treat less than 200 patients/year
    1. 44% have no doctor or nurse
    1. 75% have no psychologist or social worker
    1. The major professional group is counselors who are paid the least in  the clinical hierarchy and have a 50% turnover rate in a year.

In addition:

    1. There are about 5 million offenders in the community with about 50% having a Substance Use Disorder.
    1. 700,000 offenders are released into the community.
    1. There are opportunities to intervene at Pre-Arrest, Pre-Trial, Prosecution, Sentencing, Jail and Prison time, and Re-Entry into the community.

 The latest results from the  2008 National Survey on Drug Use and Health (NSDUH) found that 20.8 million needed (but did not receive) treatment for illicit drug or alcohol use. In the year prior to the survey, they found the following–

Of those aged 12 or older who needed treatment for illicit drug or alcohol use, but who did not receive treatment:

    1. 95.2% Did not feel they needed treatment

    1. 3.7% Felt they needed treatment and did not make an effort to get treatment

    1. 1.1% Felt they needed treatment and did make an effort to get treatment

In 2010, with all we know about addiction, we reach a small fraction of people; and then many are the sickest of the sick.  Imagine if we only treated people with breast cancer who were late stage; or people with hypertension who were heading towards a stroke; or those with diabetes who presented first for help in diabetic coma.

Half Full

I can hear you lamenting such a negative and pessimistic appraisal of where we are in 2010 in behavioral health treatment.  Perhaps you are objecting and countering with your list of innovations:

    • Screening and Brief Intervention, Referral and Treatment (SBIRT)
    • Research-based Prevention strategies
    • Evidence-based practices like Integrated Dual Disorders Treatment (IDDT); Motivational Interviewing (MI) and Motivational Enhancement Therapy (MET); Client-directed, Outcome-Informed approach (CDOI); Cognitive Behavioral Treatment (CBT); Twelve Step Facilitation (TSF); Multi-Systemic Therapy (MST); Community Reinforcement Approach (CRA); Contingency Management (CM) and on and on
    • Genetic testing for personalized prescribing of psychotropic medications; and a variety of anti-addiction medications including extended release, injectable medications, vaccines, patches, therapeutic inhalants
    • Performance Improvement and Process Improvement like the Network for the Improvement of Addiction Treatment (NIATx) now also applicable to mental health agencies
    • Assertive Community Treatment and Intensive Case Management with a variety of housing, supportive employment and community supports for people with severe mental illness.
    • Computer-assisted CBT and internet-based support groups and chat rooms

I’m not aware of all the innovations.  That is the point of SAVVY this month.

Here’s a request:

If you are already doing some effective innovations, I’d like to share those with TIPS and TOPICS readers. Please e-mail a brief description of what you are doing and how the innovation operate. In what way is it effective? Over the coming months, I will be highlighting innovation in behavioral health.

Reference:
National Survey on Drug Use and Health (NSDUH): National Findings and Results From the 2008 National Survey on Drug Use and Health. Substance Abuse and Mental Health Services Administration (SAMHSA). Published September, 2009.

SKILLS
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Even if there was not the current political focus on healthcare reform, we would need to re-think how we do behavioral health care.

TIP:
Identify one innovation you are willing to do in at least one of the following three C’s – even if you have to start small

Consider these three C’s:

    • Community citizens, Customers, Clients and Patients
      There are many opportunities for prevention and early intervention; brief treatment; engagement into active treatment and continuing care.  With 32 million more people to be covered by health insurance, with statistics on the 68 million “harmful use” drinkers, with the majority of the 20 plus million people needing treatment (but not accessing it), along with the millions in the criminal justice system, innovations are needed to meet the huge needs.

Examples of what you can do and where to start:

    1. If you are an addiction provider, ensure mental health screening and linkage to services
      -> If you are a mental health provider, ensure screening for addiction and linkage to services
      -> If you are a primary care provider, ensure screening for mental health and addiction
    1. Get involved in Universal, Selected and Indicated prevention
    1. Work with Drug and Mental Health Courts and Criminal and Juvenile Justice to have people mandated for assessment and treatment adherence, not mandated to a fixed level of care and fixed length of stay. Promote improved function; public safety; and responsible self-change;
      “doing treatment” rather than “doing time”

    • Cost Control
      In the June 2009 edition of TIPS and TOPICS (TNT),I stated that whatever system eventually is established, the cost of health care has to come down because we spend proportionately more than any other country. Whether you are a consumer, counselor, clinician, administrator or payer, we all have the responsibility to be more efficient and effective with the mental health and addiction treatment dollars that are spent.

Examples of what you can do and where to start:

Take a look back at the SAVVY section of the June 2009 edition of TNT and consider the proposals I suggested.

    • Comparative Effectiveness Research (CER)
      CER is the direct comparison of existing health care interventions to determine which work best for which patients and which pose the greatest benefits and harms. The core question of comparative effectiveness research is which treatment works best, for whom, and under what circumstances. Visit Link Here.

How CER applies to behavioral health is still an open question.  But we do know a lot about what works in psychotherapy and addiction treatment (Mee-Lee D, McLellan AT, Miller SD (2010) and some ways to do practice-based evidence in a client-directed, outcome-informed approach (Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005)

Examples of what you can do and where to start:

Take a look back at that SKILLS section of the February 2009 edition of TNT and consider the tips I suggested.

References:

1. Institute of Medicine (IOM, 1994): “Reducing the Risk for Mental Disorder: Frontiers for Prevention Intervention Research” Patrick Mrazek and Robert Haggerty (eds)

2.  Mee-Lee D, McLellan AT, Miller SD (2010): “What Works in Substance Abuse and Dependence Treatment”, Chapter 13 in Section III, Special Populations in “The Heart & Soul of Change”  Eds Barry L. Duncan, Scott D.Miller, Bruce E. Wampold, Mark A. Hubble.  Second Edition.  American Psychological Association, Washington, DC. pp 393-417.

3.  Miller, S.D., Mee-Lee, D., Plum, B. & Hubble, M (2005): “Making Treatment Count: Client-Directed, Outcome Informed Clinical Work with Problem Drinkers.”  In J. Lebow (ed.).  Handbook of Clinical Family Therapy.  New York: Wiley.

Also re-published in Psychotherapy in Australia (2005) Vol. 11 No. 4 pp 42-56

SOUL
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This is not an advertisement for automobiles.  But I love my VW Golf and have had VW Beetles, Rabbits, Golf in all different colors since I was 17 years old.  My current VW Golf is still zippy, but it’s ten years old. I also need a reliable car and my Golf is not fuel efficient.

So today, I am going to look at the most fuel efficient car in the USA – a Toyota Prius (I know about the runaway Prius, but I’m looking anyway). That is an innovative car and maybe I can be good to myself and the environment all at the same time. Like the airline industry, the automobile industry has come up with much innovation in the past thirty years – in the past three years.  Hard to say that about our behavioral health industry.

Visiting China this month, I learned many things and witnessed incredible changes since our first trip 31 years ago in 1979.  Regarding automobiles, China is now the largest car market in the world. There are thousands of new drivers on the road every day. Our English-speaking guide in Beijing was an enterprising young mother who had just bought a new Hyundai in order to expand her one-person tour guide business: she’s aiming at spending more of her time stress-free driving people to the Great Wall versus the more tiring job of walking tourists around Tiananmen Square every day.  She paid CASH, the equivalent of about $17,000 US dollars which she had saved up. This is a lot of money to save, considering her previous earnings working for a tour company shepherding around large groups of tourists was roughly US $30 a day.  Then she decided to start her own business. What a charming, hard working woman she was. (I’ll give you her contact information if you ever go to Beijing.  I want to support such initiative and enterprise).

She admitted to us that she has a driver’s license, but can only drive in the same lane as she has not mustered up enough courage yet to quickly change lanes in the busy roads.  I’m glad she arranged for her friend to drive us to the Great Wall of China!

If you complain about lack of resources, you are probably correct based on available resources where you live and work.  However visiting the National Drug Dependence Treatment Center of the Beijing Mental Health Hospital was eye-opening. There were only about 30 inpatient beds for people with alcohol and other drug problems in Beijing.  Beijing’s population in 2010 surpassed 22 million people.  Those in China who work in the behavioral health field in China are very dedicated and eager to expand services. Talk about needing health care reform!

I wonder if we can be as resourceful and enterprising as our tour guide in Beijing?  I wonder if we can make innovative and effective changes to improve outcomes in our field?  I’m glad the airline and automobile industries are focused on innovation to improve results, efficiency and customer satisfaction.  I’m going to enjoy that Toyota Prius 50 miles per gallon.

Until Next Time
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Glad you could be with us for the start of Year 8.  See you again in late May

David