Jennifer E. Johnson, Ph.D C. S. Mott Endowed Professor of Public Health Michigan State University

1. Creating an NIH career trajectory: Case example in mental health and substance use treatment research Jennifer E. Johnson, Ph.D C. S. Mott Endowed Professor of Public Health Michigan State University

2. OR… “The story of 13 NIH proposals” 8 funded, 1 pending, 2 dead, 2 could be resubmitted (plus a few others on which I am a Co-I)

3. Take-home points • NIH treatment research is a team sport • Importance of strong, senior, mentorship core • The more you submit, the more you get – NIDA’s best predictor • Good hit rate also helps • Colleagues are most critical part of this • Need lots of time to write • Need to be able to respond quickly • Get faster with practice • PI of 8 NIH studies worth > $14,000,000 I’m going to give you the REAL DEAL

4. Interest in interpersonal issues • Clinical psychologist who does mental health and substance use treatment and implementation research • Group psychotherapy research • Therapeutic relationship • Johnson et al., 2005. Group climate, cohesion, alliance, and empathy in group psychotherapy: Multilevel structural equation models. • Interpersonal interventions (IPT, network support treatment) • Social support (emotional, practical, EOR, support for sobriety) & social relationships as predictors, mediators, and targets of interventions Progression from research on intervention specifics to research on services, implementation, and policy issues over time

5. Brown T32 • Mentorship structure • 100 NIH funded researchers in one department, almost as many over in public health • If you can fund 100% of your salary after 2 years of postdoc, you get to stay as faculty

6. K23 • Writing process • Pilot study • Incarcerated women have high levels of co-occurring MH and SUD and interpersonal challenges (K23 DA021159 awarded in 2006, PI: Johnson; Group Psychotherapy Foundation 2005, PI: Johnson)

7. Method: Study 1 (K RCT) • Small (n = 38) randomized trial of an adapted group IPT for co-occurring MDD and SUD for women within 3-5 months of prison release • Two attention-matched study treatments (IPT and psychoeducation on co-occurring disorders) • Group tx in prison. • 6 weekly individual sessions in the community after release • Used trained MH providers

8. Results: Study 1 Sample characteristics: • 74% legal income under $10,000 USD • Mean intake HRSD score of 28 • Median number of past depressive episodes of “10 or more” • 64% taking antidepressant medications at baseline (and still met criteria for MDD). • 40% had attempted suicide before In-prison outcomes: • IPT resulted in lower post-tx depressive symptoms than did PSYCHOED (p = .016). • Cohen’s d = 0.82 (95% CI = 0.15 – 1.48). Trend toward lower post-release SU - underpowered (Johnson, Williams, & Zlotnick, 2012, Journal of Psychiatric Research) Johnson & Zlotnick (2012). Journal of Psychiatric Research, 46, 1174-1183.

9. In Prison

10. Study 1: Conclusions • IPT: • is feasible and acceptable in a women’s prison. • resulted in significant decreases in depressive symptoms relative to PSYCHOED during incarceration. • However, the 6 weekly sessions we offered after release from prison were not enough to help women maintain gains and avoid relapse after release (caveat: power). • Several lines of research came from this, including re-entry intervention and qualitative research.

11. K23 next steps • Stopped RCT • 3 next steps to figure out what to do (all with K23 $): • Qual/quant studies to better understand processes of MH & SUD relapse at re-entry • Participant qual paper (Johnson et al., International Journal of Prisoner Health, 2013) • Provider qual paper (Johnson et al., 2014, JBHSR). • Go back to the literature. • Tx theory problem • Service linkage problem • Sober phone pilot trial (Johnson et al., 2015, The Prison Journal)

12. System is under-resourced • Providers nearly universally felt they lacked the resources to provide the care women need • My problem in mental health is I don't have enough resources to provide them counseling and psychoeducation in addition to medication management. I could use a lot more. Oftentimes we're just treating crises, we had gotten away from that somewhat but now I’m having staffing problems so we're back to more crisis management.

13. Lack of resources in prison • You are in for domestic [assault] and your biggest need is to learn how to manage your anger and the only thing I can offer you is why don’t you see [the social worker] once a month? And work on that. Okay well, I’m here for three months. Okay so you’ll see [the social worker] three times. It’s better than nothing. But how is that going to impact her at all? It’s not.” • One provider said that in a perfect world, s/he would “find grant money and get programs and I would try—I would get more social workers. Are you kidding me? We should probably have three in each building. Why shouldn’t you be getting therapy every week?” • We don't have enough resources… I mean it's so hard, it's—and this is just a fault of, it's a societal issue. Prisons are being asked to do stuff that they're not really set up to do.

14. Lack of community MH resources • [In prison] they have all of this support right at their fingertips… The mental health worker on the wing is right down the hall… [then] when they leave, it’s like, nothing. ‘Whaddya’ mean I gotta’ call and make an appointment? Whaddya’ mean I gotta’ wait three weeks?’ ‘No I don’t have insurance.’ Yeah. Then, what are they doing in that three weeks? Do you really think they’re sitting quietly and reading books?” • So someone like this didn’t show up okay?... And then they call back and they have to wait or they owe $30.00 and they can’t come back. So then this person is struggling, teetering on going back to drugs. And they’re screwed because they can’t get their mental health appointment and they have to go through hoops. Based on K experience and qual results, I started targeting studies to address resource issues

15. Meanwhile… • ‘08: Prison SU-HIV related R01 to save prison mentoring program: S, RS: unfunded • ‘09-’10: R34 MH086682: Group IPT for major depression following perinatal loss • ‘09-’10: R34 DA030428: Sober network IPT for perinatal women with comorbid substance use and depression • ’10: R01 for sober phone intervention: unfunded first round, not resubmitted Because of the crazy 4-application cycle: • ‘10: R34 MH094188: HIV/STI risk reduction for incarcerated women with a history of violent victimization • ‘10: R34 to adapt treatment feedback system: good score first time, worse score second time: unfunded

16. Fully Powered Hybrid Effectiveness/Implementation Study(R01 MH095230) First fully powered study of any tx for MDD among an incarcerated population (my n = 38 pilot trial was the largest to date) • Despite ~150 per year published for non-incarcerated populations (see Weinberger et al., 2010) • Demonstrates need for MH implementation research for justice-involved individuals Examines effectiveness and pilot implementation outcomes of an evidence-based MDD tx (interpersonal psychotherapy; IPT) in prisons

17. Effectiveness methods • 181 prisoners with MDD in 9 facilities across 2 states with > 6 mo left to serve • 35% female • 18% Hispanic; 21% African-American • Assessments at baseline, 4 mo, and 7 mo • Randomization to group IPT (B.A. and MSW prison providers without prior IPT experience) or prison mental health TAU • 9 counselors; 24 IPT groups • Small group tx, 2x/week – much more frequent than prison MH TAU (which is often 1x/month)

18. Effectiveness Outcomes(chosen to be persuasive to prison decision-makers) • Depression • Depressive symptoms (p = .05 HRSD at post-tx). • Likelihood of remission (p = .06; no difference in rates of recovery) • Suicidality • Suicidal thoughts at post-tx (NS: Beck Suicide Scale) • Hopelessness (p = .001 for Beck Hopelessness Scale at post-tx) • Among those with SI in the 6 months prior to baseline, median % weeks with SI during f/u period was 3% for IPT and 53% for TAU • In-prison functioning • No differences in # programs completed or # disciplinary reports, perceived social support (MSPSS scores) or aggression/victimization (adapted CTS scores) When counselors had run 1+ previous IPT group, effects were larger for DS (p = .03), remission odds (p = .02), hopelessness (p < .001)

19. Outcomes Pilot implementation outcomes: 4. Cost effectiveness 5. Feasibility and acceptability of IPT to all stakeholders 6. Prison provider intervention fidelity 7. Prison provider attitudes and competencies 8. Stakeholder perspectives on implementation barriers and facilitators To inform a subsequent implementation RCT

20. Implementation Results: Facilitators • We were able to train B.A. providers, who had good outcomes (sometimes better than the MSWs). Training was easier and took less time with MSW providers • Motivated providers/administrators. Survey results indicate that providers/administrators: • Viewed MDD among prisoners as an important problem • Saw current strategies for treating MDD within prisons as inadequate • Tended to be oriented toward rehabilitation rather than punishment • Were friendly toward evidence-based practices • Viewed IPT as appropriate and acceptable • Motivated (desperate?) patient population • Most readily available MDD tx in prisons is antidepressants (still not easy to get) b/c they are inexpensive. Many prisoners want alternatives because (1) they are taking antidepressants and are still depressed; (2) they want to talk about severe psychosocial stressors; and (3) some are skeptical of meds or worried meds will affect parole status

21. Implementation Results: Barriers • There is more mental health need in the prisons that there is money in the MH contracts to meet all of it. • Allocation of justice money is often set by state legislature; therefore those directly involved with MH care have little control over this • Limited resources translate into: • Heavy case loads, focus on crisis management • Some facilities had inadequate supervision b/c managers and supervisors were overwhelmed. This sometimes led to: • Infighting • Staff and leadership turnover

22. Conclusions • Prison providers are motivated and friendly toward innovation, but public investment in offender health is low and resource and system barriers are substantial. • Some barriers to implementation of mental health EBP (such as questions about whether incarcerated individuals “deserve” adequate care, and resulting extremely limited resources and budgets) may be unique or extreme in justice settings (see also Taxman, 2011) “We don't have enough resources… I mean it's so hard, it's—and this is just a fault of, it's a societal issue. Prisons are being asked to do stuff that they're not really set up to do.”

23. But also: • Co-I on R34MH102466 & R34 MH103570: Studies of interventions and service needs for perinatal bipolar disorder (Weinstock PI). • R01 AA021732: AA linkage for alcohol abusing women leaving jail (Johnson and Stein) • From Sober phone study • R34 for prison tx of bipolar disorder: submitted, decent score, not resubmitted because two other things happened… • Another try with Caron to submit an R01 that would save prison mentoring program: S spring 2014, did OK, not resubmitted • Story of jail suicide U01/R01 – will get to in a minute…

24. Background: U.S. CJ System • > 15 million people pass through U.S. CJ system each year • 12 million jail admissions (~3-7 days) each year • 2.3 million incarcerated (in prison or jail) on any given day • 1/4 of world’s incarcerated are in the U.S. • 1/3 of world’s incarcerated women are in U.S. • Not what you would think from watching TV, movies • 4.7 million are on community supervision (probation or parole) • 1 in every 100 U.S. adults is currently incarcerated • 1 in 34 has current CJ involvement, including supervision under probation or parole Sources: Walmsley, 2009; Pew Center, 2008

25. What does CJ have to do with public health? U.S. CJ system is a catchment area for individuals at high health risk • 15-25% of HIV+ individuals in the U.S. pass through CJ system each year (other STIs, hepatitis, TB rates also high) • 10% of U.S. suicides with known causes occur following a criminal legal stressor (e.g., arrest and jail detention) • 10 times as many individuals with severe mental illness are incarcerated as are in state hospitals • ~20% of people with SU disorders are justice-involved (in fact, among incarcerated, 56% have MH and 66% have SU disorders) • Most of incarcerated are back in the community quickly; communities take on costs of their untreated health problems

26. CJ and public health (cont) • 3 largest MH treatment providers in the country are jails (LA County, Cook County, Rikers) • CJ system is a high-impact locus of intervention in fight against many public health problems • Disproportionately poor, less educated, disenfranchised, have difficulty engaging in many standard health care systems (access to care) • 68% from racial or ethnic minority groups and • 70% < $2,000 of personal income in the month before arrest. • Therefore, CJ involvement is a public health opportunity

27. Incarcerated women • ~70% are sentenced for nonviolent (drug, property) crimes. • Many sentences are short (70% of women in RI serve sentences that are 6 months or shorter) • Tend to be young (20s and 30s), single, 7 in 10 are mothers. • ~70% have lifetime substance use disorders (SUD) • ~30-35% have lifetime PTSD, 20-25% have lifetime MDD, ~30% have Borderline personality disorder. • A majority have experienced physical abuse or assault. A majority have experienced sexual abuse or assault.

28. Prisoner and detainee health is public health Public health differs from public safety: the justice system has mandates to do both

29. System is under-resourced: What can be done? Study extremely low-cost or free interventions that expand existing infrastructure • Sober phone open trial (Johnson et al., in press, Prison Journal) • re-entering women with COD • blend of IPT and Network Support tx • sober phones for service linkage (city block) • B.A. providers • R01 AA021732 (Johnson & Stein, PIs): AA linkage for alcohol abusing women leaving jail (in Year 1) • importance of face time from sober phone trial

30. System is under-resourced:What else can be done? Put cost-effectiveness/pilot implementation piece into every effectiveness study • R01 MH095230 (Johnson PI): Effectiveness of IPT for men and women with major depression (Year 3) • U01 MH106660 (Johnson & Weinstock, PIs): Suicide risk reduction in the year following jail release (CE, service linkage, 10% of all U.S. suicides in context of recent criminal stressor)

31. SPIRIT TrialSuicide Prevention Intervention for at-Risk Individuals in Transition

32. What else? Effects of prisoner re-entry context on cognitive ability to manage mental health at re-entry (R21 MH105626) • Extends lab findings on the effects of scarcity and self-control depletion to re-entering women prisoners with MH and SU disorders • (reversible) decrements in fluid intelligence and ability to inhibit impulses, rendering decisions prone to favoring impulsive, intuitive, and regrettable options. • “I firmly believe that when these inmates leave, they really, truly intend to succeed.” But, “They just—they get defeated so quickly. So quickly and they feel that once they’re knocked down they’re done, that’s it.” (Johnson et al., in press)

33. Purpose of R21 • Failure to devote adequate resources to discharge planning and re-entry services may contribute to women being cognitively impaired • “As soon as they hit [the community], everybody—the men went from the family, the kids—everyone’s pulling at them, pulling at them.” “Clinicians make these great plans, but unless you have somebody walking with this individual to get these things done, to keep this person focused, it’s not going to happen. Because they’re not strong enough to do all these different things” (Johnson et al., in press) • Characteristics of re-entering prisoners that profoundly affect health behaviors (fluid intelligence, attention, self-control) previously thought to be static individual difference variables may be influenced by contextual factors and thus more open to remedies than previously believed.

34. Project to tackle resource shortages more directly? A house divided: Promoting behavioral healthcare EBPs in a public safety context • R01 MH104204 (Johnson, PI: under review)

35. Messaging research to tackle resource shortages more directly? Despite pressing public health needs and responsibilities in CJ, unlike most healthcare systems, the CJ system has a primary goal of public safety rather than public health, posing a problem of multiple (and sometimes competing) system goals. Resulting challenges to behavioral healthcare evidence-based practice include: • Tensions in both inner (i.e., within CJ organizations) and outer (sociopolitical environment) contexts between the emphases placed on public health relative to public safety, • Ambivalence about whether offenders are able to change health risk behaviors or are “deserving” of good healthcare, • associated ramifications for budgeting and political support for EBP in CJ provide challenges to EBP adoption and maintenance.

36. Prisoner and detainee health is public health Public health differs from public safety: the justice system has mandates to do both Our findings are consonant with Taxman’s 2011 conclusion that the most fundamental barrier to D/I of MH & SU evidence-based practices in CJ is multiple (and sometimes competing) system goals. The public is more invested in public safety than in public health in CJ

37. Aim 2: Messaging as implementation strategy (see Powell, Taxman) Identify effective targeted communication strategies for messages identifying behavioral healthcare EBPs, their role in CJ, and the resources needed to support them. Using these strategies and an RCT design, develop and evaluate messages about behavioral health EBP for inner and outer context stakeholders, including correctional officers, facility leaders, treatment directors, legislators, and the public.

38. Why messaging? • Public indirectly controls: • how many people are in CJ; • resources are available to treat them • which treatments are acceptable • To implement a health practice, need the support of CJ agencies, as well as politicians, legislators, prosecutors, judges, and defenders, who may have different agendas and attitudes. • Elected officials, and the people who elect them also have to support the notion that CJ agencies should be involved in activities that focus on offender change, including behavioral healthcare (Taxman, 2011)

39. Why messaging? • A dilemma about providing treatment to offenders is that the customers are people who have wronged society and who are being punished. • Offenders are often considered lesser citizens and have diminished civil liberties and responsibilities (i.e., limitations on voting, employment, public housing). • These factors may affect the empathy of general society and the attitudes of treatment agencies toward offenders. • The external community may debate whether treatment services for offenders are essential or the responsibility of tax-payers (Taxman, 2011)

40. Messaging components of proposal • Targeting the message to subgroups based on group membership or demographics, position, and/or attitudes. • Framing refers to choosing among alternate ways to convey a message (e.g., what is gained or lost by taking an action) and among outcomes emphasized (e.g. improved offender health, improved offender behavior, lower recidivism). • Source credibility • Narration style (kind of evidence presented) • Channels (e.g., print media, websites) widely viewed and trusted by the target audience • Actionable knowledge (i.e., clear suggestions for how to act on the information).

41. U54 MD011227 • Flint Center for Health Equity solutions • Written in 3-4 weeks • What I learned about community partnership from writing it • Score of 24, waiting on funding decision

42. Next 3 R01 submissions • Implementation trial for evidence-based post-partum depression prevention intervention • Implementation trial of IPT for MDD in prisons (MI, RI, MA) • RS R01 MH104204: A house divided: Promoting behavioral healthcare evidence-based practices in a public safety context

43. Take-home points • NIH treatment research is a team sport – need people sharing ideas and helping with the work • Importance of strong, senior, mentorship core • The more you submit, the more you get – NIDA’s best predictor • Good hit rate also helps • Colleagues are most critical part of this • Need lots of time to write • Need to be able to respond quickly • Get faster with practice Follow both the funding opportunities and the next research question that naturally arises

44. How can we collaborate? Topics for collaboration: women, mental health, substance use, service linkage research, policy research, implementation research Data available for paper-writing: • R01 MH095230: Effectiveness of IPT for men and women with major depression (RCT, n = 180, includes CE data) • R01 AA021732: AA linkage for alcohol abusing women leaving jail (in Yr 2) • R34 MH086682: Group IPT for major depression following perinatal loss • R34 MH094188: HIV/STI risk reduction for incarcerated women with a history of violent victimization • R34 DA030428: Sober network IPT for perinatal women with comorbid substance use and depression • K23 DA021159, of IPT for MDD (examines gender effects) • In a couple years, baseline papers on the jail suicide study

45. Acknowledgements Collaborators: Caron Zlotnick, Michael Stein, WendeeWechsberg, Faye Taxman, Bob Stout, Ted Miller, Peter Friedmann, Ann Back Price, Lou Cerbo, Joel Andrade, Lauren Weinstock, Van Miller, Steve Sloman, Yael ChatavSchonbrun, Caroline Kuo, Rochelle Rosen, Jessica Nargiso Project coordinator: Linda Brazil Research assistants: Collette Williams, Marlanea Peabody, Jen Kao, Adam Chuong, Karen Fernandes, Nicole Coggins, Stephanie Arditte, Kendra Capalbo, Stephanie Anthony Community partners: MDOC, Genesee County Jail, RI DOC, MA DOC, Providence Center CMHC, Genesee Health System Deb Davis, Michelle NeSmith, Kelly Levesque, Ashley Capdeville, Noelle Kelly, Penny Welch, Emily Woodward, Kayoon Cho, John Copeland, Joshua Cohen