Contingent Benefits Study Richard Ries, M.D.

1. Contingent Benefits StudyRichard 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 study was supported by a grant from the National Institute on Drug Abuse.

2. Dual Disorders Among the Severely Mentally Ill

3. Monthly “check effect” • A variety of studies ranging from large data bases to individual ER’s and trauma units have found that alcohol and drug ( esp cocaine) related admits peak in the first week after receipt of checks or benefits…Catalano 99, 2000, Grossman 97 others • Shaner et al demonstrated an association of cocaine use, tox screens and ensuing psych admits for Veterans with Schizophrenia and cocaine abuse, showing a first week of the month repeated pattern

4. Dual Treatment Outcome

5. Harm Reduction in Severely Mentally Ill What Harm? • Self (direct) Suicide Psychosis Grave disability Housing Loss Victimization Infection • Others (indirect) Aggression Inappropriate behavior Property damage Family destruction

6. 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

7. TREATMENT TRACKS AND CLINICAL VARIABLES Wingerson & Ries, 1999

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

9. TREATMENT TRACKS AND CLINICAL VARIABLES Wingerson & Ries, 1999

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

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

12. Engaging the ChronicallyPsychotic Patient • Noncoercive engagement techniques • Assistance obtaining food, shelter, and clothing • Assistance obtaining entitlements and social services • Drop-in centers as entry to treatment • Recreational activities • Low-stress, non-confrontational approaches • Outreach to patient’s community • Coercive engagement techniques • Involuntary commitment • Mandated medications • Representative payee strategies CSAT TIP 1994

13. Payee vs. Non Payee MICA PatientsRies: Am J Addict 1997

14. Contingency Management of Disability Benefits in SMI Dually Diagnosed • Evaluate feasibility and clinical effectiveness of payee intervention • Contingency based on work by Higgins, Stitzer et al • Monthly cycle of Disability $ >>> Substance use >>> Hospitalization….Shaner et al • NIDA funded randomized clinical trial

15. Contingency Management of Disability Benefits in SMI Dually Diagnosed • MHC based • Already have MHC as Payee …ie SSI representative payee • SMI plus current substance dependence • Weekly Case manager ratings and U-tox • Removed from study if clinically destabilize…but analyzed Intent to Treat

16. CHARACTERISTICS OF SAMPLE AT BASELINE Ries et al., 2003

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

18. “Week Used” • Defined as either (+)Case Manager rating OR (+) clinically blinded Research U tox • Case managers met each week with pts for Payee Log completion • Subjects met with research team each week for U tox and “rewards” • Results “In Press” Psych Services 2003

19. Case manager ratings vs weeklyblinded U-tox…Ries et al: Psych Services 2000 Percentage of weeks substance use by urine toxicology (UT) or case manager (CM) rating

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

21. SUBSTANCES USED AT BASELINE Ries et al., 2003

22. 5. Treatment Adherence a. Attendance (% of Rx plan) b. Medications (frequency/amount; % correctly taken) c. Enter lowest % of attendance or medication adherence Weekly Adherence Summary Code 0>80%; 1=60-79%; 3<60% 4. Substance use a. Total # of days/week use (if “0”, leave b,c,d blank) b. Specific Days Alcohol M T W Th F Sa S c. Specific Days Drugs M T W Th F Sa S d. Unknown substance M T W Th F Sa S Weekly Substance Use Summary Code 0=No use; 1=1 day; 3=2+ days 6. Money Management • Budgets and spends payee money appropriately • Circle best response: 0-19% 20-49% 50-79% 80-100% • Weekly Money Management Summary Code 0>80%; 1=50-69%; 3<50%

23. 4. Substance use a. Total # of days/week use (if “0”, leave b,c,d blank) b. Specific Days Alcohol M T W Th F Sa S c. Specific Days Drugs M T W Th F Sa S d. Unknown substance M T W Th F Sa S Weekly Substance Use Summary Code 0=No use; 1=1 day; 3=2+ days

24. 7. Last week’s disbursement schedule: 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. Last week’s amount: Cash $____ Coupons/meal tickets $_____ c. Changing “incidentals” this week? Y / N (if Y note in “Plan”) Incidentals? Y / N Plan? Y / N 8. Social & Occupational Functional Assessment Scale (see back of form)

25. 9. Adverse Events: Number of... a. Psych Admissions, Voluntary b. Psych Admissions, Involuntary c. Detox Admissions d. Emergency Room Visits (MH or CD, no admission) e. Emergency Room Visits (medical only, no admission) f. Medical admits: Psych/CD caused g. Incarcerations h. Loss of Housing i. Significant harm to self/others (if yes, call site coordinator 10. Client in hospital/jail for a “partial week?”Y / N If yes, which days in hospital/jail (circle all that apply) M T W Th F Sa Su

26. Scoring:WEEKLY DECISION SUMMARY INSTRUCTIONS • If Weekly Status Sum=0, circle “0” in Decision Summary Score (below), congratulate, give gold award. • If Weekly Status Sum=1 or 2, circle “1” in Decision Summary Score (below), encourage better behavior, give silver award. • If Weekly Status Sum=3 or greater, circle “3” in Decision Summary Score (below), encourage better behavior, give red award. Weekly Decision Summary Score (circle one): 3 1 0 Type of Award Given (circle one): Red Silver Gold

27. Scoring: MONTHLY DECISION SUMMARY INSTRUCTIONS Review last 4 weekly logs by the 20th - when you do your budgeting. If Sum of Weekly Decision Summary Scores is: > 7, tighten management level (either/both form or frequency--describe on reverse under “Plan”) 2-6, maintain management level 0-1, loosen management level (either/both form or frequency--describe on reverse under “Plan”)

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

29. OUTCOMES: SUBSTANCE USE % Weeks Used Contingent group used significantly less alcohol (p<0.01) and drugs and alcohol combined (p<.05) Ries et al., 2003

30. 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

31. OUTCOMES: ADVERSE EVENTS Total Adverse Events Baseline Mean Post Randomization Mean Baseline Mean Post Randomization Mean Ries et al., 2003 Contingent group had significantly more baseline adverse events (p<.01) ANOVA at outcome was NS, ALL 5 Safety Net subjects were Non-Contingent

32. CONTINGENT BENEFITS STUDY-NIDAPOWER: THEORETICAL ANALYSIS • 100 Contingency effect • 75 Multiple, weekly dispersals • 50 • 25 Having Rx center be payee • 0 Ries unpub. 5/99

33. CONTINGENT BENEFITS STUDY-NIDASUMMARY OF PRELIMINARY FINDINGS 1. Contingent management of benefits resulted in decreased substance use. 2. Effect appeared greater for alcohol during the week than for drugs on the weekend. 3. Power would likely increase if earlier phases of intervention were studied. Ries unpub. 5/99

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

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