Skyland Trail Outcomes Research Summary 2014

REAL SUSTAINED

PROGRESS Offering Hope, Changing Lives

GE CH AN GE

“excellent” FUNCTIONALITY

CH AN

SYMPTOMS

CH A

NG

E

Outcomes Research Summary 2014

better

How We Measure

REAL, SUSTAINED

PROGRESS Success is built on a two-way committment.

We’re committed to our patients and we ask our patients to commit to our approach. Each client has to put in the time and effort needed to make real and sustainable progress.

Clients who do that return to their communities with reduced symptoms and improved skills to pursue more independent and productive lives.

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 standard in the mental health field to measure the effectiveness of our treatment programs.

Outcome data from 2008 through 2014 confirm that our unique integrated, whole person approach helps our clients grow, recover, and reset to a new normal.

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.

2014 CLIENT COMMUNITY >1% Anxiety disorders <1% Other

Primary Psychiatric Diagnoses Confirmed at Admission 43% Major Depression

39% Bipolar illness

16% Psychotic Disorders

82% of Clients Had Three or More Co-occurring Diagnoses Confirmed at Admission (e.g. co-occurring anxiety disorder, substance abuse, borderline personalty disorder, etc.)

18% Less Than 3 Co-occurring Diagnoses

31% 3 Co-ocurring Diagnoses

51% 4 or More Co-occurring Diagnoses

Gender 48% Male

52% Female

Age at Admission 54% Ages 18-25

1

9% Ages 46-55

20% Ages 26-35

11% Ages 36-45

6% Ages 55+

2014 Key Outcomes

ASSESSMENT SCALES

92

%

of all clients experienced a statistically significant improvement in their attitude toward activities of daily living & overall functioning1

90%

of clients with anxiety experienced statistically significant improvement in control of anxiety7

86%

of all clients experienced a statistically significant improvement in feelings of hopelessness2

80%

of clients who are depressed experienced statistically significant improvement

98%

of clients would recommend Skyland Trail to someone else

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 & Shizoaffective 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) PHYSICAL HEALTH OUTCOMES Indicators of cardiometabolic health including: • BMI • Cholesterol levels • Sugar metabolism • Vital signs SATISFACTION WITH SERVICES • Client satisfaction survey

“Without the change Skyland Trail helped me make in my life through the care and kindness I was shown there, I could not have even taken the first step towards recovery.” - Ivey M.

Serving Clients from Across the Country and Around the World

National 14% Southeast 27% Georgia 59%

Average Length of Stay

4-6

months

2

FUNCTIONAL IMPROVEMENT

92%

of all clients experienced a statistically significant improvement in their attitude toward activities of daily living & overall functioning1

In 2014, patients consistently showed statistically significant improvement in functional improvement as measured by the BASIS-32 at admission and discharge.

Comprised of 5 subscales, the BASIS-32 contains an overall average score ranging from 0 to 4, with higher scores indicating greater levels of disabled functioning in daily life, interpersonal relationships, impulsivity, psychosis, depression, and anxiety.

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 2014 IMPROVEMENT

>1.5 Significant and systemic impairment in daily

life and/or interpersonal relationships, with extreme impulsivity, psychosis, depression, and/or anxiety present.

.5–1.5 Moderate impairment in daily life and/or

interpersonal relationships, with some impulsivity, psychosis, depression, and/or anxiety present.

<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.

68

%

2.0 2.0

1.5 1.5

1.79

t(141)=16.37, p=.000

.78

0.5 0.5

0.0 0.0

ADMISSION

DISCHARGE

Admission

Discharge

Full Functioning

The 32-Item Behavior and Symptom Identification Scale (BASIS-32). © Copyright McLean University, Affiliate of Harvard Medical School.

Medication Attitude Inventory 2014 More Positive

88 77

IMPROVEMENT

3

Significant Impairment

1.0 1.0

of all clients experienced a statistically significant improvement in attitudes towards medication, which correlates with improved medication adherence3

Skyland Trail patients showed a statistically significant improvement in attitudes towards medication adherence from admission to discharge on the Medication Attitude Inventory (MAI).

Scores on this measure range from 0 to 10, with higher scores indicating more positive attitudes towards medication use and medication adherence. Clients went from an average attitude score of 3.21 at admission to a 7.11 at discharge.

(Paired Sample Means)

6 55 4 33 22 11 00

>6 Indicates generally positive attitudes towards

medication use and are correlated with greater levels of medication adherence in a clinical setting.

7.11

t(125)=-9.764, p=.000

More Negative

3.21 ADMISSION

Admission

DISCHARGE 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.

Discharge

When broken down by diagnosis: •

93 percent of individuals diagnosed with bipolar disorder show clinically significant improvement from admission to discharge. (t(29) =8.13, p =.000)

•

86 percent of individuals diagnosed with major depressive disorder show clinically significant improvement from admission to discharge. (t(80) = 12.04, p =.000)

•

100 percent of individuals diagnosed with a major thought disorder show clinically significant improvement from admission to discharge. (t(16) = 7.30, p =.000)

All three groups showed a significant change from significant impairment at admission to moderate impairment at discharge.

BASIS-32 Overall Change Score By Diagnosis 2014 IMPROVEMENT

2.0 2.0 1.5 1.5

1.89

1.79

1.0 1.0

1.86

1.64 (N=142)

ADMISSION (N=28)

.78

0.5 0.5 0.0 0.0

(N=81)

(N=15)

.74

ALL

BIPOLAR

DEPRESSION

THOUGHT DISORDERS

All

Bipolar

Depression

Schizo

More Positive

DISCHARGE

(N=132)

3.0 3.0 2.0 2.0

3.08 2.51

2.98 2.53

2.56

2.78

IMPROVEMENT

• self-esteem

1.0 1.0 0.0 0.0

A sample of 132 clients who completed the Making Decisions Scale at both admission and discharge in 2014 demonstrated statistically significant improvement in their ability to use self-esteem, optimism, activism, and personal power in making decisions.

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 0.5 0.5

Full Functioning

The 32-Item Behavior and Symptom Identification Scale (BASIS-32). © Copyright McLean University, Affiliate of Harvard Medical School.

ADMISSION

2.5 2.5

DISCHARGE

.89

.52

Making Decisions Scale 2008–2013

3.5 3.5

Significant Impairment

• optimism

SELF-ESTEEM*

Self-Esteem More Negative

OPTIMISM*

PERSONAL POWER*

Optimism

Personal Power

• activism • 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. *statistically significant p<.005

4

SYMPTOM REDUCTION

86

In 2014 clients continued to experience a statistically significant decrease in feelings of hopelessness, t(113) = 13.3, 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 moderately low hopelessness or hopeful future expectations at discharge.

%

of all clients experienced a statistically significant improvement in feelings of hopelessness2

Beck Hopelessness Scale Scores by Diagnosis 2014 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 Indiviudals have nihilistic preoccupations.

10 10 88

8.56 7.33

66

5.89 (N=114)

2.69

22 00

p<.001 for all comparisons

9.93

44 <3 Individuals are said to be hopeful.

DISCHARGE

(N=28)

2.04

(N=68)

(N=15)

3.25

2.20

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

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 moderately low hopeless thinking.

CLIENT SATISFACTION As part of the end of treatment process, all clients are invited to complete a satisfaction of care survey, which measures clients’ satisfaction with various domains of the Skyland Trail experience. Three general areas of satisfaction have been found to be the most reliable indicators of satisfaction of care: overall satisfaction, satisfaction with quality of services, and satisfaction with facilities. In 2014:

97%

of clients were satisfied with our services or programs

93%

of clients rated the quality of services as good, very good or excellent.

98%

of clients would recommend Skyland Trail to someone else

“Tomorrow is no longer a terrifying unkown; it’s now just the day after today. I up to face the day knowing I can handle whatever hardships it may bring and be happy with myself.” –West C. 5

DISEASE-SPECIFIC IMPROVEMENTS

76

%

of clients with thought disorders experienced statistically significant improvement in symptoms of psychosis4

80

%

of clients who are depressed experienced statistically significant improvement5

100%

of clients with mania broke their mania while in treatment6

90

%

•

The Brief Psychotic Rating Scale (BPRS) is given to individuals with thought disorders (schizophrenia and schizoaffective disorders).

•

The Montgomery-Asberg Depression Rating Scale (MADRS) is given to individuals with major depression as a primary diagnosis.

•

The Young Mania Rating Scale (YMRS) is given to individuals with a primary diagnosis of bipolar disorder.

•

The Hamilton Scale of Anxiety (HAM-A) is given to individuals with a primary diagnosis of anxiety.

Preliminary comparisons, looking at scores closest to admission and closest to discharge, show that for all four measures, clients show a statistically significant improvement of symptomology.

Though the scales differ for each measurement, lower scores always indicate improved symptomology.

SCORE CLOSEST TO ADMISSION

BIPOLAR ILLNESS

Brief Psychotic Rating Scale 2014

Young Mania Rating Scale 2014

t(57) = 3.11, p =.003

t(9) = 1.48 p = .173

40 40 30 30

10 10

36.71

00 Overall JE, Gorham DR. The Brief Psychiatric Rating Scale. Psychological Reports. 1962; 10:799-812.

7.8

2.9 Young, et. Al. (1978). A rating scale for mania: reliability, validity, and sensitivity. British Journal of Psychiatry, 133, 429-435.

ANXIETY DISORDERS

MAJOR DEPRESSION

Hamilton Scale of Anxiety 2014

Montgomery-Asberg Depression Rating Scale 2014

t(8) = 2.13, p =.066

t(40) = 3.37, p =.002

15 15 10 10

55

20 20

15.11

15 15

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

20 20

IMPROVEMENT

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.

43.26

812 7 10 6 58 46 34 2 2 1 00

IMPROVEMENT

50 50

20 20

References

SCORE CLOSEST TO DISCHARGE

THOUGHT DISORDERS

IMPROVEMENT

of clients with anxiety experienced statistically significant improvement in control of anxiety7

Skyland Trail administers disease-specific outcome measurement tools every two weeks of treatment, based on the confirmed diagnosis at admission. Four measures are given to clients continuously throughout their treatment.

17.73 12.98

00 Montgomery, S.A. & Åsberg, M. (1979). A new depression scale designed to be sensitive to change.

British Journal of Psychiatry, 134, 382-389.

6

HEALTHLY MINDS AND BODIES 30–50% of patients with clinical depression are at risk of developing cardiovascular disease.

Individuals with mental illnesses face particular risk for developing heart, pulmonary, and energy problems, collectively called cardiometabolic syndrome. High Body Mass Index (BMI), hypercholesterolemia, hypertriglyceridemia, hypertension, and hyperglycemia are the components of this syndrome.

Two classes of medications used to treat individuals with schizophrenia, bipolar illness, and depression – atypical antipsychotics and mood stabilizers – are known to exacerbate the problem, as are a number of the correlates of serious mental illness including a sedentary lifestyle and social isolation.

In 2014 Skyland Trail completed a pilot study of the Healthy Challenge Program.

Components of the program included: •

access to a personal trainer for weight control and to promote lean muscle mass

•

a low-carbohydrate, high-lean-protein meal plan for six daily meals

•

psychoeducation about the link between physical and mental health

•

tobacco cessation if indicated

•

nutritional education

•

meditation and relaxation classes, including yoga,

•

regular monitoring of physiologic indices

•

medication treatment of insulin resistance and/or hyperglycemia was provided as indicated

“I have increased knowledge of cardiometabolic syndrome.”

“The evidience is becoming clear that mental illnesses and physical illnesses are inextricably linked. We know that people with mental illnesses have twice the rates of heart disease and diabetes and maybe even higher rates of pulmonary disease. If we don’t provide effective care to prevent those medical problems, we are not really doing all we can to help our clients live quality lives.”

- Ray Kotwicki, MD, MPH Chief Medical Officer

83% “I am satified with the Healthy Challenge Program.”

83%

200

TOTAL CHOLESTEROL (mg/dL)

150 TRIGLYCERIDE LEVEL (mg/mL)

100 100

Admission

Month 1

Month 2

Timepoint in Healthy Challenge Program

7

Month 3

Results Patients who completed the program to date experienced several changes in their physical functioning.

•

Body mass index (BMI) manifested a statistically significant decrease of 62 percent of patients, p=.040. This BMI decrease is more substantial when considering that, compared to patients not enrolled in Healthy Challenge, participants experienced a net loss of 4 BMI points.

•

54 percent of participants manifested a decrease in their total cholesterol during treatment (mean =42 points), p=.002 and also in triglycerides (mean=45 points), p=.019.

•

HgA1c scores measuring average blood glucose were available for 78 percent of patients. Of those, 60 percent experienced a decrease (mean=.234% points), p=.022.

•

Finally, 38 percent had more than one day where they walked more than 10,000 steps, 54 percent had 2 or more days with more than 8,000 steps, and 69 percent of patients did not have a day without 6,000 or more steps, thus showing that the intervention is associated with excellent levels of physical activity.

Results were achieved in 12 weeks.

61%

of participating patients experienced a statistically significant decrease in BMI

54%

of participating patients experienced a decrease in total cholesterol and triglycerides

46%

of participating patients experienced a decrease in average blood glucose

Conclusion

69

%

of participating patients walked at least 6,000 steps each day of the program

The Healthy Challenge intervention leads to decreased BMI and high levels of physical activity. Activity levels were high for most patients, and cholesterol levels manifested a marginally significant decrease for the sample as a whole, with the decrease being over 40 points on average.

These findings suggest that a healthy living intervention is feasible in the context of a day treatment for serious mental illness.

8

ABOUT SKYLAND TRAIL Joint Commission National Quality Approval

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 and day treatment programs, we help our clients grow, recover, and reset to a new normal.

PROGRAMS

CONTINUUM OF CARE

Residential Treatment

We offer a unique continuum of care with deliberate step-downs and reintegration points â&#x20AC;&#x201C; from residential and day treatment, to job coaching and social opportunities for individuals living in the community.

Day Treatment Intensive Outpatient Independence Coaching Vocational Services Alumni Program

SPECIALIZED COMMUNITIES LEARN MORE

Cognitive Behavioral Therapy

866-528-9593

Dialectical Behavior Therapy

skylandtrail.org

Young Adult / First Psychotic Episode Social Integration Dual Diagnosis

NOT ONE-SIZE FITS ALL We offer a tailored mix of evidencebased and supportive therapies to help clients reclaim their lives. Clients participate in the development of 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.

(offered as sub-specialty for clients in all communities)

COMPLEMENTARY SERVICES Vocational Services Primary Care & Wellness Art & Music Therapy Horticultural Therapy Recreation Therapy Pastoral Counseling Nutrition Counseling LEAP Social Club Cognitive Remediation Therapy Family Education, Support & Therapy Certified Peer Counselors 9

WHOLE PERSON APPROACH 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.

“By far the most helpful treatment center I have ever been to I met so many amazing people and learned helpful skills.”

– SAMANTHA A. “This organization is truly professional, compassionate, and a team. From the initial contact to my discharge I felt I was in their care, had their attention and was given the best treatment available. I learned what is appropriate care, what progress looks like and to begin to trust myself with the future.”

– LAURA S.

“The most influential entity in my life thus far, maybe a one of a kind opportunity for anyone struggling with a mental illness.”

– CHARLES I. “Skyland Trail is the kind of place that accepts you for where you are when you walk in the door and then helps you be your best self, whatever that means to you. It is individualized care at its best.”

– TRACIE H. “I spent two years trying to overcome my depression through medication and outpatient therapy with very little success. Skyland Trail’s staff, community, and services were essential to my recovery from my treatment resistant depression.”

– PATRICK S.

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 Manager Skyland Trail PHOTOGRAPHY

Jerry Mucklow, Sarah Tabor 10

Skyland Trail 1961 North Druid Hills Road NE Atlanta, GA 30329

Non-Profit Org. U.S. Postage

tele: 404-315-8333 | fax: 404-315-9838 www.skylandtrail.org

Atlanta, GA Permit No. 3536

PAID

ADDRESS SERVICE REQUESTED

Offering Hope, Changing Lives

CONTACT US 1961 North Druid Hills Road NE Atlanta, Georgia 30329

866-528-9593 www.skylandtrail.org

AWARDS & RECOGNITION American Psychiatric Association Gold Award Rosalynn Carter/Johnson & Johnson Caregiver Award

PROGRESS

BY THE

NUMBERS

92%

of all clients experience a statistically significant improvement in their attitude toward activities of daily living & overall functioning

86%

of all clients experience a statistically significant improvement in feelings of hopelessness

Community Foundation for Greater Atlanta Managing for Excellence Award Georgia Center for Nonprofits Revolutions Award Mental Health America of Georgia Heroes in the Fight Award Joint Commission National Quality Gold Seal of Approval Since 1995

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“Symptom reduction is an essential first step, but when graduates describe having a stimulating job, a meaningful relationship, and hope for the future, we can really see the kind of transformation made possible by effective comprehensive treatment.”

Dr. Ray Kotwicki Chief Medical Officer