Cooccurring Disorders Phenomenology: Experience, Meaning, Intention, and Treatment Principles

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Co-occurring Disorders Phenomenology
Experience, Meaning, Intention, and Treatment
Principles

• Fred C. Osher, M.D.
• SAMHSAs Co-Occurring Center of Excellence
• October 2, 2007

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Goals of the Session

• An overview of co-occurring disorders
• Principles of care associated with good outcomes
• Stages of Change and Phases of Treatment
• Set the stage for the ongoing implementation of
  best practices in Ohio

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Increasing COD Traction

• SAMHSA Priority
• Report to Congress
• Policy Academies
• COSIG Grants
• COCE
• COD Treatment Improvement Protocol 42
• Integrated Dual Disorders Treatment Toolkit
• New Epidemiologic Data
• The 7th Annual Ohio SAMI CCOE conference!

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Case Example Helen

• 34 y.o. AA Female
• Homeless
• Bipolar Affective Disorder
• Opiate Dependence
• Released from State prison on parole

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The call for change

• Prevalence rates are high
• Consumers, families, providers are frustrated by
  systemic barriers
• Associated morbidity and mortality is stunning
• Costs of ineffective care are enormous
• Effective interventions have been demonstrated

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PARALLELS MENTAL ILLNESSES AND
ADDICTIONS Minkoff

• MAJOR MENTAL ILLNESS
•  
• A biological illness.
• Hereditary (in part).
• Chronicity
• Incurability
• Leads to lack of control of behavior and emotions
• Affects the whole family
• Symptoms can be controlled with proper treatment
• Progression of the disease without treatment
• Disease of denial
• Facing the disease can to lead to depression and
  despair. 
• Disease is often seen as a moral issue, due to
  personal weakness rather than biological causes
• Feelings of guilt and failure
• Feelings of shame and stigma
• Physical, mental, and spiritual disease

• ALCOHOLISM/ADDICTION
•  
• A biological illness.
• Hereditary (in part).
• Chronicity
• Incurability
• Leads to lack of control of behavior and emotions
• Affects the whole family
• Symptoms can be controlled with proper treatment
• Progression of the disease without treatment
• Disease of denial
• Facing the disease can to lead to depression and
  despair. 
• Disease is often seen as a moral issue, due to
  personal weakness rather than biological causes
• Feelings of guilt and failure
• Feelings of shame and stigma
• Physical, mental, and spiritual disease

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Definition Co-occurring Disorders

• The term refers to co-occurring substance use
  (abuse or dependence) and mental disorders.
• Clients said to have co-occurring disorders when
  at least one disorder of each type can be
  established independently of the other and is not
  simply a cluster of symptoms resulting from a
  single disorder.
• Yet, diagnostic certainty cannot be the sole
  basis for service planning and design

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Definition Co-occurring Disorders - for System
Planning and Service Design

• Individuals who are pre diagnosis
• Individuals who are post diagnosis
• Individuals with a unitary disorder that
  present with acute signs and symptoms of a
  co-occurring disorder
• Every initiative must clarify the purpose of
  defining COD in order to match COD populations to
  specific system and service planning efforts.

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Relationships between Substances of Abuse and
Mental Disorders (Lehman et al.,1989)

• 1. Acute and chronic substance use can produce
  psychiatric symptoms
• 2. Substance withdrawal can cause psychiatric
  symptoms
• 3. Substance use can mask psychiatric symptoms
• 4. Psychiatric disorders can mimic symptoms
  associated with substance use
• 5. Acute and chronic substance use can exacerbate
  psychiatric disorders
• 6. Acute and chronic psychiatric disorders can
  exacerbate the recovery process from addictive
  disorders

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Co-Occurrence of Serious Psychological Distress
and Substance Use Disorders among Adults Aged 18
or Older 2006
A
B
C
NSDUH 2006
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Prevalence Data General Population

• Epidemiologic Catchment Area Study
• Presence of a mental disorder triples the risk of
  having a co-occurring substance use disorder
• Presence of addictive disorder quadruples the
  risk of having a co-occurring mental disorder
• National Co-morbidity Study
• 83.5 of time, mental disorder precedes the
  addictive disorder
• National Survey of Drug Use and Health
• Uses a uniform definition of serious mental
  illness to identify 5.6 million Americans with
  SMI and co-occurring SA dx

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Prevalence of Co-Occurring Disorders-ECA Study
of respondents
Regier et al., JAMA, 1990
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Comorbidity of Mental Disorders with Any
Substance Abuse
Rank Order of Mental Disorders by Odds Ratio
with Substance Odds Axis
/ Disorders Abuse or Dependence Ratio
Bipolar I 61 7.9 Bipolar II 48 4.7 Schiz
ophrenia 47 4.6 Panic Disorder 36 2.9 Obse
ssive Compulsive Disorder 33 2.5 Dysthymia 3
1 2.4 Unipolar Depression 27 1.9 Phobia 2
3 1.6
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National Epidemiological Survey on Alcohol and
Related Conditions (NESARC)

• Used DSM-IV Criteria to Establish Diagnosis
• National Representative Sample (N 43,093)
• Addressed specific diagnostic conditions and
  subsets of those conditions
• Mood Disorders
• From Depression to Dysthymia
• Anxiety Disorders
• From Panic to GAD
• Personality Disorders

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NESARC - Twelve Month Prevalence of Independent
Mood Disorders Among Those with Substance Use
Disorders Clark, 2005
Percentage
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NESARC - Twelve Month Prevalence of DSM-IV
Substance Use Disorders Among Those with
Independent Mood Disorders Clark, 2005
Percentage
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NESARC - Twelve Month Prevalence of Independent
Anxiety Disorders Among Those with Substance Use
Disorders Clark, 2005
Percentage
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NESARC - Twelve Month Prevalence of DSM-IV
Substance Use Disorders Among Those with
Independent Anxiety Disorders Clark, 2005
Percentage
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NESARC - Prevalence of Mood Anxiety Disorders
Clark 2005

• Of the approximately 19.3 million adults who had
  a current mood disorder, only 202,211 experienced
  episodes that were classified exclusively
  substance induced.
• Of the approximately 23 million adults with a
  current anxiety disorder, only 50,980
  experienced episodes that were exclusively
  substance induced.
• Of those respondents who were classified as
  having at least one current independent mood or
  anxiety disorder, only 7.35 and 2.95,
  respectively, experienced independent and
  substance induced episodes in the year preceding
  the survey

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Prevalence Data Site Bias

• Persons with co-occurring disorders seek help
• National Longitudinal Alcohol Epidemiologic
  Survey (Grant et al)
• DD 5xs more likely to seek services than singly
  diagnosed
• National Comorbidity Survey (Kessler et al.)
• 19 alcohol dependent and 26 drug dependent in
  tx within 12 months
• with co-occurring dx - 41 alcohol dependent and
  63 drug dependent in tx
• Outpatient Public Mental Health Clinics
• Outpatient Drug and Alcohol Treatment
• Inpatient Settings
• Homeless Populations
• Jails and Prisons

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Co-Occurring Substance Use Disorders Among Jail
Detainees with Serious Mental Disorders

• With Co-Occurring Substance Use Disorders
• Without Co-Occurring Substance Use Disorders

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Consequences of Co-occurring Disorders

• Increased vulnerability to relapse and
  rehospitalization
• More psychotic symptoms
• Inability to manage finances
• Housing instability and homelessness
• Noncompliance with medications and treatment
• Increased vulnerability to HIV infection and
  hepatitis

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Medical Complications of Co-Occurring Substance
Use with Schizophrenia HIV and Hepatitis B and C

• Persons with Substance Use Disorders had
• 2.95 (1.25-6.86) increased chance of having HIV
• 1.74 (1.20-2.51) increased chance of having HBV
• 2.42 (1.62-3.63) chance of having HCV

Rosenberg et al., A J Public Health, 2001
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Consequences of Co-occurring Disorders (cont.)

• Lower satisfaction with familial relationships
• Increased family burden
• Violence
• Incarceration
• Increased depression and suicidality
• Higher service utilization and costs

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Principles of care

• 1. Integrated treatment
• 2. Screening, Assessment, and
• Individualized treatment planning
• 3. Assertiveness
• 4. Close monitoring
• 5. Longitudinal perspective
• 6. Stages of change
• 7. Stable living situation
• 8. Cultural competency and consumer
  centeredness
• 9. Optimism

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1. Integrated treatment

• Traditional models of treatment for dual
  disorders results in poor outcomes
• no treatment -- high utilization of E.R., jails,
  hospitals
• sequential treatment
• parallel treatment -- burden of integration on
  individual
• Integrated treatment associated with better
  outcomes

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Past Year Treatment among Adults Aged 18 or Older
with Co-Occurring SMI and a Substance Use
Disorder 2006 (NSDUH)
Treatment Only for Mental Health Problems
Treatment for Both Mental Health and Substance
Use Problems
39.6
8.4
2.8
Substance Use Treatment Only
No Treatment
49.2
5.6 Million Adults with COD
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FIDELITY TO DUAL DIAGNOSIS PRINCIPLES
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Heterogeneity of the Population with Co-occurring
Disorders
Alcohol and other drug abuse
Mental Illness
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Organizational Processes that Support Systems
Integration (Curie et al., 2005)

• Committed leadership
• Integrated planning implementation
• Value driven, evidence based priorities
• Shared vision and integrated philosophy
• Dissemination of technology to help improve
  clinical practice/program design
• True partnership between all levels
• Data driven, incentivized, and interactive
  performance improvement processes

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2. Screening, Assessment, and Individualized
Treatment Planning Definition Screening

• A formal process of testing to determine whether
  a client does or does not warrant further
  attention at the current time in regard to a
  particular disorder and, in this context, the
  possibility of a co-occurring substance or mental
  disorder.
• The screening process for co-occurring disorders
  (COD) seeks to answer a yes or no question
  Does the substance abuse or mental health
  client being screened show signs of a possible
  mental health or substance abuse problem?
• Note that the screening process does not
  necessarily identify what kind of problem the
  person might have, or how serious it might be,
  but determines whether or not further assessment
  is warranted.

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Features of Screening Instruments

• High sensitivity (but not high specificity)
• Brief
• Low cost
• Minimal staff training required
• Consumer friendly

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Some Recommended Screening Instruments for COD

• Mental Health Screening Form III
• Simple Screening Instrument for Substance Abuse
  (SSI-SA)
• Dartmouth Assessment of Lifestyle (DALI)
• Texas Christian University Drug Screens

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The Goal Universal Screening

• All individuals presenting for treatment of a
  substance use disorder should be routinely
  screened for any co-occurring mental disorders.
• All individuals presenting for treatment of a
  mental disorder should be screened routinely for
  any co-occurring substance use disorders.

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2. Screening, Assessment, and Individualized
Treatment Planning Definition Assessment

• A basic assessment consists of gathering key
  information and engaging in a process with the
  client that enables the counselor/therapist to
  understand the clients readiness for change,
  problem areas, COD diagnosis, disabilities, and
  strengths.
• An assessment typically involves a clinical
  examination of the functioning and well-being of
  the client and includes a number of tests and
  written and oral exercises. The COD diagnosis is
  established by referral to a psychiatrist or
  clinical psychologist.
• Assessment of the COD client is an ongoing
  process that should be repeated over time to
  capture the changing nature of the clients
  status.

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Domains of Assessment

• Acute Safety Needs
• Quadrant Assignment
• Level of Care
• Diagnosis
• Disability

• Strengths and Skills
• Recovery Support
• Cultural Context
• Problem Domains
• Phase of Recovery/Stage of Change

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The Best Assessment Tool
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2. Screening, Assessment, and Individualized
Treatment Planning
Definition ITP

• A collaborative process of working with a client
  and his family or support system to specify
  personal goals and the means by which treatment
  can help a client reach those goals.
• Treatment planning is derived from a
  comprehensive assessment
• Accurate assessment is difficult to do
• poor clinician assessment skills
• lack of standardized instruments
• inaccuracy of self-report

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Individualized Treatment Planning - Steps

• 1. Evaluate pressing needs
• 2. Determine motivation to address substance
  use/mental health problems
• 3. Select target behaviors for change
• 4. Determine interventions to achieve desired
  goals
• 5. Choose measures to evaluate the
  intervention
• 6. Select follow-up times to review the plan.

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3. Assertiveness

• Responsibility of systems to support outreach and
  engagement services
• Need to increase treatment penetration
• Successful interventions
• go wherever the client is
• work with family, landlords and employers
• Assertive Community Treatment (ACT)

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4. Close monitoring

• Intensive supervision needed until stable
• Sometimes coercive, always persuasive
• representative payeeship
• mandatory substance abuse treatment
• urine testing
• Often used as an extension of court sanctions

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5. Longitudinal perspective

• Mental health, substance use disorders, and
  disease are chronic, relapsing conditions
• Treatment occurs continuously over years
• Progress measured over time

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6. Stages of change

• Engagement - connecting people to treatment
• Persuasion - convincing engaged clients to accept
  treatment
• Active treatment - range of behavioral,
  psychoeducational and medical interventions
• Relapse prevention - prevention and management of
  relapses

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COURSE OF ATTAINING STABLE REMISSION (Drake et
al, 1997)
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7. Stable living situation

• Not having a home makes assessment difficult and
  protracted
• Range of safe, affordable housing options are
  necessary
• safe havens or low demand residences for
  engagement and persuasion
• alcohol and drug free housing during active
  treatment and relapse prevention
• Separate assessment and treatment from housing
• Flexibility and tolerance required to retain
  people in housing

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8. Cultural competency and
consumer centeredness

• Seek to understand - dont assume a shared set of
  values or impose ones own
• Respect cultural differences
• Value the consumers point of view

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9. Optimism

• Critical ingredient for recovery
• Hope as an antidote to despair
• Must have courage to connect with the reality of
  despair
• Share belief that because the problems are
  severe, the person deserves help
• Create a vision of what a hopeful outcome might
  be
• Peer supervision and training to bolster staff
  optimism

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Future Directions

• Horizontal and Vertical Dissemination
• Workforce Development
• Graduate Education
• Co-occurring certification
• Measuring Effectiveness
• National Outcome Measurements
• Performance Based Contracting
• Ohios CCoE

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SAMHSAs COD Resources

• www.samhsa.gov under Co-Occurring Disorders
• Co-Occurring Dialogues Discussion List
  Membership is free and unrestricted and can be
  done by sending an e-mail to dualdx_at_treatment.org
• Co-Occurring Center for Excellence (COCE) at
  www.coce.samhsa.gov or samhsacoce_at_cdmgroup.com
  for technical assistance

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• To the extent that we respond to the health
  needs of the most vulnerable among us, we do the
  most to promote the health of the nation.
• David
  Satcher, M.D.,Ph.D.

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Helen