Serious Mental Illness and Substance Use Disorder

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Serious Mental Illness and Substance Use Disorder

• Bob Drake
• October, 2007

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NarcolepsySummary

• Serious mental illness
• Co-occurrence
• Consequences
• Recovery
• Integrated treatment
• Simple strategies for change

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Serious Mental IllnessMakes a Difference

• Diagnosis, disability, duration
• 5-7 of adults in any year (Kessler, 1997)
• 30 of SSI (Medicaid), SSDI (Medicare)
• Mental illness makes a difference
• Substance use disorder is different
• Dual diagnosis treatment is different

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Co-occurring Disorders Are Common

• 50 or more of people with serious mental
  illnesses have co-occurring substance use
  disorders

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Prevalence of Co-Occurring Disorders-ECA Study
of respondents
Regier et al., JAMA, 1990
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Co-occurring Disorders Have Severe Adverse
Consequences

• Clinical, psychosocial, familial, legal, health,
  victimization, housing

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Correlates of Medication Noncompliance
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Medical Complications of Co-Occurring Substance
Use HIV and Hepatitis B and C

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

Rosenberg et al., A Jl Public Health, 2001
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Monthly Income and Expenditures for Illegal Drugs
and Alcohol Among Schizophrenic Patients

• Monthly income 650
• Disability income 645
• Expenditures for illegal drugs 250
• Expenditures for alcohol 10
• Median values

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Costs of TreatmentMassachusetts Medicaid
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Recovery

• Dual recovery
• Recovery is modal
• Recovery may take years
• Morbidity and mortality

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Recovery Index

• Living independently
• Controlling symptoms
• Active remission of substance abuse
• Competitive employment
• Socializing with non-substance users
• Expresses life satisfaction
• Drake et al., 2006

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Recovery Score by Year
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How Do People Attain Recovery?

• Ethnographic perspective
• Safe and stable housing
• Sober support network
• Regular activity/work
• Trusting clinical relationship
• ALVERSON ET AL., 2000

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What About Treatment?

• Parallel treatment
• Integrated treatment
• Specific interventions

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Parallel Treatment Is Ineffective

• High dropout rate
• Less than 10 get both services
• Poor communication
• Interventions not modified
• Poor outcomes

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Integrated Treatment is More Effective

• 46 controlled studies
• Drake et al., JSAT, in press

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Integrated vs. Non-integrated Treatments
(McHugo et al, 1999)
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Principles of Integrated Treatment

• Integration
• Assertiveness
• Stage-wise treatments
• Comprehensiveness
• Long-term perspective
• Algorithms

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Integration

• Clinical integration, not collaboration
• Clinicians working together
• One coherent message
• Interventions modified for co-occurring disorder
• Drake et al., 2004

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Assertiveness

• Consumer friendly
• Outreach to community, jail, hospital, homeless
  shelter
• No terminations algorithms instead
• Drake et al., 2006

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Serious Mental IllnessTreatment Epidemiology

• 50 get no care
• 45 get poor care
• 5 get evidence-based care

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Stages of Treatment

• Engagement
• Motivation
• Active Treatment
• Relapse Prevention
• Drake et al., 2004

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Comprehensiveness

• Recovery means meaningful life
• Different interventions for
• Preferred outcomes
• Specific stages
• Subgroups
• Mueser et al., 2005

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Specific Interventions

• Individual counseling 7 studies
• Group counseling 8 studies
• Family psychoeducation 1 study
• Intensive outpatient program 2 studies
• Residential treatment 12 studies
• Case management 11 studies
• Contingency management 6 studies
• Legal interventions 5 studies
• Peer support 1 study
• Medications 2 studies
• Effective for substance use disorder

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Supported Employment

• The nature of recovery
• Relationship to institutionalization
• Relationship to costs

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Long-term Perspective

• Sustained abstinence is goal
• Occurs over years for most
• Relapse vulnerability
• Drake et al., 2005

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Program Fidelity

• Degree to which a particular program follows the
  standards for an evidence-based practice

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Why is Fidelity Important?

• Programs that faithfully implement the key
  elements of an EBP have better outcomes
• Correlations 0.5 to 0.8

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NH ACT Study (McHugo,1999)
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Simple Strategies for Change
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Be Modest

• Pervasive change strategies fail
• Pick achievable goals
• Build momentum over time

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Early Adopters

• Leadership
• Readiness
• Build momentum

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Client-centeredness

• All aspects of program
• Relationships critical
• Peer recovery
• Choice and shared decision-making

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Assessments

• Standardize
• Information technology
• Education
• Treatment planning

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Training

• Everyone
• Videos
• Web-based training
• People in recovery

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Supervision

• Clinical learning
• Longitudinal
• In the field
• Outcomes-based
• Resources for supervisors

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Outcomes

• Keep it simple
• AUS, DUS, SATS
• Client reports
• Direct entry

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Groups

• Multiple options
• Involve people in recovery
• Self-help

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Residential Programs

• Options
• Residential treatment
• Flexible boundaries

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Supported Employment

• Recovery means getting a new life
• People can work
• Cost-effective

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Dual Recovery

• Hope
• Relationships
• Employment
• Many chances
• Choices
• Time

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Further Information

• videos, books, manuals, research papers
• Karen.Dunn_at_Dartmouth.edu
• 603-448-0263

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Group Trajectories (Xie et al., 2006)
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Trajectory Groups

• Early abstinence
• Low levels of physiological dependence
• Clozapine
• Group counseling
• Late abstinence
• Steady treatment involvement
• Residential dual diagnosis treatment
• Fluctuating
• Continued psychiatric and psychosocial
  instability
• No abstinence
• Inconsistent treatment participation

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National EBP Project DesignImplementation Phase

• 53 sites in 8 states
• 5 EBPs implemented
• Fidelity assessed at baseline, 6, 12, 18, and 24
  months
• Fidelity assessment used as quality improvement
  tool
• 4.0 used as standard of adequate fidelity

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Stages of Recovery(McHugo et al., 1995)
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Key Implementation Factors

• Facilitators/Barriers
• Leadership, training, supervision
• Barriers
• Financial health, turnover

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Specific Interventions

• Individual counseling 7 studies
• Group counseling 8 studies
• Family psychoeducation 1 study
• Intensive outpatient program 2 studies
• Residential treatment 12 studies
• Case management 11 studies
• Contingency management 6 studies
• Legal interventions 5 studies
• Peer support 1 study
• Medications 2 studies of naltrexone/disulfiram

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Limits

• Few replications
• Little consistency of designs, interventions,
  outcomes, length
• Heterogeneity of clients
• Attrition
• Assessment of substance abuse
• Different contexts

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Research Issues

• Testing standardized interventions
• Interventions for stages
• Sequencing and combining interventions
• Interventions for subgroups
• Implementation
• Transforming systems of care

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Conclusions

• Co-occurring disorders are modal
• Integrated treatment is effective
• Long-term perspective is key
• Many questions about specific interventions,
  subgroups, timing, implementation

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Fundamental Flaw in Correlational Studies

• Different populations
• Need for longitudinal follow-up

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Integrated vs. Non-integrated Treatments
(McHugo et al, 1999)