Helping the Homeless and dually diagnosed: meeting the challenge

1. Helping the Homeless and dually diagnosed: meeting the challenge Cheryl Gonzales-Nolas MD James A. Haley VA Hospital Tampa, FL

2. Homelessness statistics: the scope of the problem(SAMHSA) • On a given night in 2010: • 407,966 individuals were homeless in shelters, transitional housing programs, or on the streets • 109, 812 individuals were chronically homeless (this was actually an improvement from the previous year) • (US Department of Housing and Urban Development’s 2010 Annual Homeless Assessment Report to Congress)

3. More statistics. . . • Over the course of one year (October 2009- September 2010): • 1,593,150 individuals experienced homelessness • 85% of homeless clients were single (National Survey of Homeless Assistance Providers and Clients, 1986) • 26.2% of all sheltered persons who were homeless had a severe mental illness • 34.7% of all sheltered adults who were homeless had chronic substance abuse issues

4. Veterans and Homelessness • (Veteran Homelessness: A Supplement to the 2009 Annual Homeless Report, January 2011) • An estimated 75,609 veterans (male and female) were homeless on a single night in January, 2009 • Roughly 160,000 veterans experienced homelessness over the course of one year (about 10% of the total homeless population) • roughly 44,000 to 66,000 veterans are experiencing chronic homelessness

5. Veterans and homelessness, cont’d • Nearly half of all homeless veterans on a single night were located in just four states (California, Florida, New York, and Texas) • Almost all sheltered, homeless veterans are single adults. • 4% of homeless veterans are part of families

6. Characteristics of the veteran homeless population • Tend to be single male adults, older than their non-veteran peers, more likely to have a disability, and are equally likely to be white non-hispanic as they are to be a minority. (Veteran Homelessness, 2009) • 8.4% are between the ages of 18-30 • 45% are between 31-50 • 38.1% are between 51-61 • 8.9% are 62 or older

7. Risk factors for homelessness among veterans • Less than 1% of the veteran population is actually homeless. Certain groups of veterans are at higher risk of homelessness. (Veteran Homelessness, 2009) • Women veterans and younger veterans between ages 18-30 are at particularly high risk of becoming homeless • Rates of homelessness are higher for veterans who identify as minority groups. • 10% of veteran living in poverty became homeless at some point during the year, double the rate of their non-veteran peers. • Women veterans living in poverty are nearly 3 times more likely to be homeless than non veteran women living in poverty.

8. Serious Mental Illness, Substance use, and Homelessness • About 45% of homeless veterans experience mental illness • 70% experience alcohol or other drug abuse problems • Many homeless veterans experience both

9. The importance of the issue • Use of and withdrawal from alcohol and other drugs of abuse can cause, mimic, or mask other psychiatric symptoms. • We no longer carry the assumption that all psychiatric symptoms are caused by the drug of abuse and recognize that there is interaction between psychiatric and substance induced symptoms.

10. Cause or Effect. . . • Is my patient depressed because he is drinking heavily, or is he drinking heavily because he is depressed? • Is my patient anxious because she is withdrawing from benzodiazepines, or does she abuse benzodiazepines because she has an underlying anxiety disorder? • Is my patient hearing voices because he smokes marijuana daily, or does he smoke marijuana because it helps him to think more clearly?

11. Ramifications • Some substance abuse providers have refused to treat patients psychiatric symptoms until the individual is sober for several months. • Individuals with severe mental illness are usually unable to sustain remission of their illness without pharmacologic treatment • This can lead to a relapse into both substance use and mental health disorder, as there often is a self medicating element to relapse in dual diagnosis patients.

12. How the dually diagnosed are different • Many substance misusers suffer from both addiction and mental health disorders. • Individuals with comorbid disorders do not typically respond well to traditional SUD treatment approaches. • A comprehensive approach is necessary when treating these patients, individualized to the patient in treatment.

13. Dually Disordered vs. Co-occurring Conditions • It is rare for an individual to have only 2 complicating conditions. • The term “co-occurring conditions” is taking precedence when discussing this population. • These individuals suffer from an entire spectrum of difficulties including social, financial, and psychological. • Optimal treatment requires the coordinated efforts of an entire team of providers including medical and psychiatric, social workers, and therapists.

14. Demographics • According to NIDA and NIAAA data, abuse of alcohol cost the USA 245.7 billion dollars in 1992. This represented a more than 50% increase from 1985. • This number represents total cost of treatment for the substance user as well as drug related diseases. (cirrhosis, liver failure, hepatitis, and HIV, decreased employee productivity, premature death, and legal costs.)

15. Addiction in Mental Health Populations • Looking at a community sample (Regier et al)- individuals with any mental disorder have a lifetime prevalence of 29% for an addictive disorder. • In treatment and institutional settings, the percentages increase.

16. Specialized settings and populations • Treatment settings such as the Veteran’s Administration, Community mental health centers, and inpatient samples have up to 66% comorbidity. • Bipolar disorder patients as a cohort have up to 75% comorbidity. (Tohen et al) • Data from studies of sample cohorts with PTSD are showing similar findings.

17. Impact of Co-Occurring Disorders • Poverty and homelessness • Increased risks of being both the victim and the perpetrator of assault. • Less compliant with medications and more likely to drop out of treatment.

18. Treatment Strategies • Sequential- treatment for the mental health issues follows treatment for substance use disorders. • Parallel- treatment for the mental health disorders occurs simultaneously to the treatment for substance use disorders, but the treatment teams act independently • Integrated- one integrated treatment team follows the patient and addresses the mental health and substance abuse problems simultaneously.

19. Provider role in Treatment • Help the patient develop strategies for dealing with each of his/her respective diagnoses • Strategies often include medication, especially for individuals with severe mental illness and psychotic disorders.

20. Special Issues in the Evaluation of Co-occurring Diagnosis • Treating provider needs to be capable of performing a basic psychiatric evaluation. • Evaluation must include assessment of past diagnosis, past hospitalizations, response to treatment, family history, and medications used. • Suicidal ideation is a MUST (include current, past SI as well as attempts)

21. Suicide and Substance Use • Acute and chronic use of substances vastly magnify the risk of suicide in individuals with mood disorders and other chronic, severe mental illnesses (including psychosis and bipolar disorder).

22. How do I know what came first? • Do psychiatric symptoms predate the onset of substance abuse? • Do the psychiatric symptoms improve, disappear, or worsen when the substance misuse is stopped? • What is the individual using and what is the length of effect of the substance used? Is the drug screen clean or still positive? • What is the clinical effect of the substance? Is it a stimulant or depressant, and how does it correlate with the patient’s reported symptoms?

23. Treatment Retention • Working with a patient and helping to treat the patient’s underlying symptoms significantly increases the chance of long term engagement of the patient. • Treatment in a program which identifies and treats all significant mental health issues helps to increase retention and treatment outcome.

24. Dual Diagnosis Programs vs. Traditional substance use treatment • Dual diagnosis programs must be able to adjust to accommodate the needs of the clientele they serve, on an individual basis. • Permitting the patient only to participate when abstinent may render the severely ill patient unable to obtain the care that they need. • Repetition is essential as psychiatric symptoms often impair learning.

25. Use of medications • Medications should be used when necessary. • Avoid medications which cause euphoria or dependence (benzodiazepines, stimulants). • Encourage patients to take non-narcotic medications for pain. • Be aware of safety concerns and utilize medications that are effective for the condition treated.

26. When should medications be started? • Any emergent mental health issue (psychosis, suicidal ideation/homicidal ideation, severe depression or manic symptoms) needs to be addressed and treated appropriately and immediately. • Non-emergent but problematic symptoms (mood symptoms, anxiety, etc.) should be evaluated in the context of treatment and treated as well. • If psychiatric symptoms last longer than the known action of the substance used, need to consider the possibility that you are dealing with a co-occurring disorder.

27. Entry to Treatment for SUD • Only a small fraction of individuals in need of treatment actually enter treatment • SAMHSA reports that in the year 2000, 120,000 homeless persons were admitted nationwide for treatment for alcohol and drug problems • Estimating 2.5-3 million homeless persons, those needing treatment would equal 1.25-1.5 million persons (less than 10% entered treatment).

28. Why Don’t They Enter Treatment? • The role of outreach in referring the homeless to treatment needs to be better defined and more uniform • Waiting lists create long wait times before entering treatment • Lack of SUD treatment accessibility • Programs simply don’t exist in certain areas of the country (methadone programs) • Lack of money or infrastructure to assist individuals to get to treatment • Community resources are often fragmented with poor coordination between resources

29. How Outreach Providers Can Help • Colocation of services at a single site with an integrated treatment team. • Employment of specialized interventions including motivational interviewing and cognitive/ behavioral counseling • Harm reduction techniques • Ready availability of transitional and affordable housing • Ongoing case management

30. Questions and Discussion

31. References • US Department of Housing and Urban Development’s 2010 Annual Homeless Assessment Report to Congress • U.S. Department of Housing and Urban Development (HUD) & U.S. Department of Veterans Affairs (VA). (2011). Veteran homelessness: A supplement to the 2009 annual homelessness report. Washington, DC: U.S. Department of Housing and Urban Development. [2009 VH] • Kuhn, J. H., & Nakashima, J. (2010). Community homelessness assessment, local education and networking group (CHALENG) for veterans. The sixteenth annual progress report on public law 105-114. Services for homeless veterans assessment and coordination. U.S. Department of Veterans Affairs. Retrieved from http://www.va.gov/HOMELESS/docs/chaleng/chaleng_sixteenth_annual_report.pdf • http://homeless.samhsa.gov/resource

32. References • National Institute on Drug Abuse. “Drug abuse cost to society set at $97.7 billion.” Rockville, MD: National Institutes of Health, 1998:1, 12-13 • Regier H et al. “Comorbidity of mental disorders with alcohol and other drug abuse: results from the Epidemiology Catchment area study.” JAMA 1990; 264(19): 2511-2518 • Winokur G, Coryell W, Akiskal H et al. “Manic depressive (bipolar) disorder: the course in light of a prospective ten year follow up of 131 patients.” ActaPsychiatrScand 1994; (2): 102-110 • Tohen M, Zarate CAJ. “Bipolar disorder and Comorbid Substance Use Disorders”. In Bipolar Disorder: Clinical Course and Outcome. (Goldberg JF, Harrow M<) eds. Washington DC- American Psychiatric Press, 1999: 171-184