Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders

1. Treating the Whole Person: Integrating Care for Persons with Co-Occurring Disorders Thomas E. Freese, Ph.D. Beth A. Rutkowski, M.P.H. UCLA ISAP/Pacific Southwest ATTC www.uclaisap.org www.psattc.org UCLA

2. Ice Breaker • In pairs, discuss a consumer who has experienced both mental health and substance use disorders. • How is this consumer unique from other mental health consumers? • How does the consumer present? What behaviors does he/she exhibit that are different from a consumer with mental illness only?

3. Introduction:What we will cover • Overview of the evolving field of Co-Occurring Disorders • What is happening in the brain? • Using motivational interviewing with this population—why and how • Importance of conducting effective screening and assessment for COD • Conducting a brief intervention for consumers with COD • Ways in which trauma and HIV impact COD

4. Co-Occurring Disorders Co-occurring disorders • Refers to co-occurring substance use(abuse or dependence) and mental disorders In other words… consumers with co-occurring disorders have: • one or more disorders relating to the use of alcohol and/or other drugs of abuse and one or more mental disorders

5. Co-Occurring Disorders Diagnosis of COD occurs when: • at least one disorder of each type can be established independent of the other and • is not simplya cluster of symptoms resulting from the one disorder Clinicians knowledge of both mental health and substance abuse is essential, but challenging to achieve

6. So, all of that is well and good, but… …is dealing with drug abuse REALLY important to my job?

7. Prevalence of COD • In 2006, 5.6 million adults (2.5% of persons aged 18+) met the criteria for both serious psychological distress (SPD) and substance dependence and abuse (i.e., substance use disorder, SUD) • In 2006, 15.8 millionadults (7.2% of persons aged 18+) had at least one major depressive episode (MDE) in the past year • Adults with MDE in the past year were more likely than those without MDE to have used an illicit drug in the past year (27.7 vs. 12.9 percent) SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

8. Past Year Treatment of Adults with Both Serious Psychological Distress (SPD) and SUD (2006) 5.6 Million adults with co-occurring SPD and substance use disorder. SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

9. Past Year Treatment of Adults with Both MDE and AUD SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

10. Percentage of Adults with Past Year MDE and AUD by Age Group SOURCE: 2007 National Survey on Drug Use and Health, SAMHSA.

11. Substance Use and Depression among Adults SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

12. Substance Use and Depression among Adolescents *Aged 12-17 SOURCE: 2006 National Survey on Drug Use and Health, SAMHSA.

13. Adolescents with Substance Use Disorders... • Are largely undiagnosed • Are distributed across diverse health and social service systems • Are more likely to be involved in the juvenile justice system • Have higher rates of child abuse(neglect, physical and sexual abuse • Have high co-morbidity with psychiatric conditions

14. Data from LA County DMH, 2007 • 61,739 new episodes opened in DMH Directly Operated Programs: • 17,647 (29%) dual code field was empty (i.e., neither presence nor absence of substance use noted); • 44,092 episodes where dual field was completed: • 31,187 (71%) indicated NO substance abuse issues • 12,905 (29%) indicated substance abuse issues.

15. Prevalence and Other Data Data now show: • COD are common in general adult population. • Increased prevalence of people with COD and programs for people with COD • People with COD are more likely to be hospitalized and the rate may be increasing • Rates of mental disorders increase as the number of substance use disorders increase • If we treat the SUD, we also address mental health symptoms

16. So, the answer is… Yes, this really IS important to your job! We must address SUD in order to increase the effectiveness of mental health treatment

17. One Client’s Perspective

18. …and to complicate the picture even more…

19. Substance Use and Trauma • The co-occurrence of PTSD and substance use among those in treatment is 12-34%; for women it is 30-59%. • Up to two-thirds of men and women in substance abuse treatment report childhood abuse or neglect. • People with PTSD and substance abuse are vulnerable to repeatedtraumas. • Becoming abstinent from substances does not resolve PTSD; some symptoms may become worse with abstinence. • Treatment outcomes for those with PTSD and substanceabuse are worse than for those with substance abuse alone.

20. Substance Use and HIV •By 2010, HIV/AIDS will have caused moredeaths than any disease outbreak in history. • “HIV is spread by unsafe behaviors that mental health care providers are often in the best position to identify and address.” ** • Individuals with Severe Mental Illness (SMI) are disproportionatelyaffected by HIV/AIDS. • Persons with HIV/AIDS and who have a mental illness have special needs. **McKinnon, K. 1999. Psychiatric Services, 50 (9) 1225-1228.

21. So, How Do We Treat COD? TIP 42 Guiding Principles and Recommendations

22. Six Guiding Principles (SAMHSA, TIP 42) • Employ a recovery perspective • Develop a phased approach to treatment • Address specific real-life problems early in treatment • Plan for cognitive and functional impairments

23. Delivery of Services (SAMHSA, TIP 42) • Provide access • Complete a full assessment • Provide appropriate level of care • Achieve integrated treatment - Treatment Planning and Review - Psychopharmacology • Provide comprehensive services • Ensure continuity of care

24. Vision of Fully Integrated Treatment • One program that provides treatment for both disorders • Mental and substance use disorders are treated by the same clinicians • The clinicians are trained in psychopathology, assessment, and treatment strategies for both disorders

25. Vision of Fully Integrated Treatment (continued) • Treatment is characterized by a slow pace and a long-term perspective • Providers offer motivational counseling • 12-Step groups are available to those who choose to participate • Pharmacotherapies are utilized according to consumers’ psychiatric and other medical needs • Sensitivity to issues of trauma,culture, gender, and sexualorientation

26. Consumer Improvement Strategies • Increase the focus on consumer satisfaction and consumer perception of care • Increase the use of behavioral enhancement techniques (use of positive reinforcement techniques). • Increase the use to strategies to increase consumer access to care and appreciation of care (eg. NIATx) • Increase measurement of service effectiveness and greater provider accountability 30

27. Provider/practice barriers • Differing practice styles • Differing practice cultures and language • Difficulty in matching provider skills with patient needs • Heavy reliance on physician services • Tension between direct patient care services (reimbursable) and integrative (non-reimbursable) services 31

28. Provider/practice barriers • Lack of recognition of provider limitations • Lack of MH knowledge in PC providers and lack of health knowledge in BH providers • Lack of clinical competence in integrated service models (MH/SU and BH/PC) and selection of proper integration model based on practice context • Differing coding and billing systems • Provider resistance 32

29. Addiction: A Brain Disease Putting Drug Use into Context with other Mental Disorders

30. Onset of Mental Health Disorders • Oppositional Defiance: 5yo • Attention Deficit Disorder-ADHD: 1.3-2.4 yo • Anxiety Disorders: 3.8 yo • Conduct Disorder: 5.6 yo • Depression: 10.1 yo • Schizophrenia-affective disorders: mid-teens to mid-thirties

31. Typical Progression of Use FAS---Substance use in-uterus No Social Use Experimentation Use Use Abuse Dependence ----------------------------------------------------------------------------------------------- 0-2 3-5 6-8 9-10 11-12 13-14 15-16 17+ Infant Child Pre- Adolescent adol Mental Health Disorder’s onset----------------------------------

32. What are we talking about? Alcoholism/Addiction Major Mental Disorders Both heredity and environment play a role Characterized by chronicity and “denial” Affects the whole family Progresses without treatment Feelings of shame and guilt Inability to control behavior and emotions Often seen as a moral issue Leads to feelings of despair and failure Biological, psychological, social and spiritual components

33. Collision of Symptomology Differential Diagnosis is essential for accurate assessment. Is the presenting problem affected by a medical condition or substance? Is it depression or alcohol, prescription pain killer, heroin use? Is it ADHD or is it methamphetamine, cocaine use? Is it bipolar disorder or cocaine use? Is it schizophrenia or methamphetamine use? Is it PTSD or polysubstance use?

34. A Major Reason People Take a Drug is They Like What It Does to Their Brains

37. …Hoping to Change their Brain Initially, A Person Takes A Drug Hoping to Change their Mood, Perception, or Emotional State Translation---

38. The Brain Undergoes Tremendous Changes During Development Increase of brain activity that accompanies the growth of the brain, in the same patient, from the age of 1 to 12 months. Information taken from NIDA’s Science of Addictionhttp://www.drugabuse.gov/ScienceofAddiction/

39. Continuing Brain Development During Adolescence • Strengthening the Circuitry Synaptic connections are strengthened • Pruning Unused Connections - Adolescent brain is in a unique state of flux -Neurons are eliminated, pruned and shaped - This process is influenced by interactions with the outside world (Seeman, 1999) - Pruning occurs from back to front so frontal lobes mature the last. • Other brain areas are also growing during adolescence (e.g., sub-cortical areas, receptors)

40. Continuing Brain Development Early in development, synapses are rapidly created and then pruned back. Children’s brains have twice as many synapses as the brains of adults.(Shore, 1997)

41. Brain Development Ages 5-20 years • MRI scans of healthy children and teens compressing 15 years of brain development (ages 5–20). • Red indicates more gray matter, blue less gray matter. • Neural connections are pruned back-to-front. • The prefrontal cortex ("executive" functions), is last to mature. Information taken from NIDA’s Science of Addiction http://www.drugabuse.gov/ScienceofAddiction/ Gagtay, N., et al. PNAS, 101, 8174-8179

42. The interaction between the developing nervous system and drugs of abuse leads to: • Difficulty in decision making • Difficulty understanding the consequences of behavior • Increased vulnerability to memory and attention problems • This can lead to: • Increased experimentation • Substance addiction • (Fiellin, 2008)

43. Young Brains Are Different from Older Brains Alcohol and drugs affect the brains of adolescents and young adults differently than they do adult brains Adolescent rats are more sensitive to the memory and learning problems than adults* Conversely, they are less susceptible to intoxication (motor impairment and sedation) from alcohol* These factors may lead to higher rates of dependence in these groups (Hiller-Sturmhöfel and Swartzwelder, 2004)

44. Triggers and Cravings Human Brain

45. Triggers and Cravings Ivan Petrovich Pavlov

46. Triggers and Cravings Pavlov’s Dog

47. Classical Conditioning: Addiction • Over time, drug or alcohol use is paired with cues such as money, paraphernalia, particular places, people, time of day, emotions • Through classical conditioning these cues are paired with pleasurable effects of the drug (“high”). • Eventually, exposure to cues aloneproduces drug or alcohol cravings or urges that are often followed by substance abuse

48. Development of Craving Response Entering Using Site AOD Effects Use of AODs Heart Blood Pressure Energy

49. Development of Craving Response Mild Physiological Response Entering Using Site  Heart Rate  Breathing Rate  Energy  Adrenaline Effects AOD Effects Use of AODs Heart Blood Pressure Energy

50. Development of Craving Response Entering Using Site Powerful Physiological Response AOD Effects Use of AODs Heart Blood Pressure Energy  Heart Rate  Breathing Rate  Energy  Adrenaline