Co-Occurring Disorders 101 2011 National TASC Conference May 5, 2011 Denver, Colorado Roger H. Peters, Ph.D.,

1. 1 Co-Occurring Disorders 101 2011 National TASC Conference May 5, 2011 Denver, Colorado Roger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu

2. 2 Goals of this Presentation Review: How to access relevant resources Challenges in addressing CODs Core components of COD screening, assessment, and treatment for offenders

3. Resources CSAT TIP #42 and #44 Co-Occurring Disorders Integration and Innovation (CODI) Initiative CMHS National GAINS Center CMHS Toolkit – CODs/IDDT Council of State Governments NIDA 3

4. 4 Defining “Co-Occurring Disorders” The presence of at least two disorders: A substance abuse or dependence disorder A DSM-IV major mental disorder, usually Major Depression, Bipolar Disorder, or Schizophrenia

5. 5 Serious Mental Disorders Axis I Disorders: Major Depressive Disorder Bipolar Disorder Schizophrenia Axis II (Personality) Disorders: Antisocial Personality Disorder Borderline Personality Disorder

6. 6 Other Axis I Mental Disorders Anxiety Disorders (Panic, Obsessive-Compulsive, Social Phobia) Eating Disorders (Anorexia, Bulimia) Adjustment Disorders (with anxiety, or depressed mood) Sleep Disorders

7. 7 Other Axis II Mental Disorders Narcissistic Personality Disorder Dependent Personality Disorder Adjustment Disorder Paranoid Personality Disorder Histrionic Personality Disorder

8. 8 Prevalence of Mental Disorders 26% of adults experience a diagnosable mental disorder each year (60 million persons) 6% have serious mental disorders One third have lifetime history of drug use Co-occurring disorders common

9. 9 Prevalence of Mental Disorders 10% of adults have a mood disorder (e.g., major depression) 3% of adults have Bipolar Disorder 2% of adults have Alzheimer’s Disease 1% of adults have Schizophrenia 33% have lifetime history of drug use

11. 11 Co-Occurring Substance Use Disorders

12. 12 Mental Disorders in Juveniles 67-70% of juveniles experience mental disorders Key disorders Substance use disorder – 46% Conduct disorder – 46% Anxiety disorder – 34% Mood disorder – 18%

14. 14 Location of COD Services by Severity of Disorders

15. 15 Offenders with CODs Repeatedly cycle through the criminal justice and treatment systems Experience problems when not taking medications, not in treatment, experiencing mental health symptoms, using alcohol or drugs Small amounts of alcohol or drugs may trigger recurrence of mental health symptoms Antisocial beliefs similar to other offenders More criminal risk factors than other offenders

16. 16 Challenges in Addressing CODs At risk for relapse Criminality/criminal thinking Housing needs Transportation needs Family reunification Greater psychological impairment (e.g., trauma) Job skills deficits Educational deficits Stigma related to criminal history and SA and MH disorders Scarce prevention and treatment resources

17. 17 Outcomes Related to CODs More rapid progression from initial use to substance dependence Poor adherence to medication Decreased likelihood of treatment completion Greater rates of hospitalization More frequent suicidal behavior Difficulties in social functioning Shorter time in remission of symptoms Higher rate of failure on probation

18. 18 Relapse Factors and CODs The most common cause of mental illness relapse is substance abuse The most common cause of substance abuse relapse is untreated mental illness Criminal thinking triggers substance abuse relapse

19. 19 Clinical Considerations Cognitive impairment Reduced motivation Impairment in social functioning (Bellack, 2003)

20. 20 Elements of Cognitive Impairment Difficulty comprehending or remembering important information (e.g., verbal memory) Not recognize consequences of behavior (e.g., planning abilities) Poor judgment Disorganization Limited attention span Not respond well to confrontation

21. 21 Traditional MH Services are not Effective for Offenders with CODs Unaddressed and ongoing SA interferes with individuals’ ability to follow MH treatment recommendations Active substance use interferes with effectiveness of MH treatment (i.e., medications, etc.) MH treatment may not focus on changing substance use and other maladaptive behaviors

22. 22 Traditional SA Services are not Effective for Offenders with CODs Absence of accurate MH diagnosis prevents effective treatment Cognitive impairment detracts from understanding and processing information Confrontational approaches used in SA treatment are not well tolerated Frustration and dropout may result from requirements of abstinence

23. 23 Traditional Supervision Approach is Ineffective for Offenders with CODs Large caseloads discourage responsive and individualized approach to CODS Authoritarian and confrontational approach less effective with CODs Focus on sanctions vs. problem-solving, use of low revocation thresholds Inconsistent engagement and monitoring in SA and MH treatment Absence of specialized COD training

24. 24 Why Screen and Assess for CODs?  High prevalence rates of mental disorders in justice settings Persons with undetected mental disorders are likely to cycle back through the criminal justice system Allows for treatment planning and linking to appropriate treatment services

25. Screening for CODs Routine screening for both sets of disorders Criminal risk level Acute MH and SA symptoms: Suicidal thoughts and behavior Depression, hallucinations, delusions Potential for drug/alcohol withdrawal History of MH treatment including use of meds Determine need/urgency for referral

26. 26 Challenges in Selecting  Screening Instruments Proliferation of screening instruments Use of non-standardized instruments Instruments not validated in CJ settings Absence of comparative data Direct to consumer marketing of instruments with poor psychometric properties (e.g., SASSI)

27. 27 Enhancing Accuracy of Screening and Assessment Maintain high index of suspicion for both disorders Use non-judgmental approach and motivational interviewing techniques Gather substance abuse information before mental health information Supplement self-report with collateral information

28. 28 Assessment Considerations Substance abuse can mimic all major mental health disorders Several strategies will help to gauge the potential effects of SA on MH disorders Use drug testing to verify abstinence Take a longitudinal history of MH and SA symptom interaction Compile diagnostic impressions over a period of time Repeat assessment over time Pink text identifies recommended screens Identify which screens are brief and which are in-depth—make distinction between screening vs. assessment vs. evaluation instruments. GAIN designed to screen for MH and SA Pink text identifies recommended screens Identify which screens are brief and which are in-depth—make distinction between screening vs. assessment vs. evaluation instruments. GAIN designed to screen for MH and SA

29. Placement Issues and CODs Excluding persons with CODs is NOT a viable option How to determine eligibility for services? Triage to specialized COD services Target moderate to high criminal risk levels

30. 30 Unique Needs among Offenders who have CODs Antisocial beliefs and behaviors Antisocial peers Need for structured therapeutic activities, supervision, and monitoring Interrelated nature of MH/SA disorders Managing community reentry

31. 31 COD Treatment Targets for Offenders Mental disorders Substance use disorders Criminal thinking/cognitions Developing prosocial peer supports Educational and vocational skills Family interventions Reentry services

32. What Works? Evidence-Based Practices Cognitive-behavioral treatment Motivational enhancement Contingency management Integrated treatment for CODs (IDDT) Medications

33. What Works? Evidence-Based Practices Illness self-management Family psychoeducation Assertive Community Treatment (ACT) Supported employment Specialized supervision caseloads

34. Specialized Interventions Trauma and PTSD Criminal Thinking Juveniles Specialized Community Supervision Teams

35. 35 COD Program Phases Orientation Intensive treatment Relapse prevention/transition

36. 36 Pharmacological Interventions Medications are routinely and effectively prescribed for individuals with CODs Medications serve to successfully: - Decrease drug cravings - Reduce reinforcing effects of drugs - Assist in acute withdrawal

37. 37 Pharmacological Interventions Abuse of illicit drugs and alcohol can impair the action of medications Toxic effects can occur if alcohol or illicit drugs are used while taking certain medications (e.g., lithium, tricyclic antidepressants, MOI inhibitors) Medications with addictive potential should be avoided, or used with caution

38. 38 Peer Support Interventions Traditional 12-step programs have not always meshed well with the needs of individuals with co-occurring disorders 12-step models such as AA and NA have been adapted for co-occurring disorders “Double Trouble” and similar groups have been developed throughout the U.S.

39. 39 Development of re-entry or transition plan Assistance to engage in community-based SA and MH treatment Engagement in peer support and self-help networks to assist in recovery Stable housing Vocational training and employment support Case management and community supervision Key Transition Services

40. 40 15% of offenders have CODs (> gen. population) Cognitive impairment and lower functioning Require specialized services Blended screening and assessment Integrated treatment Focus on special needs (e.g., criminal thinking, trauma/PTSD) Specialized supervision teams Evidence-based practices are available Summary of Key Points

41. 41 Screening instruments Conceptual model to drive COD services (Risk-Need-Responsivity) Modifying treatment for CODs Special populations and CODs COD 102