Co-occurring psychiatric and substance use disorders: What’s the fuss?

1. Co-occurring psychiatric and substance use disorders: What’s the fuss? Richard A. Rawson Ph.D. UCLA Integrated Substance Abuse Programs San Diego, California October 2004

2. What are we talking about? Co-Occurring Disorders Dual Diagnosis Dual Diagnosis Depressed Co-Occurring Depressed Mentally Ill Mentally Ill Anxious Addict DSM - IV DSM - IV Co Morbid Co Morbid Anxious Addict Traumatized ICD - 10 ICD - 10 Traumatized

3. Mental Health Services Leadership-psychiatrists Staffing-psychologists, social workers, nurses, MFTs Role of medications-Substantial Impact of behavioral therapies research-Substantial Knowledge of substance use disorders and their treatment Minimal Role of self-help-Minimal Substance Abuse Services Leadership-A mixture of recovering addict/alcoholics, business people, professionals Staffing-paraprofessionals, with increasing role of professionals Role of medications and behavior therapies-Minimal Knowledge of psychiatric disorders-Minimal Role of self-help-Substantial An oversimplified picture of the behavioral healthcare service systems in the US

4. The mental health service system The uncomplicated schizophrenic The “simple” affective disordered individual The “pure” bi-polar patient The substance abuse service system The “plain vanilla” alcoholic The addict who uses only heroin The stimulant dependent individual w/o other psych diagnoses The prototype patients for the current service delivery systems

5. What’s the Problem? • Estimates of psychiatric co-morbidity among clinical populations in substance abuse treatment settings range from 20-80% • Estimates of substance use co-morbidity among clinical populations in mental health treatment settings range from 10-35% * Differences in incidence due to: nature of population served (e.g.: homeless vs. middle class), sophistication of psychiatric diagnostic methods used (psychiatrist or DSM checklist) and severity of diagnoses included (major depression vs. dysthymia).

6. Why are substance use disorders treated in separate systems from other psychiatric disorders? How has the split occurred between substance use disorders and other psychiatric disorders? • Before 1970 in the US, research and treatment for alcoholism and drug abuse were administered out of the National Institute of Mental Health. • A number of factors prompted the separation of alcoholism/drug abuse into their own specialty areas, distinct and separate from general psychiatry.

7. Why are substance use disorders treated in separate systems from other psychiatric disorders? • A pervasive perception existed among the public and policymakers that the professional fields of psychiatry, psychology and medicine were extraordinarily unsuccessful in providing treatment to addicts and alcoholics; and, that there was a tendency within much of organized psychiatry (and psychology) to avoid alcoholics and addicts as inherently untreatable individuals, incapable of insight.

8. Why are substance use disorders treated in separate systems from other psychiatric disorders? • Two major factors prompted the establishment of new institutes in early 1970s: • Sen. Harold Hughes’ promotion of treatment for employees with alcohol problems in the workplace was a major influence in the field of alcoholism. Health insurance began to include alcoholism treatment benefits, EAPs began and NIAAA was created. • Huge increases in drug experimentation in late 1960s and concerns about returning heroin addicted Vietnam Veterans, prompted public concern about drug abuse and prompted the creation of NIDA.

9. Why are substance use disorders treated in separate systems from other psychiatric disorders? • The result was: • National Institute of Mental Health (NIMH) responsible for research on and treatment of psychiatric disorders. • National Institute on Alcoholism and Alcohol Abuse (NIAAA) responsible for research on and treatment for alcoholism and related issues. • National Institute on Drug Abuse (NIDA) responsible for research on and treatment of illicit drug problems (and later nicotine). • Each institute had its own experts, treatment systems, funding streams and each viewed the other as parochial, misinformed and naïve. • Cooperation was uncommon.

10. Why are substance use disorders treated in separate systems from other psychiatric disorders? • Since early 1970s- • Within treatment settings, alcoholism and drug abuse disorders are treated within the same treatment system; hence, there are now essentially two service delivery systems: 1. Alcoholism and Other Drug (AOD) system 2. Mental health system • Psychiatry has formally incorporated the study and treatment of substance use disorders as part of psychiatry.

11. DSM and ICD: The “Bibles”

12. Studies on Co-morbidity • Most widely cited studies: • Epidemiologic Catchment Area (ECA) study • National Comorbidity Study

13. ECA Study • Epidemiologic Catchment Area (ECA) Study • 20,291 interviews at 5 sites • Data Collected 1980 – 1984 • DSM – III Diagnoses Regier, DA, et al. (1990). Comorbidity of Mental Disorders with Alcohol and other Drug Abuse: Results From the Epidemiologic Catchment Area (ECA) Study, JAMA, 264, 2511-2518

14. ECA DSM-III Diagnoses (rates per 100 people) Regier, et al. (1990)

15. Lifetime Prevalence and Odds Ratios ECA Study

16. NC Study • National Comorbidity Study • 8,098 interviews across the country • Data collected 1990 – 1992 • DSM-III-R Diagnoses Merikangas, KR, et al. (1998). Comorbidity of substance use disorders with mood and anxiety disorders: Results o the international consortium in psychiatric epidemiology. Addictive Behavior, 23, 893-907.

17. NCS DSM-III Diagnoses % Merikangas, KR, et al. (1998)

18. NCS DSM-III Diagnoses OR Number of mental disorders Merikangas, KR, et al. (1998)

19. Summary • There is a problem • We have documented it for a long time • We need more information to figure out • The current state of affairs • What we do about it

20. Treatment of Co-occurring Disorders • Treatment System Paradigms • Independent, disconnected • Sequential, disconnected • Parallel, connected • Integrated

21. Treatment of Co-occurring Disorders • Independent, disconnected “model” • Result of very different and somewhat antagonistic systems • Contributed to by different funding streams • Fragmented, inappropriate and ineffective care

22. Treatment of Co-occurring Disorders • Sequential Model • Treat SA Disorder, then MH disorder • Treat MH Disorder, then SA disorder • Urgency of needs often makes this approach inadequate • Disorders are not completely independent • Diagnoses are often unclear and complex

23. Treatment of Co-occurring Disorders • Parallel Model • Treat SA disorder in SA system, while concurrently treating MH disorder in MH system. Connect treatments with ongoing communication • Easier said than done • Languages, cultures, training differences between systems • Compliance problems with patients

24. Treatment of Co-occurring Disorders • Integrated Model • Model with best conceptual rationale • Treatment coordinated best • Challenges • Funding streams • Staff integration • Threatens existing system • Short term cost increases (better long term cost outcomes).

25. Elements of an integrated model • Staffing • A true team approach including: Psychiatrist (trained in addiction medicine/psychiatry); Nursing support; Psychologist; Social worker; Marriage and family therapist; Counselor with familiarity with self-help programs. (Others possible, vocational, recreational educational specialists).

26. Elements of an Integrated Model • Preliminary assessment of mental health and substance use urgent conditions • Suicidality • Risk to self or others • Withdrawal potential • Medical risks associated with alcohol/drug use

27. Elements of an integrated model • Diagnostic process that produces provisional diagnosis of psychiatric and substance use disorders using: • Urine and breath alcohol tests • Review of signs and symptoms (psychiatric and substance use) • Personal history timeline of symptom emergence (what started when) • Family history of psychiatric/substance use disorders • Psychiatric/substance use treatment history

28. Elements of an integrated model • Initial treatment plan that includes (min- one day-max ten days): • Choice of a treatment setting appropriate to initially stabilize medical conditions, psychiatric symptom and drug/alcohol withdrawal symptoms • Initiation of medications to control urgent psychiatric symptoms (psychotic, severe anxiety, etc) • Implementation of medication protocol appropriate for treating withdrawal syndrome(s) • Ongoing assessment and monitoring for safety, stabilization and withdrawal

29. Elements of an integrated model • Early stage treatment plan that includes ( min day 2-max day 14) • Selection of treatment setting/housing with adequate supervision • Completion of withdrawal medication • Review of psychiatric medications • Completion of assessment in all domains (psychology, family, educational, legal, vocational, recreational) • Initiation of individual therapy and counseling (extensive use of motivational strategies and other techniques to reduce attrition) • Introduction to behavioral skills group and educational groups • Introduction to self help programs • Urine testing and breath alcohol testing

30. Elements of an integrated model • Intermediate treatment plan that includes (up to six weeks): • Housing plan that addresses psychiatric and substance use needs • Plan of ongoing medication for psychiatric and substance use treatment with strategies to enhance compliance • Plan of individual and group therapies and psychoeducation with attention to both psychiatric and substance use needs • Skills training for successful community participation and relapse prevention • Family involvement in treatment processes • Self-help program participation • Process of monitoring treatment participation (attendance and goal attainment • Urine and breath alcohol testing

31. Elements of an integrated model • Extended treatment plan that includes (up to 6 months): • Housing plan • Ongoing medication for psych and substance use treatment • Plan of individual and group therapies and psychoeducation with attention to both psychiatric and substance use needs • Ongoing participation in relapse prevention groups and appropriate behavioral skills groups and family involvement • Initiation of new skill groups (e.g.; education, vocational, recreational skills) • Self help involvement and ongoing testing • Monitoring attendance and goal attainment

32. Elements of an integrated model • Ongoing plan of visits for review of: • Medication needs • Individual therapies • Support groups for psych and substance use conditions • Self help involvement • Instructions to family to recognize relapse to psych and substance use In short, a chronic care model is used to reduce relapse and if/when relapse (psychiatric or substance use) occurs, treatment intensity can be intensified.

33. Building integrated models • Challenges of building an integrated model • Cost of staffing • Training of staff • Resistance from existing system • Providing comprehensive, integrated care with efficient protocols • The most likely strategy for moving toward this system is in increments • Psychiatrist attend at AOD centers • Relapse prevention groups introduced to mental health centers • Staff exchanges; attending case conferences; joint trainings • Gradual shifting of funding

34. Treatment of Co-occurring Disorders: Areas of Promise • Integration of SA treatment and treatment of affective disorders • Depression • Use of tricyclics and SSRIs produces excellent treatment response in SA patients with depression. Can be used with SA populations with minimal controversy. • Good evidence of effectiveness with methadone patients, women with alcoholism and depression.

35. Treatment of Co-occurring Disorders: Areas of Promise • Bipolar Disorder and SA Disorders • Medications for BPD often essential to stabilize patients to allow SU treatment to be effective • Challenges often occur in diagnosis • Cocaine/methamphetamine use disorders often mimic BPD, medications for these disorders not yet with demonstrated efficacy and do not respond to medications for bipolar disorders

36. Treatment of Co-occurring Disorders: Areas of Promise • Schizophrenia and SU Disorders • Differential diagnosis with cocaine and methamphetamine psychosis can be difficult. • Medication treatments frequently essential. • Knowledge about medication side effects and the possibility that these side effects can trigger drug use is important.

37. Treatment of Co-occurring Disorders: Areas of Promise • Understanding of neurobiological mechanisms and genetic foundations may provide key knowledge for both sets of disorders. • Key issues in improving treatment effectiveness • Training, training, training • Increased contact between professionals from both systems • Flexibility of funding streams • Training, training, training

38. Treatment of Co-occurring Disorders: Areas of Controversy • Should the treatment of SUDs be fully incorporated within the mental health system(e.g.;Integrated Behavioral Health Agency)? • If yes, will treatment protocols unique to substance abuse system be discarded? • Will funding for SUDs be reduced?

39. Co-Occurring Disorders Center for Excellence (COCE) Subcontractor’s Kick-Off Meeting February 13, 2004The CDM Group, Inc. Chevy Chase, Maryland Rose M. Urban, M.S.W., J.D., LCSW COCE Executive Project Director The CDM Group, Inc.

40. Co-Occurring Disorders -Advances in the Field • Better definitions • Treatment needs better understood • Improved screening and assessment • Improved systems and processes • Evidence-based practices exist

41. Key COD Products and Technology Transfer Initiatives • CSAT’s National Treatment Plan, Changing the Conversation; • CSAT’s Substance Abuse Treatment for Persons with Co-Occurring Disorders TIP; • CMHS’s Co-Occurring Disorders: Integrated Dual Disorders Treatment Implementation Resource Kit; • SAMHSA’s Report to Congress on the Prevention and Treatment of Co-Occurring Disorders and Mental Disorders; • SAMHSA’s Strategies for Developing Treatment Programs for People with Co-Occurring Substance Abuse and Mental Disorders

42. Contributors to Knowledge Base • Federal agencies • Grantees (Including COSIG grantees) • States • Service providers • Consumers • Researchers • Addiction Technology Transfer Centers (ATTCs) • Centers for the Application of Prevention Technologies (CAPTs) • National Mental Health Information Center (NMHIC)

43. SAMHSA’S VISION FOR COD PROVIDE LEADERSHIP AND DIRECTION IN DEFINING AND TRANSFERRING THE LATEST EVIDENCE-BASED PRACTICES/ SYSTEMS, SERVICES, & INFRASTRUCTURE TO ALL LEVELS OF THE COD SERVICE SYSTEM

44. OPERATIONALIZING THE VISION:SAMHSA’S CO-OCCURRING CENTER FOR EXCELLENCE (COCE)

45. COCE APPROACH COCE will: • Advance a unified substance abuse and mental health approach; • Address all levels of client disorder severity; and • Adapt solutions to the unique needs of each service recipient

46. CRITICAL INPUTS What is the COCE? COCE: Analysis Integration Priorities Mental Health, Substance Abuse,& COD Research SAMHSA’s Mission & Priorities State/Local Experience & Innovation Federal Policy COCE GOALS WORK OF THE COCE Consumer Needs And Perspectives State Policy LEADERSHIP IN CLARIFYING Definitions Nosology Measurement Evidence & Consensus-Based Practices Unified Approach ACTIVITIES Training Technical Assistance Training of Trainers Institutes Coordination with other SAMHSA Centers THE COD SERVICE SYSTEM AGENDA SETTING Professional Education Practice Improvement Research Policy Workforce Development PRODUCTS Templates for Product Development Technical Reports Articles Literature Reviews Models of Change Technology Transfer Principles and Practices RESOURCE TO SAMHSA Logistical/Operational Execution/Implementation Informational

47. Who is the COCE? VISION & LEADERSHIP SAMHSA CSAT CMHS CSAP Insures accuracy and integrity of scientific and clinical content Advises SAMHSA and COCE on planning and conduct of COCE activities Plans and oversees COCE activities CONTENT IMPLEMENTATION PLANNING, MANAGEMENT, & ACCOUNTABILITY EXPERT LEADERSHIP GROUP SENIOR MANAGEMENT TEAM STEERING COUNCIL SENIOR FELLOWS e.g., Richard Ries, MD FELLOWS CONSULTANT AND SUBCONTRACTOR POOL Advises and assists Expert Leaders in developing overall COCE content Conducts technical assistance, cross-training, and assists in development of materials Provides expert input on specific COD content areas

48. The COCE Team • Awarded as a 5-year contract to The CDM Group, Inc. (CDM) on September 29, 2003 in association with: • The National Development Research Institutes (NDRI) • The Center for Behavioral Health, Justice & Public Policy (CBHJPP) at The University of Maryland • The National Opinion Research Center (NORC) at the University of Chicago

49. The COCE Senior Team • Directed by CDM • Rose M. Urban, J.D., M.S.W., Executive Project Director • Jill G. Hensley, M.A., Project Director

50. The COCE Senior Team CDM • Michael Klitzner, Ph.D. – Senior Social Scientist • William Reidy, Jr., M.S.W. – TA/CT Specialist • Sheldon Weinberg, Ph.D. – TA/CT Specialist • Robert O’Brien, Ph.D. – Evaluation Adviser