Integrated Dual Disorder Treatment (IDDT)

1. Integrated Dual Disorder Treatment (IDDT) Evidence Based Practice Kick Off Presentation

2. What are dual disorders? • Mental illness and substance use disorder occurring together in one person

3. Why focus on dual disorders? • Substance use disorders are common in people with severe mental illness • Mental illness is common in people with substance use disorders • Dual disorders lead to worse outcomes and higher costs than single disorders

4. Mental illness Depression 15% Anxiety Disorders 13% Bipolar 1% Schizophrenia 1% Substance use disorders Alcohol 20% Men 30% Women 10% Drugs 9% Men 11% Women 7% How common are these problems in Americans?

5. Substance abuse is common in people with mental illness • Over 50% of people with schizophrenia, bipolar disorder and other severe mood disorders have a substance use disorder at some time in their life • About one third of people with anxiety and depressive disorders have a substance use disorder at some time in their life

6. Prevalence of substance use disorders in mental illness

7. Prevalence of Co-Occurring Disorders-ECA Study % of respondents Regier et al., JAMA, 1990

8. Prevalence of mental illness in alcohol disorder samples • In community, 24.4% have mental illness • In institutions, 55% have mental illness • In substance abuse treatment, 65% have mental illness

9. Combination and levels of illness

10. Types of Dual Disorders • Three categories • Milder mood/anxiety disorder with substance use disorder • Personality disorder and substance use disorder • Severe mental illness and substance use disorder

11. Integrated Dual Diagnosis Treatment Implementation Materials • Materials focus on treatment for persons with severe and persistent mental illness and substance use disorder • Psychotic disorders • Bipolar disorders • Other severely disabling mental disorders • Any level of co-occurring substance use disorder

12. Course of dual disorders • Both substance use disorders and severe mental illness are chronic, waxing and waning • Recovery from mental illness or substance abuse occurs in stages over time • Precontemplation • Contemplation • Preparation • Action • Maintenance • Prochaska, DiClemente, and Norcross 1992; • Miller and Rollnick 1991

13. Course of dual disorders • People SMI and social substance use • Become abstinent or develop substance use disorder • Can’t tolerate social use • People with more severe substance use disorders • Most get worse • Bartels et al, 1995

14. Attaining remission occurs in stages

15. Dual disorders lead to worse outcomes than single disorders • Relapse of mental illness • Treatment problems and hospitalization • Violence, victimization, and suicidal behavior • Homelessness and Incarceration • Medical problems, HIV & Hepatitis risk behaviors and infection • Family problems • Increase service use and cost

17. Characteristics Associated with Medication Noncompliancein Six-Month Longitudinal Study

18. Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C Persons with Substance Use Disorders had 3 times higher chance of having HIV 2 times higher chance of having HBV 2. 5 times higher chance of having HCV Rosenberg et al., A Jl Public Health, 2001

19. Monthly Income and Expenditures for Substances Among 105 Patients with schizophrenia • Monthly income $650 • Disability income $645 • Expenditures for illegal drugs $250 • Expenditures for alcohol $10 • Median values

20. Costs of treatment for persons with dual disorders compared to SMI only

21. Recovery • Dual disorders are treatable • Many people attain stable remission of substance use disorders over time • Recovery encompasses other areas of adjustment • Health, work, housing, relationships • Mead et al, 2000

22. Traditional treatment • Treat each disorder separately • May be parallel or sequential • Separate treatment is NOT effective

23. Evidence Based Practice • Definition of EBP • Research evidence that practice is more effective than usual treatment from multiple studies across the country • Overview of national project • Implementation kits for 6 evidence based practices for public mental health • Several states attempting to implement each EBP • National study of implementation • Process, feasibility, outcomes

24. Integrated dual disorders treatment: What is it? • Treatment of substance use disorder and mental illness together • Same team • Same location • Same time • Other characteristics to be described later

25. Why integrated treatment of dual disorders? • More effective than separate treatment • 10 studies show integrated treatment is more effective than traditional separate treatment • (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services 2001 for summaries).

26. IDDT improves abstinence

27. Fidelity to IDDT principles improves abstinenceMcHugo et al, 1999

28. Abstinence leads to improvements in other outcomes Drake et al, 1998 • Reduce institutionalization • Reduce symptoms, suicide • Reduce violence, victimization, legal problems • Better physical health • Improve function, work • Improve relationships and family

29. Stable remission improves other aspects of life • Objective: Living situation, victimization • Subjective: overall satisfaction with life, housing, family, health

30. NH Dual Diagnosis Study (1989-1994 Drake et al, 1998) 1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail, homeless setting or doubling with friends or family) increased for all dual diagnosis clients. 2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months).

31. NH Dual Diagnosis Study (1989-1994) 1. Percentage of persons hospitalized during each six months declined significantly for all clients. 2. It declined much more for those in recovery.

32. NH Dual Diagnosis Study (1989-1994) Arrests and Incarcerations decline as persons treated for dual disorders recover from substance abuse.

33. NH Dual Diagnosis Study (1989-1994) 1. Median treatment costs decline more for persons in recovery. 2. Inpatient costs decrease. 3. There is a shift to community based treatment. 4. Those who are most successful often begin with higher than average treatment costs.

34. How do people obtain remission from dual disorders? • Stable housing • Sober support network/family • Regular meaningful activity • Trusting clinical relationship • Alverson et al, Com MHJ, 2000

35. Treatment factors for recovery • Integration of mental health and substance abuse treatment • Stage-wise interventions • Assertive outreach • Motivational counseling • Substance abuse counseling

36. Principles of Integrated Dual Disorder Treatment • Integrated • Same team of dually trained people • Same location of services • Both disorders treated at the same time • Stage-wise services • Different services offered at different stages of treatment

37. Principles - Stagewise treatment • Precontemplation - Engagement • Outreach, practical help, crisis intervention, develop alliance, assessment • Contemplation & Preparation - Persuasion • Education, set goals, build awareness of problem, family support, peer support, • Action - Active Treatment • Substance abuse counseling, medication treatments, skills training, family support, self help groups • Maintenance - Relapse prevention • Relapse prevention plan, continue skills building in active treatment, expand recovery to other areas of life

38. More treatment factors for recovery • Social support interventions • (groups, self help, family) • Long term perspective • Rehabilitation of skills • (coping, social, leisure, work) • Cultural sensitivity and competence • Program fidelity

39. Recovery model • Consumer driven • Unconditional respect and compassion • Clinician responsible for helping client with motivation for treatment • Focus on client goals and function, not on adherence to treatment • Client choice and shared decision making are important

40. IDDT improves outcomes McHugo et al, 1999

41. Program implementation:15 years in several states • 60% of programs attain successful implementation • High fidelity to model leads to good outcomes • Without focus, fidelity erodes over time

42. Systems Issues • How to integrate treatments? • Stages of implementation: motivating, enacting, and sustaining • Each stage 6 months - 1 year • Changes at 5 levels • (1) Health authority • (2) Program leadership • (3) Clinician/supervisor • (4) Family • (5) Consumer

43. Strategies for policy makers • Building consensus for the vision of integrated dual disorder services • Conjoint planning • Define standards • Structural, regulatory, reimbursement, and contracting mechanisms • Demonstrations • Training and monitoring

44. Strategies for program leadership • Consensus and vision • Specific leader • Train all clinicians • Comprehensive integration • Records • Outcomes • Quality assurance

45. Strategies for clinicians and supervisors • Outcome based supervision • Knowledge base • New skills • Assessment • Motivational treatment • Substance abuse counseling • Specialty training • Secondary strategies

46. Strategies for families/supports • Information • Support • Collaboration • Skills and reinforcement • Advocacy and involvement

47. Strategies for consumers • Information • Peer discussion • Counseling • Rehabilitation • Training • New roles - life is more persuasive than research

48. Conclusions • Implementation of integrated dual disorder treatment is challenging but critical to outcomes • Multiple strategies are helpful • 3 stages for implementation: motivating, enacting, and sustaining • Include all stakeholders