Co-Occurring Disorders

1. Co-Occurring Disorders Tim Hicks, PCC Community Counseling Center Alcohol or Other Drug (AOD) Department

2. Co-Occurring Disorders • Disclaimer • Today’s presentation is without bias of any commercial product or medication

3. Objectives • Increase understanding of Co-Occurring Disorders • Be able to Identify common mental health disorders likely to co-occur with substance use disorders in adolescents • Be able to Identify common mental health disorders likely to co-occur with substance use disorders in adults • Be able to describe the stages of change and how it applies to individuals with co-occurring disorders • Have a better understanding of how individuals with co-occurring disorders are likely to be referred.

4. Definitions • Co-Occurring Disorders • Substance Related Disorders • Mental Illness

5. Definitions • Co-Occurring Disorder • Co-Occurring Disorders refers to having at least one substance use disorder and at least one mental health disorder. • Dual Disorders • This term is used to refer to someone who has an Axis I Diagnosis of Mental Illness and an Axis II Diagnosis of Mental Retardation

6. Definitions • Substance Related Disorders • “The Substance-Related Disorders include disorders related to the taking of a drug of abuse (including alcohol), to the side effects of a medication, and to toxin exposure” (APA, 2000, p. 191) • There are two categories of Substance Related Disorders: Substance Use and Substance Induced Disorders

7. Definitions • Substance Use Disorders • Dependence vs. Abuse vs. Withdrawal vs. Intoxication vs. Substance Induced Disorders. • The DSM defines Substance Dependence as “a cluster of cognitive, behavioral, and physiological symptoms indicating that the individual continues use of the substance despite significant substance-related problems” (APA, 2000, p. 192).

8. Substance Dependence • Symptoms according to DSM (p. 197) • Tolerance • Withdrawal • Greater Amounts and/or Longer Periods • Desire to stop, can’t stop or control • Third of the day • Giving up or reducing important activities • Mental or Physical Health issues caused by or made worse by substance use • According to the DSM a person must have at least three symptoms over a 12 month period

9. Substance Abuse • The DSM defines a Substance Abuse Disorder as “a maladaptive pattern of substance use manifested by recurrent and significant adverse consequences related to the repeated use of substances (APA, 2000, p. 198). • The DSM states a person must have at least one symptom over a 12 month period • Not meeting expectations at home, school, or work • Using when dangerous • Legal problems • Relationship problems caused or made worse by the use

10. Mental Disorder • The DSM (p. xxxi) defines a mental disorder “as a clinically significant behavioral or psychological syndrome or pattern….that is associated with ….distress or functioning.”

11. Use, Intoxication, Withdrawal • People with Co-Occurring Disorders often meet criteria for dependence/abuse to multiple substances. Furthermore, many mental health disorders tend to be comorbid (i.e. depression and anxiety, Bipolar and anxiety disorders) The key in diagnosing Co-Occurring Disorders is that each disorder is able to be shown to be a separate problem from the other. People with Substance Use Disorders often present with mental health symptoms, but don’t meet criteria for a psychiatric illness because the symptoms are due to intoxicating, withdrawal, or the consequences of using. For instance people in withdrawal from Stimulants often present with severe depressive symptoms. Feelings of anxiety, depression, and guilt are very common in early recovery.

12. Substance Induced Disorders • Is a Duck really a Duck just because it quacks? • Alcohol and Drugs can • Cause Mental Health Problems (Semi-Independence) • Exacerbate Mental Health Symptoms (Clients I have worked with have reported their anxiety tended to get worse during the actual use. Usually this is not noticed until they have been abstinent for 3-4 months) • Mimic Mental Health Symptoms: Individuals who abuse certain substances may report experiences similar to mental health symptoms (i.e. the person using Methamphetamines may talk quicker, have difficulty sitting still, and be hypersexual. Individuals using Hallucinogens may experience scary visual hallucinations similar to those experienced in Schizophrenia. Individuals withdrawing from Stimulants appear very depressed, lose appetite, have low energy, and sleep disturbances. People withdrawing from Opioids or Alcohol may hallucinate. • Cover Up Mental Health Symptoms- Many individuals with Major Mental Health symptoms may start using to cope with their illness. Initially the substances work for them. (i.e. the person with an anxiety disorder who drinks alcohol to feel more confident around others)

13. Matrix Model • The recovery process can lead to symptoms that are similar to mental illness. • Four Stages of Recovery • Withdrawal • Early Abstinence • Protracted Abstinence • Readjustment • “The chemistry of the brain is altered by habitual substance use; clients can think of this adjustment period as a “healing” of the brain.” (CSAT, 2006, p. 48)

14. Matrix Model • Four Stages of Recovery • Withdrawal • Lasts 7-14 days • Duration and Intensity of the withdrawal stage depends on the type of substance(s) used, frequency and amount used, length of abuse history. • Symptoms can include increased heart rate, vomiting, diarrhea, seizures, increased blood pressure, increased sweating, chills, muscle aches, cramping, visual hallucinations, depression, anxiety, loss of appetite, decreased energy, weight loss, and paranoia. Suicidal ideation and/ or attempts, while not symptoms of withdrawal needs to be assessed for during this stage due to the possible severity of withdrawal. • Early Abstinence • Lasts approximately 4 weeks • Nicknamed the “Honeymoon Stage” or “The Pink cloud” • People in this stage are feeling better as cravings are likely to have decreased, they are experiencing increased energy, their appetites and sleep patterns are starting to stabalize, their mood has improved, and they are able to think more clearly. • People in this stage of recovery are at a greater risk for relapse because they begin to think they are cured.

15. Matrix Model (continued) • Protracted Abstinence • Lasts approximately 3.5 months • Starts around week six of recovery lasting to the 5th or 6th month of recovery • This stage of recovery is called the “Wall” • People in this stage of recovery experience symptom similar to mental illness, but do not meet full diagnostic criteria. • Symptoms include depressed or irritable mood, mild paranoia, loss of energy, loss of interest leading to feelings of boredom, distractibility. • People in this stage of recovery are at a greater risk for relapse due to what recovering people call “The Fuck Its.”

16. Matrix Model • Readjustment • Lasts approximately 2 months • Starts around the 5th or 6th month of recovery • People in this stage can begin to develop personally meaningful goals and take action towards those goals. • Because people in this stage are more stable due to decreased cravings and less emotionality, other important issues can be addressed in treatment such as marital counseling, employment counseling, etc. • People in this stage need to be vigilant to relapse warning signs.

17. Adult Characteristics • Based upon information reported by states to SAMHSA a DASIS reported called Admissions of Persons with Co-Occurring Disorders, 2000 was released in 2003. • Based upon this information the following characteristics were reported • 40% of individuals with Co-Occurring Disorders were female while only 28% of admissions for substance use only were female

18. Adult Characteristics • 68% of individuals with Co-Occurring disorders were white, while 54% of those who were admitted for substance use only treatment were white • Individuals with co-occurring disorders were less likely to be working compared to those admitted for substance use only treatment. • Individuals admitted for substance use services who met criteria for a mental health disorder were more likely to be divorced or separated than those presenting for treatment with just a substance use issue. When examined by gender women with co-occurring disorder were more likely to be separated or divorced than their male counterparts.

19. Prevalence • National Epidemiological Survey on Alcohol and Related Conditions (NESARC) (Grant, B.F. et. al., 2004) • Sponsored by the National Institute on Alcohol Abuse and Alcoholism • 43093 surveys conducted between 2001 and 2002 • Focused on Adults 18 and older

20. NESARC Findings • Prevalence of Mental Disorders • First looked at Mood Disorders and Anxiety Disorders as two groupings. • Any Mood Disorders (Major Depression, Dysthymia, Bipolar, Types I and II) • 9.21% • Any Anxiety Disorders (Panic Disorder with and without Agoraphobia, Social Phobia, Specific Phobia, GAD) • 11.08%

21. NESARC Findings Continued • Prevalence of Substance Use Disorders • Reported prevalence for three categories • Any Substance Use Disorder: 9.35% • Any Alcohol Use Disorder: 8.46% • Any Drug Use Disorder: 2.00%

22. NESCAR Co-occurrence • Examined people who had Substance Use Disorder to assess prevalence of Mood and Anxiety Disorders during the same 12 month period • Findings • 19.6% had at least one mood or anxiety disorder • 17.71% had an anxiety disorder • Top two Mental Health Disorders identified as co-occurring with substance use disorders were Major Depression and Specific Phobia

23. NESCAR Co-occurrence • Examined people identified as having mood or anxiety disorder to assess prevalence of substance use disorders amongst this group • Found that people who had been identified with mood or anxiety disorder 19.97% also had a substance use disorder in the same 12 month period. • Found greater co-occurrence between mood and anxiety disorders and substance dependence than abuse. • Panic Disorder with Agoraphobia and Generalized Anxiety Disorder had highest prevalence of co-occurrence with substance use disorders. • Of the mood disorders Bipolar, Type I had greatest co-occurrence with substance use disorders

24. NESCAR Findings • Assessed for respondents who sought treatment. • Separated this group for further analysis • Alcohol Use Disorders • 40.7% had mood • 33% anxiety disorder • Drug Use Disorder • 60% mood disorder • 43% anxiety disorder • Mood Disorders • 20% Substance Use Disorder • Anxiety Disorders • 16% Substance Use Disorder • Individuals who reported seeking treatment for mood or anxiety disorders were more likely to have a co-occurrence of alcohol use disorders than drug use disorders.

25. Prevalence of Co-Occurring Personality Disorders and Substance Use Disorders • Part of the National Epidemiologic Survey on Alcohol and Related Conditions (NESCAR) Study • Examined individuals with diagnosed alcohol or drug use disorder to determine rate of personality disorders. • Alcohol Use Disorder: 28.6% had a personality disorder • Drug Use Disorder: 47.7% had personality disorder

26. Prevalence of Co-Occurring Personality Disorders and Substance Use Disorders • Examined rates of alcohol use and drug use disorders amongst those with diagnosed personality disorder. • Personality Disorders and Alcohol Use Disorders: 16.4% • Personality Disorders and Drug Use Disorder: 6.5% • Specific Personality Disorders and Substance Use Disorders: • Individuals with Alcohol Use Disorders or Drug Use Disorders were most likely to have the following Personality Disorders: • Antisocial Personality Disorder • Histrionic Personality Disorder • Dependent Personality Disorder

27. Prevalence of Co-Occurring Personality Disorders and Substance Use Disorders • Gender Differences • Women had a stronger relationship between alcohol and drug use disorders with the following personality disorders compared to men: • Obsessive Compulsive Personality Disorder • Histrionic Personality Disorder • Schizoid Personality Disorder • Antisocial Personality Disorder • The only significant difference favoring men was between Drug Dependence and Dependent Personality Disorder

28. Adolescents-Characteristics • Based upon the Drug and Alcohol Service Information System (DASIS) Report entitled “Adolescents with Co-Occurring Psychiatric Disorders: 2003” • Compared overall adolescent admissions licensed substance use treatment facilities for substance use problems with adolescents admitted to licensed substance use treatment facilities who had Co-Occurring Disorders

29. Adolescents-Characteristics • Adolescents with co-occurring disorders were more likely to be female. • Adolescents with co-occurring disorders were likely to be Caucasian. • African American and Hispanic Adolescent admissions were more likely to be substance use only admissions. • Both adolescents with co-occurring disorders and those with substance use only, the majority identified Cannabis as their drug of choice.

30. Adolescents-Characteristics • Adolescents with co-occurring disorders were more likely to report age of first use younger than the age of 12. • Both groups were likely to be referred by the criminal justice system. • Adolescents with co-occurring disorders were more likely to be at least 1 and a half years behind expected grade level for age compared to substance use only adolescents.

31. Adolescent Prevalence Rates • In 2002 SAMSHA made a report to congress on Co-Occurring Disorders. • Key finds in the report based upon peer reviewed research include • 43% of youth receiving mental health treatment had a diagnosed substance use disorder • 62% of males and 83% of female admitted for substance use treatment met criteria for emotional and/or behavior disorders. These disorders include Conduct Disorder, Attention Deficit/Hyperactivity Disorder, Major Depression, and Post Traumatic Stress Disorder.

32. Adolescents Prevalence Rates • Report to Congress (2002) continued • Citing Costello et. al. SAMSHA reported the following • Behavioral Disorders increased the likelihood of developing a substance use disorder • Adolescents with Major Depression were four times as likely to develop a substance use disorder • Adolescents with an anxiety disorder were twice as likely to develop a substance use disorder

33. How do people with Co-Occurring disorders get into treatment • “No Wrong Door” • In their second Over View Paper on Co-Occurring Disorders, CSAT emphasizes that because assessment is an ongoing processes individuals who have Co-Occurring Disorders can come into the appropriate system of care through multiple avenues. • For instance individuals may show at CCC for a mental health assessment and then be referred to the Alcohol or Other Drug department for a substance use disorder assessment and treatment to address the mental health and substance use disorders. Individuals may present at a substance use only program and then be referred to CCC if that agency suspects the person also has a mental health diagnosis.

34. Referral Sources • The Centers for Substance Abuse Treatment identified several ways persons with Co-Occurring Disorders may be referred for COD Treatment. • Family Practitioners • CCC provided screening and assessment services at a PCP’s office due to the high number of individuals with Substance Use Disorders and Mental Health Disorders • Hospitals • Several of the individuals I have treated were referred after being treated on an inpatient psychiatric unit. They presented for assessment at the hospital after suicidal ideation. They also were in withdrawal.

35. Referral Sources • Child Protection Services • We frequently have clients who are referred to us after CPS opens services due to charges of neglect or abuse. If CPS suspects substance abuse problems the individuals are referred for screening and assessment. The Mental Health Disorder is often identified at this time. • Courts/Parole/Probation • Individuals with substance related charges or charges that result from behavior under the influence are often referred for treatment. Mental Health Disorders may be found at this time. • Individuals may need to complete Mental Health and/or Substance Use treatment as part of their parole.

36. Referral Sources • Substance Use/Mental Health Treatment Providers • As discussed earlier, individuals may show at CCC for a mental health assessment and then be referred to the Alcohol or Other Drug department for a substance use disorder assessment and treatment to address the mental health and substance use disorders. Individuals may present at a substance use only program and then be referred to CCC if that agency suspects the person also has a mental health diagnosis. • In the 2005 DASIS report on Adolescents SAMSHA reported the most likely referral source for Adolescents with Co-Occurring Disorders was the criminal justice system. • In the 2003 DASIS report on Adults with Co-Occurring Disorders, individuals with Co-Occurring Disorders were more likely to be referred from Substance Use only providers and Medical providers, where as Substance only clients were more likely to be referred by the criminal justice system.

37. Screening, Assessment, and Treatment • The recommended treatment for people with Co-Occurring Disorders is Integrated Treatment. • Integrated treatment involves a clinician or a team of clinicians who are trained to address both mental health and/ or substance use disorders. • Ideally, Integrated treatment starts with the screening and assessing of both substance use disorders and mental health disorders at the same time. For substance use only treatment centers this means screening for mental health problems with the substance use assessment. Mental health only facilities need to screen for substance use problems at intake. Appropriate referrals, followed by ongoing collaboration should take place during treatment. • However, the relationship between Co-Occurring Substance Use and Mental Health Disorders lies along a continuum, which can be addressed through different levels of integration from Minimal Coordination to Integrated Co-Occurring Treatment.

38. Screening, Assessment, and Treatment • The National Dialogue on Co-Occurring Mental Health and Substance Use Disorders • Annual meetings between the National Association of State Mental Health Program Directors and the National Association of State Alcohol and Drug Abuse Directors. • Developed Four Quadrant Model to understand Co-Occurring Disorders and direct levels of integration • Model takes into consideration level of severity of symptoms, not diagnosis

39. Screening, Assessment, and Treatment • Quadrant I: Low severity of mental health and substance use disorders • Minimal Coordination can be used to address treatment • Minimal Coordination consists of knowledge the person being treated is receiving mental health or substance use disorder treatment by another provider but little to no interaction occurs between providers. One provider may have referred the person being treated to the other provider.

40. Screening, Assessment, and Treatment • Quadrant II: More severe mental disorder combined with less severe substance use disorder • Quadrant II: More severe substance use disorder combined with less severe mental health disorder. • Treatment can be addressed through consultation or collaboration • Consultation involves both treatment providers exchanging information about the care of the person being treated. If one provider has referred to the other provider there is follow up to ensure the person being referred actually has entered into services • Collaboration involves the development of a formal agreement between providers. The providers regularly share information about the person’s being treated care on a regular basis including progress. Roles of the providers is clearly defined in the formal agreement.

41. Screening, Assessment, and Treatment • Quadrant IV: More severe mental health disorder combined with more severe substance use disorder. • Recommended treatment is integrated treatment. The providers are trained to address co-occurring mental health and substance use disorders. The providers, in collaboration with the person being treated, develop one treatment plan that addresses both substance use and mental health disorders. Integrated treatment can occur at different agencies. However, the providers need to meet on a regular basis to share information including progress.

42. 12 Principles of Care • Principle 1 • Co-Occurring Disorders are to be expected in all behavioral health settings, and system planning must address the need to serve people with COD in all policies, regulations, funding mechanics and programming. • Agencies have a responsibility to higher and train clinicians who are capable of working with clients who have mental health and substance use disorders including screening, assessment, and treatment. • Agencies have a responsibility to work to obtain and develop funding sources that will help meet the needs of individuals with co-occurring disorders.

43. 12 Principles of Care • Principle 2 • An integrated system of mental health and addiction services that emphasizes continuity and quality is in the best interest of consumers, providers, programs, funders, and systems. • Client needs are what drives the treatment and treatment intensity. What this means is that treatment providers need to be flexible in addressing these concerns. For instance if a client is being provided services by an Substance Use only facility and a Mental Health facility the agencies need to work together and not be dogmatic about how often a client is expected to participate in services. You can’t expect someone who is have flashbacks of a trauma to participate in Intensive Outpatient Treatment.

44. 12 Principles of Care • Principle 3 • The integrated system of care must be accessible from multiple points of entry (i.e., no wrong door) and be perceived as caring and accepting by the consumer. • To the best of their ability agencies have a responsibility to help clients overcome barriers to treatment. Collaboration with other agencies is vital to overcoming these barriers. This may mean meeting the client at their home. • All staff, including receptionists and billing staff, need to be able to greet individuals with Co-occurring disorders in a respectful manner.

45. 12 Principles of Care • Principle 4 • The system of care for COD should not be limited to a single “correct” model or approach. • Square pegs don’t fit round holes. Therefore we can’t take clients and expect them to fit certain treatment models. We need flexibility within and between service agencies to best meet client needs. • Quality improvement is a fundamental aspect of this principle and needs to be ongoing at an organizational and community level.

46. 12 Principles of Care • Principle 5 • The system of care must reflect the importance of partnership between science and service, and support both the application of evidence and consensus-based practices for persons with COD and evaluation of the efforts of existing programs and services. • It is important to be utilizing interventions and protocols that are well supported by research or that the fields as a whole agree upon as being acceptable. • Encourage your system of care to allow you to access continuing education in scientifically validated treatments.

47. 12 Principles of Care • Principle 6 • Behavioral health systems must collaborate with professionals in primary care, human services, housing, criminal justice, education, and related fields in order to meet the complex needs of persons with COD. • Clients with Co-Occurring Disorders have multiple needs that we alone cannot address. • Service agencies, medical providers, criminal justice systems, social welfare systems need to collaborate to help people address these needs. This can occur through sharing of resources, programs, or creating task forces.

48. 12 Principles of Care • Principle 7 • Co-occurring disorders must be expected when evauate4ing any person, and clinical services should incorporate this assumption into all screening, assessment, and treatment planning. • While not every agency or provider will specialize in treating people who Co-occurring disorders, all treatment providers should be able to at least recognize co-occurring disorders and be able to assist clients in entering into appropriate treatment. • If persons with co-occurring disorders are receiving treatment at separate agencies the two clinicians needs to meet regularly to manage the clients needs. They need to have an understanding how the two disorders can interact and affect each other.

49. 12 Principles of Care • Principle 8 • Within the treatment context, both co-occurring disorders are considered primary. • Mental Health and Substance Use Disorders interact, thus one disorder can trigger a relapse to the other disorder. • Sometimes clients may be making progress in managing one disorder, but struggling with managing the other disorder. • We need to meet the client where the client is at in addressing there needs. If the mental health symptoms are causing the most problems these need to be addressed. Sometimes we need to work on the substance use more than the mental health.

50. 12 Principles of Care • Principle 9 • Empathy, respect, and belief in the individual’s capacity for recovery are fundamental provider attributes. • Clients aren’t just receiving treatment. They are an essential part of the team. Their perspective of what will work, what is happening to them matters. • Because of the double stigma of having mental health disorders and substance use disorders clients are likely to feel unwanted and demoralized. Part of treatment is helping them to feel valued as persons and capable of change.