Co-Occurring Disorders – Session I

1. 2010 College of Advanced Judicial Studies May 25, 2010 Fort Myers, FloridaRoger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu Co-Occurring Disorders – Session I

2. Goals of this Session Review: • Relevant resources • Importance of co-occurring mental disorders • Differences between mental disorders • Impact of co-occurring disorders on functioning • Co-occurring disorders in youth and adults

3. Resources • CSAT TIP #42 and #44 • CMHS National GAINS Center • CMHS Toolkit • Council of State Governments • NDCI/NADCP Materials • NIDA CJDATS-2 Network

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

5. At risk for relapse Criminality/criminal thinking Housing needs Transportation needs Family reunification Lengthier stays in jail Job skills deficits Educational deficits Stigma related to criminal history and SA and MH disorders Scarce prevention and treatment resources Challenges in Addressing CODs

6. 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

7. High Severity Low Severity High Severity Typical Location of Services for Different Co-Occurring Populations Substance Use Disorders Mental Health Disorders

8. (N. GAINS Center, 2004; Steadman et al., 2009)

9. Prevalence of Mental Problems in Justice Settings by Gender GenderState PrisonFed. PrisonJail Male 55% 44% 63% Female 73% 61% 75% * Based on a modified clinical interview for the DSM-IV, describing experiences during the “past 12 months”. (U.S. Department of Justice, 2006)

10. Rates of Substance Use Among Offenders with Mental Problems 74% of state prisoners with mental problems also have substance abuse or dependence problems (U.S. Department of Justice, 2006)

11. Prevalence of Mental Disorders Just the Facts: • 26% of adults in US experience a diagnosable mental disorder each year (60 million persons) • 6% have serious mental disorders • Mental disorders are the leading cause of disability in US/Canada for ages 15-44 • About half suffer from multiple mental disorders • Co-occurring substance use disorders common

12. Prevalence of Mental Disorders Just the Facts: • 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

13. Mental Disorders in Juveniles Just the Facts: • 67-70% of juveniles experience mental disorders • Key disorders • Substance use disorder – 46% • Conduct disorder – 46% • Anxiety disorder – 34% • Mood disorder – 18%

14. Severity of Disorders in Juveniles • Over half of juveniles have multiple disorders - 61% have co-occurring substance use disorders • 27% have disorders requiring immediate treatment

16. 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 useand other maladaptive behaviors

17. 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

18. Serious Mental Disorders Axis I Disorders: • Major Depressive Disorder • Bipolar Disorder • Schizophrenia • Posttraumatic Stress Disorder Often accompanied by Axis II (Personality) Disorders: • Borderline Personality Disorder • Antisocial Personality Disorder

19. 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

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

21. Challenges Related to Mental Illness • Vulnerability for rehospitalization • Psychotic symptoms • Severe depression and suicidal behavior • Higher rates of violence and incarceration • Difficulty with daily living skills • Difficulty complying with treatment regimens • Vulnerability to HIV infection, and • High service utilization

22. 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

23. Major Depression and Substance Use • Onset of Major Depression usually begins in late adolescence, about the same time drug use patterns are established • Involves withdrawal from pleasurable activities, tearfulness, depressed mood, changes in appetite, sleep, morbid thoughts.

24. Major Depression and Substance Use • No “drug of choice” has been identified, i.e., no single drug is preferred over others, or used exclusively • Drug use exacerbates depression, but can be perceived as reducing symptoms

25. Schizophrenia and Substance Use • Onset can include odd behaviors, withdrawal from peers, unusual thoughts and beliefs, depressed mood. • Creates vulnerability for substance use to impair concentration, impulse control, abstract reasoning

26. Schizophrenia and Substance Use • As with other mental disorders, no single “drug of choice” has been identified • Persons with schizophrenia may use drugs for same reasons as peers: To get along in groups, feel relaxed, reduce boredom

27. Bipolar Disorder and Substance Use • Onset appears at younger age, perhaps due to concurrent substance use. • Rapid ‘cycling’. • During mania, can be irritable or elated, judgment is compromised, disturbed sleep, distorted thinking and speech • No single drug associated with bipolar disorder. May use alcohol or stimulants during mania and depression

28. Relapse Factors • The most common cause of mental illness relapse is substance abuse • The most common cause of substance abuse relapse is untreated mental illness

29. 2010 College of Advanced Judicial Studies May 25, 2010 Fort Myers, FloridaRoger H. Peters, Ph.D., University of South Florida, Tampa, Florida; Peters@fmhi.usf.edu Co-Occurring Disorders – Session II

30. Goals of this Session Review: • Relevant resources • Key behaviors relevant to treatment of CODs • Evidence-based practices for CODs • Modifying court-based programs for CODs

31. Why Traditional Approaches are not Effective for Persons 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

32. Challenging Behaviors Related to CODs • Participant who remains silent in response to the judge’s questions due to paranoia • Participant who hears voices and talks to herself during treatment sessions • Man on community supervision who reports not sleeping for days due to change in medications

33. Behaviors Related to CODs • Limited attention span • Difficulty understanding and remembering information • Not recognize consequences of behavior • Poor judgment • Disorganization • Not respond well to confrontation

34. Clinical Features • Cognitive impairment • Reduced motivation • Impairment in social functioning (Bellack, 2003)

35. Types of Cognitive Impairment • Attention • Memory (particularly verbal) • Executive functions

36. Consequences For Not Addressing CODs in Court Settings • Difficulty in adjusting to treatment groups, employment, and other program activities • Frequent hospitalization and other mental health emergencies • High rates of dropout from problem-solving court programs • Rapid cycling to other parts of the criminal justice system – re-arrest, re-incarceration

37. Placement Issues in Court Settings • Excluding persons with co-occurring disorders is NOT a viable option • Courts need to determine which individuals are eligible for services • Individuals should be matched to COD services

38. Factors Affecting Participation in Court and Community Programs • Severity of mental disorder • Functional abilities • Motivation for recovery and “stage of change” • Available resources in the court-based program and affiliated community treatment programs

39. What Works?: Evidence-Based Practices • Integrated treatment for co-occurring disorders • Medications • Illness self-management skills • Motivational enhancement • Contingency management • Family psychoeducation • Assertive Community Treatment (ACT) • Supported employment

40. Features of COD Treatment • Highly structured therapeutic approach • Destigmatize mental illness illness • Focus on symptom management vs. cure • Education regarding individual diagnoses and interactive effects of CODs • “Criminal thinking” groups • Basic life management and problem-solving skills

41. The Case for an Integrated Approach for CODs • Traditional, non-integrated approaches result in poor outcomes • An integrated, multidisciplinary approach is needed: • Similar to the integrated multidisciplinary team process routinely used in court-based programs • Incorporates approaches used in MH field • You already work with these individuals AND can be more effective

42. Key Modifications for CODs • Blended screening and assessment • Integrated and more intensive treatment • Linkage with community treatment • Medication monitoring • Education on CODs • Court hearings and judicial monitoring • Flexible application of sanctions and incentives • Community supervision

43. 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

44. Screening • Routine screening for both sets of disorders • Identify acute symptoms: • Suicidal thoughts and behavior • Depression, hallucinations, delusions • Potential for drug/alcohol withdrawal • History of MH treatment including use of psychotropic medications • Determine need/urgency for referral

45. Assessment • Acquire information from previous court evaluations • Focus on areas of functional impairment that would prevent effective program participation: • Cognitive capacity • Communication and reading skills • Capacity to handle stress • Ability to participate in group interventions • Assess participant motivation

46. Assessment Considerations • Substance abuse can mimicall 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

47. Treatment Modifications - I • Higher staff-to-client ratio • Increased length of services: • Pace of treatment slower • Flexible progression through treatment allowed • Ongoing tracking and case monitoring • Extended exit and re-entry policies • Treatment may last for more than one year

48. Treatment Modifications - II • Integrated treatment to address MH and SA issues • More emphasis on education and support rather than compliance and sanctions • Motivational interventions in both group and individual settings • Cognitive and memory enhancement strategies • Case management and outreach services • Focus on housing, employment, medication needs

49. 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

50. 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