Integrating Substance Abuse and Mental Health Services for Individuals with Co-occurring Disorders

1. Integrating Substance Abuse and Mental Health Services for Individuals with Co-occurring Disorders Christine Grella, Ph.D. UCLA Integrated Substance Abuse Programs UCLA Addiction Clinic: 2006 Seminars in Addiction Psychiatry June 1, 2006 Funded by NIDA-R01-DA11966

2. Overview • Prevalence of COD and availability of services • Approaches to services integration • Policy initiatives in U.S. • UCLA Dual Diagnosis Study

3. Persons with Alcohol, Drug Abuse, or Mental Disorder in the Past YearU.S. Population, Age 15 to 54, 1991 Source: Kessler et al., 1994.

4. Receipt of and Unmet Need for AOD and MH Services Among Adults with COD Perceived Unmet Need Among Untreated Adults Services Received Source: SAMHSA 2002 National Survey on Drug Use and Health

5. Individuals with COD Have Higher Rates of Treatment Utilization and Poorer Treatment Outcomes • Psychiatric symptoms • Hospitalization • Relapse to substance use • Housing stability • Psychosocial functioning • Arrest and incarceration

6. Individuals with COD Seek Treatment in Both AOD and MH Programs • Over half of AOD outpatients had “probable MH disorder” (Watkins et al., 2004) • Clients with COD in AOD and MH settings showed “minimal differences” in severity and type of disorders (Havassy, Alvidrez, & Owen, 2004) • National data in U.S. show that 30% of individuals with AOD disorders either used or perceived an unmet need for MH services in past year (Mojtabai, 2005)

7. Services for COD in AOD Programs • Little increase in “comprehensive services” in outpatient drug treatment, 1990-2000 (Friedmann et al., 2003) • About half of AOD programs provided services for COD in national surveys, 1997-2002 (McFarland & Gabriel, 2004; Mojtabai, 2004) • Over half of private AOD providers “out-refer” clients with COD rather than treat on-site, 1995-2001 (Knudsen, Roman, & Ducharme, 2004)

8. Substance Abuse Treatment Facilities Offering Special Programs for Clients with COD,1999-20021 1Survey reference dates were October 1 for 1999 and 2000 and March 29, 2002. Source: Office of Applied Studies, Substance Abuse and Mental Health Services Administration, UFDS Survey, 1996–1999; National Survey of Substance Abuse Treatment Services (N-SSATS), 2000 and 2002.

9. Approaches to Services Integration • Incorporate MH services into AOD treatment programs • assessment and diagnosis • pharmacotherapy, med management • psychotherapy • Incorporate AOD services into MH programs • psychoeducation • contingency management • motivational interviewing • relapse prevention • 12-step groups • Develop “specialized” programs for COD that are fully integrated

10. Four-Quadrant Framework for COD High severity Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002 Less severemental disorder/more severe substanceabuse disorder More severemental disorder/more severe substanceabuse disorder Less severemental disorder/less severe substanceabuse disorder More severemental disorder/less severe substanceabuse disorder High severity Lowseverity

11. HIGH - HIGH LOW - HIGH Integration of services Eligible for public alcohol/drug and mental health services High Severity Psychiatric Symptoms/Disorders And High Severity Substance Issues/Disorders Services provided in specialized treatment programs with cross-trained staff or multidisciplinary teams Collaboration between systems Eligible for public alcohol/drug services but not mental health services Low to Moderate Psychiatric Symptoms/Disorders And High Severity Substance Issues/Disorders Services provided in outpatient and inpatient chemical dependency system LOW - LOW HIGH - LOW Consultation between systems Generally not eligible for public alcohol/drug or mental health services Low to Moderate Psychiatric Symptoms/Disorders And Low to Moderate Severity Substance Issues/Disorders Services provided in outpatient chemical dependency or mental health system Collaboration between systems Eligible for public mental health services but not alcohol/drug services High Severity Psychiatric Symptoms/Disorders And Low to Moderate Severity Substance Issues/Disorders Services provided in outpatient and inpatient mental health system Service Delivery for COD Source: Ries, 2004

12. National Treatment Plan Initiative - “No Wrong Door” Approach ACCESS AND INTER-SYSTEM LINKAGES Develop a plan to create a nationwide expectation for alcohol and drug treatment such that no matter where in the human services, health, or justice system an individual appears, his or her alcohol or drug problem will be appropriately identified, assessed, referred, or treated.

13. “No Wrong Door” to Treatment • Assessment, referral, and treatment planning for all settings must be consistent with a “no wrong door” policy. • Creative outreach strategies may be needed to encourage some people to engage in treatment. • Programs and staff may need to change expectations and program requirements to engage reluctant and “unmotivated” clients. • Treatment plans should be based on clients’ needs and should respond to changes as they progress through stages of treatment. • The overall system of care needs to be seamless, providing continuity of care across service systems. This can only be achieved through an established pattern of interagency cooperation or a clear willingness to attain that cooperation.

14. REPORT TO CONGRESS ON THE PREVENTION AND TREATMENT OF CO-OCCURRING SUBSTANCE ABUSE AND MENTAL DISORDERS U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICES Substance Abuse and Mental Health Services Administration 2002

16. Levels of Program Capacity in Co-Occurring Disorders

17. Treatment Guidelines for COD are Emergent, but Lack Consensus • Empirical evidence is lacking for most recommendations, particularly regarding: • need to treat patients in integrated settings • sequencing of AOD and MH treatment • “Integrated treatment” is variously defined: • unified treatment program, staff, approach • co-location of services at primary site • system-level linkages and referrals • Recommendations tend to be broad, rather than diagnosis- or setting-specific Source: Watkins et al., 2005

18. UCLA Dual Diagnosis Study Project Aims • To assess AOD and MH programs with regard to service delivery and treatment approaches for COD • To compare differences in attitudes, beliefs, and perceptions between administrators and staff in AOD and MH programs • To evaluate outcomes of clients with COD who are treated in AOD programs that vary in services integration

19. Services for COD in Los Angeles County • AOD and MH treatment in Los Angeles County have been provided in separate and divergent service systems • Countywide initiatives have aimed to improve coordination and collaboration across the 2 systems • Partnerships have been developed between AOD and MH providers in the same area, with varying degrees of service integration

20. Service Delivery for COD in Los Angeles County DHS ADPA DMH Administrators Administrators Services Coordination/ Collaboration AOD Programs MH Programs Staff Staff Study entry Clients Families CJS Housing Health Welfare Community Stakeholders

21. Methods • Interviews and surveys were conducted with administrators of 16 residential AOD treatment programs and 10 MH programs in Los Angeles County • Staff (N = 252) who have direct client contact were surveyed • Clients (N = 400) sampled from AOD programs were assessed at treatment entry, 6-month follow-up, and 12-month follow-up • Focus groups (n = 7) were conducted with program staff, clients, and community stakeholders

22. Client Data Collection (87.8%)1 (77.5%)1 Number 1An additional 18 clients (4.5%) were unable to be interviewed, refused to be interviewed, or were deceased. There were no significant background differences between the interviewed and non-interviewed groups.

23. Demographic Characteristics Percent

24. Background Characteristics Percent

25. Diagnosis of Mental Disorder1 1Based on DSM-IV criteria

26. Alcohol/Drug Dependence1 Percent 1Lifetime; based on DSM-IV criteria

27. Treatment History Percent

28. Treatment Outcome at 6-month Follow-up (N = 351) *No alcohol or drug use in past 30 days & living in the community (i.e., non-incarcerated, not in residential treatment)

29. Outcome Analyses • Latent variable structural equation models • Baseline client characteristics • ethnicity • MH status (SF-36, BSI) • frequency of substance use in past 30 days (marijuana, heroin, cocaine/crack, alcohol)

30. Outcome Analyses • Program characteristics • specialized “dual-diagnosis” groups on-site • sum of on-site psychological services • percent of staff who had training in COD • Psychological service utilization • no. of services received during follow-up period • Time in treatment (M = 93.1, SD = 51.5 days) • Outcome variables • MH status (SF-36, BSI) • frequency of substance use

31. Baseline African American .08* .44*** RAND SF-36 MH RAND SF-36 MH .10* -.12* .13* .47*** .69*** BSI BSI -.18** .10* -.14* .27*** .11* Heroin Heroin .40*** .19** Marijuana Marijuana -.10* .14* .13* Cocaine/Crack Cocaine/Crack -.08* -.11* .22*** .22*** Heavy Alcohol Heavy Alcohol -.12* Program Characteristics .17** -.11* Dual Diagnosis Groups .16** .64*** Number of Psychological Services .12* .24*** .21*** % Staff with Training in COD .15** Follow-up Psychological Service Utilization Time in Drug Treatment *p<.05, **p<.01, p<.001; CFI = .95, RMSEA = .039, RCFI = .95

32. Variables Not Related to Treatment Outcome Client Factors • Type of psychiatric disorder • Legal, housing, or physical health status • Degree of family assistance • Quality of life, treatment history or motivation Treatment Factors • Type of referral to treatment • Self-help participation following treatment (95% yes) • Rapport with AOD counselor • Satisfaction with AOD treatment

33. Conclusions • Integration of specialized services for COD in AOD treatment increases services utilization, which positively benefits client outcomes • Staff training is critical to increasing access to services for COD • African Americans had higher need for, but less access to, mental health services

34. Policy/Practice Implications • Continue system-wide efforts at services integration and staff training • Promote innovative service collaborations • Address health disparities in access to MH services

35. References Gil-Rivas, V., & Grella, C.E. (2005). Treatment services and service delivery models for dually diagnosed clients: Variations across mental health and substance abuse providers. Community Mental Health Journal, 41(3), 251-266.  Grella, C.E. (2003). Contrasting the views of substance misuse and mental health treatment providers on treating the dually diagnosed. Substance Use & Misuse, 38(10), 1427-1440.  Grella, C.E. (2004, August). Dually diagnosed in drug treatment: Patient, treatment, and program effects. Presentation at the annual meeting of the American Psychological Association, Honolulu, Hawaii.  Grella, C.E. (2003). Effects of gender and diagnosis on addiction history, treatment utilization, and psychosocial functioning among a dually diagnosed sample in drug treatment. Journal of Psychoactive Drugs, 35(4), 169-179.  Grella, C.E. (2004, June). Multi-level models of outcomes of patients with co-occurring disorders. Poster presented at Complexities of Co-Occurring Conditions Conference, Washington, D.C.  Grella, C.E., & Gilmore, J. (2002). Improving service delivery to the dually diagnosed in Los Angeles County. Journal of Substance Abuse Treatment, 23,115-122.  Grella, C.E., Gil-Rivas, V., & Cooper, L. (2004). Perceptions of mental health and substance abuse program administrators and staff regarding service delivery to persons with co-occurring substance abuse and mental disorders. Journal of Behavioral Health Services & Research, 31(1), 38-49.  Hamilton-Brown, A., Grella, C.E., & Cooper, L. (2002). Living it or learning it: Attitudes and beliefs about experience and expertise in treatment for the dually diagnosed. Contemporary Drug Problems, 29(4), 687-710.