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4/24/2013
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
MAKING CONNECTIONSFOR RECOVERY
Integrating Treatment
11/14/20121
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
SAMHSA’s 2002 report to Congress defines co-occurring disorders as:
Individuals who have at least one mental
disorder as well as an alcohol or drug use
disorder. While these disorders may interact
differently in any one person (e.g., an episode of
depression may trigger a relapse into alcohol abuse, or cocaine
use may exacerbate schizophrenic symptoms), at least one
disorder of each type can be diagnosed
independently of the other.
11/14/20122
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
11/14/20123
The term “co-occurring disorders” typically refers to having one or more diagnosed mental illness coupled with
one or more addictive disorder.
Simply put,
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Are Co-Occurring Disorders Common?
As a matter of
fact, YES
41% to 65.5% with Substance Use Disorder (SUD)
have at least one Mental Health (MH) disorder; 51%
with a MH disorder also have at least one SUD
(Kessler et al).
10 million U.S. residents each year.
11/14/20124
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
As a matter of
fact, YES
Are Co-Occurring Disorders Common?
10% account for 71% of our nation’s healthcare costs.
Two-thirds of that 10% are diagnosed with co-occurring
MH/SUD (Buck, 2001, CMHS Office of Managed Care).
It is estimated that 196,000 Tennesseans suffer from co-
occurring disorders. (National Household Survey, 2008
noted that 393,000 Tennesseans reported dependence or
abuse of illicit drugs or alcohol. This estimate is based on
NHS and national COD prevalence data.)11/14/20125
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Parallels (Minkoff)1. Biological (no fault) illness2. Hereditary (in part)3. Chronicity4. Incurability5. Leads to lack of control of behavior and
emotions6. + and – symptoms7. Affects the whole family8. Disease progresses without treatment9. Symptoms can be controlled with proper
treatment10. Disease of denial, (both disease & its
chronicity)
11. Facing the disease can lead to depression & despair
12. Disease is often seen as a “moral issue” & personal weakness rather than biological
13. Feelings of guilt & failure14. Feelings of shame & stigma15. Physical, mental and spiritual disease
11/14/20126
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Mental Illness Addiction
Which came first . . .
There are several hypotheses regarding the onset and
direction of co-occurring disorders. Science has not
settled on one specific explanation and there may be
multiple causal factors. The prevalence of co-occurring
mental illness and addiction does not necessarily prove
causation.
11/14/20127
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Drug abuse may bring about symptoms of another mental illness. Increased risk of psychosis in
vulnerable marijuana users suggests this possibility.
Mental disorders can lead to drug abuse, possibly as a means of “self-medication.” Patients suffering
from anxiety or depression may rely on alcohol, tobacco, and other drugs to temporarily alleviate their
symptoms.
These disorders could also be caused by shared risk factors, such as—
Overlapping genetic vulnerabilities. Predisposing genetic factors may make a person susceptible to both
addiction and other mental disorders or to having a greater risk of a second disorder once the first appears.
Overlapping environmental triggers. Stress, trauma (such as physical or sexual abuse), and early
exposure to drugs are common environmental factors that can lead to addiction and other mental illnesses.
National Institute of Health, 2010 11/14/20128
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Involvement of similar brain regions. Brain systems that respond to reward and stress,
for example, are affected by drugs of abuse and may show abnormalities in patients with
certain mental disorders.
Drug use disorders and other mental illnesses are developmental disorders. That
means they often begin in the teen years or even younger—periods when the brain
experiences dramatic developmental changes. Early exposure to drugs of abuse may
change the brain in ways that increase the risk for mental disorders. Also, early symptoms
of a mental disorder may indicate an increased risk for later drug use.
National Institute on Drug Abuse, 201011/14/20129
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Early Occurrence Increases Later Risk. Strong evidence has emerged showing early
drug use to be a risk factor for later substance abuse problems; additional findings
suggest that it may also be a risk factor for the later occurrence of other mental illnesses.
However, there are several factors at play: genetic vulnerability, psychosocial
experiences, and/or general environmental influences. A 2005 study highlights this
complexity, with the finding that frequent marijuana use during adolescence can increase
the risk of psychosis in adulthood, but only in individuals who carry a particular gene
variant.
National Institute on Drug Abuse, 200711/14/201210
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
It is also true that having a mental disorder in childhood or adolescence can increase the risk of
later drug abuse problems, as frequently occurs with conduct disorder and untreated attention-deficit
hyperactivity disorder (ADHD). This presents a challenge when treating children with ADHD, since
effective treatment often involves prescribing stimulant medications with abuse potential. This issue has
generated strong interest from the research community, and although the results are not yet conclusive,
most studies suggest that ADHD medications do not increase the risk of drug abuse among children
with ADHD.
Regardless of how comorbidity develops, it is common in youth as well as adults. Given the high
prevalence of comorbid mental disorders and their likely adverse impact on substance abuse treatment
outcomes, drug abuse programs for adolescents should include screening and, as needed, treatment for
comorbid mental disorders.
National Institute on Drug Abuse, 2007 11/14/201211
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Poorer functioning and outcomes
Higher rates of relapse
Significantly higher physical healthcare costs and more severe
and chronic medial conditions
At least 50% of individuals who are homeless have COD
(SAMHSA, 2011)
Increased emergency service use
Increased criminal justice involvement and arrests
The Impacts of Co-Occurring
Disorders
Higher risk for HIV and higher rates of HIV infection
Slower treatment progress
More likely to be refused admission or to be prematurely discharged from A&D and MH
treatment
59% more inpatient psychiatric admissions
Primary predictor of readmission
Major predictors of excessive inpatient
utilization
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
We actually know a lot about
the impact of co-occurring
disorders on individuals,
families, and our
communities.
11/14/201213
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Impact on our health care system
People who suffer with this usually have more
episodes of relapse and more emergency room visits.
They have to go to inpatient hospitals to address
symptoms of mental illness and addiction more often
than people who are dealing with one disease. We
also know that people with co-occurring disorders have
higher rates of chronic diseases such as HIV, diabetes,
hepatitis and high blood pressure. 11/14/201214
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Impact on our communities
Workforce – Mental illness and substance abuse drains over $100
billion from American businesses. More workers are absent due to
stress and anxiety than physical illness or accident. 11/14/201215
Homelessness – At least 50% of people who are
homeless have co-occurring disorders. Left
untreated, they have little chance at obtaining
jobs and permanent housing.
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Impact on the criminal justice system
In the local jail systems, 76% of inmates
with mental health issues reported
substance use.
Untreated mental illness (or mental illness and a co-occurring
substance abuse disorder) is a strong predictor of recidivism.
11/14/201216
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Impact on our families
It is estimated that 40% to 80% of
families of children involved in the
child welfare system have
substance abuse problems.
In 2010, Tennessee had approx. 8,000 children and adolescents in state
custody.
Of the families involved in the state’s foster care system, prevalence data
tells us that approx. 2,000 to 4,000 families are impacted by substance
abuse issues or co-occurring disorders. 11/14/201217
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Changing Philosophy Moves Us Together
Historically, mental health service providers
and addictions service providers had differing
philosophical approaches to treatment and
recovery of co-occurring disorders.
Providers addressed screening, diagnosis, treatment and
recovery from (sometimes) opposing standpoints.
11/14/201218
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Bringing the Pieces TogetherThe idea that mental illness and
addiction are separate and unconnected
has led to treatment programs that are separate
and unconnected.
However, we know that an integrated treatment
approach works best.11/14/201219
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
A “No Wrong Door” Approach
Motivating (& Pre-motivating – Assertive Outreach)
Empathic
Integrated
Comprehensive & Individualized
Continuous Hope in Recovery
11/14/201220
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
Continuous Focus onHope in Recovery
Three Step Process (Minkoff)
1. Empathize with reality of despair.
2. Establish legitimacy of need to ASK for extensive help.
3. Emphasize a hopeful vision of pride and dignity to
counter self-stigmatization.
11/14/201221
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
R E F E R E N C E SDiClemente, C. (2004). Addiction and Change:
Understanding and Intervening in the Process, UMBC
Psychology, www.umbc.edu/psych/habi
Kessler, R., Nelson, C., McGonagle, K., Edlund, M., Frank, R.,
& Leaf, P. (1996). The Epidemiology of Co-occurring
Addictive and Mental Disorders: Implications for Prevention
and Service Utilization. American Journal of Orthopsychiatry,
66 (1), 17-31.
National Institute on Drug Abuse. (2007). Topics in Brief:
Comorbid Drug Abuse and Mental Illness.
http://www.drugabuse.gov/publications/topics-in-brief/comorbid-
drug-abuse-mental-illness
National Institute on Drug Abuse. (2010). Comobidity:
Addiction and Other Mental Illnesses. Pub. No. 10-5771.
http://www.drugabuse.gov/publications/research-
reports/comorbidity-addiction-other-mental-illnesses
U.S. Department of Health and Human Services, Substance Abuse
Mental Health Services Administration, Center for Substance Abuse
Services. (2007). Substance Abuse Treatment for Persons with
Co-Occurring Disorders (DHHS Publication No. (SMA) 05-3992).
U.S. Department of Health and Human Services, Substance Abuse
and Mental Health Services Administration. (2002). Report to
Congress on the Prevention and Treatment of Co-Occurring
Substance Abuse Disorders and Mental Disorders. Rockville, MD:
Substance Abuse and Mental Health Services Administration.
Genetic Science Learning Center. (2012, August 6). Drugs Alter the
Brain's Reward Pathway. Learn.Genetics. Retrieved November 12,
2012, from
http://learn.genetics.utah.edu/content/addiction/drugs/index.html
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331
11/14/201223
Randy Jessee, Ph.D.Senior Vice President Specialty ServicesFrontier Health1167 Spratlin Park Drive Gray, Tennessee 37615423-467-3720rjessee@frontierhealth.org
Vickie Harden, MSSWSenior Vice President for Clinical ServicesVolunteer Behavioral Health Care System118 North Church StreetP.O. Box 1559Murfreesboro, Tennessee 37133-1559615-278-6255vharden@vbhcs.org
Hilde Phipps, MA, LADACDirector of Adult Addiction ServicesHelen Ross McNabb CenterCenterpointe5310 Ball Camp PikeKnoxville, Tennessee 37921865-523-4704 ext. 3417hilde.phipps@mcnabb.org
Jim JonesClinical Manager/Crisis ManagerPathways Behavioral Health Services238 Summar DriveJackson, Tennessee 38301731-541-8200jim.jones@wth.org
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
11/14/201224
What do we mean by co-occurring
disorders?
In the Substance Abuse Mental Health Services Administration 2002 Report to Congress, co-occurring disorders were defined as . . . “. . . individuals who have at least one mental disorder aswell as an alcohol or drug use disorder. While these disorders may interact differently in any one person (e.g., an episode of depression may trigger a relapse into alcohol abuse, or cocaine use may exacerbate schizophrenic symptoms), at least one disorder of each type can be diagnosed independently of the other.“
Simply put, a co‐occurring disorder typically refers to an individual having one, or more, diagnosed mental illness coupled with one, or more, diagnosed addictive disorder.
How many people are affected?It is estimated that over 10 million people across the United States are struggling with co-occurring disorders. Many of these people do not access treatment services, and when they do, the treatment is often not “integrated” or delivered in a way that best meets their needs. Based on national prevalence data it is estimated that in Tennessee approximately 196,000 individuals suffer from co-occurring disorders.
What is the impact of co-occurring disorders?We actually know a lot about the impact of co-occurring disorders on individuals, families and our community.
• Impact on our healthcare system . . . People who suffer with this usually have more episodes of relapse and more emergency room visits. They have to go to inpatient hospitals to address symptoms of mental illness and addiction more often than people who are dealing with one disease. We also know that people with co-occurring disorders have higher rates of chronic diseases such as HIV, diabetes, hepatitis and high blood pressure.
• Impact on the Criminal Justice System . . . In the local jail systems, 76% of inmates with mental health issues reported substance use. Untreated mental illness, or mental illness and a co-occurring substance abuse disorder, is a strong predictor of recidivism.
• Impact on our families . . . It is estimated that approximately 60% of families of children involved in the child welfare system have substance use problems with at least one-half of those being diagnosed with a co-occurring mental illness. In 2010, Tennessee had approximately 8,000 children and adolescents in state custody. Of the families involved in the state’s foster care system, prevalence data tells us that approximately 2,000 to 4,000 families are impacted by substance use and a co-occurring mental illness which have a negative impact on health, relationships, safety, employment and education and poses greater challenges in maintaining recovery or resiliency than those with a single diagnosis.
• Impact on our communities . . . Homelessness - At least 50% of people who are homeless have co-occurring disorders. Left untreated, they have little chance at obtaining jobs and permanent housing.Workforce - Mental illness and substance abuse drains over $100 billion from American businesses. More workers are absent due to stress and anxiety than physical illness or accident.
CO-OCCURRINGDISORDERS:
Moving TennesseeToward Integration
What can we do to influence change?• Create and support a “no wrong door” community-based integrated treatment
approach, so that mental health centers and addictions treatment providers are equipped to help, no matter who comes through their door for assistance. The presence of co-occurring disorders is the expectation rather than the exception.
• Increase treatment opportunities. Last year in Tennessee, approximately 12,000 people received treatment for addictive disorders. Due to limited resources, less than 3% of those with co-occurring disorders received treatment through our addictions treatment system.
• Advocate for a continuum of treatment options, including inpatient and outpatient care, supportive housing, and peer-to-peer support provides the best possible opportunity for recovery.
• Provide Tennesseans with the resources to manage these diseases and the support to maintain life-long recovery. Treatment works and recovery is possible.
• Provide co-occurring disorder training. Workforce development is critical. Tennessee has a wealth of experienced, dedicated clinicians who want to help. Providing them with the most up-to-date information and training on evidence-based practices will ensure our place as leaders in the field of co-occurring disorders treatment.
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Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331Joint
Resolution . . . Whereas, it is recognized that consumers with co-occurring disorders have unique and complex needs.Whereas, there is an identified need for increased education and awareness among treatment providers, consumers, families and our communities regarding co-occurring disorders and its impact. Whereas, we recognize that a collaborative effort involving consumers, families and treatment providers insures the most effective treatment and recovery outcomes. Whereas, NAMI Tennessee, the Tennessee Association of Mental Health Organizations (TAMHO), and the Tennessee Association of Alcohol, Drug and Other Addiction Services (TAADAS) commit to the provision of ongoing education and increasing awareness to eliminate barriers to access for persons with co-occurring disorders.Whereas, these organizations commit to develop the strongest treatment delivery system, recovery/support services, and advocacy activities for persons with co-occurring disorders in communities across our state.Whereas, such efforts will reduce barriers between treatment professionals, reduce stigma experienced by consumers and their families and increase our communities’ ability to respond to the needs of consumers with co-occurring disorders.Whereas, each organization has a unique perspective and expertise in the area of co-occurring disorders treatment, recovery and advocacy. Now Therefore Be It Resolved, NAMI Tennessee, TAMHO, and TAADAS will hereby collaborate with one another to increase awareness of the impact of co-occurring mental illness and addictive disorders on consumers, their families and our communities. 11/14/2012
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MISSION STATEMENTThe mission of the Co‐Occurring
Disorders Collaborative is to create a common understanding of the
impact and treatment of co‐occurring disorders in our communities and to
share knowledge about the conditions and available resources, reduce stigma, and accurately direct
people to timely and effective prevention, treatment, and support.
Tennessee Co-Occurring Disorders CollaborativeSTRENGTHENING INDIVIDUALS, FAMILIES, AND COMMUNITIES THROUGH EDUCATION AND AWARENESS
42 Rutledge Street, Nashville, TN 37210-2043(615) 244-2220 | (800) 568-2642 toll free in TN | Fax: (615) 254-8331
11/14/201226
CHARGEThe Co‐Occurring Disorders
Collaborative Steering Committee serves as the
primary statewide structure to oversee and coordinate the planning, development, and
implementation of all phases of the Co‐Occurring Disorders Collaborative activities and
initiatives to include ensuring consistency, accountability, and
sustainability of co‐occurring disorder strategies and provide
strategic and operational recommendations through the committee and subcommittee
structure.
STEERING COMMITTEE CHAIRMANRandy Jessee, Ph.D., Senior Vice President Specialty Services, Frontier Health, Gray
GRANT ADMINISTRATORTennessee Association of Mental Health Organizations
TENNESSEE ASSOCIATION OF ALCOHOL, DRUG & OTHER ADDICTION SERVICES (TAADAS)Mary Linden Salter, Executive Director, TAADASDebbie Hillin, President, TAADAS, NashvilleCharlotte Hoppers, Executive Director Grace House, Memphis
TENNESSEE VOICES FOR CHILDREN (TVC)Charlotte Bryson, Executive Director, Nashville
TENNESSEE COALITION FOR MENTAL HEALTH AND SUBSTANCE ABUSE SERVICESRobert J. Benning, Chairman (CEO, Ridgeview, Oak Ridge)
TENNESSEE ASSOCIATION OF ALCOHOL AND DRUG ABUSE COUNSELORS (TAADAC)Toby Abrahms, President, NashvilleCharlie Hiatt, River City Counseling, Chattanooga
MENTAL HEALTH AMERICA OF MIDDLE TENNESSEE(Formerly Mental Health Association of Middle TN)Tom Starling, Ed.D., President/CEO, Nashville
TENNESSEE MENTAL HEALTH CONSUMERS’ ASSOCIATION (TMHCA)Anthony Fox, Executive Director, NashvilleCarolina George, Nashville
NAMI TENNESSEECO‐FOUNDING ORGANIZATION OF THE TENNESSEE CO‐OCCURRING DISORDERS COLLABORATIVEJeff Flahey, Executive Director, NAMI Tennessee, NashvilleDick Baxter, Ph.D., President, NAMI TennesseeRobin Nobling, Executive Director, NAMI Davidson County, Nashville
TENNESSEE ASSOCIATION OF MENTAL HEALTH ORGANIZATIONS (TAMHO)CO‐FOUNDING ORGANIZATION OF THE TENNESSEE CO‐OCCURRING DISORDERS COLLABORATIVERandy Jessee, Ph.D., Senior Vice President Specialty Services, Frontier Health, GrayJim Jones, Clinical Manager/Crisis Manager, Pathways, JacksonVickie Harden, Senior Vice President for Clinical Services, Volunteer Behavioral Health Care System, MurfreesboroVickie Griffey, Coordinator A&D Carey Counseling Center, ParisTeresa Fuqua, Director of Member Services, TAMHO, NashvilleEllyn Wilbur, Executive Director, TAMHO, Nashville
TENNESSEE DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES (TDMHSAS)Rod Bragg, Assistant Commissioner, Division of Substance Abuse Services, NashvilleSejalWest, Assistant Commissioner, Division of Mental Health Services, NashvilleKen Horvath, Co‐Occurring Disorders Specialist, Division of Substance Abuse Services, NashvilleAngela McKinney Jones, Director of Prevention Services, Division of Substance Abuse Services, Nashville