Integrating Substance Abuse and Mental Health Services for Individuals with Co-occurring Disorders...
Transcript of Integrating Substance Abuse and Mental Health Services for Individuals with Co-occurring Disorders...
Integrating Substance Abuse and Mental Health Services for Individuals
with Co-occurring Disorders
Funded by NIDA-R01-DA11966
Christine Grella, Ph.D.
UCLA Integrated Substance Abuse Programs
UCLA Addiction Clinic:2006 Seminars in Addiction Psychiatry
June 1, 2006
Overview
Prevalence of COD and availability of services Approaches to services integration Policy initiatives in U.S. UCLA Dual Diagnosis Study
Persons with Alcohol, Drug Abuse, or Mental Disorder in the Past Year
U.S. Population, Age 15 to 54, 1991
4.7%
11.3%
22.9%
29.5%
0
5
10
15
20
25
30
Any alcohol, drug abuse, or mental disorder
Any mental disorder
Any substance abuse/dependency
Co-existing mental disorder and
substance abusedependency
(52 Million)
(40 Million)
(20 Million)
(8 Million)
Source: Kessler et al., 1994.
Receipt of and Unmet Need for AOD and MH Services Among Adults with COD
23.9%
6.3%
8.9%
60.9%
34.2%
1.9%
11.8%
52.1%
MH TreatmentOnly
AOD TreatmentOnly
Both MH andAOD Treatment
Neither MH norAOD Treatment
Services Received Perceived Unmet Need Among Untreated Adults
Source: SAMHSA 2002 National Survey on Drug Use and Health
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
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)
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)
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.
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
Four-Quadrant Framework for COD
Source: NASMHPD, NASADAD, 1998; NY State; Ries, 1993; SAMHSA Report to Congress, 2002
Less severemental disorder/
less severe substanceabuse disorder
More severemental disorder/
less severe substanceabuse disorder
More severemental disorder/
more severe substance
abuse disorder
Less severemental disorder/
more severe substance
abuse disorder
High severity
High severity
Lowseverity
Service Delivery for COD
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
LOW - LOW HIGH - LOW
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
LOW - HIGH
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
HIGH - 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
Source: Ries, 2004
ACCESS AND INTER-SYSTEM LINKAGESDevelop 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.
National Treatment Plan Initiative - “No Wrong Door” Approach
“No Wrong Door” to Treatment
1. Assessment, referral, and treatment planning for all settings must be consistent with a “no wrong door” policy.
2. Creative outreach strategies may be needed to encourage some people to engage in treatment.
3. Programs and staff may need to change expectations and program requirements to engage reluctant and “unmotivated” clients.
4. Treatment plans should be based on clients’ needs and should respond to changes as they progress through stages of treatment.
5. 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.
REPORT TO CONGRESSON THE
PREVENTION AND TREATMENT OFCO-OCCURRING SUBSTANCE ABUSE AND
MENTAL DISORDERS
U.S. DEPARTMENT OF HEALTH AND HUMAN SERVICESSubstance Abuse and Mental Health Services Administration
2002
Levels of Program Capacity in Co-Occurring Disorders
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
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
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
Services Coordination/Collaboration
DMH
DHS
ADPA
MH Programs
AOD Program
s
Administrators
StaffStaff
Administrators
Clients
Community Stakeholders
Familie
s
CJS Housing Health Welfare
Study entry
Service Delivery for COD in Los Angeles County
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
Client Data Collection
Number
310
351
400
0 100 200 300 400
12-monthFollow-ups (8/00 - 4/03)
6-monthFollow-ups
(2/00 - 10/02)
BaselineInterviews (8/99 - 4/02)
(77.5%)1
(87.8%)1
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.
Demographic Characteristics
58
50
47
18
35
47
0 10 20 30 40 50 60 70 80 90 100
Completed HS
> 35 years
Female
Hispanic/Other
Af-Am
White
Percent
27
38
48
55
57
0 10 20 30 40 50 60 70 80 90 100
Receives SSI disability
Referred by CJS
Employed past year
Health is good/excellent
Stable housing
Percent
Background Characteristics
Diagnosis of Mental Disorder1
Mood Disorder65%
Psychotic Disorder
35%
1Based on DSM-IV criteria
Alcohol/Drug Dependence1
23
28
44
46
68
83
0 10 20 30 40 50 60 70 80 90
Sedatives
Opioids
Amphetamines
Cannabis
Cocaine
Alcohol
Percent
1Lifetime; based on DSM-IV criteria
Treatment History
26
64
81
91
91
0 20 40 60 80 100
Dual Diagnosis Treatment
Prior Drug Treatment
Inpatient Mental Health Treatment
Self-help Participation
Outpatient Mental Health Treatment
Percent
Treatment Outcome at 6-month Follow-up (N = 351)
Still in treatment
4%
AOD use or incarcerated
46%No AOD
use/living in community*
50%
*No alcohol or drug use in past 30 days & living in the community (i.e., non-incarcerated, not in residential treatment)
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)
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
Heavy Alcohol
Cocaine/Crack
Marijuana
Heroin
RAND SF-36MH
BSI
Psychological Service
Utilization
Time in Drug Treatment
.16**
.15**
.12*
.17**
-.11*
.24***
.08*
.13*
-.10*
.44***
.47***
.11*
.40***
.13*
-.14*
-.18**
.22***
-.12*
*p<.05, **p<.01, p<.001; CFI = .95, RMSEA = .039, RCFI = .95
Dual Diagnosis Groups
Heavy Alcohol
Cocaine/Crack
Marijuana
Heroin
African American
RAND SF-36MH
BSI
Number of Psychological Services
% Staff with Training in COD
.10*
-.12*
.10*
.69***
-.11*
.21***
.64***
-.08* .22***
.14*
.27***
.19**
Program Characteristics
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
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
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
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.
References