Integrated Dual Disorder Treatment (IDDT) Evidence Based Practice Kick

Integrated Dual Disorder Treatment (IDDT) Evidence Based Practice Kick Off Presentation Evidence-Based Practices Copyright West Institute

What are dual disorders? Mental illness and substance use disorder occurring together in one person Evidence-Based Practices Copyright West Institute

Why focus on dual disorders? Substance use disorders are common in people with severe mental illness Mental illness is common in people with substance use disorders Dual disorders lead to worse outcomes and higher costs than single disorders Evidence-Based Practices Copyright West Institute

How common are these problems in Americans? Mental illness Depression 15% Anxiety Disorders 13% Bipolar 1% Schizophrenia 1% Substance use disorders Alcohol 20% Drugs 9% Evidence-Based Practices Men 30% Women 10% Men 11% Women 7% Copyright West Institute

Substance abuse is common in people with mental illness Over 50% of people with schizophrenia, bipolar disorder and other severe mood disorders have a substance use disorder at some time in their life About one third of people with anxiety and depressive disorders have a substance use disorder at some time in their life Evidence-Based Practices Copyright West Institute

Prevalence of substance use disorders in mental illness 60 50 40 % of respondents with substance 30 use disorder 20 10 0 Evidence-Based Practices Gen pop Schiz Bipolar Maj dep OCD Panic Copyright West Institute

% of respondents Prevalence of Co-Occurring Disorders-ECA Study 100 90 80 70 60 50 40 30 20 10 0 Schizophrenia General Population Alcohol Use Disorder Evidence-Based Practices Regier et al., JAMA, 1990 Drug Use Disorder Alcohol or Drug Use Disorder Copyright West Institute

Prevalence of mental illness in alcohol disorder samples 70 60 50 40 30 20 10 0 Community In community, 24.4% have mental illness In institutions, 55% have mental illness In substance abuse treatment, 65% have mental illness SA Treatment Evidence-Based Practices Copyright West Institute

Combination and levels of illness Mild to moderate mental illness symptoms Mild to moderate substance use disorder Severe mental illness symptoms Mild to moderate substance use disorder Mild to moderate mental illness symptoms Severe substance use disorder Severe mental illness symptoms Severe substance use disorder Evidence-Based Practices Copyright West Institute

Types of Dual Disorders Three categories Milder mood/anxiety disorder with substance use disorder Personality disorder and substance use disorder Severe mental illness and substance use disorder Evidence-Based Practices Copyright West Institute

Integrated Dual Diagnosis Treatment Implementation Materials Materials focus on treatment for persons with severe and persistent mental illness and substance use disorder Psychotic disorders Bipolar disorders Other severely disabling mental disorders Any level of co-occurring substance use disorder Evidence-Based Practices Copyright West Institute

Course of dual disorders Both substance use disorders and severe mental illness are chronic, waxing and waning Recovery from mental illness or substance abuse occurs in stages over time Precontemplation Contemplation Preparation Action Maintenance Prochaska, DiClemente, and Norcross 1992; Miller and Rollnick 1991 Evidence-Based Practices Copyright West Institute

Course of dual disorders People SMI and social substance use Become abstinent or develop substance use disorder Can’t tolerate social use People with more severe substance use disorders Most get worse Bartels et al, 1995 Evidence-Based Practices Copyright West Institute

are Gra Quic Attaining remission occurs in stages 100 90 80 Recovered 70 Relapse Prevention Percent 60 Late Active Treatment 50 Early Active Treatment 40 Late Persuasion 30 Early Persuasion 20 Engagement 10 Pre-engagement 0 0 mo. Evidence-Based Practices 6 mo. 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Assessment Point Copyright West Institute

Dual disorders lead to worse outcomes than single disorders Relapse of mental illness Treatment problems and hospitalization Violence, victimization, and suicidal behavior Homelessness and Incarceration Medical problems, HIV & Hepatitis risk behaviors and infection Family problems Increase service use and cost Evidence-Based Practices Copyright West Institute

Evidence-Based Practices Copyright West Institute

Characteristics Associated with Medication Noncompliance in Six-Month Longitudinal Study Characteristics Odds Ratio 95% CI Substance Abuse 8.1 2.5-26 0.13 0.01-1.2 0.53 O.25-1.1 (0 none, 1 current) Observed Side Effects (0 none, 1 any SE) Outpatient Contacts (0 none, 1 1-6, 3 6) Owen et al, Psychiatric Services 1996 Evidence-Based Practices Copyright West Institute

Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C 25% 20% 15% 10% 5% 0% Seroprevalnce Rates in SMI Sample HIV (N 931) HBV (N 751) Persons with Substance Use Disorders had 3 times higher chance of having HIV 2 times higher chance of having HBV 2. 5 times higher chance of having HCV HCV(N 751) Evidence-Based Practices Rosenberg et al., A Jl Public Health, 2001 Copyright West Institute

Monthly Income and Expenditures for Substances Among 105 Patients with schizophrenia Monthly income 650 Disability income 645 Expenditures for illegal drugs 250 Expenditures for alcohol 10 Median values Evidence-Based Practices Copyright West Institute

Costs of treatment for persons with dual disorders compared to SMI only Treated for Substance Not treated for Use (N 1,493) Substance Use (N 4,394) No substance use (N 10,509) 22,917 13,930 20,049 Dickey and Azeni, Am J Public Health, 1996 Evidence-Based Practices Copyright West Institute

Recovery Dual disorders are treatable Many people attain stable remission of substance use disorders over time Recovery encompasses other areas of adjustment Health, work, housing, relationships Mead et al, 2000 Evidence-Based Practices Copyright West Institute

Traditional treatment Treat each disorder separately May be parallel or sequential Separate treatment is NOT effective Evidence-Based Practices Copyright West Institute

Evidence Based Practice Definition of EBP Research evidence that practice is more effective than usual treatment from multiple studies across the country Overview of national project Implementation kits for 6 evidence based practices for public mental health Several states attempting to implement each EBP National study of implementation Process, feasibility, outcomes Evidence-Based Practices Copyright West Institute

Integrated dual disorders treatment: What is it? Treatment of substance use disorder and mental illness together Same team Same location Same time Other characteristics to be described later Evidence-Based Practices Copyright West Institute

Why integrated treatment of dual disorders? More effective than separate treatment 10 studies show integrated treatment is more effective than traditional separate treatment (Drake et al, Schiz Bull 1998 and Drake et al, Psych Services 2001 for summaries). Evidence-Based Practices Copyright West Institute

IDDT improves abstinence Abstinence after Integrated Dual Disorder Treatment 70 60 50 40 30 20 10 0 0.00 IDDT Parallel 1.00 2.00 3.00 4.00 Years Evidence-Based Practices Copyright West Institute

Fidelity to IDDT principles improves abstinence 60 McHugo et al, 1999 *** If current & subsequent points 1 then the current score 1 Figure 1. Percent of Participants for High-Fidelity Assessment Points Baseline 6 mo. 12 mo. in Stable 18 mo. Remission 24 mo. 30 mo. 36 mo. Hi-Fidelity 19.67 26.23 29.51 37.7 42.62 55.74 Programs ( E ; 0n 61) vs. Low-Fidelity ACT Programs (G; n 26). Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38 ACT 50 40 30 20 10 0 Baseline 6 mo. Evidence-Based Practices 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Copyright West Institute

Abstinence leads to improvements in other outcomes Drake et al, 1998 Reduce institutionalization Reduce symptoms, suicide Reduce violence, victimization, legal problems Better physical health Improve function, work Improve relationships and family Evidence-Based Practices Copyright West Institute

Stable remission improves other aspects of life Objective: Living situation, victimization Subjective: overall satisfaction with life, housing, family, health Evidence-Based Practices Copyright West Institute

NH Dual Diagnosis Study (19891994 Drake et al, 1998) Proportion of Days in Stable Community Housing 1.0 0.9 0.8 0.7 Beginning 6 months 12 months All DD Patients (N 203) 18 months 24 months 30 months 36 months Patients in Recovery (N 54) 1. Proportion of days in stable community housing (regular apartment or house, not in hospital, jail, homeless setting or doubling with friends or family) increased for all dual diagnosis clients. 2. They increased more rapidly for persons in recovery (no substance abuse for at least 6 months). Evidence-Based Practices Copyright West Institute

NH Dual Diagnosis Study (19891994) Percentage of Persons Hospitalized 70.0 60.0 50.0 40.0 30.0 20.0 10.0 0.0 Beginning 6 months 12 months All DD Patients (N 203) 18 months 24 months 30 months 36 months Patients in Recovery (N 54) 1. Percentage of persons hospitalized during each six months declined significantly for all clients. 2. It declined much more for those in recovery. Copyright West Institute Evidence-Based Practices

NH Dual Diagnosis Study (19891994) Number of Arrests and Incarcerations (N 203) 60 50 40 30 20 10 0 Beginning 6 months Arrests 12 months 18 months 24 months 30 months 36 months Incarcerations in Jails or Prisons Arrests and Incarcerations decline as persons treated for dual disorders recover from substance abuse. Evidence-Based Practices Copyright West Institute

NH Dual Diagnosis Study (19891994) Median Treatment Costs: Patients in Recovery (N 54) 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 Beginning 6months 12months Inpatient 18months 24months 30months 36months Outpatient 1. Median treatment costs decline more for persons in recovery. 2. Inpatient costs decrease. 3. There is a shift to community based treatment. 4. Those who are most successful often begin with higher than average treatment costs. Copyright West Institute Evidence-Based Practices

How do people obtain remission from dual disorders? Stable housing Sober support network/family Regular meaningful activity Trusting clinical relationship Alverson et al, Com MHJ, 2000 Evidence-Based Practices Copyright West Institute

Treatment factors for recovery Integration of mental health and substance abuse treatment Stage-wise interventions Assertive outreach Motivational counseling Substance abuse counseling Evidence-Based Practices Copyright West Institute

Principles of Integrated Dual Disorder Treatment Integrated Same team of dually trained people Same location of services Both disorders treated at the same time Stage-wise services Different services offered at different stages of treatment Evidence-Based Practices Copyright West Institute

Principles - Stagewise treatment Precontemplation - Engagement Outreach, practical help, crisis intervention, develop alliance, assessment Contemplation & Preparation - Persuasion Education, set goals, build awareness of problem, family support, peer support, Action - Active Treatment Substance abuse counseling, medication treatments, skills training, family support, self help groups Maintenance - Relapse prevention Relapse prevention plan, continue skills building in active treatment, expand recovery to other areas of life Evidence-Based Practices Copyright West Institute

More treatment factors for recovery Social support interventions (groups, self help, family) Long term perspective Rehabilitation of skills (coping, social, leisure, work) Cultural sensitivity and competence Program fidelity Evidence-Based Practices Copyright West Institute

Recovery model Consumer driven Unconditional respect and compassion Clinician responsible for helping client with motivation for treatment Focus on client goals and function, not on adherence to treatment Client choice and shared decision making are important Evidence-Based Practices Copyright West Institute

IDDT improves outcomes McHugo et al, 1999 60 *** If current & subsequent points 1 then the current score 1 Figure 1. Percent of Participants for High-Fidelity Assessment Points Baseline 6 mo. 12 mo. in Stable 18 mo. Remission 24 mo. 30 mo. 36 mo. Hi-Fidelity 19.67 26.23 29.51 37.7 42.62 55.74 Programs ( E ; 0n 61) vs. Low-Fidelity ACT Programs (G; n 26). Low-Fidelity 0 3.85 3.85 7.69 7.69 15.38 15.38 ACT 50 40 30 20 10 0 Baseline 6 mo. Evidence-Based Practices 12 mo. 18 mo. 24 mo. 30 mo. 36 mo. Copyright West Institute

Program implementation: 15 years in several states 60% of programs attain successful implementation High fidelity to model leads to good outcomes Without focus, fidelity erodes over time Evidence-Based Practices Copyright West Institute

Systems Issues How to integrate treatments? Stages of implementation: motivating, enacting, and sustaining Each stage 6 months - 1 year Changes at 5 levels (1) Health authority (2) Program leadership (3) Clinician/supervisor (4) Family (5) Consumer Evidence-Based Practices Copyright West Institute

Strategies for policy makers Building consensus for the vision of integrated dual disorder services Conjoint planning Define standards Structural, regulatory, reimbursement, and contracting mechanisms Demonstrations Training and monitoring Evidence-Based Practices Copyright West Institute

Strategies for program leadership Consensus and vision Specific leader Train all clinicians Comprehensive integration Records Outcomes Quality assurance Evidence-Based Practices Copyright West Institute

Strategies for clinicians and supervisors Outcome based supervision Knowledge base New skills Assessment Motivational treatment Substance abuse counseling Specialty training Secondary strategies Evidence-Based Practices Copyright West Institute

Strategies for families/supports Information Support Collaboration Skills and reinforcement Advocacy and involvement Evidence-Based Practices Copyright West Institute

Strategies for consumers Information Peer discussion Counseling Rehabilitation Training New roles - life is more persuasive than research Evidence-Based Practices Copyright West Institute

Conclusions Implementation of integrated dual disorder treatment is challenging but critical to outcomes Multiple strategies are helpful 3 stages for implementation: motivating, enacting, and sustaining Include all stakeholders Evidence-Based Practices Copyright West Institute