Presentation on theme: "Co-Occurring Disorders Expected rather than the Exception"— Presentation transcript:
1Co-Occurring Disorders Expected rather than the Exception Tribal Justice & Safety – One OJPTribal Training and Technical Assistance – Session IIIShelton, WAJune 5, 2007Elizabeth I. Lopez, Ph.D.US Department of Health and Humans ServicesSubstance Abuse and Mental Health Services Administration
2Presentation Overview Definition of Co-Occurring DisordersEpidemiology of Co-Occurring DisordersOverview of SAMHSA Co-Occurring ActivitiesSAMHSA Targeted Co-Occurring ProgramsCOSIGCOCENational Policy Academy on Co-Occurring DisordersUpcoming AI/AN Policy AcademyDiscussion
3Definition: Co-occurring Disorders The term refers to co-occurring substance use (abuse or dependence) and mental disorders.Clients said to have co-occurring disorders have one or more mental disorders as well as one or more disorders relating to the use of alcohol and/or other drugs.A diagnosis of a co-occurring disorder (COD) occurs when at least one disorder of each type can be established independently of the other and is not simply a cluster of symptoms resulting from a single disorder.
4Co-Occurring Disorders EpidemiologyWhat do we know aboutCo-Occurring Disorders?
5Co-Occurring Disorders We know that co-occurring disorders are increasing becoming the expectation rather than the exception.
6Substance Use Disorder Co-Occurrence of SMI and Substance Use Disorders among Adults Aged 18 or Older: 200315.2 Million15.4MillionCo-OccurringDisordersSubstance Use DisorderOnlySMI Only4.2 MillionThis data is from NSDHU 2003 but it was important to include this slide because the NSDHU 2004 did not have this graph showing the number of people with CODs.* NSDUH 2003
7Co-Occurrence of SPD and Substance Use Disorder in the Past Year among Adults Aged 18 or Older: 2005 Up by 1 million in 2 years14.9 Million19.4Million5.2 MillionSubstance Use Disorder (SUD) OnlySerious Psychological Distress (SPD) OnlyCo-OccurringSUD and SPD
8Substance Use among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2005
9Substance Use among Youths Aged 12 to 17, by Major Depressive Episode in the Past Year: 2005 Percent Using SubstancePast Year Illicit Drug UsePast Year Marijuana UsePast Year Psycho- therapeutics UseDaily Cigarette Use in Past MonthPast Month Heavy Alcohol Use
10Co-Occurring Psychiatric Problems Co-occurring psychiatric problems are the norm among adolescents presenting for substance abuse treatment. The most common are externalizing conditions like conduct disorder and ADHD. There are also significant rates of depression, trauma and anxiety disorders. The lower half of this panel shows that a wide range of other key psychiatric issues are also present including any victimization, high severity victimization (i.e., that occurred multiple times, multiple people, someone they trusted, involved sexual penetration or near death, that people did not believe when they sought help), running away, homicidal or suicidal thoughts, and self multilation.Source: CSAT AT Outcome Data Set (n=9,276 adolescents)
11Co-Occurring Disorders Expected rather than the Exception We know that individuals with aco-occurring disorder are less likely to receive treatment for BOTH disorders.
125.2 Million Adults with Co-Occurring SPD and Substance Use Disorder Past Year Treatment among Adults Aged 18 or Older with Both Serious Psychological Distress and a Substance Use Disorder: 2005Treatment Only for Mental Health ProblemsTreatment for Both Mental Health and Substance Use Problems34.3%8.5%Substance Use Treatment Only4.1%No Treatment53.0%5.2 Million Adults with Co-Occurring SPD and Substance Use DisorderNote: Due to rounding, these percentages do not add to 100 percent.
13Mean Age for Past Year Initiates, by Illicit Drug: 2004 MarijuanaHeroinPain RelieversCocaineLSDTranquilizersPCPEcstasyInhalantsStimulantsSedativesNSDUH, 2004
14Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2004 Percent Using in Past MonthAge in Years
15Co-Occurring Disorders Expected rather than the Exception American Indian/Alaskan Native Communities faceunique challenges with co-occurring substanceabuse and psychological conditionsHistorical traumaStigma / DiscriminationPreserving cultural healing traditionsMultiple funding streams / delivery systems for behavioral health services
16Substance Use and AI/AN Rates of past year use disorders were higher among American Indians and Alaska Natives than members of other racial groups for alcohol, illicit drug use, marijuana, cocaine, and hallucinogen use disorders. Although in the past year American Indians and Alaska Natives were less likely than persons of other racial backgrounds to have used alcohol (60.8% vs. 65.8%), they were more likely to have an alcohol use disorder (10.7% vs. 7.6%).For illicit drug use in the past year, American Indians and Alaska Natives were more likely than persons of other racial backgrounds both to have used an illicit drug (18.4% vs. 14.6%) and to have an illicit drug use disorder (5.0% vs. 2.9%).NSDUH 2005
17Substance Abuse/Dependence & MDE or SPD by AI/AN and Non-AI/AN % with Co-Occurring ConditionsSource: NSDUH 2004 & 2005AI/AN=American Indian/Alaska Native; MDE=Major Depressive Episode; SPD= Serious Psychological Distress; ID= Illicit Drugs; Alc=Alcohol
18Current Use of Illicit Drugs among Persons Aged 12 or Older, by Race: 2002 -2004 Percent Using in Past MonthNSDUH
19Current Use of Illicit Drugs among Youth Aged 12 to 17, by Race: 2002-2004 Percent Using in Past MonthNDSUH
20Current Use of Illicit Drugs among Persons Aged 26 or Older, by Race: 2002-2004 Percent Using in Past MonthNational Survey on Drug Use and Health 2004
21Current Use of Alcohol among Persons Aged 12 or Older, by Race: 2002- 2004 Percent Using in Past MonthNational Survey on Drug Use and Health 2004
22Heavy Use of Alcohol among Persons Aged 12 or Older, by Race: 2002-2004 Percent Using in Past MonthNational Survey on Drug Use and Health 2004
23Received Substance Use Treatment in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage
24Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older, by Race: 2004 Percentage
25Substance Abuse Individuals with alcohol and drug problems Prevalence rates for current alcohol abuse and/or dependence among Northern Plains and Southwestern Vietnam veterans have been estimated to be as high as 70% compared to % of their white, black, and Japanese American counterparts.The estimated rate of alcohol-related deaths for AI/AN is much higher than for the general population.According to the US Public Health Service…
26Mental health Exposure to trauma The rate of violent victimization of AI/AN is more than twice the national averageHigher rate of traumatic exposure - 22% rate of PTSD for AI/AN, compared to 8% in the general U.S. populationAccording to the US Public Health Service…
27Mental health Availability of Mental Health Services Approximately 101 AI/AN mental health professionals are available per 100,000 AI/AN, compared to 173 per 100,000 for whites.In 1996, only about 29 psychiatrists in the U.S. were of AI/AN heritage.
28Mental health Access to Mental Health Services The Indian Health Service (IHS) is the Federal agency responsible for providing health care to Native populations20% of AI/AN report access to IHS clinics, which are located mainly on reservations
29Mental health Medicaid is the primary insurer for 25% of AI/AN Approximately 50% of AI/AN have employer-based insurance coverage, compared to 72% of whites24% of AI/AN have no health insurance, compared to 16% of the U.S. population
30Risk and Protective Factors for Substance Use among American Indian or Alaska Native Youths American Indian or Alaska Native youths were more likely to perceive moderate to no risk of substance useA larger percentage of American Indian or Alaska Native youths did not perceive strong parental disapproval of youth substance use than youths in other racial/ethnic groupsAmerican Indian or Alaska Native youths were more likely to believe that all or most of the students in their school get drunk at least once a weekNSDUH
31SAMHSA Response to address the Co-occurring Disorders
32SAMHSA Co-Occurring Initiatives Report To Congress (2002)Federal LeadershipCross Agency Matrix Action PlanCo-occurring State Incentive GrantsCo-occurring Center for ExcellenceKey publications: TIP 42/COD ToolkitsCo-occurring Policy Academies
33Congress called on SAMHSA to prepare a report outlining the scope of the problem of co-occurring disorders, current treatment approaches, best practice models, and prevention efforts. This report was mandated to include:· a summary of the manner in which individuals with co-occurring disorders are receiving treatment,· a summary of practices for preventing substance abuse disorders among individuals who have a mental illness and are at risk of having or acquiring a substance abuse disorder;· a summary of evidence-based practices for treating individuals with co-occurring disorders and recommendations for implementing such practices; and· a summary of improvements necessary to ensure that individuals with co-occurring disorders receive the services they need.
34Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental DisordersReleased November 2002Raised the awareness of Co-occurring DisordersIncluded a Five-Year Blueprint for ActionSAMHSA adopted road map to address Co-occurring Disorders
36Co-Occurring Matrix Workgroup Chair and Membership A. Kathryn Power. M.Ed.DirectorCenter for Mental Health Service (CMHS)H. Westley Clark, M.D., J.D. M.P.HCenter for Substance Abuse Treatment (CSAT)SAMHSA Workgroup representation:Center for Mental Health Services Office of the AdministratorCenter for Substance Abuse Treatment Office of Applied StudiesCenter for Substance Abuse Prevention Office of CommunicationsOffice of Policy, Planning & Budget
37“No Wrong Door” PolicyEach provider should be aware that he/she has the responsibility to address the range of client needs…wherever a client presents for carewhenever a client presents for careproperly refer clients for appropriate care as neededfollow-up on referrals to ensure clients received proper care
38SAMHSA Co-occurring Matrix Action Plan FY 2006/2007: Purpose To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders.Approximately 5.2 million individuals in the United States are estimated to be affected by co-occurring mental and substance abuse disorders. However, only a small percentage of these individuals receive treatment that addresses both disorders.
39SAMHSA Co-Occurring Matrix Action Plan Long Term Measures Increase the percentage of persons with co-occurring disorders who receive appropriate treatment services that address both disorders.Increase the percentage of adolescents aged 12 – 17 who receive appropriate prevention services that address substance abuse and mental health.Increase the percentage of persons who experience reduced impairment from their co-occurring disorders following appropriate treatment.
40SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures Increased percent of prevention and treatment settings that:screen for co-occurring disordersassess for co-occurring disordersprovide treatment to clients through collaborative, consultative and integrated models of care
41SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures Increase the number of grantees (States, Tribes, communities, and providers) measuring and reporting on co-occurring programs, practices, and models of treatment (accountability)Increase the number of States and Tribes with State or Tribal-Level actions plans for improving access to mainstream and specialty services for individuals with co-occurring disorders(capacity)Increase the number of people trained to implement appropriate co-occurring prevention and integrated treatments among States, communities, providers and consumers (effectiveness)
42SAMHSA Co-Occurring Action Plan: FY 2006-2007 Key Activities Ensure that co-occurring disorders are a significant focus in the following major grant programs, as appropriate: Mental Health Systems Transformation SIG, Access to Recovery, and the Strategic Prevention Framework SIGMonitor the extent to which the Co-Occurring State Incentive Grant (COSIG) addresses those populations prioritized on the SAMHSA Matrix that are appropriate and relevant to the programs within the matrix areaCreate and disseminate a nationally accepted framework for developing, implementing, and sustaining co-occurring disorders prevention and treatment service systems.
43SAMHSA Co-Occurring Matrix Action Plan: FY 2006-2007 Key Activities-continued Increase the number of candidate programs addressing co-occurring disorders that apply for review to the National Registry of Evidence-based Programs and Practices (NREPP) addressing co-occurring disordersHold a policy academy for Tribal organizations, tribal communities, and tribal governments to assist in developing and sustaining service systems for the unique needs of AI/AN with and at risk for co-occurring disorders and for interested States who have not participate in a policy academy to date.
44SAMHSA Strategic Plan for Co-Occurring Disorders MissionTo expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disordersKey DriversReport to CongressPresidents New Freedom InitiativeSAMHSA Co-Occurring Action PlanSAMHSA MatrixIOM ReportTarget PopulationAdult and Youth with Co-Occurring DisordersAdult and Youth at risk for Co-Occurring DisordersStates, Tribes, Local CommunitiesMechanismsCOSIGSpecialized TA(COCE/Policy Academy)Training Curriculum/Publication (TIP 42/Tool Kits)OutcomesIndividualIncrease access to appropriate prevention & treatment servicesProviderIncrease number of people trained to implement appropriate COD treatmentCommunity/SystemIncrease number of States, Tribes, Communities with comprehensive action plans
45National Outcome Measures (NOMS) Domains Abstinence from Drug / Alcohol Use / Reduced MorbidityEmployment / EducationCrime and Criminal JusticeFamily and Living ConditionsAccess / CapacityRetentionSocial ConnectednessPerception of CareCost EffectivenessUse of Evidence-Based PracticesCOD matrix action plan key activities need to be linked to client/consumer outcomes…10 domains identified by SAMHSA
46Co-Occurring Disorders Expected rather than the Exception Linking Co-Occurring Disorders with key SAMHSA Matrix AreasMental Health System TransformationSubstance Abuse Treatment CapacityStrategic Prevention Framework
47Treatment Implications of Comorbidity Between Alcohol and/or Drug Use Disorders and Other Psychiatric DisordersAdolescents and adults with co-occurring disorders are not treatedIncreased severity, disability and impairment in social/occupational functioningResistance to pharmacologic treatmentLower probability of recoveryIncreased suicidalityIncreased economic burden of each comorbid condition
48Co-Occurring Disorders Expected rather than the Exception Areas of Focus for the Treatment of CODInnovative Models of Integrated TreatmentSharing Lessons Learned across programsWorkforce DevelopmentWorking with Tribal, Rural CommunitiesChild, Adolescent, Family and Older AdultsCultural Competency Training for Local Providers
49Co-Occurring Disorders Expected rather than the Exception Co-Occurring ProgramsCo-Occurring State Incentive Grant(COSIG)
50Co-occurring State Incentive Grants (COSIG) Supports grantees in overcoming service delivery barriersSupports grantees in systems change and infrastructure developmentEnhancing service coordination, networks and linkages to support quality careImproving financial incentives for integrated careInformation sharing among stakeholders17 grantees
51Co-occurring State Incentive Grants (COSIG) Key Program AccomplishmentsImplemented first COD program within CJ SystemRedesigned and implemented a website to transfer information between local practitioners and StatesImplemented a voucher system to acquire ancillary services needed by COD clientsEstablished Statewide common data warehouse about persons within the MH and SA systems
52History of COSIG Funding Grants Awarded (annually in September)YearNumber AwardedStates Receiving AwardFunding Agency20037AR, PA, HI, MO, TX, AK, LAJointly by CSAT and CMHS20044OK, VA, AZ, NMCMHS2005CT, DC, ME, VT20062MN, SCCSAT
53Co-occurring State Incentive Grants (COSIG) Lessons LearnedInvolve Senior State/Tribal LeadershipFamily/Consumer ParticipationEngage provider community in COSIG planningProgram accountabilityMeasures of success – Linking outcomesEvaluation Update
54Co-Occurring Disorders Expected rather than the Exception SAMHSA Co-Occurring Center for Excellence (COCE)
55COCEFunded through SAMHSA, is a leading national resource for the field of co-occurring mental and substance use disordersConsists of national and regional experts who join service recipients in shaping COCE’s mission, guiding principles, and approachesAccomplishes its mission through technical assistance and training, delivered through multiple vehicles
56COCE MissionTo receive and transmit advances in treatment for all levels of COD severityTo guide enhancements in the infrastructure and clinical capacities of service systemsTo foster the infusion and adoption of evidence- and consensus-based COD treatment and program innovations into clinical practice.
57COCE Targeted Populations States / Tribes receiving COSIG fundingStates / Tribes not yet receiving COSIG funding, including Co-Occurring Policy Academy States and all other States / TribesAI/AN tribes and organizations, clinical providers, other providers, agencies and systems through which clients might enter the COD treatment system
58Key Focus of COCE Program COSIG TAPolicy Academy TACommunity TACOCE Web siteCOCE Training / Material DevelopmentCompleted 22 individual COSIG TA requests for information and expert consultations;Created a learning community of COSIG States that is supported by COCE and has evolved into a self-sustaining State-led group for sharing information and lessons learned;Convened between 2-3 separate COSIG workgroups on a monthly basis involving over 30 expert consultant presentations on a range of topics of interest, resulting in 13 presentations (to date) that are now available for broader dissemination through the COCE Web site (www.coce.samhsa.gov);Supported planning for and convened three annual face-to-face COSIG meetings designed to provide federal information to new grantees and serve as a forum for information sharing and technical assistance to facilitate the achievement of COSIG program goals and objectives;Developed five interim TA reports on workgroup content areas for States’ use as they move to implementation in the workgroup content area (i.e., COD Screening, for example);COCE facilitates sharing of knowledge of parallel developments across States; andCOCE content experts have presented at plenary and breakout sessions at State COD conference, designed to advance COSIG planning and overall COD implementation in the State.
59Co-Occurring Disorders Expected rather than the Exception Prevention & Co-Occurring DisordersOperationalizing the Role of Prevention
60Prevention Strategies for Co-Occurring Disorders Develop evidence based strategies, programs, and practices that target risk/protective factors of at risk kidsDevelop individual and family-based case management systems that target families of addicted and/or those presenting w/ mental health disorders to clinics, hospitals etc.Develop programs across the life span
61Tip 42: Substance Abuse Treatment for Persons with Co-Occurring DisordersThis TIP revises TIP 9,Assessment and Treatmentof Patients With CoexistingMental Illness and Alcoholand Other Drug Abuse.1st printing of Tip 42—27,0002nd printing of Tip 42—50,000
62Co-Occurring Disorders: Expected rather than the Exception National Policy Academy on Co-Occurring Disorders
63National Policy Academy on Co-Occurring Disorders The purpose of the National Policy Academy on Co-Occurring Mental and Substance Abuse Disorders is to enhance the provision of co-occurring services in States, Tribes and communities.The Policy Academy brings together Teams comprised of individuals with policy-making influence in conjunction with nationally recognized faculty and facilitators who assist the Teams to develop a comprehensive Action Plan to enhance the provision of, and expand access to, effective prevention, treatment, and related services for co-occurring disorders within their jurisdiction.
64National Policy Academy on Co-Occurring Disorders The overarching goal of SAMHSA’s National Policy on Co-Occurring Substance Use and Mental Disorders is to enhance the provision of co-occurring services in States, Tribes and communities.This goal is supported by four objectives of the Policy Academy.
65National Policy Academy on Co-Occurring Disorders Objectives To assist States, Tribes and local policymakers in the development of an Action Plan intended to improve access to appropriate services for people with co-occurring substance use and mental disorders;To create and/or reinforce relationships among the Governor’s office, Legislators, Government and local program administrators, and stakeholders from the public and private sectors;To provide an environment conducive to the process of strategic decision-making within the context of co-occurring disorders; andTo assist State, Tribal and local policymakers in identifying issues or areas of concern that may result in a formal request for technical assistance.
66National Policy Academy on Co-Occurring Disorders The Policy Academy model sequential process:Pre-meeting work, a technical assistance site visit, and SWOT (Strengths, Weaknesses, Opportunities, Threats) analysisFormal Academy meeting (on-site “live” technical assistance)Post-meeting technical assistance and follow-upOngoing implementation (on-site technical assistance)
67National Policy Academy on Co-Occurring Disorders Strategic / specialized technical assistance approachNot a grant program - no new funding for servicesFocus on improving services for people with co-occurring disordersInnovation in health care reimbursementFocus on prevention / recoveryEvidence of partnership with substance abuse and mental health treatment systems
68National Policy Academy on Co-Occurring Disorders Desired OutcomesOperationalize “No Wrong Door” for all people with co-occurring disordersCulturally relevant and appropriate service systemsBuilding partnership across mental health andand substance abuse prevention services & treatment systemsIdentify institutionalized barriers and develop strategies to overcome
69National Policy Academy on Co-Occurring Disorders Cohort I (April 2004)—Alabama; Arizona; Connecticut; Hawaii; Louisiana; Maine; Michigan; Missouri; North Carolina; South DakotaCohort II (Jan 2005)—California; Georgia; Illinois; Iowa; New Mexico; Oklahoma; Texas; Virginia; WashingtonCohort III (Sept. 2005)—Delaware; Indiana; Kansas; Maryland; Montana; New York; Ohio; Rhode Island;Tribal Policy Academy (Sept. 2007)
70National Policy Academy on Co-Occurring Disorders Key Program AccomplishmentsMuch of the success of the Policy Academy is that it transcends a typical strategic planning retreat or a conference, in that it seeds a process of cross-agency collaboration and systems change.The design facilitates leaders, policy makers and advocates from each Team to build on its strengths, develop policy strategies and implement action plans for transforming practice before, during, and after the Academy meeting.
71National Policy Academy on Co-Occurring Disorders Key Program Accomplishments (cont.)Locally defined shared visionInnovative financing strategies and leverage existing resourcesCulturally relevant approachCross sector policy makers / providers / stakeholders working together
72National Policy Academy on Co-Occurring Disorders – AI/AN Planning Underway for tentatively scheduled academy - September 2007Invitation released May 2007 – applications due June 15, 2007.
73National Policy Academy on Co-Occurring Disorders Key review factors that will shape eligibility criteria:Capacity/ReadinessOutline NeedCurrent Health/ Behavioral Health Delivery ApproachMulti-level commitmentCurrent Health / Behavioral Health Financing StructuresWillingness to collaborate / partner with other entities delivering behavioral health delivery servicesInterest and willingness to share lessons learned from the policy academy with other communities
74The National Policy Academy on Co-Occurring Substance Use and Mental Disorders: A Schematic Overview The Policy Academy Model: A Multi-Stage ProcessPost-Academy TechnicalAssistanceSelection ProcessAcademy OrientationFormal Academy MeetingConference calls, SAMHSAcommunications introduce Tribesto Academy processPre-Academy site visits:provide Academy orientationenhance understanding ofAcademy modeldevelop common vision, priorities, strategies, and draft S.W.O.T. analysisinitiate identification of technical assistance needsformalizes team leadership and decision- making processFacilitates delivery of technicalassistance and action plandevelopment across multipleformats (i.e., plenaries,presentations, Team workingsessions)Teams present visionstatements and Tribal-related keyissues and effortsFormal presentations on systems change, evidence- based practices, prevention, funding, resources, and other co-occurring curriculum areasPolicy Teams:continue developing action plans and identifying technical assistance needsreceive feedback and technical assistance from faculty and peersreport out on action plan, priorities, next steps, and technical assistance needsPolicy teamsfinalize strategies (short-and long- range) and specific action stepssubmit revised action plan for SAMHSA review/feedbackprioritize and coordinate technical assistance with COCE and other TAimplement action planssubmit semi-annual progress reports to SAMHSAApplicants responded to aLetter of Invitation specifyingformal eligibility criteriaclearly defined problemhigh-level commitmentbreadth, depth, andauthority of proposedTribal teamPeer review selection process of participating teams/delegationsEnhances the Provision of Co-Occurring Services in Communities
75Next Steps for SAMHSA Co-occurring Portfolio Institutionalizing “No Wrong Door”Unique needs of special populations(Children, rural, AI/AN)Core Co-Occurring CompetenciesSupporting Integrated System SustainabilityEvidence-based COD programsDisparate Funding Streams/ReimbursementLicensing/CertificationCultural Competent/Relevant Service System
76Co-Occurring Disorders Expected rather than the Exception For more information:(TDD)Publication Ordering and Funding Information
77Co-Occurring Disorders Expected rather than the Exception Thank you!Elizabeth I. Lopez, Ph.D.US Department of Health & Human ServicesSubstance Abuse and Mental Health Services AdministrationOffice of Policy, Planning & Budget(voice)(fax)
78Co-Occurring Disorders Expected rather than the Exception DiscussionRecommendationsQuestionsThoughts