1. Co-Occurring Disorders Expected rather than the Exception
Tribal Justice & Safety – One OJP
Tribal Training and Technical Assistance – Session III
Shelton, WA
June 5, 2007
Elizabeth I. Lopez, Ph.D.
US Department of Health and Humans Services
Substance Abuse and Mental Health Services Administration

2. Presentation Overview
Definition of Co-Occurring Disorders
Epidemiology of Co-Occurring Disorders
Overview of SAMHSA Co-Occurring Activities
SAMHSA Targeted Co-Occurring Programs
COSIG
COCE
National Policy Academy on Co-Occurring Disorders
Upcoming AI/AN Policy Academy
Discussion

3. Definition: 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.

4. Co-Occurring Disorders
Epidemiology
What do we know about
Co-Occurring Disorders?

5. Co-Occurring Disorders
We know that co-occurring disorders are increasing becoming the expectation rather than the exception.

6. Substance Use Disorder
Co-Occurrence of SMI and Substance Use Disorders among Adults Aged 18 or Older: 2003
15.2 Million
15.4
Million
Co-Occurring
Disorders
Substance Use Disorder
Only
SMI Only
4.2 Million
This 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

7. Co-Occurrence of SPD and Substance Use Disorder in the Past Year among Adults Aged 18 or Older: 2005
Up by 1 million in 2 years
14.9 Million
19.4
Million
5.2 Million
Substance Use Disorder (SUD) Only
Serious Psychological Distress (SPD) Only
Co-Occurring
SUD and SPD

8. Substance Use among Adults Aged 18 or Older, by Major Depressive Episode in the Past Year: 2005

9. Substance Use among Youths Aged 12 to 17, by Major Depressive Episode in the Past Year: 2005
Percent Using Substance
Past Year Illicit Drug Use
Past Year Marijuana Use
Past Year Psycho- therapeutics Use
Daily Cigarette Use in Past Month
Past Month Heavy Alcohol Use

10. Co-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)

11. Co-Occurring Disorders Expected rather than the Exception
We know that individuals with a
co-occurring disorder are less likely to receive treatment for BOTH disorders.

12. 5.2 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: 2005
Treatment Only for Mental Health Problems
Treatment for Both Mental Health and Substance Use Problems
34.3%
8.5%
Substance Use Treatment Only
4.1%
No Treatment
53.0%
5.2 Million Adults with Co-Occurring SPD and Substance Use Disorder
Note: Due to rounding, these percentages do not add to 100 percent.

13. Mean Age for Past Year Initiates, by Illicit Drug: 2004
Marijuana
Heroin
Pain Relievers
Cocaine
LSD
Tranquilizers
PCP
Ecstasy
Inhalants
Stimulants
Sedatives
NSDUH, 2004

14. Past Month Illicit Drug Use among Persons Aged 12 or Older, by Age: 2004
Percent Using in Past Month
Age in Years

15. Co-Occurring Disorders Expected rather than the Exception
American Indian/Alaskan Native Communities face
unique challenges with co-occurring substance
abuse and psychological conditions
Historical trauma
Stigma / Discrimination
Preserving cultural healing traditions
Multiple funding streams / delivery systems for behavioral health services

16. Substance 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

17. Substance Abuse/Dependence & MDE or SPD by AI/AN and Non-AI/AN
% with Co-Occurring Conditions
Source: NSDUH 2004 & 2005
AI/AN=American Indian/Alaska Native; MDE=Major Depressive Episode; SPD= Serious Psychological Distress; ID= Illicit Drugs; Alc=Alcohol

18. Current Use of Illicit Drugs among Persons Aged 12 or Older, by Race: 2002 -2004
Percent Using in Past Month
NSDUH

19. Current Use of Illicit Drugs among Youth Aged 12 to 17, by Race: 2002-2004
Percent Using in Past Month
NDSUH

20. Current Use of Illicit Drugs among Persons Aged 26 or Older, by Race: 2002-2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004

21. Current Use of Alcohol among Persons Aged 12 or Older, by Race: 2002- 2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004

22. Heavy Use of Alcohol among Persons Aged 12 or Older, by Race: 2002-2004
Percent Using in Past Month
National Survey on Drug Use and Health 2004

23. Received Substance Use Treatment in the Past Year among Persons Aged 12 or Older, by Race: 2004
Percentage

24. Substance Dependence or Abuse in the Past Year among Persons Aged 12 or Older, by Race: 2004
Percentage

25. Substance 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…

26. Mental health Exposure to trauma
The rate of violent victimization of AI/AN is more than twice the national average
Higher rate of traumatic exposure - 22% rate of PTSD for AI/AN, compared to 8% in the general U.S. population
According to the US Public Health Service…

27. Mental 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.

28. Mental health Access to Mental Health Services
The Indian Health Service (IHS) is the Federal agency responsible for providing health care to Native populations
20% of AI/AN report access to IHS clinics, which are located mainly on reservations

29. Mental 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 whites
24% of AI/AN have no health insurance, compared to 16% of the U.S. population

30. Risk 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 use
A 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 groups
American 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 week
NSDUH

31. SAMHSA Response to address the Co-occurring Disorders

32. SAMHSA Co-Occurring Initiatives
Report To Congress (2002)
Federal Leadership
Cross Agency Matrix Action Plan
Co-occurring State Incentive Grants
Co-occurring Center for Excellence
Key publications: TIP 42/COD Toolkits
Co-occurring Policy Academies

33. Congress 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.

34. Report to Congress on the Prevention and Treatment of Co-Occurring Substance Abuse Disorders and Mental Disorders
Released November 2002
Raised the awareness of Co-occurring Disorders
Included a Five-Year Blueprint for Action
SAMHSA adopted road map to address Co-occurring Disorders

36. Co-Occurring Matrix Workgroup Chair and Membership
A. Kathryn Power. M.Ed.
Director
Center for Mental Health Service (CMHS)
H. Westley Clark, M.D., J.D. M.P.H
Center for Substance Abuse Treatment (CSAT)
SAMHSA Workgroup representation:
Center for Mental Health Services Office of the Administrator
Center for Substance Abuse Treatment Office of Applied Studies
Center for Substance Abuse Prevention Office of Communications
Office of Policy, Planning & Budget

37. “No Wrong Door” Policy
Each provider should be aware that he/she has the responsibility to address the range of client needs…
wherever a client presents for care
whenever a client presents for care
properly refer clients for appropriate care as needed
follow-up on referrals to ensure clients received proper care

38. SAMHSA 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.

39. SAMHSA 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.

40. SAMHSA Co-Occurring Matrix Action Plan: Outcome / Annual Measures
Increased percent of prevention and treatment settings that:
screen for co-occurring disorders
assess for co-occurring disorders
provide treatment to clients through collaborative, consultative and integrated models of care

41. SAMHSA 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)

42. SAMHSA 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 SIG
Monitor 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 area
Create and disseminate a nationally accepted framework for developing, implementing, and sustaining co-occurring disorders prevention and treatment service systems.

43. SAMHSA 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 disorders
Hold 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.

44. SAMHSA Strategic Plan for Co-Occurring Disorders
Mission
To expand and improve prevention, appropriate treatment and other supportive services to individuals with and/or at risk for co-occurring disorders
Key Drivers
Report to Congress
Presidents New Freedom Initiative
SAMHSA Co-Occurring Action Plan
SAMHSA Matrix
IOM Report
Target Population
Adult and Youth with Co-Occurring Disorders
Adult and Youth at risk for Co-Occurring Disorders
States, Tribes, Local Communities
Mechanisms
COSIG
Specialized TA
(COCE/Policy Academy)
Training Curriculum/Publication (TIP 42/Tool Kits)
Outcomes
Individual
Increase access to appropriate prevention & treatment services
Provider
Increase number of people trained to implement appropriate COD treatment
Community/System
Increase number of States, Tribes, Communities with comprehensive action plans

45. National Outcome Measures (NOMS) Domains
Abstinence from Drug / Alcohol Use / Reduced Morbidity
Employment / Education
Crime and Criminal Justice
Family and Living Conditions
Access / Capacity
Retention
Social Connectedness
Perception of Care
Cost Effectiveness
Use of Evidence-Based Practices
COD matrix action plan key activities need to be linked to client/consumer outcomes…10 domains identified by SAMHSA

46. Co-Occurring Disorders Expected rather than the Exception
Linking Co-Occurring Disorders with key SAMHSA Matrix Areas
Mental Health System Transformation
Substance Abuse Treatment Capacity
Strategic Prevention Framework

47. Treatment Implications of Comorbidity Between Alcohol and/or Drug Use Disorders and Other Psychiatric Disorders
Adolescents and adults with co-occurring disorders are not treated
Increased severity, disability and impairment in social/occupational functioning
Resistance to pharmacologic treatment
Lower probability of recovery
Increased suicidality
Increased economic burden of each comorbid condition

48. Co-Occurring Disorders Expected rather than the Exception
Areas of Focus for the Treatment of COD
Innovative Models of Integrated Treatment
Sharing Lessons Learned across programs
Workforce Development
Working with Tribal, Rural Communities
Child, Adolescent, Family and Older Adults
Cultural Competency Training for Local Providers

49. Co-Occurring Disorders Expected rather than the Exception
Co-Occurring Programs
Co-Occurring State Incentive Grant
(COSIG)

50. Co-occurring State Incentive Grants (COSIG)
Supports grantees in overcoming service delivery barriers
Supports grantees in systems change and infrastructure development
Enhancing service coordination, networks and linkages to support quality care
Improving financial incentives for integrated care
Information sharing among stakeholders
17 grantees

51. Co-occurring State Incentive Grants (COSIG)
Key Program Accomplishments
Implemented first COD program within CJ System
Redesigned and implemented a website to transfer information between local practitioners and States
Implemented a voucher system to acquire ancillary services needed by COD clients
Established Statewide common data warehouse about persons within the MH and SA systems

52. History of COSIG Funding
Grants Awarded (annually in September)
Year
Number Awarded
States Receiving Award
Funding Agency
2003 7
AR, PA, HI, MO, TX, AK, LA
Jointly by CSAT and CMHS
2004 4
OK, VA, AZ, NM
CMHS
2005
CT, DC, ME, VT
2006 2
MN, SC
CSAT

53. Co-occurring State Incentive Grants (COSIG)
Lessons Learned
Involve Senior State/Tribal Leadership
Family/Consumer Participation
Engage provider community in COSIG planning
Program accountability
Measures of success – Linking outcomes
Evaluation Update

54. Co-Occurring Disorders Expected rather than the Exception
SAMHSA Co-Occurring Center for Excellence (COCE)

55. COCE
Funded through SAMHSA, is a leading national resource for the field of co-occurring mental and substance use disorders
Consists of national and regional experts who join service recipients in shaping COCE’s mission, guiding principles, and approaches
Accomplishes its mission through technical assistance and training, delivered through multiple vehicles

56. COCE Mission
To receive and transmit advances in treatment for all levels of COD severity
To guide enhancements in the infrastructure and clinical capacities of service systems
To foster the infusion and adoption of evidence- and consensus-based COD treatment and program innovations into clinical practice.

57. COCE Targeted Populations
States / Tribes receiving COSIG funding
States / Tribes not yet receiving COSIG funding, including Co-Occurring Policy Academy States and all other States / Tribes
AI/AN tribes and organizations, clinical providers, other providers, agencies and systems through which clients might enter the COD treatment system

58. Key Focus of COCE Program
COSIG TA
Policy Academy TA
Community TA
COCE Web site
COCE Training / Material Development
Completed 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 (
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; and
COCE 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.

59. Co-Occurring Disorders Expected rather than the Exception
Prevention & Co-Occurring Disorders
Operationalizing the Role of Prevention

60. Prevention Strategies for Co-Occurring Disorders
Develop evidence based strategies, programs, and practices that target risk/protective factors of at risk kids
Develop 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

61. Tip 42: Substance Abuse Treatment for
Persons with Co-Occurring Disorders
This TIP revises TIP 9,
Assessment and Treatment
of Patients With Coexisting
Mental Illness and Alcohol
and Other Drug Abuse.
1st printing of Tip 42
—27,000
2nd printing of Tip 42
—50,000

62. Co-Occurring Disorders: Expected rather than the Exception
National Policy Academy on Co-Occurring Disorders

63. National 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.

64. National 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.

65. National 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; and
To assist State, Tribal and local policymakers in identifying issues or areas of concern that may result in a formal request for technical assistance.

66. National 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) analysis
Formal Academy meeting (on-site “live” technical assistance)
Post-meeting technical assistance and follow-up
Ongoing implementation (on-site technical assistance)

67. National Policy Academy on Co-Occurring Disorders
Strategic / specialized technical assistance approach
Not a grant program - no new funding for services
Focus on improving services for people with co-occurring disorders
Innovation in health care reimbursement
Focus on prevention / recovery
Evidence of partnership with substance abuse and mental health treatment systems

68. National Policy Academy on Co-Occurring Disorders
Desired Outcomes
Operationalize “No Wrong Door” for all people with co-occurring disorders
Culturally relevant and appropriate service systems
Building partnership across mental health and
and substance abuse prevention services & treatment systems
Identify institutionalized barriers and develop strategies to overcome

69. National Policy Academy on Co-Occurring Disorders
Cohort I (April 2004)—Alabama; Arizona; Connecticut; Hawaii; Louisiana; Maine; Michigan; Missouri; North Carolina; South Dakota
Cohort II (Jan 2005)—California; Georgia; Illinois; Iowa; New Mexico; Oklahoma; Texas; Virginia; Washington
Cohort III (Sept. 2005)—Delaware; Indiana; Kansas; Maryland; Montana; New York; Ohio; Rhode Island;
Tribal Policy Academy (Sept. 2007)

70. National Policy Academy on Co-Occurring Disorders
Key Program Accomplishments
Much 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.

71. National Policy Academy on Co-Occurring Disorders
Key Program Accomplishments (cont.)
Locally defined shared vision
Innovative financing strategies and leverage existing resources
Culturally relevant approach
Cross sector policy makers / providers / stakeholders working together

72. National Policy Academy on Co-Occurring Disorders – AI/AN
Planning Underway for tentatively scheduled academy - September 2007
Invitation released May 2007 – applications due June 15, 2007.

73. National Policy Academy on Co-Occurring Disorders
Key review factors that will shape eligibility criteria:
Capacity/Readiness
Outline Need
Current Health/ Behavioral Health Delivery Approach
Multi-level commitment
Current Health / Behavioral Health Financing Structures
Willingness to collaborate / partner with other entities delivering behavioral health delivery services
Interest and willingness to share lessons learned from the policy academy with other communities

74. The National Policy Academy on Co-Occurring Substance Use and Mental Disorders: A Schematic Overview
The Policy Academy Model: A Multi-Stage Process
Post-Academy Technical
Assistance
Selection Process
Academy Orientation
Formal Academy Meeting
Conference calls, SAMHSA
communications introduce Tribes
to Academy process
Pre-Academy site visits:
provide Academy orientation
enhance understanding of
Academy model
develop common vision, priorities, strategies, and draft S.W.O.T. analysis
initiate identification of technical assistance needs
formalizes team leadership and decision- making process
Facilitates delivery of technical
assistance and action plan
development across multiple
formats (i.e., plenaries,
presentations, Team working
sessions)
Teams present vision
statements and Tribal-related key
issues and efforts
Formal presentations on systems change, evidence- based practices, prevention, funding, resources, and other co-occurring curriculum areas
Policy Teams:
continue developing action plans and identifying technical assistance needs
receive feedback and technical assistance from faculty and peers
report out on action plan, priorities, next steps, and technical assistance needs
Policy teams
finalize strategies (short-and long- range) and specific action steps
submit revised action plan for SAMHSA review/feedback
prioritize and coordinate technical assistance with COCE and other TA
implement action plans
submit semi-annual progress reports to SAMHSA
Applicants responded to a
Letter of Invitation specifying
formal eligibility criteria
clearly defined problem
high-level commitment
breadth, depth, and
authority of proposed
Tribal team
Peer review selection process of participating teams/delegations
Enhances the Provision of Co-Occurring Services in Communities

75. Next Steps for SAMHSA Co-occurring Portfolio
Institutionalizing “No Wrong Door”
Unique needs of special populations
(Children, rural, AI/AN)
Core Co-Occurring Competencies
Supporting Integrated System Sustainability
Evidence-based COD programs
Disparate Funding Streams/Reimbursement
Licensing/Certification
Cultural Competent/Relevant Service System

76. Co-Occurring Disorders Expected rather than the Exception
For more information:
(TDD)
Publication Ordering and Funding Information

77. Co-Occurring Disorders Expected rather than the Exception
Thank you!
Elizabeth I. Lopez, Ph.D.
US Department of Health & Human Services
Substance Abuse and Mental Health Services Administration
Office of Policy, Planning & Budget
(voice)
(fax)

78. Co-Occurring Disorders Expected rather than the Exception
Discussion
Recommendations
Questions
Thoughts