Integrated Treatment of Co-Occurring Disorders 4/16/2017 Dual Diagnoses Principles of the Minkoff model for treating co-occurring mental health & substance use disorders

“Dual diagnoses are an expectation, not an exception” Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Dual diagnoses are an expectation, not an exception” According to epidemiological studies, approximately 50% of people with a diagnosis of severe mental illness also meet lifetime criteria for a diagnosis of substance use disorder. (Drake, 1995)

Prevalence of substance use disorders with mental illness Integrated Treatment of Co-Occurring Disorders 4/16/2017 Prevalence of substance use disorders with mental illness This graph shows the percentage of people surveyed who had a substance use disorder. The bar on the left shows that about 15% of people in the general population had a substance use (alcohol or drug) disorder at some time in their life. The next bar show that almost 50% of people with schizophrenia had a substance use disorder and the next bar shows that people with bipolar disorder had even higher rates. The final three bars show that a quarter to a third of people with milder mood and anxiety disorders also have a substance use disorder at some time in their life. Regier et al, JAMA 1990

“Dual diagnoses are an expectation, not an exception” Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Dual diagnoses are an expectation, not an exception” According to the National Comorbidity Study, people with mania are 9.7 times as likely as the general population to meet the lifetime criteria for alcohol dependence. (Kessler et al, 1996)

Integrated Treatment of Co-Occurring Disorders 4/16/2017 Prevalence of Co-Occurring Substance Use Disorders with Schizophrenia (ECA Study) % of respondents This slide shows that rates of alcohol and drug use disorders in people with schizophrenia (green bars) are much higher than rates in people in the general population (blue bars). A third of people with schizophrenia develop an alcohol disorder, and a fourth of people with schizophrenia develop a drug disorder, for a total over almost half of people with schizophrenia developing a substance use disorder of some type over their lifetime. Regier et al., JAMA, 1990

“Dual diagnoses are an expectation, not an exception” Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Dual diagnoses are an expectation, not an exception” In community studies evaluated for the Epidemiologic Catchment Area (ECA) study, 33.7% of people diagnosed with schizophrenia or schizophreniform disorder and 42.6% of people with bipolar disorder also met the lifetime criteria for an alcohol use disorder (AUD) diagnosis, compared with 16.7% of people in the general population. (Regier et al, 1990)

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Use the Four-Quadrant model to understand & inform effective treatment” HIGH PSYCHIATRIC (SPMI) HIGH SUBSTANCE (Dependence) IV LOW PSYCHIATRIC (psychiatrically complicated) III (Dependence) LOW SUBSTANCE (Abuse) II (mild psychopathology) I (Abuse)

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Emphasize the empathic, hopeful, integrated aspects of the treatment relationship” The most significant predictor of treatment success is an: (1) empathic, (2) hopeful, (3) continuous treatment relationship in which (4) integrated treatment and (5) coordination of care can take place through multiple treatment episodes. Within this context, (6) case management / care and (7) empathic detachment / confrontation are appropriately balanced at each point in time.

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Consider both disorders primary and integrated, and treat accordingly” Both treatment systems (Mental Health & Substance Abuse) have myths that clinicians can’t treat one illness while also treating the other.

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Consider both disorders primary and integrated, and treat accordingly” In fact, treatments for each condition work well together, and staff can learn to integrate both. Both substance disorders and mental illness fit into the disease-management / recovery model.

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Apply the Disease / Recovery model with diagnosis-specific and stage-of-change-specific interventions” (r/d-1) Leads to lack of control of behavior &/or emotion Symptoms can be controlled with treatment Physical, mental and spiritual disease Progressive illness w/o treatment Disease miscast as a moral issue Affects the entire family Depression & despair Shame and stigma Hereditary factors Biological Illness Guilt and failure Denial factor Incurable Chronic

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-specific interventions” (d/r-1) Initial phase is stabilization, which may require hospitalization, &/or medication (detox), &/or psychotropic medication Following stabilization, the next phase is rehabilitation   Rehabilitation involves maintaining stability by following a long-term program (don’t use, attend meetings, work the 12 Steps, etc / take meds, use therapy or other helpful supports / services, etc.) Denial needs to be overcome

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Apply the Disease/Recovery model with diagnosis-specific & stage-of-change-specific interventions” (d/r-1) Powerlessness over the disease needs to be acknowledged Help must be asked for, from a power greater than the self, in order to control symptoms (higher power, AA, NA, sponsor, meds, therapist, doctor, case manager, etc) Recovery proceeds ‘One Day At A Time’ Recovery is never done, but gradual progress can be made  

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Apply the Disease / Recovery model with diagnosis-specific & stage-of-change-specific interventions” (d/r-2) Relapse is always a risk Families / friends benefit from involvement in a program to get help for themselves in dealing with the disease Education about the disease is an important piece Treatment must include focus on feelings about the disease, and feeling good about oneself Recovery is a physical, mental, emotional and spiritual process

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “Apply the disease / recovery model with diagnosis-specific and stage-of-change-specific interventions” (Prochaska, Norcross, & DiClemente) Precontemplation Relapse / Recycle Contemplation Maintenance Preparation Action

Evaluating Stages of Change Integrated Treatment of Co-Occurring Disorders 4/16/2017 Evaluating Stages of Change Precontemplation (Denial) “What problem? I’m not thinking about it.” Contemplation (Ambivalence) “I wonder if I might have a problem? I’m thinking about it but not ready to decide anything yet.” Preparation / Determination (Admission) “I have a problem.”

Integrated Treatment of Co-Occurring Disorders 4/16/2017

Evaluating Stages of Change Integrated Treatment of Co-Occurring Disorders 4/16/2017 Evaluating Stages of Change Action (Taking steps / Making changes) “I have a problem and I’m ready to do something about it.” Maintenance (Continuing what works) “I’m stabilized and doing well. How can I support my ongoing recovery?” Relapse / Recycle (Trying again) “I’m stabilized but have relapsed. How can I get back into active recovery?”

Integrated Treatment of Co-Occurring Disorders 4/16/2017

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “There is no single correct intervention!” Individualize treatment per . . . . . . Quadrant designation (see) . . . Diagnoses (DSM-IV) . . . Level of functioning (evaluate – GAF, other tools) . . . External constraints (Assessment, Tx plan) . . . External supports (Assessment, Tx plan) . . . Phase of Recovery / Stage of Change (see) . . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)

Integrated Treatment of Co-Occurring Disorders 4/16/2017 “There is no single correct destination!” Individualize outcome expectations per . . . . . . Quadrant designation (see) . . . Diagnoses (DSM-IV) . . . Level of functioning (evaluate – GAF, other tools) . . . External constraints (Assessment, Tx plan) . . . External supports (Assessment, Tx plan) . . . Phase of Recovery / Stage of Change (see) . . . Multidimensional assessment of level-of- care requirements (ASAM PPC-2R)

NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) Integrated Treatment of Co-Occurring Disorders 4/16/2017 NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) I’m going to show you some evidence from the New Hampshire Dual Diagnosis study. This slice shows that people in recovery get more stable community housing as they recover.

NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) Integrated Treatment of Co-Occurring Disorders 4/16/2017 NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) This slide shows that people stay out of the hospital more as they recover. Staying out of the hospital improves people’s quality of life and reduces cost.

NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) Integrated Treatment of Co-Occurring Disorders 4/16/2017 NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) This slide shows that people are able to stay out of jail as they recover. Staying out of jail implies that these people are no longer engaged in activities that lead to jail time.

NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) Integrated Treatment of Co-Occurring Disorders 4/16/2017 NH Dual Diagnosis Study (1989-1994) (Drake et al, 1998) This slide shows how the cost of treatment shifts from inpatient services to outpatient services. The overall costs go down over time as well.