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

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

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

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

5. Copyright  West Institute Evidence-Based Practices 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 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 About one third of people with anxiety and depressive disorders have a substance use disorder at some time in their life

6. Copyright  West Institute Evidence-Based Practices Prevalence of substance use disorders in mental illness

7. Copyright  West Institute Evidence-Based Practices Prevalence of Co-Occurring Disorders-ECA Study % of respondents Regier et al., JAMA, 1990

8. Copyright  West Institute Evidence-Based Practices Prevalence of mental illness in alcohol disorder samples In community, 24.4% have mental illness In institutions, 55% have mental illness In substance abuse treatment, 65% have mental illness

9. Copyright  West Institute Evidence-Based Practices Combination and levels of illness

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

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

12. Copyright  West Institute Evidence-Based Practices Course of dual disorders Both substance use disorders and severe mental illness are chronic, waxing and waning 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 Recovery from mental illness or substance abuse occurs in stages over time PrecontemplationPrecontemplation ContemplationContemplation PreparationPreparation ActionAction MaintenanceMaintenance Prochaska, DiClemente, and Norcross 1992; Prochaska, DiClemente, and Norcross 1992; Miller and Rollnick 1991 Miller and Rollnick 1991

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

14. Copyright  West Institute Evidence-Based Practices Attaining remission occurs in stages

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

16. Copyright  West Institute Evidence-Based Practices

17. Copyright  West Institute Evidence-Based Practices Characteristics Associated with Medication Noncompliance in Six-Month Longitudinal Study

18. Copyright  West Institute Evidence-Based Practices Medical Complications of Co-Occurring Substance Use: HIV and Hepatitis B and C 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 Rosenberg et al., A Jl Public Health, 2001

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

20. Copyright  West Institute Evidence-Based Practices Costs of treatment for persons with dual disorders compared to SMI only

21. Copyright  West Institute Evidence-Based Practices 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

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

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

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

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

26. Copyright  West Institute Evidence-Based Practices IDDT improves abstinence

27. Copyright  West Institute Evidence-Based Practices Fidelity to IDDT principles improves abstinence McHugo et al, 1999

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

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

30. Copyright  West Institute Evidence-Based Practices NH Dual Diagnosis Study (1989-1994 Drake et al, 1998 ) 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).

31. Copyright  West Institute Evidence-Based Practices NH Dual Diagnosis Study (1989- 1994) 1. Percentage of persons hospitalized during each six months declined significantly for all clients. 2. It declined much more for those in recovery.

32. Copyright  West Institute Evidence-Based Practices NH Dual Diagnosis Study (1989- 1994) Arrests and Incarcerations decline as persons treated for dual disorders recover from substance abuse.

33. Copyright  West Institute Evidence-Based Practices NH Dual Diagnosis Study (1989- 1994) 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.

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

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

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

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

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

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

40. Copyright  West Institute Evidence-Based Practices IDDT improves outcomes McHugo et al, 1999

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

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

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

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

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

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

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

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