Integrated Dual Disorder Treatment IDDT Evidence Based Practice

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

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

Why focus on dual disorders? n n n 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? n Mental illness • • Depression 15% Anxiety Disorders 13% Bipolar 1% Schizophrenia 1% n Substance use disorders • Alcohol 20% n n Men 30% Women 10% • Drugs 9% n n Men 11% Women 7% Copyright West Institute

Substance abuse is common in people with mental illness n n 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 Copyright West Institute

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

Prevalence of mental illness in alcohol disorder samples n n n In community, 24. 4% have mental illness In institutions, 55% have mental illness In substance abuse treatment, 65% have mental illness Copyright West Institute

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

Types of Dual Disorders n 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 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 n n 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 n Prochaska, Di. Clemente, and Norcross 1992; n Miller and Rollnick 1991 Evidence-Based Practices Copyright West Institute

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

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

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

Evidence-Based Practices Copyright West Institute

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

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 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 n n Monthly income Disability income Expenditures for illegal drugs Expenditures for alcohol $650 $645 $250 $10 • Median values Copyright West Institute

Costs of treatment for persons with dual disorders compared to SMI only 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 n Treat each disorder separately • May be parallel or sequential n Separate treatment is NOT effective Evidence-Based Practices Copyright West Institute

Evidence Based Practice n Definition of EBP • Research evidence that practice is more effective than usual treatment from multiple studies across the country n 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 n Process, feasibility, outcomes Evidence-Based Practices Copyright West Institute

Integrated dual disorders treatment: What is it? n 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? n n 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 Evidence-Based Practices Copyright West Institute

Fidelity to IDDT principles improves abstinence Evidence-Based Practices Mc. Hugo et al, 1999 Copyright West Institute

Abstinence leads to improvements in other outcomes Drake et al, 1998 n n n 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 n n Objective: Living situation, victimization Subjective: overall satisfaction with life, housing, family, health Evidence-Based Practices Copyright West Institute

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). Evidence-Based Practices Copyright West Institute

NH Dual Diagnosis Study (19891994) 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) 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) 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? n n Stable housing Sober support network/family Regular meaningful activity Trusting clinical relationship • Alverson et al, Com MHJ, 2000 Copyright West Institute

Treatment factors for recovery n n n 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 n Integrated • • • n 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 n Precontemplation - Engagement • Outreach, practical help, crisis intervention, develop alliance, assessment n Contemplation & Preparation - Persuasion • Education, set goals, build awareness of problem, family support, peer support, n Action - Active Treatment • Substance abuse counseling, medication treatments, skills training, family support, self help groups n 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 n Social support interventions • (groups, self help, family) n n Long term perspective Rehabilitation of skills • (coping, social, leisure, work) n n Cultural sensitivity and competence Program fidelity Evidence-Based Practices Copyright West Institute

Recovery model n n n 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 Mc. Hugo et al, 1999 Evidence-Based Practices Copyright West Institute

Program implementation: 15 years in several states n n n 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 n (2) Program leadership n (3) Clinician/supervisor n (4) Family n (5) Consumer n Evidence-Based Practices Copyright West Institute

Strategies for policy makers n n n 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 n n n n 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 n n n Outcome based supervision Knowledge base New skills • Assessment • Motivational treatment • Substance abuse counseling n n Specialty training Secondary strategies Evidence-Based Practices Copyright West Institute

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

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

Conclusions n n 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